The panelists debate the distinction between killing and removing obstacles to death, and the appropriateness of administering palliative procedures that may hasten death. (13:07 min)

Stephan Mayer
When I started out doing neuro intensive care, curiously, I had relatively little interest in bioethics. When I was in medical school, my eyes would glaze over during ethics lectures. I was more interested in the technology. And what happened was, in the line of work that I'm in, increasingly I began to become involved in cases where we were removing people from life support because it was clearly a hopeless situation and that was clearly what they would want. The way I started, it was really something that I felt should just be between myself and the families. It was low-key and I was happy with that, until I had one experience where we withdrew life support for a woman in her fifties who we thought was being admitted with a fairly routine and reversible, treatable problem. She had myasthenia gravis, which is muscle weakness, and she got an attack of weakness--or so we thought. But then we found out that actually she had widely disseminated cancer in her lungs, and as each day went by she deteriorated. She perforated her bowel, her blood pressure dropped, her lungs were filling with fluid, and she was a picture of agony. She was still competent, had capacity, was writing messages saying, "Please let me go." The family came in, and, to make a long story short, once it was clear that she was only suffering and she really wanted to go off--and that's what the family felt strongly as well, that it was the right thing to do--that's what we did. We took her off the respirator. We had to give her relatively large doses of morphine to be sure she was comfortable, and I hugged the husband. That was difficult. The medical students were crying. This was really heavy. But I had a good feeling about what I did.

Then, a week later, I got a phone call from my chairman saying that there was some word out that I had "killed" a patient and that I was to write a report of this event immediately for the chief of staff, and they were talking about suspending my privileges. It became just some kind of game of telephone where it got passed along: "Did you hear what happened? Dr. Mayer gave morphine!" Administrators and people in nursing were saying it--people who weren't there and just heard it secondhand. It was a difficult time for me.

In the end, what ended up happening was that it was all reviewed. We met with the then director of ethics at the hospital and it turned out that it was a textbook case of an ethically perfectly OK thing to do, and the right thing to do, which I knew in my own heart.

But it was a difficult experience. I really felt like I was guilty until proven innocent, and that experience made me realize that there are a lot of hang-ups on many levels, maybe from the institution's point of view. And I realized, in fact, that in order to take that patient off the respirator I had to do some real convincing of the consulting pulmonologist, though I really thought it was the most direct way and best way to deal with it. But there was a lot of hesitancy, and it was that experience that made me realize that this practice that I call "terminal extubation," which in the lay public we call "pulling the plug," is a completely ethically, legally sanctioned medical procedure, with a methodology. There's a way to do it, and it's perfectly OK to do in the right setting.

Brian Lehrer
How long ago was that incident?

Stephan Mayer
I think about five years ago now.

Brian Lehrer
Has much changed since then?

Stephan Mayer
Yes. In our hospital, absolutely. Things are changing, much for the better. And by that I mean that, without a lot of hard numbers, it's definitely my impression that in the hospital, more and more, people are removed from life support in futile situations where it's clearly a losing battle and it's clearly what the patient would want. And I've seen this in the other ICUs. The frequency with which we do this in our ICU increased over the first few years until we hit a kind of steady state.

Brian Lehrer
Professor Frymer-Kensky, he used the term "pulling the plug." Is that killing?

Tikva Frymer-Kensky
No. There is a difference between killing and removing an impediment to dying. And there are things we can do which prolong dying by placing impediments in its way. They aren't going to cure, and they aren't going to prevent suffering. In Jewish ethics, this started to be discussed, strangely enough, in the thirteenth century, where you wouldn't think they could do much to save the dying.

Brian Lehrer
We didn't have ventilators then.

Tikva Frymer-Kensky
No, and the examples are kind of silly in our eyes. Such as, if a person is close to death, and salt has been placed on the back of that person's tongue to prevent dying, or a woodchopper's noise is preventing dying, you are supposed to take away the salt and stop the woodchopper because this person needs to die and you are stopping it. That got codified 300 years later into Jewish law. But there has been a lot of dispute over the last 600 years.

As we've gotten better and better at putting impediments to dying, it has become clear that we need to make that distinction. It's one thing to kill or withdraw something that can cure, and it's quite another to say this is no more than salt on the tongue. It's not really a medically sufficient thing. It's not helping that person; it's just some kind of a thing that we think will impede the dying.

Brian Lehrer
So somewhere between there and Dr. Kevorkian is the line?

Tikva Frymer-Kensky
Somewhere between there and Dr. Kevorkian is a line, but it could be drawn even closer. You don't have to make that big a leap.

Brian Lehrer
Is it worth taking a crack at it? Is there a practical function to trying to say where that line is in a given procedure, or in general?

Tikva Frymer-Kensky
I don't think we should leave it to professional ethicists, which we tend to do. We kind of warehouse it. We say the ethics committee will take care of it, and then we as a society don't have to think about dying. And I don't think we leave it to the individual. In Holland, where assisted suicide is legal, they've been seeing families that lay a guilt trip on the terminally ill to kill themselves before all the money is used up, to kill themselves because of the mental anguish to the family. They badger the patients. Clearly, we don't want that. We need to discuss these things.

Brian Lehrer
Dr. Prager, have you seen that happen? Families badgering their dying loved ones to pull the plug or allow someone to pull the plug?

Kenneth Prager

	Thinking Points
	Do you think there is an ethical difference between euthanasia and removing an impediment to dying? What do you think is the defining line between these two procedures?

I have had patients' families come to me with the following sentence: "Can we expedite things?" I've had that term used more than once. And I have told them no, we cannot expedite things. We can--and I make the distinction very clear--we can remove an impediment to dying, but we cannot hasten death. I think that it's absolutely crucial for the moral fiber of our society to maintain that distinction. Sometimes the line may be considered rather vague, but I'm opposed to physician-assisted suicide. I'm opposed to euthanasia. I am not opposed to removing an impediment to death. I think the case that Stephan mentioned was the right thing to do, specifically because the patient had requested it. The patient was suffering, and this was a case of prolonging death. But I can tell you that it's a very short line from there to seeing somebody who is suffering, whose wishes we may not know, and just giving them an extra dose of morphine.

Brian Lehrer
What is euthanasia, as you see it?

Kenneth Prager
Euthanasia as I see it is administering a drug to kill a patient who is suffering and to justify the administration of that drug by saying we have put the patient's suffering to an end. It is the act of taking a life. It comes from pure motives, shall we say, of stopping suffering, but I'm firmly opposed to it, because I think that it is a slippery slope. Let's say somebody had said, "If I get Alzheimer's and I'm very seriously ill with Alzheimer's and can no longer recognize my family, I want to be put to sleep. I want to be put to death." I think that's wrong, and I think there's a short step from that to thinking, Well, we have somebody who really never actually said this, but we know him well, we know he never would have wanted to exist in this condition. I'm sure that had they been able to they would say to give him a lethal dose, etc. These are slippery slopes, so the distinction between removing an impediment to death and hastening death is a very important one that should be maintained.

Brian Lehrer
Is anyone less sure than he is? That physician-assisted suicide and euthanasia, as he defines them, are wrong?

Stephan Mayer
Well, just starting and taking the tiniest nibble here, the first issue is one where, practically speaking, if you take a dying patient who has got a plastic tube in his trachea and you remove that tube, and you understand that it was really the main thing keeping him alive, you understand that he is going to die as a result of removing that impediment to death. You may be looking at an individual who is very uncomfortable--choking for air, hungry for air, what we call agonal respirations. I think the appropriate reflex is: My goodness! Because when we do this we say we're going to shift the goal of care from extending and prolonging life to making the patient as comfortable as possible. That becomes our number one goal. When we do this, we need to in many cases give a medication like morphine, which is a painkiller. It has sedative effects that put you to sleep and suppress breathing, and we give it when we see rapid, ineffective, labored breathing, what we would imagine is uncomfortable breathing. And then the question becomes, how much morphine can we give? In the patient I was describing, there were big questions about--among other issues--how much morphine was given. Was that appropriate, or not? I think that the answer is that you have to give as much as you need to in order to attain as much comfort as you can reasonably get, and no more. If the sedation hastens the dying process, that's OK. There's a name for that, the principle of double effect. And this is what we explain to families, that we're doing it just to take away the suffering and no more.

Tikva Frymer-Kensky
I think that the key is intent. If you intend to relieve suffering sometimes you will inadvertently hasten the death. But the key is the intent.

Brian Lehrer
Julia Quinlan?

Julia Quinlan
This is the same argument that we brought to court 25 years ago. We wanted Karen removed from the respirator. We wanted her to die in a natural state without the maze of technology. We weren't aiming to cause her death but just to keep her in comfort. That's all.
We have been faced with assisted suicide in the hospice also, where a patient will ask the doctor to hasten death and he will just refuse. But of course I don't believe in assisted suicide or euthanasia, either. There is definitely a distinction. And also, in hospice, when we give them morphine, we have to be very careful, because we want to be sure that it does not hasten their death. If we feel that it is a situation in the home where the patient could possibly overdose on the morphine, then we just draw back or we have them use a patch so that this doesn't happen. We're very aware of this in hospice, and we will not hasten anyone's death.