In this episode of Family Matters, Simon O’Connor welcomes Dr. Sharon Quick, a retired anaesthesiologist and bioethicist, to discuss the ethical and medical aspects of euthanasia and assisted suicide. Drawing on her extensive experience, she shares the reality of what actually happens when drugs are used to end a person’s life.
Dr. Quick, who is part of the Charlotte Lozier Institute and president of the Physicians for Compassionate Care Education Foundation (PCCEF), outlines her organisation’s mission to protect vulnerable individuals at the end of life, oppose assisted suicide, and promote palliative care.
She explains the critical difference between autonomy and capacity to choose, highlighting the risks of unrecognised depression and subtle coercion in decision-making processes in terminally ill patients. The conversation delves into the lack of training among physicians in detecting coercion and the ethical issues surrounding doctors using lethal drugs.
Dr. Quick draws attention to the chilling potential for patients to experience consciousness without the ability to move or communicate during euthanasia due to use of neuromuscular blockers, comparing the protocols to those used in prison executions. She critiques the legalisation of euthanasia for undermining the foundational equality of persons and shares insights from her extensive medical experience. The discussion also covers how proper palliative care can holistically address pain and suffering at the end of life, advocating for a compassionate and ethical approach to care.
Show transcript auto-generated by Descript app:
Simon O’Connor: Hi everyone. Welcome back to Family Matters, and we’re heading back to the United States. As viewers and listeners know, I’m all over the world interviewing different people, but delighted to be back in the United States. And to introduce to you Sharon Quick, MD and MA, and if I might be so informal.
Sharon, welcome to the show. New Zealanders would think of you as Dr. Sharon Quick. We tend to put titles at the end, but your good self coming from America, obviously a medical doctor and importantly an MA in bioethics as well. And if I could as a bit of an introduction, you’re an anaesthesiologist and I managed to get my tongue around that.
Retired from paediatric anaesthesia and critical care and as say an MA in bioethics. You are part of the Charlotte Lozier Institute. One of, I would argue our premier institute’s delving into matters of life and death from an ethical side of things. But you’re also the president, and I have to read this because it’s quite a long title.
You are the president of the Physicians for Compassionate Care Education Foundation. So look, welcome to the show. If you don’t mind, tell us a little bit about yourself and your role here at the. Physicians for Compassionate Care Educational Foundation.
Sharon Quick: Thank you so much for having me. This is such an important topic.
Our organisation, I call it PCCEF for short, so I don’t have to continue to utter that. And our website is www.pccef.org. If, do you have any interest in looking up anything about our organisation? We primarily exist to protect the vulnerable at the end of life. We oppose assisted suicide in euthanasia and we promote good palliative care.
One of our goals is to create a network of physicians and other healthcare professionals, not only in the US but even across the world. We get occasionally patient requests or requests from family members. Wanting a life affirming physician for their loved one. And I would like to be able to recommend a healthcare professional in their area.
So that is one of our, one of our goals.
Simon O’Connor: How long’s the organisation been running for, if you don’t mind me asking?
Sharon Quick: It started actually in Oregon back in the late nineties when Oregon first passed their assisted suicide law. And it’s continued since then. So I’m trying to it was in a bit of a decline.
So when I took over, it was a funny story. I got to be President. I’m involved in a coalition in Washington that helps fight expanded assisted suicide in Washington state. And some of the people in the coalition said, why don’t you ask the people in PCCEF if they could help us by notifying their Washington members about this potential law. And so I met with some of the board members and they, I suggested some ways they could help us. And they said those are great ideas. Do you want to become President? And anyway, I ended up. Doing that and realizing that the organisation was in a bit of a decline. And so I’m trying to get it back on track and not just to pose assisted suicide, but I think we really need to promote good palliative care.
So that’s an increased focus that we be for that and not just against something.
Simon O’Connor: It’s certainly something that resonates with me. It’s very easy to oppose things to be against things. That actually, as you say, promoting something that’s quite positive. And it’s very much a big debate here in New Zealand, and I’m not going to draw you into that because of course you are in the United States and we’re here, but we effectively have a fully funded euthanasia and assisted suicide program.
But we do not have properly funded palliative or hospice care in New Zealand. Which instantly brings us to the question of autonomy, actually, because I would argue it, says me to you with an MA in bioethics, but there isn’t an autonomous decision here because basically you’re being railroaded in one particular direction.
But before we came on camera, you were talking a lot about autonomy and the place of pain. And of course, you are well versed to talk about both being an anaesthesiologist and a bioethicist. So maybe we can start with autonomy. Why is this put forward so often in arguments to promote euthanasia?
And what are the problems with it?
Sharon Quick: Autonomy that has two parts actually. It’s not only the right to choose, which is what most people think about when they’re saying people with auto, people should have the right to decide about lethal drugs because of autonomy, but there’s a capacity to choose. So if you have someone who does not have sufficient capacity, and that goes unrecognised, then if someone just.
Abides by what may be a superficial decision to end their life without understanding that they have deficits in that capacity to choose, and you’ve actually violated. Their autonomy because that hasn’t been recognised. So if you just think about the capacity to choose people who are terminally Ill have a declining capacity to choose as they approach death.
And it’s not just the cognitive decision making capacity, which is what most people think about. There are multiple factors that go into that. There can be depression that. Often goes unrecognised of up to 40% of cases of depression are unrecognised by physicians. And even the capacity for decision making that cognitive decision making is often unrecognised by physicians as well.
There was a study done of cancer patients that showed that 90% of cancer patients have deficits on some subscale of their capacity. To make decisions, and yet most of the physicians did not recognise that they had those deficits. So you’re also seeing a lot of emotional and psychological liability at the end of life where people may be really discouraged one day, but the next day they’re fine.
They can, there can be a lot of subtle coercion a feeling that. They’re devalued because how our culture puts such a focus on youth beauty, strength, intelligence, and independence. And when they have losses in those areas, they, they feel devalued and other people can contribute to the making them feel that way with body language, subtle cues, avoiding people who have developing disabilities at the end of life.
So there are a lot of reasons why someone’s capacity can decline towards the end of life.
Simon O’Connor: Seems the part we don’t discuss all that often. It’s certainly been my experience as we debated this politically and ethically here in New Zealand that it was all about choice, but not willing to discuss the impediments as you say.
Obviously there’s a lot of similarities between the training of doctors or physicians in America and New Zealand, from your experience, are doctors actually trained into being able to detect coercion? I assume if you’re a psychiatrist or psychologist, that would be pass part of the core, but for most doctors, I’m assuming, like here in New Zealand, there wouldn’t be a lot of training in that?
Sharon Quick: No, there’s not. In fact, if there is a survey done of psychiatrist and. The majority actually recommended that if you were going to try to evaluate someone to see whether or not they had the capacity to make such a decision to end their life, they recommended that you have a forensic psychologist with a subspecialty in that.
And even then, only 6% thought that you could determine that in one visit. These are specialists who think that can’t even be easily determined. So it’s pretty concerning that you have people relying on, and sometimes it’s physicians that have only seen the patient once. They don’t even know the patient, and they’re catching that patient at one point in time and making a decision, and they may not have any idea what’s going on in the person’s background.
That person may not even understand that they have subtle coercion. They may not understand, like if they heard, overheard a family member talking about the finances and concern that the medical care is going to take up all the family’s finances, they may not see that as coercion and they may not mention it.
So instead of addressing financial issues, they the doctor doesn’t even notice that and is providing lethal drugs because of a financial problem. So that’s a real problem.
Simon O’Connor: I suspect it’s a part of New Zealand’s as well with hundreds of people seeking euthanasia or physician assisted suicide here. I don’t have the exact number but I think it’s even less than 10%. It might even be less than 5%. And I’m sorry, I’ve forgotten the number, but very few are actually even passed on for any psychological analysis and I find it extraordinary. With all the talk here in New Zealand and I suspect in America around mental health and stress and anxiety and resilience issues, that somehow when it comes to the end of life these doctors basically just seem to know first time from one little visit that everything’s perfectly okay and you’re going, that doesn’t make any sense whatsoever.
And I wonder, does a lot of it come down to what you just mentioned, that our society culturally focuses so much on youth, beauty, and ability. That we go, we are not actually worried if there’s coercion in the way we would for say, a 16-year-old, if someone was saying, I want to terminate my life when they’re 16 or 25, 35, we’d be going, whoa, we’re sending you to that forensic psychologist.
Yeah, but we don’t do it at the end, do we?’
Sharon Quick: No, and I think you’re absolutely right that there’s a sense that doctors devalue those with disabilities as well. And there’s actually good studies to show that doctors will view the quality of life as of patients with disabilities as less, and those patients view themselves.
And what is sad is if you really look at what happens. To people with disabilities. They may be very depressed when they initially lose functions, but over time, if they have the proper support and medical care, they will adapt and they will come to see that disability is not essential to their value.
And that’s where the disability community is largely against assisted suicide in euthanasia because what it really is. It condemns those with disabilities because it’s not only is terminal illness a disability in and of itself, at least it is classified as that in the United States, but the reasons why most people seek lethal drugs are not due to pain, although that is one small issue.
But it’s due to seeing a loss of function, a loss of independence, feeling like they lack dignity because they can’t do the things that they used to do, the things that gave them identity and value. And if you would wait long enough they would overcome that depression and they would get better. And there are good studies to show that when someone has initially a diagnosis of a terminal illness or a serious medical complication.
That their depression level may be high, but within about six months it’s usually much lower. Just a little bit above the general population. So what we need to be doing is really supporting people during that time and not devaluing them – in reality what the laws do. They really don’t give patients any new options because as sad as it is and tragic people can commit suicide without any help.
But they give doctors new powers to create two categories of people. So that those who want to end their life are either placed into the category of being protected, that they get standard mental health services, or they can be put into a category of that’s marginalised, where they can get lethal drugs.
And that second category is only those with the disability of terminal illness or those who develop disabilities in the course of their terminal illness. So it’s really a condemnation and a discrimination against the disability community.
Simon O’Connor: It’s certainly been my experience with a number of friends in the disability community.
It’s not complete comprehensive, but as you said, most oppose it because so much of what’s been said is I’d rather be dead than like this person who has whatever the disability it is. And I find that for me quite profoundly shocking that our societies have accepted that because the choice for suicide or euthanasia is making a very direct statement about others living their lives.
And again, I don’t have your medical background, but having been at many people’s bedsides the first days, weeks, months of finding out there’s a terminal illness or facing death, depression, anxiety, anger, quite normal. But as you say, time goes on, there’s just an acceptance, not an all in every case, but more often than not.
I suppose that’s then the place of good palliative care, not exclusively, but in particular does seek to address that.
Sharon Quick: Yes. That’s really holistic care that addresses psychological, emotional, physical, spiritual issues, and it really comes alongside people and helps them to see that. They are valuable not because of their circumstances, because they, but because they have intrinsic value.
And some people get confused about what’s the difference between palliative care and hospice. Palliative care is for any chronic serious disease and it can be, doesn’t have to be terminal. And then hospice is more, at least in the US it’s more of an insurance benefit. When someone is thought to have only six months to live, then it’s palliative care basically at the end of life.
Simon O’Connor: We have a sort of a blend here in, in New Zealand and so far as we would, we have private insurance, but we have a more socialised system without taking us down a giant rabbit hole of the different health systems between our two countries. But the palliative care is certainly all embracing.
Hospice is certainly seen as more of end of life, although a lot of the hospices I know are often saying to people ‘come to us earlier on, you don’t need to be the last six weeks or even six months, we can start providing that holistic care’, which is more than just the drugs being prescribed or the pharmaceuticals being prescribed, is that wider holistic side, which does seem to have such a profound ability.
And I, I suppose with your work over many years and now your research, you would’ve seen that.
Sharon Quick: Yes. And I, the other thing I would mention about the whole equality of persons is that, our laws are founded on equality of persons. And that’s for most democratic societies, that is the foundation.
Our Declaration of Independence, for example, says that all people were created. Equal and endowed by the Creator with rights to life, liberty and pursuit of happiness. And those are ordered rights. The equality of persons is the foundation for all the others. And you need that equality of persons in order to have the right to life. And you need life in order to have liberty. And then you need liberty for pursuit of happiness, which is essentially autonomy. And so when you take away any of those more foundational rights, you topple all the rights above it. So when you have an assisted suicide or euthanasia law that puts people into two different categories so that you’re marginalising one group, you’ve created an unequal law, basically, where you treat some people differently than others, that takes away autonomy.
You’ve then you’re taking away their life. Someone who’s dead can’t have autonomy, you basically topple that. And what I found very interesting in your law is that it said one of the principles upon this, which this was based was equality of persons. And it does the exact opposite. It actually takes away equality of persons and creates a two-tiered health system.
So that’s another contradiction in your, in the law itself.
Simon O’Connor: It was full of contradictions. I think it’s a terrible law and people who follow this podcast know my views quite clearly on it. It’s full of contradictions and the manipulation of language, as you just mentioned, equality. The others talk a lot about compassion, which we know means to suffer with. That’s what compassion literally means to co-passionate. Yet compassion here has been turned on its head, which is, oh we’ll knock granny off, but it, it’s, yeah, it’s mind boggling. Look it won’t surprise you, I agree with the ordering of, so my background’s philosophy and ethics, and familiar with, as you say that, that ordering, what would you say to the pro-euthanasia side who would say actually the right to life includes the right for me to say it’s over. What would be your response to that?
Sharon Quick: You have to have life before you can even say that it’s over. And I think that you cannot, again, the equality of persons is underneath that and the whole, you can’t have a right to life unless you have equality of persons.
Otherwise, you could take the life of another innocent person that you thought was not as valuable as yours. So when you take away the equality of persons, you essentially have taken away the right to life. And so I think you have to go one level deeper and say that the euthanasia laws are actually destroying equality of persons.
Simon O’Connor: I think, too, and it’s probably an extension of what you’ve said, and please correct me on any of this, I’ll defer to your research and work. But the choice of someone ending their life is actually having impacts on others. That equality side and, had to debate over the years with some people, terrible conditions, and in some ways we are saying actually we will do all we can to care and help for you, but by allowing your death by you to exercise what you perceive as autonomy will have an effect on others in our society, which is why we have rules and guardrails and all sorts of. All sorts of ways.
But unfortunately, whether it’s Oregon, I think you mentioned Washington, certainly here in New Zealand, we’ve thrown all that caution to the wind.
Sharon Quick: Yes. And there, there actually are studies that show that suicide itself increases in regions that have legalised assisted suicide in the us. So there is that concept of suicide contagion.
If it’s seen as okay in the culture and you try to normalize it. Then, you can put all those guardrails up, but in reality, those are easily changed. Why is it that we have terminal illness only? Why is it that it’s six months? Why is it that you have all these boundaries about when it’s possible and when it’s not, and there’s no logical reason for those boundaries.
If autonomy is the reasoning behind that, then people should be able to just do whatever they want, whenever they want. And why do you have to be terminally ill? Some of those people are suffering just as much as those. Who are who are terminally ill. And so you have then, that’s what happens in pretty much every jurisdiction where they pass those laws is they end up expanding them and in some cases, to really horrific things like what’s happening in Canada or in, in a couple of states.
In the US they’ve actually have this waiving of the waiting period, which is another really medically contraindicated provision to do that.
Simon O’Connor: Yeah, it’s too early in New Zealand for us to get the any correlation yet because it’s only been three and a bit years. I would expect looking at overseas that we will see wider problems and suicide because it basically, we’ve said there is a category of people where we think it’s fine and my experience working with people, if they’re suffering and they perceive themselves to be suffering, then it doesn’t matter again, are they 16 or 35, what the conditions are. In fact, I would make the argument, very briefly, that what happens quickly in the euthanasia or assisted suicide is we move it from a health issue very swiftly to a justice issue, which therefore means well, you shouldn’t discriminate. It’s not up for you or anyone else to decide. It’s my choice, so on and so forth. And again, it becomes a right. Therefore everyone should have it.
It’s very frightening. Yes. Pain though is often brought forward as one of the other. Big issues, and you and I touched on it very briefly before we, we started recording.
We obviously have the autonomy side, but a lot of people would say it’s pain and there are some terrible conditions out there that you will know better than I as a medical professional. What is your response, particularly as an anaesthesiologist to these issues of pain that people, do suffer?
Sharon Quick: Pain is always treatable. And in fact, people at the end of life are easier to treat their pain than at any other time because you don’t have to worry so much about narcotics becoming addicting. The person’s dying. So there aren’t really, you don’t have to be as concerned about those limits.
And there are so many different modalities to treat pain. It’s not just. Narcotics, but there are a lot of adjuvant medications. There are nerve blocks and a holistic concept to pain means that you need to treat the whole person. Sometimes social problems, psychological problems, depression can contribute to making physical pain worse.
And I remember hearing a story from one palliative care doctor who said she had a patient whose pain was really difficult to manage and. She found out that he was had a poor relationship with his mother, and when they managed to allow the two to reconcile, all of a sudden his pain was no longer difficult to manage.
So it’s really important to manage the whole person. I think there’s a lot of underuse of the more complex treatments for pain management. For instance, like epidurals, you can actually put in long-term epidurals. They can be putting in the operating room tunnelled under the skin, and they can be used for months.
And you could even have a patient controlled analgesia, which would give you better pain control, with much less interference with your mental functioning. So options like that, or nerve blocks, for instance, pancreatic cancer may cause pain, but a celiac plexus block can block, or even the use ablation of the nerves to the pancreas can be done to, to eliminate that pain.
And if all else fails, you can always sedate someone. So really there’s never a reason that lethal drugs should be needed. Or even considered for treating pain. In fact, there’s one doctor in the US who actually is in favour of assisted suicide, but in his booklet, he writes that lethal drugs should never be a reason for someone to seek lethal drugs. That pain should never be a reason for them to seek them. That’s what palliative care and hospice is for. And they do a really good job of managing that. So really if someone is using that excuse, and I’ve heard doctor after doctor use that excuse and testimonies in the us, it’s because they lack knowledge about complex pain management.
And lethal drugs are not a good solution for lack of education of physicians.
Simon O’Connor: It is one of the big go-tos here, because understandably it’s highly emotive. No, none of us want to be in pain and I think it’s me just theorising as we talk or speculating it we can project our thoughts into the future and drawing off previous episodes, I don’t want any worse than that, or I don’t even want to conceptualize it, but it’s, it is the go-to argument. Here, and I think it, really good to hear from a professional like yourself quite definitively that actually we do now have the pharmaceutical products required to help.
Some would then argue we use it too much. There’s always the classic, I always hate saying this to anaesthesiologist because I know you’d have heard it a thousand times before, but they go I just saw the doctors pumping my mum or dad or aunt or uncle full of morphine and that’s what killed them. I don’t know if you have a thought or response to that argument?
Sharon Quick: Yes, and I have heard that too, and I do have to say, I’ve heard that enough that I think where there’s smoke, there may be fire. I think there’s two issues that could be going on. One is that people do get more somnolence towards the end of life, and so they’re going to be more sleepy.
And if they’re not well educated about that, they may think that it’s the morphine or the narcotics causing that instead of it just being a natural death process. But there are unfortunately off also cases where I think patients are overmedicated and I think there are some legitimate fears that people have.
And especially when you have a society where lethal drugs are normalized, it may not be seen as, the healthcare professionals, how do you separate in your mind, killing from healing when you can do either. And so it may be even a subconscious kind of shift, but they just give a little extra morphine and what does it matter if they’re overdosing the patient too much?
So I do think that on occasion is a concern.
Simon O’Connor: Which probably comes back to what you had mentioned earlier is a lot of doctors – I’m trying to find the right words here – they’re not qualified to be able to reach that level of care, and that’s no disrespect to doctors. They know they specialise into particular areas, but end of life care and particularly that the complexities of those.
The anaesthesia type drugs that you would understand in your specialty is just not something which most doctors really have a grasp of.
Sharon Quick: Yes that’s true. And if, I don’t know what the what kinds of doctors are doing euthanasia in New Zealand? I know in Canada there’s only a minority that are anaesthesiologists.
The majority are family practice. Doctors and they certainly have not used anaesthetic drugs to any great degree. So that is concerning.
Simon O’Connor: We’ve got about 120 doctors willing to do the euthanasia in New Zealand out of a total physician workforce of about 20,000. So I won’t throw you into the math, but a very limited number of doctors.
And exactly like Canada, andother jurisdictions mostly in what we’d call general practice or primary care. They’re not anaesthetists or anaesthesiologists, they’re not specialists into this area at all, which is deeply concerning whether it helps or hinders. Always a member of friend of mine Baroness Ilora Finlay around the morphine question. So she’s a palliative care physician in the United Kingdom. Said there’s always the last cup of tea, just as there’s often the last shot of morphine. What she meant by that, families around dying, loved ones beds, seee the doctors coming in and administering, in this case morphine. And then the patient passes, they make the instant link.
But as Ilora says there was the last couple of tea too. But we don’t think that’s what knocked them off.
Sharon Quick: Yes. And the other thing that’s often people think that. Morphine is going to cause the person to die sooner, and in reality, if morphine is, or any narcotic is appropriately dosed it, I’ve actually never seen that cause somebody to die or cause respiratory depression if it’s appropriately dosed. If, certainly if there’s an overdose that can cause a problem, but it’s extremely rare for a regular morphine dose to cause someone to die.
Simon O’Connor: Again, I think it’s just a general lack of knowledge in this space, not only in some medical spaces, but actually just in the general public. As you rightly pointed out, morphine isn’t actually suppressing the respiratory system. In fact, just make you get for, I think a Laura also said it to me would have a whole lot of it. It’s just a very long, deep sleep you’re going to have at the end of life. There’s obviously a fragility before we actually get on.
This will be a heavy topic for people to, to listen, which is around some of the drugs or what does happen when euthanasia is chosen, the deployment of those lethal drugs. But before we get there, you had mentioned earlier, and I noted it down as often euthanasia is for the family and not the patient, which I thought was quite profound.
And I just wonder, Sharon, if you’d be comfortable to talk through what you meant there?
Sharon Quick: That actually does have to do with the types of drugs that are given. In the US, the euthanasia or the euthanasia protocols are very similar to what was instituted for. We don’t do euthanasia in the US but euthanasia protocols are actually similar to what’s done for lethal injections in the US and those were developed by a pathologist not an anaesthesiologists. And so what is usually done there is some sort of anaesthetic, general anaesthetic, I’m going to mix this and tell you what’s used in Canada.
Propofol is the general anaesthetic most often used in Canada. And then also a neuromuscular blocker or a paralysing agent, which causes the person not to be able to move any voluntary muscles so they can’t move their arms or legs. They can’t breathe, they can’t speak, they can’t even blink.
And then finally, usually in the, and for the prisoners, they’re given a cardiotoxic drug most often, something like potassium chloride or bupivacaine. And both of those in overdoses will stop the heart. And the reason for giving each of those, obviously the anaesthetic will, will make the person unconscious.
Propofol is actually a very, it has a very quick onset of action, but it also will wear off very quickly. So even if you’ve had someone on a propofol infusion, say in the intensive care unit for a length of time, like days even when you stop that they can start becoming awake within even a half an hour of time, then the neuromuscular blockers are given they cause someone to be paralysed.
And the reason why they said, for prison executions, why they use this is because when someone is given just a large overdose of anaesthetic, it will cause them to stop breathing and become hypoxic. It may cause the heart to have arrhythmias or low blood pressure. It could even cause a cardiac arrest, but it does not always cause the cardiac arrest.
So if the person becomes hypoxic, they could have seizures, they may have unusual respiratory patterns, gasping things that could be difficult to watch. So they didn’t want the people injecting these drugs to see them causing these things in prisoners. So therefore, if the neuromuscular blocker agents are given, the person is paralysed and you can’t see any seizures, you can’t see the gasping, you can’t see anything.
And then finally the cardiotoxic drug is just to shorten the whole process so it stops the heart immediately instead of having to wait for it to stop due to hypoxia. So the concern in Canada when you give these drugs is if you look at the time to death, the it ranges from one minute to over two hours.
So my concern is, what happens for those patients? First of all, one minute is impossible. It takes at least two minutes that you’re going to wait to ensure that the hardest stop before you can pronounce someone dead. Some people would say you need to wait five or 10 minutes to make sure there’s not auto resuscitation.
So the idea that someone can die in one minute should be, is not, possible. And then the other extreme two hours. I am concerned that someone’s propofol, their anaesthetic has worn off and they are paralysed and they’re unable to speak. They’re unable to move. They’re unable to say, I can feel everything I can.
I want to breathe, but I can’t breathe, and they’re just extremely so they may be dying in agony. But the protocols are to prevent them from moving so that there aren’t any uncomfortable, like seizures or uncomfortable looking motions for the families to witness. And yet we have no idea what’s going on in the heads of those patients who are taking that long to die.
Simon O’Connor: It’s something I’ve come across before, more in reading and in an ethical position. I want to make it clear, I’ve not been in anyone’s death this way. But it is not an unfamiliar situation to me, but it sounds like a horror potentially. That as you say, yes, people have basically been paralysed, but they could well be conscious.
And actually yes. Oh, it’s horrific to even just ponder it.
Sharon Quick: Yeah, and that will rarely happen under anaesthesia. We have cases of awareness under anaesthesia. It’s usually when you have someone that’s extremely compromised, you can’t give them huge amount of anaesthetics without causing their, their heart to malfunction.
And though people that have had that happen find it really horrific when they’ve had, when they’ve been aware under anaesthesia, they can hear the surgeons talking and they know what they can, and they may even feel pain. And they can’t do a thing about it. And so that can cause a long-term post-traumatic stress problem for those patients.
We normally monitor patients in the operating room if you have, a heart monitor and blood pressure cuff on, if someone’s in pain and distressed, their vital signs change. And yet these people that are undergoing anaesthesia – not anaesthesia, undergoing euthanasia – they have no monitoring, so there’s no way to know if their heart rate’s gone up and they’re still feeling something.
And my impression is, at least in Canada, they’re giving one drug after another. So the other issue is IVs are not perfect. What if you don’t get the IV in a good spot and you get some of the drug extravasated outside the vein? They actually recommend that you put in two IVs to start with, because once you’ve given them some of the euthanasia drugs, their blood pressure may fall to the point that it would be difficult to get in a second IV.
And so there are failures in Canada. They mention those and I don’t, it’s not specific as to what has happened, but we know that prisoners have sometimes had a failure of IV access. Some of those drugs burn going in. So what if you’ve gotten just enough of the anaesthetic in to make them look like they’re asleep and you think it’s working okay?
Then you give the paralysing agent, which is going to last for two hours or more. And so the patient may be paralysed, but having adequate anaesthetic and you’re not going to know that because you have no monitors. It’s could be horrific.
Simon O’Connor: It could be, and I think that’s, and again, please correct me on this, we’re not suggesting that this is frequent or often, it’s though within the realm of possibility, there’s enough evidence that this can happen. And certainly in New Zealand, as they celebrate assisted suicide, it’s always put forward as people on a beach or on a farm paddock or at home, and it’s just exceptionally simple. As we’ve talked here, there’s real potential, again, not in all cases, I don’t want to over egg it, but there’s real potential actually they’ll get this wrong. And the consequences, yeah. I just keep coming back to that word. Are horrific. Actually horrific.
Sharon Quick: We, you know what’s interesting is that in the United States, the veterinary associations, have for the large part, do not recommend, or even outlaw giving neuromuscular blockers to dogs or cats or pets for euthanasia because of the concern that there could be awareness when they’re trying to euthanize them. And so it’s interesting that they’ve banned neuromuscular blockers for pets and yet they are used for people.
We often I’ve heard people say that we need to allow assisted suicide or euthanasia because we’re treating animals better than we are people by not allowing that, and yet in this case, we’re treating persons worse than our pets because we’re using a drug that is for the benefit of the onlookers and not for the patient.
Simon O’Connor: Which I think is a really key point. And one of the, amongst many reasons to, to have you on the show is to really drive that point home, because so much has ultimately been, whether it’s that coercive side we talked about earlier, where the family either knowingly or unconsciously is putting coercive pressure on their loved one, or as you’re saying here at the very end, it all just looks so lovely and peaceful.
But as you’re saying, as an anaesthesiologist, ‘hey there’s a lot going on here with these lethal drugs’. I’ve heard a lot about the barbiturate usage as well. Is that sort of an old school, because that’s more for the lungs and so forth, isn’t it? To stop breathing. Is that something you’ve come across that’s been used in this lethal drugs in euthanasia space?
Sharon Quick: The quinol that was used was the most prominently used drug for assisted suicide in Oregon until it became too expensive. And so then they had to go to alternatives. And it’s interesting, there was actually an article published where they were trying to come up with protocols that would work, and they said the first concoction burned people’s mouths and throats so much that they were screaming in pain.
So then the second one they tried caused prolonged deaths. And so what they’re basically doing is experimenting on people to the point of death. And this would be a violation of the Nuremberg Code of Ethics, but yet that’s not, that’s not considered a problem. You’re using people as Guinea pigs with death as the outcome.
And I find that pretty horrific.
Simon O’Connor: Oh, I do too. And again, I’m the layman here, but isn’t one of the first principles in medicine – isn’t it ‘Primum non nocere’, ‘first of all, do no harm’. And yet it’s as you’re saying, it’s really experimenting. But of course the patients never can never fight back and never report back.
It’s too late.
Sharon Quick: Yeah. It’s quite horrible.
Oh, the other issue when you talk about medicine, the whole foundation of medicine is equality of persons. And I know they have these four principles. Beneficence or doing good; nonmaleficence or do no harm; justice; and autonomy.
But autonomy seems to be elevated above all the others. But if you think about the reality of medical practice, in every area of medicine, we do not offer options to patients that are not for their benefit. I’ve had patient, paediatric patients come in and their parents want them to have antibiotics for what is really a viral illness and I wouldn’t prescribe that because the antibiotics are not going to do any good for the patient, they’re only going to cause the possibility of side effects. And so we refuse to offer things to patients that they might even want if it’s not for their benefit and if it might harm them. And so that is autonomy is not the primary value that is should be the top value in medicine. It has to be a mix of all those different things and doing no harm, and doing good for the patient, has to take precedence over their autonomy because a lot of times patients are in a really poor condition, mentally, physically, they’re vulnerable and they may ask for things that they may regret, they asked for when they get to a better point in life. And the other thing that I think is horrendous about putting autonomy at the top is that it really it makes medicine to be more this consumer profession where doctors are vending machines to hand out whatever the patient wants and that takes the professionalism out of medicine.
We are not providers. I don’t like that terminology. We’re professionals and we should not be doing whatever the patient wants. Medicine is an ethical profession that uses science as a tool. Every decision you make in medicine is a should. What should I do for the patient? That implies an ethical decision, not just a physical, scientific decision.
Science can tell you, for example this chemotherapy agent is going to be effective in 20% of the patient patients for this particular type of tumor. But that doesn’t tell you if you should prescribe that one or another one, because that depends on the patient’s circumstances. It depends on the patient’s own values, what they want.
It depends on their circumstances in life. There’s a huge number of factors that have to go into making a medical decision what is really an ethical decision that’s using science as a tool. And so when you start destroying the ethical foundation of medicine by allowing doctors to treat patients unequally, you’re actually destroying all of medical ethics, and it creates a huge problem with distrust between patients and doctors.
We have, when I go to my doctor now because assisted suicide is legal, I have to be concerned about who my doctors are. Would they ever prescribe lethal medications because I’m not above getting depression. What if I got depression? People will throw out their values when they get depression.
I could ask for lethal drugs. And so I don’t want a doctor who would ever do that. And even between doctors. I know a doctor in Oregon who had a patient with a cancer and he referred that patient to an oncologist, and the oncologist called him a couple weeks later and said, would you be the a second opinion to prescribe prescribed lethal drugs for your patient?
And he said, no, my patient has depression that’s documented in the chart, and he needs treatment for depression. He does not need lethal drugs. The oncologist found another doctor to second the opinion and his patient was dead in two weeks. So he can now not trust who he can refer patients to because he doesn’t know who’s going to treat my patient wrongly and kill them instead of helping them.
Simon O’Connor: I think it’s actually, in some ways, it’s a good bookend to where we even started this discussion because it is that complete reversal of actually what it does mean to be equal or autonomous and so forth. And I love that you bring up the trust element. I’ve often try to put it to people that now that we have euthanasia and assisted suicide, if you’re unlucky enough to be in hospital, is the nurse and doctor coming with that syringe to heal or kill you. You didn’t have to ask that question once. Now you have to ponder it.
And I have found caring for loved ones now having to be quite explicit to the medical staff of what our expectations are, which is don’t kill my parent. Sadly too Sharon in New Zealand, again, without taking you down a rabbit hole of our medical politics our Ministry of health is very big into the consumer model.
You and other health professionals are just to be providers. They’re wanting to remove doctor’s conscience rights, their autonomy, that you are not to bring that ethical consideration. You’re just to do what the patient wants. And I personally find that exceptionally scary and the antithesis of what is good medical practice.
Sharon Quick: That really takes the whole foundation of medicine out because like I said, medicine is an ethical profession. You don’t want a non-ethical doctor. You don’t want a doctor who just gives the patient what they want, that’s not going to necessarily be good for the patient. You sometimes have to give patients what they don’t want because they’re very vulnerable and they can sometimes not understand or not, that doesn’t mean you, you go against their autonomy, but people can decide.
To withhold treatment, for instance, and that, that’s another area of ethical problems where people try to equate withdrawing, support with euthanasia. And those are completely different things. So if you withdraw support because someone finds the treatment burdensome, that’s okay. No one has to be treated in any way. They don’t have to get chemotherapy, they don’t have to get a ventilator. That’s an assault for a physician to treat someone, against their will. But the cause of death and the motive behind that death are very different. For withdrawing support, the motive is to remove the very burdensome treatment and the cause of death is in the underlying illness.
With euthanasia or assisted suicide, the motive is to make the patient dead. It’s to kill the patient. And the underlying cause of death is not the illness, it’s the lethal drugs. So there’s a big difference between those two, and they should not be confused.
Simon O’Connor: As they deliberately do confuse those and in New Zealand the death certificate has to really emphasise the underlying causes. It’s yes they did have cancer or a terrible neurological condition and probably would’ve killed them, but what did kill you were these lethal drugs, which the doctor gave, but that sort of put on the down low. Sharon, I just exceptionally grateful that you’ve taken the time part you all the way there from the United States and the joys of our different time zones to come in, talk us through this. This is immensely difficult stuff, I think, for some people to hear, but I think it’s important that people do understand what is happening around the likes of assisted suicide and euthanasia. What’s really going on, and I’m grateful for you not only bringing your ethical knowledge, but your medical knowledge as an anaesthesiologist.
I have no idea why I keep getting that word so difficult.
So look, thanks so much.
