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The contents of this website are for contemplative purposes only. No medical advice will be given, and emails asking for medical advice will be ignored.

Although patient vignettes are based on my experiences with real individuals, I liberally change details to maintain patient confidentiality.

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Saturday
Jun252016

California's Right-to-Die Law

If I tried to write everything I could about California’s new right-to-die law, and, by extension, about euthanasia, I would have to write a book. But I will strain to be brief.

There seems to be a movement, at least among liberal states, to legalize physician-assisted suicide. Five states — Washington, Oregon, Montana, Vermont, and now most recently California -- have some type of legal provision that allows doctors to write prescriptions for lethal doses of medication, for the purpose of facilitating the suicide of patients.

And I understand the reasoning behind these laws. The miracles of modern medicine, while remarkable indeed, sometimes enable people to live long beyond their time. Patients can be brought back from the brink of death again and again, up to the point where extreme pain and suffering make death a considered alternative to fighting on.

No one wants to live on indefinitely in misery. No one wants to suffer. Modern people, who enjoy so many comforts courtesy of technology, are unused to hardship and seem to fear physical pain especially. We are used to anxiety, depression, stress, divorce, loneliness — but are terrified of the dentist.

I can understand the fear of dying of a dread disease (usually cancer), the fear of having no way out and nothing but a long path of pain — physical pain — to look forward to until the end. This very thought often leads people to also desire the power to end it.

But one thing is never discussed when the right-to-die comes up: Right-to-die laws have little to do with the right to die. From a practical standpoint, everyone already has the right to die. In most states, suicide is technically illegal. But has anyone ever been prosecuted for it? If someone attempts suicide and succeeds, that person is beyond the reach of the law; if he attempts suicide and fails, he goes into psychiatric treatment. No one is ever prosecuted for attempting suicide. So strictly speaking, the "right to die" is not the issue here. People who want to kill themselves can do so if they choose.

Right to die laws are really about authorizing certain people to help others commit suicide. And who is permitted — even mandated — to help? Doctors. That’s the long and short of it — the right to die isn’t about the right of suicide, it is about making it legal for doctors to kill their patients.

Oh sure, the laws pussyfoot around. They are larded with regulations, such as that the patient has to be terminally ill, and that the doctor is supposed to provide the means of suicide, but not to actually administer it. And that, I guess, is supposed to absolve the doctor. As a physician, I am expected to explain to the patient that he is terminal, that he will die a horrible death, that I am going to write him a prescription that could allow him to end it, and then turn him loose, to do whatever his conscience allows.

That isn’t absolution, legal or otherwise. And I don’t see why a physician should be forced to do it.

Forced, you say? No way -- no one is forcing anyone to do anything. The doctor can refer the patient to another doctor. Right? But while that is technically true, the reality complicated. The very existence of physician-assisted suicide has the potential to sabotage the doctor-patient relationship. As a doctor, I may take care of a patient for years, but then, when the patient is diagnosed with a terminal illness, because of my objections to euthanasia I am forced into a very difficult situation when the final days begin. And the patient slips in to a difficult situation as well.

I have to tell my patient I am personally opposed to euthanasia and must require that they agree never to ask me to do such a thing, and if they wish to pursue this option they must seek another doctor. What this means in practice is that the majority of doctors who have objections to euthanasia will refer all of their terminal patients to the few doctors who will assist with suicide. In other words, the medical community will divide itself the same way it has over abortion, with a large majority who won’t do it and a rare few who will, thus leaving all abortions to a handful of full-time abortion doctors.

But the circumstances with the terminally ill are not the same as they are with abortion. In the case of abortion, most doctors can avoid the problem by choosing not to take care of pregnant patients on a regular basis. They simply go into internal medicine, or cardiology, or dermatology, and avoid the problem altogether.

This cannot be the case with the right to die. Since the dying process is a natural endpoint in almost every area of medicine, there are very few doctors who can avoid caring for the terminally ill. A small number — the pediatrician, the dermatologist, the psychiatrist — can largely evade dying patients because of their patient population, but none have the ability to run a death-free practice. Eventually every doctor will be faced with counseling a dying patient. And it is wrong that a doctor who has treated a patient for years should be forced to send a dying patient away simply because he has moral reservations about assisted suicide.

If you are one of those people who wants suicide as an option when facing a terminal illness, fine. But understand that if you want to die in the face of terminal illness, that decision should be yours. It is not fair to ask another person, let alone a medical professional, for a seal of approval.

Because that is what assisted suicide is. To qualify for the right to die in California, you have to have the opinion of two physicians that you are in a terminal condition and have less than 6 months to live, and that you are mentally competent. These are all medical decisions. Thus, the ball sits in the court of the doctor. Not a lawyer, not a judge, not a counselor, not a clergyman. Lawyers and politicians carefully wrote themselves out of this law because they are smart, and don’t want people coming to them from the street asking for permission to kill themselves. So they dumped the responsibility on doctors.

As a doctor, I don’t have the ability to make decisions like this either. I never, ever tell my patients they have 6 months to live. I don’t own a crystal ball. I have seen patients I thought had six months last 2 years. I have seen patients I thought had 6 hours last a month. Any doctor will tell you -- there is no magic book in our libraries that we can consult to look up the patient’s diagnosis and physical findings and get a lifespan estimate. Everything is a guess, and any doctor who says differently is not telling the truth.

The matter of patient competence is even more difficult. If a patient comes to me who has a terminal illness, this is a person who is likely to be depressed and very anxious. Is such a person fully competent? Would you, under most circumstances, think a person who is depressed is in a place to decide if he or she wants to die or not?

Standard medical practice says otherwise. Psychiatrists are authorized to lock up a suicidal patient against his will precisely because the medical community does not believe a severely depressed person is mentally competent.

And there is more. People with terminal diseases are profoundly ill. They may be taking chemotherapy, they may have cancer metastases in the brain. They may be on painkilling drugs. Again, how do you judge competence in such cases? While I would agree that many of them are competent, not all of them are, and as a doctor I certainly would not be comfortable standing as judge in such difficult circumstances.

In my medical career, I have never had a patient or a patient’s family approach me and ask to euthanize a patient. And as a physician who specializes in hospital medicine, I have seen many, many terminal patients. Perhaps this is a function of the community I live in. Mississippi culture is different from the culture of California and Oregon in many ways.

But also, I think it is a function of life. The number of people who are actively dying and want to be euthanized is vanishingly small. In a state like Oregon, who has legalized assisted suicide for quite some time, the practice is rare. I am sure that most Oregon doctors, like me, more often have the opposite problem. The most common problem I run into with dying patients is not that they want to die, but that they continue to struggle against death when death is inevitable. I see patients suffer mightily from this. I see family members who think their 80 pound grandmother will one day walk again, or that a patient whose brain is riddled with metastatic cancer will be cured if he just gets one more chemo treatment.

We are all born to die. It is the great human equalizer. There is nothing any of us, including us doctors, can do about it. Many patients cannot accept this, and I watch with sadness as they struggle against an invincible opponent. Instead of making the best of the time they have left, they spend their time extending their suffering to no good end.

Death simply is. You don’t get out of it by fighting until the end. And you don’t get out of it by committing suicide before your time. While some people think those who seek physician assisted suicide are bravely facing death, I do not. I think people who want their doctors to help them die are mostly looking to the doctor, one of the few authority figures modern society has not discredited, to agree with them that they are justified in seeking suicide.

As a doctor, I am not willing to extend my seal of approval to anyone’s suicide. If a patient wants to die, he can do so without my help. And it is not right that state governments, frightened to accept responsibility for the right to die themselves, are now writing laws to absolve themselves of responsibility in the matter, and turn it over to the people whose jobs are to heal, relieve suffering, and comfort in the hour of death.

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