Aid in dying should be personal choice

I cared for patients for more than 41 years as a general practitioner in Hawaii. I helped found Hospice Hawaii because I wanted to help terminally ill patients live life as fully and comfortably as possible. As a doctor, I believe terminally ill patients should be free to control how much suffering they endure and die with dignity.

During that time, I had the unfortunate experience of having terminally ill patients say, "Doc, can you give me something to end this? I’m miserable." I knew what those patients were asking for and wanted very much to honor their wishes. But because of my understanding of the law then, I thought I couldn’t. It’s very traumatic for a doctor to have to turn a patient down when they ask you for something like that. Today, I know I can honor that choice.

In my practice, it was not uncommon for a patient for whom I had written a prescription for sleeping pills some months earlier to tell me that he or she had not taken any. It was such a comfort merely having the pills in their medicine cabinet that they had no difficulty falling asleep. Many patients who request aid in dying respond in a similar way, as is shown by evidence from Oregon. Under that state’s Death with Dignity Act, some 30 to 51 percent of patients who obtain a prescription choose not to ingest the medication but die from their disease. So I look at aid-in-dying as giving the patient insurance.

And there is an incredible paradox: The people you end up writing a prescription for may live longer than expected. Their toxic anxiety is gone and this lets them live their remaining days more fully. They know they can take the medication if and when suffering becomes intolerable. So when I write a prescription for a potentially lethal dose of medication, my intention is not primarily to end their life but rather to end their toxic anxiety. When I hand my terminally ill patient the prescription, I will say, "I hope you won’t ever need to take this."

This newspaper recently wrote about a legal opinion on "assistance with dying" from the office of Hawaii’s attorney general. It focused narrowly on one law, HRS 453-1, and said that single law did not give explicit government permission for aid in dying.

Sylvia Law — Hawaii resident and New York University Law School professor — holds a different opinion. She feels that there is a "constellation" of laws in Hawaii that gives patients autonomy over end-of-life decision making.

The opinion that really counts is the opinion of the people of Hawaii, and the people have spoken. A recent QMark Research poll of Hawaii voters showed overwhelming majorities believe self-determination at the end of life is their right. Ninety percent of Hawaii voters agreed the decision about aid in dying is a personal one between patient and doctor; 83 percent said the medical community — not the government — should establish proper guidelines and safeguards.

This is not surprising. Most medical care is guided by best practice guidelines formulated by physicians, not voted on by politicians. Many end-of-life practices predictably hasten the time of death. These practices include stopping of eating and drinking, palliative sedation and withdrawal of life-sustaining treatment (ventilators, pacemakers, kidney dialysis). Physicians have established standards for these procedures, and we can trust them to do so for aid in dying.

Responding to the desire for peace of mind and comfort is one of the most powerful ways a doctor can support a patient approaching the end of life. This complements the cornerstones of hospice by providing comfort care and honoring a patient’s choices whenever possible.

I want to be able to support patients in this way, and other doctors do, too. The people of Hawaii overwhelmingly agree with me: They want the medical practice of aid in dying accessible, open and safe.

Robert "Nate" Nathanson, a retired general practitioner who retains his medical license, lives in Waialua. He is a founder of Hospice Hawaii.