Doctors Divided Over End of Ban on Aided Suicide

TIMES MEDICAL WRITER

The landmark federal court ruling lifting the ban on physician-assisted suicide was hailed by many physicians Thursday for granting terminally ill patients much-needed control over their fate. But it also revealed deep divisions within the healing profession, with some doctors worrying that it might touch off a wave of unnecessary and perhaps grisly suicides abetted in the name of mercy.

"Doctors are not in the business of speeding people on their way out of their lives," said Dr. Jack Lewin, chief executive of the California Medical Assn., which opposes physician-assisted suicide.

"This act has a tremendous potential for abuse," he said. "In today's for-profit health care world, one could imagine in the future a corporation wanting to save money on hospital beds by hastening a patient's death."

At the heart of Wednesday's ruling by the U.S. 9th Circuit Court of Appeals, which was prompted by a challenge to the state of Washington's ban on physician-assisted suicides, was an observation that few doctors dispute: Far from always easing suffering, high-tech medicine seems increasingly to plunge gravely ill people into a sort of dark tunnel of futile care with no exit.

By holding that "a competent, terminally ill adult . . . has a strong liberty interest in choosing a dignified and humane death," the court has given great new impetus to death-with-dignity measures by arguing that they are protected by a constitutional right to personal liberty.

Still, the ruling does not automatically render physician-assisted suicide legal. It is likely to be challenged, with the Supreme Court having the final word, legal experts say. And even doctors who have hesitated to provide such assistance out of fear of penalty are expected to wait until states and medical licensing boards draw up guidelines regulating the practice.

In California, no such professional or legal guidelines are currently in place.

The controversy concerns how doctors should usher sick people through their last days. Some see physician-assisted suicide--in which a doctor prescribes lethal drugs to a mentally competent adult with a certifiable terminal illness--as merely a logical extension of their practice.

"This is a medical procedure," said Dr. Lonny Shavelson, a board member of the San Mateo-based advocacy group Death With Dignity. "It should be regulated very carefully like other medical procedures." He added that the ruling should make doctors confronting the dilemma feel "easier" about helping dying patients end their lives.

Many doctors were ambivalent about the ruling, saying they were glad to have the issue so prominently debated but also concerned that doctors do not know enough about how to perform the task adequately.

That was reflected in a survey of Oregon physicians published last month in the New England Journal of Medicine. Although 60% of those surveyed were in favor of legalizing assisted suicide, more than half of them said they were not sure they could rule out the possibility that a patient's request to die reflected depression, which may be treatable.

And half of those in favor said they would not know which drugs to prescribe to help patients end their lives, raising the specter of botched suicides. "I'm concerned that there will be a number of bungled attempts," said Dr. Miles Edwards, an ethicist and emeritus professor of medicine at the Oregon Health Sciences University. "What do you do then? What does an emergency room physician do if someone comes in comatose? Resuscitate him? Should he back off?"

Another potential problem that lawmakers will have to grapple with is that patients may be subtly coerced into ending their lives by physicians, hospitals, even family members.

"Most of the time when it comes up, it's the doctor who initiates the discussion," said Dr. Leslie Blackhall, medical director of Assisted Home Hospice, a health care service in Thousand Oaks, who has studied end-of-life issues. "I don't doubt that these decisions will be driven by health care professionals."

Most ominous, numerous doctors said, is the possibility that facilitated suicide might someday be viewed as a cost-cutting measure. "I'm sure there will be pressure from the business side" to turn to physician-assisted suicide, said Dr. Victor Dorodny, president of the Pacific division of the National Assn. of Managed Care Physicians. "Something like 70% of expenditures occur in the last six months of life."

Dr. Linda Emanuel is an internist at Massachusetts General Hospital and an incoming vice president of the ethics standards committee of the American Medical Assn., which opposes physician-assisted suicide. She said that all of the patients who have asked for her help in committing suicide have later withdrawn the request once she discussed with them other options, such as aggressive pain management. "Once they understood that I was not about to abandon them, and that there were [natural] ways of dying that were not burdensome or painful," they changed their minds.

Blackhall said: "There are people who say they want to die. If you probe them, you find out they're in pain. But if you control their pain, they say, 'Well, maybe I'll go out in the garden today.' Life starts to look a little better. The request for suicide is usually a request for help."

Ironically, Shavelson, who applauded the new ruling, speculated that physician-assisted suicide, which is today practiced in secret, may become less common if it's legalized. He recalled a patient with an inoperable brain tumor whose ability to swallow was fast disappearing. She killed herself by swallowing morphine pills while she still could.

Shavelson said that if she had been able to trust that a physician was ready to help her in the end, "She would have had a better chance at a natural death."

"The most significant thing we can offer patients," he said, "is the reassurance that no matter what, they'll be OK."

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