The panel discusses physician-assisted suicide, the ethics of prolonging life for patients whose wishes were never specified, and dilemmas posed by patients in vegetative states. (17:06 min)

Julia Quinlan
It is an individual's right, I suppose, to choose how they die. I cannot approve of it, and I don't, and I think as a society it would be very dangerous if we were to legalize it. But you do have some doctors who are willing to assist in suicide. I cannot approve of that. I think that 25 years ago it was difficult for people to understand what we were asking for. They were under the impression that we were asking the court to kill our daughter, and that was not the case. We were just asking the court to remove what we felt was an extraordinary means and then to allow her to die.

Kenneth Prager
If I could just comment on physician-assisted suicide, Brian. I think we still have a long way to go in the United States before physicians are expert enough in dealing with the dying. We have become much better, as Stephan said, even in a short period of five years. We've come a long way in our own institution. But I still think across the country there is a lot we can do much better than we are currently doing to alleviate the suffering of dying people. I think that, if and when that time arrives--and I think it will, because I think a great deal of money, time and effort is being directed toward that effort--once we've arrived there, I suspect that the impetus in many cases for physician-assisted suicide will be less. It's also been shown that patients' requests may change from time to time, that a patient may feel particularly in distress or depressed at a particular time and then withdraw their desire for suicide after their needs have been ministered to, after depression has been treated, etc. But I think, again, the thrust of society should be in improving our care of the dying rather than in trying to get physician-assisted suicide legalized in more states.

Stephan Mayer
I think it's almost a shame that, in the popular press, Dr. Kevorkian and physician-assisted suicide are given so much attention. This is something that is really very rare, that happens to very few people. Remember a few years ago, in Manhattan, there was a woman who was chronically debilitated from M.S. and she just reached a point where she said, "I've had enough of this." And her husband gave her a lethal overdose of something, and that's suicide. But aside from these rare cases that gain a lot of sensation, much more common is the person who is in the act of dying and who basically crosses that line where he no longer has even the minimum cardiovascular function to maintain life. He's being kept alive on machines, and we have to accept the futility of the situation. But families and physicians and we as a society are hesitant and reluctant to basically stop this death-prolonging intervention, and that's the epidemic. This is what's rampant and this is where we hear these statistics about how a huge percentage of Medicare dollars are spent on the last two weeks of life--in ICUs--because of this reluctance to just let go.

Julia Quinlan
I think if we could improve the care at the end of life, and perhaps have the person not suffering so much, there would be little or no need for assisted suicide. We have an obligation to educate the public about their options. We find in hospice that the patient often does not fear death but fears suffering. And that's why pain control is important.

Brian Lehrer
Do you agree, Professor Frymer-Kensky?

Tikva Frymer-Kensky
That there would be less doctor-assisted suicide if we improve? Yes. If people had a way of facing not only that they wouldn't be in such pain but also that the treatment would be better, if they knew what to think about how to adapt themselves to the idea that they were going to cross into death, then there would be less.

There are no rituals. There were, once upon a time. There are some ancient rituals and manuscripts that maybe we should look at again, but currently we have a vacuum, because we have not wanted to accept the inevitability of our dying. I don't want to accept the inevitability of my death. I mean, I know it's inevitable, but somehow deep inside me I'd like to live forever.

Brian Lehrer
Dr. Prager, do class issues ever come into play on the Medical Ethics Committee around this, if we're talking about poor people, non-English speakers, people with not much family, racial minority group members, very old people as opposed to merely old people? Those are all classes of one kind or another. Do they enter into our decisions, and always in the right way?

Kenneth Prager
I would say that these issues do not enter into the committee discussions. But these issues do come up when people of different cultures, for example, bring with them different cultural baggage. A recently arrived immigrant from China or India or Russia, say, will react differently to a particular medical situation than will a yuppie from New York City, and so in that respect the class issues enter into it greatly. But in our own deliberations, we obviously don't say, well, this person is poor or a minority and so therefore we're going to apply different standards. I think that we try to be on as level a playing field as possible.

Brian Lehrer
But say you have a homeless person for whom you cannot locate any family. That must be a very different kind of ethical challenge for you than somebody whose family has gathered around, and they're all educated.

Kenneth Prager
Yes, we recently had exactly such a case of a man who was found in the street, who was a known homeless individual. He came into the hospital with a severe surgical emergency, was operated on, developed catastrophic complications postoperatively, developed strokes, could not make his wishes known, was on a ventilator, and the surgeon came to the ethics committee and said, "What do I do? This patient is critically ill; we don't know how hard to push. The chances of this individual's surviving to leave the hospital are getting smaller and smaller each day. Where do we draw the line?" And that is a difficult question. In a situation like that, what we try to do is to put ourselves into the mind of every man, common man, reasonable man, and say, what would Mr. or Mrs. So-and-so want, if they were in this type of situation? I don't know what other rules there are that would be appropriate to apply. Just to say that we will do everything to the nth degree because we have no guidance from the individual seems unreasonable. On the other hand, to say, well, since this individual cannot express his wishes, we'll have a lower threshold for pushing on and let's call it quits now, also seems unreasonable. So we sat down, we talked to the doctors, and at a particular point we felt that the likelihood of this individual having any sort of existence that any other reasonable person would want to have was so remote as to make further aggressive intervention inappropriate. I suppose that maybe 1 or 2 percent of the population in a situation like that would say to do everything. We think that 98 percent of the population would say, "Enough." This very much guided our deliberations, and we said, "Enough." Thankfully, at that point, we felt we must continue ventilation and nutrition and hydration, but we would not put this person through the sort of surgery that might be necessary to deal with their particular problem. And we would not treat every episode of sepsis.

Stephan Mayer
A lot of times when dying, and certainly in a critical illness, the patient loses decision-making capacity. We then have to depend on our family members to act in our stead, and I feel very strongly about this. The people I feel the sorriest for are the people who are all alone in the world. You see this all the time. The elderly woman who outlived every relative, made it to 98, but then something happens to her and there are no relatives to go to bat. Or people in dysfunctional families where nobody likes each other and nobody even bothers to come in and call and see what's going on. Or the homeless individual. More often than not, these people end up getting more than is really reasonable and more than they would want, because in order to say, "Enough is enough," generally somebody has to step up to the plate and say OK.

If there's no one there to do that, sometimes these are the saddest cases of all. And I really believe that, in the appropriate setting, when it's clear that death is imminent, and interventions are unwanted based on the patient's wishes, removing life support and allowing the patient to die in a comfortable way is an act of love. It may sound corny, but it only happens when there are people around who love that person very dearly. That's one of the essential steps. It's one of the essential things for us when we lose our ability to master our own destiny, for us to have the kind of death that we would want.

Kenneth Prager

	Discussion
	When a patient is in a vegetative state, the end-of-life decisions often fall on courts, family members and doctors. Who should decide whether or when to take a patient off life support?

Up until now we've been talking about mostly prolonging death situations where we deemed it futile for that patient to survive. The really difficult questions are quality-of-life issues, not just a question of whether the person will survive. You have a person in so-called persistent vegetative state. This is a patient whose eyes are open, who has random movements of his eyes, but who lacks any cortical activity, lacks consciousness, cannot interact with his environment. The patient is certainly alive, and patients like this, if treated aggressively medically, can sometimes live for years. Is this a life worth living?

In the case of the individual I spoke to you about before, the homeless man, it was not a question so much of whether we could prolong this person's life; it was a question of whether we could keep this patient going when he was in a persistent vegetative state. There are other issues: patients with severe brain damage, with severe problems, again, where they lack capacity and cannot make their own wishes known, and even relatives are not quite sure whether their father, brother, sister or uncle would have wanted to have live with this degree of brain damage. These are really agonizing, difficult questions.

Brian Lehrer
Is that getting closer to killing, because, in that sense, you're passing judgment on the person's personhood rather than their physical capacity to live?

Kenneth Prager
I would say in situations like that, where it is a question of quality of life--not quantity, not survivability to discharge--we generally do not stop treating these patients. We assume that, unless there are advance directives, unless there is a health proxy who we feel can speak in this person's stead, or unless this person has given clear and convincing verbal evidence before getting sick that they would not want life support, a patient like that would be maintained on life support.

Tikva Frymer-Kensky
I think the category of quality of life is a really slippery slope, and we have to be careful to use it. There may be other categories that we can think of. Some have suggested the category of transitional state. Just as, to those who do not declare that it is a person, a fetus is in a transitional state to becoming a person, and therefore does not have the same claims to total protection that somebody who is alive has, so, to some thinkers, is persistent vegetative state really a transitional state to dying. The systems would shut down if you left them alone, and so you should leave them alone to shut down. How much brain activity indicates a person still in life and not in transition to dying probably needs to be looked at on a case-by-case basis until we have better medical measurements.

Brian Lehrer
So, just as with the abortion issue, we're really asking what it means to be human?

Tikva Frymer-Kensky
Yes, absolutely. The people who have that kind of severe brain damage and are on their way out have a lot of similarity ethically to the people on the way to becoming human.

Kenneth Prager
Except that, as opposed to abortion, we're not asking what it means to be human and saying that the person in persistent vegetative state is not quite human and therefore we can kill them. In abortion, we take the life of the fetus, and I don't think anybody is advocating taking the life of people in persistent vegetative state because they are subhuman. They have rights, they are just as human as you and I, even though they have profound brain damage. The question is really how aggressively to sustain their life and, at least in New York state, which is one of the most conservative states on this issue, such a patient has to be maintained alive unless one of those three criteria that I mentioned before were met about advance directives, or having a surrogate or proxy, or clear and convincing evidence.

Stephan Mayer
I think one of the cornerstones of bioethics is this principle that all of us have a right to refuse any kind of treatment that we don't want. If you're sick and you need some kind of operation to live, and the surgeon says you need this operation to live, you have a right to say, as crazy as it may be, "I just don't want it." They can't attack you and assault you and do the surgery if you don't want it, even if the consequence is that you will die. People who are in vegetative states are a vulnerable population. They're vulnerable because they're not able to go to bat for themselves. Things will just get done to them. But I think anybody in a vegetative state who has made it clear that they wouldn't want to be prolonged indefinitely in that kind of situation has a right to say, "I don't want these things that will prolong me." What that amounts to is the artificial feeding, and eventually when you're in this condition you get medical complications that need aggressive care. People have rights to say, "I just wouldn't want to have these things done to me to make me continue on and on like that."

Julia Quinlan
You have to draw a line, though, on the aggressive care. When Karen was in a vegetative state, it was a very, very difficult decision for a family to make for someone you love, for your own daughter. But you do not have to just ask to have the person removed from the ventilator; you also don't want to continue with aggressive care--the feeding tube and so on. We refused to have a feeding tube in Karen. But she still lived for 10 years, and so you just don't know. But it's a very, very difficult decision to make. I wouldn't want to see anyone have to make that decision for a loved one.