 Aloha and welcome to the 60-Second Weekly Webcast of Navigating the Journey. My name is Scott Foster. While our program is primarily about elder care, end-of-life issues, and medical aid in dying, it's also about the politics we deal with while working to pass a medical aid in dying law in Hawaii. Today our guest is Hawaii Island resident Dr. Lawrence Hines. Larry is an emeritus professor of philosophy at the University of Hawaii at Hilo and was an original member of Governor Cayetano's Blue Ribbon Panel on Living and Dying with Dignity from 1996 to 1998. His areas of specialization are ethical theory, professional ethics, health care ethics, social and political philosophy, and philosophy of law. Dr. Hines has taught and performed health care ethics research at Oxford University and the United Kingdom, Free University in Amsterdam and the Netherlands, the University of Auckland in New Zealand, and he has also taught at Southern Oregon State University in Oregon and California State University. Professor Hines has been a consulting medical ethicist since 1983. Aloha and welcome Larry. Nice to see you, Scott. Thank you, thank you. It's good to see you. I understand you have a statement you'd like to read to us. Yes, Hawaii House Bill 2739 tries to address the plight of a group of terminally ill, competent patients whose last months of life are filled with pain, suffering and anxiety. This is not a new topic in Hawaii. As a member of the governor's 1996 panel, which after 18 months of deliberation supported a comparable piece of legislation, in fact one that was even more comprehensive than the one that's before the legislature today, physician-assisted suicide was legalized in Oregon five years before that panel met. And Dr. Timothy Quill had published his articles about Diane, a patient of his in the New England Journal of Medicine in 1991. Diane was Dr. Quill's patient for eight years, suffering from a protracted death from leukemia. And finding the Diane process unbearable, he requested that he give her barbiturates, which she did. He gave her a prescription, which she used four months later. In 2001, Dr. Quill published a book, Caring for Patients at the End of Life. And I think this is possibly still the best book on this topic. It's been nearly 30 years since Oregon's physician of dying law and an additional 20 years from similar legislation in the Netherlands. What is notable about Oregon and the Netherlands is that from the outset, they have produced empirical studies which investigate their practice and their law. In 1987, again in 1994 and 2001, I studied the Dutch experience of end-of-life care. And while serving as a visiting professor in southern Oregon, in Ashland, Oregon, I engaged in the study of the practice of the new law in Oregon at that time. But Quill in his book and a recent article in the Des Moines Register shows is that the empirical record is clear. The fears, the claims of slippery slopes, the inability to take safeguards and abuse against are all unwarranted claims and they're not substantiated by the 30 years of Oregon and data in Oregon, nor by the 47 years of reports and empirical research in the Netherlands. The most inflammatory claims that are made about this are that the practice will spiral out of control, that it's impossible to create adequate safeguards and so on. The empirical research shows that after 30 years in Oregon and 47 and in the Netherlands, the incidence of utilizing these laws is roughly 1.5 percent, approximately the same as it was at the outset. And the final thing I wanted to just point out is that since the passage of this legislation in Oregon, the major consequence has been an improvement of immigrant life care in Oregon, an increase in the use of hospices, and an improvement in pain medication care. I think that what this law does is offer people competent individuals a chance to relieve themselves from intractable pain at the end of their life. Thank you. Thank you. Larry, Gush, a lot of questions. I don't know how closely you followed the bill last year when it was deferred in the house, but the opposing forces, to me, really were off the wall with their criticisms of the Oregon statistics. And here we have, you know, 18 years as at 16 years of empirical data, and of course, the other states that are reporting now. Now, the biggest concern that I find of some validity is the possibility of coercion, and what came up in the original governor's panel on that particular part of it, coercion? It's interesting, one of the claims that people will be coerced, I take it what they're concerned about is that the family ill patient would be coerced by home, by their family, by physicians, by health care workers. Once one starts to look at that, the health care that's being delivered and usually these patients are in the hospital is quite public. There are nurses, other health care providers, physicians, consultants involved. So it would seem to me that if there were any coercion, there would be reports of it. There would be incidents of it. It also would put the coercer in great jeopardy. What is more difficult is the possibility of coercion by family members. But my experience is that if any day family members are trying to do everything to encourage the patient to do everything to sustain their life. I have been working with patients who are terminally ill since 1983. I have never seen any coercion or anything that would remotely suggest that coercion is taking place. As I think you know, we now have three bills in the house that are moving as of this broadcast. We're waiting for a hearing notice. I'm fairly well certain that we're going to get a hearing. And as I might have said some years ago, the vibe is good down at the legislature. But one never knows. I do worry that we get so many safeguards, restrictions placed on the patient that they never can get to the medication in time to really help them. Any thoughts on that as far as safeguards? Yes, the issue of safeguards. If anything, there has been a overreaction to making safeguards too extensive. For instance, the patient must be terminally ill in the Oregon and the Hawaii proposed legislation. But there are many people who are in intractable pain that's not treatable and who wish not to continue to have such pain. The other thing about the safeguards is that these have to be certified, terminal illness, for example, that the patient will die within six months. And by two different physicians, and so the safeguards are really quite extensive. In the blue ribbon panel, there were several members who supported the legislation proposal, but thought that the safeguards were extraneous, as a matter of fact. Maybe it'd be interesting for our audience to know a little more about the blue ribbon panel, how it was created, and you mentioned it went on for four years, sort of how that the panel actually functioned, and maybe some of the, I was very impressed with the list of names of people that were on the panel. Maybe just give us covered a broad overview of the panel itself and how it came to be. Actually, the panel actually lasted for about two years, 18 months. We met for 18 months, the report, and by the time it came out was about a two-year process. I was just contacted by the governor's office. My name had been submitted by healthcare professionals and administrators of the local hospital. So I don't know how people were selected, but I was nominated, as several others were, from the big island. There were representatives from all the islands. There were representatives from the religious community, nuns from the Catholic Church, ministers, Buddhist minister, and a priest from Hawaii, and a rabbi, a retired family, practiced family circuit judge. There was the representation was quite broad, several physicians, main care specialists from the university, representative of the senior law center, Richardson School of Law. So the governor of the head of the Department of Health was on the community. So I think they stretched quite broadly to come up with the 18 people to be on the committee. Larry, hold that thought a moment and we're going to take a one-minute break. We'll be right back. This is Think Tech Hawaii, raising public awareness. I just walked by and I said, what's happening guys? They told me they were making music. Aloha, welcome to Hawaii. This is Prince Dykes, your host of The Prince of Investing. Coming to you guys each and every Tuesday at 11 a.m., right here on Think Tech Hawaii. Don't forget to come by and check out some of the great information on stocks, investings, your money, all the other great stuff, and I'll be your host. See you Tuesday. Aloha, welcome back. My guest today is Dr. Lawrence Hines, Consulting Medical Ethicist, and he's speaking with us via Skype from Hilo on the Big Island. Thank you, Larry. We were talking about the Blue Ribbon panel when we took the break. My interest, I was actually in Governor Cayetano's administration for the two years, I think just before the panel began, I had been very interested in the issue for some years because I was a member of the Hemlock Society, National Hemlock Society. And by the way, Derek Humphries is coming over in April. We'll be our guest here on Oahu, and I'll let people know more about that later. But Andy Vanderbord, I don't know if you ever met Andy. Andy was a formidable lady, is all I can tell you. But then in 2002, of course, Governor Cayetano submitted the first bill, or at least the first one to get any action. And I was retained by the Oregon Death with Dignity Organization and the National Hemlock Society to help manage that campaign. And our goal was just to get a house hearing. We thought that that would be wonderful just to have a house hearing. And lo and behold, we wound up coming within three votes of passing the bill in 2002. And here we are, what, 16 years later, still at it. I guess I would lead us back to your role. I'd like to know more, what is an ethicist? What tell us more about being a medical ethicist? I'm very curious. We certainly could use more ethics in Hawaii. Well, in 1982, I received a fellowship to be a philosopher in residence at the local hospital. At that time, it was Hilo Hospital. It's now Hilo Medical Center. And so for nine months, I was a resident at the hospital, basically shadowing physicians, focusing on end of life care. And after a year of experience doing that, I was asked by the medical staff to continue in the capacity of consulting with them on ethical questions, moral questions, helping them review policy, and so on. But as you might expect, although there are a wide range of issues, everything from abortion to end of life issues, most of the cases that I ended up being involved with were having to do with end of life care. I must have consulted with physicians, families, administrators, in over 500 cases since 1983. And again, like I'm saying, the vast majority of the cases have to do with conflicts between physicians and patients and nursing administrators or policies about life sustaining treatment, for example. A patient may or may not want a life sustaining treatment or any extraordinary measures at the end of life. But the problem there is its amount of interpretation as to what's an extraordinary measure. And the physician has a very large part to say. As you know, eventually Hawaii passed an advance directive bill establishing living wills and durable powers of attorney for health care in which a patient could express their wishes in writing, which were then expected to be followed. But those oftentimes resulted in even though you had a patient's expression of what their wishes were, that was to be interpreted by family members and physicians. And often those interpretations were in conflict with with what the patient asked for. And I was called in to review the case and basically to make recommendations. And as a consultant, just like a physician consultant, I would write up a report and make it a part of the medical record. That gives you some idea of what I was doing and still do today. That opens up, gives me a lot of questions. Now, Hilo Medical Center now is owned and operated by who? It's Hawaii Health Corporation Systems. Okay. During this process that you went through and afterwards, and I guess you're still involved, has this been have your recommendations or have you done a paper on this that that has been promulgated to all the hospitals in the state? Or where could one find your writings on medical ethics? Well, I published at least three articles in the Hawaii Medical Journal. One of them was study on advanced directives at Hilo Medical Center. So it's just a matter of going back through and finding. I don't have them at the top off the top of my head. I think it was about 1994. I did a study on advanced directives. I looked at every death at the Hilo Medical Center for one year, looked at what percentage of those cases involved in advanced directive, looked at what percentage of advanced directives were actually abided by or followed. I have also published in ethics journals and medical journals. I'm sorry to give this off the top of my head, but I can certainly supply you with a list of over 30 publications in philosophical journals. As I told you off camera, I was very excited to finally meet a member of the governor's Blue Ribbon panel because I wanted to talk to someone who, and you're the goldmine. I mean, you're more than what I was looking for. There's another goldmine right there on Oahu, and that is Professor Ken Kipnis at the University of Hawaii at Manila. I'm not sure if he's retired or not, but he also is a medical ethicist as worked with Capulani and Queens and so on. I didn't know that and I do know Ken, so what I'll do, maybe let me back up a minute, when I helped found the Hawaii Death with Dignity Society in 2002, and we were just sort of an ad hoc group going into that political fight that wound up with, you know, coming within the three votes of passing. It was very clear we needed a local organization. We had the two mainland organizations that come in from time to time, usually only when the legislature's in session, but what I found with the Hawaii Death with Dignity Society, because I've always had my name, phone number, and email address up on our website and in our communications, I began getting phone calls from all sorts of people. The most passionate ones were from people who are from people because I continue to this day to get several calls a month. Someone who's just been diagnosed and they want to talk to somebody, they don't even know the questions they have, but I've grown accustomed to people are looking just for somebody to hold their hand and help give them some guidance as to how to confront their imminent death and all that's entailed. It's not a pleasant thing that I do, but I've learned to... I've lost sound. You've lost sound? Yeah. Okay, I can hear you now a little bit. Okay. What I was saying, can you hear me now? Yes. Okay. The calls that I take with the Hawaii Death with Dignity Society are from people in great agony because they maybe have just been diagnosed with six months to live. Amongst all those calls I get are questions certainly about advanced directives and I hear constantly of people who are having their advanced directives ignored and one in particular was the late A.Q. McElrath, who was one of my political mentors and close friends, she called me a week before death and she said, Buster, you've got to get this bill passed. Here I am all hooked up to all these machines just like I didn't want to be and then she was gone in a week or 10 days. So what did you see at Hilo about the reasons for people's advanced directives being ignored? The first thing is that in order for advanced directive to be implemented, the springing conditions must be met and those springing conditions are that the patient is no longer competent to participate in health care decisions in their own case. Another springing condition is that the patient must be certified by the physician as terminally ill and a lot of times what happened is physicians would not be willing to go on record that the patient is terminally ill. That is to say they fully expected that the patient would die within six months. So you'd have people saying, well I know what the advanced directive says but it's not relevant because the patient is still competent and we can speak with them and then since they're competent and they're asking for care or their family is asking for care, the patient may be giving all kinds of signs that they don't want these life sustaining interventions, don't want nutrition and hydration. Then there are physicians who and there are many people who believe IV fluids are not an extraordinary measure for somebody who is expected to die within a week or two when those fluids in fact are quite extraordinary and are continuing basically extending the dying process. So what I often was involved with is cases where a family member would say but she doesn't want these things and a physician would say but their their standard medical practice in this circumstance we can we can prolong this person for another month and unless you have a very strong agent who will say yes but that specifically is not what my mother wanted. You often have people saying well let's just let nature take its course. Physicians are very low to have their patients die and understandably so and they have a professional responsibility to do everything they can to extend people's lives and so unless you have a strong advocate to counter that they're going to they're going to stick with the default decision of doing everything they can to extend the life of their patients and that that itself I think is quite interesting as a strong argument against the possibility of abuse of these kinds of laws because nobody is eager to end people's lives especially caregivers. Yes Larry unfortunately our clock is running out we've got just less than a minute left here. I want to first of all thank you again for for joining us today and hopefully we can do this again because there's a lot more to discuss. We should know in very few days whether our bills are going to be moving at the legislature. We'll keep people posted on that and I urge our audience to check in with our website which is the Hawaii Death with Dignity Society. We'll keep you up to date as much as we can there and Larry aloha to you and thank you for having me. My pleasure thank you Larry Hines from the Big Island. Good bye.