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Join us as we delve into the complex terrain of end-of-life care and the contentious debate surrounding assisted suicide legislation. Cardiologist Joseph E. Marine offers unique insights into the ethical, medical, and societal implications of this polarizing issue. From disparities in health care access to the importance of palliative care, Joseph shares his expertise, challenging conventional perspectives and advocating for a more holistic approach to supporting patients with advanced illnesses and disabilities.

Joseph E. Marine is a cardiologist.

He discusses the KevinMD article, “Assisted suicide is the wrong prescription.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Joseph Marine. He’s a cardiologist, and today’s KevinMD article is “Assisted suicide is the wrong prescription.” Joseph, welcome to the show.

Joseph Marine: Thanks, Kevin, thanks for having me on.

Kevin Pho: So let’s start by briefly sharing your story and journey.

Joseph Marine: Sure. Well, I’m an EP cardiologist. I’ve been with Johns Hopkins in Baltimore for about 20 years. I trained in California in an interesting program where we were introduced early on to ethical and legal issues in medicine, so I’ve always been very interested in that area. And so that’s part of what led me to become interested in this topic.

Kevin Pho: All right. So let’s talk about this article, “Assisted suicide is the wrong prescription.” And before talking about the article itself, tell me about the events that led up to you writing this article in the first place.

Joseph Marine: Sure. So I remember way back in my ethics courses back in California in the 1980s, early 1990s, that this issue started coming up, the issue of euthanasia. In the United States it was just being introduced, the idea was being introduced in Oregon. So I remember it way back then.

And then when I moved to Maryland, established my practice there, this issue came up around 2015 when proponents started introducing a similar law into the Maryland legislature. And that’s when I got involved in Maryland.

Kevin Pho: All right. So tell us about your stance, and for those who didn’t get a chance to read your article, tell us what it’s about.

Joseph Marine: Sure. So euthanasia more broadly, and assisted suicide more specifically, is physicians prescribing a lethal overdose of prescription drugs to cause the death of a patient who has a six-month prognosis. That’s the way these laws are written.

It first was passed in Oregon in 1994, passed in Washington state in 2008, in California in 2015, and several other states since that time. There’s an organized proponent group that introduces similar laws in about 20 states every year, and Maryland is one of those states where it’s been introduced year after year.

I got involved around 2016, from a physician colleague at a neighboring institution who was also interested in this issue, learned about it. And the more I learned about it, the more I started to understand how destructive it was going to be to the ethics of our profession and professionalism. And that was kind of my hook to get involved, to learn more about it. And the more I learned, the more I thought that this was a very, very bad law that needed to be opposed.

I got involved in communities of other physicians, nurses, other clinicians, as well as the disability rights community, who generally is very opposed to these laws as well.

Kevin Pho: So I’ve had guests on the show who are indeed proponents of these laws. So tell us your arguments against these laws.

Joseph Marine: Well, the core one, I think, is that it’s not medical care. It has no basis in medical science, no basis in medical practice or tradition. Very few physicians participate in this practice in states where it’s been legalized.

It really undermines the ethics of our profession, going back to the Hippocratic oath 2400 years ago. It’s very specifically forbidden in the Hippocratic oath, and for 2400 years our profession has really said that this is not the role of a physician.

I think the AMA says it best, that it’s not the role of a physician, it undermines our role as a healer, it would be difficult to control, and poses serious societal risks.

In every other country where this has been introduced, it leads rapidly to expansion into euthanasia for virtually any group. So I think we have to watch what’s happened in Canada, what’s happened in the Netherlands and other states where this has been introduced, to see where it’s going.

I think it’s also important to understand that this will affect everybody. It will change the practice of medicine, it will change how physicians see patients with advanced disabilities, with advanced illnesses. And so it’s, I think, a very important issue, even though it’s sometimes framed as a peripheral issue. I think it’s really one of the most important ethical and professional issues of our time.

Kevin Pho: So you mentioned that we need to observe what’s happening in Canada, in the Netherlands, and in some states where this is legalized. So what in fact is happening in those areas?

Joseph Marine: Well, I think in other countries, it starts as a very limited option for patients at the very end of life, and then it expands to patients with any condition that can cause suffering, including those that are not terminal. In some countries it’s allowed for patients who don’t even have a physical illness, for patients exclusively experiencing mental illness such as PTSD or depression or autism.

So these stories periodically hit the media and you scratch your head wondering, how could they have arrived at this position? But I think if you allow that this is medical care, and that it’s a legitimate way for physicians to relieve suffering, then the possibilities for expansion are virtually limitless.

Kevin Pho: In the United States specifically, are you seeing such cases where assisted suicide is being used indiscriminately or inappropriately?

Joseph Marine: We have not. In the United States it’s been much more limited, and I think that’s because there still is much more physician and clinician opposition, as well as societal opposition, to it.

I think once that breaks down, though, it’s very likely that we would see the same process develop in the United States as it has in every other country where it’s been introduced. Because if you accept the premise that this is medical care, that this is a legitimate way to address suffering, as I said, the opportunities for expansion are limitless.

Kevin Pho: So you’re a cardiologist, you obviously have experience in critical care situations. So when you are talking to families in end of life situations and they bring up the topic of assisted suicide, and knowing what you’re talking about here, how do you approach these conversations with patients when they approach that topic?

Joseph Marine: Well, I’ve actually never had a patient bring this up specifically. I’ve had one patient bring up, when her husband passed away from an advanced illness, talking about wanting to end her life.

I approach it as suicide prevention, which is how we’re trained. We’re trained as physicians, when a patient has suicidal thoughts or beliefs, we address that as an opportunity to intervene, to understand what’s causing the distress, and to get them the appropriate help and support that they need. That’s always been the conventional medical approach. These laws would then effectively change the standard of care from suicide prevention to suicide promotion.

For those patients who are nearing the very end of life, we have hospice services, we have pain management services, we have palliative care services. And that’s kind of one of the curiosities of this, is these fields have developed so far in the last 10 to 20 years, we’ve really had less need for euthanasia than at any point in the history of medicine. And it’s only now that euthanasia is being proposed as something that’s necessary.

So our answer and our response should be hospice care, palliative care services, pain management services. This is really what we should be promoting, and not undermining and cutting off these services with euthanasia.

Kevin Pho: So in your piece you talk about the lack of formal mental health evaluations for patients seeking assisted suicide. So talk more about that.

Joseph Marine: Sure. Well, these laws generally do not require a formal mental health evaluation, which is surprising and concerning, because it’s very well documented that depression is very common in patients with advanced illnesses.

And yet in Oregon, which is the first state to have this, less than 1 percent of patients referred for assisted suicide do receive a formal mental health evaluation to see if any other intervention is available for them. So it suggests that, even in the states where this is passed, they recommend a mental health evaluation if there’s concern about competency, it’s very rarely being used.

Kevin Pho: So tell us about some paths forward. So what would you like to see done? Would you like to see a repeal of these laws for states that have legalized this? So what do you see as a reasonable path forward going, knowing how fraught this issue is ethically?

Joseph Marine: Well, I’ve never really thought about what to do in states that have already passed it. My focus has really been in Maryland, working with our coalition to spread the word, to help people understand the dangers that these laws pose, and to keep it from being passed in my state.

I’ve also talked to groups in other states, to educate them, to help them learn what I’ve learned about it, to address the issue as it comes in their state.

So I think that physicians just need to be aware of this. And in those states that do have it, I think we should be promoting hospice care, palliative care, and pain management programs as an alternative, so that it’s unnecessary.

Kevin Pho: What are some of the leading arguments that proponents have for assisted suicide, and tell us how you would refute those arguments?

Joseph Marine: I think the leading arguments are compassion and autonomy.

Addressing the autonomy issue first, I think that is a fallacy, because if you look at the structure of these laws, they say nothing about patient autonomy. They do not provide patients with any rights. They’re exclusively designed to shield the physicians involved from liability for being involved.

Assisted suicide in general is illegal just about everywhere, because the law recognizes the value of protecting life and the potential for abuse if somebody is involved in encouraging or enabling the suicide of another person. So these laws essentially are a carve out for physicians.

Every assisted suicide that takes place under these laws requires five people to participate. They require two physicians, a prescribing physician and a consulting physician. It requires two witnesses, and it requires a pharmacist to participate. So it really is not about autonomy, if you read the law carefully.

In terms of compassion, compassion means suffering with somebody. And I think that you can make an argument that euthanasia really cuts off compassion. It’s not a sign of compassion. Our compassion is to accompany the patient, to help them in every way that we possibly can, and to use the services that we have, hospice, palliative care, and pain management.

Kevin Pho: So as I mentioned before, I’ve had physicians on the show who are ardent proponents of assisted suicide. So tell us about what it’s like in Maryland when you have discussions with physicians who don’t agree with you. What are those discussions like? Tell us about some of that tension whenever you have hearings or meetings discussing the issue.

Joseph Marine: Yeah, I think they’re very polite. It doesn’t come up a lot in general conversation. It’s more when the bill gets introduced, we all congregate at the legislature, and the proponents and the opponents are together, often waiting for their turn to testify. And I could say it’s very cordial, and I respect different views about this.

My own experience has been that the more that physicians and other people learn about the dangers of the law, that they learn about the alternatives that exist, the more people come around to the opponent view. That’s not always the case, but in the areas where I’ve seen in Maryland, it’s a respectful and polite disagreement.

Kevin Pho: So what’s the landscape today in the United States in terms of how many states are considering assisted suicide laws, and what is the path forward in the foreseeable future?

Joseph Marine: Well, the proponent groups introduce the bill repeatedly in legislatures year after year in about 20 states. There’s some states where it just is thought to have little chance of passing, so they tend to bypass those states. But there are a lot of states where it’s very close, where it comes down to a very close vote in the committee, a very close vote of the legislature. So they tend to come back year after year, so the opponent groups like myself have to be ready every year.

I think there was concern in the opponent groups after California passed the law in 2015, that there was going to be an avalanche of bills passing in states around the country. That really hasn’t happened, and I view that as a hopeful sign.

I think more and more people are waking up, as I said, that this is not a peripheral issue, this is a central issue, it’s really the medical ethical issue of our time. And what I found is, the more people learn about it, the more people recognize the problems, and that the solution is to promote better alternatives.

Kevin Pho: And for people who are interested in learning more about this debate, what kind of resources would you recommend for them?

Joseph Marine: The Patients Rights Action Fund, or PRAF, has a great website that has a whole host of materials to learn about this issue, what’s going on on a state-by-state basis. So I think that’s the number one site.

The National Council on Disability issued a position paper in 2019. That’s a federal agency that advises on disabilities and disability rights. They issued a very strong statement outlining all the problems with these laws in a 2019 position paper, so you can go to their website as well.

Kevin Pho: We’re talking to Joseph Marine. He’s a cardiologist, and today’s KevinMD article is “Assisted suicide is the wrong prescription.” Joseph, we’ll end with some of your take-home messages that you want to leave with the KevinMD audience.

Joseph Marine: Great. Well, assisted suicide and euthanasia is not medical care. It really poses a danger to our profession and to our professionalism and the trust that the public has in us. It will ultimately affect everybody. And so I urge all of my clinician colleagues to learn as much as they can about it, and to understand the issue, and hopefully to oppose it.

Kevin Pho: Joseph, thanks again for sharing your perspective and insight, and thanks again for coming on the show.

Joseph Marine: Thank you, Kevin. Great to be with you.