Cancer case shows way to affirm a right to die

SAN DIEGO — Brittany Maynard was soon to die. The question was whether she could do so on her own terms, as a last act of autonomy. Dr. Lynette Cederquist, who regrets that Maynard had to move to Oregon in order to do so, is working with others to change California law to allow physician assistance in dying.

Maynard, a 29-year-old newlywed, knew that her brain cancer would fill her final months with excruciating headaches, seizures, paralysis, loss of eyesight and the ability to speak. Radiation and chemotherapy would have purchased mere months. “I’m not killing myself,” she said. “Cancer is killing me.” She would not put her loved ones through her cancer’s depredations.

Advances in public health and medical capabilities for prolonging life — and dying — intensify interest in end-of-life issues. Reductions in heart disease and stroke have increased the number of people living to experience decrepitude’s encroachments, including dementia.

“Dementia,” Cederquist says, “is a whole different dilemma.” Assisted suicide perhaps should be allowed only when survival is estimated at six months or less, but at that time persons suffering dementia have lost decisional capacity.

Physician-assisted dying has been done surreptitiously “as long as we have been practicing medicine,” says Cederquist, professor of internal medicine at the University of California, San Diego. Today, even in the 46 states without physicianassisted dying, doctors may legally offer “terminal sedation” — say, a life-shortening dose of morphine — when intense physical suffering cannot otherwise be satisfactorily alleviated. Some Catholic and other ethicists endorse a “double effect” standard: If the intent is to alleviate suffering but a consequence is death, the intent justifies the act.

Cederquist says the most common reason for requesting assistance in dying is not “intolerable physical suffering.” Rather, it is “existential suffering,” including “loss of meaning,” as from the ability to relate to others. The prospect of being “unable to interact” can be as intolerable as physical suffering, and cannot be alleviated by hospice or other palliative care.

In some countries, doctors actively administer lethal injections. No U.S. jurisdiction allows doctors to go beyond writing prescriptions for life-ending drugs to be self-administered orally by persons retaining decisional capacity.

Almost 30 percent of Medicare expenditures are for patients in the last six months of life and about 16 percent of patients die in, or soon after leaving, intensive care units. Financial reasons should not be decisive in setting end-of-life policy, but Cederquist notes that reducing “expensive and inappropriate care” — costly and agonizing resistance to imminent death — “is the lowest-tech thing we can do in medicine.” Hence the importance of “slow medicine geriatrics,” avoiding a “rush to those interventions that build on each other” and thereby enmesh doctors and patients in ethical conundrums.

The American Medical Association remains opposed to physician assistance in dying; the California Medical Association has moved from opposition to neutrality. Litigation has been unsuccessful in seeking judicial affirmation of a right that California’s Legislature should establish. Legislation to do this has been authored by Assemblywoman Susan Eggman, chair of the Democratic caucus.

There are reasons for wariness. An illness’s six-month trajectory can be uncertain. A right to die can become a felt obligation, particularly among bewildered persons tangled in the toils of medical technologies, or persons with meager family resources. And as a reason for ending life, mental suffering itself calls into question the existence of the requisite decisional competence.

Today’s culture of casual death (see the Planned Parenthood videos) should deepen worries about a slippery slope from physicianassisted dying to a further diminution of life’s sanctity. Life, however, is inevitably lived on multiple slippery slopes: Taxation could become confiscation, police could become instruments of oppression, public education could become indoctrination, etc. Everywhere and always, civilization depends on the drawing of intelligent distinctions.

Jennifer Glass, a Californian who died Aug. 11, drew one. She said to her state legislators, “I’m doing everything I can to extend my life. No one should have the right to prolong my death.”

The Economist reports that in the 17 years under Oregon’s pioneering 1997 law, just 1,327 people have received prescriptions for lethal medications — about 74 a year — and one-third of those did not use them. Possessing the option was sufficient reassurance.

There is nobility in suffering bravely borne, but also in affirming at the end the distinctive human dignity of autonomous choice. Brittany Maynard, who chose to be with loved ones when she self-administered her lethal medications, was asleep in five minutes and soon dead.