The right to die

The results of the recent U.S. elections have thrown many Americans for a loop.  While we work to unpack a lot of feelings about a Trump presidency, I thought it might be better to talk about another result from last Tuesday.  Colorado became the sixth state to pass a bill that allows terminally ill patients to seek life-ending medication.  Supported by 65% of the constituency, the measure applies to individuals with 6 months to live or less who can self-administer the lethal dose.

The measure requires that people “make two oral requests, separated by at least fifteen days, and a valid written request to his or her attending physician.” It also requires that people be capable of taking the medication unassisted, and stipulates that patients can rescind a request for life-ending medication at any time during the process.

Oregon – along with Washington, Vermont, Montana, California, and most recently Colorado – has had an aid-in-dying measure since 1997.  Winner of a Grand Jury Prize at the 2011 Sundance Film Festival, How to Die in Oregon, an HBO documentary tells the stories of people impacted by this law.  To date, 1,327 prescriptions have been filled with 859 deaths.  The most commonly cited reasons for requesting the prescription include loss of autonomy, decreasing ability to participate in activities that made life enjoyable, and loss of dignity.

So-called aid-in-dying and Death with Dignity measures are highly controversial, perhaps due in part to Dr. Jack Kevorkian’s unabashed commitment to “physician-assisted suicide.”

Forms of assisted suicide are legal in the Netherlands, France, Germany, Switzerland, and Belgium.  While the laws in France, Germany, and Switzerland are more passive, the Netherlands and Belgium are anything but.  Passed in 2002, Belgium law allows doctors to prescribe life-ending drugs to individuals suffering “intractable and unbearable pain.”  This includes pain caused by mental illness.  The Economist produced a documentary about a 24-year-old Belgian woman on her journey to euthanasia due to severe and chronic depression.  In February 2014, Belgium became the first country to allow minors to request euthanasia with parental consent.  To qualify, children must give informed consent, be terminally ill, and beyond all hope of medical intervention.  The first case of physician-assisted suicide of a minor occurred earlier this year.

Of course, euthanasia is fraught with controversy.  The act alone conflicts with the ethical and professional codes of the medical profession:

A physician’s assistance in suicide can indeed be construed as helping the patient: helping in the sense of being an ally in the patient’s quest to fulfill personal goals, or helping by buttressing individual autonomy. However, there are also features of such action that can be qualified as harmful: harmful by sowing confusion in trainees about the conceptual core of traditional clinical methods, or harmful by eroding respect for absolute moral values such as “do not kill.”

Others argue that the Hippocratic Oath is irrelevant including its oft misquoted tenet: “First do no harm.”  In the case of physician-assisted suicide, isn’t harm avoided by allowing patients autonomy and freedom from painful, protracted deaths?  Patients with Amyotrophic lateral sclerosis (ALS), called Lou Gehrig’s disease, remain cognizant while the rest of their body shuts down.  Though progression differs from person-to-person, an individual with ALS can expect to lose mobility, use of hands and arms, the ability to chew and swallow, and finally the ability to breathe without assistance.

The vast majority of deaths in ALS are the result of respiratory failure, a process that progresses slowly over months. Medications can relieve discomfort, anxiety and fear caused by respiratory insufficiency.

Given this prognosis, it is plain to see why an increasing number of ALS patients in Oregon are seeking a death with dignity.  Do you think physician-assisted suicide has a place in public health discourse?

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