Linda livingsto its good to be here. Scott samuelson okay, well becky, lets just start off with the big question. Should iowa have a law that allows mentally competent, terminally ill adults to voluntarily request and receive drugs to end their own lives . Becky benson well, i think thats a very difficult question. I think my first answer to that would be that i dont think that thats the best solution to how do we take better care of people at the end of their lives. I think that putting more money and emphasis into Palliative Care programs and really i think weve become disconnected from the natural prprcess of dying in america and we like the idea of control. Thats a very unifying principle for most americans is we like to control when things happen but i think that death is a mystery in some ways, and it happens on itssown timeline. I feel that we shohold have more people who can guide us through that process well, rather than try to wrench control over it. I think that without really discussing advance directives with people early on in their disease courses and making very effective ways of helping them control symptoms towards end of life, that the easiest step might be to say, yes, lets let physicians write these prescriptions and let people decide when theyve had enough but im not sure thats really the best answer to the question. Scott samuelson can you just say a quick word, we might have to come back to it, about what you see as the romise of Palliative Care as a kind of first step, at least, before we even get to these other issues . Becky benson sure, i see Palliative Care as one of the fields that has expertise in how to manage symptoms and suffering that often come along with end of life or with a serious illness. I think that thats often what people are struggling with when theyre deciding that they need this control or this way out of the dying experience. I think that even physicians are disconnected from the process of natural death. Were involved unplugging people frfrm machines or sudden death but very few of us really experience natural death anymore, the way it can happen, and so we cant even describe what that should look like to familles and help them see that it can be a safe experience, even though its a new journey for each of us when we go on it. Scott samuelson right, okay well youve put a lot of issues on the table well have to come back to but lets get francis in on the discussion with some terminology. Maybe first and foremost you hear this issue discussed in lots of at here, that these laws are doing, and whats at stake in these terminological issues . Francis degnin well, the first thing i always wor about, im cautious about the word euthanasia because it means so many Different Things to different people. Literally in the greek it means, good death, right, which would be a really cool thing. We have better to have a good death than a bad death. Very, very broad, it means a whole bunch of things and some people it means just narrow mercy killing. What i like to do is just when im talking to my students, i try to keep it as simple as possible. We have several different levels. At one level you keep the body alive at all cost. Most people would agree that that actually is a violentntthing to do. Youre causing people to suffer terribly. Thats where Palliative Care, and again just to simplify the definition, i just think of Palliative Care is how do we provide comfort and pain relief from suffering, right . The second level would be Something Like allowing natural death and thats where Palliative Care also comes in very, very well, hospice, groups like ttt where basically were keeping people comfortable but were no longer aggressively trying to keep their bodies alive. Its because we know that perhaps either its because the patient doesnt want it or because weve run out of our options, okay . The next level down i think of is physician suicide differs from mercy killing because itits thth patients decision and mercy killing its not my decision; its being done for me. Stt samuelson right. Francis degnin assisted suicide and this i ialso part of the reason why theres a lot of different questions around it where does it attack, for example, the integrity of the medical profession. Mercy killing, i think, would challenge that but not assisted suicide because again, its respecting the patients rights. On the other hand, we have to avoid what im going to call also subtle coercion. If we dont have good Palliative Care, if we dont have good resources to take care of people, it becomes too easy to right that prescription. Scott samuelson right, it becomes a temptation for the patient to think that maybe i do need to let go here or have my life taken from me so i dont Francis Degnin correct. Scott samuelson become a burden on people or whatever. Francis degnin or just because theyre suffering and theyre not getting the help they be slightly different from what youre thinking here and its this, i think that in almost all cases, when someone asks for assisted suicide, thees a need thats not being met that can be addressed. Oregon has one of the highest rates of satisfaction around dying of any state in part because when its the question gets asked about assisted suicide the conversation takes place and in that converssion we often find that other need and can address it. Scott samuelson our options become. Francis degnin options become possible. Scott samuelson possible. Francis degnin im not willing to say that thats true for everybody. I think there are still going to be, well, i dont know, but i respect the fact that there may be some people out there for whom this is really what they want. I also want to respect that as well but i ant to make sure that every resource is exhausted first to protect them and provide a palliative death, a different kind, a good death that doesnt require this. Scott samuelson yeah, okay, well lets get linda in on this as well. I think weve heard a fairly convincing case thattwe should at least take steps to ease peoples pain, to give them a sense of options, but does there come a has a right to take their own life, to have a physician help them, to die painlessly, or is that somehow violating some sense of a sacredness of life . Linda livingsto i personally would welcome a law similar to oregons that i think has safeguards to protect against all of those things that people were so worried about, the slippery slope. We have, for most of a century, made medical advances that have allowed people to intervene and take control to extend their lives. There are now a generation of people who have lived beyond what they know they would have because they had that bypass surgery, because theyve been mobile twenty years longer than they expected because they have a new hip and two new knees. Theee same people now, i believe, when diagnosed with a good life and i do want a good death. When that is done prayerfully, from my point of view, when that is done in conversation with family, and in consultation with physicians i think there is an opportunity to provide death with dignity that does not violate the sacredness of life in any way, that becomes a celebration. My understandin g of the statistics in oregon, are hat the people who have taken advantage of that law have predominantly died at home. The ability to be at home, surrounded by family, in what is a much more natural situation than the majority of the people who die in the united states, becomes part of the goal for these people. I am open to those you were saying, it sounds like youre saying weve already sort of being of life and death. Weve already been able to extend life one way so this is a kind of natural response to that, that we we can push the back date of death, perhaps we also can bring it forward a little bit when we no longer see the life as being one that is going to provide us any kind of meaning. Does that, i mean, becky, you were talking about the kind of respecting the mystery of life. Does that worry you at all that if we start to take control of when we die that it somehow overrides some of that sense of, the sense of mystery and how ultimately the line between life and death is not in our power . Becky benson it worries me a little bit, to be honest, because im a physician. I sometimes am in the role of telling somebody how long i think they have. Im the type of person who then are actually pretty bad at predicting. There are certain standard course. Scott samuelson yeah. Becky benson there are many others with lots of fluctuations and particularly when you go as far as six months out. Thats fairly difficult for us to tell with any certainty. I know plenty of people who who lived two years, five years, and even longer. I know others who our best guess was six months and they lived for two weeks. Really we struggle. The closer it gets to the actual time of death, i think, the better we are but i would confidence guestimate of what time they have left is, and then make decisions that that. About the case thatatlinda, i take it, was referring to that says, okay, you know ive already had some major surgeries. Ive lived longer ive had my fair innings, as we sometimes say, and so yeah, maybe i dont know if its going to be six months or two years but its going to be sometime soon. Why shouldnt i be allowed to say, id rather be on my own terms . Id rather know that it could be at home. Id rather it be painless rather thaadragging out. Becky benson yeah, i think another interesting thing about the oregon data that actually speaks to this point is that not everyone who requests to fill a prescription actually uses it. Linda livingsto yeah. Becky benson in fact, i think its around a third who actually go ahead and use it. The rt, i think, want that as a back up in case the dying proccss becomes Scott Samuelson becomes too much. Becky benson too much. Too much suffering. I think really our job as Healthcare Professionals and as physicians in particular isiso help people experience. It saddens me when i hear people say things like, i dont want to starv to death, which really is part of the bodys natural way of dying the last weeks of life sometimes. Weve become so distanced from that, that it seems horrifying to us. I think we need to be better at helping people to understand what a natural process looks like aa that we can support them. I can totally understand that people who have been told they might experience seizures or their lungs filling up with fluid. These are scary things but we do have ways of treating those symptoms nd helping even those deaths be good deaths. Im not also one say that i would never, ever consider this but i think it really should be for those few people who sort of want autonomy and dignity above some other need, whether its that they are depressed or theyre worried about their family, that we can help be addressed in that space to take the stress and anxiety and help them achieve the sense of well being even when theyre dying. Scott samuelson i want to hear what you have to say about this too, francis. We often talk about things like euthanasia or physician assisted suicide as somehow violating the sacredness of life. Its playing god. We take some of what beckys saying. We could even just talk about it in terms of we humans, we dont really know whats going on here. We cant predict and so should we not, at some level, at the most basic level of life and death, respect that line and say we cant ultimately draw it . It is not in my hands to say when i die. That perhaps thats not as bad as taking someone elses life but it is still a kind of act of murder in some ways to determine when the line between life and drawn. Francis degnin i think question is who gets to make that decision, right, because i certainly wouldnt want to make that decision for somebody else. Even, we run into this question of playing god all the time in the hospital. When i see patients and the patients say, well, if you turn off theeventilator arent we playing god . Well, we were playing god by putting them on the ventilator in the first place, right . Scott samuelson right. Francis degnin turning off the ventilator, i think is a much easier decision under the right kinds of conditions. Scott samuelson yeah. Francis degnin because then were kind of admitting our humility before god. Scott samuelson right. Francis degnin now, this is a little stronger because were taking a positive action. Scott samuelson right, so thats this idea of letting die somehow perhaps francidegnin letting die Scott Samuelson different from Francis Degnin as opposed to taking it and theres a big difference there. Becky benson yeah. Scott samuelson taking a life. Francis degnin it gets a lot harder. This is why i think we need to do Everything Possible to address the other concerns and also to make sure that theres not things that they havent thought about, right . That its not just a temporary depression. That its not Something Like that. Ultimately im not going to take away, if somebody is thoughtful, and if theyre spiritual, if theyre prayerful about it, if their relationship with god tells them that this is okay, i dont wan to take away that coice from them but i do want to make sure that every other alternative has been exhausted first. Scott samuelson right, right. Well, you mentioned, linda, some safeguards about this and you seem to be on the same page in terms of saying, this should be a very, very serious decision. Linda livingsto yes. Scott samuelson done, as you put it, prayerfully or at least in light of the big issues that are going on, last resort. It should not be done lightly. Can we have a law that mandates that people make the decision . Linda livingsto no, obviously not and i think that Francis Degnin well, thoughtfully though. Scott samuelson or thouutfully linda livingsto tughtfully. Ott samuelso kthe cision . Linda livingsto the safeguards of oregon, i think, require that it is a thoughtful es that mean . Whats linda livingsto nltation, not only with one ctor but with cd physician who together are making a ruling onmpetency, omenenal health. Ancis degnin and terminal. Nda livingsto yes, e rminality ofe diagnosis. Becky benson to the best at we can linda vingstoyeah. Becky benson come up with. Nda lingsto yeah, i think therare people who are francis dein ll, eres also a waiting period. Nda livingsto right. Francis gnin t has be multiple requests whtness. Inda livingsto ltiple verbaleests and aquest inghting. Scott samuelson right. Linda livingsto separated by, i think, fifteen ys. Ancis degnin fifteen days. Linda livingsto it really Scott Samuelson right, so it cant be a light decision. Linda livingsto requires a oughtfulne ss Scott Samuelson right. Linda vings on the part of peopleo are going through that process. Scott suelson then, okay, so thateems very reasonable buthen what out meone who says, well, i have is chronic illness that isdebilitatg. Its not terminal but i dont want to live with this rever. Wham i different om the person who a doctor hasgiven a year and the doctor could be wrong anyway . Why nt i also have thright to ke my life . Heres where i think people start to worry about linda liingsto that slippery slope. Linda livingsto yeah. Scott samuelson why is it so important that the illness is diagnosed as terminal and isnt just, im in a lot of pain and i dont really want to continue with that . Nda livingsto i think the concern on the parts of a lot of people is that laws like this, and thus far i dont think the concern has been born out, but the concern is that a right to die with dignity might become a burden of a duty to die. I dont want my family to be burdened Scott Samuelson right. Linda livingsto with this prolonged, potentially Scott Samuelson right. Linda livingsto expensive end of life. Scott samuelson right. Inda livingsto safeggards that say that we will protect against that, it wont become an issue of easily pushing people toward that decision. Pastorally i have been with people who, becaase of the treatment theyre receiving, can make a choice. A person on kidney dialysis can decide to discontinue that dialysis and within a people who are taking medication that is life supporting can make a determination to discontinue their medication. The danger with that, of course, is that it might not lead to death. It might lead to a stroke, a heart attack. It might lead to debiliition but not death and so theres a fearfulness, i think, on the part of a lot of people who would say, if i could be certain that within a couple of weeks i would die if i discontinue my medication, we might see choice. In the hospital, i remember just a contact i h with a family that was so poignant to me. The father, grandfather was dying, had been diagnosed terminally ill with cancer, best guess of the doctors was he would die within seventy two hours. Now were a week and a half in. The family has hard and difficult. I was in the room with extended family and one son was just clclarly so agitated and i invited him out and went into a consultation room to talk. I said, what can i do to help you . He said, you can get my family out of that room and i will take care of this. I said, ell, i cant do that, and he said, i know but if that were my dog i could take him behind the barn. Thats my father. He was so passionate and what i was able to do was give him permission to leave the hospital, to not have to be there through every prolonged breath that he had been watching for a week and a hhlf. Benson i think those are often more distressing for the family. I think a lot of times we can get a sense that the patient, by the way their face is, is actually at peace but family because were not used to watching and death takes its time. That process takes its time and thats not something were accustomed to. When it happens on tv its not drawn out like that so its just very different from what were used to. I think one of the questions that youve bn asking is whats the difference between if you have a terminal diagnosis or if you have a chronic diagnosis thats causing a lot of suffering . I cant fully answer that but i do think that ive heard people who have terminal diagnosis say, im not suicidal. Im not requesting death. I dont want to die but my disease is killing me and i want to have some control er that process. Scott samuelson right. Becky benson versus somebody who might live years continue on with their current treatments or even if they dont have treatments but theyre suffering in one way Scott Samuelson right. Becky benson existentially often. Scott samuelson yeah, and im, i have to say im sympathetic to the distinction that youre drawing and it does seem to me a legitimate one, but at the same time it does seem a troubling one to draw at some level because were all going to die and theres going, in some cases, to be some pain before it happens. Te person whos saying, okay, im forty five years old and i have a chronic illness and that might mean im going to die in thirty years and its going to be thirty years of suffering, versus the person whos eighty and theyre told theyre going to die in six months. I dont know. Its, to me, its a little bit of a difficult distinction. I know, francis, youre Francis Degnin it also gets more complicated because, and this is threason we talk about physician assisted, is because many people when they try to commit suicide on their own are unsuccessful. Scott samuelson right. Francis degnin they merely injure themselves or themselves and greater suffering down the road. Scott samuelson right. Francis degnin its a hard one. I know nuland is going to, you know nuland who wrote the prize winning book, how we die, hes going to say yes to both of your cases. Scott samueeson right. Fraracis degnin i think its really difficult, more difficult with the chronic because you also say, well, what if we find a cure . Scott samuelson right. Francis degnin what if we find a real treatment for them . Scott samuelson right. Francis degnin sometimes we do but also sometimes we donn. Scott samuelson right. Francis degnin again, it comes its difficult but nuland writes basically either in a devastating, extreme old age, or i believe a devastating illness, that may or may not be terminal. Scott samuelson right. Well, but so then what about then the doctor issue . It seems like a doctor not to someone. Francis degnin thats also a misunderstan ding of the hippocratic oath. Scott samuelson okay. Francis degnin the hippocratic oath was actually not common among greek physicians. It tradition and so forth. They actually, when they made the oath not to help in suicide, actually that was to set samuelson from Francis Degnin what was thought. Right. Francis degnin even biblically, the bible doesnt say suicide is wrong. In fact, perfectly okay. Its rather, the notion that its wrong in the bible comes from st. Augustine who says that, is life itself and therefore to commit suicide is to reject it, but its not even biblical. Scott samuelson okay, well fair enough but could not one say that while of course there have always been traditions that have allowed suicide that there is a powerful tradition that says its wrong . Francis degnin thats true. Scott samuelson you can go back to augustine, theres a religious tradition that at some of wrong relationship to life itself. Okay, and so do that but then the question is should a doctor then also be part of that . Linda livingsto i semantics get tricky scsctt samuelson right. Linda livingsto because there are those who are opposed to Palliative Care because they believe it is passive euthanasia, slippery slope. Francis degnin thats a misunderstan the e y, too because the problem with the slippery slope argument is its used to say because that end is so bad we need to go as far as we can in this direction. Scott samuelson right. Francis degnin the place of least violence is always somewhere on the slope. The place of but theres always a bit of a gray area. Scott samuelson right. Francis degnin were not going to be perfect about that. Scott samuelson right. Francis degnin the arguments often misused but its not what it the slippery slope argument works really well as a caution to be careful where we are on the slope. Scott samuelson that seems right to me but again im coming back to this issuuof does a doctor have any kind of, i mean i take it, it would be a kind of moral dilemma, at least for many doctors to say, im going to use drugsp to take this persons life. Becky benson it certainly is, yes, and the American Medical Association and most medical associations are not supporting death with dignity or aid in dying at this point because of that realization that it can be a harr thats irreversible. Many Palliative Care physicians, in fact, would say, we need to do everything we can to support a help them with in their dying in an active way, such as prescribing something or they can use to take within the healing realm that a doctor would espouse of theeselves. Scott samuelson yeah, Francis Degnin thats also a reason why no doctor should be required to do this, i know, because then its not necessary but let me push the Palliative Care issue one steppurther. Theres also, i think, a really important thing that many people misunderstand, even some doctors misunderstan d, often times when were doing Palliative Care we actually hasten death. The difference in Palliative Care is this, were doing enough to relieve the suffering, if it incidentally happens to hasten death, thats acceptable and thats also by this Us Supreme Court washington versus glucksberg decision. Its legal in all fifty states but some doctors are afraid to give enough pain medication because then theyre afraid its assisted suicide, which is not considered assisted intent, and its a large amount given, and also taken by the patient, in order for that purpose. Yeah, in Palliative Care there are times we do hasten death a little bit. Scott samuelson right. Becky benson although recent studies have shown that good Palliative Care alongside curative treatment is actually more likely to be life extending Francis Degnin thats true. Becky benson and to improve quality of life so i think, you know i dont want people to shy away from Palliative Care and i think if we gave people the option of having hospice as easily as in some states they can get a prescription for a life ending medication, if they had the same availability of hossce, i think that would really be a much better way to address this issue of how to ease suffering at the end of life. Francis degnin right, hospiccshould not be the last six months. There are place where Palliative Care is even where a person might need six months of it to help them to get back to a normal life. Its a much richer field. Becky benss yeah, well, i have about ten more questions that i want to get to but im afraid that weve run out of time. I becky, francis, and linda for a really stimulating conversation. I feel like these are important issues for us to think about. We sometimes want to put death out of our minds but perhaps, since we all have to face it in many different forms perhaps, its importtnt to bring it kind of to the forefront of consciousnes s. I really appreciate the conversation. I hope its one and communities. Thank you very much and well see you next time on ethicalal perspectives on the news. Hello, everyone, welcome to another edition of financial perspectives from premier im bob bruce, over the next 30 minutes, Jeff Johnston and brock will layout a road map for a trip to the ultimate destination of a successful retirement. Lets begin. From tloft right, gary speicher, president of Financial Planning services, spike, good morning. Good morning, robert. How are you . Im up for a a day now. All right. Jeff johnston is here from premier investments of iowa. Jeff, good morning. How you doing . Well, thank you. I shouldnt speak for these guys
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