The Montana Supreme Court's December 31 ruling upholding a physician's right to prescribe life-ending medication generated weeks of commentary from legislators, the public and the religious community. But the group still waiting on organized debate is the one most challenged by the new legality of physician-assisted death (PAD): physicians.
To that end, Missoula cancer specialist Stephen Speckart hopes to build awareness of how the Supreme Court's decision impacts Montana doctors. Aid in dying is a game-changing move in the medical field, he says, and raises questions far more complex than just its legality.
"Physicians do have an ethical obligation to relieve suffering and pain," Speckart says. "The problem is how do you describe suffering and pain? Is that to allow it to continue so it's perhaps intolerable to the patient, or are you dealing with suffering and pain by assisting patients in dying? That's something that can only be answered by the individuals involved, and can be argued on either side."
The ethical implications of participating in a patient's death tie directly to the principles that have guided medical practitioners for centuries. Physicians traditionally consider it their solemn duty to maintain the health of those they treat. And while the Hippocratic Oath may be silent on the specific issue of PAD, organizations across the country have adopted a firm stance in their codes of medical ethics. The American Medical Association (AMA), for example, has condemned the prescription of life-ending medications since the early 1990s.
"Allowing physicians to participate in assisted suicide would cause more harm than good," the AMA's code reads. "Physician-assisted suicide is fundamentally incompatible with the physician's role as healer, would be difficult or impossible to control, and would pose serious societal risks."
Chief among those risks, perhaps, is the well-being of physicians themselves. Rebecca Anderson, a hospitalist at Community Medical Center in Missoula, says physicians simply aren't used to dealing with the level of responsibility involved in helping a patient die.
"We're here to help the patient in their health and not necessarily trained emotionally and psychologically for assisting the patient in actively, to a certain extent, committing suicide," Anderson says. "I think I would have difficulty managing the emotions around that, because as a practicing physician I work so hard at keeping the patient comfortable and helping the patient control the disease process."
Like many Montana physicians, Anderson is opposed to the practice now supported by the Supreme Court. In her 19 years treating patients in Missoula, she's fully embraced the palliative services of efforts like hospice. Others agree that comfort—not death—is the best way to approach end-of-life treatment.
"It's hard to argue for killing people," says Thomas Roberts, a physician at the Western Montana Clinic in Missoula. "It's not hard to argue for keeping people comfortable."
Speckart views the ethics issue much differently. He acknowledges the strides physicians have made in keeping terminally ill patients comfortable through the dying process, and adds he helped found the first hospice service in Montana back in the late 1970s. He says PAD is reserved for rare and extenuating situations.
"It's for a very small number of patients who have terminal suffering that becomes intolerable to them and they have an honest fear of the loss of function, the loss of dignity and the problems of pain," Speckart says. "They wish not to go through additional short months or weeks of continued suffering. That does not add value to their lives."
Speckart points to the only two states besides Montana to have legalized the practice—Washington and Oregon—to show the rarity of PAD. In 2008, physicians in Oregon wrote 88 prescriptions for life-ending medication. According to the Oregon Public Health Division, 54 of the 88 recipients chose to take the drugs.
Separate from the question of professional ethics is the issue of how PAD will play into a physician's individual moral beliefs. Addressing those moral implications is one of the goals the Center for Ethics at the University of Montana has set for a panel discussion March 16. While the court's ruling makes PAD defensible in court, the state still lacks a law governing the practice, leaving room for critics to use societal dilemmas like morality as leverage in making PAD illegal. Speckart volunteered to help facilitate the March event to promote understanding of the guidelines needed in pending legislation.
But some believe no matter how well crafted the law might be, PAD will take a heavy toll on doctors.
"I think legislation would help take some of the angst away on the physician's part, but I don't think that's the only issue here," Anderson says. "Dealing with the issue of, 'Oh, I wrote a prescription for a patient who used it to kill themselves' creates a sense of almost guilt and responsibility that I think physicians would have a hard time embracing. That's just not how we've been wired all our lives."
Speckart believes PAD will ultimately hinge on personal morality. Since 1977, when he first established an oncology practice in Missoula, Speckart has heard few requests from terminally ill patients to prematurely end life. Those were tough conversations to have, he says, due not only to his powerlessness at the time, but also to the emotions involved. That fact isn't bound to change.
"To sit down and write a prescription for a certain medication that you know could be lethal for the patient, and to understand at that moment that the patient may take it...is a dramatic change from what physicians are used to," Speckart says. "I think it will be very hard and very difficult for most doctors to feel comfortable and correct morally, and in terms of their relationships with patients, in doing that."This story was updated March 4 to reflect the Center for Ethics new date for its panel discussion.