Physician-assisted dying: Honest choices

08/06/2015

Physician-assisted dying—not “suicide”—is a complex and emotional issue. Below is a perspective I wrote with a leading physician with much direct experience, who quit one of his professional medical associations over its lack of integrity on the topic. Regarding religious opposition to the California End-of-Life Options Act, S.B. 128, which is now on hold primarily due to Catholic opposition and lobbying, we can only observe that there is supposed to be a separation of church and state in our nation (and that the California Council of Churches supports the bill). While lawsuits to legalize the practice are pending, a ballot initiative—expensive and even messier than legislation—might be the next step. — Steve Heilig

 

The California End-of-Life Options Act, S.B. 128, which would legalize physician-assisted dying, or PAD, has stirred much controversy. One casualty of emotional debates can be basic truths about the personal, clinical and policy decisions surrounding the issue. 

Approaching the end of their lives, patients most want two things from their doctors: confidence that they have clinical competence and know everything that might be done to help a patient not suffer, and confidence that they will be there for the patient, no matter what.

In rare instances, being there can include hastening the end—always at the patient’s own request. Most of the time such requests are not carried out, but just knowing that one has some control and choice at the end can actually extend life. Ironic, but true.

The California Medical Association opposed PAD for many decades, but it changed its tune this year. That change came for three main reasons. First, surveys of doctors’ opinions on this topic—over 30,000 physicians have been included in published surveys so far—indicate that at least half, and likely more, support some legal options for physician-assisted dying. 

Second, experience in states where PAD has been legal for years shows that the many fears about abuses have not come about, that the practice is uncommon and that legalizing it can actually lead to improvements in general care at the end of life. 

Finally, the hallowed medical dictum “Do no harm” is now seen to include the possible harm of keeping patients alive and suffering longer than nature, their God, or they themselves might want.

A survey conducted by the medical association’s leadership found that a substantial majority supported legalizing physician-assisted dying, or at least not opposing it. While still working to ensure that all reasonable safeguards against abuse are in any PAD policy, the C.M.A. then adopted a neutral position. This is just how a democratic organization that purports to represent the profession should work.

The one vocal medical group against S.B.128, the Association of Northern California Oncologists, also conducted a survey of members on this topic. The survey showed a majority supporting legalizing PAD, but the executive leadership of the association felt otherwise, and discounted the members’ vote in deciding to continue to oppose the bill. We wish the group had the integrity of the C.M.A. in this regard. (Dr. Abrams terminated his membership as a result.) 

For those who care for patients coping with end-stage malignant disease, support of physician-assisted dying, or at least neutrality on the matter, increasingly seems like a humane option. The issue comes down to one of patient choice and control toward the vulnerable end of life. Most of us will be such patients at some point; hopefully by that time, we—and our doctors—will be empowered to make choices without outside interference.

 

Donald Abrams is chief of Oncology at San Francisco General Hospital and a professor of medicine at the University of California, San Francisco. He was a pioneer in the response to the AIDS epidemic.
Steve Heilig is on the staff of Commonweal in Bolinas, co-editor of the Cambridge Quarterly of Healthcare Ethics, health policy director for the San Francisco Medical Society and a former hospice worker and director. He drafted the original resolution urging the California Medical Association to be neutral on physician-assisted dying.