Friday, September 18, 2015

Medicalization of suicide

On September 16, the American College of Physicians sent the following letter to California Governor Jerry Brown asking him to veto the End of Life Option Act (ABX2-15), which would legalize physician-assisted suicide.

Dear Governor Brown,
The American College of Physicians (ACP), the largest medical specialty organization and the second-largest physician group in the United States, writes to urge you to veto "The End of Life Option Act." This is a physician-assisted suicide bill. ACP does not support the legalization of physician-assisted suicide (PAS) and does not support PAS as an appropriate action (see the ACP Ethics Manual and position paper). Terms such as "end of life option" and "aid-in-dying" used in the bill are confusing and obscure what is at stake when physicians are asked to facilitate suicide. We are deeply sympathetic to the concerns and fears patients and their families have at the end of life. However, PAS is not the answer and in fact, ACP sees it as abandonment of the dying patient. It is not the role of the physician to give individuals control over the cause and timing of death -- the medicalization of suicide.

The physician must always act in the best interests of the patient as healer, comforter, and trusted advisor. PAS undermines trust in patient-physician relationships and trust in the profession of medicine. Proponents of PAS claim it is an act of compassion in keeping with the physician's role as comforter. However, this argument incorrectly assumes that physicians can only provide comfort for certain patients through facilitating suicide. In fact, physicians can and do provide comfort to dying patients. It is a lack of awareness of these services and a perceived concern that patients will not have access to this care that helps drive interest in PAS as an option. We need to ensure that all patients have access to palliative care and hospice services at the end of life rather than promote suicide...

Patients often fear pain at the end of life, but physicians have an ethical obligation to treat pain with competence and compassion. Aggressive management of pain at the end of life is ethically acceptable, even when the risk of hastening death is foreseeable, if the intent is to relieve pain: the ACP Ethics Manual states that "...the physician may appropriately increase medication to relieve pain, even if this action inadvertently shortens life." The option of aggressive pain control has been consistently supported by U.S. courts, including the U.S. Supreme Court, and PAS has been distinguished from the right to refuse treatment by the courts as well (see especially Washington v. Glucksberg, 117 S.Ct. 2258 (1997) and Vacco v. Quill, 117 S.Ct. 2293 (1997))...

We also note the paradox of access to PAS where there is no general right to healthcare. In Oregon, the irony of difficulties getting coverage for palliative services and pain drugs under the state's Medicaid program -- but no problem receiving PAS paid for as a covered service -- has been noted (Toffler William L. A doctor-assisted disaster for medicine. Wall Street Journal. August 18, 2015:A1). PAS is especially troubling in an environment of cost control in healthcare and continuing disparities in care.
We hope you will join ACP in advocating that society should encourage those who seek suicide with a physician's help to instead be provided with full access to the care and compassion that can alleviate their suffering. No Californian, or any other American, should have to fear an undignified or pain-filled life or death.

Providing greater access to palliative and hospice care needs our full attention. In this way, physicians can fulfill their mission and give dying patients and their families the care, compassion, and comfort they need and deserve.

We hope that you will veto this bill.

ACP President Wayne Riley, MD, MPH, MBA, MACP
President, American College of Physicians (ACP)


  1. Since the voters of Oregon narrowly legalized physician-assisted suicide 20 years ago, there has been a profound shift in attitude toward medical care—new fear and secrecy, and a fixation on death. Well over 850 people have taken their lives by ingesting massive overdoses of barbiturates prescribed under the law. Proponents claim the system is working well with no problems. This is not true.

    As a professor of family medicine at Oregon Health & Science University in Portland, as well as a licensed physician for 35 years, I have seen firsthand how the law has changed the relationship between doctors and patients, some of whom now fear that they are being steered toward assisted suicide.

    In one case a patient with bladder cancer contacted me. She was concerned that an oncologist treating her might be one of the “death doctors,” and she questioned his motives. This was particularly worrying to her after she obtained a second opinion from another oncologist who was more positive about her prognosis and treatment options. Whichever of the consultants was correct, such fears were never an issue before.

    Under Oregon’s law, a patient can request lethal drugs only if he has a terminal illness and less than six months to live. However, it is nearly impossible to predict the course of an illness six months out, and many patients given such prognoses live full, rewarding lives long past six months.

    The law requires that patients be referred for psychological examination if the doctor suspects they have depression or mental illness. But some doctors see suicide as a solution to suffering and depression as rational given patients’ circumstances. Last year only three of the 105 patients who died under the law were referred for a psychological exam.

    A 2008 study published in the British Medical Journal examined 58 Oregonians who sought information on assisted suicide. Of them, 26% met the criteria for depressive disorder, and 22% for anxiety disorder. Three of the depressed individuals received and ingested the lethal drugs, dying within two months of being interviewed. The study’s authors concluded that Oregon’s law “may not adequately protect all mentally ill patients.”...

    A shroud of secrecy envelops the practice of assisted suicide. Doctors engaging in it do not accurately report the actual manner of death. Instead they are required by state law to fabricate the death certificate, stating that the cause is “natural” rather than suicide. (continued)

  2. (continued)In my practice, more than two dozen patients have discussed assisted suicide with me. Most did not have a terminal diagnosis. One inquiry came from a patient with a progressive form of multiple sclerosis. He was in a wheelchair yet lived an active life as a general contractor. I asked him how the disease affected his life. He acknowledged that MS was a major challenge and told me that if he got too much worse, he might want to “just end it.”

    I told him I could understand his fear and frustration and even his belief that assisted suicide might be a good option. I also told him that should he become sicker or weaker, I would work to provide him the best care and support available. No matter how debilitated he might become, his life was, and would always be, inherently valuable. As such, I said that would I not recommend nor would I participate in his suicide. He simply replied: “Thank you.”...

    The way that physicians respond to patients’ requests for lethal drugs has a profound effect on their choices and their view of themselves and their inherent worth. Such patients deserve doctors who will support them through their illnesses, not offer them a quick exit.

    One of the most troubling notions I hear is that killing oneself with sleeping pills is “dignified”—as if natural deaths aren’t. Last year my wife, Marlene, died of metastatic cancer. We’d been married for 40 years. The final five years we both knew she would inevitably die of her cancer. At one point doctors told her that she had only three to nine months left, yet she lived more than four times as long.

    While I treasure all of our years together, the last years of our marriage were among the best. There was great suffering but also great joy and meaning in the special moments we and our seven children shared together—moments that became all the more special the closer we came to the end of her life. I wouldn’t trade a nanosecond of those last years. She died peacefully and naturally at home surrounded by her family and friends. She never took an overdose, yet her death and life had great dignity.

    Some two dozen suicide bills have been introduced in legislatures around the country, from California to Maine. These states should heed the example of Oregon, where assisted suicide has been detrimental to patients, degraded the quality of medical care, and compromised the integrity of the medical profession...

    As a society we should continue to reject the legalization of physician-assisted suicide as a solution to suffering. Instead we must work to increase access to hospice and palliative care to better support those suffering from terminal illness. The sick and aging deserve better than Oregon’s mistake.

  3. Caught between conflicting moral arguments, Gov. Jerry Brown, a former Jesuit seminary student, signed a measure Monday allowing physicians to prescribe lethal doses of drugs to terminally ill patients who want to hasten their deaths.

    Brown appeared to struggle in deciding whether to approve the bill, whose opponents included the Catholic Church.

    “In the end, I was left to reflect on what I would want in the face of my own death,” Brown wrote in a signing message. “I do not know what I would do if I were dying in prolonged and excruciating pain. I am certain, however, that it would be a comfort to be able to consider the options afforded by this bill. And I wouldn’t deny that right to others.”

    The new law is modeled after one that went into effect in 1997 in Oregon, where last year 105 people took their lives with drugs prescribed for that purpose.

    The California law will permit physicians to provide lethal prescriptions to mentally competent adults who have been diagnosed with a terminal illness and face the expectation that they will die within six months.

    The law will take effect 90 days after the Legislature adjourns its special session on healthcare, which may not be until next year — January at the earliest, November at the latest...

    Tim Rosales, a spokesman for Californians Against Assisted Suicide, which includes doctors, advocates for the disabled, the California Catholic Conference and other religious groups, criticized Brown’s action.

    “This is a dark day for California and for the Brown legacy,” Rosales said. “As someone of wealth and access to the world’s best medical care and doctors, the governor's background is very different than that of millions of Californians living in healthcare poverty without that same access — these are the people and families potentially hurt by giving doctors the power to prescribe lethal overdoses to patients.”...

    Maynard talked to Brown three days before her death after the 29-year-old Californian, who was dying of brain cancer, moved to Oregon last year so she could take her own life as allowed by that state’s end-of-life law.

    “Brittany wanted this legislation in California so others would not have to go through what she went through,” Dan Diaz, Maynard’s husband, said Monday, adding that Brown’s action “granted one of her last wishes.”...

    Most Republican lawmakers opposed the bill on moral grounds. Democrats who voted against it cited religious views or experiences in which family members given months to live by doctors had lived for years.

    Brown ignored warnings that some people would be pressured into assisted suicide, Sen. Bob Huff (R-San Dimas) said...

    They also said it would be abused by greedy heirs pressuring elderly people to end their lives prematurely. But supporters of the new law said such problems have not occurred in Oregon...

    In the last 17 years in Oregon, doctors have written 1,173 prescriptions. Of these, 752 patients have used the medication to bring about their deaths and 421 have chosen not to use it, said Patricia A. Gonzalez-Portillo of Compassion & Choices. It is also allowed in Washington, Vermont and Montana, although in Montana it was by a court decision.
    Courtesy of:

  4. I recall one evening after dinner when Dad was talking to me about his mother. She’d died a slow, agonizing death due to cancer, and my dad was thinking back on those hard days. Looking me squarely in the eyes, he said: “If I ever get like that, I want you to give me hemlock.”

    Hemlock. It was his code word for assisted suicide.

    With the encouragement of my dad’s family doctor, we decided to bring Dad home on hospice. We would forego the feeding tube. No food, no water, no IVs. In other words, we were bringing him home to die. Living in California, “hemlock” was not an option. My dad would die, instead, of dehydration.

    Voluntary death by dehydration — also known as “terminal dehydration” or “TD” — has its advocates in the death-with-dignity community. Even in states where doctor-assisted suicide is not available, a terminally ill patient still has the right hasten death by refusing all food and water.

    TD advocates assert that death by dehydration is a relatively gentle way to die. As dehydration sets in, the body releases certain chemicals (“esters” and “ketones”) that have the effect of dulling the senses. These chemicals act like an anesthetic, and the dying patient feels little pain.

    In a poll of Oregon hospice nurses asked to rank “death experiences” on a scale of 0 (a very bad death) to 9 (a very good death), the nurses gave terminal dehydration an 8.

    For my father, dying would take seven days. I stayed with him the whole time. The hospice team was superb: caring, attentive, knowledgeable.

    I wish I could say he died a gentle death. But I’m not so sure.

    Over the seven days it took him to die, I watched as my father seemed to become increasingly restless. Despite the stroke, he was able to move his left arm a bit, and beginning at day two he started reaching with the arm, repeatedly pushing against the bed mattress and the bed rail. I took this as a sign of agitation and discomfort, though I will never know for sure.

    There were other suggestions of discomfort: rapid breathing, mild groaning, sweating. Both the hospice nurse and I were giving my father morphine for pain and Ativan for sedation. We were giving the medications around the clock, but as the days progressed we needed to give higher and higher doses. By day 4, we were far exceeding hospice protocol doses. Yet the signs of agitation were still there.

    Days 5 and 6 were the hardest. The arm reaching, though weakened, continued. At times, my dad’s breathing rate topped 40 breaths a minute (3 to 4 times normal). Triple doses of morphine didn’t seem to help much.

    Finally — mercifully — he began to lose consciousness toward the evening of day 6. The “esters” and “ketones” were finally kicking in.

    As I sat at the bedside watching him finally at peace, I had to ask: Why did we have to wait six days to reach this point? The moment we’d decided to withhold fluids, my father was on a sure path to death. Why stretch it out over seven days? Without a doubt, the path we’d taken was far preferable to a drawn out death in the ICU or in a nursing home. Nevertheless, I wish doctor-assisted death had been available to my father. Despite the observations of hospice nurses in Oregon, I believe it is what he would have wanted.

    He died at 10:27 p.m. on the 7th night. My mother and I were at the bedside. He took one final breath in but did not exhale. Then, he was still. I wish I could say he looked at peace in death, but he did not. There was a disturbing look on his face with the sunken eyes and the half-open mouth outlined by blue lips. To me, it was a look of perplexity, a look of bewilderment. It was a look that will haunt me for the rest of my life. To me, it was a look that said:

    “Where, Son — where my doctor son — was my hemlock?”
    Courtesy of:

  5. Dr. Peter Rasmussen, a national advocate for legalizing physician aid-in-dying, died Tuesday morning with the help of Oregon’s Death with Dignity law, his family said.

    Rasmussen, 70, was an oncologist who was passionate about caring for terminal patients and ensuring they could make own their medical choices in the face of death.He was diagnosed with grade 4 glioblastoma, a malignant brain tumor, in the spring of 2014.

    Rasmussen’s wife, Cindy Rasmussen, said her husband was surrounded by family when he took the lethal dose of drugs to end his life.

    Cindy Rasmussen described his last moments as peaceful and that he died 30 minutes after taking the medicine...

    Rasmussen was one of the few physicians who dared to speak in support of Oregon’s Death with Dignity ballot measure in the 1990s, and his medical career at times took a hit from his controversial stance. Even after Oregon voters approved the measure, state and national forces sought to shut down the policy.

    He ultimately joined a group of plaintiffs suing the federal government, which had attempted to nullify Oregon’s law.

    In 2001, then-U.S. Attorney John Ashcroft said he would penalize doctors who prescribed federally controlled substances to help patients die. The U.S. Supreme Court heard the case and decided in support of Oregon in January 2006.

    Former state Rep. George Eighmey, who worked with Rasmussen to protect the law from being blocked, said in a December 2014 interview with the Statesman Journal that Rasmussen was instrumental in keeping Death with Dignity intact.

    “He was probably one of the most bravest and received some of the most vitriolic comments from opponents,” Eighmey said. “They vilified him and it was unfortunate, because Peter is one of the most compassionate, understanding physicians I’ve ever met.”...

    Rasmussen also helped found Willamette Valley Hospice and served on Salem Hospital’s medical ethics committee and led the creation of POLST, or physician orders for life-sustaining treatment.

    The form allows patients approaching end of life to let emergency responders know whether and to what extent they wish to be resuscitated.

    POLST is now active or being developed in most states.
    Courtesy of a colleague

  6. One of the reasons why people say this legislation should not be enacted is they are worried about going down a slippery slope. If we permit it for the terminally ill, we are going to wind up permitting it for everybody and anybody who asks for it. We have seen a little bit of that behavior take place in Belgium and Holland. Belgium and Holland permit assistance in dying to people who are suffering. But suffering is a pretty vague concept. They have had people with mental illness, severe depression, disability, and people going blind or deaf saying they don't want to live that way, and they have been helped to die. And recently and most startlingly, someone was helped to die who said she could not stop grieving for her deceased husband. She was not terminally ill. She just said, "I can't stop this horrible sensation of grief," and someone helped her to die. Those are startling facts. When it's due to divorce, disability, mental illness, or financial misfortune, I would not want us to say, "If you say you are suffering, then a doctor can help you die."

    In the United States, the legislation has very strong protection. You do not get assistance in dying unless you are terminally ill. You are supposed to be certified as terminally ill in the State of Oregon by two doctors who say you have less than 6 months to live. If they are worried about your mental status, they are supposed to get a psychiatric or psychological assessment done. You have to be competent to do this. You have to be over 18. You have to make the request orally twice and then once in writing. One person, who is not part of your family, has to witness the request, so there is no hanky-panky about trying to get your estate or money or anything like that. And, ultimately, you have to take the pills yourself. No one puts them in your mouth.

    That system has worked in Oregon. We do not see big abuses. The only people who see problems in Oregon—after 20 years of experience—do not live in Oregon. There is no movement to change the law; the people in Oregon seem satisfied with it. The authorities write an annual report on who has used it, and only a relatively small number of people—in the hundreds—have actually availed themselves of requests to get lethal doses of pills over the past 20 years. Remarkably, even out of that small number, about 40% don't take the pills. They like having the parachute available to them, but they choose not to use it and probably live longer than they might have because they have this option of taking a lethal dose of medicine.

    I'm not moved by the objections. States like California can enact this legislation. It requires a lot of regulation and requires us to be very careful in circumscribing how it can be implemented. You can't just open the door and say, "Anybody who is suffering can have assistance in dying." That takes us to places where Belgium and Holland are going—where I do not think it's prudent to go. At the same time, we ought to be giving patients the right—although they don't have to use it—to die less painfully, to die in a more dignified manner, to die in a way that they are comfortable with. It is a close call, but at the end of the day, the objections do not hold. States ought to enact legislation permitting the terminally ill to have the right to assistance in dying.

  7. Colorado voters have approved a proposal that would allow physicians to prescribe lethal doses of medication to be taken by a terminally ill adult patient.

    The state is now the sixth to have laws permitting physician-assisted suicide. The others are California, Vermont, Oregon, Washington, and Montana.

    The measure, known as Proposition 106, was approved by a wide margin, with 65% of voters saying yes and 35% no.

    A spokeswoman for a pro-physician suicide organization, Compassion and Choices said "It's up to providers now to make it accessible," speaking in a televised interview.

    The law is modeled after Oregon's Death with Dignity Act. It calls for two physicians to certify that the patient has six months or less to live, is mentally competent to make the decision and physically capable of self-administering the drugs.

    The patient has to be a state resident, has to have had all "feasible end-of-life services" such as pain control and palliative care.

    The patient needs to be referred for counseling first only if he or she is depressed or mentally ill.

    The state's medical society endorsed the proposal on Sept. 16.

    While often popular with the public, such measures are controversial to medical organizations.

    Last year, in an unsuccessful bid to prevent California from enacting its statute, the American College of Physician’s President Way Riley, MD, wrote to the state’s governor saying “It is not the role of the physician to give individuals control over the cause and timing of death—the medicalization of suicide’ and that doing so “undermines trust.”

    - See more at:

  8. [revised-originally posted on November 30. 2015]"Assisted dying" means helping someone who is going to die—someone who is terminally ill—die when they want to. Ethically, it's not quite the same as a suicide, because in suicide, you were not going to die anyway. For assistance in dying, you are going to die, and the questions are how, when, and who will be there.

    Assistance in dying is still very, very controversial. Some people say, "If we don't watch out, the disabled and the frail elderly will be rushed to choose this because they cost money." People sometimes do not want to take care of them, and sometimes people are after their money if they have an estate.

    Another concern is that palliative care and hospice care are not available to everyone. If you legalize assisted dying in a state or a location that does not have good palliative or hospice care, are you kind of nudging them toward saying, "Why don't you end your life?"

    These objections are important. Nevertheless, this legislation signed by Governor Jerry Brown after going through the California legislature is ethical. Doctors can participate if they so choose. It is something that doctors need to talk to their terminally ill patients about...

    Why is it ethical? It is restricted to competent people: You have to have your wits about you. Someone with Alzheimer disease or a stroke cannot use this. You have to make the choice whether you will. It's up to you to decide whether you want to do this.

    Two doctors have to declare that you are terminally ill. It is restricted to a tiny number of people who are dying—people who are imminently dying or soon to die. They are required to put the request in writing, and do it again 2 weeks later.

    It's not going to be easy to bully anybody into doing this. If we look at Oregon, which has had this law for 20 years, there are no cases of people being rushed or bullied to choose death, or to choose this form of assistance in dying. Critics sometimes say there are a few cases from Oregon, and the authorities in Oregon who issue a report on how this legislation is working every year just do not seem to find any problems. Nor is there any effort in Oregon to overturn the law. Worry about coercion is not there, as long as we restrict this to terminally ill people who are competent and who make the request more than once.

    It is true that you should be offered hospice care. It is true that palliative care—having your pain and suffering controlled—should be an option. But, there are people who just do not want that. Once they know that they are dying and soon to die, some say, "I don't want to go through hospice care. I want to leave under my own terms, and this is how I want to go." It may not be for everybody, but it's a choice that those who want to take it should have. Probably the biggest issue around assistance in dying is whether we can continue to improve support, palliative care, and hospice care for all Americans.