“Euthanasia” Is Taking The Debate Too Far

The debate about euthanasia has gone too far.


 


Someone’s intent to do a good and necessary deed has now been transformed into a hideous misrepresentation that not only affects our humanity and dignity as a nation, but goes to the heart of the physician/patient relationship and the responsibility that physicians have to provide healing and comfort as well as treatment. 


 


That’s our oath, and that’s what we are supposed to do.  Recognizing that imperative is not something that should be punished as an evil act.


 


Perhaps some background would be helpful in framing the issue:


 


Medicare is supposed to only pay for medically necessary and effective care.  It is not allowed to provide other services such as screening or prevention unless specifically authorized by Congress.  End of life counseling falls under the category of non-covered services, but probably gets into the payment mix as part of other billing codes which doctors use to get paid for more routine “evaluation and management” services. 


 


Providing explicit payment for this service will encourage appropriate and needed discussions between physicians and patients on this very important, difficult and humanitarian topic.


 


For years, many of us have been concerned about end-of-life issues, such as living wills, pain management and hospice care.  Counseling our patients as they age about their options—and equally important, understanding what our patients’ wishes may be—is an honored part of the physician/patient relationship, especially for primary care internists, family physicians and oncologists.  The reality is that we have not been as successful as we need to be in encouraging these discussions.


 


We have tried for years to get people to sign living wills and provide durable powers of attorney for health care.  Medical professionals need guidance—preferably in advance of the moment–on what patients want done, either at the time when their lives are coming to an end or when they may not be able to speak for themselves.


 


There is nothing inhumane or inappropriate about that discussion.  It is a discussion that no one wants to have, and one that is never easy.  But it is the right thing to do, and there are plenty of medical and patient organizations who have devoted considerable effort to encourage these discussions.  There is nothing about the discussion that is preordained to limit care.  In fact, some patients and families want “everything done” even when medical professionals find that directive to be against their own ethical instincts.


 


I learned these lessons early in my career as a medical oncologist.  Having discussions about end-of-life is an unfortunate reality in cancer care.


 


What surprised me at the time—when there was less I could do for many patients than is the case today—was the number of patients and families who told me they were more interested in comfort than they were in treatment.  They wanted to be certain someone would be there to care for them through their last days or months and ease their pain and suffering more than they were concerned about getting the next drug which more likely than not would have given them more discomfort that hope and relief from their suffering.


 


Those discussions had an incredible impact on me as a person and a physician, and the experiences remain with me today.


 


I didn’t euthanize anyone, and never, never would such a thought enter my mind.  My patients taught me that having a heart beat and being alive to see the sun rise another day was not living and was not life.  That was their decision, not mine.  I would do what they wanted, but almost always what they wanted was care, compassion and relief from pain. That is what we tried to offer.


 


When I recently heard the gross misrepresentation surrounding the portion of the health care bill that referred to paying health care professionals for these end-of-life discussions, I couldn’t help but be concerned and confused.  When I heard the rhetoric stormed up to a level of “death panels” and “Nazis” I knew we had gone too far.


 


I have stayed out of the politics of health care reform in these blogs, and will continue to do so.  But as I mentioned in my comments the other day, someone has to be an honest broker of what is going on out there, dealing with some of the rhetoric that is coming from both sides and which is designed to inflame rather than inform.


 


If you are a physician who has cared for a patient for years or even decades, you know that person as a friend as well as a patient.  Your goal is to provide the best care you can, but also to provide comfort when cure is no longer the goal.  You counsel your patient and their family on what you think the best path may be at that moment and in the future, whether it be treatment or comfort.  You act as protector for their wishes, the guardian of their health, and at the appropriate time the minister for their comfort.


 


You are not a Nazi.  You are not triaging who will live and who will die.  You are not some thoughtless bureaucrat who is concerned about how much it will cost to keep someone alive.


 


I have stood in the places of remembrance for people who were killed without cause.  I have cried my tears over those who were lost by senseless murders.  I have read the writings of those who survived.  And I will never forget.


 


So please do not dehumanize the memories of those who suffered from terminal illnesses or the ravages of age by suggesting that somehow our great country, our great people, and our great physicians and health professionals are somehow going to become agents of the state and in turn agents of death. 


 


Please understand that dignity in our lives must always be paramount in our thoughts.  Discussing end-of-life wishes is humane and appropriate.  Providing counseling, care, hospice and pain control is in the noblest traditions of our profession and our country.  Listening to our patients and their families is what we do, and what we pledge to do.


 


Continue with the debate and the discussion, make your case and make your points, but do not dishonor those of us who have tried to do the right thing for our patients, families and friends and the memories of those who have died in peace, honor and dignity by make the choices that were best for them.

22 thoughts on ““Euthanasia” Is Taking The Debate Too Far

  1. A provision in the House bill would allow Medicare to pay doctors for voluntary counseling sessions that address end-of-life issues. The conversations between doctor and patient would include living wills, making a close relative or a trusted friend your health care proxy, learning about hospice as an option for the terminally ill, and information about pain medications for people suffering chronic discomfort. The sessions would be covered every five years, more frequently if someone is gravely ill.

    ———-

    The provision in the bill would formally bring doctors into a discussion that now takes place mainly among family members and lawyers. When you execute a legal document with your lawyer, it ends up in your files and in the lawyer’s files. Unless the doctor is part of this discussion, it’s unlikely that your wishes will be respected. The doctor will be the one involved in any decisions.

  2. The NAZIs use to say they were also “misrepresented” prior to giving the patients the cyanide pill. Try listening to Obama’s other advisors before you make your conclusion.

  3. Thank you Dr. Len for your reasonable explanation of this. I wish everyone could stop, take a deep breath, and take the time look for the answers to these sort of questions by listening to people of science like you, rather than political interest grouups and talk show hosts.

  4. While I agree with your statements on principle, I do not want the Government making that decision for me. And I think you are looking through rose colored glasses if YOU think YOU will still have the freedom to treat your patients as you want, when the government will be telling you what you can and can’t treat. That decision will no longer be yours to make.

    Anything that the Government has anything to do with is run poorly, over budget, and chaotic. Look at Social Security, Veterans Administration, etc. There is no way Health Care reform can work if the Government is running it. It will only make the situation worse.

    And as a middle class working person, I don’t feel it’s my responsibility to pay for others to have medical coverage. The money needed to run a Federal Health Plan has to come from somewhere. It sounds good to say everyone will have medical coverage at a reasonable cost, but it just isn’t going to happen. We are not a Socialistic country, although we are headed that way. Independent enterprise has always been the American way, and should remain so.

  5. Dear Dr. Lichtenfeld,

    Thank you for your comments.

    As a son, whose mother received the compassion and care you mentioned above, when she was empowered and helped by hospice, and who was fully engaged throughout the process in her decision to undertake this option, I agree with them.

    As a lawyer who, at times, must counsel persons about end-of-life decisions, I also agree with them.

    As a professor who, sometimes, touches on these issues, and deals with young people whose families confront them, I support them.

    As a voter, I intend on listening to reasonable people make reasonable arguments, on health care, then make reasoned use of my rights as a citizen.

    And, as a Christian, I do not see any contradiction in them with the Good Lord’s wishes in the Good Book.

    Again, thank you for your thoughts.

    FI

  6. Dear Doctor:
    Thank you for injecting a little sanity into the discussion. I wish the networks would give more airtime to you and less to the fringe nuts out there.
    My dad didn’t have any counceling on end-of-life options and he suffered more in his last weeks than he should have. As a result of what we learned, my mother and I have both made out directives to physicians and living wills.

  7. I too am a medical oncologist, and agree with Dr. Lichtenfeld. However, in our democracy, free speech is protected, as long as threats aren’t made. So, let the right-wingers have their say. It is becoming very clear how misinformed they are, though. Probably many of them are upset over the loss of their jobs, or their 401k balances. The thing that amazes me is that they feel the private sector will provide the best mechanism for looking out for their personal interests (healthcare, savings, home ownership, retirement, unemployment benefits, etc.). To them I say, good luck with the private sector and your confidence in it. Myself, I kind of relish the provision of some basic security from the Federal Government, such as Medicare and Social Security.

    Having said all this, it is inevitable that we will get healthcare reform. With all the waste in the current system, it is rather readily imaginable that the savings will go a long way to providing enough money for healthcare coverage for all. What amazes me is that the GOP didn’t see this opportunity during the last administration. Now they have lost the strategic opportunity to have done something about healthcare reform on their own terms, and are in the position of having to react to the proposals from the Democrats. This was a greatly wasted strategic opportunity on the part of the Republicans.

  8. Sorry, forgot one item. Regarding the concept that people with insurance shouldn’t have to pay more to support those who have no health insurance, here is the reality. Everyone with insurance is already paying $1,000 to defray the economic costs of taking care of the uninsured. This $1,000 average shows up in one’s higher insurance premiums, higher deductibles, and higher out-of-pocket costs. So, everyone is actually paying for the uninsured already. It is not too hard to imagine, then, that there will be some future savings for those with insurance, if the 47M uninsured can be provided some affordable coverage (which the private sector currently does not provide).

  9. Dear Dr.: You may have excellent and noble wishes as a practicing doctor (and not a Nazi!), but I hope you can understand the doubt that many Americans have (given the evidence provided by many failed, and wasteful government
    programs) when considering the practices of future doctors once their (the doctors’) bread is being buttered by the government. Please do not preach to us about what we shouldn’t fear. Thank you.

  10. Thank you, Dr. Lichtenfeld, for your insightful post. As a worker in a health care organization, I see the greed and profit-before- patients mentality these corporations perpetrate, daily. We must change the path of health care provision in this country. Those who think that the protesters at these meetings are there because of a “grassroots” effort are gravely mistaken. They are backed by the HC industry, which is dumping 1.4 million dollars a DAY into defeating any change to the status quo. Wake up America, and listen to the voice of reason! Don’t let others do your thinking for you.

  11. I hope I’m not the only comment, saying thank you. If you are as considerate, as mindful in end of life counseling as you are in this commentary, your patients are indeed lucky and must feel very cared for and respected…something that has been sadly trampled in the ongoing debate. I hope your words will inspire others to take a deep breath and remember we are all human beings with very deep feelings this debate is not a fight to the death it’s about how we care.

  12. The people who are still not convinced are probably the same people who were “afraid” that Obama was a Muslim and a terrorist. Their fears seem paranoid to me. This is very upsetting.

  13. Thank you Dr! Your blog comments are well thought out and very valid 🙂 I agree that the critics of the reform are just trying to create fear throughout the country. They have no basis for their comments about “Death Panels” and “Nazis”. They are just throwing that stuff out there to create fear. It has gone way too far! Thank you!

  14. Thank you Dr. Lichtenfeld for your heartfelt posting. As a physician working with those affected by HIV and AIDS I, too, have enjoyed the privilege of helping people move through illness and dying with dignity and without pain. Your arguments are cogent and insightful, but clearly from some of the responses you got there are too many people in this country for whom facts don’t matter, only prejudice and anti-government feelings. I think it is clear that most Americans desperately want the right to determine how they will pass out of this life. It is unfortunate that in their anti-government, anti-progressive, know-nothing way there are those who will continue to seek to deny people that right. Although you may want to avoid the politics we all need clear-headed thinking such as you show.

  15. As a nurse and hospital administrator, I plan to circulate this posting and will try to get as many people as possible to read it. Your hit the nail right on the head.We must stop the hysteria and the misinformation and you have explained the truth in no uncertain terms. THANK YOU!

  16. Thank you Dr Lichtenfeld.
    I am also a practicing physician and agree with all you have written (so well!)
    Let us pray we can get this done, and go back to the work we love. If only these people (who say they are frightenned of this change) would spend a day with a physician dealing with the profit over care system existing (motivated by its very nature) they would understand how sick the US health system is.
    Of course, I cannot believe these folks are not driven by another motive , it is just too much for me to believe Americans are that ignorant.

  17. Because there is so much riding on heath care reform for both patients, hospitals, insurance companies and doctors, every stakeholder is at the table looking out for their interest. Hopefully a final health care bill will come out that takes into account everyone’s interest. In the mean time there are also political forces that have nothing to do with health care specifically that will mischaracterize any bill that comes out of congress. Not just health care. This is an important component of any proposed government intervention or solution. And thus we must come to understand and look beyond this. I would hope that everyone carefully research the facts and not just the political rhetoric regardless of the topic at hand or your political persuasion.

    My father is currently facing some of these end of life decisions as well. Having been diagnosed with cancer of the lungs, liver and pancreas he has opted to take radiation but not chemotherapy. While he and I have spent a lot of time going over the ramifications and reasons behind his decision, we have not spent a lot of time with his oncologist discussing this. Perhaps she will at a later date and simply bill Medicare for general consultation. It seems that my father values the quality of his remaining years over the quantity of his remaining years. Everyone who has a stake in his care should take the time to go over these important decisions carefully. Just this morning I heard a reporter asks Senator Max Bakus why not just remove this controversial component. His answer was that for one it is very important to keep it in and secondly if it wasn’t this component it would be something else that critics will find to latch onto.

    Separating fact from fiction should be every person’s homework not only on this debate but any debate.

  18. Thanks Dr lichtenfeld for your post. Appreciate reading your blog (I have NHL)

    Still I feel there is a bit of misdirection going on here from the critics. it is not the end of life counseling that concerns me (though as folks get sicker, the counsel attempts will go up) but the cost control regulations that are discussed in other part of the proposed House Bill. In this case, it is not a board of folks meeting but a table of some sort that will be generated. the issue then becomes how much value is placed on an extra six months of life or comfort by those who are now on a budget. (Resonates with me as I have NHL) Hard to believe some would do that but as a former military guy, I have seen numerous times when the good of the unit is above that of the individual or as a government guy, when the bigger program numbers outweigh even the benefits of a smaller program and that smaller program is cut. Trust me, bureaucrats don’t see people, they see dollars. How many vaccinations could be provided for by the cost of one chemo treatment? Just look at your hospital’s financial management staff and how they operate, hence the health insurance and hospital horror stories. A couple of real life examples where a national health care system is in place. There are more. First, the value of six months more life has been put about (US dollars) $22-25 thousand in Great Britain where certain cancer drugs will not be given. easy to google. Second, did you see the story of how roughly (US dollars) $150 million would be eased out of the Vancouver Canada health care budget (mostly by delaying elective surgeries) to cover down the cost of the upcoming Winter Olympics. Lastly, saw an interesting video in which someone tried to sign up for a primary care physician in Toronto. They were told there was a two to three year waiting list unless they were willing to go pay $900 Canadian dollars for a blood test at a private clinic. In Denmark, children with severe handicaps and older adults being euthanized for a variety of reasons, many associated with cost. All easily googled for those who want cites. All anecdotal and I am sure you can come up with counter examples but these type of decisions resonate with me.

    The first law of economics is supply and demand. unlimited demand in combination with limited supply always leads to one of two things, rising cost or delay in receiving good if cost is capped.
    There will be rationing and there will be cost shifting to those who can more “afford” it. And that will be the fifty percent of the population that still pays income tax and the top twenty percent who pay the majority of the income tax. That is discretionary money that will further depress the economy which will lead us to an economy that has resembled the negative growth economies of Europe over the last decade.

    So why can’t we look at the real reasons costs are rising so much and address them instead of trying to fix the problem with more money? You don’t get out of debt by buying more of the same stuff.

  19. I just want to take a moment and thank everyone for their thoughtful and insightful comments. Obviously, this issue has created a lot of interest and discussion, and I am gratified to see how many have taken the time and thought to respond, both here and at the ABC News website.

    Thank you!

  20. My concern is having the federal government in charge of my healthcare. The government doesn’t do a good job with any of its current programs, so what makes us think these people would do a good job managing my family’s health care? Good examples are Social Security which has no money due to government mis-management, Medicare and Medicaid, the Veterans Administration, etc. This is just not what I want for my family. I don’t want some government beaureaucrat telling me when I can and can’t have the treatment I may need. And I truly don’t believe that 47 million Americans are without insurance because they can’t afford it. I think a lot of these unisured CHOOSE not to be insured. They would rather spend their money on ipods, big screen TVs, cell phones, etc. I have no desire to spend my hard earned money insuring the likes of these people.

  21. I think that Oncologists should form partnerships with local hospice organizations to help with discussion about end of life care and the options patients have. We have the answer in our hands about helping with this task. No one wants to discuss these options with the patient. The patient receives their results after the first round of chemo to find out their cancer has not improved but is worsening. The patient is then given options to continue their chemotherapy, and only given statistics and other options that a distraught patient cannot understand.

    With a partnership with foundation that gives the patient information that they can understand, that can give resources such as palliative care programs, hospice programs, enable the patient to speak with someone who is not under time restraints to see the next patient, and be given facts. This will help the patients live their last six months to one year of life with dignity and empower them to complete anything they may have on their "bucket list".

    I personally am trying to form this type of relationships with local oncologists. I have worked with a group in the phoenix area for the past few years. And I have seen patients with the joy of survivorship who have beaten cancer, and I have seen patients who have gone through agonizing hours of chemo therapy, bone marrow transplants, growth factor injections weekly, frequent blood tests, and opportunistic infections. Then finding the patient had a bad outcome and had to live their last hours of life in the ICU on a ventilator.

    Patients should be given the chance to have their end of days at their home with their families. This will provide the patient and families with more favorable outcomes, and could enhance their survival rate to two months.

    As physicians, Nurses, and social workers, we need to take charge of the resources we have in the public and make that choice.

    I am forming the sacred heart foundation; this foundation will give patients the opportunity to know their options. Empower them to make the right decisions. As, I struggle to gain the trust and willingness of the oncology providers to welcome this type of service into their practices. This organization will prove to serve the patient and family wishes first, and help with end of life planning with volunteer social workers and case managers.

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