A29-year-old woman with terminal brain cancerhas announced a campaign to support physician-assisted suicide leading up to her own death next month. Since Oregon became the first state to legalize physician-assisted suicide for terminally ill patients, Montana, New Mexico, Vermont and Washington have permitted it.
Should the right to die be expanded further, and if so, what should the standards be?
Oregon Shows That Assisted Suicide Can Work Sensibly andFairly
Thaddeus Mason Pope is the director of the Health Law Institute at Hamline University, and a frequent legal commentatorand bloggeron end-of-life medical issues.
UPDATEDOCTOBER 7, 2014, 12:39 PM
Since theOregon Death with Dignity Actwas enacted in 1997, more than 1,100 people haveobtained life-ending prescriptions, and about 750 used them. Most were dying of cancer. And most feared a loss of autonomy, dignity and decreasing ability to participate in activities that made life enjoyable.
These and other statistics on Oregon’s experience are available, because of neutraldata collection and reporting. This has permitted legislatures and courts around the world to assess Oregon’s experience. Overwhelmingly, they have found it worthwhile.
In significant part, this is due to many safeguards in Oregon’s law, which only allows participation by defined categories of patients. Patients must be mentally healthy residents of Oregon, 18 or older, who have had two physicians determine that they have no more than six months to live.
The safeguards also ensure that patients are making a voluntary and informed decision. A physician must educate the patient about all options, including palliative care, pain management and hospice. The patient must make three separate requests (two oral and one written). The oral requests must be separated by at least 15 days, and the written request must be independently witnessed by two people. The patient can rescind these requests at any time. Finally, to further ensure that patients remain in full control of the process, they must administer the medication themselves.
These safeguards work. There is no evidence of an inordinate impact on vulnerable populations. Indeed, over 97 percent of the patients who died from ingesting a lethal dose of medication were white. Over 98 percent had health insurance, over 90 percent were enrolled in hospice and over 72 percent had gone to college. Nor does available research show any negative impact on the availability of palliative care or on the physician-patient relationship. Today Oregon is a universally recognized leader in end-of-life care across the entire continuum of options. In short, the Oregon law has been a success.
It is no surprise that many other states and countries have looked to Oregon as a model. Notable among these are Washington in 2008, British Columbia in 2012, Vermont in 2013 and Quebec this year.
In short, while once widely rejected, assisted suicide is receiving — and surely will continue to receive —increased recognitionas an appropriate response to the suffering of patients at the end of life. This is due in large part to Oregon’s proven safe and effective implementation.
Doctor-Assisted Suicide Is Unethical andDangerous
Ira Byock, a professor at Dartmouth's Geisel School of Medicine, is chief medical officer of the Institute for Human Caring of Providence Health and Services and the author of "Dying Well" and "The Best Care Possible."
OCTOBER 6, 2014
American health care is undergoing tumultuous changes and showing signs of strain. A recent Institute of Medicinereportattests to persistent deficiencies in care and social support that seriously ill people and their families experience. Witnessing the suffering of our relatives, friends and, for clinicians, our patients, gives rise to moral distress.
It is not surprising that support for physician-assisted suicide is also rising. The age-old dictum that doctors must not kill patients can appear antiquated, out of touch with hard realities, and even heartless.
On the contrary, this is when such principles are most important. Principles are the I-beams of civilization’s architecture, designed to withstand the forces of social upheaval. Prohibitions on medical practice protect vulnerable patients and the public from the power that doctors wield due to their specialized knowledge and skills. People who are poor, or old and frail, or simply have long-standing disabilities, may worry that when they become acutely ill, doctors might see their lives as not worth living and compassionately act to end their supposed misery.
When doctor-induced death becomes an accepted response to the suffering of dying people, logical extensions grease the slippery slope. Last year in Holland, where voluntary euthanasia is permitted, over 40 people sought and received euthanasia for depression or other mental illness. Eventhe psychiatrist who began this practicein the 90's recently declared the situation had gone “off the rails.” In April, a 47-year-old Dutch mother of two was granted her wish to die because of long-standing tinnitus (ringing of the ears). In late 2012, 45-year-old congenitally deaf twins were euthanized in Belgium rather than face the prospect of losing their sight.
Proponents of Oregon’s law claim that such excesses couldn’t happen in the United States. Really? Holland and Belgium are sophisticated countries with universal health care. In America patients are commonly pauperized by a profit-driven health care system, doctors are often inadequately trained in basic palliative skills, and nursing homes are understaffed, leaving people to feel uncomfortable, unwanted and undignified.
Even today, people with advanced cancer, heart disease or neurological disorders in Montana, Oregon, Vermont and Washington may qualify for physician-assisted suicide, but be deemed ineligible for hospice under Medicare and Medicaid, either because they are too healthy or still want treatment for their terminal condition.
Moral outrage is appropriate and needed to fix the sorry state of dying in America. Legalizing assisted suicide fixes nothing. The principle that doctors must not kill patients stands. Two moral wrongs don’t make a right.
Too Many Questions Remain About Assisted Suicide
Ilora Finlayis a professor of palliative medicine at Cardiff University in Britain and a member of the House of Lords.
UPDATEDOCTOBER 7, 2014, 12:45 PM
There are some who think the United Kingdom should follow Oregon's example and legalize physician-assisted suicide. They present Oregon as a model of how to provide end-of-life choice and they tell us that Oregon's "Death with Dignity Act" has been a success.
But there are many us who are far from persuaded that this is the right road to take. We have seen the steady rise in Oregon's death rate from physician-assisted suicide, currently betweenfour and five timesthe number when the law was enacted.
We have seenresearchindicating that some people in Oregon with undiagnosed clinical depression have been supplied with lethal drugs and used them to end their lives. We have seen that many doctors in Oregon will not participate in providing physician-assisted suicide and that some people are being assessed by doctors to whom they have been introduced specifically for the purpose and who know little or nothing of them as patients.
Nor are we taken in by the siren voices that tell us that there has been no abuse of Oregon's law. Why, we ask ourselves, can't the audit system do a more thorough job of showing how these decisions are being made and what, if any, steps are taken to ensure that there is no coercion or that people are not requesting assisted suicide out of
sense of duty or obligation to others? The official annual reports shed little or no light on this.
This is a complex and often emotive subject and it is important to keep in sight what is the central question. This is not about compassion or choice or morality. These are common currency to both sides of the debate. The central question is whether doctors should be licensed by law to supply lethal drugs to terminally ill patients who ask for them and are thought to meet certain conditions.
To answer that question our legislators need clear evidence that such a law we would be better for all seriously ill people, not just for a small number of strong-minded and determined individuals. To date Ihave seen no convincing evidence on either count.
Limit Agressive Treatments for the Sickest and OldestCitizens
Sandeep Jauhar, a cardiologist, is theauthorof "Intern: A Doctor's Initiation" and, most recently, "Doctored: The Disillusionment of an American Physician."
OCTOBER 6, 2014
In the debate over how to treat people near the end of their lives, allowing assisted suicide is a relatively extreme position. It is much more reasonable — and relevant for most people — to limit aggressive treatments for our sickest and most elderly citizens. In America, unfortunately, even this position can seem extreme.
Not long ago, an internist called me about a patient who had a right lung “consolidation”— probably pneumonia, though a tumor could not be excluded — that a lung specialist had decided to biopsy. My colleague, who was from Nigeria, wanted me to provide “cardiac clearance” for the procedure.
“Sure, I’ll see him,” I said. “How old is he?”
“Ninety-two.”
I stopped what I was doing. “Ninety-two? And they want to do a biopsy?”
My colleague started laughing. “What can I tell you? In my country we would leave him alone, but this is America, my friend.”
Sadly, he was right. In the United States, about a third of Medicare dollars are used to treat people in the last six months of their lives. This amounts to more than one dollar out of every 100 that we spend in this country. This has the negative consequences of crowding out spending on other societal projects, such as education and infrastructure. But what is often lost in this debate is the harmful effects on patients themselves.
As a doctor, I see it all the time: sick, elderly patients being treated by a slew of specialists who aggressively order tests and procedures that result in physical (not to mention psychological and financial) harm. Many septuagenarians and octogenarians have chronic illnesses or “overlap syndromes” (we used to call it aging), which cannot be compartmentalized into individual problems and are probably best managed by a good general physician. When aggressive, high-tech treatments are brought to bear, the patients often end up worse off.
Of course, disease and death always win in the end, but not infrequently in the short term, too. Interventions such as coronary bypass surgery or implantable defibrillators provide no survival benefit over more conservative treatments unless a patient is going to live at least one year. We have to keep this in mind when we decide what is rational care for our growing elderly population. Medical care for these patients must focus on quality, not just quantity, of life.
End-of-life care has become the third rail of American medicine. Too often reasonable debate is stifled by irresponsible talk of death panels and rationing. But we need to have an honest discussion on this important subject that will affect us all. Limiting expensive, high-tech interventions on very elderly patients makes as much sense for them as it does for us.
Denying Someone a Peaceful Death Can Be Unethical
John M. Grohol, a psychologist, is the founder ofPsych Central, a mental health website, and a founding board member of the Society for Participatory Medicine.
UPDATEDOCTOBER 7, 2014, 5:06 PM
Sometimes it can be hard to let go. Nowhere do we see that more clearly that when it comes to a person’s right to die with dignity at the end of their life.
But perversely, sometimes the difficulty in letting go isn’t expressed by the person with a terminal disease. Instead it's expressed by their doctor. Doctors often fall back on medical ethics to defend their stance against euthanasia or assisted suicide. Some doctors believe that since their primary responsibility is to heal, helping someone along to a quickened death is contradictory to their oath.
But when doctors confuse or equate healing with the length of life, they ignore the importance of a person’s quality of life. When a patient’s end is near and suffering becomes intolerable, what’s the point of continuing that suffering?
Instead, it appears incredibly inhumane, insensitive and disrespectful of a person’s free will to deny them an end to their misery. It’s old-school medical paternalism at its worst: “I’m the doctor, and I know what’s best for you” — even when the patient may only have a few weeks left to live.
The doctors who rationalize and minimize such suffering — explaining that it can be “managed” with even greater doses of opioid medications — miss the point. If one of our doctors' primary jobs is to relieve suffering, they’re abdicating responsibility at this crucial moment. Doctors regularly undertreat pain complaints because they’re afraid to prescribe opioids at the levels necessary.
At the end of life, when medicine cannot help a person live any longer or stop a terminal disease, it seems in keeping with a physician's ethics to help an individual maintain their dignity and choose the date of their own death. Indignity and loss of independence can be viewed as forms of pain, even if they're not traditionally seen in that light. Ask any prisoner whether being imprisoned is a painful life experience, and I'm pretty certain what their answer will be. The same could be said for when we age — we can become prisoners of our own failing bodies.
If the mind is healthy (something mental status examinations by psychiatrists can determine) why not allow an individual the freedom of this one last, important choice?