Killer or Healer? Mercy or Muder?

The proposed legislation would affect a competent adult who has been determined by the attending physician and the consulting physician to be suffering from a terminal illness and who has voluntarily expressed his or her wish to die, in a written request witnessed by at least two individuals.

"Terminal illness" here means an incurable and irreversible illness which will, within reasonable medical judgment, result in death within six months. There would be a minimum of 48 hours between the patient's written request and the writing of the prescription. Only patients physically able to administer the dosage themselves are to be covered under the law. This law would not apply to patients in a coma.

The proposed law must pass the Assembly and Senate and then be signed by the Governor, who has yet to take a position on the measure.

Background
This bill has been patterned after the Oregon Death With Dignity Act, initially approved in 1997. Oregonians also voted down an effort to strike the law in 1998. Until now, the Oregon law has allowed 171 terminally ill patients to end their lives, which is only one seventh of one per-cent of all Oregon deaths. In the absence of a federal law prohibiting this practice, individual states are the primary regulators. The Bush Administration's challenge of the Oregon law has now gone to the U.S. Supreme Court.

In California, voters did not approve Proposition 161, California's Death With Dignity Act in 1992; in 1999, an assisted suicide bill failed to move out of the lower house.

Nationally, 58 percent of Americans believe individuals have a right to end their own lives if they have an incurable disease (National Opinion Research Center, June 2000). According to a 1999 Field Poll, 75 percent of Californians believe that incurably ill patients should have the right to request life-ending medication - quite a change from 1992 voting. An additional group of studies found that between 63 percent and 90 percent of patients with terminal illness supported PAD and would like the option available to them. They would like the choice to be available whether or not they use it themselves.

Physician Attitudes
The policy of the CMA (HOD 516-97) is, "While opposition to the legislation of PAD remains the position of the CMA, the CMA shall remain receptive to multiple views" and "that CMA actively seek input from all stakeholders in this important societal dialogue." This is a step back from the earlier hard-line opposition.

In the Annals of Internal Medicine of February, 2003, Quill et al urged the medical associations to adopt a position of neutrality on assisted dying laws. Among individual physicians, the opinion ranges from "I am concerned that too few people are requesting it in Oregon" (Dr. Marcia Angell, former executive editor of the New England of Medicine) to outright opposition: "It ridiculously oversimplifies the details of decision making in the end of life care" (oncologist Dr. Rex Greene).

A 2001 survey published by JAMA found 51 percent of responding physicians in Oregon supported PAD. A nationwide survey found 45 percent of respondents support PAD, and only 34 percent were against it (Journal of General Internal Medicine 2001). To one physician at San Francisco General, "It is the key out of the locked room."

Many are concerned about potential abuse in which physicians and family members, instead of the patient, would make critical decisions. In addition, one has to be sure that the patient's decision is not arising out of depression.

My own opinion is that doctors are supposed to help people live, and not to kill them. An incurable patient should be offered adequate pain control, hospice care, pastoral support, family counseling and multidisciplinary intervention, including psychiatric care.

Moreover, there is nothing certain in a medical prognosis. The course of a terminal illness is not always predictable. Someone given six months to live may live several years with a reasonable quality of life.

On the other hand, I fully understand there will be rare cases in which a patient's pain and suffering may not be adequately controlled even with the best of hospice care, and there may be a case for PAD intervention. Forgoing life sustaining treatment is legal and may help some in refusing to accept tube feeding and intravenous fluids. Over the years, the stance of physicians (including mine) is softening, but at this point society is not ready to accept physician-assisted dying (suicide is a poor word because it denotes an abnormal mental condition).

We should discourage the death with dignity approach. However, I recommend a position of neutrality, not outright opposition. Morality surrounding the issue is not clear cut.

patiec@cwnet.com