Go slow on doctor-assisted suicide
This month, New York’s highest court struck a blow to those seeking the right to obtain medical aid in dying in the context of terminal illness. It dismissed a case initiated in 2015 by three terminally ill patients requesting the legal right to receive the lethal medications from their doctors.
The ruling, foreclosing the possibility of establishing this right through judicial fiat, will give new momentum to an ongoing legislative effort.
I’m a California physician. Last June, my state became the fourth in the country to pass a Medical Aid in Dying (MAiD) law. This allows patients with a terminal illness who meet certain criteria to receive lethal medications from their doctors. Given that we are now in the second year of implementing such a law, I’d like to offer some insights that might be helpful to New Yorkers as you consider this weighty option.
California’s bill was introduced on the heels of the death of Brittany Maynard. Dying of brain cancer, this young woman elected to move from California to Oregon, where she could legally access MAiD under that state’s Death With Dignity Act. This very public and dramatic story reenergized a longtime advocacy effort in California, and the law was signed by our governor within a year of her death.
But many physicians felt uncomfortable, including myself. It is not that we don’t support the idea, it’s just that it all happened so fast. We weren’t prepared.
Ideally, we would have had a period of open public debate, stakeholder outreach and professional education and training before passing a law with such serious ethical ramifications and the potential to harm. And we would have created a wellthought-out infrastructure to support patients, as well as the physicians who are called on to respond to these requests.
Instead, many physicians and health care systems scrambled during the first year to decide if and how they were willing to participate. Given the moral gravity of this procedure, ample preparatory thought and infrastructure are essential to its successful implementation.
New York, you still have time to do this work.
There are many things to consider, starting with the procedures for managing a patient with this request, and determining which providers are willing to participate. In my first encounter with a patient requesting MAiD — a mere three months after the bill was passed — I was profoundly ambivalent and thoroughly unprepared.
Although a majority of California physicians support the law, we are not required to participate and vary greatly in our willingness to do so. I have heard anecdotal reports of patients unable to find a doctor to provide them with the lethal drugs, and there is now a case alleging that a medical center in San Francisco misled a patient about its willingness to help her die, creating stress and suffering in her final days.
Access to the option aside, there is also variable medical care for patients requesting this intervention. The response should never simply be the writing of a prescription, but rather include ongoing access to a range of services. Participating physicians must be trained and guided by carefully crafted protocols and procedures.
And ideally, it’s not just doctors responsible for this care. UCLA Healthcare Center has created an exemplary program. There, patients requesting MAiD are offered a broad range of interdisciplinary services — psychological, palliative, spiritual and social — in order to alleviate any treatable sources of suffering. And only 25% of the initially requesting patients actually ingest the medication, a lower percentage than I have seen reported anywhere else.
Unfortunately, this excellent care is not accessible to most patients approaching the end of life, whether requesting MAiD or not. Data demonstrate a dearth of good medical care for the dying in our country.
Death is overmedicalized, with attention primarily paid to the function of individual organs rather than the overall needs of the patient and her family. Thus too many are dying on machines, in pain, their families bewildered and suffering at the bedside.
We don’t want to run the risk of Medical Aid in Dying being widely embraced as an easy option simply because end-of-life care is subpar.
New York, you still have time to lay the groundwork for the potential passage of MAiD. You can ensure excellent and accessible care is provided for those patients suffering enough to make this request.
But there is another lesson to be learned from the rising public demand for this right. Patients feel out of control when it comes to the dying process in this country. Let’s use this legislation as an opportunity to ensure we better meet this population’s needs through skillful communication and patient-centered treatment.
As a doctor, it is my wish that the last few years of life for all patients, not just those seeking a physician’s help to die, is highquality and patient-centered, with ample attention paid to personal needs.