Thursday, November 20, 2008

Dr. Diane Meier interviewed about why she opposes assisted suicide.

Diane E. Meier, MD, director of the Center to Advance Palliative Care in New York, a professor of geriatrics and internal medicine at the Mount Sinai School of Medicine and the school’s Catherine Gaisman Professor of Medical Ethics, talked to HemOnc Today about the difficulty in diagnosing depression in terminally ill patients, her reasons for switching sides in the assisted suicide debate and overlooked issues in medical ethics.

Meier responds to the underdiagnoses of depression as being a factor for assisted suicide by referring to the recent Ganzini et al. study on depression and assisted suicide in Oregon:
It is tough to measure the presence of clinical depression in people who are seriously ill. The usual diagnostic tools we use to detect major depression are things like weight loss, change in appetite, or change in sleep patterns, all of which are affected by the illness the person is living with. ...Then the criteria that we have to use to identify serious depression in the seriously ill are narrower, such as things like a sense of hopelessness, guilt, rumination or inability to take any pleasure in life. You can see how those are more subjective than things like having lost 10 lb and not eating and not being able to sleep. Nonetheless, those are the criteria that we have to use in this particular medically ill patient population. So the fact that 15 patients met criteria for depression and 13 met criteria for anxiety, (Ganzini study) in a way, you have to be surprised that it wasn’t all of the patients given how inclusive the criteria were. ...

Meier was then asked - Is it possible to be clinically depressed, but still make a rational decision to die? Meier responded:
That is where there is a lot of debate in the field and I don’t think there is a right answer. Many people on either side feel very strongly about their position. ...

My view as a clinician would be that if a patient approached me — and it’s not legal in New York — for help in dying and I identified signs or symptoms of depression, I would not even consider assisting them and would strongly encourage them, bordering on insisting, that they accept treatment. And I would usually offer a combination of psychopharmacology and psychotherapy or counseling.

Meier was then asked - Does it make a difference if they’re depressed and making this decision? They’re already terminally ill. ...Meier responded:
... every one of us is going to die and we don’t know when. But there are major risks to helping people ...whose problems can be addressed with tools within our reach, established and safe psychopharmacology or effective and safe counseling methods. To assist people to hasten their death in that circumstance smacks of … almost an indifference to the genuine needs of patients. Particularly in an environment of intense cost-containment pressures and an intense financial crisis in health care, anything that makes it easy to stop taking care of someone whose problems are challenging and might be expensive to address, such as depression and psychotherapy for depression …
Yes, it is a lot easier and faster to help them kill themselves but it is absolutely wrong. Our job as physicians is to convey to our patients that their life is precious to us as physicians. How will patients ever trust us and be persuaded that our goal is to do our best by them if we are convinced during periods of depression that their life is no longer worth living?

She was then asked about her change in position, from supporting assisted suicide to opposing assisted suicide. Meier said:
I was younger and less experienced when I was an advocate of legalization and thought about it primarily as a medical ethical issue: that is, the rights of individuals to self-termination. The more experience I had as a physician taking care of very sick, fragile people with multiple illness who had all kinds of physical and emotional symptoms, all kinds of stress on their families, all kinds of financial challenges, it became clearer and clearer to me that it was impossible to meet the criteria for assisted suicide. ...

You have to make public policy based on your average doctor and your below average doctor, because not every doctor is way above average and yet this policy applies to every physician in Oregon and Washington now, many of whom are not adequately trained nor sophisticated enough to handle the nuances of this request, nor to identify and treat depression. We are notoriously bad as a profession at identifying and treating depression.

Meier was then asked if she would forsee a day when the instruments did exist to make determinations for assisted suicide? She said:
I do not know if I can answer that. Public policy is a fairly blunt instrument — it has to apply to the entire bell curve of patients and their physicians. ...I’m not sure I could ever foresee a time when every physician could go through this complex differential diagnosis when a patient approached them for aid in dying. That makes me very nervous because this an extremely vulnerable, extremely costly patient population.

Meier concludes her interview by stating:
... I feel that the harm to trust of the public in the medical profession is potentially enormous if doctors begin to take a routine role, whether it’s a separate specialty group or all doctors who take care of seriously ill patients, that you cannot always trust doctors to be on the side of your life. That might be too big of a price to pay.

The other point I should make is that it is a tiny, tiny fraction of people dying in Oregon who either seek a prescription or use it. We ought to remember where the really big ethical issues are in health care in this country. It is about access to care. It is about equity. It is about quality. It is not about a right to assisted suicide. Sometimes I get frustrated that this seems to be a sexy topic, but in the big picture it is not an important topic. The important topic is making sure everyone has access to decent health care. I wonder why that is not what we’re writing about all the time as opposed to something that is relevant to a minute fraction of people with serious illness in the United States. We are counting angels on the head of a pin while the ship is sinking.

The importance of the Meier interview is that Meier puts the experience of caring for the terminally ill and the frail into the light of the person. She is caring for people who are not just physical beings. These are complicated decisions and to add assisted suicide to the mix of medical care will result in a weaker and less caring medical system.

Link to the interview with Dr. Diane Meier in Hem Onc Today:

1 comment:

Secular Heretic said...

We have the same problem here in Australia. A group of politicians and in particular Dr Nitschke want to make euthanasia legal.

The forget that there is no such thing as a "right to die." A right is a moral claim, and we have no claim on death—death has a claim on us.

I've written about it on my blog.