Posted on: Sunday, February 6, 2005

ISLAND VOICES
What is the right end-of-life choice?

DEATH WITH DIGNITY

By Robert Nathanson

If the Legislature is in session, can discussion about death with dignity be far behind?

Death with dignity bills have once again been introduced in both houses (HB1454 and SB1308). I have already seen a number of letters to the editor, and a half-page ad critical of the bill has run almost daily. There are serious legislative misgivings.

I would like to explain why I and other physicians are in favor of the enactment of Hawai'i's death-with-dignity bill.

I am a retired physician, having been a general practitioner here in Hawai'i for more than 40 years. I am a co-founder and past president of Hospice Hawaii and the founder of Hawaii Physicians for Assisted Dying. I formed the group in response to critics who said there were no doctors who supported death with dignity.

To the contrary. I've encountered dozens of physicians who believe that this legislation is sorely needed.

One of the main arguments against the death-with-dignity bill is that "there is no reason in modern-day medicine for anyone to die the agonizing death that seems to be the main reason for the proposed physician-assisted suicide legislation. The treatment of pain is better than it has ever been before."

The main error in that statement is that pain is actually low on the list of reasons given for people to request physician-assisted dying as noted in the sixth annual report on Oregon's death with dignity act, released in March 2004. The report states that the four most commonly mentioned end-of-life concerns were loss of autonomy, a decreasing ability to participate in activities that made life enjoyable, losing control of body functions and loss of dignity.

Also, it is well recognized that hospices are the experts in comfort care for the terminally ill. The Oregon report revealed that 85 percent (145 of 171) of the patients who availed themselves of a lethal dose of medication were already enrolled in hospice.

Another criticism is that somehow the passage of this bill would lead to a breakdown of the patient/physician relationship. I have found in my own experience that when I listened to a patient's concerns and wishes and took them seriously, the bond between me and my patient grew stronger.

In the ad I alluded to, it was stated that death with dignity "doesn't mean abandonment through assisted suicide." It implies that the physician decides that there is no reason for the patient to live, and the physician then dismisses the patient with a prescription for a lethal dose of medicine.

Nothing could be further from the truth. It is the patient who must plead with the doctor to get that prescription and it is only after going through more than a dozen safeguards that the prescription can be written.

The Hawai'i death-with-dignity bill is modeled after Oregon's death-with-dignity act, which has been in effect for more than seven years. Because the Oregon law required patient counseling on alternative treatments, almost half of the patients withdrew their request for a lethal prescription.

Of those who had prescriptions filled, about half died of their disease without ever availing themselves of the medication. Many referred to it as "an insurance policy" against an undignified death.

The Oregon law has been working well. There has not been one single documented instance of abuse, despite what critics might say. The annual report says just that. During its seven-year existence, only 206 patients have ended their lives by self-administering a lethal dose of medication.

In that same seven years, more than 210,000 Oregonians died of various causes, making the number of hastened deaths less than one-tenth of 1 percent. This is a far cry from the claims of opponents who alleged that passing such a law would make Oregon the "suicide mecca" of the United States.

Those are dry statistics. What the statistics don't tell is what having the medication in their possession really means to the patient. It means that now they have a choice. They really don't want to end their life, but they now have the means to do so if the situation becomes intolerable.

Can you possibly imagine the peace of mind that this gives to people in a terminal condition who every day see their body functions waning?

They get to decide what is unbearable, no one else. So the benefit of the death-with- dignity law is not measured by how many people die from taking the prescribed medication; it is in the peace of mind that it can give to thousands of people in the state of Oregon and hopefully in Hawai'i that have just found out that they have cancer or some other potentially lethal diagnosis.

They can know that at the end, if they cannot be cured, they can at least have control of their dying.

Some of the peripheral benefits of the Oregon death-with-dignity act include physicians increasing their hospice referrals, increasing their use of morphine (considered the "gold standard" for relieving pain in end stage cancers) and getting better trained in end-of-life issues.

Also, Compassion In Dying of Oregon, an organization that supports death with dignity, has been able to document a direct correlation between the number of assisted deaths and a reduction in violent suicide among the terminally ill such as by the use of a gun or hanging. Many of those planning to end their life by violent means were able to die peacefully instead of carrying out the act in secrecy and leaving loved ones to discover their body.

Let us allow the terminally ill to make their own choice!

Robert Nathanson M.D., a Waialua resident, is founder of Hawaii Physicians for Assisted Dying and co-founder and former president of Hospice Hawaii. He wrote this article for The Advertiser.

NO TO ASSISTED SUICIDE

By Inam Rahman

Hawai'i's doctors oppose physician-assisted suicide.

I believe I can make that statement as president of the Hawaii Medical Association.

While roughly 50 percent of all doctors in Hawai'i are members of HMA, I believe I speak for most because the mainstream medical community is united and of one voice on this issue.

Some recent letters and articles represent physician-assisted suicide as a positive thing for the people of Hawai'i. It is not. The physician community in Hawai'i opposes doctor-aided suicide based on concern for our patients first, and as a public policy issue second.

Physician-assisted suicide does not promote dignity or excellent end-of-life care. Instead, patient welfare and good medical practices are harmed by pretending that a dignified death requires suicide.

There are clear reasons for opposing doctor-aided suicide.

Physician-assisted suicide is unnecessary. Pain can be managed by modern medicine. Advocates of suicide are misleading when they claim pain is a significant reason for requesting physician-assisted suicide.

Even in Oregon, the only state where the practice of physician-assisted suicide is legal, 92 percent of reasons given for physician-assisted suicide were social concerns, such as being a burden. When pain is mentioned at all, the concern is fear of pain, not actual pain. There has been no documented case of assisted suicide being used for untreatable pain. The fear of pain for a patient may be real, but doctors have the means to help manage pain.

And Hawai'i law already allows you to direct your end-of-life care and have your final wishes honored, including refusing any treatment.

Physician-assisted suicide fatally damages the doctor-patient relationship and the trust necessary for good care. In Oregon, doctors report a profound shift in attitude among their patients. Patients are asking if a physician is one of those "death doctors." Oregon physicians say such fears were never an issue before physician-assisted suicide.

When physicians take the Hippocratic Oath, we pledge to keep the sick from harm and injustice. This oath is one of the oldest binding documents in history and dates from before the Christian era.

Everyone wants a dignified death. But calling assisted suicide dignified does not make it so. Dignity is not enhanced by focusing only on a person's illness or disability. Your life and worth as a person is independent of illness. Fear of becoming a burden is the most common reason for assisted suicide in Oregon.

That is not death with dignity.

Doctors have the medical skill to help a person reach a dignified death via good pain management and comfort care, including new methods of pain control, mitigating care, hospice, and treatment if depression is present.

In Oregon, safeguards protect no one. There is a growing list of documented cases of abuse. HMO administrators have overruled their physicians to authorize physician-assisted suicide. Doctors have given suicide drugs to depressed patients they met only two weeks earlier.

In clear violation of the law, a family member administered suicide drugs to his brother. And physicians have already crossed the line and euthanized patients.

Physician-assisted suicide is dangerous because it is cheaper than good care and eliminates treatment options for the poorest and most vulnerable. The state of Oregon will pay for suicide drugs but will not pay for more than 150 different appropriate treatments that its citizens need.

Since physician-assisted suicide has been legalized, Oregon has continued to deeply cut health services to the poor, creating financial pressure that shifts the balance to favoring cheap health solutions.

Independent experts, state legislatures, state courts, and the United States Supreme Court have all rejected physician-assisted suicide. Since 1994, at least 54 physician-assisted suicide measures have been introduced in 21 states. Not one has passed. Physician-assisted suicide advocates have lost at the ballot box in five more states.

State courts in four more states have rejected physician-assisted suicide as a right. The New York Task Force studied this issue for more than 10 years and rejected it as public policy — unanimously. And the U.S. Supreme Court rejected the right to assisted suicide in two different cases, citing the profound social dangers.

Physician-assisted suicide is ultimately a withdrawal from the harder path of compassion. Our role as your doctor is to be with you and advocate for quality care in even the most difficult circumstances. Together we can cherish life and preserve the bond of harmony between body, mind and soul, rather than destroying it with assisted suicide. We will not abandon our patients in times of greatest need.

Dame Cicely Saunders, the founder of the hospice movement, said it well: "You matter to the last moment of your life, and we will do all we can, not only to help you die peacefully, but also to live until you die." That commitment cannot be delivered in a cheapened environment of suicide on demand.

We want our patients to know that the physician's pledge to do no harm or injustice is at the heart of medical practice. That pledge is the basis of trust between patient and doctor and that trust makes the healing relationship possible.

When we ask you to take a medicine with uncomfortable side effects, if we advise you to submit to surgery, it is this bond of trust that supports your following our advice. Our patients who are disabled must know we see more than their disability. Our cancer patients must understand the hopes we see are real. The dying must know their life is not dismissible just because it may be ending soon.

Inam Rahman, M.D., is a Kane'ohe resident and president of the Hawaii Medical Association.