Medically assisted death: Wariness is warranted

Physician-assisted suicide is a contentious and polarizing issue. People of integrity, compassion and intelligence may hold contrary views. It is easy to understand why polls find the general public sympathetic to what, on the surface, seems a simple question of personal choice and individual liberty. Yet, a deeper dive into both public safety concerns and the possible unforeseen impact on our community, give us pause to think.

Space precludes a full discussion but, with the goal of balancing personal choice with patient safety, those in our legislative and judicial systems and the public should consider the following:

>> Proponents of assisted suicide raise the lack of documentation of any abuse under Oregon’s Death With Dignity Act as a reassurance. With national estimates of elder abuse at 10 percent, the lack of documentation of a single case of abuse is far from reassuring: it strongly suggests the lack of a system to monitor and prevent abuse.

>> There is a strong association between the desire for hastened death and depression. Therapy has been shown to be effective in reducing the desire for hastened death among those with terminal illness. Yet, very few of those requesting assisted suicide in Oregon are even referred for a mental health evaluation, less than 4 percent in the most recent report. Elsewhere in medicine, when a depressed patient expresses a desire to die, we use all of our resources to prevent it. Why should the seriously ill be provided a lower standard of care?

>> The slippery slope is not an irrational fear: it is inevitable. Canada and some European countries already permit assisted suicide as well as active euthanasia and do not require that one be terminally ill to qualify. For a truly chilling experience, visit the government website for the Netherlands to see that a 12-year-old may petition for euthanasia for unbearable suffering, absent any terminal illness.

>> Understandably, many people take comfort from having lethal medication available and never ingest it but, instead, die naturally. In Oregon, 1,545 lethal prescriptions have been written resulting in 991 (64 percent) deaths by ingestion. What happens to the other 36 percent of lethal medication? We have a national suicide epidemic, with suicide now a leading cause of death among youth. None of the other states with assisted suicide laws adequately secure unused medication. When access to lethal medication is increased at the same time that society sends a clear message that ending one’s life in the face of suffering is sanctioned as a rational and personal choice, how can we not expect suicide to continue to rise?

>> These laws give immunity to prescribe lethal medications to all licensed physicians. Yet, few doctors have the added training and skills to attend to the many forms of suffering experienced by those living with terminal illness. We hold our medical colleagues in the highest regard. Our dermatologists, orthopedic surgeons and ophthalmologists all provide us with exceptional care within their scope of specialization. Yet, we would not expect them to have the skill to assess or treat suffering in a terminally ill patient. These laws do not distinguish among doctors: all are authorized to prescribe lethal medication. Skills in attending to suffering are not required, just a prescription pad.

Close to 11,000 people die in Hawaii each year, over 200 from suicide. Based on the Oregon experience, perhaps another 40 in Hawaii would opt for physician assistance. As much as we all respect and can empathize with the desire for self-determination, those entrusted with enacting and interpreting laws to both guard our civil liberties and ensure public safety, should carefully consider these risks.

The authors are physicians and certified specialists in hospice and palliative medicine: Daniel Fischberg of Kailua; Nancy Long of Kula, Maui; and Michael H. Plumer of Lihue, Kauai.