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- [00:02]
Bari Weiss
From the Free Press this is honestly and I'm Bari Weiss. One of the most complex medical, ethical, moral, religious questions of our era is that of physician assisted suicide, also known as medical aid in dying or maid. Eleven American states and Washington, D.C. have legalized some form of maid for terminally ill patients and my state, New York might join them. Over the summer, a Medical Aid in Dying act passed New York State Legislature. It's now sitting on Governor Kathy Hochul's desk as she decides whether or not to sign it into law. Under the proposed bill, terminally ill adults with a prognosis of six months or less to live would be able to access a prescribed self administered life ending medication. Now supporters argue that this is a compassionate option, one that can relieve people of immense pain and suffering, allowing them to choose when and where they die and to do so surrounded by loved ones. But opponents see it as a violation of physicians fundamental oath which is to do no harm. They also worry that while access may begin narrowly, it could expand over time to include people seeking death for reasons other than a terminal illness, such as mental suffering or simply a desire to stop living. And they're not crazy. Cases like this have already occurred in Belgium, the Netherlands, Canada and Switzerland. My producer, Rafaela Siewert, sat down with two experts who see this topic very differently for a heated debate. David Hoffman is a healthcare attorney, clinical ethicist and professor of bioethics at Columbia University. He argues that hypothetical future abuses shouldn't outweigh the needs of terminal patients in the now. Dr. Lydia Dugdale is a physician, a medical ethicist and a professor of medicine at Columbia University. In her view, legalizing this practice of physician assisted suicide risks undermining the responsibilities of governments, medical systems and families to care for the mentally ill, the poor and the physically disabled. She fears that the potential for excessively expanded access over time is simply too great. I am among the many Americans who feel torn about this issue. I don't know what the right answer is, and I can see both sides, which is why grappling with the nuances of this subject is so very important. This is an urgent debate you will not want to miss. Stay With Us. Honestly is proudly supported by the Jack Miller Center. At a time when our democracy faces real challenges, one question matters more than ever. Are we preparing the next generation to understand and uphold the principles that define America? At the Jack Miller center, they believe the answer begins in the classroom. Their mission is to revive the teaching of America's founding ideals, documents and history on college campuses. In K12 schools and beyond. Since 2004, the Jack Miller center has built a national network of over 1300 scholars who are bringing the American political tradition to life for students across the country. And through their Teach for Freedom campaign, they're working to reach millions more by 2026, our nation's 250th anniversary. Why? Because a strong democracy depends on informed citizens. The Free Press is really proud to partner with the Jack Miller center on Old School, a new podcast about how great books can change your life, hosted by the brilliant Shiloh Brooks. To learn more about their work or to get involved, visit jackmiller center.org Again, that's jackmiller center.org.
- [04:09]
Rafaela Siewert
Doctor Lydia Dugdale. David Hoffman, thank you so much for being here.
- [04:13]
Dr. Lydia Dugdale
Pleasure to be here.
- [04:14]
Rafaela Siewert
Well, we're here because right now in New York, there's a bill that is called the Medical Assistance in Dying Act. Eleven states have already legalized something similar, several European countries, Canada, and it has sparked an enormous debate about the medical and ethical questions. So I actually just want to start to get everyone on the same page and explain what this practice is that is commonly dubbed as medical assistance in dying or physician assisted suicide. We'll start with Lydia.
- [04:47]
Dr. Lydia Dugdale
Sure. So as it is legalized in this country, in the United States, physician assisted suicide, the old term or maid, which is the more common term, refers to a physician or in some jurisdictions, a non physician prescribed lethal prescription that a patient who has a terminal diagnosis, usually six months or less, can take at his or her own will to end life. And so it's just pills. You have to be able to self ingest, you have to have a terminal diagnosis. And that is what it is in this country. In other jurisdictions, it might be termed euthanasia, more accurately, which is a lethal injection. And it's lethal injection, like what happens to your dog when your dog is old and you take it to the vet to be put down. It's that sort of thing. It's also that the kind of lethal injection that is used for many prisoners on death row, that is the kind of maid medical assistance in dying that is done in several countries around the world.
- [05:52]
Rafaela Siewert
Let's go to the terminology question because I know, David, you and I have spoken about how different terminology is used and what the implications are. How do you understand the difference in the terms between physician assisted suicide and what's commonly referred to as maid medical aid in dying?
- [06:07]
David Hoffman
It's a critically important distinction for legal, ethical and clinical reasons. Let's start with clinical to call what a person who wants to end their suffering at the very end of their life by medication. The same thing as someone who wants to end their life because otherwise their life and their suffering will not end. The same thing is confusing, it's linguistically unnecessary, and frankly, it's disrespectful to people who are what we consider classically or conventionally suicidal, meaning those seeking death out of despair in order to end their life because it won't end otherwise. People seeking medical aid and dying by definition in the United States have a terminal illness. They have a prognosis of six months or less to live. The six months isn't the important part. It means it's the end of their dying process. And they are looking to end their suffering because their life is going to end anyway. So it doesn't so much matter what words we use. What matters is that we're able to distinguish between those who seek death out of despair because otherwise their life won't end and therefore their suffering won't end, and those who are at the end of their lives because they have one of a relatively small group of terminal illnesses and they're going to be dying soon anyway, and they want to use medication as a means of ending their suffering so that they can exercise some control over something that is otherwise uncontrollable for the purpose of having a death that is three things, safe, certain, and painless. And I'll shift from the clinical to the legal. When we talk about a law that facilitates this, we're talking about a law that is removing an impediment that was created by law in the first place. And so the notion that that patient needs the state, the government, society, to put a gatekeeper between them and chemical formulations, medicines that can give them a safe, certain and painless death, just serves no purpose legitimate from a legal perspective, because every law has to have a rational relation to a legitimate state interest. That's what this debate is about.
- [08:43]
Rafaela Siewert
I want to give Lydia, you the opportunity to respond before we get into exactly what this New York bill is making legal.
- [08:49]
Dr. Lydia Dugdale
Sure, I use the language interchangeably. I do think physician assisted suicide or assisted suicide is probably the most accurate, because suicide has always meant the taking of one's own life. That's what it means etymologically. So to sort of redefine suicide as being the kind of death that is only taking your life when you are deeply in despair. It's just a contemporary. It's a modern falsehood. But there are sort of three things I want to say about the language of Physician assisted suicide. While I'm perfectly happy to use language interchangeably for the purpose of this conversation, the first is that the term that has long been in use before Canada legalized maid in 2016 and put that term in the vernacular is physician assisted suicide. And so many, many advocates have used that term. And here I'm thinking of someone from your own profession, David. Judge Richard posner from the 7th District Court in Chicago, now retired, very strong advocate of legalization. And the term he used very liberally is physician assisted suicide. So just to put it out there that this is. It's not like, you know, the pros say one thing and the cons say another thing. It's language that's used across the board. And in fact, I know major media outlets routinely use the language interchangeably. So that's one point I wanted to make. Second is that the nonprofit organization that is leading the way, and I think spending about $20 million a year to, in the effort to spread legalization of aid in dying or assisted suicide in US States is called Compassion and Choices. It's a brilliant name. Who doesn't like compassion and choices, especially at the end of life? But it's a rebrand, right? And what is it a rebrand of? Well, previously it was called the Hemlock Society. Now, what does the Hemlock Society refer to? Well, Hemlock refers to Socrates, who died, who killed himself by ingesting poisonous hemlock. So the very name of the organization that sponsors legislation all around the country is in fact the Suicide Society before it was rebranded. Third thing I just want to say about this is that if you speak to a room full of middle schoolers about physician assisted suicide, which I've done, and you try to distinguish, if you don't use the language assisted suicide, and you try to distinguish the activity of maid from conventional suicide, they will all call your bluff. They'll all say, well, wait, the patient gets the prescription and then the patient ends his life. Isn't that suicide? Suicide is killing yourself because it's elective. Well, because the act of taking one's own life has always been understood as suicide. And so to try to redefine the act of maid as distinct from suicide, I think is a bluff. It's an important one for advocates of legalization, I think. But at the end of the day, it's really just a euphemism.
- [12:00]
David Hoffman
And I would only say what we have historically done and what organizations have done in the past doesn't speak to this modern moment, and we ought to be speaking to this modern moment, because people who are suicidal, as we conventionally understand it, not related to a terminal illness, not related to they're going to die anyway, not related. Those people need a special kind of help. And we ought to have words that enable us to distinguish between these two groups of people. That's very important. It's important for the third graders and it's important for the families of both groups of individuals who seek death for very different reasons and who need different kinds of help and protection.
- [12:47]
Rafaela Siewert
Well, let's move to the New York bill specifically, because we're sitting in New York in an elevator pitch. What exactly does it make legal and what is the criteria to access this practice?
- [13:00]
David Hoffman
So the medical Aid and dying bill in New York, which is working its way to the governor's desk and in fact there was some news about this this morning, is modeled on the law that was adopted in Oregon in 1997. There are some subtle differences and in fact there's some discussion about some tweaks in the New York law before the judge, before the governor signs it. But it is a law that removes that restriction that the Food, Drug and Cosmetics act put in place that required for the first time that this gatekeeper individual, a physician, had to give you permission to get certain chemicals right. Anyone can go into a hardware store and buy rat poison. You could use that to kill yourself. It's not a particularly effective or wholesome way of achieving end of suffering by end of life, but you can do that. Medicines, this concoction, this cocktail of ddmaph, that's the formulation that is in most common use, is behind this barrier because the government thought it was necessary to 1938 to protect people from unintended side effects of those medications. That's simply not needed when a patient is seeking these medications for medical assistance in dying. We have good data, lots of it, that outlines and describes the process by which clinicians decide who is an appropriate individual under their respective state laws to receive medical assistance in dying. And then what formulation of medication is most appropriate. Also, what route of administration is most appropriate with all of the safeguards that have been selected by each of the respective states other than Montana.
- [14:59]
Rafaela Siewert
Lydia, can you tell us what the criteria is within this bill to access this option?
- [15:06]
Dr. Lydia Dugdale
So you have to be 18 years of age, you have to be able to consent to this. You have to have a terminal diagnosis, understood as six months or less to live. You have to be able to self ingest.
- [15:19]
David Hoffman
Some of the criteria vary from state to state with subtle nuance. For example, Oregon initially had A residency requirement that you had to be a resident of Oregon. Why? Because they feared at the time, I can understand why they would, that people would travel from around the world to Oregon, get their prescription for lethal medication, go to the beach, watch the sunset, take the medication, and bodies would litter the shoreline. Well, that never happened, but. So Oregon eliminated its residency requirement. Vermont eliminated its residency requirement. There are lawsuits going on right now challenging the legality, the constitutionality of the residency requirements in New Jersey, Colorado and I think maybe New Mexico. And if not, they're coming soon. So the residency requirement is itself suspect, both legally and morally.
- [16:17]
Rafaela Siewert
And the implication is that people from other states will make it sort of like a tourism element of traveling to the state to get the practice.
- [16:22]
David Hoffman
Right now, 20% of the US population is covered by a legal form of medical assistance in dying. When New York's law is put into effect and Illinois's law is put into effect. I haven't done the math, but that percentage will jump dramatically. That's another 40. Close to 40 million people.
- [16:42]
Rafaela Siewert
Yeah, a lot of people.
- [16:43]
David Hoffman
And all of that accomplishes the purpose of the equal protection clause of the U.S. constitution and the commerce clause that says that states ought not to make laws that interfere with the enjoyment of privileges by people of the entire nation, not by state.
- [17:04]
Dr. Lydia Dugdale
I just want to go back quickly to the idea that these so called safeguards in the bills and sort of one other distinction that we haven't mentioned about New York, which I'll just throw out there and then go back to what I just said, is that New York has no waiting period from the time that one makes the initial request to the time that one gets the lethal prescription. And some see that as a big concern that we know that many people who are despairing of life and, or facing imminent death and despairing of that fact might act impulsively. And so all states initially put in safeguards of waiting. Most of them said 15 days. Now that has been rapidly dwindled down. Less than half now have a waiting period of 15 days. I think it's actually only three states have a waiting period of 15 days. Oregon, that can be waived if death is imminent. Most states it's 48 hours now, so not a big time. But New York, no waiting period.
- [18:01]
Rafaela Siewert
So in some of the reporting I was reading, and I'm curious if this is accurate, is that people could request this and then hypothetically within 24 hours be administered.
- [18:11]
David Hoffman
No.
- [18:11]
Rafaela Siewert
You say no, you say yes.
- [18:13]
Dr. Lydia Dugdale
Well, there's no waiting period.
- [18:14]
David Hoffman
So there's no number of specified Days, no arbitrary barrier to a patient getting relief from their suffering. There is a functional waiting period tied to the process that the New York law, and in fact all of the state laws, and again all jurisdictions except Montana, because they just have a Supreme Court decision requirements, a process that inherently takes at least several days. Because you have to have a request orally, you have to have a request in writing. You have to have assessment by the initial physician, the attending physician for the patient. You then have to have a second assessment by someone that the attending physician refers the patient to.
- [19:02]
Dr. Lydia Dugdale
But David, why couldn't that happen within a couple of hours?
- [19:07]
David Hoffman
Because I don't know any physicians and you don't either. Who would want to rush this process when their ethical obligations are implicated, when their exposure to the penalties for not abiding by the law are implicated. And frankly, these are the same doctors. These are not a mysterious group of doctors who are beaming down from Mars. These are the same doctors that we all trust every day to provide medical care in every other area of practice. And by the time you get through the written request, the oral request, the two physician assessments, referral to a mental health provider, if either of the physicians thinks that there may be a mental health condition that is impairing decision making capacity, there are enough opportunities for either of the physicians or the patient to share information that requires further consideration and the law requires of the physicians. This will be an obligation of every physician who chooses to participate in providing evaluation and where indicated, prescription for medical assistance in dying. There's a whole process that is spelled out in the statute that requires description of all available alternative quality courses of treatment for that patient, including obviously palliative care, hospice care, other curative options that the patient hasn't considered.
- [20:42]
Dr. Lydia Dugdale
If somebody wants to die, they've already kind of made up their mind and so laying out the alternative options. I mean, that's a nice, it's a nice gesture. I just want to go back to a few things.
- [20:54]
David Hoffman
Can I just respond to that point?
- [20:56]
Dr. Lydia Dugdale
No, no, no. It's my turn now.
- [20:57]
David Hoffman
Okay, but you said something that really needs to be clarified.
- [21:01]
Rafaela Siewert
We'll go after, we'll see, then we'll.
- [21:03]
Dr. Lydia Dugdale
I think what's really important to this conversation is that this is a conversation where the lawyers are trying to put in safeguards. But what happens in practice is that physicians do not abide by all of these so called safeguards.
- [21:17]
David Hoffman
And I think that's ridiculous.
- [21:18]
Dr. Lydia Dugdale
It all becomes very subjective. It all becomes very subjective.
- [21:22]
David Hoffman
There are no reported cases, None.
- [21:24]
Dr. Lydia Dugdale
I think what's important to Emphasize here is that at the end of the day, the lawyers can put safeguards into place, but this is a practice that is being asked of physicians to make a judgment about whether someone is meeting all of these criteria. And I can tell you as a practicing physician that that is highly subjective. So, for example, the possibility of me being able to make an accurate diagnosis that someone even has six months or less to live is. We know that doctors are terrible prognosticators, Oregon used to keep track of this data. They used to keep track of the data from the time someone first requested a prescription to the time that they finally took the medication, the lethal medication. One patient was more than a thousand days, which is about three years. So to say, oh, you're definitely dead within six months is a very difficult thing to do. A second point I want to make about physicians being implicated in this is that there are a lot of pressures on physicians to execute care efficiently, to render treatments efficiently. And if it is possible to streamline a maid program and there is no instituted waiting period, there's no reason why a doctor is going to belabor this process if he or she doesn't have to.
- [22:46]
Rafaela Siewert
So I just want to make sure I mention what I'm hearing is there's this sort of informal, practical waiting period. But what you're arguing is that we need something written on the books because if it becomes common practice, this amount of time that you're alluding to that it takes to get things passed could actually shorten.
- [23:03]
Dr. Lydia Dugdale
Yes.
- [23:03]
Rafaela Siewert
Am I getting that right?
- [23:04]
Dr. Lydia Dugdale
Yes. And I think people will inadvertently end their lives who probably didn't want to. So, for example, my colleagues who practice in Canada, I've talked to them a lot about this. Some initially were big supporters of maid and even provided maid. And then some have decided not to provide maid anymore because they have seen so many concerns. What happens in all jurisdictions is that it ends up being the minority of clinicians who continue to practice. And so the more you do a particular procedure, speaking as a physician, the more accustomed you become to it, the less you have to think through it deliberately. And you look at the numbers in places where it's legal and it is a few doctors doing the majority. I think that that is noteworthy as well. I had a final.
- [23:54]
Rafaela Siewert
Can I ask one question? Are you opposed to the waiting period? I guess my question is like, why not? I mean, right now I know one of the amendments is a seven day waiting period on the New York bill. What's so wrong with seven days for someone to think it through?
- [24:09]
David Hoffman
Because it's not the appropriate functional measure of regulation of the practice of medicine. Seven days has no particular significance. Some people will need more time for their workup. Some people will need less. Some patients will be in horrific circumstances and may not live seven days, but will have to wait seven days in agony for no reason. Let's step out of this notion of a hypothetical universe where New York is the first place that anyone ever thought about doing medical aid dying. Because that's a fantasy. The reality is we have 25 years, almost 30 years of actual lived experience. And there are no reported cases of physicians ignoring procedural safeguards. None. I've done a study on it, got to write it up over the summer. And there are no circumstances, none reported, where any patient was coerced or subject to undue influence to, to obtain a prescription for medical assistance in dying. What that tells us is that the safeguards have worked to the point that Lydia raised about people show up having already made up their minds. Sure, that's what patients do, and that's why there are clinicians. So in addition to being a practicing healthcare attorney and bioethics professor, I'm a practicing clinical ethicist. So I consult with patients and with clinicians about end of life circumstances. And as an example, one of the patients that I consulted on from a hospice told his hospice nurse, I've had enough of this. Get me a gun. So if somebody asks for a gun, a you don't get them a gun, or you don't say, no, we don't give out guns, and then drop the subject. That is the opening, the invitation for a discussion, a consultation. That patient happened to suffer from one of the top five diagnoses that are found in the study that we did that's about to be published in the British medical journal copd, Chronic Obstructive Pulmonary Disease. And it turned out that if that patient wanted to end his suffering by ending his life, he could simply turn off his supplemental oxygen. So the initial presentation is just the invitation for, for a conversation.
- [26:43]
Dr. Lydia Dugdale
So let me just respond to a couple of things. First, you said that there have been no abuses, no reported abuses of physicians who have not followed protocol. And I hope I'm stating that more or less accurately. But we also know that although Oregon and Washington and California do report in some detail, many of the other states do not. And so we just have a paucity of data on the question of whether there are abuses. There are many, many scenarios where people with chronic illness have been denied expensive treatments, but instead offered by their insurance companies, drugs for medical aid in dying.
- [27:22]
David Hoffman
Name one.
- [27:23]
Dr. Lydia Dugdale
Yeah. There is a mother of four who is dependent on a very expensive infusion. When California legalized her insurance company, which was the state insurance, said we can give you medical aid and dying drugs for $1.20, but we won't pay for your infusion. Oh, no. There are a bunch of these stories now that has changed, I think, because so many of these stories stories went public. California backed down. But then there, I mean, there are stories in Canada of people with devastating neurologic diseases who have been encouraged to take maid rather than simply not true.
- [27:52]
David Hoffman
No, David, I know the doctor who took care of that patient.
- [27:56]
Dr. Lydia Dugdale
These stories are in the news. This is not, this is not a secret, David.
- [28:00]
David Hoffman
There's lots of stories in the news that are false. No, I know that doctor. So I know the patient.
- [28:05]
Dr. Lydia Dugdale
Do you even know the name of the patient that we're discussing?
- [28:07]
David Hoffman
Discussing the name of the patient? No. But that patient who has been discussing.
- [28:14]
Dr. Lydia Dugdale
There have been multiple stories of this. There was a veteran who applied to have a wheelchair ramp for her apartment in Canada and she was told by the Veterans Affairs Bureau that she could have made but they would not provide the wheelchair ramp. These stories are all over the news. So it's not a secret. So that is a concern. That is a concern.
- [28:35]
David Hoffman
That's not an instance where the safeguards failed because none of those patients got a prescription or got administration for medical aid and dying. And by the way, we should stop talking about Canada. I love Canada. I learned to rock climb in Canada. We are not Canada. We will never be Canada.
- [28:52]
Dr. Lydia Dugdale
We established at the outset the reason why people have concerns is because we are watching things go awry so magnificently in Canada that, that, that is what gives us pause.
- [29:03]
David Hoffman
It's simply not true.
- [29:05]
Rafaela Siewert
I want to get to what's happening in other countries and how it might be related to what could potentially or not potentially happen in the US I do want to stick on the New York bill just because there's a lot of questions with regard to the specific way it's written and who qualifies. I know one thing that is under debate is it is applied to terminally ill patients. I know there is some question about what actually constitute as. As terminal versus not terminal. I know. Lydia, you've written about this. Can you talk about that concern?
- [29:33]
Dr. Lydia Dugdale
So a terminal illness is, is completely relative because so many of our patients now are on therapies that if they stopped, they would become terminal. That makes so. So just as a, as an easy example, if someone is Dependent on insulin. Someone with diabetes is dependent on insulin, and they stopped their insulin, they would become terminal. And so that sort of a scenario, and diabetes is very common disease in the population, that sort of scenario suggests that the idea that something is terminal is very broadly considered.
- [30:09]
David Hoffman
That's fine in concept, but bears no relation to the reality of patients lived experiences. In the study that I just completed, the top five diagnoses, and just the first of them, cancer, accounts for over 90% of cases. The top five diagnoses are cancer, congestive heart failure, chronic obstructive pulmonary disease, ALS and Parkinson's disease. The instances of people refusing some treatment and then qualifying for medical aid and dying. I don't know of any documented cases where that was an issue, because, frankly, if you stop taking your insulin, you're gonna die anyway.
- [30:55]
Rafaela Siewert
I guess the concern, and I'm just reiterating how people are thinking about this, is say someone is, you know, potentially depressed or something else going on in their life, and they have diabetes, and then they, if it's not explicitly written into the legislation, they can say, oh, well, like, technically, as you're saying, if I stop taking my insulin, I am terminal, and therefore I can qualify. And this, I mean, I'm just trying to reiterate what the concern is like. How do you reckon with that?
- [31:22]
David Hoffman
That's the exercise of medical judgment that is required of the New York statute and every other statute. And those safeguards have worked with remarkable, remarkable consistency for nearly 30 years. There are odd and unusual circumstances are admitted, but that doesn't mean we ought to ignore the elephant in the room, which is the vast, vast number of patients who have one of those five diagnoses I just described who are suffering, certainly balanced against the abstract possibility that someone might refuse to take their insulin, which is their right, whether they have decisional capacity or not. We don't generally force that kind of a treatment upon a person.
- [32:14]
Dr. Lydia Dugdale
We don't force any treatment on someone who's competent.
- [32:17]
David Hoffman
And for that reason, the exception, the extraordinary circumstance that Lydia is describing as the abstract possibility, ought not to stand in the way of people who have one of these five clearly terminal diagnoses.
- [32:36]
Dr. Lydia Dugdale
David, those aren't all terminal diagnoses, though. They are not terminal diagnoses. The people live with those diseases for years. So again, all of this requires, as you say, medical judgment. But to say, oh, COPD is terminal, but diabetes is not, is a misrepresentation anyway.
- [32:54]
David Hoffman
But these are the diagnoses of the people who are getting medical assistance and dying, whether they should or shouldn't be, right? Well, if they shouldn't be.
- [33:03]
Bari Weiss
This is the problem, David.
- [33:05]
David Hoffman
This is the problem. If they shouldn't be. I am quite confident we would have heard. Heard about these documented, Documented cases in the US and we have not. And I've asked states.
- [33:15]
Dr. Lydia Dugdale
Let's just be clear about what goes on death certificates. What goes on death certificates is the disease that someone had prior to lethal ingestion, prior to swallowing the pills. And so if someone did have copd, regardless of whether they're terminal, stop the oxygen, stop the treatments, you will become terminal. Right. But regardless of whether someone is actually terminal, and again, doctors are bad prognosticators, then of course that's the disease that goes on the death certificate. I just want to bring up one thing.
- [33:44]
David Hoffman
Doctors are not bad prognosticators.
- [33:45]
Dr. Lydia Dugdale
Oh, my goodness. David. There's data on.
- [33:47]
David Hoffman
I think you're giving your colleagues a bad treatment on situations where a patient comes to them having exhausted curative treatments, because that's the definition of terminal. I think you're being disrespectful to your colleagues.
- [34:03]
Dr. Lydia Dugdale
There are data that show that doctors are bad prognosticators.
- [34:06]
David Hoffman
That's what I am referring to. Not about this. That's a misrepres.
- [34:10]
Rafaela Siewert
I know there was something else you wanted to do.
- [34:11]
David Hoffman
Prognostication is difficult. It's not difficult when you have a patient who, as a clinician, you have determined has one of these five diagnoses, has exhausted all available curative treatment. That is not a hard exercise in prognostication.
- [34:26]
Dr. Lydia Dugdale
I gave you the data from Oregon, where many, many, many cases are reported to have been, had, had more than six months elapsed from the time people asked for the drugs and to the time they took them. Oregon no longer reports this data. So we just don't know. There's so much data that aren't reported. Here's the concern. Here's the concern. My concern that we haven't talked about with the New York bill is that there is no requirement for mental health screening. Okay, let me just.
- [34:54]
David Hoffman
That's false.
- [34:55]
Dr. Lydia Dugdale
No, that's false. There is no requirement. This, again, is physician's judgment. And specifically, if the physician has reason to think that the patient requesting MAID has impaired judgment, so that is who then is referred. Now, let me just throw some things out there. Most patients seeking assisted dying, maid, assisted suicide. Most patients have cancer. Most patients are elderly. You put that together. Most of those patients, by virtue of being a part of those demographics, are likely to have major depressive disorder. I'm A primary care doctor. What we know as primary care doctors is that, sorry to throw my own specialty under the bus again, but we are not very good at diagnosing depression. So when you study elderly on a population level, yes. High, high rates of depression. When you study patients with advanced cancer, high, high rates of depression. These are the people seeking assisted suicide, and yet they are not routinely being screened for depression. It's only if the physician has concern that the patient has impaired judgment. So let me just give you one number. In Oregon in 2024, 607 people sought these lethal drugs through the Death with Dignity act, and only three were sent for psychiatric evaluation.
- [36:24]
Rafaela Siewert
I think a lot of laypeople will hear this and say, obviously, if someone has a terminal illness or even severe suffering, they probably are also going to have depression, because it's depressing to have those things. And so my question is, even if people are asked to screen for this, what is the practical difference? Because some might say, well, they're dying anyway, like, we might as well give them, because they're asking for maid.
- [36:46]
Dr. Lydia Dugdale
The difference is that depression is often treatable, more often than not. And so maybe they wouldn't want to die.
- [36:53]
Rafaela Siewert
I see. Even if they have the terminal illness. Do you want to respond?
- [36:56]
David Hoffman
And physicians, under the New York law and under the law in every state that has a law, are obligated as an exercise of their professional judgment to evaluate the patient for depression and any other mental health condition that would impair their ability to exercise decisional capacity to choose what is right for them. Because all we're talking about is giving patients the ability to choose what is right for them. And frankly, it should not surprise anyone that an elderly patient with cancer who's been told that there's no additional available curative treatment for you is going to be a little depressed. That's not the issue. The issue is whether the patient has decisional capacity, whether they understand the components of the assessment that the physician has done, whether they understand the nature of their diagnosis, and whether they're making a reasoned judgment on their own behalf to forego the additional weeks, months, or even years of life that might hypothetically be possible because they're suffering.
- [38:11]
Dr. Lydia Dugdale
Because why should it be a physician who does this? So any.
- [38:14]
Rafaela Siewert
As opposed to.
- [38:16]
Dr. Lydia Dugdale
As opposed to anybody else. I'm just thinking, why should the physician be the agent of death?
- [38:20]
David Hoffman
Because some physicians want to, and physicians who don't want to don't have to.
- [38:24]
Dr. Lydia Dugdale
This is not legalization, is not being pushed forward because doctors want to kill patients. That is not why this legislation is being put forward. This legislation is being put forward by the less than 1% who want to be able to control the timing and manner of their death, to have it safe, certain and painless. When in every US State conventional suicide is legal, you can go to Walmart and buy a gun, it will be safe, it will be painless, and it will be certain. And so why should a physician, physicians who have committed to healing the sick, physicians who have committed to non abandonment, not killing their patients since the time of Hippocrates, why is it that physicians should be the agents of death? And I have an alternative proposal, but I'm just wondering why you think, okay, so what would be better than having doctors do this?
- [39:10]
David Hoffman
So there are a great many doctors we know from nearly 30 years of experience who are willing to assess patients and where appropriate, prescribe for patients to self administer medication to end their suffering by ending their life. That's a fact. If there were a shortage of physicians, then we could look to alternatives. One alternative that I presented at a recent conference in Where Were We, Oregon is the development of a new profession of interventional clinical ethicists. This individual would have the training of a level three advanced EMT or paramedic and a master's degree in bioethics. And that individual could be the alternative prescriber if there were a need. But there's no need. There are more than enough physicians who, who are willing to engage in this kind of an evaluation and treatment of patients at the end of life to assess them, to determine whether medical assistance in dying is both appropriate and legally permissible under the statute. Physicians who don't want to be involved in this, who want to lean on the pronouncement of Hippocrates, they can do so. No one is ever, ever. Nothing in this law creates a single obligation for anyone on the day that it is adopted. It is entirely, entirely voluntary and an exercise of medical judgment by the individual physician.
- [40:43]
Dr. Lydia Dugdale
I was just going to say, when Washington D.C. was considering legalizing physician assisted suicide, which they did, as you said, there was a picture and an article on the front page of the Washington Post Post that said it's really a law to get rid of old black people. And I do think, which is absurd if you look at the numbers, I do think, well, most places where it has been legalized are largely white. But that also goes to underscore that this tends to be something that is taken up by the vast majority of people in this country who are educated, have insurance, are white. And so it's really a question of the less than 1%. It's an elite question for which we spend a lot and a lot of airtime, if you will.
- [41:29]
David Hoffman
And the problem of access to end of life care generally is something that our society should take up, but we shouldn't be delaying, providing relief by removing a legally imposed impediment for those who are absolutely suffering at this moment. As we take up the issue of providing greater access to palliative care, to hospice care and to ending life care, including medical aid and dying.
- [41:59]
Rafaela Siewert
Before we get to some of the questions of economic disparity, which is sort of like what seems to be coming up, I just want to take one more beat on a subset of a conversation within the mental health component. And I know you don't want to talk about Canada. However, so much of the general population, they look at stories from Canada, Belgium, the Netherlands, and they see this scenario that plays out. And the concern is this legislation is legalized in maybe a more narrow way, but over time it potentially opens with regard to access. We had reporting from a Free Press writer, Rupa supramagna, about these two women in the Netherlands. One was 28 and one was 29 and they both elected made in the Netherlands. One had, I believe, autism, adhd, depression, anxiety, chronic fatigue syndrome. The other one had also depression, personality disorder, and they chose to die. And you know, people worry that we start with the narrow use of terminal illness, but over time it gets to a place where 28 and 29 year olds who are depressed have this option. And I'm just, I would love for you both to contend.
- [43:10]
David Hoffman
Automatically changes this law in New York or the law in any U.S. jurisdiction.
- [43:16]
Rafaela Siewert
Well, I think it's a social question.
- [43:18]
Dr. Lydia Dugdale
In Europe.
- [43:19]
David Hoffman
No, I, I'm your question.
- [43:21]
Rafaela Siewert
Yeah.
- [43:21]
David Hoffman
In Europe they have made a different set of societal decisions about where patients ought to have access to medical assistance in dying. The Netherlands is one case. Switzerland is another case. Those are important, important to be aware of so that we can more clearly understand that we are not either of those systems and neither are we. Canada, where there's an enormous debate about patients having access to medical assistance in dying, where a mental health condition is the sole underlying condition. That's the phrase that's used. It hasn't even gone into effect yet and can't go into effect any sooner than 2027. So again, we're talking about prejudicing individuals who have an immediate real need for relief today in service of a speculative concern about other people that doesn't even exist yet.
- [44:20]
Rafaela Siewert
Do you worry at all about the sort of like, cultural consequence of. I know you're saying it's speculative and I understand, and I take that. But I think a lot of people would say over time that it normalizes and some might even say there's some like romantization or social contagion. And I'm just curious if that worries you at all or not at all.
- [44:41]
David Hoffman
It doesn't because this is a legally regulated activity. Vast, vast parts of the practice of medicine are subject only to accepted standards of medical practice. Some areas of medical practice have been subject to legal scrutiny and legal restriction. Abortion obviously is the first one that comes to mind. And it is for that reason that I don't have a concern at all that this situation is going to, of its own gravity, turn into something else. There will be discussions and have been in the United States since the Oregon law was passed in 1997 about whether there ought to be incremental changes and improvements. Those all get debated and Lydia and I will be back here debating all of those proposed changes. And they will not happen mysteriously or of their own momentum because that's not how the law works. It's one of the areas where the law, medical practice, and ethical practice work together really kind of well.
- [45:48]
Dr. Lydia Dugdale
But since, since assisted suicide has been legalized in the 12 jurisdictions, there have been additional legal efforts made to expand access. Right. So waiting periods have shrunk to 48 hours in most places. No waiting period, if death is so called imminent. In Oregon, there's now access to the lethal prescriptions by mail or Courier. In one state, it's been extended, expanded to APRNs in at least one, if not two states. I think two residency requirements have gone away in Oregon and Vermont, as we said. So it is true that since legalization, that has expanded. And the thing that I think is most worrisome is California in 2024. Now, that law did not pass, but there was a bill put forward to expand maid access to non terminal conditions. So the expansion to non terminal conditions, of course, then brings all these other questions to the fore. How do you define suffering? What suffering is enough to be able to cross the line?
- [46:52]
David Hoffman
So the points Lydia has made about incremental improvements in the laws as experience has gathered and as different states have entered into this discussion exactly proves the point is that none of this is the proverbial slippery slope. These are deliberate, widely debated improvements from my perspective, maybe not from others perspective, but they're changes that are made in order to address specific circumstances that we understand better by Virtue of our experience.
- [47:28]
Dr. Lydia Dugdale
I appreciate that you say that they're widely debated because I believe the Illinois bill, which is waiting to be signed by Governor Pritzker was pushed through in a food safety bill or something at 2am on a Tuesday. So I don't know that they always get the attention that they need. I just want to bring up one other point going back to the mental health question and something that you were talking about a little bit ago. There is a researcher at Oxford University who has looked at the rise of so called conventional suicide in jurisdictions where physician assisted suicide has been legalized. And there is always a concomitant increase in, you know, plain old suicide in places where MAID is legalized. And, and he does, he's very careful to say this is not causation, this is just a correlation. But when the taking of one's own life becomes normalized, it has implications for the rest of society. And there is a phenomenon known as the Werther effect of or suicide contagion that has been well documented by sociologists studying Marilyn Monroe's high profile suicide years ago. But that same phenomenon of when a very a famous person dies by suicide, many other people with in a similar demographic attempt suicide or die by suicide. This idea of suicide contagion has been shown to happen in jurisdictions where maid is legalized.
- [48:56]
Rafaela Siewert
I'd like to throw in two curveball questions. There's this question of what is in the bill and what the criteria is. As you read a lot of these op eds on this issue, a lot of people will come up with all sorts of questions about who should be included. And some will say why shouldn't someone who is suffering a severe illness but is not terminal, why should they be forced to live with that? And I'm curious how you contend with that.
- [49:22]
Dr. Lydia Dugdale
Well, this is why I'm opposed to legalization, because I think that that is so difficult. I'm a physician who has never practiced in a jurisdiction where aid and dying is legal. And yet I have been asked by many patients to help them die. And it's for all different reasons. I'm lonely. And there are more than 3,000 people in Canada last year. One of the reasons they said they were seeking MAID was because of loneliness. People have told me they're lonely, they don't have family members, they have no one to care for them. I've had patients tell me because of their pain. And you can say, well, why weren't you treating the pain? Complicated questions. But once the pain was treated, they did not want to die. People who didn't know how to afford their medical bills said they would rather die. These are my own patients.
- [50:12]
Rafaela Siewert
So you're saying giving the option disincentivize us solving the other problems?
- [50:15]
Dr. Lydia Dugdale
Oh, absolutely, absolutely.
- [50:17]
David Hoffman
And that's why physicians have to exercise their medical judgment in determining whether a patient is appropriate medically, ethically, and legally, according to the safeguards written into law, to receive one of those prescriptions. And those safeguards have worked very well. And notwithstanding the fact that we are in the United States. Let me respond that the loneliness argument with regard to Canada is completely fallacious and unsupported. Yes, loneliness is reported as a condition at the time of death. No one in Canada has ever gotten medical aid in dying. It would be illegal to do so.
- [50:58]
Dr. Lydia Dugdale
That's correct.
- [50:58]
David Hoffman
Simply because they are experiencing loneliness.
- [51:01]
Dr. Lydia Dugdale
No, but one of the reasons they state. Yes, one of the reasons that the physicians state that they were seeking it
- [51:07]
David Hoffman
can never be the reason that any physician in Canada, let alone any physician in the United States, even entertains a discussion about providing medical aid and dying. It is, as with my patient with the request for the gun, an invitation for good medical practice, something that every physician I've known, and I've known many, many physicians in my career is entirely capable of, because really smart people become doctors.
- [51:38]
Dr. Lydia Dugdale
But if you have an irremediable illness or an advanced illness and you are desperately lonely, why not just, you know, hasten it all along?
- [51:48]
David Hoffman
Because no doctor will facilitate that. No, because you have the terminal standards.
- [51:52]
Dr. Lydia Dugdale
No, you have the terminal illness, so you qualify.
- [51:55]
David Hoffman
Then that is not the reason someone is eligible for medical assistance in dying.
- [52:00]
Dr. Lydia Dugdale
But Canada just asked their doctors who are providing maid to report the reasons that the patients are seeking maid. And loneliness is one of the criteria that they offer.
- [52:10]
David Hoffman
There are bound to be lots of people with cancer and congestive heart failure and congestive obstructive pulmonary disease and ALS and Parkinson's disease, who are feeling very lonely and lots of other things that has nothing to do with why they're seeking medical assistance in dying.
- [52:27]
Rafaela Siewert
If I can maybe characterize both arguments back to you and you'll correct my characterization, I think what I'm getting from you is that you're concerned about protecting both people who have other underlying issues, the mental health, but also people who are poor or disabled. And what I'm hearing from you is there's a lot of people who are living right now in the present that are really, really suffering and are going to die and therefore should have access. And this is sort of where the the tension lies. I do want to turn to circle back to the issue of poverty. I know as we established that the majority of people using this are not in that socioeconomic bracket. One of the concerns, however, is that as this becomes more accessible or more normalized in society, maybe families or hospital systems might pressure or coerce is too strong, but that the option in and of itself will then disproportionately impact people who don't have other means to potentially pay for their medical treatment and so forth.
- [53:25]
David Hoffman
But we have 25 to 30 years of experience on this question from three states, though we have 25 to 30 years of Experience among the clinician community and there have been no such incidents. I went looking for them. We surveyed every organization that works in patient advocacy both for and against access to medical assistance in dying, and we have found zero documented cases.
- [53:53]
Dr. Lydia Dugdale
But if you ask the people whose job it is to approve the stake, whether they did a bad job, you know, approving the stake, they're not going to tell you that they themselves did a bad job, right? I mean, if you're the regulator, if you're the provider, you're not going to then, you know, out yourself for doing a bad job. But again, New Mexico, one of the poorest states in the country, doesn't report. We don't know. I mean, it's already one of the poorest states in the country that has expanded to allow APRNs, advanced practitioners, nurses to prescribe. And there's a shortage of physicians in New Mexico. It's an incredibly poor population. It includes a large native population. And we have no data. We just don't know about what the stats are. We have data from California, Oregon and Washington that is highly reliable.
- [54:39]
David Hoffman
We know that the physicians exercising their independent medical judgment regarding every patient that they encounter who seeks care or consultation about end of life options is doing their job as a physician. And it's outrageous to me that any physician would say, oh, we can't trust physicians to exercise good medical judgment about whether a person is seeking medical assistance in dying because they're poor. But by the same token, we shouldn't act in an overtly paternalistic or maternalistic manner and say because you're poor or because you have a disability, we have to protect you from relieving yourself from suffering. That's unkind and unfair.
- [55:27]
Dr. Lydia Dugdale
But then there are lots of stories from Canada if you want to go there, which I know you don't want.
- [55:32]
David Hoffman
I don't, because I don't live in
- [55:34]
Dr. Lydia Dugdale
Canada, People can't afford their rent. But it paints the picture of what happens when more than 5% of your population dies this way. People can't pay their rent, they have a condition that qualifies them. They can't afford their medications, they can't afford their treatments. All of these are reasons that people are seeking maid alongside having a condition that qualifies them. And so I think we have to be careful to say just cause we don't have data in this country doesn't mean it's not a phenomenon. I have had patients myself tell me they would rather die because they can't afford their treatments.
- [56:05]
David Hoffman
I have no objection to expanding the social safety net so that more poor people and more people with disabilities have access to more resources. But the inability of our society to make that decision at the level that Lydia and I might think is appropriate is no reason to condemn the people who have a terminal illness. Overwhelmingly untreatable conditions. The five I mentioned that they need to suffer because there might be some poor person in New Mexico who's feeling pressured to end their life because they're poor. That's just irrational. And that's not my opinion. That's the opinion of Peter Singer, who I discussed this very question with a year and a half ago, who said that in any ethical debate between an immediate risk of harm to a particular individual and a speculative protection from harm for some hypothetical individuals, the person suffering immediate harm has to get first consideration because they are real and they are sitting in front of us and we need to be able to relieve them of this barrier that the law created in the first place.
- [57:31]
Bari Weiss
More with Dr. Lydia Dugdale and David Hoffman after the break. Stay with us.
- [57:44]
Rafaela Siewert
My understanding is that only people who are 18 or above legal adults can access this. As I was reading about this, I learned that in the Netherlands and in Belgium, individuals under 18 can legally access given parent consent and some other criteria should minors ever have access. And I'm asking in the case of minors with terminal illness who are in the exact situation that you're talking about with tremendous pain. How do you both think about that?
- [58:10]
Dr. Lydia Dugdale
Well, so maybe since you brought up Belgium and the Netherlands, let me just say briefly that Belgium is a great both. Both countries, but Belgium I'll just speak to first is a great example of how what was legalized in 2002 had very, had very strong safeguards and it was a very narrow set of people with irremediable suffering that met certain conditions, blah, blah, blah, blah blah. And since then, Belgium has expanded to include not only children but also patients with Alzheimer's patients, with other kinds of mental illness and all sorts of disorders, you know, trans patient who didn't like the way that the gender affirming surgery went, et cetera. All of these now are people who qualify for euthanasia, which is lethal injection in Belgium. So I think that, you know, if you want to use the language of slippery slope, if you want to use the language of rapid expansion, where does it go? It just keeps expanding, expanding. And then induced death or state mandated death, or state controlled death becomes the way people die. And I don't want to live in a world and I don't want my kids in a world where we die by killing people. That that becomes the norm. And I just think it's highly problematic. So no to, no to maid with for children and no to maid in general.
- [59:33]
David Hoffman
We don't live in Belgium. And it's very telling that the conversation in the United States as advanced by people opposed to access to medical aid and dying so often turns to Canada, Belgium, the Netherlands, Switzerland. There are lots of other places around the world, Spain, countries in South America. That's not what we're here to talk about. And it is misleading to bring those circumstances into the discussion about legalizing medical aid and dying in the United States, because that will never happen in the environment that we currently live in. And if that environment changes, that will be a conscious, deliberate decision of our populace. Not because somehow this is a contagion that will cross the Atlantic Ocean and infect the United States.
- [60:28]
Dr. Lydia Dugdale
But we could talk about, for example, anorexia nervosa. And their most psychiatrists think that anorexia is a treatable condition. But there is a physician in Colorado who has administered or given lethal prescriptions to I think, at least three patients with anorexia. And that is actually considered, you know, a form of mental illness to psychiatrists. We don't have assisted suicide for mental illness in this country, except that these women qualified for assisted suicide on one physician's assessment. You can see how messy it gets and how the possibility of expansion exists even if you try to keep the safeguards in place.
- [61:10]
David Hoffman
Again, children in Belgium, again, you're prioritizing the interests of a hypothetical group of people against the suffering of a defined, identifiable, very real group that are suffering today. Anorexia nervosa is our most compelling ethical issue in bioethics. And it is a difficult case. It is no part of any discussion about medical assistance dying in the United States. And the one case that is documented in Colorado where a patient with anorexia nervosa pursued medical assistance in dying, that the system worked, the safeguards held, and the patient didn't get her prescription. Sadly, she died tragically of her condition two years later.
- [62:01]
Rafaela Siewert
I just want to make one point, which is the reason I bring up these examples is one, because as people are thinking about the US legislation, they are reading these stories. So I understand why you make the distinction and why that's important. At the same time time it's very much on the minds of people and it's a point of fear. And beyond that, I think people would say, like, we're not that culturally different from people in Europe and, and beyond that, like we're all in the same social media world in the sense of, you know, a lot of these people who have take. Let me just finish this point. Who have taken their lives, they're posting about it on TikTok on Twitter and American women of the same age are dressing the same, shopping at the same places, like there's this sort of homogenization across the ocean. And so I definitely take your point, but I just wanted to explain why I bring that up.
- [62:53]
David Hoffman
Understood.
- [62:53]
Rafaela Siewert
Yeah.
- [62:54]
David Hoffman
That's why I'm here today. Because there is too much misinformation and misleading information being applied to the debate about medical assistance and dying in the United States that is confusing the conversation. The discussion in the United States, however fashion, and other social norms may migrate in both directions across the Atlantic Ocean. Our medical community, our bioethics community, our legal community has for now almost 30 years created very strong, very firm safeguards that are only modified on the basis of learned experience from actual patients being treated by actual physicians. And that is how it should be in the United States. We are as different as day and night from our European colleagues, as evidenced by the fact that we don't have a single payer health care system.
- [63:54]
Dr. Lydia Dugdale
David, what do you think the governor of Washington state and Oregon should do about the fact that conventional suicide is rising parallel to the increase in maid.
- [64:08]
David Hoffman
I think we should first define our terms more clearly so that we can have a discussion about suicide of despair by people who will otherwise not be relieved of their suffering because they won't die from ending the lives of people who are suffering who are going to die anyway. And I think we ought to address the issue of suicidality. And I think having clear vocabulary that enables us to distinguish between these two groups is the first most important step.
- [64:41]
Dr. Lydia Dugdale
But if you want to distinguish between the groups, doesn't it concern you that there's a correlative Increase in conventional suicide in jurisdictions where MAID is legalized? Or do you say, forget about the people who have suicidal thoughts of despair? Despair. We need to, you know, plow ahead with allowing those who are. You keep using this language, Interestingly, those who are dying anyway, when we're all dying anyway, like, mortality is 100% right? So that's not. That's not changing. But does it not at all concern you that there are competent increases in conventional suicide distinguished from what you're called, you know, what you're referring to as the suicide that qualifies or the. The dying that qualifies for maid? Is there an obligation for you and your colleagues and all of those in compassion and choices to also fund conventional suicide prevention programs? Because the legislation they're pushing is perhaps normalizing the taking of one's own life?
- [65:41]
David Hoffman
As you observed earlier, correlation does not equal causation. And it's dangerous to have a conversation where those two phenomena are interchanged. What we're talking about in the real present is people who are terminally ill because they have, for the most part, one of those top five diagnoses that I mentioned earlier that are no longer amenable to curative treatment. They are suffering. Now. We should not subordinate their suffering in order to address the suffering of people who are, as we classically understand the word, suicidal, because they need a whole different kind of help. And, yes, I think we as a society have an obligation to address the needs of both of those communities. No question.
- [66:34]
Rafaela Siewert
I think one of the strongest points related to what you're saying actually comes from my colleague Coleman Hughes, whose mother had a long struggle with breast cancer. And he wrote something for the Free Press that I want to put to both of you and actually ask, have Lydia sort of respond how you think about this. I mean, basically, he says, the only saving grace in my mother's case was that she died somewhat sooner and less painfully than she otherwise would have. And on her schedule, surrounded by family. This was a decision that didn't come lightly or quickly. She faced two choices. To die painlessly on the day of her choosing, surrounded by family, or to experience extreme and escalating pain for the next few weeks and then die at a random time, possibly alone. I guess I'm just wondering, like, from a personal perspective, like, how you grapple with this lived reality.
- [67:22]
Dr. Lydia Dugdale
Yeah, I get it. Right. I get it. Taking care of many, many dying patients, the desire for most people is to die at home, surrounded by loved ones. I completely empathize and agree with what Coleman's saying. There at the same time there's a. Well, let me say two things. First is that there is almost no pain we cannot treat in medicine now. Now that doesn't mean every jurisdiction around the world has access to that treatment, which is a problem. But there is almost no pain we can't treat, especially in places that are well resourced. And so some of the worst pain is actually cancer in the bones. And we can, and I am an advocate, when the pain is so extreme that we escalate the pain medication such that we render the patient unconscious because that is, it's the, it's the loss of consciousness then that brings relief. And so that kind of deep sedation where the patient may say, like, put me under and then bring me back in a day, like, give me a day of relief and then bring me back and let, let me kind of see how I am. That is a different option to, to, to death. But I don't know the specifics of what Coleman's mother endured. And so I don't, I don't want to try to speak to that. But I do want to say, the second thing I wanted to say is that in bioethics, which David and I are both bioethicists, medical ethicists, there's a, well, sort of worked out doctrine called the doctrine of double effect. And it comes from just war theory from the 12th century, 13th century. And it says that there are two possible outcomes. You aim at the good outcome. So there are two possible outcomes, which is we can relieve pain, but that pain medicine might kill you. Okay, you're aiming at the good while foreseeing the possibility of the bad. And then you increase the pain medicine proportionately to the pain. And so it might mean that increasing that pain medicine enough to take away the pain of a patient dying with cancer in the bones means that the patient then stops breathing. You're not going to then resuscitate that patient. Right. But you're increasing the pain medicine proportionately, recognizing that the bad outcome might happen. Importantly to this doctrine of double effect is that you don't pursue the illicit means the bad end to get to the good end. So you don't say, we want relief of pain, therefore let's kill the patient to get the pain relief. You always aim for the good, which is relieving pain. And you don't do that vis a vision, ending the suffering by ending the sufferer, but you can increase pain medication proportionately.
- [70:18]
David Hoffman
That's the double effect. Lydia accurately described it. And the double effect circumstance where you titrate up medication, typically morphine, to maximally address the patient's pain without direct regard for whether it will shorten the patient's life, is an appropriate management philosophy for some patients under some circumstances. And yes, we are better at treating bone pain in cancer patients than a lot of the suffering that attends the other diagnoses that are most common in medically aided dieting, principally Parkinson's, ALS and copd. For those patients, when they decide in consultation with their physician that the double effect or the palliative approaches to care aren't working, they ought to have access to medical assistance in dying as the final available means of relieving their suffering. The idea is just to get the law out of the way so that doctors and patients can make these decisions for themselves.
- [71:28]
Rafaela Siewert
One thing that I've been grappling with is the dividend, because I don't think there's a clear right or wrong in the sense of. On one hand, people would say it is compassionate to help people who are severely suffering and are going to die anyway because they're terminal end their life if they feel that that's their choice. On the other hand, you have people saying it's not compassionate to help anyone die under any set of circumstances. I mean, Ross Douthit writes about this. I mean, I pulled a quote cause I thought it was illuminating. I mean, he said the idea that a healing professional should include death in its battery of treatments. These are inherently destructive ideas. And I'm just curious. I think you probably both come to the table with different understandings of this, but outside of the legal framework, outside of like the purely in the doctor's office framework, like how you think about this choice as compassionate or not without realizing it.
- [72:20]
David Hoffman
Ross has referenced what we can call the Canadian model, where the physician is an active participant in the process. What we're talking about in the United States exclusively is just the law getting out of the way and not blocking the patient from the means that we know is the surest road to a safe, certain and painless death. And that's a patient choice.
- [72:49]
Rafaela Siewert
But isn't the physician always involved, physicians implicated?
- [72:52]
David Hoffman
Let me respond to that part of your polemic, please. We always face these dilemmas in bioethics where there's a conflict between two or more ethical principles. That is the definition of an ethical dilemma. And in everything we do in medical ethics, we are always striking that balance. We have no real absolutes in law or philosophy. The right to free speech does not give you the right to yell a fire in a crowded Theater. The right to keep and bear arms does not give you the right to own a tank or a nuclear weapon. Right. All rights are viewed in the context of their balance against other rights and responsibilities in the area of medical aid and dying. All we're talking about is removing what was intended as a protection in the Food, Drug and cosmetics act in 1938, the power of the prescription pad for people who don't need that protection and who ought normatively to have the ability to make this decision subject to the safeguards that the legislature acting on behalf of society has decided to put in place so that they can end their suffering.
- [74:08]
Dr. Lydia Dugdale
Okay, so just to respond, the physician is absolutely integral to the whole process of physician assisted suicide. The patient, if the patient is coming to the doctor's office for a maid prescription, the patient is absolutely asking the physician to be the agent of the lethal drug that will allow them to end their lives. So there's no other way to conceptualize it, to say that the doctor is not integral.
- [74:35]
David Hoffman
It's just false because the law has created that barrier.
- [74:40]
Dr. Lydia Dugdale
Furthermore, the nature of the law. You read the. Yes, but again, suicide, taking one's life, if you don't wanna use the word suicide, the act of taking one's life is legal in every US state. And there's no reason that a physician, or, I'm sorry, that a patient who wants to end his life can't just do it. There's no reason. So the physician does not need to be the agent of death now, and notably a state sanctioned agent of death, which I think is really important to flag because we also have a history of what it means to be a state sanctioned agent of death. You use the language, David, of rights and responsibilities. The rights and responsibilities of medicine has always been to restore people to health. We are not executioners, we are not agents of death. That is not why people go into medicine. And I think it's misguided to continue to push for legislation that gives people, that gives, that gives entitled people access to drugs that they want just to give a veneer of acceptability. I mean, Richard Posner, the judge from Chicago said this. He said, look, lots of people want to die by suicide, but they don't. He specifically says, because to dispose of one's own corpse is a problem. And he says, but if the physician becomes the agent of death, then all of those problems go away and people have access to ending their lives when they want to. And I know we have these so called safeguards, but as I've said, it continues to Expand in every jurisdiction where legislation is passed. And we don't want to have a profession, a healing profession that is an agent of death. And we don't want to live in a world where it becomes the norm to just take one's life on a whim.
- [76:25]
David Hoffman
I will say that one cannot create a circumstance and then claim to be victim of that circumstance. And while Lydia might want not want to be involved in this at all, and I respect that and the law respects that there are lots of physicians who want to be able to have this discussion with their patients and to provide a prescription where the law makes that prescription necessary. Remember, a child who kills their parent can't go into court and ask for mercy because they're an orphan.
- [76:57]
Rafaela Siewert
Do you ever think about or worry about a scenario where it could be considered malpractice if, say, you have a Catholic doctor and the patient is asking for maid and the Catholic doctor feels ethically, morally, religiously opposed, what happens in that scenario?
- [77:13]
David Hoffman
I've been asked that question many, many times. And the reality is that no physician has a moral, medical or legal obligation to treat any given patient. And every physician decides, decides what is appropriate for their practice, sometimes on moral or ethical grounds, sometimes just on the basis of their competency or experience. I know of no general practice physician who has ever been compelled to perform neurosurgery because their patient needs neurosurgery. Every physician makes that decision. And though I know that Lydia wants to, to speak for all physicians to protect them from the burden of this responsibility, Lydia does not speak for all physicians because I know lots of physicians who are willing to do this work. And the law should not both burden them with the responsibility as gatekeeper and then tell them that they can't act as gatekeeper.
- [78:15]
Dr. Lydia Dugdale
So just to respond to that, since you've brought up some studies that you've published or are about to publish, I'll say I did a nationwide survey of physicians attitudes on legalization and participation in physician assisted suicide. And what we found is, not surprisingly, about 2/3 of doctors think that patients should have access to physician assisted suicide or maid, but only about a third of those, so that gives us around 20 to 25% total, would actually be willing to do it. And then as some of my colleagues in Canada have said, they've decided to stop doing it because they feel like it is getting too unwieldy. You know, I just want to put a little asterisk by your statement that you've made many times, David, that lots of doctors want to do this pushing for legalization, I mean, the doctors who want to do this are probably boomers who want access. But pushing for legalization is really a patient rights move more than it is a physicians demanding the right to kill their patients.
- [79:16]
Rafaela Siewert
I have one question for you. I know there's a Pew survey and a Gallup survey, which both indicate roughly around 70% of Americans want some form of maid. And I'm wondering how you reckon with that and think about how public opinion should shape this policy.
- [79:30]
Dr. Lydia Dugdale
Yeah, I'm aware of that data. And I think most people want the right to choose right. Most people want the right to bodily autonomy and a sort of my body, my choice idea lends itself very naturally to my body, my death. I can understand that sentiment so well because I've had many patients say it to me. At the same time, I think that if people really studied the issue more, not narrowly, the legislation that's put forward in America, in the States, recognizing that only a few states are actually reporting well, but not that narrowly, but taking it sort of worldview, a worldwide view of the issue, and reading story after story after story of people who feel that they had no choice but to take maid, I think then the public might feel differently. Do you think?
- [80:33]
David Hoffman
Except as my coercion and undue influence study demonstrated, there are none of those documented cases in the United States. And speaking to this notion of public desire for the law to catch up with the reality of modern circumstances, the Completed Life Initiative, an organization that I helped found, and another organization, Death with Dignity, which was founded in Oregon and led to the adoption of the Oregon law. We did a study, a survey, and found that In New York, 72% of New Yorkers support access to medical assistance in dying. And since the reason they can't have access to that is something that the government did for what at the time were legitimate and important purposes, tells the government that it's doing something that no longer serves the purpose that was intended and they should get out of the way.
- [81:36]
Rafaela Siewert
Lydia, is there any form of a policy or bill that could be so airtight that would meet what you think would be protective enough, or do you feel like that's totally impossible?
- [81:47]
Dr. Lydia Dugdale
I don't think it's possible. I mean, when you talk about stepping over the line of killing or of providing a lethal substance, I don't think it's possible to make it that airtight. One of my mentors, the late legal scholar Bo Burt at Yale University, has a really beautiful book on death, and he compares what he calls physician assisted suicide with A lethal injection on death row and abortion. And he talks about how once you cross the line of legalization, sort of all bets are off. It's better to keep the idea of hastening death, maybe the way it occurred with Coleman Hughes mother, to keep that not legally sanctioned, but sort of within the realm of possibilities for patients who have severe suffering. That was Boebert's argument, and I think there's a lot of wisdom there. He said to me, once, you know, if this is legalized. We were in Connecticut at the time, if this is legalized, I think that the doctors who are most opposed should be the ones who do the assessments for who needs it. Which is to say we need to be so, so careful with this once it's legal. Because once it's legal, the cat is out of the bag.
- [83:10]
David Hoffman
To your point earlier, it is specifically because the government created this impediment for reasons totally unrelated to medical aid and dying, that that impediment ought to be removed. This is not the government taking an affirmative step to say we are making this available. The government is merely saying that the purpose behind the power of the prescription pad to yield only the means that are less safe, less certain and less painless as being available for patients to exercise their autonomous right to end their lives under any number of circumstances. Circumstances. That's exactly why this ought to be legal, as something available to patients and clinicians who want to be involved. On the day that Governor Hochul signs the New York bill, not a single obligation for any patient or any clinician will be created that doesn't exist already. This bill merely removes an impediment that was never intended in the first instance to be an impediment to patients making their own decisions and having access to any of the chemicals that can give them a safe, certain and painless death, the subgroup of which we're discussing now being medicine.
- [84:37]
Rafaela Siewert
I guess I would love to just close by asking you each to sort of articulate if this does pass and if Maid becomes largely available in the United States States, how you see it playing out, whether that be the consequences or the benefits, so people can understand how this might affect their future. We'll start with Lydia.
- [84:57]
Dr. Lydia Dugdale
Great. So that reminds me. Your question reminds me of something that I was hoping we would talk about. So just put on the table. We have an aging population. The oldest of the boomers turn 80 next year. We are having far fewer children. We have an elder care deficit. And Louise Perry has written in the Times really beautifully about government officials who, whether on record or not, but she got record of it. Have said that legalizing maid is going to be the way that we help save health care dollars. I find that very concerning. And years ago, Rahm Emanuel and Peggy Batten did a study that was again repeated by some folks in Canada when Canada legalized, where both groups were trying to figure out how much money the governments would save if assisted suicide or maid were legalized nationwide. The fact of saving health care dollars is a real one and it is going to put pressure on people. What they found is that it's only going to save a small amount of money. But on an individual level, that small amount of money can put a lot of pressure. So I'm concerned about what it looks like as a society, as more and more states, if more and more states legalize, what will happen? The other thing I do want to say is that since Oregon legalized, yes, many other states, 11 more jurisdictions have legalized in the country, but 27 states have also passed laws making it more restrictive. And so I don't know if we'll end up seeing a bit of a checkerboard pattern like we see with abortion, where there are some states where there is access, of course, there's access to every American by virtue of Oregon and Vermont no longer having residency requirements. But if some states will be very in favor and some states very opposed, we may see that kind of a phenomenon too. But we can imagine that with the demographic shifts in the aging population, there will be a lot and spiraling out of control healthcare costs. There will be a lot of incentive pressure to make use of medical aid in dying.
- [87:19]
David Hoffman
David, speaking on behalf of the entire baby boom generation and all senior citizens of whom I became one this past August, there's a problem with the way we handle the practice of medicine in senior years. There's a problem with the way we describe the benefits of high tech, high cost interventions. And patients and their doctors ought to be able to have that discussion among themselves because we know lots of bad decisions get made to pursue interventions that are of no real benefit. And we ought to be able to have that discussion. Part of the reason for that difficulty is the absence of tort reform, which is a whole other discussion we could have. There are pressures to maximize interventions so that no one can ever say, oh, you should have done this and you didn't. That's creating the dilemma that we have as a macro healthcare economics issue that has nothing to do with medical assistance in dying being available as a discussion and a decision between doctors and patients. What we have to do is acknowledge that doing more isn't always in the best interest of the patient. And we need to be able to have that discussion. Part of the irony of the circumstance we find ourselves in is that some people, only some people in palliative care and some people in the hospice movement object to availability of medical assistance in dying because that would discourage people from taking advantage of palliative care and hospice. Guess what? That's the exact same argument that the oncologists made about palliative care in hospice. If we offer palliative care and we offer hospice, people will lose hope in the cures that oncology can provide. And that would be a shame. Well, it hasn't turned out that way. And the problem won't manifest itself anymore in the expanded legalization of access to medical assistance and dying than it did when palliative care fought that same battle. We can be bigger than that.
- [89:41]
Rafaela Siewert
Well, Dr. Lydia Dugdale, David Hoffman, I think you've given everyone a lot to think about, and I just really appreciate your time and willingness to engage on this topic. So thank you both so much.
- [89:51]
David Hoffman
Thank you.
- [89:51]
Dr. Lydia Dugdale
Thank you.
- [89:59]
Bari Weiss
Thanks for listening. If you liked this conversation or disliked it, or most importantly, if it provokes you, share it with your friends and family and use it to have an honest conversation of your own. Last but not least, if you want to support the Free Press, there's just one way to do it. It's by going to vfp.com and becoming a subscriber today. Thanks, and I'll see you next time.