Death with Dignity

Ever since Oregon passed the Death with Dignity Act, many states have considered passing similar laws to allow physician-assisted dying. The whole "death with dignity" movement is a fascinating one to me because it has changed so dramatically over the last few decades. In the past, medical associations, most physicians, and most medical education took a stance against physician-assisted dying. They found it not ethically permissible for a physician to prescribe or administer a medication with the intent of ending someone's life. This is quite different from palliative care and the principle of double intent. Here, a medication can be given if it is intended to treat pain, anxiety, or discomfort even if it may incidentally hasten death. That has been ethically defensible since Sir Thomas Aquinas. If someone is suffering, we have the means and obligation to treat it even if it means a shorter life. But prior to "death with dignity" laws, we would not give pain (or other) medications to someone who wasn't suffering even if they had a terminal diagnosis.

Recently, California has considered legislation legalizing "death with dignity." Notably, all such laws (in the U.S. at least) have very narrow scopes. They allow an adult patient with a terminal diagnosis and less than six months to live to initiate a request for a lethal dose of medication. Any physician, pharmacist, or health care provider who has moral objections does not have to participate. There must be witnesses and a second medical opinion. The patient cannot have a psychiatric illness that would impair decision making. Even after a request is authorized, there is a waiting period before the prescription may be filled. If there are any concerns for the ability to make an informed decision, a psychological evaluation must be completed.

Many of the initial objections to this measure - that masses of patients would commit suicide or coercion would be a major problem - simply haven't borne out. For the most part, it seems that those who choose to "die with dignity" have appropriate medical illnesses and evaluations.

This is a tough ethical dilemma. I believe that in some circumstances, people should have the right to choose how they die. Faced with a progressive terminal illness that robs one of independence, mental faculties, and wellness, a patient can and should be able to choose otherwise. Even though hospice may take care of pain and anxiety, the question is one of choosing how to die. We are able to choose many things in our life; it seems that we should still maintain control over our death. In addition, many of patients' fears at the end of life revolve around lack of control. I believe this empowers patients even if they never use it.

The greater question is whether physicians should aid this, and I'm not sure I have the answer. We go into this profession to treat disease, relieve suffering, and ensure wellness and happiness. If we have no more treatments for a disease and a patient wants more than relief of suffering - wants instead, agency and control, should we be the enablers? I think every physicians needs to ask herself that question. It is new, uncharted territory. In no case should any physician be required to participate. But I think that giving physicians the option to help patients in this way is not out of the question.

There are many forms of suffering. We treat pain, anxiety, air hunger, constipation, confusion, agitation, and a dozen other different symptoms and sensations at the end of life. But what about existential suffering, that feeling that one has lost control, independence, and agency? Maybe that's a category better left to priests and clergymen. But maybe it is a type of suffering we too can aid. I wait to see how the medical community adapts to these changes in scope and practice.