Complex thinkers address knotty issue of Physician Assisted Death at GVSU colloquy


By Cynthia Price

Legal News

For some it may appear to be black and white, but Physician Assisted Death is for most, particularly doctors, a complicated mesh of grey-area issues relating to end of life.
The subtly-shaded minds of Dr. Timothy Quill and Dr. Robert Arnold, both national experts in Physician Assisted Death (P.A.D.), are well-
suited to delineate the complexities and help others draw their own conclusions.

On a theoretical basis, Dr. Quill is in favor of P.A.D. — he was the main plaintiff in the Supreme Court case challenging the law prohibiting P.A.D., Quill v. Vacco —and Dr. Arnold is opposed to it.

But at Monday night’s DeVos Medical Ethics Colloquy presentation on “The Ethics of Physician Assisted Death” hosted by Grand Valley State University at the Cook DeVos Center for Health Sciences, it was difficult to tell where either presenter stood. Each was skilled at giving weight to all the pros and cons of P.A.D.

As Quill himself said during the question-and-answer period, in reality the two are not that far apart. Arnold added, “I was more against it when I started than I am now.”

Quill v. Vacco, a 1997 case, upheld the State of New York’s right to ban P.A.D. Arguments were based on equal protection under the law, and whether the prohibition against physicians actively helping mentally competent patients end their own lives while allowing physicians to honor patient requests to remove them from “heroic measure” life support represented unequal treatment of those who had never been treated with such life supports.

Quill, two other physicians, and their three patients with life-ending illnesses — all three of whom died before SCOTUS took up the case — sued the state of New York. As the opinion written by Chief Justice William Rehnquist states, “They assert that although it would be ‘consistent with the standards of [their] medical practice[s]’ to prescribe lethal medication for ‘mentally competent, terminally ill patients’ who are suffering great pain and desire a doctor's help in taking their own lives, they are deterred from doing so by New York's ban on assisting suicide.” All nine justices joined in the judgment which stated, “New York's statutes outlawing assisting suicide affect and address matters of profound significance to all New Yorkers alike;” therefore both allowing doctors to comply with patients to refuse or discontinue life-support measures, and disallowing doctors to agree to helping patients end their lives were applied equally.

The opinion did not, of course, make any judgments about whether a state could pass legislation that allowed P.A.D., and five states have done so: California (most recently), Colorado, Oregon, Vermont, and Washington state. Washington, D.C., has as well, while Montana has legal P.A.D. due to a court ruling.

As it played out, however, P.A.D. was less the focus of the colloquy than an impassioned discussion of how physicians, and the broader culture, need to devote more time and energy to the process of dying.

Both Quill and Arnold said that, even in the case where someone is directly asking for assistance with ending their lives, it is of utmost importance to focus on what is behind their request. “Non-abandonment” was a phrase both used often. “Some of what they’re asking for is to have a discussions where you let them know that you’re going to be with them if the going gets rough, you’re willing to take a pledge of non-abandonment,” Arnold said.

Both also stressed that doctors should be more conversant with palliative care. Palliative care is defined by the World Health Organization as “an approach that improves the quality of life of patients ... with life-threatening illness, through the prevention and relief of suffering by... early identification... and treatment of pain and other problems ...”

There are any number of tools available in palliative care, and Drs. Quill and Arnold said that use of them may address some of the background fears of patients who request P.A.D.
Quill also noted in all honesty that the use of heavy pain-relieving drugs and sedatives toward the end of life, a common practice in hospice-type care, may have the effect of allowing the patient to die with dignity.

Arnold, who started out his presentation drawing the distinction between P.A.D. and physician-assisted suicide — in the first, the doctor supplies the means but the patient follows through with the act itself, whereas in the second, the doctor performs the act, though both require consent — felt strongly that more emphasis should be placed on training doctors.

“In the United States, we don’t do a very good job of having emotionally difficult conversations, so there’s no reason to believe that physicians should know how to do it. If you don’t teach them how to do it, they’ll never do a good job,” he said.

Quill presented both before and after Arnold, and he showed one part of a video of a young resident who found out he had a huge mass on his chest. Going through chemotherapy, he had “every problem you could possibly have,” Quill said, and the resident seriously considered P.A.D. He spoke about it intelligently and explained the comfort he felt knowing it was a possibility.
In the second part of the presentation, and video, the resident looked sicker and discussed more seriously his desire to have control over his death if life became not worth living. Eventually, Dr. Quill sought out for him the best experts in the country, who advised that he needed to have the mass removed surgically. The patient recovered and is now thriving, but Quill commented, “Would I have helped him? You bet I would.”

Arnold explained, “There is this fantasy Americans have that death is optional. It’s all about not quitting fighting to the end because a miracle will come. But then there is this tension over control, with people saying, if I can’t get back to normal, then I want it to end quickly. We have little ability to live with uncertainty and to find meaning in uncertainty and inaction. In health care we promote that.”

Again, both agreed that it is critical to let terminal patients know both what you will do for them and what you cannot do.

The Medical Ethics Colloquy is transitioning away from funding by the Richard and Helen DeVos Foundation, and would appreciate assistance. To do so, visit ethics.

The proceedings were recorded and will be available for viewing in a few months at