Quietly, Doctors Already Help Terminal Patients Die : Ethics: A Westside physician tells of two ‘caring acts.’ Prop. 161, to legalize such aid, divides the medical field.

As a doctor his primary goal is to prolong lives.

But twice in the 30 years since he took the Hippocratic Oath and added MD to his name, he has written prescriptions for drugs requested by terminally ill patients so they could end their lives.

And in one case two decades ago, the doctor administered the poison himself to a pain-racked patient. In that instance, he botched the job.

“I still agonize over the first one,” he said. “If I were going to do it, why didn’t I do it better?” Then he added wryly: “I’m a failed murderer.”

A soft-spoken middle-aged practitioner on the Westside of Los Angeles, the doctor agreed to discuss his experiences with a reporter as California voters prepare to take sides on the emotional issue of doctor-assisted death.

If Proposition 161 on the Nov. 3 ballot passes, California would become the first state in the nation--and apparently the first government in the world--to put a law on the books authorizing doctors to help patients die.

The initiative would allow physicians to administer fatal doses of drugs to terminally ill patients who request euthanasia, or provide the dying patients with chemicals needed to take their own lives.

The Westside physician is prominent in the Southern California medical community. He agreed to be interviewed after being assured that his name would not be divulged. Knowingly providing the means for suicide is a crime in California, and mercy killing can be prosecuted as murder.

The doctor, who said he has rejected more than 30 other requests for help in dying, supports Proposition 161 to remove the legal threat from doctors who comply with their patients’ wishes--”something that I consider a very compassionate and caring act,” the physician said.

Clearly, not all physicians feel the same way. The measure has become the subject of a fierce debate among doctors and religious groups, hospitals and lawyers, ethicists and patients.

Proposition 161, written by Southern California attorneys Robert Risley and Michael H. White, follows the failure last year of a similar proposal in Washington state.

Proposition 161 is backed by a diverse list of groups, including the American Civil Liberties Union, the Gray Panthers and the Hemlock Society, a group that advocates a dying patient’s right to suicide. Among the supporters is Dr. Warren Bostick, the former president of the California Medical Assn.

But the California Medical Assn. itself opposes the measure, along with the California Nurses Assn. and religious organizations. Most of the money raised to fight the initiative has come from the Roman Catholic Church and Catholic hospitals. Catholic bishops took the unusual step of calling for volunteers and political donations in a plea read from pulpits statewide.

Supporters say Proposition 161 protects patients from a rash decision to die by requiring that two doctors certify that the illness is likely to cause death within six months. Under the measure, the patient must sign a witnessed directive, which can be revoked at any time.

Opponents argue that the safeguards are not sufficient to protect patients who may request to die while influenced by extreme pain, depression or drugs. Some opponents go even further and say that doctors should avoid any role in their patients’ deaths.

“Most of us believe that a suicide wish is a result of fear and depression and not because it is truly the answer people are looking for, but because it seems the only way out,” said Dr. Michael-Anne Browne, who chairs the California Medical Assn.’s medical ethics committee.

Physicians opposed to Proposition 161 say that in recent years practitioners have been freed to give large enough doses of medications to deal with pain in all but rare instances.

California was the first state to put into law the right of patients and their families to refuse life-extending treatment through “living wills.”

As for the next step--actually assisting in suicide--there is wide agreement in the medical field that it already occurs illicitly in that anguished, private world occupied by dying patients, their families and closest friends, and their doctors and nurses.

“I can tell you that many doctors do that,” said the Westside physician. “It’s part of the practice of medicine. We don’t like doing it but we do.”

Those few cases in which he intervened to help cut short a life still cause him stress: “They’re uncommon, but you remember every one of them.”

The first time he attempted to help a patient die was more than 20 years ago, not long after he began private practice. A man in his 20s came to the hospital complaining of bruises. Tests revealed extensive cancer.

“The diagnosis was made in hours and he never left the hospital,” the doctor recalled. “He failed chemotherapy and it was a downhill course.”

Despite being given higher and higher doses of morphine, the patient was in great pain and kept crying for his doctors to “end it,” the physician said. Along with a nurse and another doctor, he prepared a syringe containing a deadly dose of potassium chloride, a chemical used in some states for capital punishment by lethal injection.

“I gave him a bolus (a large amount) directly into a vein,” the physician said. “He did gasp and shudder, and we watched him. A minute later he began to breathe again. We had failed.” The patient died later that day when an intern deliberately injected a fatal dose of a drug commonly used in surgery, the doctor said.

More recently, a woman with breast cancer that had spread throughout her body came to him to ask for enough barbiturate to commit suicide. Her cancer had invaded her kidneys, bones, liver, and the lining of her intestines.

“She told me at the same time she had another 30 or so (pills) from her oncologist,” the Westside physician said. She was “a very well read, very bright lady. . . . She was competent and she made the decision in advance.”

He provided her with a prescription for the requested drugs. “She went home that night and took the pills the next morning,” the doctor said. He signed the death certificate, listing her cause of death as cancer.

In recent months, the doctor said, he has also supplied pills to an AIDS patient. The man has not used the medication, nor is the doctor sure he will.

Both patients knew what drugs to ask for, he said: “They read about it and they know one way (to commit suicide). They ask, ‘Do you think 50 will do it?’ ”

Just how often physicians in thS. play a role in patient suicides is at best uncertain. The subject is not often discussed openly, but occasionally a sensational case like that of Dr. Jack Kevorkian vaults the issue into public view.

Kevorkian, a Michigan physician, has openly provided suicide-assist devices to five patients in the past two years. Proponents of Proposition 161 point out that only one of the patients, a woman with terminal lung cancer who committed suicide last Saturday, would qualify for aid in dying under Proposition 161. None of the others had a terminal condition that would have led to death within six months.

Dr. Timothy Quill of New York wrote an essay last year in the New England Journal of Medicine in which he described prescribing a lethal quantity of barbiturates to a leukemia patient identified only as Diane.

“I made sure that she knew how to use the barbiturates for sleep, and also that she knew the amount needed to commit suicide,” Quill wrote.

The American Society of Internal Medicine sent an informal survey on the subject to 1,000 members a year ago. Of the 402 internists who responded, 80 said that they had “taken deliberate action that would directly cause a patient’s death.” Slightly more than half said they would oppose a ballot measure to legalize physician-assisted suicide.

In a 1989 New England Journal article, 12 distinguished academic doctors acknowledged that some physicians “do assist patients who request it, either by prescribing sleeping pills with knowledge of their intended use or by discussing the required doses and methods of administration with the patient.”

The authors said that there was no way of knowing how often this takes place, but that such actions “are not rare.” Of the 12 doctors, “all but two of us . . . believe that it is not immoral for a physician to assist in the rational suicide of a terminally ill person.”

But many doctors emphatically oppose that position. They argue that physicians should never take on the role of executioners, and say medical science can relieve most of the pain for dying patients.

Earlier this year, the American Medical Assn.’s council on ethical and judicial affairs rejected arguments in favor of physician participation in suicides or mercy killings “at this time.”

“Physicians must not perform euthanasia or participate in assisted suicide,” the panel concluded.

Dr. David Cundiff, who directs the cancer pain service at Los Angeles County-USC Medical Center, agrees with that position.

“Relatively few terminally ill patients request euthanasia or assisted suicide,” Cundiff said. “Those who do, do so because of uncontrolled pain and a feeling of helplessness and abandonment. But the problem is that physicians haven’t been trained to treat those symptoms.”

Critics of the ballot initiative also point to the traditional oath of Hippocrates, which requires physicians to promise: “To please no one will I prescribe a deadly drug, nor give advice which may cause death.”

But the Westside doctor who admits helping his patients to die contends that modern medicine, which has the power to slow the process of dying, sometimes requires doctors to abandon simple black-and-white rules of conduct.

“The Hippocratic Oath is really not the final word any more than the Ten Commandments,” he said. “People have always suffered in the end. We haven’t done much to relieve this.”

Times researcher William Holmes contributed to this report.