Hawaii’s “Our Care, Our Choice Act,” which took effect this month, allows terminally ill adult residents facing a prognosis of six or fewer months to live, to obtain a lethal medication prescription.
Two years go, Dr. Chuck Miller teamed up with John Radcliffe — a longtime state political lobbyist and terminally ill cancer patient — and Compassion & Choices, a national nonprofit advocate organization for terminally ill patients, to launch legislative and lawsuit strategies that rallied support for the new law.
During the preceding decades-long debate on the matter, state law effectively banned doctors from helping patients die; a prescribing physician could be charged with manslaughter, sued for medical malpractice and face professional discipline.
“I became aware of the need for a medical aid-in-dying option in about 1979, almost from the first time I took care of cancer patients in Hawaii,” Miller said.
“As chief of oncology at Tripler Army Medical Center, I was seeing many terminal cancer patients die terrible, prolonged and painful deaths despite good palliative care. I knew there had to be a better way for patients to end their suffering when they had exhausted all treatment options and their quality of life was so awful.”
A native of Decatur, Ill., Miller graduated from the University of Southern California’s medical school in 1970 and elected for post-graduate training in the U.S. Army, with an internship and residency at Tripler and an oncology fellowship at Walter Reed National Military Medical Center.
After serving 30 years as an Army physician, most years treating cancer patients, Miller retired from the military and joined Kaiser Hawaii, where he served as chief of the hematology-oncology service for several years.
Kaiser, the largest health maintenance organization in the islands — both a medical provider and insurer — has contracted Miller as a part-time attending physician to write prescriptions for the state’s medical-aid-in-dying program and help educate other doctors and staff, both in and outside of the organization.
(Editor’s note: Miller’s responses to questions below are his personal opinions. They do not reflect Kaiser’s policies and positions. Most health-care facilities have adopted neutral policies on the program — leaving it up to doctors on whether to participate.)
Question: What are your thoughts on the new state law? Is it in need of changes or tweaking?
Answer: It’s a good first step to ensuring that dying patients can have a peaceful death, and Hawaii residents should be proud. However, the qualification process to get a prescription for medical aid in dying is too complicated for dying patients who have weeks or days to live. A simpler process is just as safe, but would provide more comfort and relief to dying patients.
For example, we are the only state to place an additional burden on a dying patient by requiring not only two, but three evaluations of their mental capacity to make their own health-care decisions, including a mandatory evaluation by a mental health practitioner. This is completely unnecessary and stigmatizing for patients. Physicians are experts at informed consent and make mental capacity determinations every day.
The other patient barriers I believe need to be changed are the 20-day waiting period and having witnesses sign a patient request form, which is also unnecessary.
(Hawaii is among seven states, along with Washington, D.C., that have enacted medical-aid-in-dying laws. Each stresses that a patient must always be in control of his or her participation in the process.)
Q: The debate over the merits of the new law is expected to continue. What do you say to the argument that a doctor’s signing off on a prescription directly collides with the Hippocratic Oath?
A: The debate is over. Medical aid in dying is now an authorized compassionate end-of-life care option in Hawaii and now we need to focus our attention on successful implementation so that dying people have real access to the law. Doctors should be putting their patients’ autonomy and needs first.
It’s interesting that you bring up the Hippocratic Oath because it is an ancient Greek document that is no longer used at any U.S. medical school graduation ceremony. In fact, that oath actually begins by asking for allegiance to Apollo and other mythical gods and goddesses! But many of its important principles endure while the application of those ideals has evolved over time.
Modern standards of medical ethics can be found within it: Patient autonomy. Beneficence. Non- maleficence. Social justice. And most of all, duty to one’s patients and the patient’s desires and goals. As medical professionals, one of our greatest challenges is to respect our personal commitment to do no harm in the face of the ambiguities resulting from advanced medical technology.
My perspective is that ignoring a patient’s suffering or autonomy is harm. We can no longer simply fight disease at any cost, but must help patients weigh risks, benefits and quality of life as they make their own medical choices. Those who refuse their patients the right not to prolong the dying process are placing their beliefs above the needs of their patients. This is harmful and borders on unethical.
Q:John Radcliffe became the first Hawaii patient to request the prescription. He received a six-month prognosis in June 2014. Under the new law, what happens when a patient outlives prognosis?
A: Once a patient receives the medication, they are able to focus on maximizing their remaining days and keep it as an “insurance policy” if their suffering becomes unbearable. In fact, about one-third of patients who receive a prescription for medical aid in dying choose never to use it. If a patient dies without using the medication, it will be safely disposed of in the same manner as all of the medication that often surrounds a terminal patient’s bedside.
John has been amazingly fortunate; he has terminal cancer that has been temporarily controlled by his treatments. He loves life and certainly does not want to die. But eventually his chemotherapy will stop working. I will fight with John as long as he wishes, and I will also be there to support him when he decides that quality of life is more important than quantity.
Q: We’re seeing reluctance to take part in the state program among some doctors and pharmacists. Thoughts on that?
A: Change is hard, but I am convinced that any reluctance that some providers may feel about the new law will go away after they see the comfort and sense of peace it brings to dying patients. It’s important for patients to let their providers know that this is an important issue for them. And experience shows that doctors and pharmacists may not think about their position much until their first beloved patient makes a request for support.
The good news is that the pharmacy at CVS/Longs also has a policy of engaged neutrality, which means they will support patients who request the drug(s) but will not require individual pharmacists to dispense it if doing so would violate their particular beliefs. Other pharmacies are in the process of firming up their own similar policies. Overall, pharmacies and systems should become more comfortable in supporting dying patients’ wishes as this process becomes more integrated into the entire spectrum of end-of-life care in our islands.
Q: What do you think the biggest misconception is about the new law?
A: The confusion created by continued use of the phrase “assisted suicide” among some who oppose the practice of medical aid in dying. Not only is it medically, legally and factually incorrect, but it is cruel and offensive to patients who need this option, and to their surviving families. These patients are not suicidal. They want to live, but have been handed a death sentence by their disease. This law allows them not to be forced to prolong a painful dying process and to choose when, where, and with whom it will happen.
Q: What do you find most satisfying/rewarding in practicing medical-aid-in-dying?
A: It’s in respecting my patients’ choices and needs. Coming face to face with a patient who knows that he/she is dying is profound, and I believe it is my highest calling to be able to take their hand and say: “I am here to help you. I will not abandon you.”
