FamilyVoice Australia’s journalist Caleb Stephen interviewed Professor William Toffler, MD from the Oregon Health and Science University (OHSU) while Dr. Toffler was in Adelaide in early July as part of his nation-wide tour.
As a Professor of Family Medicine and Medical Physician for over 35 years, Professor Toffler has seen the dire effect of assisted-suicide laws on patients and his profession.
Caleb Stephen: In your opinion, is euthanasia an inherent conflict of interest for physicians?
William Toffler: Euthanasia is clearly an inherent conflict of interest for physicians. I often use the analogy – and I think people can relate to this – if you had a lawyer defending you in a capital crimes case where you were literally facing the death penalty, you wouldn’t want your defense lawyer to walk across the courtroom and then all of a sudden make the arguments for the prosecution.
So you can see the inherent conflict of interest that any lawyer would recognize immediately. And what’s worse is that the physician would act like judge to decide which argument is the most powerful and whether you would be declared innocent or guilty and what’s worse, if you still don’t think there’s a conflict of interest, the physician would then take the role of judge essentially where he would decide whether you live or die.
So this is an inherent conflict of interest. It is empowering doctors to end the life of people suffering either physically suffering, emotionally suffering, psychological, spiritual.
It’s empowering doctors to do something I’m not licensed to do in any other state but Oregon and I think it’s sad in that it’s violating the ancient oath to “do no harm”, it is creating distrust between patients and their physicians.
It clearly is dangerous to empower doctors to end people’s lives.
CS: Do you see a conflict between suicide prevention and euthanasia? What is the experience in Oregon?
WT: There’s clearly a conflict between suicide prevention which I’m not only entrusted to do, I’m empowered if I cant keep a person safe from themselves to even put them in the hospital against their will to protect them.
So here we now are empowering doctors to do exactly the opposite under the circumstances of labelling someone ‘terminal’. I’m now empowered to give massive overdoses so they can kill themselves. I’m essentially a helper in suicides.
In Oregon, this has clearly eroded the protection for people with suicidal ideations and desires and in fact, we have no money now going to suicide prevention programs.
The suicide rate in Oregon has gone up. It was above the national average before passage of assisted suicide. And now it’s going up at a rate even faster.
Now I can’t prove cause and effect. On the other hand, it’s not reassuring if people think by legalizing assisted suicide that you somehow decrease non-assisted suicide rates.
The states of Oregon and Washington both undermine that argument. And I’ve literally heard people espouse such an argument that somehow by legalizing and regulating it that you would have less of it.
We actually have a phenomenon that news reporters here in Australia know very well. Suicide can be contagious. So at the end of the article about the tragedy of the three people killing themselves in Queensland, there’s a note saying if you feel depressed and you need help, call this number. And of course we’re doing that because we care and value lives and we don’t want to encourage suicide as the solution to suffering.
Never has the solution to suffering been to end the life of the sufferer.
We need to redouble our efforts to help with pain management, we need to get consultation from palliative care, we need to invoke a transition from curative care to comfort care but care is always there. We should emphasize care, not killing.
CS: Do you see a conflict for doctors in having to self-report, and report the cause of death as natural, rather than suicide?
WT: Well there’s clearly a conflict for doctors in reporting in the state of Oregon. There’s a shroud of secrecy over the whole process. The doctors aren’t there 86% of the time when the patient takes the massive overdose and presumably dies. We really don’t know. The death could take anywhere from minutes to hours to days. One patient woke 67 hours later – and I’m quoting his first words – ‘what the hell happened, I thought I was supposed to be dead’.
So the suicides don’t always work. It creates a conflict – are you supposed to help the person if they were not successful in killing themselves or are you supposed to reach for a baseball bat?
It’s a terrible conflict of interest.
And of course, if you are a doctor promoting this and wanting this to expand like many of my colleagues are in Oregon, are you going to report faithfully the problems, the consequences?
In fact the absence of saying anything’s gone wrong should tell us how suspect this whole process is.
Even Aspirin causes side effects and problems. People bleed. People have problems with taking the Aspirin, anaphylactic reactions. Where are these?
48% of the reports coming in to the Oregon Health Division leave the line for complications blank. Now it’s not saying none. It’s blank simply because perhaps the doctor actually has the integrity to not put down ‘none’ when he or she doesn’t even know because they weren’t there – they weren’t there over 86% of the time.
Those are the numbers from the Oregon Health Division. What’s worse is the actual records that might go in on the forms are actively destroyed by the Oregon Health Division within a year. It’s the only place in medicine I know where there’s active destruction of medical records long before the seven year statute of limitations for record keeping comes around.
Again I think [its] an effort to not keep the process transparent – to keep it under a shroud of secrecy.
The death certificates – there’s a double reporting system where doctors actually list the cause of death as the supposedly terminal underlying disease, not that they took an overdose – a massive overdose that killed themselves. And the death is listed as natural rather than suicide.
So it’s fraudulent reporting really as part of the law.
It’s a terrible step backwards and I’m very hopeful people in Australia do not embrace this.”
CS: In your address to a Columbia committee, what did you mean by saying: “Data that is reported to Oregon Health Division is all self-reported hearsay predominantly from doctors who prescribed but weren’t actually present when the overdose occurred.”
WT: Clearly from the Oregon Health Division’s skimpy records, they indicate that the doctors not present at the time that the overdose was taken 86% of the time. So how could they possibly know what’s going on – what went well or what didn’t?
So the complications clearly aren’t reported. The doctors have a self-interest in not covering problems because you don’t want to be reporting it. It would be like asking the tobacco institute to report on the problems with tobacco smoking. They’re trying to sell cigarettes.
So the promoters of assisted suicide – some of whom are the very doctors giving overdoses to people – who think this is a good idea and the solution to suffering is to end the life of the sufferer.
CS: What are the different ways patients describe their interest in euthanasia? What insights do you have into what assurance or help they are asking for?
WT: People have come to me dozens of times since this was passed twenty years ago – patients, my own patients – and some people who aren’t my patients because they know the stand that I take and that they want to get reassurances from me. But often when people express the desire to end their life – whether they’re labelled terminal or not – they’re expressing some sense of hopelessness or fearfulness and so my first question to people who say ‘I’m thinking about assisted suicide’ is ‘gosh you must be feeling bad. Tell me about that.’ And it begins a dialogue about what the real issue is.
In one case, a person wasn’t getting good pain control.
Most of the time that’s not the issue. Most of the time it’s just simply wanting to have control and they’re fearful of not having control so I have to reassure them that I’m not going to artificially do things to them that they don’t want done. I’m going to do whatever they want, the level they want. I’m going to support them. I’m going to encourage them. I’m going to help them get through it in the process of the end of their life – if they’re that close.
The sad reality is that many people talk about this and are fearful about this long before they’re even any more terminal I am or you are. The reality is we’re all terminal.
The notion of artificially treating people who are labelled terminal – for whatever reason – is dangerous. It’s a dichotomous scare model where I’d try to help somebody who’s suicidal, who’s not labelled terminal and then I’m supposed to help the person kill themselves who is labelled terminal.
It’s a horrible differential approach to caring for people that I think is dangerous.”
CS: What was the full context of your remarks about veterinarians “giving overdoes to living things”. You said, “at least you’d keep the House of Medicine from an apparent conflict of interest, and you’d have trust in your doctors.”
WT: There’s no question if society wants to do this – and I don’t recommend it – that’s the first thing, I mean I’m not recommending society ends the lives of humans. Humans have – I believe – have an inherent value from conception to natural death – that’s what I believe. You know, when people say they don’t, I say ‘which part of humanity are you opposed to, that you think are not worthwhile’. I mean it’s a chilling question but literally that’s what we’re saying – we’re going to dichotomize and say some parts of humanity aren’t worthwhile. But if I’m a minority – and I might be – I don’t know and certainly based on the vote, I’m a minority in the state of Oregon or maybe Washington then it would be better for patients, it would be better for medical care that someone outside of doctors did it and in fact it’s not rocket science – again, I’m not recommending it but ending your life happens too often. In the United States, 43,000 people end their lives every year – they do it without doctors’ help. It’s non-assisted suicide. It’s all too easy to take your life. So the notion of involving doctors is corrupting the practice of medicine, it’s causing patients to be fearful of the motives of their doctors or their healthcare beauracracies. We now have health plans that are covering assisted suicide but they won’t cover the care patients need.
I mean if you’re for assisted suicide, you can see this is awful – that we’re going to encourage people financially to end their lives – cover them for that but not cover them for care to extend their lives.
This is horrible, this is dangerous and this is not a theoretical risk, this has already happened to at least a couple patients – maybe hundreds – we don’t know because there’s a shroud of secrecy where the state of Oregon literally sends them a letter saying we won’t cover your care because we think your prognosis isn’t positive.
And you know this whole notion of prognosis – doctors aren’t crystal ball readers – we have no courses in medicine about that. So we are wrong a lot of times. I’ve been wrong.
My wife was told that she had 3-9 months to live and thankfully we were blessed with 4 times that much life and then the drugs she took that were covered by her private insurance but would have not been covered by the state Medicaid program – those drugs extended her life. And I was grateful for every nanosecond of my wife’s life and yes there is suffering in the dying process but there was also great joy in bringing together and I believe that the last few years of life with my wife was among the best of our 40 years of marriage. I wouldn’t trade a nanosecond of my time with my wife and my kids would say exactly the same thing. We miss her deeply, we certainly didn’t want her gone early and thankfully at least some of the drugs did give her extension of her life. We got to see our son graduate two weeks before she passed away. She passed away peacefully at home with dignity.
So again if society embraces this, if they’re misguided enough that they believe caring should be substituted by killing then have someone else – veterinarians actually have training in giving lethal overdoses to large and small animals and then you don’t have the conflict of interest. So when I said that – and I mean it – I’m not encouraging society to do that, I’m just simply saying do not corrupt the practice of medicine, do not undermine the quality of Australian medical care by embracing assisted suicide by doctors, by healthcare beauracracies and worse by the government of Australia.
CS: What do some people label you ultraconservative? Do you see this is a compliment or a slur?
WT: It’s because they don’t want to talk about the issue. The reality is that independent of labels, I believe human life is inherently valuable. I don’t think that’s ultraconservative or ultra liberal. It’s basically human. And you can’t win the argument by talking paragraphs about the issue, then you want to attack the person in their faith, belief or you want to attack the person by their labels or you want to use euphemisms because all social engineering is preceded by verbal engineering. Or you want to create fear like they are.
Here in Australia you have an excellent healthcare system, there’s no immediate issue at all and so they have to conjure these images of horrible people suffering that can’t be helped with their pain which is absolutely false. I’ve been a doctor for 40 years, a family physician, and I have yet to encounter someone that either I or my palliative care specialists can’t help with their pain and it’s not the first it’s not the second, it’s not the third, it’s not the fourth or the fifth reason that patients express when patients are asking for assisted suicide. It’s often just perceptions of losing dignity, losing autonomy, losing control of body or bowel function.
I mean think of this though: if you’re going to end your life because you’re incontinent, one third of the people aged 70 who happen to be women are having experiences of incontinence and men have the opposite problem where we can’t go sometimes because we have too much anatomy – are their lives less worthwhile because either they cant pee easily or they pee too easily. This is horribly misguided that we start equating dignity with some aspect of bodily function.
This is exactly why the group called ‘not dead yet’ are concerned about the logic behind the promoters of assisted suicide because they’re talking about people like them who are disabled who ought to perhaps oft themselves because they’re not “dignified”. How dangerous could that be? And they recognize that danger, the inherent danger of devaluing human life based on some bodily function.”
CS: Can you describe for us the connection between your faith and practice of medicine?
WT: Well there was time where I parked my faith by the door and the reality is my faith is actually part of my life and who I am so when people bring up issues of faith I’m happy to talk about them. There’s very good reasons to be opposed to assisted suicide whether or not a person has faith and we actually have agnostics – the not yet dead group – are clearly opposed to euthanasia and assisted suicide and they don’t want to bring up the issues of faith because it’s a rational argument.
Faith and reason aren’t exclusive from each other so you know, it was people of faith who founded the great universities, people of faith who set calendars in place, who understood geometry and astronomy so the notion that you have to park your faith by the door as I once thought I had to is wrong and I’ve been glad that I don’t try to dichotomize that because faith is what gives us care and love at the end of life. It was before Dame Cicely Saunders in the UK enhanced end of life care with drugs borne from cocktail and trying to help people live well until they died naturally, the Christian nuns in the UK were doing it very well. mother Theresa is a great model of love and care for people even when utilitarian logic would say what sense does it make there’s too many or it’s too late – they’re going to die anyhow. Well you know she would say simple things that were absolutely true that I take to heart: ‘no one should die alone’, ‘we should always give great care’, ‘maybe I can’t do great things, I can’t cure but all of us can do little things with great love’ and it enhances not only my role as a physician, it enhances the dignity of a person and we are all part of a human family, there’s love and support and comfort at the end of life.
CS: Assisted dying has been legal in Oregon for the last 20 years, what are your reasons for saying that it’s not a good idea to make Oregon’s mistake here in Australia?
WT: Well there are obviously many many reasons why assisted suicide is a giant mistake in Oregon but chief among them is I think a distrust between a patient or his or her physician. One case comes to mind is a patient who had bladder cancer. She wasn’t my patient but she knew my public stance and she’d gone to an oncologist after recurrence of her bladder cancer and he was very pessimistic about the prognosis and possibilities of treatment. She goes to another oncologist for a second opinion and that oncologist was more hopeful, more sanguine about her prognosis. She was disturbed by the very different answers she got from the two. She calls me knowing that I believe her life is worthwhile and she asked me if one of the other doctors – the doctor with the pessimistic viewpoint was one of the death doctors.
So this question is something that would never have been asked 20 years ago before the conflict of interest among patients and doctors in the state of Oregon.
So patients are actually asking for help and the state of Oregon is denying them care. They’re actually paying for an overdose 1005 but they won’t pay for care for a patient who wants an extended life with a chance of living.
And this is come to light and it’s very very dangerous.
Barbara Wagner is one such patient who was a school bus driver, her lung cancer recurred and rather than getting coverage for the treatment she and her oncologist wanted, the state of Oregon sent her a letter saying they wouldn’t cover it because the prognosis wasn’t good enough and they would pay 100% for her to take an overdose and kill herself under “palliative care” – again, she was just astonished that the state of Oregon would pay for her to kill herself but not to hopefully extend her life. And this has happened to more than one patient. It has now happened in the state of California where an insurance company would ask the patient to pay only a $1.20 for an overdose as a co-pay and wouldn’t pay for the drugs that might extend her life.
And I take this personally. My wife had private insurance in the state of Oregon but had we had the state healthcare plan when she had extensive cancer she would have not got treatment, she would’ve gotten pain relief with medicine perhaps but they would not have paid for medication to extend her life.
I think this is chilling. Howe would we have breakthroughs for HIV patients in the 90s if they had all taken overdoses rather than worked on treatment and cures for those poor victims of HIV.
And unfortunately doctors at that time even though it was illegal actually did give overdoses to those patients and just within a few years there was good treatment that would extend their lives indefinitely, it would change the uniformly fatal disease of HIV into a chronic disease.
How sad it is that doctors colluded with their desperateness instead of bridging them until a cure could actually be worked out.