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Death with Pitfalls

According to a Field Poll in March, 70% of Californians favor physician-assisted suicide and 68% would want the option available to them if they had less than six months to live — at least in the abstract — when they’re healthy.

Support for such proposals fades when people consider the pitfalls, trade-offs and details of specific proposals. California’s prior “Death with Dignity” proposition started out with similar popular support but went down to a 54-46 defeat in 1992.

You’ve probably already heard most of the arguments in favor of Physician-Assisted Suicide — mercy killing, individual rights, “compassion.” However, people already have this “right.” Suicide is not illegal. The question is how easy and how legal should it be? And under what circumstances?

In theory physician-assisted suicide is intended to be compassionate, to alleviate suffering. No matter where you stand, you’ll have to concede that death, from whatever cause, is the end of suffering.

Now comes California’s latest physician-assisted suicide bill, AB654, the “California Compassionate Choices Act,” introduced by our assemblywoman, Patty Berg of Eureka.

Some of AB654’s general pitfalls are:

The bill says a person must have been diagnosed as terminal with less than six months to live to receive the lethal phenobarbital. But people can be and are misdiagnosed as terminal. In addition, many doctors admit to difficulty in assigning a specific time to a terminal condition.

The bill calls for patients to make an informed decision (twice) witnessed by two others, at least 15 days apart. In reality, many people with terminal conditions suffer suicidal thoughts when they first are diagnosed, but later recover, then go through ups and downs.

There’s no guarantee that the limited “safeguards” in the bill will be followed, especially in typical and common hospice care situations where the family is the primary caregiver.

We’d all like to think that family members of a terminal patient always have the patient’s best interest at heart. As ideal as that may sound, there are times when it’s just not the case. Families are complicated and can be contentious, especially under the stressful conditions associated with terminally ill family members. Motivations can range from altruistic to nefarious.

Which brings us to two uncomfortable issues specifically mentioned in AB654: coercion and insurance.

In the original draft of Ms. Berg’s bill there was the following provision:

“A person who coerces or exerts undue influence on a patient to request medication for the purpose of ending the patient’s life, or to destroy a rescission of such a request, shall be guilty of a felony.”

In the latest version of the bill that provision has been removed. No explanation was given. (Maybe because proving a felony isn’t that easy.) All that remains is a requirement that the patient sign a statement saying they are not being coerced.

Coercion and “undue influence” are hard enough to define in ordinary discourse, much less as a legal standard. What if the patient is told that they’re continued healthcare and medication is going to cost more than the family can afford? Is that “undue influence”?

What if the patient’s life insurance benefits will help another family member’s desperate financial problems? Would reminding the patient of that be “undue influence”? Are these the kinds of factors terminally ill people should consider?

What if the patient’s HMO tells the patient that their costly pain medication is not covered under their health insurance plan?

According to Ms. Berg’s bill, “suicide” by legal deadly prescription is not supposed to affect a patient’s life insurance. But Oregon’s assisted suicide website informs visitors that such coverage questions are up to the insurance carrier.

Oregon’s physician-assisted suicide website gives the following subjective and qualitative reasons that the 208 people who have used the law since its enactment in 1997 have given:

Losing autonomy (87%);

less able to engage in activities making life enjoyable (84%);

loss of dignity (80%);

losing control of bodily functions (59%);

burden on family, friends/caregivers (36%);

inadequate pain control or concern about it (22%);

financial implications of treatment (3%).

However, there’s no indication of when these “concerns” were expressed. Were they expressed when the person first asked for the phenobarbital, or were they expressed on the day the medication was taken?

Most of the terminal Oregonians using the law had cancer (more than 80%). Only five had AIDS.

But only 208 have used Oregon’s landmark assisted-suicide law in its first seven years. You can’t draw many conclusions from such low numbers. In fact, why go to such legal trouble and take so many risks in law if so few people are going to “benefit” from it?

Oregon doesn’t report on how many people applied for the lethal dosages, but changed their mind — only on actual suicides.

Then there are the doctors who are expected to prescribe the lethal dose.

A survey of Oregon physicians who did NOT oppose physician assisted suicide revealed the following concerns:

Half feared the attempt might fail and result in harm to the patient. (No information is kept/reported on this in Oregon.)

Half were not confident they could predict when a patient had less than six months to live. (And how can you know if the person commits suicide before the six months?)

One-third feared someone other than the patient would take the medication.

One-third were not confident they could recognize depression. (And what if the psychologist/psychiatrist determines the applicant is depressed and turns down the prescription?)

Some did not want to become known as “suicide doctors.”

Then there’s the Hippocratic Oath: “…Neither will I administer a poison to anybody when asked to do so, nor will I suggest such a course.” (Modern translation.) Can doctors ethically prescribe deadly doses? Can they be asked to do so?

Two American studies have shown that, among the elderly, those most vulnerable to the abuse of physician-assisted suicide — women, blacks, low-income people and poorly-educated people — fear the legalization of physician-assisted suicide.

More and more Americans who lack access to decent healthcare and support may be pushed into assisted death. In fact, assisted death can become a cost-containment strategy. (Texas’s “futile care” law which was signed into law by then-Governor George W. Bush specifically allows hospitals to declare patients hopelessly ill and in effect not worth keeping alive, irrespective of the patient’s and the family’s wishes.) Burdened family members and healthcare providers may encourage the option of “legal” assisted death — short of “undue influence,” of course.

In fact, it has been reported that some California hospitals have already set up committees to decide when care is “futile” and should be terminated regardless of a patient’s or a family’s wishes. There are disturbing stories of patients whose deaths have been hastened by these practices. Given the current and declining healthcare system, no law legalizing physician-assisted suicide, no matter how carefully crafted, can operate fairly.

Do we really want to take all these risks just so that a few terminal people can solve problems like being “less able to engage in activities making life enjoyable”?

MARK SCARAMELLA is the managing editor of the Anderson Valley Advertiser and a frequent contributor to CounterPunch. He can be reached at: themaj@pacific.net

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More articles by:

MARK SCARAMELLA is the Managing Editor of the Anderson Valley Advertiser in Mendocino County, California. (www.theava.com). He can be reached at themaj@pacific.net.

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