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Cardiologist to patient: "How about killing yourself, old chap?"

I receive occasional letters from the Human Life Foundation. In the most recent letter (May 19, 2010), Maria McFadden reprinted the following excerpt from a subscriber's letter:

I am 91 years old, had my first heart attack in January 2009. In December 2009 I paid a routine visit to my cardiologist. He checked, found no real change in condition. "Come back in four months" was the verdict. Then he added something that on reflection really shook me up. He suggested that I should, with my loved ones, consider the possibility of termination of my life.

...Understand that I am restrictively active to the extent advisable for my years and heart condition. I am well aware that I am declining physically but my Christian faith assures me that I will meet my Lord in heaven possibly not too far in the future. But I want it to be the Lord that calls me...

This is a truly shocking anecdote and more shocking the more one thinks about it. If I am interpreting the man's story correctly, his cardiologist suggested a) active suicide to his patient and did so b) out of a clear blue sky, with no prompting whatsoever from the patient. This is incredibly unprofessional behavior and should be grounds for professional censure if it were reported, though I doubt that any such thing would happen.

I wish very much that Maria had told us at least where the subscriber was writing from. Was it in the United States? If so, which state? I wish that this incident could be investigated in more detail, though it may be that the letter writer would not want to talk about it any further.

Anyone who thinks that "end of life counseling" initiated by doctors is nothing to worry about should think about this story very soberly.

Comments (54)

When my mother-in-law was battling cancer, she overheard one of her doctors say something to the effect of "oh, she's in her 70s, just an old woman" -- implying that they shouldn't be wasting the experimental treatment she was trying on her. This was not "official" and could never have been proved, of course, but it horrified and enraged us. That was in TX. I have been SO grateful that my dad is in the care of people who love the elderly and treat them with real dignity and love.

There is a great deal of contempt for the elderly out there, and it is becoming more and more acceptable among medical professionals. What this anecdote shows is that it is moving with extreme rapidity from "mere" discrimination in the use of treatments to the explicit suggestion of direct killing.

Did the doctor suggest "termination" or is that the writers interpretation? Dis he actually suggest a living will? That the doctor suggested he consult with his family inclines me towards the latter. At his age, with or without a heart condition, he should make his wishes clear to his family. I have my preferences, you, no doubt, have yours; what is the problem in communicating that?

I recently had minor surgury at a Catholic hospital. The person taking my insurance info asked if I had a living will. It was clear that this was a routine question.

To cardiologist: "It may be, that in the sight of Heaven, you are more worthless and less fit to live than millions like me."

I knew, Al, that you or someone else would come along and suggest that. I think the writer sounds sufficiently intelligent that if "making his wishes known to his family and putting them in writing" were all the doctor had suggested, the letter writer wouldn't have put it this way. Your argument--that the doctor wouldn't have suggested consultation with his family if he were really suggesting suicide--seems to me extremely poor. It seems to me very plausible that a doctor suggesting assisted suicide would give a patina of reasonableness (as if such a thing could be reasonable) to the suggestion by throwing in a reference to consultation with family. Then, you see, it's a group decision. And maybe the 91-year-old can see that it would be for the best for others to bump himself off.

It would, as I said in the main post, be excellent additional evidence if the man who wrote the letter would come forward and give further details, making it clear beyond all possibility of doubt that the doctor did not merely suggest that he make a living will. If the conversation occurred in Oregon or Washington State, this would also be relevant, as assisted suicide is legal in those states.

But let me ask you, Al: If it did occur in a state where suicide is legal as an allegedly medical act, and if the doctor did really suggest to the patient, on his own initiative, that the patient consult with his family and consider committing medical suicide, would you consider that professionally inappropriate and/or wrong?

Of course, that wouldn't be proper. It also doesn't make sense. as long as the patient is alive the doc has a patient who comes in three times a year for a regular checkup for which the doctor gets compensated. He does have a professional obligation to suggest that his patient make his desires clear should he be in a situation where he would be unable to communicate those desires.

As for misunderstanding - lots of folks do that. We need only go back to last summers "death panel" debates. One person started a lie and others knowingly (because it suited their agenda) or unknowingly (numerous reasons) ran with it. Lots of old folks are sensitive about their ever clearer mortality. We don't know the exact words used so the misunderstanding may have been honest or the patient may be hypersensitive but I find it hard to believe the word "suicide" was used initially by the doctor.

Al, there is also the possibility that the doctor suggested that the patient consider the termination of his life. Which would be suicide. Which means that the doctor was suggesting an illegal act, and could possibly be charged with either conspiracy to a felony, or accessory, or something of that nature. (Even in the states that allow doctor assisted suicide, I am under the impression that this is only allowed when the patient is in a terminal disease).

One of the first things they explained to me during my internship in the Clinical Bioethics Department at the N.I.H. was that "living wills" are totally useless, nine times out of ten, and that health-care professionals generally recommend a durable power of attorney for healthcare arrangement instead. I'd be very surprised if the cardiologist in question suggested a "living will."

Which gets us back to why. On further reflection and depending on the conversation, the subject of a DNR order may have come up. Polls show that most folks don't want a lingering death. At a certain point, for many folks, that means a DNR should the person code. At 91 that is a discussion that needs to happen. People have the right to have their wishes respected in most cases. Along with that right comes the responsibility of the person making an informed decision. If you have ever discussed legal and medical matters with an elderly person you are likely aware that the first attempt may not resolve things. A number of years ago a neighbor in her mid-eighties and declining came to me in an agitated state, clutching a quitclaim deed her niece had given her to sign. She was confused about what it meant and a little scared. I read it and saw that it created a joint tenancy w/ros. The niece was her primary caregiver and she had discussed her wishes about her property with me previously so I explained that this allowed her niece to get the house when she dies. She said ok and signed. The niece didn't ex[lain things well.

We don't know the parties, were not there for the discussion and are getting a second hand summary based on one persons perception of what for many people is a difficult topic with which to deal.

Lydia "I think the writer sounds sufficiently intelligent that if "making his wishes known to his family and putting them in writing" were all the doctor had suggested, the letter writer wouldn't have put it this way."

My father is 83 and extremely intelligent. Nonetheless, when he wants to be clear he has understood everything the doctor had to say to him, he has me or one of his other children sit in on the appointment: we listen, take notes, ask clarifying questions if it seems necessary, and go over the conversation afterwards to be sure of what was said. Visiting the doctor is stressful, and it's no offense to his intelligence that it helps him to have a trusted person to remember and go over what was said.

Scaremongering that doctors will suggest suicide to elderly patients, which would be unprofessional, inethical, and illegal, may prevent more doctors from suggesting sensibly that patients should talk over their wishes and beliefs with their family. If this patient thought what was being suggested was that he should commit suicide, he should rather than write an anxious letter to some magazine, go back with a friend or a child and ask what the doctor said. (And the doctor should learn a lesson about clarity of communication.)

But part of the cause of this kind of fear is the right-wing fearmongering that "end of life counselling" provided by responsible geriatric healthcare providers, means encouraging elderly patients to commit suicide. This is thoughtless and irresponsible. Asking people to think and be clear to their loved ones about what they want if they're no longer able to communicate, is a helpful guide if you're ever in the awful position of having to make decisions for them.

Hi Steve, I was speaking loosely. The California probate code allows for both instructions and power of attorney and the the standard forms have both. You are right that following ones wishes sometimes doesn't happen. Recently a friends mother in law was put on life support when she had indicated that she didn't want that. In any case, advanced directives are pretty standard these days - at least around here.

I think it's interesting the way my liberal commentators _assume_ that the doctor didn't suggest termination of life and therefore _assume_ that this was a misunderstanding. Very interesting indeed. I take the patient's words at face value and am called (implicitly) a "scare-monger." I think he deserves the courtesy of having his description taken to be accurate unless shown to be otherwise. Why should he have gone back and asked the doctor to "explain himself better" if he thinks the doctor was perfectly clear the first time?

Tony, I'll have to check on Washington and Oregon. Usually "terminal condition" is defined in such a way that the doctor probably could have gotten around that. (For example, if the heart condition is bad enough that it's plausible he'll have a fatal heart attack within the next six months, that would probably fit a standard definition of "terminal.") And if the termination procedure is legal in the jurisdiction, I'm not at all sure that the doctor would have been doing anything illegal by making the suggestion outright. Which is very creepy indeed.

Well, Lydia, we're being asked to believe one of two things:

1. A doctor risked his licence, his practice, and his career, by suggesting - apparently at random! - that a patient in pretty good health commit suicide.

2. A patient misheard or misunderstood or misinterpreted as a suicide request, that a doctor who was advising him while he was still in good health to talk to his loved ones about what he wanted to happen at the end of his life.

Given the two options, I think the second is more likely. Granted this doctor could be a sociopath who takes pleasure in trying to convince elderly patients to commit suicide, it is certainly fearmongering to suggest that all doctors who work with elderly patients are sociopaths.

I love my father. And if he were upset or distressed or confused over something he thinks the doctor said to him that sounded completely not right, I would advocate that either he or one of his children should ask the doctor to clarify what was actually said: and if my father continued to be upset at the doctor, I'd suggest we find another one to go to. My father is a smart, together man: if he misunderstood something the first time, he'd be willing to listen to an explanation. If after clarification he was still certain the doctor had said something over the line, I'd report the doctor to the BMA, not crap about with letters to a pro-life magazine.

Lydia, going on the data that we have, "no real change in my condition", we don't have enough to actually rule out terminal illness as a possibility, but there is certainly not enough data to indicate terminal illness is actually there. Generally, a condition should not be called "terminal" if 4 months sees no change, and the doctor doesn't anticipate a need to see the patient for another 4 months. That simply isn't anything like a typical terminal condition. A lot of people have gotten much, much closer to thinking of advanced age as virtually identical to terminal illness. But it isn't, and we have to insist on that.

Jesurgislac, it is true that a wise and prudent doctor would think twice before doing something clearly unprofessional and illegal that might lose him his license and profession. To which we might conclude, going on the data that we have in hand - the doctor " suggested that I should, with my loved ones, consider the possibility of termination of my life." - any of the following: (1) the doctor is not wise and prudent and DID actually do something clearly unprofessional; or (2) the act he did was not clearly unprofessional because the circumstances are murky enough to provide room for doubt, or (3) he knew that even though the act was outside of professional behavior he risked nothing because there is no way anyone is going to successfully prosecute this; or (4) the patient misunderstood a possible phrase like 'end of life' to mean 'terminate'.

As for 3: there is incontrovertible evidence from other countries that have assisted suicide laws, that doctors sometimes engage in unprofessional and illegal behavior by "assisting" suicides where the death is actually explicitly contrary to the patient's wishes, and there have been no repercussions on the doctors. It is impossible to say with confidence that any and every comparable unprofessional and illegal act by a doctor here would be pursued actively. Likewise, for 2, we simply don't know enough about the medical condition, but it is believable that the condition is in a gray area between being "terminal" and "not terminal", and with that kind of grayness, he was not doing something clearly unprofessional, and decided to leap towards a possible "treatment" that he would prefer himself, given similar circumstances. And there certainly are stories out there of doctors that are incompetent, unprofessional, or unethical, and who suggest treatment that they have no business doing. That is, after all, why medical boards do in fact remove licenses with some frequency, though the overall percentage of doctors thus reprimanded is very low. Statistically, the percentage of reprimandable behavior has to be higher than the number of actual reprimands, we just don't know how much higher.

Based on the evidence in hand, there is more evidence to believe that the patient's condition is not terminal than otherwise, and that - if reported accurately - the doctor's comment was out of bounds. The caveat "if reported accurately" is a pretty big one, since a comment involving a phrase like "end of life" or "do not resuscitate" could be mistaken by anyone as being comparable to "terminate." We don't actually have any evidence on how accurate the patient's capacity for noticing details and remembering them really is. But discussing some other putative situation (like some theoretical comment that we might put into a doctor's mouth) might be enlightening but would be something other than what we have here.

I would also distinguish between "unprofessional" in what I would call an "objective" sense--something that no professional medical person _should_ do, based on an objective notion of what the medical profession is all about--and "unprofessional" in the sense of being sufficiently contrary to the letter of the law/guidelines that you could in theory get in big trouble for it. I've been using "unprofessional" in the former sense. Even if the patient's heart condition is sufficiently bad (who says he's in "good health" if he's seeing a cardiologist regularly and has already had one heart attack?) that some legal definition of "terminal condition" could be applied without too much twisting, and even if there is no explicit regulation that dictates that a doctor can lose his license for spontaneously suggesting that a patient consider being actively terminated under those circumstances, and even if the incident occurred in a state with legal assisted suicide, this would still be _extremely_ unprofessional according to, let us say, a Hippocratic view of the medical profession.

This is from the Oregon statute.

"127.890 s.4.02. Liabilities.

(1) A person who without authorization of the patient willfully alters or forges a request for medication or conceals or destroys a rescission of that request with the intent or effect of causing the patient's death shall be guilty of a Class A felony.


(2) A person who coerces or exerts undue influence on a patient to request medication for the purpose of ending the patient's life, or to destroy a rescission of such a request, shall be guilty of a Class A felony."

The law also requires a second opinion. It is impossible to operate under the Oregon law without involving at minimum of six individuals. A doctor would be a fool to make an unsolicited suggestion to a patient that he consider suicide.

"Based on the evidence in hand..."

Tony, there is no evidence. All we have is a third hand, unsupported allegation (which on its face makes no sense) sourced through a newsletter (apparently unavailable online) with an ideological ax to grind. Did the news letter folks vet the letter? How? Absent considerably more information we don't know the 91 year old subject exists or that he wrote the letter if he is real.

This is not idle speculation. Consider what the proper reaction would be if the letter was from an eleven year old and referenced suggestions from a doctor that had sexual implications. We would expect a response from someone receiving such a letter to go beyond scoring ideological points with true believers. If all the publishers of the newsletter did was pass it on and tut-tut a little, it doesn't say much for them.

Al, it's not clear to me that a doctor who merely said something like the following would be liable for anything under the statutes you cite:

"Now, Mr. Jones, as you know, this state has a law permitting patients who wish it to end their lives with dignity at their own choice. You should discuss all your medical options with your family, and you might want to discuss this one as well. I can advise you as to the process if this is something you want to pursue."

Is somebody going to be able to convict on "undue influence" there? Why? No more so than for a doctor who mentions any other legal option. It's not even clear that the cardiologist would have been the doctor writing the prescription. If the patient had gotten back to him and expressed a desire to pursue that "option," he might have referred him elsewhere.

This was clearly a living will talk that the patient misunderstood for whatever reason--the mental fuzziness of being 91 years old, the unfamiliarly of the concept and having no idea what measures could be taken to extend life after he were brain dead, etc. You're purposefully misunderstanding it. Doesn't that violate your precious ninth commandment?

This was clearly a living will talk that the patient misunderstood for whatever reason

Pope Constantine has spoken.

I love "you're purposefully misunderstanding it." Um, no, I'm _quoting the letter_ and refusing to _reinterpret_ it to say something different from its normal meaning in the English language.

By the way, Al--given your liberalism, I can understand to some extent your willingness to believe that Maria McFadden might have literally lied and made up this letter out of whole cloth, that no such letter even exists, but that's just baloney. She's a straight shooter.

Tony: As for 3: there is incontrovertible evidence from other countries that have assisted suicide laws, that doctors sometimes engage in unprofessional and illegal behavior by "assisting" suicides where the death is actually explicitly contrary to the patient's wishes and there have been no repercussions on the doctors.

Nice, except that if there was any "incontrovertible evidence" there would be repercussions on the doctors. So whatever evidence you think exists, is probably on about the same level there always is about doctors and dying patients, whether there's an assisted suicide law or not.

Also, with regard to your four possibilities, first of all we have no data in hand - as Al notes, what we have is "a third hand, unsupported allegation (which on its face makes no sense) sourced through a newsletter (apparently unavailable online) with an ideological ax to grind".

But also: there is no motivation offered why the doctor would want to suggest that a patient who was doing fine right now would want to commit suicide. There is simply the fearmongering allegation that this is what doctors of geriatrics do.

But also: there is no motivation offered why the doctor would want to suggest that a patient who was doing fine right now would want to commit suicide.

Quoted for emphasis. Why would a doctor make such a suggestion? There doesn't seem to me to be any point.

It is true that this is scant evidence to go on, but then everyone, not just the right-wing fearmongers, should stop assuming that it is what they think it is. Since we have so little evidence, what can be said other than if it is true, then it's reprehensible? Everyone seems to agree with this, so there doesn't appear to be much to discuss.

Nice, except that if there was any "incontrovertible evidence" there would be repercussions on the doctors.

Lord have mercy, J, are you ignorant of this subject, or what? Do some reading, already. Um, no: Wesley J. Smith has documented again and again and again where the courts (the _courts_) in countries such as Holland have given doctors utter slap-on-the-wrist sentences for _overtly_ violating the laws, when anything is done at all. The refusals to punish then mean that the guidelines on the books are worthless. I just had a post recently on a study in which questionnaires were mailed to doctors in Flanders who _admitted on the questionnaire_ to doing things that violated Flemish "guidelines." This was all folded into the study--the study authors weren't even overly concerned--and not a thing is going to happen to the doctors. Their evident lack of any fear of repercussions is shown in their filling out the surveys as they did.

Moreover, as you apparently are completely unaware, infanticide was legalized first in Holland by mere refusal to prosecute doctors who openly admitted doing it.

You just do not appear to have followed this subject very closely at all.

"...but that's just baloney."

No, it's at least as reasonable a speculation as the allegations you make. Did Maria McFadden vet the letter? Most states (if not all) have laws on elder abuse which also might apply here. If the letter is real and the allegations true, there is a doctor engaged in seriously unprofessional and possibly criminal conduct. She has a moral obligation to follow up on this to the extent possible. She has to have the person's contact information - no responsible person would publish an allegation like this without it.

This should be easy for you to test. Did she vet the letter and if the answer is yes, how extensively? Secondly, assuming she verified the allegation, what is she going to do about it?

Further, it has nothing to do with my liberalism. When it comes to the public square experience has taught me to trust no one, suspect everyone. At this time and place, my skepticism inclines me towards the liberal/libertarian; conservatisms in general just don't hold up well to inspection.

"Quoted for emphasis. Why would a doctor make such a suggestion? There doesn't seem to me to be any point."

Which hasn't been answered. The doctor is a cardiologist, he gets paid as long as the guy keeps coming back. Whatever goes on with doctors and nurses in hospitals with folks in very unfortunate situations, that is not what is happening here. The guy comes in, the doc listens to his heart, looks at the cardio and blood tests, maybe adjusts a drug regimen, tells him to come back in four months, and bills Medicare. Why, why, oh why, would the doctor want to prematurely end this?

This should be easy for you to test. Did she vet the letter and if the answer is yes, how extensively? Secondly, assuming she verified the allegation, what is she going to do about it?

I wish it were. If I were in e-mail contact already with Maria, I would certainly suggest that she follow this up as aggressively as her correspondent will permit. (By the way, she mentions in her letter that he is a long-time subscriber, so the letter can scarcely be a hoax concerning a non-existent person.)

What I have done instead is to ask a person (whom I'm not going to name right now) with considerably more personal contact with the McFaddens, not to mention clout in the pro-life world, to seek further info about this. I'm hoping very much that he can get more on it.

As for why the doctor would suggest this--the guy is 91. It's not like he's likely to live a very long time anyway. The doctor presumably thought that _whatever_ he said was part of his professional role of giving information to a patient about his "options." If you can't imagine a doctor who would consider it to be part of his professional role, in a jurisdiction where suicide is legal, to offer information about that option spontaneously, I certainly can. Indeed, the doctor would likely think himself high-minded for not being dissuaded from doing so by a profit motive. Many people think about what _they_ would want or do in such a situation, and doctors are by no means immune from this. If the doctor himself would seek to control the time of his own death rather than waiting around for another heart attack, and if the suicide option is legal in the jurisdiction, he could well think it his duty to suggest it.

"(By the way, she mentions in her letter that he is a long-time subscriber, so the letter can scarcely be a hoax concerning a non-existent person.)"

Which raises the possibility that years of reading one particular POV on the life issues has conditioned him to think "suicide" when advance directives and the like are mentioned. This takes us back to last summer and the death panel nonsense.

"If the doctor himself would seek to control the time of his own death rather than waiting around for another heart attack, and if the suicide option is legal in the jurisdiction, he could well think it his duty to suggest it."

Not if he has even the most basic concept of professional ethics. Besides heart attacks are fast at that age which is another reason why a cardiologist wouldn't be expected to broach the subject. Dementia certainly doesn't seem to be a factor so this guy could easily chug along for a few more years at three visits a year.

The risk is if he codes and is resuscitated and winds up in the twilight zone. He needs to make his wishes known. He has a right to wish resuscitation or to just move on. At 91, his family and doctor need to know.

A little more on this control issue. Seeking control over ones death when facing certain circumstances doesn't necessarily mean seeking absolute control in all possible cases. My actions if facing dementia or cancer would be way different then those I would take if my ticker was beginning to tock.


I just had a post recently on a study in which questionnaires were mailed to doctors in Flanders who _admitted on the questionnaire_ to doing things that violated Flemish "guidelines."

I suppose it's bootless to point out that you're comparing apples and oranges?

In any situation where a patient is dying and in pain, or being kept alive under circumstances where the patient appears to have zero quality of life, all doctors, anywhere, will be faced with the prospect of being asked by the patient's relatives if they will put an end to the patient's suffering. We can argue back and forth forever about the ethics of this - but it has no connection with assisted suicide or end-of-life counselling: it is what happens when there is no legal way for a patient to say "If I code, I don't want you to bring me back".

Where a patient is conscious or has made a clear decision when conscious, they themselves are in control of their own death.

What you are suggesting happened is that a cardiologist, with an elderly patient in pretty good shape with the prospect of living for several more years, made an illegal and sociopathic suggestion to the patient that they should commit suicide. No motivation is offered for why the cardiologist should do this: we're agreed that if the cardiologist did do this it's a serious legal and ethical offense, and if the editor who published this letter took it seriously, she ought to have followed it up - as someone else said, "vetted the letter", at the very least. We have no ability to do that. We have merely to choose between the relative likelihoods of a sociopathic cardiologist and a 91-year-old who had, as Al said, been reading about evil doctors for many years and may well have misunderstood a perfectly reasonable suggestion: What do you want your loved ones to do if they have to choose between keeping you alive by extreme means, or letting you die of a serious heart attack?

And again, in the broader picture, while I acknowledge that a specific doctor may get a sociopathic kick out of suggesting suicide, it is utter, irresponsible scaremongering to suggest that all doctors who deal with geriatric patients do so.

I just had a post recently on a study in which questionnaires were mailed to doctors in Flanders who _admitted on the questionnaire_ to doing things that violated Flemish "guidelines."

I suppose it's bootless to point out that you're comparing apples and oranges?

In any situation where a patient is dying and in pain, or being kept alive under circumstances where the patient appears to have zero quality of life, all doctors, anywhere, will be faced with the prospect of being asked by the patient's relatives if they will put an end to the patient's suffering. We can argue back and forth forever about the ethics of this - but it has no connection with assisted suicide or end-of-life counselling: it is what happens when there is no legal way for a patient to say "If I code, I don't want you to bring me back".

Where a patient is conscious or has made a clear decision when conscious, they themselves are in control of their own death.

What you are suggesting happened is that a cardiologist, with an elderly patient in pretty good shape with the prospect of living for several more years, made an illegal and sociopathic suggestion to the patient that they should commit suicide. No motivation is offered for why the cardiologist should do this: we're agreed that if the cardiologist did do this it's a serious legal and ethical offense, and if the editor who published this letter took it seriously, she ought to have followed it up - as someone else said, "vetted the letter", at the very least. We have no ability to do that. We have merely to choose between the relative likelihoods of a sociopathic cardiologist and a 91-year-old who had, as Al said, been reading about evil doctors for many years and may well have misunderstood a perfectly reasonable suggestion: What do you want your loved ones to do if they have to choose between keeping you alive by extreme means, or letting you die of a serious heart attack?

And again, in the broader picture, while I acknowledge that a specific doctor may get a sociopathic kick out of suggesting suicide, it is utter, irresponsible scaremongering to suggest that all doctors who deal with geriatric patients do so.

J, I don't know what you're talking about concerning the study I cited. In those countries people _certainly_ are not "kept alive" against their wishes and so forth. Moreover, these doctors admitted (apparently, without any hesitation) to breaking their own countries' legal guidelines concerning the attempt actively to bring about death by the use of drugs. You had implied that there couldn't be incontrovertible evidence of doctors' on a fairly broad scale doing things that are illegal under their own countries' written guidelines. But there is. Quite a lot of evidence, actually. Such guidelines are usually not worth the paper they are written on, even from the beginning of their existence.

You say that I haven't assigned any motive for the cardiologist's actions. I think I've given a pretty good one.

One thing I find interesting here is the question of whether what he did was illegal. If they were in a jurisdiction where active suicide was itself illegal, I would tend to think this fairly important evidence that there was indeed a misunderstanding. Conversely (this is how evidence works), the patient's words, taken at face value, are evidence that what the cardiologist did was not illegal or at least that he thought it was not. In the U.S., active assisted suicide is still new enough that doctors are unlikely in states where it isn't legal to be the scofflaws that they are allowed to be on the continent, etc. They are likely to be more careful. However, _if_ assisted suicide is legal in the jurisdiction in question, it seems to me plausible that either the doctor's making the suggestion was not illegal or at least that he believed it was not illegal.

In other words, I agree that he probably wouldn't do something blatantly illegal if he knew he was doing so. I take this story to be evidence that there are cases where doctors at least do not believe they are doing anything illegal by suggesting assisted suicide to their elderly patients.

You say that I haven't assigned any motive for the cardiologist's actions. I think I've given a pretty good one.

Have you? In what post, on what blog? You've offered no motive here - and obviously, the letter-writer knew of none, so we have no credible data on that regardless of what speculations you may have published elsewhere.

In those countries people _certainly_ are not "kept alive" against their wishes and so forth.

You clearly don't know very much about the practice of healthcare in other countries: indeed, given this kind of fearmongering nonsense, I don't think you can know very much about the practice of healthcare in your own country.

Well, golly, J, if you can't even be bothered to read the thread you're commenting in, I certainly can't be bothered to repeat myself. And won't.

Lydia, I really don't see anywhere in your post or on this thread where you suggested any motive for the cardiologist to risk the income from a Medicare patient, his licence, and his career, by proposing that this patient commit suicide.

I have conceded that while we know of no motive, and none has been suggested, it's possible this particular doctor is a sociopath: that he really did propose a patient commit suicide, just for the kick of it.

But you can't argue (as you appear to be doing in this post) from one possibly-sociopathic doctor (and more probably, a combination of patient misunderstanding, doctor failing to communicate), to a fearmongering presumption that all doctors who have geriatric patients are sociopaths.

There's money in suicide, especially if you're a clinic in Switzerland, where assisted suicide is legal. Why is the UK so backward and behind the times, believing in such old-fashioned notions as a doctor's duty to preserve life?

Please see my article on the Swiss death clinic Dignitas for an insight into the full horror of human euthanasia.

Death as a Lifestyle Choice

Mary, the UK is by no means where Switzerland is; that is true. However, assisted suicide is now functionally legal in the UK due to prosecutor guidelines. See my post here

http://www.whatswrongwiththeworld.net/2009/09/assisted_suicide_legalized_in.html

Wesley Smith reported recently on a case where these guidelines were used and a decision made that it was "not in the public interest" to prosecute the known assisted suicide. I can get that link if you're interested.

The Liverpool Care Pathway, especially since the UK does not have the US's emphasis on patient and/or (at least) family consent, is also of huge concern.

I went over to Secondhand Smoke and found, by the way, more incontrovertible evidence that "guidelines" are widely flouted on the continent (specifically, in Belgium) and that people are being killed without consent "beyond the legal margins of the profession." (Nice phrase.) See here:

http://www.firstthings.com/blogs/secondhandsmoke/2010/06/05/legalizing-euthanasia-in-belgium-unleashes-nurses-to-do-doctor-ordered-non-voluntary-killing/

Mary: Why is the UK so backward and behind the times, believing in such old-fashioned notions as a doctor's duty to preserve life?

Threadjack, Mary! The thread is purporting to discuss an unknown cardiologist who may or may not have made an illegal/unethical suggestion to a patient.

Patients who actually wish to die and who are seeking help with assisted suicide are a separate issue from socipathic or criminal physicians.

No, Mary, you were not threadjacking. Ignore J as much as you like. He/she is our latest liberal semi-troll.

"One thing I find interesting here is the question of whether what he did was illegal."

For you it is interesting, for the doctor (should he be a resident of Oregon) it might well come down to facts to be determined by a jury. BTW, assisted suicide outside of the current law's dispensation is still illegal in Oregon. This is very expensive as well as very stressful. Those who hold professional licenses tend to conduct themselves in ways that avoid the courts.

.I think this is what is bothering J and moi.

"I would tend to think this fairly important evidence that there was indeed a misunderstanding. Conversely (this is how evidence works), the patient's words, taken at face value, are evidence that what the cardiologist did was not illegal or at least that he thought it was not."

This is a misuse of the term "evidence". Speculation isn't evidence. We just don't have enough information. You have one hypothesis on how a doctor would likely act under a given dispensation and I have another. Neither is evidence of anything.

Also, we all seem agreed that this would violate professional canons regardless of the jurisdiction. That lead some of us to speculate on the unlikeness of the suggestion. We are still speculating, not using evidence.

I would argue that the likely reaction of a licensed professional to a new law affecting his profession would be a very conservative one. Licensing agencies notify holders of new legislation on a regular basis. Professional associations and insurance companies provide information and folks talk amongst themselves. My experience is that caution is most likely the rteaction to a law that goes into uncharted territory..

The same goes for motive. I also have yet to see anything approaching a motive. Motives are personal and discerning a motive is impossible unless we have factual information on the actors which we don't yet have.

Lydia, while it it commendable that you have followed up on this, we do have another problem here. You testified that the publisher was a "straight shooter" yet you are communicating through a third party. If you don't know someone well enough to contact them directly, you don't know them well enough to begin to assess their integrity. I, long ago, learned this the hard way. Holding a correct position on this or that issue says nothing about character. General reputation counts for little or nothing. I can name numerous people with great general reps to whom the caveat "if you really knew them" apply. You may well be correct about the person in question but we don't know the basis of your assessment.

Also, being a straight shooter isn't enough. One can have great personal integrity and still have a mode of analysis that is poisoned by an ideology.

It may be, Al, that we have here a clash between the way you use the term "evidence" as a lawyer (you are a lawyer, right?) and the way I use it as an epistemologist. If the discovery that the doctor's actions (if he were suggesting assisted suicide) would have been unambiguously illegal in his jurisdiction would be evidence that there was a misunderstanding, and the doctor was not making that suggestion, then taking the patient's words at face value--that is, the proposition that the patient _did_ understand, and the doctor _was_ making that suggestion--is evidence that the suggestion was not unambiguously illegal in his jurisdiction. That is to say, evidential relevance is a two-way street.

There is an important distinction between something being legal and something being illegal but with a recommendation not to prosecute. Assisted suicide cases are usually treated sympathetically, but not always, especially where the person is not able to give consent.

Something is either legal or it isn't, and in the UK assisted suicide is illegal.

What bothers me about this post, and continues to bother me - and Lydia hasn't addressed this anywhere in the comments! - is that Lydia is directly interpreting "end of life counseling" as if this will allow the mass of sociopathic doctors she seems to think are caring for the elderly, to recommend to their patients that they commit suicide.

End of life counseling is not about suicide at all. That's why I felt "assisted suicide" was a non-sequitur. It's about what happens when your life is coming to an end and something happens which could require extreme measures to save your life.

It could be something like a patient with advanced cancer, who will live at most another three to six months, developing pneumonia and rejecting antibiotics: pneumonia being a pleasanter death than the last weeks of cancer. Or it could be catastrophic heart failure which could entail spending the last few months on a ventilator in a hospital bed - or a quick death in your own home. End of life counselling is about pointing out to a patient that if they have not made their wishes clear to their loved ones, they need to.

I had an elderly relative - a great-aunt whom I loved like a grandmother - who lived into her nineties, after a major heart attack and a succession of strokes. Towards the end, she was wandering a little in her memory (we talked mostly about events years in the past, which she could still remember clearly, since she couldn't always recall if she'd had lunch or what I'd said last week) and her body was failing her and causing her much pain. But she had made her wishes very clear to me and to others who loved her: she wanted to live as long as she could and die a natural death in her own home. And, with the invaluable help of the NHS, the local welfare services, her family, and her neighbours, that's what happened, and I know we were doing what she wanted for her. That's what should always happen. People should know they have the right to say what they want, no matter if that's not the most convenient for other people.

But for that to happen, a person needs to think about what they want and let the people who love them, know what they want. It's helpful and useful for a doctor to point this out. If a doctor does it badly, it's helpful and useful for the doctor to have this pointed out to them. If a sociopathic doctor takes this as permission to suggest suicide, this should have serious professional consequences - something a letter to a newsletter will not ensure, though a complaint to the doctor's partners or professional body should.

It's not helpful or useful to fearmonger that all doctors are sociopaths and that no doctor should be allowed to do end-of-life counseling, because all that will mean is more ignorance. Ignorance is never a good thing. Everyone should know they have the right to end their life in any way they choose, and that to get that right they need to tell those they love and trust most what they want. That's what my great-aunt did. No fearmongerers for her!

"Assisted suicide cases are usually treated sympathetically, but not always, especially where the person is not able to give consent."

??????????????????????????????????????????????

I see a problem with the terms here, elaborate please.

I take it from your comment, J, that the NHS doesn't have "death panels" that impose end of life decisions on patients. That will come as a surprise to some of the folks around here given all the misinformation surrounding the recent HCR discussions.

Mary, I certainly agree that the absence of patient consent would be important in the UK for what was admitted to be active assisted suicide, though it has no impact on the imposition of the Liverpool Care Pathway, I'm sorry to say. But the reason for the importance of consent in what is admitted to be assisted suicide is that the prosecutor's express guidelines for prosecution list request of the patient as relevant.

I would like to think that the "either it's illegal or its not" statement were as applicable to the assisted suicide situation in the UK as it sounds. But the fact is (as my link showed) that the Court there required the prosecutor to give express guidelines that would enable family members to know in advance when they would in all likelihood not be prosecuted despite breaking the letter of the law, and the prosecutor complied. This definitely blurs that nice, sharp distinction between legal and illegal. What the prosecutor did _not_ do was simply say, "I will prosecute all cases of active assisted suicide under the law that come to my attention." Instead, he said in some detail when it would likely not be regarded as "in the public interest" to prosecute. This is functional legalization for those cases, regardless of what remains on the books.

al: I take it from your comment, J, that the NHS doesn't have "death panels" that impose end of life decisions on patients.

Yeah, never could figure out what that was about. It's US private health insurance companies that do "death panels", with recission decisions based on profit, not good solid socialist healthcare for all.

Lydia, one of the key cases in "assisted suicide" was a woman who has MS, who knew that eventually she would reach a point where she might want to die, but would at that point be unable to kill herself - she would to be able to ask for help. Her husband was willing to do whatever she asked of him, and to stand the risk that he could be put on trial for assisted suicide, but she was not willing to put him at risk of being prosecuted. In her own words:

Debbie Purdy said: "I don't know what's going to happen to me in terms of the progression of my disease, and I don't know that my life will ever become unbearable. But I'm facing making a decision before I'm ready to about whether I want to end my life or not. I want the right to make the choice." Debbie Purdy wanted to know where the director of public prosecutions (DPP) would "draw the line" and prosecute someone who had helped a loved one go abroad to die; whether that is buying the plane tickets, pushing her wheelchair or looking up information. "Because it's so unclear, we don't know what my husband can do." BBC

Debbie was planning to go to Switzerland, if that became necessary: she didn't want her husband prosecuted for helping her go.

Yeah. And your point is what, exactly?

Lydia: Yeah. And your point is what, exactly?

Well, the thread appeared to have moved on from discussing doctors and end-of-life oounselling, to discussing why the UK now has guidelines for public prosecutors about whether or not a prosecution would be "in the public interest": which was because Debbie Purdy wanted to know, before she asked her husband to book tickets to Switzerland, before she asked him to push her wheelchair aboard the plane, would he be prosecuted for assisting in her intended suicide if she did so? She hadn't even yet got to a point where she might decide, then: she simply wanted to be clear how she could, legally, ask her husband to help her.

The connection between end-of-life counselling and assisted suicide is not clear to me, but you assured me you thought there was a connection.

No, I was merely discussing the fact _that_ there are such guidelines, which in effect legalize assisted suicide in the cases the guidelines specifies.

Lydia: I was merely discussing the fact _that_ there are such guidelines, which in effect legalize assisted suicide in the cases the guidelines specifies.

No, they really don't. cite The guidelines make it quite, quite clear: if you assist someone to commit suicide, even if you think your case falls within the guidelines, you are still liable for prosecution for murder or manslaughter. All they do is offer the possibility that if Debbie Purdy needs the assistance of her husband to travel to Switzerland when or if she decides to commit suicide, he will not be prosecuted for buying plane tickets or pushing her wheelchair. There will still be a police investigation on his return to the UK, if this happens, and there will still need to be independent and recent evidence that Debbie Purdy intended to commit suicide and was directly asking for assistance.

I still don't see how this relates to doctors having a duty of care to their patients, pointing out to them that they should discuss what they want with their loved ones while still mentally capable. I assure you it was a comfort to know that we were doing what my great-aunt wanted: she might have been more comfortable in a nursing home towards the end, but she had made clear to us that she wanted to stay home.

One point which occurred to me reading through the guidelines, too:

Suppose that someone decides to commit murder and to cover it up by claiming it to be an assisted suicide. Supposing that they do a good initial job, and convince the police/the public prosecutor that there's no real case to prosecute.

The decision not to prosecute actually makes that murderer less safe than if they were prosecuted and acquitted. If they're tried and acquitted of murder, they cannot then be tried for that crime again - not even if new evidence arises that this wasn't an assisted suicide. If there was a requirement to prosecute automatically in cases of assisted suicide, this could actually help murderers get away with it - they'd be automatically tried, acquitted because it appeared to be suicide, and then able to boast of their crime in public if they liked - you can't be tried twice for the same crime.

But if the public prosecutor decides that because it appears to be a case of assisted suicide which falls within the guidelines, there will be no prosecution, this leaves it open for all time that the murderer may still be prosecuted if new evidence arises - if, for example, it turns out that the victim may have changed their mind, if the murderer is benefiting from the victim's death and concealed that fact from the police, if there's new independent evidence that the victim had deteriorated mentally such that they could not have given recent and definite instructions for assisted suicide - etc.

Legalization of assisted suicide, or even decriminalization, would mean that Parliament had decided that assisted suicide was not prosecutable, which would mean the police would have no cause to seek evidence with a view to prosecution. That's an entirely different matter.

As is doctors telling their patients to be specifically clear to their loved ones what they want to happen as their life comes to an end, and after. It's like making a will: better to be clear and specific than expect people to just know.

Clever enough, _if_ you think that assisted suicide should not be prosecuted. I think it should be. And I've read the guidelines, and I understand the statement that "even if you think" what you've done falls within them, you're not getting any hard and fast promises. But the whole purpose was to set people's minds at rest by giving them guidance about what they can expect, and as I pointed out, there has already been a case where the prosecutor followed the guidelines and did not prosecute. If you can't see the functional legalization involved in such deliberate guidelines, I can't help you any further.

But the whole purpose was to set people's minds at rest by giving them guidance about what they can expect

Specifically, the whole purpose was to set Debbie Purdy's mind at rest by giving her guidance about what her husband could expect after her suicide, if she decides she needs to kill herself.

Admittedly it will serve for other people who are dying and who do not want to die worrying that their best friend or their spouse may be prosecuted for murder, too.

I'm in favor of a person who wants to pick their moment of death - when death is certain to come soon and it's only a matter of when - being allowed to so, without that being a crime.

I'm in favor of that person not having to do so alone or stressed, afraid to tell their family or friends what they plan in case their family/friends will be prosecuted, afraid that if they ask for help, the person they ask will run the risk of being done for murder.

If you don't see the difference between providing that reassurance to a person who is dying, and legalization, well: I think you need to study the issue a bit more, and look at actual examples of people who wanted to die and were, or were not, able to ask for help.

So the word "legalization" now means somehow that one is against what is legalized? Very confusing. Why not just admit that every word you just said means that you want assisted suicide *not to be illegal* in the cases where you approve it? Most people on your side of the issue do say that. Why should the word "legalization" indicate disapproval? "Providing that assurance to a person who is dying," where the "reassurance" is that the person who "helps" them won't be prosecuted, is providing reassurance that the act will not be treated as illegal. Sounds like a neutral description to me. Can't understand why you're arguing over the term.

So the word "legalization" now means somehow that one is against what is legalized?

Does it? I wasn't aware of that. Nor do I believe I said anything that could remotely be interpreted as such.

Providing that assurance to a person who is dying," where the "reassurance" is that the person who "helps" them won't be prosecuted, is providing reassurance that the act will not be treated as illegal.

No: it is providing assurance that the act, though illegal, may not be prosecuted, providing the illegal act committed is only helping someone to die who has expressly and recently said they want to commit suicide and asked for that help, who is gravely ill but of sufficiently sound mind that they know what they are asking for. Of course the option to prosecute later is always open, if further evidence transpires.

Also, it provides assurance that a murderer who tries to conceal their crime as an "assisted suicide", will not find an easy route of automatic prosecution and acquittal. I like that assurance, personally: I disapprove of murder, as Hercule Poirot used to say. You may find this a trivial point, which I find odd, given your apparent belief in sociopathic doctors.

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