O.C. in Middle of ‘Death With Dignity’ Debate

James Ward, once a heavy smoker, is dying of emphysema. Since April, he has been rushed to the hospital 14 times and had a tube thrust down his throat so a ventilator could help him breathe. He wants no more of that.

Tucked in his wallet, Ward, 68, carries a paper he has signed to prevent hospital personnel from reviving him if his lungs fail again. Moreover, he said, he wishes that when he comes within a month of dying he could instruct a doctor to give him a lethal injection to end his suffering, which grows worse by the day.

“Who says you have to suffer? I think if a man is suffering, the choice should be his,” said Ward, an Arizona resident who has been visiting his eldest daughter in Mission Viejo.

Today the carrying out of such a directive from a terminally ill patient would be considered murder anywhere in the country. But if enough people who share Ward’s views turn out at the polls in November, doctor-assisted suicide could become an option in California. Proposition 161, called the Death With Dignity Act by its supporters, would allow mentally competent adults to instruct their physicians in writing to hasten their deaths within the last six months of their lives.

It has special significance in Orange County, which has two Leisure World retirement communities and a substantial number of people infected with the AIDS virus. Even without the sanction of law, the Hemlock Society within Leisure World has been teaching terminally ill people the least painful ways of committing suicide, and members of the gay community relate that some of their friends in the later stages of AIDS have used drug overdoses to cut short their dying.

Giving physicians the ability to help patients out of their misery when they can no longer help themselves, the proposition’s advocates say, would reduce the number of premature and bungled suicides, restore the dying patients’ sense of dignity, and remove the stigma from their choice of death.

But the idea conflicts with the medical profession’s basic ethic of saving lives and with the religious beliefs of many, most notably Roman Catholics.

Ward’s 39-year-old daughter, Angela, who unlike her father was raised a Catholic, sharply disputes her father’s backing of the ballot measure.

“I see my dad suffer every day, but I wouldn’t have him injected,” she said. “There is only one person who can take or give life, and that is God.”

A division of opinion has appeared not only within families, but within the medical profession. Two of the leading proponents of the proposition are Orange County physicians: Dr. Warren Bostick, a past president of the California Medical Assn. and former dean of the UCI School of Medicine, and Dr. Ronald Koons, a Laguna Hills physician who treats cancer patients with radiation.

However, while some individual doctors and nurses support the proposed law, most of organized medicine, including the California Medical Assn., the Orange County Medical Assn. and the Southern California Hospital Council, have aligned themselves in staunch opposition.

Even many who support the concept of self-determination worry that there are not enough safeguards to ensure that patients have time to fully think through their decision and receive counseling on the alternatives.

They also cite opportunities for abuse. They warn that a patient might be pressured to choose an earlier death by relatives and care-givers for whom the patient has become an emotional or financial burden.

“How long will it be before the right to die becomes the duty to die?” asked Greg Satchwell, community liaison for the Saddleback Memorial Medical Center’s home-care program.

Although the proposition provides that two physicians would have to agree that a patient had no more than six months to live before granting his wish to die, opponents note that the diagnosis of terminal illness is an inexact science. Corrine Bayley, an ethics specialist for St. Joseph Health System, a Catholic hospital chain based in Orange, said: “I was just in a hospital where I met someone who was given a terminal diagnosis of six months three years ago. She had cancer and has recovered with chemotherapy.”

Bayley said too many people believe that the proposition is simply an extension of an existing law that enables a terminally ill patient to reject medical treatment that is sustaining his life. The next step, she contends, is a giant one.

“It is one thing to stop treatment and allow a person to die of their disease, and another to empower a physician to end a person’s life,” she said.

Gloria Davenport, a counselor for older adults at Rancho Santiago College who has done doctoral research on aging, said Gallup polls have shown that 34% of Americans approved of physician-assisted death in 1950, a percentage that increased to 65% in 1990.

Davenport attributes the change of opinion to the nation’s fast-expanding elderly population, many of whom, she contends, are being kept alive too long by medical technology. “We are prolonging dying rather than the quality of life,” she said.

Some of the strongest advocates of doctor-assisted suicide live in Leisure World in Laguna Hills, where residents who visit the deathbeds of neighbors are intimately acquainted with their yearning to escape suffering. Within that community paramedics have been finding copies of “Final Exit,” the Hemlock Society’s best-selling suicide manual, next to some bodies.

Last year, “Final Exit” sold out twice at Waldenbooks in the Laguna Hills Mall next to Leisure World. And early this year there was standing room only when the book’s author and Hemlock Society founder, Derek Humphry, talked about the need to legalize doctor-assisted suicides for the terminally ill. The audience interrupted Humphry’s address several times with thunderous applause.

Opponents of doctor-assisted death, however, contend that much of the public is ignorant about recent advances in drugs for pain management and hospice care that can make the last weeks of dying more bearable, even rewarding.

“Individuals faced with terminal illness, if given adequate support from physicians, can have a very peaceful end to their life,” said Joan Randall, a nurse and vice president of the Visiting Nurse Assn. of Orange County, which operates a hospice to assist dying patients and their families in their homes.

Helen Spates said the hospice program was “wonderful” by providing the nursing, drugs and counseling for her 66-year-old husband, Garrett, who died of cancer in their San Juan Capistrano home, surrounded by his children.

Spates said her husband “knew all about (Proposition 161) and was very much against it. We are all against it. He had time to make his amends and do what he wanted to do. He was prepared to go, and we were prepared to let him go.”

Dr. Melvyn Sterling, president-elect of the Orange County Medical Assn. and medical director for the visiting nurses’ hospice program, acknowledged that not only are many patients not apprised of the advances in pain management, but many physicians don’t know how to provide compassionate care to the dying.

“The real heart of the problem is that medical educators need to do more to train physicians to treat appropriately people with terminal disease,” Sterling said.

He also contends that the proposition, if passed, would give physicians an all-too-easy solution.

“Instead of keeping us focused on the goal of educating physicians to relieve the terrible symptoms, the pain and nausea and all the discomforts of terminal illness, this initiative would instead just put patients out of their misery. That would be awful,” he said.

Koons, a cancer specialist with a practice on the outskirts of Leisure World in Laguna Hills and a member of the Hemlock Society, said he strongly favors hospice care and the use of modern pain management techniques. He said the provisions of Proposition 161, which he supports, are intended to be applied only to the “the few patients whom we cannot prevent from going though the tortures of the damned.”

He emphasized that under the proposal, only people with terminal diseases such as AIDS and cancer would be eligible for euthanasia. Those with severely disabling, but not life-ending, ailments such as Alzheimer’s or Parkinson’s disease would not qualify.

Koons, another physician who favors Proposition 161, said he opposes the “dehumanizing” of a patient who in the last days of his life not only suffers his own pain but also “looks up from his bed and feels the agony of his family.”

Several of Koons’ patients said they agree. Louise McNew of Irvine, who was having radiation therapy following removal of a malignant lump from a breast, said she wished that Proposition 161 was passed before her mother died of congestive heart failure three years ago.

“She lived with me, and I watched her suffer every day,” McNew recalled. “She was 87 and knew she wouldn’t get well, and she really wanted to pass away. The doctor wouldn’t even give her tranquilizers.”

Lucille Nemet, whose surgeons could not remove all of the malignancy in her colon, says she would want the option of euthanasia when she is close to death--but not now.

“I plan to fight as long as I can,” said Nemet, a spry woman from San Juan Capistrano who says she loves to take walks and is happy to be able to eat on her own after being on feeding tubes.

Koons said Nemet has the right idea.

“She is eating normally and keeping her weight up, so why look at something so negative right now?” he said. “I wouldn’t tell her to sign the directive (for euthanasia) today. She is still dynamically enjoying life.”

Surprising to some, many organizations that represent and serve AIDS patients in the gay community have not taken a position as yet on the euthanasia measure, either because they want more information or because they feel it is too controversial.

Laurie McBride, executive director of the Life AIDS lobby in Sacramento, said: “We have not taken a position on this measure. A lot of people in the community would support it and a lot are afraid of it. They are afraid it could be used to force people with AIDS to die.”

Some AIDS-related service groups say supporters of Proposition 161 have done very little so far to get out their message.

By contrast, the Catholic Diocese of Orange has been decrying the initiative at Masses throughout the county and registering new voters outside the churches.

Msgr. Jaime Soto, coordinator of the diocesan campaign to defeat Proposition 161, said: “I am aware some Catholics may feel differently about this, but we have received an overwhelming response from our parishioners in our efforts to organize against 161.”

One of his concerns, he said, is that the initiative’s supporters may elicit the support of people biased against the church.

“There is a deliberate attempt to slap this thing as a Catholic issue, to cash in on anti-Catholic sentiment,” he said, noting that opposition to the measure is broader reaching.

Jack Nichol, spokesman for Californians Against Human Suffering, which is campaigning for Proposition 161, admits that its efforts are limited by a shortage of funding and outgunned by the opposition.

“It is what you would call an invisible campaign by people who believe choice should exist at the end of life. We hope it can stand up against the bullying and intimidation of the Catholic Church,” Nichol said.

Some who mull over the pros and cons of Proposition 161 are having difficulty taking any stand.

Jim Lacy, a home health care nurse, said: “I feel that a person should have a right to choose his time of death. I feel that in my heart.”

But he said also that he sees shortcomings in the proposed law. And he said he doesn’t know many physicians who would agree to participate.

Lacy, who has lost 40 friends to AIDS, recalled how agonizing it was to instruct hospital personnel to honor his lover’s wishes to die rather than be placed on a ventilator. “It is very difficult to let go,” he said.

“I am really on the fence with this one,” Lacy said. “I probably won’t make up my mind until I walk into the polling booth.”

What Prop. 161 Would Do: Arguments For and Against

Proposition 161 provides a terminally ill, mentally competent adult the legal right to voluntarily request and receive a physician’s help to die. The act requires the signing of a witnessed, revocable directive in advance, and then requires a terminally ill patient to communicate his request to the treating physician on at least two occasions.

Safeguards, according to the Yes on Proposition 161 Committee, include:

* Terminal condition means an incurable or irreversible condition which will, in the opinion of two certifying physicians, result in death within six months or less.

* The act declares that it is a crime to pressure a patient to seek help to die because the patient is a financial, emotional or other burden to someone or to the state. It also is a crime to tamper with the directive of another.

* A legally aided death will not constitute suicide. So medical and life insurance companies may not deny benefits for that reason.

* Physicians who follow a patient’s directive will not be liable for prosecution or loss of license.

* No physician or facility will be forced to help a patient die if the party is morally or ethically opposed. But the party also cannot block the transfer of a patient to someone who will follow the patient’s request.

* The directive of a nursing home patient must be witnessed by a patient advocate or ombudsman designated by the California Department of Aging.

Shortcomings of the act, according to the No on 161 Committee, include:

* Although witnesses are required to sign a directive for aid in dying, which may occur years before it is put into effect, no witnesses are required for the final request or at the time of death.

* There is no waiting period between the request to die and the act itself, in which the patient could reconsider, overcome a temporary depression or receive counseling about the alternatives such as pain management and hospice care.

* The illness could be misdiagnosed.

* No professional requirements are set for the physicians who make the diagnosis or help the patient die.

* The act does not require that a person experience a certain level of pain and suffering before she requests help to die.

* The definition of terminal illness is vague and could be interpreted to include people with life-threatening ailments such as diabetes.

* The act does not require patients to receive a psychological evaluation.

Times staff writer Davan Maharaj contributed to this story.