Transcript: 'Death Book' Debate on 'FOX News Sunday'

The following is a rush transcript of the August 23, 2009, edition of "FOX News Sunday With Chris Wallace." This copy may not be in its final form and may be updated.

CHRIS WALLACE, HOST: We're going to do something different here today. Usually, we discuss the news, but today we're going to tell you about something you may never have heard about, what critics are calling the "death book."

It's a 52-page pamphlet the Department of Veterans Affairs is using right now in end-of-life counseling for the nation's 24 million veterans.

We're going to talk with Jim Towey, former director of faith-based initiatives in the Bush administration, who broke this story. And then we'll turn to Tammy Duckworth, assistant secretary of veterans affairs. Miss Duckworth insisted on being interviewed separately.

Mr. Towey, welcome to "FOX News Sunday."


WALLACE: Let's start with an overview. What's wrong with this material, "Your Life, Your Choices," that the V.A. is using for end-of-life counseling right now?

In the article that you wrote in the Wall Street Journal in which you disclosed this, you say the message is clear, hurry up and die.

TOWEY: Well, the message that they want to communicate, I think, is if you have a stroke or if you have a coma situation that somehow your life has lost a little value and it may not be worth living anymore.

My problem with the document, Chris, is that the author of it is a proponent of assisted suicide. He's way out there on that issue. And the V.A. has been using this. A new directive just came out in July, urging providers to refer patients to it. So in my view, there should be a balanced treatment. And this is a slippery slope that kind of makes people — when you look at the document, it makes people feel like they're a burden and that they should do the decent thing and die.

WALLACE: All right. We're going to get to the specifics in this book in a second, but I want to ask you another general question.

President Obama calls talk of a government-run "death panel" a, quote, "extraordinary lie," but I want to put up what you said in your Wall Street Journal article this week.

You said the following, "When the government can steer vulnerable individuals to conclude for themselves that life is not worth living, who needs a death panel?" Explain.

TOWEY: Well, I think the fear that Americans have is that somehow when they are fragile and they're vulnerable, and they're facing serious illness, that a discussion they're going to have with the doctor is going to be biased or tilted in some fashion.

Here you have the government that has a financial stake in the answers that they give, and I think a lot of people are afraid that somehow they're going to be steered toward a denial of care.

And I think that whole right to die movement, which Dr. Perlman has written about — I think that whole right to die movement means that the right to die is a right the poor will get. And I think a lot of people are afraid about it.

So whether there's "death panel" written in a law or not, the real issue is why would the V.A. be promoting a document written by an assisted suicide advocate that has such a — kind of an obsession with death and with pushing people, I think, in a direction to deny care.

WALLACE: All right. You are especially critical of this worksheet on page 21 of the book.

TOWEY: Right.

WALLACE: And I'm going to first tell the audience what's in it and then I'll talk to you about it.

Let's put up this page 21. It's called "What makes your life worth living?" and it asks the veteran to check off whether a variety of situations are difficult but acceptable, worth living but just barely, or not worth living.

And here are some of the situations. "I can no longer walk but get around in a wheelchair." "I live in a nursing home." "I am a severe financial burden on my family." "I cannot seem to shake the blues."

Mr. Towey, what's wrong with that?

TOWEY: The biggest problem is that when you go beyond those questions to the boxes you check, the first option you have, "it's difficult but acceptable," a lot of people with disabilities, a lot of people who have family members with stroke, find life beautiful. There's meaning and purpose. Sure, they're suffering, but their life hasn't been diminished by that illness.

I think there — if you were trying to be biased and fair, you'd have a box that starts off that says "My life is beautiful. Yes, I suffer, but I find meaning in it."

And I think the problem with this document, and it permeates the whole thing, is there's a bias toward a depression. And so when you see the one that says, for example, "I can't shake the blues," you can actually check the box that says "My life's not worth living."

Another one said if I can't go outside on my own, so you check a box, life's not worth living.

WALLACE: I guess one of the questions I have about it is why would those even be in a document about end of life? Usually people don't even contemplate end of life until they're in an irreversible coma.

Why would being in a nursing home or having to live in a wheelchair be a not-worth-living option?

TOWEY: Good question. I think advanced care planning's important. And there are a lot of great V.A. doctors and nurses out there providing superior care. So families need to talk about these issues well in advance of a deep decline in health.

My problem is when you treat individuals like their life has less worth because they have dementia, for example, I think that that's a dangerous slippery slope.

And when government has a financial stake in it, they shouldn't be talking about quality of life and kind of pushing people toward a predetermined conclusion.

WALLACE: You're also upset about another question in the booklet, and I want to put that up. "Have you ever heard anyone say, 'If I'm a vegetable, pull the plug?'"

TOWEY: Yeah. I think the word vegetable's demeaning. It's used three times in the document. And it kind of communicates somebody that's not human.

This is why I think the document is so fundamentally flawed that the V.A. ought to throw it out. They've had it out there kind of as a research tool, and then a few years ago they tried to push it and promote it — two years ago tried to push it and promote it, and now they're at it again, a July directive telling health care providers to refer patients to it.

WALLACE: All right. We're — you mentioned earlier one of the primary authors of the workbook, and this is a fellow named Dr. Robert Perlman. He's a member of the V.A. Center for Ethics in Health Care, and he's the — listed as the prime author in the document. Who is Dr. Perlman?

TOWEY: Well, that's a good question. A lot of Americans have never heard of him, and yet he's influenced the course of V.A. health care. He's written this document and he's an adviser.

I think he got the initial research grant with tax dollars to write this document, and — and I — and he's been an advocate for assisted suicide both in a U.S. Supreme Court case where he filed an amicus brief but in other writings where he was a contributor to a book about physician- aided killing.

So I think — I think the problem is in America there's a lot of people that wrestle with care-giving issues and with serious illness. We should be encouraging people to have a hopeful vision.

When a veteran comes back from Iraq, they shouldn't be given a book like this. They should be encouraged to talk about their preferences on how they can maintain their dignity, because that's what I think America owes them.

WALLACE: Now, in fairness, the book also offers other ideas and statements for veterans to consider, and let's put those on the screen. "My life should be prolonged as long as it can, no matter what its quality and using any means possible."

And then there's this. "I believe that it is always wrong to withhold, not start, treatments that could keep me alive." Mr. Towey, aren't both sides presented?

TOWEY: There's — There are lines like that in the book, but if — a fair reading of the book — just looking at the cases they give as examples, where the woman that has the stroke says, "I don't want to live if I can't take care of myself," and — and then when you look in the back of the book, Chris, who do they refer you to?

The 2007 edition said go to Compassion Choices. That's the Hemlock Society. The 1997 version referred you to an organization that was the American Euthanasia Society. I think the bias of the document's clear. Why would Americans be given such a poor document, a poor planning tool, on a subject so important?

WALLACE: Now, we need to point out that those references which were in the '97 edition and the 2007 edition are not in the edition that is currently being circulated at the Veterans Administration.

TOWEY: That's right. They pulled that page after we raised concerns about it, and I think it wasn't just aging with dignity. It was a lot of individuals in America that I think when they saw that in the V.A. system, they're thinking, "Why are they referring me to the Hemlock Society?"

WALLACE: All right. You were instrumental, as you point out, back in 2007 — you had left the Bush White House by then. You'd been the head of faith-based initiative for four years.

But in 2007, the V.A. tried to put this out and make this a tool that was widely distributed to veterans. You were instrumental in getting it stopped and put up on a shelf. What happened?

TOWEY: Well, I think that President Bush was — and his administration were very surprised to hear that this document has moved so far through the V.A. chain of command and was about to be approved. The secretary there didn't even know about it.

That's the fear Americans have, of course, is these bureaucracies have a way of getting something out there like this that people don't even know about, Congress never heard of.

So when I raised it with the Bush White House, they said, "This isn't a vision of life. People have their dignity. They're endowed with that. It's not lost when they get dementia or stroke," and so they pulled it.

WALLACE: So after President Bush suspended the use of this document, why did the Obama administration last month reinstate it?

TOWEY: Good question. I don't fault President Obama on this yet, because I suspect he was like President Bush and knew nothing about it. The question is why hasn't it been pulled from their Web site now.

To put a statement up after the Wall Street Journal piece came out that says this document is currently being revised — that just tells me they're in a damage control mode. What they should be doing is pulling the document and then revise this — this order that told physicians to refer patients to it.

WALLACE: Finally, you have been involved with end-of-life issues for years. You worked in an AIDS home back in the '80s. You have written an end-of-life document yourself called "Five Wishes," which is widely used around the country.

In the course of this controversy in the last couple of days, V.A. officials are suggesting that you want the government to buy and use your book.

TOWEY: They can if they want. Millions of Americans do. But that's not what this is about. That's a not-for-profit, Aging With Dignity.

I want Americans to have access to a document that treats their life with respect, that's not pushing them to hurry up and die, that's not guilt-tripping them, that's not saying that if you can't shake the blues maybe your life's not worth living.

It's the pressure, Chris, and it's wrong for government to do it. There's so many documents out there that help families plan for and discuss end-of-life care.

People should access the one they're comfortable with, but the government should not be pushing exclusively this approach, and I think it's wrong, and I think to have an author of the assisted — that supports assisted suicide doing it is terribly wrong.

WALLACE: Mr. Towey, we want to thank you for coming in today and discussing this issue with us.

TOWEY: Thank you.

WALLACE: For the Obama administration's response, we're joined now by Tammy Duckworth, an assistant secretary at the V.A. who knows all about veterans issues. She lost both legs during a mission as a helicopter pilot in Iraq.

And, Secretary Duckworth, welcome to "FOX News Sunday."


WALLACE: I want to ask you about the worksheet, page 21 in the V.A. booklet. You're a hero who, despite severe injuries, lives a full life, but you have to get around some of the time in a wheelchair yourself.

Do you have any problem with the V.A. asking elderly veterans whether life is worth living if they have a disability, if they live in a nursing home, if they're unable to shake the blues?

DUCKWORTH: Well, I have to say, Chris, that this is a really important discussion because when I was in Iraq and I was injured, thank goodness I had an advanced directive, that I had both a living will and a medical power of attorney that my husband was able to use to really execute my wishes.

And I don't think that anybody values life more than somebody such as myself or those of us who work at V.A. who've been in combat, who knows what it's like to be given a second choice.

I think that any worksheet that any veteran wants to use that helps him make those decisions in advance for his family members so that they know what your wishes are, that you do want your life prolonged, that you do want to be resuscitated — those are all important.

And V.A. is very happy for veterans to use any booklet that they would like. This booklet was used throughout the Bush administration under two secretaries. But if veterans want to go out and — and we provide it free of charge. There are many other free-of-charge booklets that are out there.

If they want to go and spend $5 apiece and buy Mr. Towey's book, they are welcome to do that. And that all falls under V.A.'s advanced directive policy which was...

WALLACE: But — but...

DUCKWORTH: ... put in place by President Bush.

WALLACE: ... if — if I — if I may, Ms. Duckworth, because we have limited time here...


WALLACE: ... why would a question — I can understand questions about if you're in an irreversible coma, do you want us to pull the plug. But why — as I asked Mr. Towey, why would you even have a question in a — in an end-of-life counseling book about if you're in a wheelchair, if you're living in a nursing home, does that make life worth living?

DUCKWORTH: Well, I know that before I was injured, I certainly let my husband know that, you know, being in a wheelchair was something that I feared and I was afraid for, but that I also wanted my life prolonged.

This is a tool. This is a simple tool that was put into place, as I said, under Secretary Nicholson. It was something that was used throughout.

And let me make a correction. We've not used it since 2007 when, under the Bush administration, we decided to go ahead and revise it.

This checklist is still under revision on a timetable according to a program that was actually decided on under the previous administration, because I know that President Bush and Secretary Nicholson and Secretary Peake all valued life. And that's what we're doing is we're revising it.

WALLACE: But — but ...

DUCKWORTH: It will be out in 2010. It's not yet out. So Mr. Towey was not correct.

WALLACE: That's a — Secretary Duckworth...


WALLACE: ... that's just not true. The VHA put out a directive on July 2nd, 2009, and I want to put up two pages from that directive. The first one, page 8, "Primary care practitioners are responsible for giving patients pertinent educational materials, e.g. refer patients to the 'Your Life, Your Choices' module."

And on page 9 it says, "If they request more information, patients may be directed to the exercises in 'Your Life, Your Choices.'"

So as of July 2nd, 2009, last month, more than a month ago, V.A. health practitioners were told to refer all veterans, not just end-of-life veterans but all 24 million veterans, to this document, "Your Life, Your Choices."

DUCKWORTH: Let me make a correction there, Chris. What our practitioners were told is to refer patients to any type of a tool. They can use Mr. Towey's if they want to spend the $5 apiece.

V.A. simply was not willing to buy his booklet at $5 per veteran at the time. This is a decision that was made...

WALLACE: But — but how do you explain...

DUCKWORTH: ... by the previous administration.

WALLACE: It doesn't — it doesn't say give them — give them access to anything. I mean, in the specific V.A. booklet — it's only 15 pages long — it specifically refers to this booklet twice.

DUCKWORTH: The only directive that is out there is actually left over from — I believe it was the beginning of 2007, which our advanced planning directive put into place, and it is actually very clear in saying that we need to provide veterans with information that they can make on how they want their care.

You know, this ultimately is about the care and health care for veterans, and we're actually expanding benefits for veterans. We're actually trying to get more priority aid veterans to sign up for V.A. benefits. We estimate that there'll be another 500,000 veterans coming in for benefits.

We are expanding V.A. benefits to veterans. It is in our best interest to make sure that every veteran out there receives the care and access to the treatments and everything that he needs, because, after all, these are the men and women who fought for us and fought — and they deserve nothing less than the best care.

WALLACE: Secretary — well, we certainly agree on that. Secretary Duckworth, when you look at the workbook now on your Web site, as you point out, there's a disclaimer there. We're going to put the disclaimer that is now on the Web site if you go to the — to the "Your Life, Your Choices" link.

And it says, "The document is currently undergoing revision for release in V.A. The revised version will be available soon." But when the V.A. first reinstated the document a month ago — six weeks ago...


WALLACE: ... it sent veterans directly there, as you can see in the screen grab. I guess the question I have is why, Secretary Duckworth, did the disclaimer about the book only appear this week after Mr. Towey's article appeared in the Wall Street Journal?

DUCKWORTH: Actually, that disclaimer has been there since 2007 when we pulled...

WALLACE: Well, it wasn't — it wasn't...

DUCKWORTH: ... when we pulled...

WALLACE: ... there before August 20th of — between July 20th — July 2nd and August 20th, the disclaimer was not on the Web site, because we checked. DUCKWORTH: Chris, the disclaimer has been at the beginning of the "Your Life, Your Choice" booklet since 2007 when the Bush administration decided to pull it off and revise it on an — on an established time schedule.

WALLACE: The record doesn't show that.

DUCKWORTH: But it — you can go on the Web site now. We have many things on our Web site. They're up there because they receive federal dollars. They're public research grants. We have to keep them on our Web site.

But I will tell you that this booklet has not been in use. It was pulled off the shelves in 2007. We very clearly told all of our medical practitioners not to use it because it was under revision...

WALLACE: I don't...

DUCKWORTH: ... and this is ultimately — again, let's bring this back to...

WALLACE: Miss Duckworth, that just — Miss Duckworth, I don't want to — I don't want to argue with you, but — but the...


WALLACE: ... but the facts are that it wasn't in use from 2007 until July 2nd of 2009 when, in the VHA handbook, you specifically reinstated it and specifically told health care practitioners to refer veterans to it.

DUCKWORTH: Chris, it has not been reinstated. Let me make it clear. The only advanced directive that we have is dated February of 2007. And it actually encourages veterans to use any type of tool or checklist they would like to.

There are many, many good ones out there. This "Your Life, Your Choice" is widely used out there, not just within V.A. There are many others that are out there. And veterans are free to use whatever they would like to use.

WALLACE: I — and let — let me — I mean, I...

DUCKWORTH: We just urge them to use some...

WALLACE: I just — I have a problem here. And too often on these shows we say one person said, and another person said.

Secretary Duckworth, I don't know if we're able in the control room to put up the first — the full screen of the VHA directive, but I'd like you to put up the first full screen, if you can.

In the VHA directive of July 2nd, 2009, it says the following on page 8, "Primary care practitioners are responsible for giving patients pertinent educational materials, e.g. refer patients to the 'Your Life, Your Choices' module." I mean, it's just there in black and white on the VHA directive of July 2nd.

DUCKWORTH: Chris, I — I'm sorry, I can't see that on the monitor in here. I will tell you that I know for a fact that the only directive signed by Secretary Shinseki — I mean, signed by a V.A. secretary was actually signed by Secretary Nicholson, and it's dated February of 2007.

What you're looking at may not actually be a directive, so I — since I can't see it...

WALLACE: Well, we'll...

DUCKWORTH: ... I'd be happy to come back and discuss it with you, but let's talk about what V.A. is trying to do.

We have the largest increase in our budget in over 30 years. We are going to be expanding access to veterans. We are working with the new G.I. bill for the 21st century. We are fighting to end homelessness. And we are doing quite a lot for veterans.

And I don't think that there's anybody that understands better the importance and value of life than those of us who have worn the uniform and faced combat.

WALLACE: I apologize. We're running out of time.

DUCKWORTH: Oh, I'm sorry.

WALLACE: I want to ask you one last question. If you feel so strongly about the value of life, although the disclaimer is on there, this document, "Your Life, Your Choices," is still on the V.A. Web site.

Secretary Duckworth, while it's supposedly being revised, it's still up there. Can you promise us that this will be taken down today?

DUCKWORTH: It is still up there with the disclaimer that it's under revision and do not use it. It cannot...

WALLACE: It doesn't say don't use it.

DUCKWORTH: Let me, Chris...

WALLACE: But why have it up there at all? Why not just say we're going to take it down?

DUCKWORTH: Because we are bound by federal law. It was developed with federal research grant monies, and most of our — all of our programs that were results of federal research grants are online for people to use for research purposes.

But we very clearly tell all of our veterans, "Please use any type of a tool that is most suitable for you and your loved ones," and you can certainly — there are many great ones out there, including Mr. Towey's, if they want to go spend the $5 for it apiece.

V.A. makes ours available for free. The checklist that we're actually using is a completely different checklist from this one, because this one has been taken off for revision.

WALLACE: Well, it hasn't been taken off. It's being revised, but it's still on the Web site.

Secretary Duckworth, we want to thank you. We want to thank you for giving us the V.A.'s response. And we also personally want to thank you for your service to our nation.

DUCKWORTH: It was my pleasure to be here. Thank you.

WALLACE: If you want to read the V.A. book for yourself, you'll find a link at our blog, And we will stay on this story of end-of-life counseling for our veterans.

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