On Assisted Suicide, Going Beyond ‘Do No Harm’

I recently posted an essay about a close friend who was dying of pancreatic cancer had taken advantage of California’s new assisted suicide law.  A few days before her death she implored me to work to improve access to assisted suicide for terminally ill people.  She was aware that while legal in many states that access was limited due to medical providers (physicians and pharmacists) refusing to make available the “cocktail” (Samaritan, the primary health care provider in Lincoln County, Oregon prohibits its health care providers from participating in assisted suicide).  The “Op Ed” below appeared in the November 4, 2016 edition of the New York Times:

NOV. 4, 2016

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DURHAM, N.C. — Out of nowhere, a patient I recently met in my clinic told me, “If my heart stops, doctor, just let me go.”

“Why?” I asked him.

Without hesitating, he replied, “Because there are worse states than death.”

Advances in medical therapies, in addition to their immense benefits, have changed death to dying — from an instantaneous event to a long, drawn-out process. Death is preceded by years of disability, countless procedures and powerful medications. Only one in five patients is able to die at home. These days many patients fear what it takes to live more than death itself.

That may explain why this year, behind the noise of the presidential campaign, the right-to-die movement has made several big legislative advances. In June, California became the fifth and largest state to put an assisted suicide law into effect; this week the District of Columbia Council passed a similar law. And on Tuesday voters in Colorado will decide whether to allow physician-assisted suicide in their state as well.

Yet even as assisted suicide has generated broader support, the group most vehemently opposed to it hasn’t budged: doctors.

While “withdrawal” implies a passive act, terminating artificial support feels decidedly active. Unlike assisted suicide, which requires patients to be screened for depression, patients can ask for treatment withdrawal even if they have major depression or are suicidal. Furthermore, withdrawal decisions are usually made for patients who are so sick that they frequently have no voice in the matter.

Some doctors skirt the question of assisted suicide through opiate prescriptions, which are almost universally prescribed for patients nearing death. Even though these medications can slow down breathing to the point of stoppage, doctors and nurses are very comfortable giving them, knowing that they might hasten a “natural” death.

In extreme cases, when even morphine isn’t enough, patients are given anesthesia to ease their deaths. The last time I administered what is called terminal sedation, another accepted strategy, was in the case of a patient with abdominal cancer whose intestines were perforated and for whom surgery was not an option. The patient, who had been writhing uncontrollably in pain, was finally comfortable. Yet terminal sedation, necessary as it was, felt closer to active euthanasia than assisted suicide would have.

While the way people die has changed, the arguments made against assisted suicide have not. We are warned of a slippery slope, implying that legalization of assisted suicide would eventually lead to eugenic sterilization reminiscent of Nazi Germany. But no such drift has been observed in any of the countries where it has been legalized.

We are cautioned that legalization would put vulnerable populations like the uninsured and the disabled at risk; however, years of data from Oregon demonstrate that the vast majority of patients who opt for it are white, affluent and highly educated.

We are also told that assisted suicide laws will allow doctors and nurses to avoid providing high-quality palliative care to patients, but the data suggests the opposite: A strong argument for legalization is that it sensitizes doctors about ensuring the comfort of patients with terminal illnesses; if suicide is an option, they’ll do what they can to preclude it.

And, again, we are counseled that physicians should do no harm. But medical harm is already one of the leading causes of death — and in any case, isn’t preventing patients from dying on their terms its own form of medical harm?

Instead of using our energies to obfuscate and obstruct how patients might want to end their lives when faced with life-limiting disease, we physicians need to reassess how we can help patients achieve their goals when the end is near. We need to be able to offer an option for those who desire assisted suicide, so that they can openly take control of their death.

Instead of seeking guidance from ancient edicts, we need to re-evaluate just what patients face in modern times. Even if it is a course we personally wouldn’t recommend, we should consider allowing it for patients suffering from debilitating disease. How we die has changed tremendously over the past few decades — and so must we.

 

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