Physician Assisted Dying


Physician Assisted Dying

Voltaire’s "The best is enemy of the good" is a common aphorism in ethical discourse. It is an appropriate response to millenarian insistence on perfection, while scorning partial and gradual advances. And it is the appropriate response to the final observation of Stephanie Levy in her talk "Ethical Considerations in Physician Assisted Dying."

Ms Levy noted that her one serious reservation as to physician assisted dying (PAD) was that it would be managed by physicians—who had so notably messed up the entire end-of-life palliative care situation in America. Yes—there are serious deficiencies in EOL palliative care today. But PAD is ultimately a type of palliative care. Why not achieve some modest advance in that area, along with a major drive on improving palliative care generally? After all, to indulge in another settled aphorism, "Something is better than nothing."

Again, in many if not most cases the physician, while a necessary agent, is not the controlling one as to PAD. PAD liberates the patient and family from the constraints of physicians and hospitals. The patient can direct that she be discharged from hospital, nursing home or hospice. (An overwhelming number of those using PAD in Oregon have previously been in hospice but found it insufficient.)

If PAD be appropriate, a helpful physician can be found to make the finding of appropriateness and write the necessary prescription. The patient can thus die at home, surrounded by family and friends, flowers, loved music, art, pets and books. And liberated from institutional constraints. PAD returns the dying process to the dying person and her family—where it belongs. Thus it is mistaken to characterize PAD as run by physicians.

Again, Esther Barcun’s objection is also misplaced. Esther argued that with there being such signal deficits in EOL palliative care in America today, the campaign for PAD was in substance a distraction: we should instead focus on the main problem: better palliative care.

This is a false dilemma. Nothing precludes us from doing both. And though in some sense PAD is in fact a small problem (when contrasted, for instance, with AIDS in Africa) for those facing intractable pain and suffering it is a toweringly huge one. If we claim to respect the worth of each individual, we are called upon to respond to those intractably suffering human beings who beg for PAD—however few they may be.

And if the problem be small, unlike AIDS it is one that is simply and easily solved: enact a Death with Dignity Act along the lines of Oregon’s.

And if the Oregon experience be examined, this will have the collateral effect of improving palliative care generally (!). Since the Death with Dignity Act requires the physician certifying as to terminality, etc. carefully to explain to the dying patient all alternatives open, physicians in Oregon had to become knowledgeable in EOL care. Hospitals and medical societies responded with seminars and courses. Today Oregon is acknowledged as the leader in EOL care, with more people dying at home (about two-thirds, the reciprocal of our situation in the East) and in hospice and higher levels of EOL morphine usage than in any other state.

At the practical level the drive for PAD achieves not alone freedom for the dying who choose it, but a higher level of palliative care for all of the dying—even those who most fervently oppose it.

The objections to PAD are misplaced. PAD respects the worth and dignity of the dying. PAD gets government off our backs and our beds. PAD hands dying back to the dying and their families.

This essay was written by Winthrop Thies, former President of The Hemlock Society of New Jersey (the predecessor organization to Compassion and Choices of New Jersey, Inc.).