I had the privilege of learning from fellow Greenwall Faculty Scholar Lisa Harris about a term she termed, "dangertalk." As an ob/gyn and abortion provider, Lisa found the debate around the legality of abortion so polarizing that it created a false dichotomy: you're either for or against. Any talk about misgivings, uncertainty, ambiguity, or ambivalence was silenced. Talking about these issues in the face of polarization was deemed dangerous and undermining to one side or another. "How could you?" For Lisa's work in finding common ground and embracing nuance she was awarded the 2023 Bernard Lo Award for forging connections across divisions.
In today's podcast we focus on the equivalent experience of moral uncertainty, distress, and residue among prescribers of medical aid in dying. We are joined by Carly Zapata and Dani Chammas, prescribers of medical aid in dying in California. We discuss:
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Their journey prescribing medical aid in dying, and reasons for choosing to prescribe
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The legality of prescribing in California. We compare California to Canada, as we have previously on this podcast. We discuss new limited survey data suggesting that legal barriers may not explain the remarkable 20 fold differences in use of medical aid in dying between California and Canada; rather, Canada has 6x the number of providers per capita as California, and much greater awareness of the legality of medical aid in dying. We talk about cases that are not as clear - e.g. people who have voluntarily stopped eating and drinking.
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Moral issues, including ambiguity and ambivalence, distress and residue. For example the moral distress created when a patient requests medical aid in dying due to what is clearly a systems failure (see this Atlantic article for clear examples from Canada). We ask if they sometimes feel frustrated that more people who are in favor of medical aid in dying are not prescribing, instead leaving prescribing responsibility to a relatively small group of clinicians.
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How core ethical ideas might lead to very different conclusions about medical aid in dying, and ways Dani teaches ethics to trainees.
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Psychological models that can help navigate this complex terrain with patients and families, including formulations and countertransference.
And I can't believe I haven't played, "I will follow you into the dark" previously - but google couldn't find it - really? In 400+ GeriPal podcasts? Great song. So fitting. My son Renn plays guitar on the audio only version.
-Alex Smith
Additionally, some take home points, sent by Dani after recording:
(1) Holding the dialectic: On one hand, people deserve the highest level of attention to their personhood and their suffering—an effort that, at times, can soften or even resolve a desire for hastened death. And on the other hand, some people will authentically experience this as the most values-aligned way of dying, given their circumstances.
(2) Learning to accept that while laws create the safety rails, within those boundaries, morality is pluralistic. Both patients and clinicians bring deeply held moral frameworks to these decisions—and those frameworks deserve to be acknowledged and respected.
(3) We have to be willing to ask the hard questions—and to show up for one another as we do. Because this work, more than almost any other, has taught us the profound impact of not feeling alone when navigating grey terrain.
I view the discussion as an invitation for our field to not necessarily to become more certain, but to be willing to wrestle with the hard questions—while still showing up with rigor and compassion.
And to remember that our patients are people before they are cases. If we can stay close enough to truly know them, we're much more likely to respond in ways that honor both their suffering and their dignity—whatever path that ultimately leads to.
