Making the case: Allow the terminally ill to control their own death

The undersigned are physicians, attorneys and professors of philosophy who address issues of medical ethics in our work. Our field of interest is known as bioethics. We study, write, advise and teach on the ethics of various medical options at the end of life. We consider enabling a mentally competent, terminally ill patient to determine the circumstances of his or her imminent death to be ethically sound and write in support of the California Compassionate Choices Act, AB 374.

A physician’s ongoing medical care for an alert, terminally ill patient appropriately includes assistance in enabling a terminally ill patient to manage the time and manner of death. Such assistance is part of a continuum of humane medical care that begins with efforts to cure, then transitions to a focus on alleviation of symptoms and, when neither of these objectives remains attainable, proceeds to provide the patient who so wishes with autonomy over how death is encountered. Empowering a competent dying patient with the power to determine time and manner of death is integral to effective end-of-life medical care for patients who seek such control, in the view of an emerging majority of physicians practicing in the United States today.

Oregon’s Death With Dignity Act, now in effect for more than seven years, enables a mentally competent, terminally ill patient, after advice regarding the availability of palliative care, two oral requests, a written request, a psychological examination by two physicians, and a waiting period to obtain a prescription for medicine to enable the patient to control the time and manner of death.

The Oregon statute’s procedural protections have proved effective. The record, available as a result of the statute’s extensive reporting requirements, establishes that the law provides a welcome option for a small number of terminally ill Oregonians. Relatively few patients seek prescriptions under the statute: Last year, 60 patients obtained prescriptions. Seven years into its existence, the statute provides an option of last resort for a few patients, one utilized with care and thought.

Fears about intimidation of patients and abuse of the underprivileged have proved unfounded.

Up to one-third of the patients who obtain the medications never use them, a figure that suggests the absence of patient intimidation. Patients who seek prescriptions are on average better educated and more well-to-do than the average Oregonian, reflecting that the law is not imposed on the state’s most vulnerable citizens.

There is evidence that the statute provides considerable comfort and unanticipated benefits, including improved psychological and palliative care for all terminally ill. In addition, the statute protects against certain dangers, including the underground and unregulated practice of physician assistance in death. The statute also deters some desperate patients from resorting to violent and painful acts of self-destruction, without medical help, in order to preclude survival at the end of life in a condition that the patient considers unbearable. The Oregon statute is thus a reasonable medical and social response to difficult end-of-life circumstances faced by some terminally ill patients. It is working as the people of Oregon intended and poses no threat to their health or safety.

The CCCA would do the same for Californians.

For patients with certain prognoses, palliative care and the ability to refuse treatment do not address their concerns about their final days. Some face a process of dying that includes extensive suffering involving progressive and inexorable loss of bodily function and autonomy, pain, nausea, shortness of breath, debilitating fatigue and loss of ability to interact meaningfully with others. Some find this prospect unbearable and an affront to their values, beliefs, integrity and personhood. Increasingly, the medical profession and the public have come to consider it appropriate to offer these patients who would so choose a humane escape from a protracted dying process of this nature.

The question, we believe, is: “Are we a society sufficiently compassionate to allow the choice of a hastened death to terminally ill, competent patients who are receiving state-of-the-art end-of-life care but are still suffering?” The undersigned bioethicists urge that California be such a compassionate society and that the CCCA be enacted. Thank you for considering our views on this important matter.

C. Ronald Koons, MD, is chairman of the Ethics Committee at the UC Irvine Medical Center. He was assisted in this article by Judith F. Daar, professor of law; Albert Flores, PhD; Jerome S. Tobis, MD; W. Noel Keyes, professor of law emeritus; and Elena Bezzubova, assistant clinical professor.

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