I am a psychiatrist with twenty-five years of experience in private practice. I hold the rank of Part-Time Clinical Associate Professor in the Department of Psychiatry, University of Vermont College of Medicine, where for many years, I taught the practice of ethics and psychoanalytic psychotherapy to residents and medical students. I am a past chair of the Ethics Committee of the Vermont District Branch of the American Psychiatric Association.
The Code of Ethics of the American Medical Association prohibits physician involvement in prescribing or advising on lethal prescriptions or any other form of patient suicide: “Physician-assisted suicide is fundamentally incompatible with the physician’s role as healer.” I do not belong to the AMA, but I do subscribe to this principle of ethics. My code of ethics does not compel me to interfere in any way with the choices of others about how their lives may end; my code of ethics applies only to my own actions as a physician. I am not here to tell my neighbors how to live or end their lives, nor am I here to tell my colleagues how to practice. Rather, I am here to inform you about the clinical problems that are created as the State of Vermont gets involved simultaneously in the patient-physician relationship in two key areas: end of life care and the rationing of medical care.
Under Act 39, patients in Vermont can have access to lethal prescriptions, as long as they and their doctors follow a complicated protocol prescribed and legally enforced by the state. The protocol contains artificial timelines and clinically superfluous documentation requirements that are much less about patient welfare and much more about conferring legitimacy on a process that is banned by the profession. The end of life, with all its complexity and subtlety, is one place where a one size fits all approach is especially contraindicated. By spelling out such a detailed protocol, the state takes ownership of the process away from patients and their doctors. When patients and doctors get preoccupied with following externally imposed rules, they lose track of their own reasoning processes and clinical intuitions, the quality of clinical decision-making suffers, and we have less confidence that patient values are truly being served.
Vermont’s plans for information technology and payment reform, available online, lay out a plan for rationing care. Under Green Mountain Care, physicians will be monitored electronically to see if they are complying with state-approved clinical practice guidelines—selected for cost-containment purposes—and the doctors will be penalized financially if patients’ unique medical circumstances require treatment approaches that fall outside the guidelines (“pay for performance”). Even when physicians dutifully comply with all guidelines, if patients are simply so ill that the cost of care busts a budget set by state or federal actuaries, then physicians will be expected to share the economic pain with third-party payers (“shared savings” and “episodic” payment). Green Mountain Care creates serious financial conflicts of interest for physicians.
Trust is about appearances as much as it is about actual intentions. If the state simultaneously promotes physician-assisted suicide and rationing of care, it is eminently rational for citizens to perceive the two as potentially linked. If you tell me that it is not your intention as legislators that physician-assisted suicide will be used a method of cost containment, I sincerely believe you, but not one of you is a physician who is responsible for treatment decisions, under pressure from the state to lower costs, and under pressure from patients to reduce or end suffering. Act 39 creates a climate where things legislators did not intend can happen.
When the dying or severely ill patient speaks of suicide as a way to shape his own destiny, the physician must ascertain whether the patient has reasoned it through, or whether the patient does not really want to end his life, but instead wants the physician to affirm some sort of hope and meaning. Evaluating decision-making capacity and instilling hope, if that is the indicated intervention, requires unhurried time for patient and doctor. Under Green Mountain Care, face to face time with patients will be reduced, because doctors will be under tremendous pressure to make up for reduced pay, and clinical time will be lost as physicians personally enter data that will be used for nonclinical purposes.
I do not believe that a Vermont physician would ever intentionally offer a lethal prescription as a way to protect his end of the year bonus. Here instead is a realistic scenario for how physician-assisted suicide could be linked to Vermont’s plan for rationing care: Imagine a physician who starts her day with a committee meeting. Her medical director informs her and her colleagues that the hospital is running over budget, which means that the hospital and the doctors might be penalized financially at the end of the year. Worried and stressed after the meeting, this physician meets her first patient of the day, a patient who is suffering with pain and a potentially terminal illness. This patient requests a lethal prescription. Do we really believe that this physician’s clinical judgment will be unbiased? A subtle shift in the unconscious mind that orients a physician to doing less rather than more can lead to subtle shifts in the response to these kinds of dilemmas. No amount of data collection by the state can ever measure a physician’s conscience.
On top of all this, we live in a culture of what I call “medical moralism.” People with complex medical conditions that are costly to treat, and people who interpret the scientific literature in alternative ways, are criticized regularly in public discourse for “costing all of us money” or “putting us all at risk.” In this ugly climate of recrimination, patients with severe illness might very well feel self-imposed pressure to get out of the way. If that is the motivation, then suicide is not the answer we want to promote.
If we want physicians to be optimally positioned to provide scientifically sound advice that accommodates the values of individual patients, then the state should not be using regulation to manage the specifics of clinical decision-making for any disorder or condition, especially the most sensitive ones, and no third party payer should be using financial incentives to influence the clinical decisions of doctors. If we want citizens to trust that there is no link between physician-assisted suicide and the rationing of medical care, then the state should get out of the business of directing the end of life, or rationing care, or optimally, both. Pain and suffering at the end of life is a clinical and moral problem that should be addressed exclusively through clinical and moral avenues. Act 39 should be repealed.
Adapted from Testimony to Senate Health and Welfare Committee
Robert S. Emmons, M.D.
February 18, 2015