No
A Change of Hearth on Assisted Suicide

By Diane E. Meier, guest editor

A recent survey, which I co-wrote, found that doctors are often asked by their patients for help in dying, but seldom honor these requests.

Some years ago, I believed that doctor-assisted suicide should be legalized and that terminally ill people in great pain deserved more control over the circumstances of their death.

It is true that terminally ill patients sometimes find themselves in truly unbearable circumstances. But after caring for many patients myself, I now think that the risks of assisted suicide outweigh the benefits.

Proponents of doctor-assisted suicide say that strict regulations can reduce the chances of abuse and protect the most vulnerable from feeling coerced. But rules would be difficult, if not impossible, to enforce. For instance, Oregon, the only state to legalize assisted suicide, has guidelines that mandate the following:

* A patient must be mentally alert. It is the rare dying patient, particularly if elderly, who remains consistently capable of rational deliberation about medical alternatives. Intermittent confusion, anxiety, and depression are the rule rather than the exception, inevitably clouding judgment.

* A patient must be within six months of death. Abundant evidence shows that accurately predicting when patients are going to die doesn't become possible until just days before death. The guidelines assume that such a prognosis is possible and deny the uncertainty inherent in such predictions.

* A doctor must certify that the patient's decision is not coerced. This is an impossible task, given the financial and other burdens that seriously ill patients pose to their families. Indeed, legalizing assisted suicide is coercive in and of itself. Society would no longer promote the value of each life, and instead sanction an expedient death rather than continued care and support.

The push to legalize doctor-assisted suicide could not come at a worse time. Spiraling health costs and our aging population have led to radical changes in how care is financed, with doctors and hospitals rewarded for doing less for their patients. Seriously ill people need help easing their pain, time to talk to their doctor, answers to their questions, and reasonable attempts to prolong their life when death is not imminent.

If this kind of care were available to every patient, it would certainly reduce, if not eliminate, the desire for a hastened death. But legalizing assisted suicide would become a cheap and easy way to avoid the costly and time-intensive care needed by the terminally ill. It could be seen as an appealing alternative when resources are stretched and family members and doctors are exhausted. The terminally ill patient could feel subtle and not-so-subtle pressure to opt for suicide. Our society should not be reduced to offering patients a choice between inadequate care and suicide.

The proposed guidelines for assisted suicide are well-meaning, but unrealistic and largely irrelevant to the reality faced by the dying. While I have had patients whose desire to die was compelling and understandable, such patients are few. The distress of the last days, when it occurs, can be effectively treated with analgesics and sedatives. Although we have the knowledge and tools to reduce suffering near the end of life, we are debating instead whether it should be legal for doctors to hasten death.

Diane E. Meier, M.D., is associate professor of geriatrics and director, Palliative Care Initiative, Mount Sinai School of Medicine, New York. Originally published in The New York Times. Reprinted by permission.

Yes
What Experience Teaches About Legalization of Assisted Dying

By Barbara Coombs Lee

Since 1994, Oregon has witnessed energetic public debate and two political campaigns over legalization of assisted dying. Proponents provided a legal, predictable means by which terminally ill, mentally competent adults can obtain the means from their doctors to hasten death if suffering becomes intolerable. Opponents predicted abuse of the law, poor regulation, and coercion of women, minorities, and the poor for financial gain.

Had it not been for voters' reaffirmation of the Death with Dignity Act in 1997, a debate based on fears and speculation could have continued for years. Instead, we now have data and stories of actual experience with a law in effect for a year and a half.

Initial reports document careful, well-considered use of the Oregon law under compelling circumstances:

Of 29,000 deaths in Oregon in 1998, only 15 resulted from ingestion of medication to cause death. The median age of these patients was 69. Seven were women and almost all (13) were dying of cancer. Almost three-quarters were receiving hospice care.

A comparison of these 15 patients with a control group showed assisted death was not disproportionately chosen by patients who were poor, uneducated, uninsured, fearful of financial consequences, or lacking end-of-life care. The 15 patients differed from the control group only in concern about loss of autonomy and loss of control of body functions during the dying process.

Over the same period, Oregon residents experienced a dramatic improvement in the quality of end-of-life care. Some of the most telling findings are the following:

Since 1994, the percentage of Oregonians dying in hospice increased from 22 percent to 32 percent. This number compares very favorably with a national average of 17 percent. Since 1994, Oregon moved from eleventh to second in the nation in per capita use of medical morphine. This figure is an acknowledged indicator of good symptom control at the end of life.

Deaths in acute-care hospitals fell dramatically. A recent study shows Oregon doctors have a heightened sensitivity regarding patients' desires. This sensitivity results in more people dying at home or in a nursing facility. Only 30 percent--fewer than in any other major U.S. city--die in Portland hospitals. Seminars, courses, and dialogue about improving end-of-life care abound in Oregon, and they are well attended.

It appears that empowering patients with acceptable choices to avoid prolonged and inexorable deterioration has a secondary effect on physicians. It causes them to listen more carefully and address the patient's needs more consistently.

In the meantime, even though the Death with Dignity Act is rarely used, it is of enormous comfort to the dying and their loved ones. There are no numbers on how many dying individuals turn to guns and other devastating means to escape their last weeks of agony, but there are many stories. In Oregon we have already prevented a number of these violent suicides. Instead of experiencing a tragedy, families have been able to gather and hold their loved ones as they passed on gently--and legally.

Experts acknowledge that even the best comfort measures cannot eliminate such devastating symptoms as fatigue, weakness, breathlessness, and loss of mental and physical function. Even pain does not always respond to treatment, with 5­15 percent of pain at the end of life being intractable.

What about these people, who suffer in a system that forces them to seek a humane death with illegal, covert, and even violent means? I don't believe that responding to a request for assistance in dying heralds a "devaluation" of life. I believe such compassion can demonstrate the highest standards of integrity, mercy, and respect for the individual. One cannot truly respect life, yet discount the values, beliefs, and desires of an individual lying before us.

Barbara Coombs Lee, F.N.P., P.A., J.D., is executive director, Compassion in Dying Federation, Portland, Ore.