Physician-assisted suicide
Price of Paradise · Hawaii Public Radio · aired 1997-05-25
Guests: Max Botticelli (Emeritus Professor of Medicine, University of Hawaii); Cass Sunstein (Professor of Law, University of Chicago); Sister Roselani Enomoto (Director, Maui County Catholic School Ministry Office)
Duration: 1:00:59

[00:00:02] Randall Roth: Aloha, this is Randy Roth, host of the Price of Paradise Radio Show. Our sponsor is the Hawaii Community Foundation, an organization that encourages grass-root efforts to improve the quality of life in Hawaii and that administers charitable funds with efficiency and compassion.
[00:00:18] Randall Roth: Our topic this morning is physician assisted suicide and with me to discuss it are Dr. Max Botticelli, Sister Roslani Inamoto, and Professor Cass Sunstein. I'll tell you a little bit more about each of them in just a bit, but I first want to ask Dr. Max Botticelli, who's with me in the studio, to tell us just generally what's going on with this topic and how it relates to Dr. Jack Kevorkian, which I think all of our listeners have read about from time to time.
[00:00:47] Max Botticelli: Max, you're an emeritus professor of medicine at the University of Hawaii John A. Burns School of Medicine. Uh, tell us how does what Kevorkian is doing, so-called doctor death, fit in with today's topic of physician-assisted suicide? I think the, the problem that we are facing is one that is related to advances in medical technology. And as a result of that, we've been able to keep people alive longer than in some instances seems reasonable. There has been a response to that. The response has been organizations such as the Hemlock Society and individuals like Dr. Kevorkian who took it upon themselves to draw attention to this problem and sometimes in brutal and unseemly ways.
[00:01:45] Randall Roth: So you're not a fan of his in terms of his way of going about doing this?
[00:01:50] Max Botticelli: I think it's it was good that he brought attention to it, but the way he went about it was abhorrent to me.
[00:01:58] Randall Roth: But as I understand it, you basically are in support of physician-assisted suicide. Tell us briefly what is physician-assisted suicide, and then how does that fit in with this blue ribbon panel that I think a lot of people have heard something about.
[00:02:12] Max Botticelli: Physician-assisted suicide is occurs when a physician helps a patient bring about their own death. For instance, by prescribing medication or administering medication that would bring about that death.
[00:02:33] Randall Roth: And I think some people believe the terminology varies depending upon which side of the issue you're on. Some people call it physician-assisted suicide, some people call it physician-assisted death. But you were telling me that there really is a distinction between the two terms. Again, could you briefly tell us what that is and then we'll hear from our other guests.
[00:02:51] Max Botticelli: Yeah, this is an important distinction and I didn't realize it until I I read the decision of the Ninth Circuit Court. And in there, they distinguished between physician-assisted suicide, when a physician assisted a patient to commit suicide and physician-assisted death, when the physician actually administered the lethal agent and caused the death.
[00:03:17] Randall Roth: So with Dr. Kevorkian so-called death machine where the patient actually pushes the button, technically that's physician-assisted suicide.
[00:03:25] Max Botticelli: Yes. I think the important thing there is that the at least the decision of the Ninth Circuit, as I read it, did not deal with physician-assisted death. They they dealt specifically with physician-assisted suicide.
[00:03:40] Randall Roth: Okay. And then this Governor's blue ribbon panel, you're a member of that, we've got a number of other members and what is it that you've been asked to do?
[00:03:49] Max Botticelli: Well, I basically we've been asked to look at the way we live and die and to look at whether or not there we do that in a dignified way. I I think our our focus is really on how we live while we're dying, and and the focus, it's not been a narrow focus, although clearly it started out in reaction to this to the Supreme Court's upcoming decision and preparing for that, but the focus has been wider. As I tried to point out in my article this morning in the paper, it also includes making sure that advance directives are are made out and and that they're followed, and that people have choice and choice includes not being treated and allowing death to come rather than raging against it.
[00:04:54] Randall Roth: Okay. That's Dr. Max Botticelli, an emeritus professor of medicine at the University of Hawaii. And we'll hear a lot more from Max later on in the hour. Now we have Sister Roslani Inamoto. Sister is currently director of the Catholic Church's Office for Social Ministry in Maui County and I'll give you more of her background in just a bit. Sister Roslani, you're also on this governor's blue ribbon panel?
[00:05:16] Sister Roselani Enomoto: Yes Randy, and good morning to all of you. Yes, I was appointed by the Governor as, I think, a representative of Maui County. There were several nominees appointed. I was the one representing Maui County.
[00:05:32] Randall Roth: I know from your article in this morning's paper that you are against the idea of physician-assisted suicide or physician-assisted death, and I also happen to attend one of your panel meetings a month or so ago when you and representatives of other mainstream religious organizations were testifying. Could you sum up real briefly, not just what you were saying about the Catholic Church, but what the representatives from the other religious organizations, the Buddhists and the Jewish tradition and those sorts of things. Can you sum up what the position of the religious organizations was?
[00:06:08] Sister Roselani Enomoto: Very briefly, which doesn't do justice to the entire topic. However, I think since ancient times, particularly in the Jewish and Christian traditions, there has been an opposition to suicide. The centuries-long discussion talked about suicide as being wrong because it went against one's duty to one's self and the natural inclination of self-perpetuation. From the traditional Buddhist point of view, this is to really not do justice at all to Reverend Fujitani's excellent presentation at the panel last month, but if I understood him correctly, traditional Buddhists believe in what they call the five precepts, the four signs, mandates that people do not kill, and that it is a sign of filial piety to respect one's life until death, and because one has received life from one's parents, so it's a matter of being unfilial to kill one's self.
[00:07:16] Sister Roselani Enomoto: There is unclear discussion contemporarily around the topic of suicide, and it appears that the contemporary discussion is focusing primarily on the ethics of assisted suicide rather than the ethics of suicide itself. There's just a lot of philosophical and religious discussion and debate going on now, but the personal viewpoint, if I may just briefly sum up, my belief is that the value of human life outweighs the claim to any kind of quote liberty or autonomy about one's own ending one's own life, so I would argue against permitting assisted suicide or euthanasia, regardless of the motives.
[00:08:12] Sister Roselani Enomoto: And and I do agree with Max. We have a task ahead of us on the panel to seriously look at all of the viewpoints and to respect each other's views in the process, so that we may come out with recommendations that will be in coincidence with what the Governor has asked us to do, and that is to recommend some policies for the state.
[00:08:39] Randall Roth: And Sister Roslani, as I understand it, you were suggesting then, and in your piece this morning, that society, rather than focusing on giving people a right to commit suicide or physicians to to assist them in their death, that we as a society should be focused more on providing compassionate care to people who are toward the end of their lives.
[00:08:58] Sister Roselani Enomoto: Yes, I certainly believe that there are many religious perspectives that would support that, and that is my own personal stand, that compassion towards the severely ill should be expressed by offering care which includes pain management as well as companionship, but not assisted death.
[00:09:16] Randall Roth: Sister Roslani, we'll be back to you in just a moment. Now, we're going to hear from Professor Cass Sunstein, who is the Distinguished Service Professor of Jurisprudence at the University of Chicago Law School. Cass, good morning.
[00:09:27] Cass Sunstein: Good morning to you.
[00:09:29] Randall Roth: Cass, could you start by telling us what the Supreme Court has already said about a person's legal right to refuse medical treatment including food and water, even if that for sure is going to lead to that person's death?
[00:09:45] Cass Sunstein: Yeah, the court has come very close to saying that there is a constitutional right to resist doctors giving you food and water and forcing medicines on you when you don't want them. The court hasn't said exactly that there's a constitutional right in those circumstances. The issue hasn't been squarely presented, but the court has come pretty close to saying that.
[00:10:04] Randall Roth: And as I understand it, there are some people who will argue that that's a form of suicide, to refuse food and water knowing that it's going to lead to your death.
[00:10:15] Cass Sunstein: Absolutely.
[00:10:16] Randall Roth: So what we're talking about now is something different than that, but presumably related. Now, we're talking about somehow implicating the physician in this process that will lead to a person's death. Could you tell us a little bit about the legal background of physician-assisted suicide?
[00:10:34] Cass Sunstein: Yeah, the big background really is the right to privacy, which is in the very controversial abortion decision and cases involving the right to use contraceptives, so there is a right to privacy. Now, the question is whether that right to privacy extends to other very intimate and personal decisions. And the arguments being made that if any decision is very intimate and personal, it's the decision whether to live or die, and that's up to the individual, not to the state.
[00:11:01] Randall Roth: And what we know that the Supreme Court has has heard oral arguments and any day now we're expecting a decision from them. What led to this particular dispute that they're now resolving?
[00:11:14] Cass Sunstein: Well, there were two cases, one in Washington, one in New York, involving the question whether people have a right to end their lives under medically hopeless conditions, and in different ways, courts in both areas, both on the West coast, including the court that governs Hawaii and in the East coast, the court that governs New York, in different ways the court said there is an individual right.
[00:12:07] Randall Roth: And what are the different directions the Supreme Court of the United States could go?
[00:12:12] Cass Sunstein: Well, there are three things the court could say. I expect the court to say that there is no constitutional right to physician-assisted suicide, or if there is a right, the state can qualify it, very heavily, because the state has good reasons to do that. So the first direction is the court to say basically there's no such right. The second direction is the court could say that there is such a right, and I don't expect the court to say this, but there is such a right and all the state can do is make sure that people's decisions are informed and voluntary. That's what a lot of people are asking the court to say. The third thing the court could say is that a state can allow people to have a right to die or it can disallow people from having a right to die. What the state can't do is make unreasonable distinctions, as for example, the distinction between the right to withhold medical treatment and the right to have the doctor actually help you die. In New York, the problem is that the state allows people to resist treatment including food and water, but it doesn't allow them to die with the aid of their physician. And one thing the court could say, I don't expect the court to say this, but the court could say that these aren't reasonable distinctions, and the state can't make unreasonable distinctions.
[00:13:08] Randall Roth: So regardless of which direction the Supreme Court of the United States goes, the people of Hawaii are in some way going to have to deal with this issue in a very real fashion sometime fairly soon.
[00:13:20] Cass Sunstein: Well, the people in Hawaii might have to deal with this in the sense that the court will say that this is an issue for the people of Hawaii and the several states to deal with. That's the most likely outcome. Another possibility, and we can't we'll know pretty soon, so this is from the standpoint of law, a very exciting time. Another possibility is the people of Hawaii will be told that there are real limits on how much they can do to limit the individual's right.
[00:13:54] Randall Roth: And they'll have to figure out what those limits are.
[00:13:58] Cass Sunstein: Correct.
[00:13:59] Randall Roth: Okay. Cass, thank you, stay on the line. We'll be back to you in a bit. For anyone who's tuned in late, this is the Price of Paradise radio show. My name is Randy Roth. Our topic this morning is Physician Assisted Suicide. With me is Dr. Max Botticelli, who did his residency in internal medicine at the Mayo Clinic, practice medicine in Honolulu from 1963 to 1988, when he joined the faculty at the University of Hawaii Medical School full-time. He was Chairman of the Department of Medicine at the University from 1991 until his retirement in 1995, and basically, we all know this issue is is much more complicated than simply saying someone is for against something, but basically Max is for physician assisted suicide. We also have Sister Roslani Inamoto, who was born and reared on Maui. She's a sister, she's a member of the Sisters of St. Joseph of Carondelet, thank you. And she's been a member of that order since 1955. She has masters degrees in history, political science, and counseling. Since 1993, she's been the Director of the Catholic Church's Office for Social Ministry in Maui County. She helped form, Nah, Ah, Aloah, Hoaloa, the Maui Interface Volunteers Caregivers, a group of people who provide compassionate service to the elderly, chronically ill, and disabled. And again, things aren't always black and white, but basically, Sister Roslani is against physician assisted suicide and I guess your opposition is really quite clear.
[00:16:26] Randall Roth: Professor Cass Sunstein is the Distinguished Service Professor of Jurisprudence at the University of Chicago Law School. He graduated with honors from Harvard College and Harvard Law School. He clerked for Justice Thurgood Marshall of the United States Supreme Court. He's written a number of articles and books and has also taught at Columbia and Harvard Law School, and his basic position is that the legislatures of each state ought to decide this issue rather than having it decided by the court, and as I understand it personally, he is mostly against physician-assisted suicide, but he can tell us a little bit more about that in just a bit when we go back to him.
[00:16:36] Randall Roth: If you'd like to ask a question or make a brief comment, you can call us at 955-8821. If you're on a neighbor island, the number is 1-800-955-8821. Again, today's topic is Physician-Assisted Suicide.
[00:19:00] Speaker 1: I'd hesitate to identify myself as an expert at what went on in the Netherlands. I can tell you that some of the feedback I've heard just recently is that the Dutch are getting tired of Americans who are coming to the Netherlands to find out about euthanasia and how it's going on there. I would like to quote just one short paragraph from the Lancet and this was the article I think that was that is quoted most often to indicate that there is a slippery slope and it's by Paul J. Vander Maas and it was it was a study that was underwritten by the attorney general of the Dutch Supreme Court.
[00:19:52] Speaker 1: And I just like to quote one statistic and this has to do with the number of deaths that were the result of euthanasia in which there was no evidence that the patient actually wanted to be euthanized. And I think it's important. And they say here that in eight-tenths of a percent of all deaths, drugs were administered with the explicit intention to shorten the patient's life without the strict criteria for euthanasia being fulfilled.
[00:20:30] Speaker 1: And more than half of these cases, the decision had been discussed with the patient or the patient had expressed in a previous phase of the disease a wish for euthanasia if his or her suffering became unbearable. I think that the that statistic has been been misquoted to some extent to indicate that people are are that this is widespread involuntary euthanasia at the request of families or other loved ones.
[00:21:04] Sister Roselani Enomoto: Yes, Max. I thoroughly appreciate your comments about Thomas Aquinas. And I hope the article was clear. I haven't seen it yet, that that that's been pretty much Thomas's teaching has been pretty much what the Catholic churches espoused for all of these centuries in terms of the basic principle that all of life is governed by God, and therefore it would be a violation for any individual to reject that gift of life.
[00:21:39] Sister Roselani Enomoto: And I agree that contemporary discussion is much more complex, much more involved, in terms of lifespan, in terms of freedom to choose the way in which one prefers to die. But I think underlying all of it is the notion of freedom and that there's a difference between freedom and autonomy, and I too, you know, certainly don't espouse to be an expert on any of these matters, nor do I pretend to be a theologian.
[00:22:17] Sister Roselani Enomoto: But in my understanding of freedom, freedom is not necessarily a right to choose life or death. Freedom is the gift to receive by reason of our human existence that the choices we make are for the perpetuation in the most natural manner possible of our own lives. I want to emphasize that end-of-life decisions cannot be made at the end of life, so the living well is the key and living with decisions about how one wishes to be treated and cared for when there is a life-threatening disease and or a situation where there needs to be some kind of treatment.
[00:23:14] Sister Roselani Enomoto: I just understand that life itself is something that is entrusted, and so it entails individual responsibility, and I think the only way I can describe it is that we are stewards of the life that we have received.
[00:23:29] Speaker 1: And so, you know, all the discussion that comes from that, which will take much longer than today's show.
[00:24:13] Cass Sunstein: Sure I have. Let me say something about the constitution and then something about what people in Hawaii or other states might do as a matter of policy. As a matter of constitutional law, the fact that there's a religious position one way or another, even if it's a widely shared religious position, even if a lot of faiths agree, that's not that can't count because ours is a very diverse society in which some people aren't religious at all.
[00:24:41] Cass Sunstein: So if there's a religious position that, and that's why the state is forbidding people to take their lives, our constitution has a problem with that. This is a society of very diverse people. So that's one point. Another point is that what happened in the Netherlands is very disputed. Some people think that there are lots of involuntary deaths, that is that the slope is very slippery from physician-assisted suicide to physician-imposed death.
[00:25:12] Cass Sunstein: In practice, some people think that that slope has slid, some people don't. As a matter of law, the fact that there's a dispute, let me suggest, is a reason for the court to be very cautious and modest. If people don't know what's happened in the Netherlands, then we have a factual dispute. We don't know what this right would mean in practice. Let's let people experiment and talk and debate and not let's not have the supreme court decide this issue authoritatively. I think that's what the court is likely to be thinking these days and likely to say within the next few weeks.
[00:25:47] Cass Sunstein: Now, as a matter of policy, I think a lot of this depends on questions of fact and that values actually in this debate are relevant, but facts are even more relevant. The doctor has said, I think very persuasively, that there are some circumstances where people, you know, are under medically hopeless conditions and their prospects are horrible and their lives have been extended just through extraordinary and unprecedented medical technology.
[00:26:16] Cass Sunstein: Those people really can be very compelling cases for physician-assisted suicide or death. Their lives, by their lights and the lights of their family are no longer worth living. Now, those can be very poignant cases. On the other side, we have a worry and the worry is that if we allow physicians to produce death in circumstances like that, we might get some deaths in circumstances we don't want. That is people whose lives maybe could be worth living or people who haven't really voluntarily said they want to be put to death. Now, the question for me is, how large are the sizes of these different cases?
[00:26:55] Cass Sunstein: We really have to know a lot of facts about what this problem looks like and what this right would actually mean in practice. And without knowing much more in the way of facts, it's very hard to to think about the problem.
[00:27:26] Speaker 1: Absolutely. One of the great things about a federal system is that you get these natural experiments, not meaning doctors are doing terrible things to people, but meaning Oregon, for example, now has created a very limited right, but a right, yes, a right to physician-assisted suicide. Now, I don't know if I'd vote for that law if I were in Oregon, but it's a beautiful fact about the federal system that Oregon is going to provide us with some information about whether this right in practice is abused in the way that the sister, I think, very reasonably fears, or whether the right uh can be limited to the cases in which you know medical conditions are hopeless.
[00:28:12] Speaker 1: People's lives have been extended uh far too long by their own lights and if it's limited to those situations, as the doctor hopes, Oregon is going to provide us some information on that, and that's one of the things the federal system is very good at doing.
[00:28:24] Speaker 2: Two years ago I had a long-time friend die of pancreatic cancer, and her will, she talked it over with her doctor, and they determined that they she would be able to go into the hospital when it came to the last end, and they would withdraw food and she would be given pain medication.
[00:28:56] Speaker 2: Well, when I went to visit her, she ended up in for four weeks in the hospital and incredible pain. She had a drip that was in going into her, and we could push a button and she would get a couple extra drops, but she was just moaning the whole time and I asked the nurse, I said why is she telling me, why am I in so much pain, why? And she just, it just got to the point where she was just incoherent toward the end.
[00:30:21] Speaker 1: Let the control pain in in almost all instances and that uh pain is probably not a very uh common uh uh cause for a physician-assisted suicide or or are the request for physician assistance in committing suicide. Unfortunately, um there are some physicians who are not very good at controlling pain and don't do a very good job of it. Uh, but the ability to control pain is there and almost every instance, there will be somewhere where it's impossible.
[00:31:13] Speaker 1: I think that sister and I both would agree that it's totally moral uh and ethical um for a physician to give as much uh anesthetic as required to control pain in the instance that Robert describes, even if it results in the death of the patient.
[00:31:43] Speaker 2: Well, my uh friend had the top uh cancer specialist in the state here, taking care of her and I talked to him and he said that he would give her the maximum that he was allowed to and he did, and it did not work.
[00:31:55] Speaker 2: Subsequently I called Senator Inouye and I found that Senator Inouye was also concerned about this and had entered into the 104th Congress, the first session Senate bill 78, which is called the compassionate pain relief act. And it was uh as he sent me a copy of it and it was for the availability of parenteral, p a r e n t e r a l, diacetyl morphine, d i a c e t y l m o r p h i n e, for the limited purposes of controlling intractable pain.
[00:32:54] Speaker 1: I'd hesitate to to second guess that particular physician, but uh not only is there uh are are there pain medications, but there are other procedures that can be used to control pain and in some instances are are very successful in doing that. I think it would be an exception. I hesitate a little bit because it's clear that not all physicians use as much pain control measures as they could.
[00:33:35] Speaker 2: Well, I wish that as people would support Senator Inouye in Senate Bill 78. I think that that is a good way to go and I totally disagree with the physician that you're talking with. There are many, many, many people that suffer intractable pain and the majority of the population and poll after poll say that they have seen their many of their relatives and close friends just die horrible deaths because of this type of of trying to further the war on drugs. They have shot themselves in the foot.
[00:34:38] Speaker 3: Well, the discussion on pain management certainly pushed a button with me. It's one of my interests as a the chair elect of the Hawaii Cancer Pain Initiative. The initiative's been around for a number of years, and of course, we I certainly agree with Dr. Botticelli. There are many, many avenues that physicians can use to manage pain quite well. I believe though that there is a great gap in knowledge and experience among physicians and nurses when it comes to pain management. So, I would hope that the panel, looking at living with dying, will look at that as maybe a recommendation to the governor.
[00:35:35] Speaker 3: Hospice does not hasten or prolong life, but we look at providing compassionate care to the terminally ill and their families. We recognize that people don't live in a vacuum, and they also don't die in a vacuum. With adequate support, meaning emotional, psychosocial, physical support, most terminal patients can remain at home. And in my experience over the last 10 years, I've spoken with close to 4,000 people who are dying. I've rarely had anyone ask for assisted suicide because they get that support.
[00:36:36] Speaker 3: I would say that one-third of all of our referrals are specifically for pain control. Physicians will call and say, I, you know, I can't do anymore medically to prolong this patient or to cure this patient, they are having pain, you know, can you help us manage the symptoms? Unfortunately, there's a very big gap in services between people who are terminal but not hospice appropriate, if you follow me. I do, and then you're trying to refer them to a physician who is up to date in terms of regulation of pain.
[00:37:43] Speaker 4: Hi, good morning. Great show. Thank you. I originally called in to just say I really enjoyed the show when I can catch it, and today is really marvelous because you're trying to look at all sides of the question. But now that I was listening longer, I do have a couple of comments and and and questions.
[00:38:00] Speaker 1: and I'd like you to comment on. I'm looking at this from both uh legal and religious or spiritual, how you will, standpoints since I'm involved in both communities and they're both close to my heart. Uh first of all the little thing I heard somebody saying uh this is a right we have. Uh well a right is something that is given to us at birth and unless it's badly abused it's never taken away whereas um like freedom of speech whereas a privilege must be earned such as a driver's license and I think this is being treated more like a privilege than a right.
[00:38:36] Randall Roth: Okay.
[00:38:37] Speaker 1: Um the way I look at this is God has given us free will and this is a very sticky question because every case is different. It's really sticky and that's why I think you're doing such a beautiful job.
[00:38:48] Speaker 1: And I'd like you to comment on on what I'm going to say. I think that uh, though God has given us free will, I shouldn't say though, and government and laws should advise, educate and help, not continually restrict on the basis of controlling every movement of ours, but try to see that law is based on equity and fairness and love, which is the at least the Judeo-Christian heritage that was built into our legal system by the founding parents of the United States of America. And how can we do this, you know, reaching around in all these corners and create something that's going to be fair to everybody? Mhm.
[00:39:33] Randall Roth: Well, that's And not abused. Of course there's always going to be abuses, there always are of everything. You've you've framed the issue very very well, Julie. I'm going to take your comments as comments for now, I want to hear from a few more callers who have been waiting patiently, and then I'm going to open it up to our guests again. Let's go to Gary on the Big Island. Good morning, Gary.
[00:39:50] Speaker 2: Good morning. If every patient can take his or her beliefs into the endgame of their life, why should the state intervene?
[00:40:00] Randall Roth: Okay, let's let's take that as a comment, and uh we'll get a few more comments and then we'll hear from our guests again. We go to Susan in Honolulu. Hello, Susan.
[00:40:10] Speaker 3: Hello. Uh following up the pain management question, there seems to be a discrepancy between what the doctor says is possible and the and the the nurse from the hospice says is possible. I'm wondering if there is a way to require doctors, uh who are unable to or refuse to provide enough pain management medicine or surgery or whatever, to refer the patient to somebody who does, to require them, not give them the option but require them.
[00:40:38] Randall Roth: Okay. Um Susan, let me ask Max that question but but first Max, my when I was listening to Pat on the phone a little bit ago, I got the impression that she was agreeing with you that that pain management is something that's more possible than what a lot of physicians realize and I I thought I was hearing her describe what you're describing earlier, that there's a a gap if you will, so far as continuing education on the part of physicians is concerned. But could you comment on that and then answer Susan's specific question?
[00:41:05] Max Botticelli: Uh yeah. Uh my comments uh come about because I've heard of a study and and I haven't read it. Um and I apologize. But basically that study showed that uh that in in uh in in experimental situations uh they discovered that well over somewhere around 95 to 98% of people who were suffering with uh with with uh degrees of pain near the end of their life could have that pain controlled uh in one way or another. There was a small percentage of people uh in whom pain control was almost impossible.
[00:41:43] Randall Roth: And what about Susan's specific question? Can a physician be required to do everything possible to minimize pain, if that physician is is reluctant for whatever reason?
[00:41:53] Max Botticelli: Yeah, I I think that uh there are ways of going about uh that sort of thing. Unfortunately, it's not built into the way um the way we deal uh with uh uh physicians and uh the way hospitals deal with physicians.
[00:42:09] Randall Roth: Okay. Susan?
[00:42:11] Speaker 3: What about what about what what would it take to require that? Would it take a passing a law to do that, so that they would be required?
[00:42:18] Max Botticelli: Well, I I um, I think you're talking to the wrong person about passing laws because I think that laws are easy to pass and hard to enforce. Uh and and this wouldn't be a difficult one to enforce.
[00:42:30] Randall Roth: But as as former chair of the Department of Medicine at the university, wouldn't you say that that how new physicians are taught is an important part of what we're talking about?
[00:42:39] Max Botticelli: I think that's important, but it's also incumbent upon healthcare institutions uh to uh uh to monitor these things and make sure that pain control is uh is at its maximum when it has to be. Uh it's not something that policemen can do or courts can do very well.
[00:43:00] Randall Roth: Okay. Susan, thank you for your call. Uh I'm going to take one more call, and then we're going to use the rest of the hour to to let our guest talk about what they've been listening to and to uh provide any closing thoughts that they want to share with us. Let's go to Jeff from Manoa. Good morning, Jeff.
[00:43:14] Speaker 4: Uh good morning, Randy. It's uh Jeff Crabtree. Good morning, Max and good morning.
[00:43:18] Randall Roth: Hi Jeff, how are you? So our listeners know Jeff Crabtree is also a member of this uh blue ribbon panel, and Jeff is someone who's put in an awful lot of volunteer hours uh on on issues related to what we're talking about this morning. Jeff, what do you have to share with us today?
[00:43:34] Speaker 4: Good morning, Jeff. Good morning. Uh the the interesting issue here to me is that you know virtually all religions and all states are currently in agreement that it's okay to withdraw life-sustaining medical treatment and tube feeding is probably the easiest example for people to think about. And the theory on that being okay is that it's sort of a passive act to withdraw tube feeding and let nature take its course. Uh I believe the Catholic faith and most other faiths are okay with that and basically there's no need to perpetuate a painful, hopeless existence.
[00:44:09] Speaker 4: So I guess the question in my mind and I don't mean this as a rhetorical question, I'm really grappling with it, but what's the real difference between that and allowing a person to speed up that process. I mean instead of making them wait 14 to 20 days for a withdrawal of tube feeding to result in their death, what's the real difference between that and maybe prescribing an overdose of barbiturates for the person to speed up the process. I mean both certainly result in death, both certainly uh end a painful and hopeless existence which the person wants to avoid. So is there a distinction without a difference between those two scenarios?
[00:44:48] Randall Roth: Well, Jeff stay on the line. It sounds like an awfully good question. I'm going to ask each of our three guests to answer it and and to try to answer it as briefly as possible so that we do have time for them to address some other issues. Uh let's start with Sister Roslani on Maui. Uh how would you answer Jeff's question?
[00:45:04] Sister Roselani Enomoto: Um, not answer but just just ask another rhetorical question.
[00:45:08] Randall Roth: Oh, that means it was a really good question, right?
[00:45:11] Sister Roselani Enomoto: What um what I if I'm hearing you correctly, Jeff, my uh interpretation is that the difference between withdrawing and speeding up is the choice of the individual and um the withdrawing if it it has been stated either in some kind of advanced directives or living will or whatever those documents are that a person has uh indicating that they don't want life-sustaining or life-support systems um then withdrawing that treatment indicates a natural uh demise, whereas if you um actively um request that um your life be uh that someone assists you in ending your life, it's it's a matter of choice and I to me, I think then that's a violation of freedom.
[00:46:06] Randall Roth: Okay. Let's go to uh Professor Cass Sunstein at the University of Chicago. Cass, can you give us a real quick answer to Jeff's question?
[00:46:13] Cass Sunstein: Yeah, I think the uh the distinction makes no sense if it's a distinction between passive and active and the fact that it's a natural demise uh for me that has is entitled to no weight. So I think the distinction between these two can be made sense of only if we say that the potential for abuse is much greater for doctor assisted suicide or death than it is for withdrawal. And so that's the real distinction.
[00:46:38] Randall Roth: So you're not on a You're not on a philosophical or theological level, you're just saying from a very practical standpoint you got a slippery slope problem you got an abuse problem with the one and you really don't with the other.
[00:46:48] Cass Sunstein: Right, the philosophical arguments for the distinction and theological arguments I suggest make no sense.
[00:46:54] Randall Roth: Okay. Dr. Max Botticelli, a quick answer to Jeff's question, then we'll go back to Jeff and then let our guests sum up everything.
[00:47:00] Max Botticelli: I I I don't think there was any difference uh philosophically uh or otherwise and I I think what we what I would like to point out is that we are not talking about humans uh who are uh uh uh we what we are talking about, let me put it that way, are about humans who are dying dying. And the question is is can we help them through this period of death. We're not talking about people who are living, who are getting their lives taken away from them.
[00:47:31] Randall Roth: Okay. Uh Jeff Crabtree, uh give you a chance to say anything else you'd want to say, but but first let me comment. I didn't know everyone on the panel when I sat in on your one meeting, but I got the impression that it was pretty well balanced in terms of where the people were coming from and and again, those that I knew what their approach to this might be. Is it your impression, I'm going to ask Max since Sister Roslani as well, is it your impression that the panel is is reasonably well balanced?
[00:47:58] Speaker 4: I think it's terrifically balanced. I give the governor a lot of credit for pointing a wide range of people from a wide range of interests. I think it's a great group. I'm every meeting we go to I'm learning a lot.
[00:48:09] Randall Roth: Okay, you've got just a a matter of seconds to share anything else and then we're going to go back to our guest.
[00:48:13] Speaker 4: Uh nothing else, great show, thanks.
[00:48:15] Randall Roth: Thank you, Jeff. Appreciate it. Well, we're down to the last 10 minutes or so and we've covered a lot of ground. Um, I would like each of our guests to tell us what hasn't been said, that really needs to be added to the conversation, or if you've heard something that you really want to take issue with or elaborate on, now would be a great time to do it. Let's start with Sister Roslani.
[00:48:35] Sister Roselani Enomoto: Um, I guess I just want to emphasize um the last paragraph of uh the article as I submitted it and that is that it isn't just the Catholic perspective that I am uh coming from, but I believe that there are many religious traditions in our country and particularly in our state by reason of our multicultural realities, who reject uh the notion of assisted suicide and euthanasia because of their general understanding of of of values which includes the appreciation for life and the value of each individual, but at the same time and and individual's responsibility to our community, as well as our society's obligations towards all of us, especially the poor and the vulnerable. So I guess I just want to um conclude by saying that um I I really believe that compassion is possible toward the severely ill, especially those who are dying, and that it should be offered by care and companionship, but not through assisted death or medical killing.
[00:50:44] Randall Roth: And Sister, for those who joined us late, I mentioned earlier that you and others have formed an organization, Na Ho Aloha, on Maui and it's an interfaith group of volunteers who who provide the kind of compassionate service to uh uh gap group people who who for whatever reason don't get into the um the hospices that are set up by the hospitals and what have you. Um, I really admire uh the work that you and those people are doing, and and if there's anything you'd like to say about it, or or how other people who might be interested in doing that type of volunteer work can can do so, uh you've got just a minute to to do that.
[00:50:22] Sister Roselani Enomoto: Uh well, actually on Oahu, the group that's much more well known uh is the Project Donna group from the Buddhist tradition, where uh Project Donna is selfless giving and they are also a group of interfaith volunteer caregivers on Oahu. Quite a number of uh different uh groups have formed there. Maui's group is small but growing. And yes, it is one of the ways in which we as individuals, regardless of our faith tradition, may contribute to care for those who are living with terminal illness and in the process of dying.
[00:50:58] Randall Roth: Okay, Sister, thank you very much. We very really appreciate your participation this morning.
[00:51:03] Sister Roselani Enomoto: Thank you.
[00:51:03] Randall Roth: Again, if you tuned in late, that was Sister Roslani Inamoto. She was born and reared on Maui. Uh, she's a member of a religious order of of nuns and has been since 1955. She has master's degrees in history, political science and counseling. Since 1993, she's been the director of the Catholic Church's office for social ministry on Maui. Uh, let's next hear from Professor Cass Sunstein. He's the distinguished service professor of jurisprudence at the University of Chicago Law School. He's an honors graduate of Harvard College, Harvard Law School, clerked for Justice Thurgood Marshall of the United States Supreme Court, written a lot of articles and a bunch of books, uh, as taught at Columbia and Harvard as well as University of Chicago. Cass, uh, you've got a few minutes to uh sum up your thoughts or add what needs to be added.
[00:51:50] Cass Sunstein: Well, I think, thank you Randy. I think it's been an excellent discussion. Uh, a lot of the questions toward the end from the callers and comments were about uh freedom of choice, and let me say a few words about that. Uh, the question, and it's a good one, is um, if a patient who's terminally ill really wants to end his life, why isn't that his business? Uh what is it uh why is it government's business? Uh we might think that there are cases, and this is my attempt to answer that good question. There are cases where we should be careful about the idea of freedom of choice. Uh, for example, uh sexual relations between doctors and patients are uh inconsistent with the ethical obligations of doctors, even if those relations are a product of free choice. Uh now, what's behind that? What's behind that is a fear that doctors would abuse their power and what seems to be freedom of choice might not really be freedom of choice. Now, the right to die, or physician assisted suicide, is a bit different. It doesn't have the same kind of abuse and coercion and ugliness as uh sexual relations between doctors and their patients. But there is an analogy that doctors are in a position of enormous authority, and the concern is that if patients have this freedom of choice, in the real world, uh they really wouldn't be so free. They'd really be subject to uh doctor pressure. Now that might not happen very often, it certainly wouldn't happen most of the time, but it happen, if it happens some of the time, it would be uh a real reason for concern. And in the Netherlands apparently it happens enough of the time to be uh a problem. So I think we should be careful about saying that freedom of choice really is a conversation stopping uh term. Now, one thing I think that's a very good outcome of this discussion is that if the debate over the right to physician assisted suicide, uh can focus us on efforts to ensure better pain management and more compassionate pre-treatment of people who are dying, then that by itself is a huge gain. Uh, an interesting fact in the conversation is that uh the doctor said rightly that we have the capacity really to handle pain in most of the cases, but a caller said, rightly, that doctors don't use that capacity, that too many people in the United States are uh dying badly and in pain when they don't have to. It's also the case that a lot of the problems here are psychological, where people aren't treated uh compassionately by um friends and family or people who really could make uh dying a lot easier. So I think the most important thing we could do first is to uh think of ways to ensure better pain management and more uh compassion with respect to the act of dying. Now there are cases in which physician assisted suicide would make sense, I believe. The question is whether uh we can legalize the practice and create that right without also creating risks uh that we don't want to have to live with.
[00:54:51] Randall Roth: Okay, Cass, we really appreciate your participation this morning.
[00:54:55] Cass Sunstein: Thank you. A pleasure.
[00:54:56] Randall Roth: Okay. Well, we're down to the last few minutes. Uh Dr. Max Botticelli is is with me in the studio. He's an emeritus professor of medicine at the University of Hawaii, John A. Burns School of Medicine. Uh, he practiced here in Honolulu for a number of years, did his residency in internal medicine at the Mayo Clinic. He was chairman of the Department of Medicine at the University of Hawaii from 1991 until his retirement in 1995. Max, uh, we've got about 3 minutes to share, you and me. Uh, what needs to be said?
[00:55:25] Max Botticelli: Well, uh first of all, thanks uh for inviting me to take part in this uh program. I've really enjoyed the conversation. I I want to thank the governor for appointing me to this uh uh panel uh uh for one big reason and that is I got to meet Sister Roslani who I have great regard for. Uh uh Sister, thanks uh so much for for uh being a part of that. Um let me just make two points. One is that uh I I don't agree with Cass that physicians uh have uh taken on too much authority when it comes to living and dying. I don't think they've taken on enough. I I think they've been pressured by uh institutions and uh patients, and and uh and and haven't exerted enough authority uh during uh the dying period for patients. Uh the other point I'd like to make is uh that we should uh take a lesson from Oregon. Um, when they passed the bill legalizing physician assisted suicide, which hasn't been enacted really because it it's tied up in the courts, um they reacted and what they did was to do what they should have done uh prior to that. Uh they made sure that people have advanced directives. Uh 91% of all the patients in uh long-term care homes in Oregon have advanced directives.
[00:56:49] Randall Roth: And there's a little bit of difference, but what most people think of as a living will is a part of what you're calling an advanced directive.
[00:56:55] Max Botticelli: Yes, yes. And uh and and and they went over their advanced directives to make sure
[00:57:00] Speaker 1: the more specific and more meaningful in terms of of of patient care during death. In in addition to that, uh all a patient has to do is make out one set of advanced directives. They can take that from the nursing home to the hospital and uh and in the ambulance on the way and everybody recognizes them. So, uh you don't have uh um uh people disregarding advanced directives because they didn't have the original copy.
[00:57:32] Speaker 2: And one hears stories here in Hawaii of that happening with alarming regularity.
[00:57:36] Speaker 1: All the time. And and and the other thing they've done is to focus a great deal on pain control and been very successful in in getting that enacted. And it and we should take this opportunity to get those things done. Okay. Well, folks, uh that's pretty much it. We've been talking about physician assisted suicide with Dr. Max Botticelli, sister Roslani Inamoto, and Professor Cass Sunstein. The Price of Paradise radio show is sponsored by the Hawaii Community Foundation. It's an organization that's been supporting our efforts for a long time and we really appreciate it. You've been listening to the Price of Paradise radio show. I'm Randy Roth. Aloha.

[00:57:49] Speaker 2: Okay. Well, folks, that's pretty much it. We've been talking about physician assisted suicide with Dr. Max Botticelli, Sister Rose Lani Inamoto, and Professor Cass Sunstein. The Price of Paradise radio show is sponsored by the Hawaii Community Foundation. It's an organization that's been supporting our efforts for a long time and we really appreciate it. You've been listening to The Price of Paradise radio show. I'm Randy Roth. Aloha.