Healthcare Unfiltered
Healthcare Unfiltered is an honest, raw, timely podcast tackling any and all topics in healthcare that affect stakeholders. Dr. Chadi Nabhan uses his dynamic conversational skills to challenge his guests to address controversial and important topics. He also brings on world renowned experts to discuss clinical advances in medicine.
Healthcare Unfiltered
Episode 283 - MAID in America: Navigating Choice, Compassion, and Controversy
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Chadi hosts Dr. Chandana Banerjee of City of Hope and Kevin Diaz, CEO and President of Compassion & Choices, for a thoughtful conversation about Medical Aid in Dying (MAID) – what it is, who qualifies, how the process works, and why it remains one of the most debated issues in modern healthcare. Together, they explore the legal, ethical, and cultural complexities surrounding MAID, including the differences between MAID, assisted suicide, and euthanasia, the role of physicians and hospice care, the history and legal challenges of MAID legislation in the US, and the deeply personal realities patients and families face when navigating terminal illness, especially when loved ones disagree about care goals or when palliative and hospice care are no longer enough.
Read more about Compassion and Choices.
https://compassionandchoices.org/
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Hey folks, it's Shadi Nabhan. It's Healthcare Unfiltered. Thank you for tuning in to this episode of Healthcare Unfiltered. I'm a hematologist and a medical oncologist with interest in all aspects of healthcare delivery, treatment, leadership, mentorship, and policy. Today's podcast is very special because we are tackling a difficult topic, the MAID program. Again, medical assistance in dying program. This program is legal in some states in the United States, as you will learn about 14 jurisdictions. And I'm going to be joined by Dr. Chandana Banerjee from the City of Hope and Kevin Diaz, the CEO and president of Compassion and Choices. You can find a lot of information on that on compassionandchoices.org. I uh got curious about this program because it is being looked at in the state of Illinois where I reside and whether it's going to be legal or not. And we're going to hear about this very soon. But what is the MAID program? How do we get to a point where physicians are assisting patients in dying? Who are the patients that are eligible for this? How do we navigate patients' goals, the cultural differences, the family dynamics? And does everybody qualify or not? And when this happens, what is the process of executing on this? What are the pros and cons of the MAID program? And as you've learned on Healthcare Unfiltered, we do discuss difficult topics. And this is one of the most challenging topics I've addressed on the show. I hope you find a lot of benefit and value in discussing these topics. So please let me know what you think about this podcast episodes, other podcast episodes, or reach out to me through Twitter, TikTok, Instagram, Facebook, YouTube, and so on. And let me know what you think. Please subscribe to the show and rate it and provide a few reviews here and there and share it with your colleagues and join the conversation about all of these topics. You can find a lot of information about my books also on shadynabhan.com, The Cancer Journey and Toxic Exposure, my next book coming out on AI and Cancer Care when Machines Meet Modern Medicine, coming out in September 2026. Without further ado, Kevin Diaz and Chandana Banerjee about the made program. Is it right or wrong? Chandana, welcome back to Healthcare Unfiltered. And we have a the new kid on the block on Healthcare Unfiltered. Kevin, welcome to the show.
SPEAKER_00Thank you.
SPEAKER_02Thank you so much. It's a real pleasure. So we're gonna do a quick intro, but uh uh and Kevin, uh rumor has it, you are like Time magazine top 100 uh healthcare influencers. So um I we really uh appreciate you joining us. You're gonna tell us what that means, by the way, because you know, I mean I could barely make it to like the high school book of my children. Um Chandan, a quick intro. You've been on the show before, but uh to remind viewers and listeners about you a little bit.
SPEAKER_01Yeah, so thank you for having me. It's uh pleasure to be back. Um so I'm a physician by training, I I practice uh palliative medicine at uh at City of Hope, which is a NCI-designated cancer center. I oversee also their graduate medical education programs as the dean and the designated institutional official at City of Hope. Um, I am very passionate about medical aid and dying. Um, in my institution, when uh medical aid and dying was approved in California, I was one of the first physicians to actually uh be a prescriber for medical aid and dying. And uh I'm really happy to talk to people about this topic that is still so, so vastly misunderstood. And I'm happy to be joined by Kevin, so I'll pass it to him.
SPEAKER_03Kevin. Well, thank you. Uh uh I'm an attorney by training, so I've been practicing law for uh almost 30 years, and I have worked in the public interest with a variety of organizations. And for the past uh, I think it's almost 12 years now, I have been uh working with Compassion and Choices, which is a national nonprofit whose mission is to uh improve care and expand options at the end of life so everyone can chart their own end-of-life journey. Uh and I'm currently the president and CEO of that organization.
SPEAKER_02It's a pleasure to be with you. And how do we, how do Chandan and I make it to the top 100 in Time magazine? Would like to do that for next year, please? Can we apply? I mean, can we like say we we had you I had you on the podcast that suffices?
SPEAKER_03I I would I would give it a shot. You know, I I was wondering the same thing, and they have some sort of cryptic little description on the website about what their process is, but it it came as uh a very pleasant surprise to me, and I'm sure the other the other members of the list.
SPEAKER_02Well, congratulations. Just a testament to the fact that uh sometimes the work that you do and others do gets recognized, and uh it hopefully motivates people to keep uh pushing forward. Chandana, what is the MIDE program? Just you know, briefly help us understand what is made.
SPEAKER_01Yeah, so um so this is good. Thank you, Chadi. I will definitely speak to the clinical aspects of medical aid and dying, and uh Kevin, who's so well versed in the legal and has helped so many states actually through compassion and choices achieve um status for their states, uh, will definitely um chime in on the legal and policy aspects of it. So, as a clinician, you know, when we look at medical aid and dying, it's um it's less complicated than it should be, right? In the in in people's eyes. Very simply put, so medical aid in dying is a medical practice that allows terribly ill patients with a prognosis or life expectancy of six months or less to live, the ability to obtain a prescription for medications that they can take or they may choose to take or self-administer to die peacefully. There's a very strict eligibility criteria anywhere where it is legal in the US and in the their jurisdictions here, and um, there are many safeguards to it. So basically, the important thing is that people still should remember that it is a medical practice uh that is part of one of the end-of-life choices, along with many other end-of-life choices that medicine allows for patients here in the United States.
SPEAKER_02Chandan, before I ask Kevin, but could you appreciate at least the fact that sometimes we are not that good, honestly, in predicting prognosis? And um in there are situations where, you know, it it's hard to say, well, I think this person has six months to live. I mean, we right? I mean, you can understand there's a pushback there.
SPEAKER_01Yeah, so I think the important thing is that because there's a little bit of a slippery slope with prognosis, um, I mean, many people can prognosticate based on the disease uh progression, but but really to avoid making sure that there's no misuse of this particular um medical practice, there are strict safeguards, not only on the patient side, but also on the physician side. So medical aid in dying is actually a process that a patient goes through. So not only one we find, we make sure that they meet the entire eligibility criteria, right? Which means that in most states that they have to be terminally ill with that six months. And when it comes to that six months prognosis, not only does that primary physician, whether it's the oncologist or the pulmonary care physician or whoever it is that is determining that prognosis, has to make sure that they are meeting that prognostication. But after that, the team that actually becomes part of the medical aid and dying team also has to make sure that that prognosis is accurate. So not just one physician, but there's usually multiple physicians being the primary physician. And if the primary physician is not part of the medical aid and dying program, it is the prescribing physician and the consulting physician in the medical aid and dying team that actually then makes sure that the prognostication is accurate. Uh, sometimes uh when there's a little bit of a concern uh with the patient and the patient's eligibility, um, if let's say they meet every eligibility and let's say they have physicians have concern with um their decision-making capacity, they will often also include a mental health provider. Um and the mental health provider's uh responsibility is not only to make sure that they're capable and decisional, but also as physicians, they also often look at prognostication.
SPEAKER_02Kevin, put on the lawyer hat. What is the legal pushback against it? Um I wanted to argue against it from a lawyer perspective.
SPEAKER_03Yeah, let me just first add a little bit to what Chandrana said before we go there, um, which is one thing that's really important to remember about medical aid and dying here in the US is that it's completely voluntary. And that's voluntary from the patient perspective and from the clinician perspective. So, you know, most of the studies I've seen is that clinicians tend to overestimate the amount of time that people have left. And if at any point someone comes to a physician and says, hey, you know, uh, I'm interested in this, and the physician, for whatever reason, doesn't feel comfortable coming up with that diagnosis of six months or less, or prognosis of six months or less, they they are not compelled to say that. So, you know, there's nothing here where it says you have to do this. So if there's any doubt in that person's mind, they can ask for a second opinion, like Chandana said, or they can say, well, I that's just not what I think is happening right now, or I don't think there's enough certainty. So I just want to make sure that's um um super clear. I think the other thing I want to highlight here is this is not a situation where people are uh going to to um because uh trying to use this process because they want to die. They are doing it because they know they are going to die and that they are in the dying process. And one of the key statistics that I think really um highlights this in the United States is that almost a third of the patients who receive a prescription never choose to self-ingest. So it's not that people get the prescription and then right away use it. What they do is they have it, that gives them the peace of mind that they're not gonna have to suffer through a prolonged dying process. And then for whatever reason, you know, for many of them, it's like, hey, you know, that moment never came for me, and therefore they never use the prescription. And because you have such a high percentage of people who are not using the prescription, to me, that gives me a lot of um comfort and that it's not something that people are rushing to do. It's very well thought out, and it's really um one of the benefits of the whole process is this palliative effect that it has for people, because then they can just concentrate on living their last days as opposed to worrying about that they're gonna get to a point where they're gonna suffer needlessly.
SPEAKER_02But Shandana, isn't that why we have in the US at least the hospice programs and the palliative care programs? Like, I mean, if somebody could say, well, I mean, why if this patient is in hospice, our hope is that they're not dying while suffering.
SPEAKER_01Right. So that's a good point. And I think we should really look at both these uh side by side, right? The hospice and palliative care programs in the US are great. However, they're not enough sometimes. Um these patients that are choosing to at least opt into medical aid and dying really have a level of suffering that sometimes is not managed well by medications, not managed well in hospices. Also, um many of these that are um choosing medical aid and dying want to be able to die in peace at their time at home. So with hospice programs, right, there's great palatin, yeah, there's great symptom management. But sometimes the disease is so uh so cruel that even the pain medication management doesn't help enough. For example, let's just take let's take a geoglastoma, right? That has that is aggressive, that that has continually made a person seize, and now their seizures are literally every minute, every two minutes, they're painful, there's there's agony, there's suffering for the patient, there's suffering for the family, right? For someone like that, knowing that they will be dying in the next week, perhaps days or even a month, right? The option to have that medication and and say, okay, enough is enough, I am going to take it now, is sometimes much preferred than saying, why don't I let hospice manage that for me, or why don't I let hospice put me on comfort care, right? I think they know people. One thing I've realized in my 12 years of working with medical aid and dying is that these patients are very knowledgeable about the diseases. They're very knowledgeable about the progression of the diseases and the suffering that's entailed with them. Sadly enough, many times I see that even some of the patients that have these situations don't really prescribe to medical aid and dying, or don't actually sign on to medical aid and dying early enough. So by the time they come to me, sometimes they are so advanced that their rapid decline makes them not decisional. And at that point, they're not eligible for medical aid and dying. So I think if you look at why these patients do medical aid and dying compared to hospice or just regular palliative care at the hospitals, one, the biggest one is patient autonomy and dignity, right? I think I think we know that in medicine that is an increasingly important aspect. Um, you know, everything we discuss with patients, the advanced care planning conversations, the conversations around even medical care and decision making are tailored many times to patient autonomy, right? And medical aid and dying actually is a key uh emblem of that. Um, really, again, the relief of unbearable suffering, which we know that sometimes hospice and palliative medicine cannot really provide unless the patient is put into a set uh terminal sedation state, right? Um, peace of mind. Um, and and and again, the aspects of improved end-of-life conversations. So all these, all these aspects really make medical aid and dying really important for someone who has that terminal disease that is an aggressive terminal disease that we know is not curable, is not curative, and and we know that hospice or palliative is not going to be the solution to them if ultimately in hospice or palliative care they're going to end up sedated, uh, not being able to converse with family and friends, and and still have to wait to suffer, wait to die, right? So medical aid and dying gives the ability to spend every single minute that they can while they're conversational, while they're decisional with their families, knowing this death is coming upon them. And then if they choose to take that medication to die peacefully when the time is right for them.
SPEAKER_03Kevin, one thing I would I would like to add too is that you know it's not an either-or. The vast majority of people who ultimately use their medication um or they get a prescription are enrolled in hospice.
SPEAKER_01Yeah, that's a very important point. Thank you for that.
SPEAKER_02So so, Kevin, um, you said something earlier that was um uh uh intrigued me a little bit, which you said these are patients who don't want to die, they know they will die. Um so um I don't know if you're familiar with Daniel Kahneman, Danny Kahneman, who um an economist who's a psychologist actually won the Nobel Prize in Economy. He did he mastered the behavioral economics, wrote thinking fast and slow, and so on. Um and uh he was in the his mid-80s, I believe, and he actually flew to, I believe, either Switzerland or Finland. I don't even remember which country. And um he did um he did get assistance in dying. Uh there was no knowledge whether he actually had any terminal illness or not, but uh it it felt based on what I read about him that he felt that he has gotten too old, he's not the same person he was before. And so this is this would not happen in the US. Like somebody like this cannot get this. So is our made program different than the MAID programs in other countries?
SPEAKER_03Yeah, that's a really critical point because our program is much more restrictive than other jurisdictions um in the world. So uh he probably went to Switzerland, is my guess.
SPEAKER_01And Pegasus, he yeah, he actually went and uh got aid from the Pegasus organization in Switzerland.
SPEAKER_03Yeah, and so um in some jurisdictions there isn't a terminality requirement. And in fact, um uh for many of them there isn't even a self-administration requirement. So in the and and the thing to add to the confusion is that other jurisdictions also call it medical aid in dying. So um so sometimes when um people are talking about it, they start to confuse terms and different legal um regimes in order to um as they're as they're thinking about it. So anyway, yes, but the short answer to your question is in the United States that that would not happen because you do have to have a terminal illness, and a terminal illness is incurable, irreversible disease. Um and it it that's not age.
SPEAKER_02Kevin, can you give us a bit of a history? Like when did the interest in having a MAID program start in the US? Is this like an old, like 50 years ago people were talking about? Is it recent? Just give us a bit of a of a historical perspective to understand even why it is happening more today as a conversation than before. When did we even start having this conversation?
SPEAKER_03So I think a conversation has been around for probably as long as medicine has been around. Um, and you know, I think um there have been some articles. Uh, you know, I think one of the ones that jumps to mind is How Doctors Die, written by a uh a physician, you know, who said, look, you know, with people who have access and knowledge about um how people die and then access to pharmaceuticals, they don't, they don't necessarily go through these prolonged processes when they know what's coming. Um, and so I think there was at least this informal, maybe even underground discussion about uh assistance in this area for as long as, you know, as long as doctors have been around. Um, where it came to a fore was here in Oregon, actually in the 90s, when there was the first uh medical aid and dying law was passed. It's the Oregon Death with Dignity Act, and that was passed through a ballot initiative. They tried to get it through the state legislature, uh, and it it didn't get through, and so ultimately it went to a ballot. And the people of Oregon ultimately enacted the law with the safeguards that we see today. Uh, and slowly but surely over the years, we've seen additional states either through ballot initiatives, through legislatures, or in one instance through the state uh Supreme Court uh authorize uh medical aid and dying as we've described here in the United States. So right now there are 14 jurisdictions where medical aid and dying is lawful in the United States. A couple of those still haven't uh been um aren't effective yet, but they've been passed. So Illinois and New York will come online this year. Um and then two of those jurisdictions, Oregon and Vermont, um allow uh do not require that people are residents of those states in order to uh obtain a prescription.
SPEAKER_02I was just gonna ask you like, can somebody go like I'm a resident of Illinois? Can I go to one of these 14 jurisdictions or I have to be resident of the well, actually, let me correct that.
SPEAKER_03So it's actually Um Oregon, Vermont, and Montana, where you don't have to be a resident.
SPEAKER_02Yeah, I see. Okay. So take me through like the to everything that we do, there's a pros and cons. I mean, I'm assuming the reason this has taken a long time, some jurisdictions, some not, and so on, because there's some opposition to this. And um lawyers have taught me that they, as part of the lawyer training, you have to always argue for and against a particular case and so on. So I get the for. Put the against hat, uh, Kevin, and argue against it.
SPEAKER_03Well, uh, so you know, when we when we're thinking about the theoretical, the people who are opposed to it come up with all sorts of essentially fear-based reasons that folks might um might engage with medical aid and dying. And I think that the ones that raised the biggest specter uh in originally when we didn't know and we didn't have the data to understand what might happen, uh, were the was the idea that somehow people might be coerced or that somehow this would be abused in some way. And the truth of the matter is that after 25 years, we just have not seen that. And and it's a testament to the safeguards that have been put in place and that anticipated those counter-arguments. I think, you know, one of the now each country has its own laws, has its own culture, has its own relationship with its the practice of medicine. Um I think that for many people in the United States, when they see what happens in some of the other jurisdictions, it gives them pause and that there is some concern about that, particularly what we've seen in Canada. Um but you know, I'd be hard-pressed, given the huge amount of evidence and the length at which we've had, or the time period for which we've had medical aid and dying here in the United States with the safeguards that we have stuck by for all those years, um, to really say that there are reasons not to allow it. And in fact, it it seems clear and clear that it is something that has really helped push um physicians to do right by their patients and also uh encouraged uh many more conversations about end-of-life care and value setting and goal setting and those kinds of things so that people really do get the care that they want at the end of life.
SPEAKER_02Chandana, how are you, how do you handle situations where there's a little bit of disconnect between the patient and the family? I could really envision that. I've dealt with it in hospice care, but there are patients who really want this and the family is completely not on board. How do you handle that?
SPEAKER_01Yeah, so you know, I've had many patients uh with families such as that. I think the most important thing is having these conversations about what really end of life looks like for the patient, right? What it looks like for the caregiving people around the patient. Um, what does MAID look like? Uh, what are the misconceptions about medical aid and dying? For most people that are not very knowledgeable about it from a clinical perspective, they look at it or they equate it to suicide or euthanasia. Absolutely misnomers, right? Medical aid and dying is not euthanasia. Um and medical aid and dying.
SPEAKER_02What's the difference? What's the difference?
SPEAKER_01The difference is that with medical aid and dying, you have the patient who's self-administering or ingesting the medication and doing it on their own accord at their home. Um, but euthanasia, you often have the physician that is administering the medication to the patient directly, right? Um, that's that's the most important distinction. Uh, and it's not suicide. Um, here the patient has a terminal diagnosis. Um, unlike some other places, like with suicide, you don't need a terminal diagnosis for someone to partake in suicide. Uh, with medical aid and dying, unless you have that criteria, that eligibility met based in the US, um, you know, it is not suicide. It is far from suicide. These patients are already dying and they will die suffering uh without the aid that medical aid can provide in many of these cases. Um, so I would say when I talk to families, it's more about really understanding why they have the misconception, what the misconception is, what are the ethical and moral objections to medical aid in dying? They could be personal, they could be religious, right? They just aren't very knowledgeable about this whole medical practice. Some of them may not even know that it's a legal medical practice, right? Um, and so all these things, including not understanding the patient's vulnerability as a caregiver, right, um, makes them very hesitant. Um, but at the end of the day, I also remind them that this is the patient's choice. This is the patient's journey. The patient is not being coerced into this, they're making their own decisions, and and the best way the families can support them and their journey to die peacefully is to understand the medical aid and dying process and you know work with the patient on making sure that their end is peaceful.
SPEAKER_03So there was also a very interesting study that was done here in Oregon uh that followed up with family members uh of folks who um had uh participated in medical aid and dying and self-ingested. And one of the interesting things was even when they didn't agree with the decision, they felt much more resolved because they knew they were, it was very clear what the patient wanted and what their values were. And so, while you know, the idea of losing someone, oftentimes that the the grief of losing them can get very um intertwined with kind of when you're gonna lose them and all those other things. Um, so it was very interesting to see that the results were that the people felt much more um resolved with their decision, even though they maybe did not dis uh agree with it. And I think that's really important too, because it lets this the family members then really just deal with the grief as opposed to having to worry about did this person get what they actually wanted? And that's also true with um uh kind of end-of-life wishes and care outside of the medical aid and dying context.
SPEAKER_01Right. And to that, Charlie, let me say that you're as clinicians, right? We know so many clinicians that still have trouble articulating really disease progression, disease burning to the dying patient. And I think that's where also it makes patients and families uh very hesitant to talk about these things. So if patients and families, or if caregivers for patients don't really grasp the concept of suffering for their loved ones at the end of life, uh, they may never understand what really the comfort made will bring to that medical aid and dying would bring to the patient, right? So I think it's really important. It also brings about this point that Kevin said, the improved end-of-life conversations that need to happen with patients is something that, again, medical aid and dying has opened the door for since its inception, right? Because of medical aid and dying and people's misunderstanding or not understanding it enough, is actually fostered broader end-of-life conversations amongst all people.
SPEAKER_02Right. So, so Kevin, what people who are watching this or listening to this should not conflate what we're talking about with what Dr. Kivorkian did, right? Because people, I mean, Dr. Kivorkian, who ended up going to jail, I believe, people associate medical aid and dying with him. Now, this could be wrong, could be right, but maybe help folks understand what Kivorkian did. Was it okay? Was it not okay? What was the difference? What's the difference?
SPEAKER_03Well, so uh my understanding, my understanding of what Dr. Kovorkian was doing was in part of what he was doing was close to what medical aid and dying is in the U.S. currently that's authorized. Of course, he was doing it at a time when uh it might not have been lawful and he was prosecuted a number of times. I think the thing that is important to recognize is that when he was convicted and sent to prison was because he euthanized somebody on camera, and then I believe they played it on 60 minutes, if I'm not mistaken. Um, so um this was not this, you know, what he went to prison for is still not lawful in the United States.
SPEAKER_02I see. I see. Okay. So, China, let's go, let's go through the process. I want to try to help listeners and viewers understand the process. First is terminal illness. Are these defined or are these in the eyes of the treating physicians? Like, do you have a list, for example, of what these terminal illnesses are?
SPEAKER_01So it's terminal illness as it clinically stands for all clinicians. Um and most often they define when uh when a cancer becomes terminal, it's pretty well defined that it's become terminal illness.
SPEAKER_02No, I'm talking like let's say heart failure, let's say line.
SPEAKER_01Right, exactly. So so there are strict, I mean, I mean, if you look at even what um NHPCO does, they have really hospice eligible criteria, which is when a patient with any disease, uh, whether it's heart disease, cancer, renal, become six months or less. So that's exactly also the hospice eligibility criteria. To be eligible for hospice in the US, you have to have a prognostication of six months or less, right? So that makes it very sort of easier for medical aid and dying to actually look at those criteria, right? There are other diseases where, like you have ALS and all that have a little bit of a different um progressive burden that also medical aid and dying can work too, but then probably Kevin can speak more to the legal aspects of it. But these are very clinically defined criteria of eligibility for a disease, right? And the important thing is that not only is it the six months and less for medical aid and dying, in addition to it being terminal, right? You can have a terminal disease that is terminal for a year or two. But that prognostication of six months or less is a very clear distinction that makes a person eligible for one hospice care and two medical aid and dying. And in addition to that, multiple other eligibility criteria when it comes to um, you know, living, being of a certain age, being decisional, having the residence, the residence of being in the state where or jurisdiction where it's legal. Uh, there's multiple things that have to be met. So again, it's not something that just a patient can wake up knowing that they're terminal and say, or I'm terminal, I would like to get medical aid in dying and use these medications. It's a process the clinicians we follow. So even the broader process, right? When the patient is determined or requests medical aid in dying, the eligibility criteria is first looked at, uh, and the prognostication is looked at by discussion with physicians that take care of them. Other than that, after that, they have to actually go through a prescribing first verbal uh with a prescribing physician, and then they have to actually see a consulting physician. In some states, you can do this within uh 48 hours, and in some states it's still longer. And many states also, uh not many, a couple of states require people to even see a mental health provider, and then you go to the final um verbal after which the patient is then written for medication. So if you look at it, it's a process, it doesn't happen immediately.
SPEAKER_02Yeah, and it's like the oncologist or the primary care has to refer the patient to somebody who is well versed in MAID.
SPEAKER_01Usually most hospital systems that have it, um, you know, have teams that practice medical aid and dying. Um, or sometimes oncologists themselves actually participate in writing prescriptions or being consultants for medical aid and dying.
SPEAKER_02Kevin, I still don't understand. And sorry, I keep going back to this because I'm what I'm struggling with is that you say it's it's legal in 14 jurisdictions. I still don't understand why it's not legal everywhere. If it's that good of a program, if it's if it's strict, if it has guardrails, if it's patient-centric, and so on, I'm trying to understand what is the opposition are saying why is it not legal in every single state in every single jurisdiction?
SPEAKER_03Well, I mean, it's it's it's a state-based law. Um, so it's uh generally speaking, in the United States, medical practice is governed by state law. It's not governed by the federal government, although there are a lot of you know payment structures and other kinds of things that really have a huge impact on how medicine is is practiced throughout the country. But when it comes to what is acceptable to the medical board and to not risk your licensure, then that is something that is state-based. And so we have had to go to each state and argue for these things. In the wake of Kavorkian, there were a um uh there was a wave of legislation that uh codified um certain uh a criminal law essentially, what they called assisted suicide, that if if that law exists in your state, then it puts into doubt whether or not a uh clinician could actually do something akin to medical aid and dying without risking both criminal, civil, and regulatory sanctions. And so um, you know, unless there's some sort of declaration by the legislature and a change of law or a court or something like that, the reality is that clinicians are not going to want to participate in this because it's it's too risky. Um and you know, they've got too much to lose. And so they don't. And and going back just to uh the previous question that uh Chantana was answering, from the legal perspective, a terminal illness has to be an irreversible, an incurable disease. So there, you know, you can think of a lot of different kinds of maladies, illnesses, and other kinds of things, but one of the things you have to go through is this incurable? Is it irreversible? And is this a dip is this because of a disease? Then you also have to say, is the person have six months or less to live? And then also, are they mentally capable of making healthcare decisions? So there are a lot of things that might be, like Chandana said, that were terminal illnesses or diseases, better said, that you might have certain elements of each of those, but you have to have them all at the same time in order to qualify. And so there, you know, it's it's strict in that way. And there are some people that will not qualify in part because they only have certain elements of those requirements and not all of them.
SPEAKER_02Chandana, what are the medications usually provided to patients who are part of in MAID? Like what do what are what do they usually get?
SPEAKER_01You know, medications for medical aid and dying have um, you know, evolved over time. But if you look at typically the medications used in um medical-aid and dying, um, initially we do give a combination of anti-emetics so that you know they they don't throw up uh because these medications are toxic in terms of the way they taste, right? They're not the best tasting. We also give um medications to slow down the heart, right? Because the heart does need to slow down. Um and then there's a combination of uh really um it's it's opioids, um, high dose of opioids and antianziolytics and also um barbiturates that are given. So um we, you know, there's uh physicians that have worked on trying to find the best cocktail for for medical aid in dying, which is uh continually being worked on. But most the most recent is that we have um, you know, a barbitruate that's pretty strong that's added to the cocktail. Initially it was um, you know, it was just uh the opioids. Um, and then we had secobarbital, which got stopped, stopped being manufactured, and now there's another barbiturate that's been added, uh, which has worked very well. So it's a combination, I would say, of anxiolyticids, opioids, and barbiturates that really help shut the body down. Very similar to, I would say, medications that are used in uh in terminal sedation, right? Terminal or continuous sedation. Um, these are the same medications in in terminal continuous sedation, they're administered via the IV route in a hospital setting or in a clinical setting. Here, these are oral medications that are uh that the patient is able to ingest orally or self-administer via a rectal tube if their oral uh capability is not present or the absorption is not that great to the GI system.
SPEAKER_02Kevin, do you envision a scenario like if we're having this conversation in a year or a couple of years from now? Um, are you imagining a situation where this is going to continue to be to improve, that it becomes legal in all states? Is that your aspiration?
SPEAKER_03I think our you know our goal is is that it is lawful in all states eventually. And I think that we will continue to see progress. I think something that's very notable and telling is that uh the vast majority of people in the United States believe that people should have this right. Uh so if you look at polling data, um, generally speaking, folks agree with us. But, you know, it's it's much easier to defeat legislation in a state than it is to pass it. And so you can have one or two legislators who really can hold everything up. So, you know, I think it's gonna take uh it's gonna take time. And I think that we have some jurisdictions where um, because of cultural and religious issues, it it will be more difficult than some of the states where it's already been passed. I, you know, I also just want to be um cognizant of the fact that in um in other areas where it comes to kind of bodily autonomy and people's rights to make certain kinds of medical decisions, we have seen um changes because of rulings from the U.S. Supreme Court. And so there's always that specter in the background that something could happen that might uh change the availability of this practice in the United States. And that's always something that we're guarding against.
SPEAKER_02Are you against the practice in Switzerland, Shandana? Do you think they're taking it to the extreme? Like, can you see where they're coming from, or do you think they're wrong?
SPEAKER_01So that's a very difficult question for me to answer. I wake up every morning having practiced medical aid and dying with understanding where do I stand on this, right? So I am a practicing physician in the United States, and as it stands today, you know, I do believe our medical aid and dying program is successful because it has the safeguards that it does, and it's used, and there's very little abuse because of the safeguards that it has, right? Um but it's not for me to say that other countries that have allowed for um medical for dying for patients with with terminal diseases or other situations um don't have their own um ethical, moral, and and personal views on them, right? I think I think I I am very confident in the practice of medical aid and dying in the United States, and that's my opinion today. Um will that change tomorrow? I don't know. I think I think life takes you through so many things clinically. Uh, you see so much as a clinician, you um you the world is constantly evolving to see best practices from every place where some form of medical aid in dying is being used. That sometimes you do wonder, should it be allowed for the people? Now you have this concern of the slippery slope, right? Where like places like Canada and Switzerland um allow for people, even with mental health disease, uh to partake in it. With Switzerland, I don't even think there's uh medical or clinical criteria to partake in uh some of these medications that they take. Um personally, I am I'm not comfortable with that. I think, you know, I think as clinicians, we do have a right and we have a duty to really work with our patients to give them the best care, the best quality of life, but also the best possible death that they deserve when when the option, when, when their diseases are not curable or reversible. So today, as I speak, I don't know if they're right or wrong. That would be wrong for me to personally take that view. I believe what we have in the US. Is one of the best models that we have. And that also is a model that's uh that's adopted by England. It's been Australia has similar models. So I'm very comfortable in saying that I really support the way we practice medical aid and dying.
SPEAKER_02Kevin, I believe you agree with that. Do you think Switzerland guy is won?
SPEAKER_03You know, uh so I I I think I would answer that the same way that Chandana does, in part because I would have to learn an awful lot more about what they do in Switzerland before I would be able to say that that's something that that makes sense for folks here in the US. Um, I think that, you know, one key difference in the US and Switzerland is um how and to what extent is medical care available to everybody, just basic medical care, right? Or what is the kind of the history of say uh uh clinicians and or the government making certain kinds of choices for people, whether it's you know, things like the Tuskegee experiments, or whether it's like um immigrant women in detention being sterilized, or other sorts of things that um, you know, give people pause, but there are real parts of our both you know history and even recent history. And so the um to what extent and and how strong do those safeguards need to be in order to not allow for abuse, I think that's a real question. And we would want uh a very vibrant and thorough debate if we would ever um move from those safeguards. And I think that our system is set up to do that if if that ever became a uh kind of a proposal.
SPEAKER_02You both have been very generous with your time. I really, I mean, first of all, I feel I I learned so much, and I think you you you really highlighted this in a very, very clear manner to everybody who's watching and listening. Anything I should have asked or anything I completely overlooked that you really think people should be aware of? Any final comments or anything that we may have completely just didn't cover?
SPEAKER_01Can I speak from the clinical perspective? I think um I personally would make the plea to clinicians um that are opposed to medical aid and dying, uh, you know, to have an open mind and understand the process and understand the patient's perspective uh more. Um and and clinicians, especially in states where this is not legal, um, I think to really start looking at why medical aid and dying is um as good a medical end-of-life option as palliative sedation or comfort care uh for certain patients. Um, again, I think limited understanding of medical aid and dying is one of the biggest barriers to clinicians participating as prescribing and consulting physicians or helping their patients navigate this process. Um I think it's really important for them to be knowledgeable about it, whether they're in a state that practices it or not. And for patients, I think patients that are at that point where they do know that the diseases are um, you know, terminal and will be approaching a prognostication of six months or less, I think it's really important to make sure that they understand medical-aid and dying along with the other end-of-life conversations. And and for physicians and clinicians really to have those transparent, open conversations about options at the end of life, whether it's this made option or another option that's available to them. I think we as people just need to be very transparent as to what's available to everybody at the end of life so that we can help people die peacefully. It's not that we are going to live forever. We might as well start being transparent in how we approach it.
SPEAKER_02Well, I'm gonna pretend I didn't hear we're not gonna live forever. There was like there's a Netflix documentary about longevity that you can actually live forever. I mean, I and I think I think Chandana needs to start watching some of these shows. What do you think, Kevin?
SPEAKER_03Uh I I haven't seen that one, so I'm not gonna endorse it uh blindly. I didn't either, I couldn't watch it.
SPEAKER_02Yeah. But any any thoughts I may have forgotten, any final thoughts?
SPEAKER_03No, I would I would just want to echo what uh Chandana said in that um if any of your listeners or viewers uh are confronting issues around end of life, that I really encourage them to go to compassionandchoices.org, which is our website. And we have a number of free resources where people can um kind of go through and do some planning for end of life and then share that information with their loved ones or their support networks so that uh regardless of whether they're interested in medical aid and dying, they get the care that is consistent with their values and beliefs, because that's what our organization really stands for. So if you you know are opposed to medical aid and dying, by all means, we we we don't want to force anything on anyone. And if you have a certain religious tradition that you want respected, then of course that's what we we we want you to die in a manner that's consistent with your values and beliefs.
SPEAKER_01Yeah, Kevin, can you? I want to thank you, Charlie, for bringing us on because again, not too many people dare talk about this and the way you brought me and Kevin together to discuss this.
SPEAKER_02I think it's very important. So I appreciate you both coming on the show. And uh, once we produce it, I'll share it broadly with you and please share it with your constituents. Thank you so much for coming on.
SPEAKER_01Thank you so much. Thank you. Take care.
SPEAKER_02Take care. Okay, folks, thank you so much for listening. Thank you to Chandana and to Kevin for coming on the show. I really appreciate it. And uh, folks, uh, please uh find me on all social media platforms and subscribe to the show, rate it, and let your friends and colleagues know about it. And before I let you go, I am going to leave you with a saying by Mark Twain: the fear of death follows from the fear of life. A man who lives fully is prepared to die at any time. Until next time, take care of the colour.