Dead se­ri­ous

Los Angeles Times - - OPINION - This in­ter­view has been edited and con­densed. patt.mor­ri­son@la­times.com Twit­ter: @pattm­la­times

For decades, Cal­i­for­ni­ans have re­sisted mak­ing as­sisted sui­cide legal for the ter­mi­nally ill. Now an­other try, the End of Life Op­tion Act, is mak­ing its way through the Leg­is­la­ture. It has passed one com­mit­tee, been en­dorsed by U.S. Sen. Dianne Fe­in­stein, and was buoyed by the at­ten­tion paid to Brit­tany May­nard, who last year left her Cal­i­for­nia home for Ore­gon to carry out her own legal as­sisted sui­cide. Dr. Ken Mur­ray is a re­tired clin­i­cal as­sis­tant pro­fes­sor of fam­ily medicine at USC, whose touch­stone es­say on death, “How Doc­tors Die,” has ric­o­cheted around the In­ter­net since it was pub­lished in 2011 on the Zocalo Public Square web­site. I asked him to as­sess the law’s ethics and op­tions.

What should the Leg­is­la­ture’s role be in end-of-life de­ci­sions?

It’s the Leg­is­la­ture’s job to open the door [to legal as­sisted sui­cide] but pro­vide safe­guards for pa­tients who are ex­tremely vul­ner­a­ble.

It’s easy to see that some­one could be co­erced or guilt-rid­den into feel­ing they need to get them­selves out of the way. I find it very dis­taste­ful, but I have to ac­cept there’s some re­al­ity to this: In the era of HMOs, where sav­ing money [is] a pre­dom­i­nant thought, you could see in­cen­tives cre­ated to treat peo­ple with ter­mi­nal ill­nesses by as­sist­ing them in com­mit­ting sui­cide. You have to worry about that.

There are pro­vi­sions in SB 128, the Cal­i­for­nia bill, to pre­vent that kind of thing, though.

Hav­ing worked in a man­aged­care set­ting, there are sub­tle ways of pass­ing the mes­sage that don’t vi­o­late the let­ter of the law, where you get physi­cians un­der con­tract to un­der­stand that it’s to their ben­e­fit to have peo­ple who are ter­mi­nally ill go in this di­rec­tion. It’s scary to talk about this stuff, and even scarier to see it in prac­tice. It jus­ti­fi­ably scares peo­ple.

What kind of safe­guards do you en­dorse?

Be­ing that very small num­bers choose as­sisted sui­cide, we can af­ford to take ex­tra­or­di­nary safe­guards. The key thing is to have in­de­pen­dent over­sight. For ex­am­ple, you’re a man­aged-care pa­tient and want to do this — you would need a physi­cian out­side your HMO to eval­u­ate your sit­u­a­tion at its ex­pense. It’s not a new con­cept. When you get an in­de­pen­dent opin­ion, that elim­i­nates a lot of prob­lems.

Does the Cal­i­for­nia bill ad­dress your con­cerns?

The law is based on the Ore­gon model, so it con­tains both its virtues and flaws. One of the big­gest prob­lems is that the track­ing mech­a­nisms are pretty weak. It’s im­por­tant that we know what ac­tu­ally hap­pens; oth­er­wise we can’t be guided too well. Un­for­tu­nately, they don’t track what the out­comes are. The [Ore­gon] Depart­ment of Health is re­quired to pro­duce a re­port ev­ery year. How­ever, that re­port is[n’t] a public doc­u­ment.

I am hap­pier [with a law] passed by the Leg­is­la­ture than by ini­tia­tive [as Ore­gon’s was]. If there’s some ma­jor flaw, the Leg­is­la­ture can change the law. If there’s a prob­lem with an ini­tia­tive, the only way you can change it is through the ini­tia­tive process, so it be­comes ex­tremely dif­fi­cult to fix an er­ror.

There’s a ma­jor ef­fort by Com­pas­sion & Choices, the [right-todie] ad­vo­cacy group [sup­port­ing SB 128], to avoid the word “sui­cide” or “physi­cian-as­sisted sui­cide.”

Polling [finds] there’s about 50% ac­cep­tance when it’s de­scribed as physi­cian-as­sisted sui­cide, but when it’s de­scribed as “com­pas­sion­ate pass­ing” or “aid in dy­ing,” the ac­cep­tance rate goes to 65% or 68%.

We have to­day a process of help­ing peo­ple die, us­ing pal­lia­tive care and hospice medicine. Th­ese are highly ef­fec­tive, but the prob­lem is they’re not as widely avail­able as they could or should be, so a lot of peo­ple die with­out the aid of this ad­vanced form of health­care.

We could say we’re go­ing to make th­ese things avail­able ev­ery­where and help peo­ple — or we can help them com­mit sui­cide. Should I con­clude you’re not in fa­vor of this kind of leg­is­la­tion?

I strongly fa­vor the con­cept of a pa­tient be­ing able to make a self­de­ter­mi­na­tion if they want to end their life. Where I have a prob­lem is the physi­cian be­ing the agent of do­ing it.

For sev­eral thou­sand years, we have specif­i­cally pro­hib­ited physi­cians giv­ing peo­ple some­thing to kill them. I’m leery of dis­card­ing thou­sands of years of eth­i­cal think­ing with­out very care­ful thought. You don’t want to have con­flict­ing loy­al­ties. The loy­alty has to be to the pa­tient and the heal­ing process.

I have a com­pro­mise: There are a lot of peo­ple who can write pre­scrip­tions — physi­cians’ as­sis­tants, nurse prac­ti­tion­ers. Vet­eri­nar­i­ans can write ba­si­cally any pre­scrip­tions for their pa­tients; we could sim­ply change the law to al­low that pre­scrip­tion to be writ­ten by a vet­eri­nar­ian and we wouldn’t have that [physi­cian] op­po­si­tion. You would still have to go through the whole process; it’s just that the fi­nal pre­scrip­tion is writ­ten by a vet­eri­nar­ian, physi­cians’ as­sis­tant, any of those. I don’t think we’re go­ing to see that hap­pen, but I find it an in­trigu­ing con­cept.

What don’t peo­ple un­der­stand about mak­ing this choice?

They don’t un­der­stand that there’s al­ready an al­ter­na­tive that will get them to the same place, a tech­nique called vol­un­tary ces­sa­tion of nu­tri­tion and hy­dra­tion, where you don’t eat and drink.

Isn’t that a rough way to go com­pared to, say, an over­dose of mor­phine?

A large sur­vey of hospice nurses rated vol­un­tary ces­sa­tion as nine out of 10 in terms of qual­ity of death. And that’s my ex­pe­ri­ence. I’ve had a num­ber of pa­tients for whom nu­tri­tion and hy­dra­tion could not be given, or who re­fused it, and who died in a very peace­ful man­ner — one of the most gen­tle types of death I’ve ever seen.

Your 2011 es­say was about how physi­cians choose to die dif­fer­ently than other pa­tients. Would doc­tors choose stop­ping food and wa­ter?

I think most physi­cians would go the pal­lia­tive care and hospice route. Fifty years ago it was com­mon for physi­cians to have a stash of medicine set aside in case they came down with some­thing re­ally bad. It’s not com­mon now. Thank­fully, we’ve pro­gressed.

Could self-ad­min­is­tered deaths make dy­ing more an in­ti­mate, fam­ily event, less clin­i­cal?

That’s a fas­ci­nat­ing ques­tion. Ev­ery day I’ll hear about some fa­mous per­son dy­ing, at home sur­rounded by fam­ily. They’re usu­ally peo­ple of means who have more choices than the av­er­age per­son, and prob­a­bly more as­sertive­ness. But over the last 10 years we’ve seen a dou­bling in the use of hospice, and that’s a dra­matic change. There hasn’t been a con­comi­tant rise in the num­ber of peo­ple dy­ing at home, but we’re see­ing an in­creas­ing move to­ward the home en­vi­ron­ment. Most peo­ple want to die at home.

To what ex­tent are doc­tors will­ing to re­lin­quish “heroic mea­sures”?

It’s been a strug­gle. I think it has to do with the train­ing peo­ple re­ceive. Thirty-five, 40 years ago, we didn’t talk about this at all. In med­i­cal schools nowa­days, they do. When I’m in a doc­tor’s dining room and peo­ple are dis­cussing dif­fi­cult cases, this sort of thing gets talked about, where it didn’t years ago.

Are doc­tors mind­ful of pa­tients’ wishes?

The big prob­lem is get­ting peo­ple to ex­press their wishes. The trite say­ing is, it’s never the right time, un­til it’s too late.

When I first met pa­tients I would make it a habit to say, “Well, how do you want to die?” That gave me an en­tree to say that when the time comes and you’re re­ally sick, I’m go­ing to have to be the one to im­ple­ment what you want done, and how can I do that if I don’t know? Most would re­spond pos­i­tively.

Ge­naro Molina Los An­ge­les Times

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