Medical Statements Against Assisted Suicide

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Medical Statements
Opposing Assisted Suicide

 

by Top Institutions,
Societies  & Medical Doctors


Statements repeatedly share similar concerns and arguments against
physician assisted suicide.

Go To….
.. Paper: Physicians’ Perspective, by Sloan Kettering, NY Medical, etc
.. A Position Statement, by AMA & 600 Oncologists
.. Dr. Mandelkern, St. Raphael-CT, On Psych Help Prior to all Suicides
.. OHSU, Netherlands, Suicide Law Overlooks the Depressed
.. AMA: Suicide – Not a Helpful or Necessary Alternative to Palliative Care
.. Dr. Honkanen, Geriatrician, NY, On Risks to Doctor Trust and Patients
.. Healthcare VP: A Suicide Option Interferes with Quality Care
.. National Cancer Inst – Damage When a 6-Month Prognosis is Wrong
.. Dr. Stevens, Oregon, Warns Us of Assisted Suicide Corruption
.. Dr. Hafer, Oregon — A Suicide Option is “A Recipe for Elder Abuse”
.. Dr. Reichel, Oregon, “Abuses are Inevitable with Assisted Suicide”
.. Dr. Bentz, Oregon, 2nd Doctor Opinions – Have Been Ignored
.. Nurse Valko: Legalized Suicide will increase suicide rates as in Oregon.
.. Dr.Toffler, Oregon, Elders May be Coerced by Family and Helped to Die
.. Dr. Kebbe, St. Raphael-CT, Doctors are to cure and relieve – not to kill


Physician Assisted Suicide In Oregon – Paper: A Physicians’ Perspective

Sponsors: Sloan Kettering Cancer Center, Suicide Prevention International NY Medical College; by:

  • Herbert Hendin, CEO and Medical Dir, Suicide Prevention International; Prof of Psychiatry, NY Medical College
  • Kathleen Foley, Attending Neurologist, Memorial Sloan-Kettering Cancer Center, Prof. of Neurology, Neuroscience, and Clinical Pharmacology, Weill Medical College of Cornell Unv; Medical Dir., International Palliative Care Initiative of the Open Society Institute.

[Note:  This paper discusses how safeguards are ignored.  For example, the two-doctor approach does not safeguard patients.  A case is given where the opinion of the first two doctors, who did not approve the patient for PAS, were ignored by the patient’s husband who shopped for another doctor.  The paper also points out how doctors, who are aligned with the staff and promoters of physician assisted suicide, circumvented the requirement to present alternatives to PAS.  Lastly, it shares that pain management of terminal patients has degraded since the Oregon PAS law was enacted.   It is one of the more alarming testimonies — by very reputable experts.]

http://www.michiganlawreview.org/assets/pdfs/106/8/hendinfoley.pdf

…Since the passage of Oregon’s Death with Dignity Act, however, various sources – patients, families, healthcare professionals, physicians, nurses, social workers, chaplains, and advocacy groups – have supplied more detailed information  that suggests that the implementation of the law has had unintended, harmful consequences for patients.

The Oregon law seems to require reasonable safeguards regarding the care of patients near the end of life, which include presenting patients with the option for palliative care;

  • ensuring that patients are competent to make end of life decisions for themselves;
  • limiting the procedure to patients who are terminally ill; * ensuring the voluntary nature of the request (no coercion);
  • obtaining a second opinion on the case,
  • requiring the request to be persistent, ie, made a second time after a two week interval;
  • encouraging the involvement of the next of kin; and
  • requiring physicians to inform OPHED of all cases in which  they have written a prescription for the purpose of assisted suicide.

The evidence strongly suggests that these safeguards are being circumvented in ways that are harmful to patients. …..

OPHD has been issuing annual reports declaring that terminally ill Oregon patients are receiving adequate care.  The available evidence, which we will present in this Article, suggests otherwise….

The unintended consequence of this provision is that it enables physicians to assist in suicide without inquiring into the source of the medical, psychological, social, and existential concerns that usually underlie requests for assisted suicide, even though this type of inquiry produces the kind of discussion that often leads to relief for patients and makes assisted suicide seem unnecessary.

When a terminally ill Oregon patient makes a request for assisted suicide, physicians are required to indicate that palliative care and hospice care are feasible alternatives. 

They are not required however to be knowledgeable about how to relieve physical or emotion  suffering in …without such knowledge, which most physicians do not have, they cannot present or make feasible alternatives available.  Nor in the absence of such knowledge are they required to refer the patient to a physician with expertise in palliative care.

In the absence of adequate monitoring, the focus shifts away from relieving the distress of dying patients considering a hastened death to meeting the statutory requirements for assisted suicide.

Physicians can merely go through the motions of presenting the possibility of palliative care for their patients.  How this happens is suggested by a case which was publicized by Compassion in Dying (now Compassion and Choices), an advocacy group which promotes legalized PAS, as the first case of assisted suicide under Oregon law.

The first case:  Helen

Helen’s own physician had refused to assist her in her suicide for unspecified reasons.  A second physician refused on grounds that Helen was depressed. Helen’s husband then called Compassion in Dying (note from Eileen –  this is the organization that promote physician assisted suicide and manages it, on a consulting basis in hospitals) and was referred to a physician who would assist her.  The medical director of Compassion in Dying said that he had spoken by phone with Helen at the time of the referral and also spoke by phone to her son and daughter.  He described Helen as “rational, determined and steadfast”…The physician who agreed to prescribe the medication had met Helen two and a half weeks before she died and described her as having more discomfort than Compassion in Dying had indicated.  He said that after 20 years, the cancer had spread to her lungs, causing some pain and shortness of breath.  He followed a protocol that included an anti-nausea medication that Helen had taken before he arrived to be with her and her family when she died.  She then took a mixture of barbiturates (nine grams) and syrup followed by a glass of brandy.  She is said to have died within 30 minutes.

Helen’s case was presented by Compassion in Dying as an example of how well the Oregon law is being implemented.  ..Contrary to their expectations, their presentation would raise troubling questions.

The physicians who evaluated Helen offered two contradictory sets of opinions about the appropriatness of her decision.

In the taped interview with Helen, the prescribing doctor told her that it is important she understand that there are other choices she could make that he will list for her, and in three sentences covering hospice, chemotheraphy, and hormonal therapy.

….subsequently he wrote an article for the British journal Lancet, in which he stated that he liked Helen immediately.  He continued:  The thought of Helen dying so soon as almost too much to bear….One the other hand, I found even worse the thought of disappointing this family.  If I backed out, they’d feel about me the way they had about their previous doctor, that I had strung them along, and in a way, insulted them.

Neither reluctance to disappoint her family nor embarrassment at backing out should have been such a significant factor in the decision to end her life.

D. The Palliative Care Alternative

The difference it makes if a cancer patient is seen by someone who has experience in providing palliative care is suggested by the following excerpt from a letter written by a practicing oncologist in response to the law:

As a practicing gynocologic oncologist in Portland Oregon, where physician assisted suicide is legal, I informed patients of my views by having a clear statement, based on the Hippocratic Oath posted in my waiting room.  This reassured most patients, however, I had two patients who objected.  The first was afraid that I would prolong her life beyond her wishes.  This conversation helped me to meet her needs and she had a peaceful, comfortable death at home with her family.  The second patient wanted me to prescribe lethal medications in case her cancer pain became unbearable.  Prior to this conversation, she had been minimizing her pain.

This conversation allowed us to work together to better control her pain, after which her desire for assisted suicide disappeared.  She died comfortably and naturally two months later.

The OPHD’s yearly progress reports contend that patients who requested assisted suicide were receiving adequate end of life care, citing the frequency with which patients were in hospice care as evidence.  However, a referral to hospice care cannot be regarded as a substantive palliative care intervention without knowing what care the hospice provided.

Moreover, available data contradicts the OPHDs contention of adequate care.

A Study at the Oregon Health & Science Unv indicated that there has been a greater percentage of cases of inadequately treated pain in terminally ill patients since the Oregon law went into effect….

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Position Statement on Physician-Assisted Suicide and Opposition to AB 374

Association of Northern California Oncologists & Medical Oncology Association of Southern California
California Medical Association
American Medical Association
American College of Physicians
April 16, 2007
http://dredf.org/assisted_suicide/Oncology%20Statement%20on%20AB%20374%20(Berg).pdf

[Note: This article offers strong protests against physician assisted suicide by a number of well-respected medical associations.  They point out that most patients requesting physician-assisted suicide or euthanasia do not ask because of physical symptoms such as pain, but for quality of life reasons.  Yet, these patients are not automatically referred for psychological or psychiatric treatment to help them. They also point to weaknesses of the law that create opportunities for vulnerable patients to be coerced or involuntarily killed such as not requiring a physician to be there at the time of death.  Another tragic consequence of this law that is discussed here is patients taking up to 48 hours to die after ingesting the lethal dose.  The doctors who wrote this speculate on the high level of suffering that some patients might have experienced  –  suffering much worse than the disease.  Also mentioned is that doctors often misdiagnose diseases and time to live.  On time to live, they say doctors are more often wrong than right.  They wonder how many patients may have given up treatment that could have cured or prolonged their life based on an inaccurate prognosis.]

The Association of Northern California Oncologists and the Medical Oncology Association of Southern California, which together represent nearly 600 oncologists in both community practice and academic medicine, oppose the legalization of physician-assisted suicide (PAS) and urge Assembly Members to vote NO on AB 374.

Physician-assisted suicide is the wrong answer to the right question. The Oregon “Death with Dignity Act” and AB 374 alleges to focus on patient autonomy, but the focus should be on doing everything we can to improve care at the end of life. The right answer to the question is that the dying need competent medical treatment, and that is best accomplished by the learned and timely application of hospice care and palliative medicine.

Legalizing physician-assisted suicide strikes at the heart of what we do as physicians and adds ambiguity to the physician-patient relationship. The physician’s primary directive is to first, do no harm. Physician-assisted suicide destroys the trust between the patient and doctor. Under the pretense of providing compassion, the physician is relieved of his or her primary responsibility to the patient – to safeguard life and to provide comfort to the suffering. It is the ultimate patient abandonment.

Oncologists are painfully aware of our own limitations in providing optimal palliative care in every situation.

We also recognize that most members of the public, as well as many physicians in other specialties who do not treat dying patients with any regularity, do not see what we see every day in our practices. We believe that far fewer physicians would support the concept of physician-assisted suicide if they had the specific training and experience that oncologists have in dealing with these types of patients and these diagnoses.

We know that cases of patients experiencing intractable physical symptoms at the end of life do exist, but this is not a justification for aid in dying. We need more research and education, not patient termination.

In this debate, it is critical to recognize that, contrary to belief, most patients requesting physician-assisted suicide or euthanasia do not do so because of physical symptoms such as pain or nausea. Rather, depression, psychological distress, and fear of loss of control are identified as the key end of life issues.

This has been borne out in numerous studies and reports. For example,in a survey of 100 terminally ill cancer patients in a palliative care program in Edmonton, Canada, a multivariate analysis showed no correlation between physical symptoms of pain, nausea, or loss of appetite and the patient’s expressed desire or support for euthanasia/PAS. Moreover, in the same study, patients demonstrating suicidal ideation were much more likely to be suffering from depression or anxiety, but not somatic symptoms such as pain.1

An important study from the Netherlands of a cohort of 138 cancer patients with a life expectancy of three months or less demonstrated similar findings.2 In this study, the authors had hypothesized that patients requesting euthanasia would be unlikely to have depressed mood or affect, since it would be expected that such a request would be a well-thought out decision, particularly since euthanasia has been legal in the Netherlands since 2002. The authors expected that these patients would be more accepting of their terminal diagnosis and therefore better adjusted. What they found surprised them – depressed patients were more than four times as likely to request euthanasia as patients who were not depressed.

Over 40% of depressed patients requested euthanasia, and of those who requested euthanasia, about half were depressed. Prominent bio-ethicist  Ezekiel Emanuel of the National Institutes of Health has written eloquently on this “depression thesis” in regards to euthanasia and PAS and notes requests for [euthanasia and PAS] tend to be guided by psychological distress rather than rational choices about a good death.

This conclusion should be especially worrisome given that approximately 15% to 25% of cancer patients are depressed, and approximately 80% of requests for euthanasia or PAS come from cancer patients. When the depression thesis is juxtaposed with epidemiologic data demonstrating that, in general, suicide is approximately 30% to 50% more likely among cancer patients and that depression is a primary motivation for suicide, euthanasia and PAS looks more like a method of acting on suicidal ideation than a type of termination of medical treatment.3

Depression and psychological distress are prevalent disorders in terminally ill patients and need to be sought out and aggressively treated. These can be difficult conversations between physicians and patients at the end of life, but our patients deserve this from us, and not the convenient resolution of a lethal prescription.

The vast majority of legitimate physician organizations oppose physician-assisted suicide.

The California Medical Association (CMA) has reaffirmed its opposition to PAS five times since the1980s, most recently at its House of Delegates in 2005 and again in 2006. In a February 15, 2007 press release, the CMA states The CMA believes in humane and compassionate care for the terminally ill, including appropriate pain control and counseling for the dying and their families. But assisting someone to die is unethical and unacceptable, and is fundamentally incompatible with the physician’s role as healer.4

The American Medical Association states in its code of ethics: Physician-assisted suicide is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks 1 Suarez-Almazor ME et al. Attitudes of terminally ill cancer patients about euthanasia and assisted suicide: predominance of psychosocial determinants and beliefs over symptom distress and subsequent survival. J Clin Oncol. 2002;20:2134-41.2Van der Lee ML et al. Euthanasia and depression: A prospective cohort study among terminally ill cancer patients. J Clin Oncol2005;23:6607-6612.3 Emanuel EJ. Depression, euthanasia, and improving end-of-life care. J Clin Oncol. 2005;23:6456-8.4 Accessed at http://www.cmanet.org/publicdoc.cfm/2/1/presssection2/384 April 15, 2007. 3

AMA:  “Instead of participating in assisted suicide, physicians must aggressively respond to the needs of patients at the end of life”.5

The American College of Physicians, the nation’s largest medical specialty society, states: The profession’s most consistent ethical traditions have always emphasized healing and comfort and have demurred at the idea that a physician should intentionally bring about the death of any patient.

Pronouncements against euthanasia and assisted suicide date back to the Hippocratic Oath and have formed the ethical backbone for professional opposition to the practice of physician-assisted suicide.[and]

To the extent that this is an ethical] dilemma partly due to the failings of medicine to adequately provide good care and comfort at the end of life, medicine can and should do better. We must solve the real and pressing problems of inadequate care, not avoid them through solutions such as physician-assisted suicide.

6 In addition, oncologists have expressed opposition to physician-assisted suicide and euthanasiain several prominent surveys.

…..increasingly, physicians and the public do not share the same views on the ethics of physician-assisted suicide, a critical implication if physicians will be the ones asked to perform PAS.8

….Despite the reporting requirements, death by physician-assisted suicide in Oregon largely occurs in the dark. There is little accurate information about what actually happens at the time of death, as physicians are not required to be present at the time of ingestion. In 2005, physicians were in attendance in only 23% of cases. Information about the actual experience of death is derived from accounts provided by other individuals who stay with the patient.

Between 1998 and 2005, the time between ingestion and death ranged from four minutes to 48 hours.

It is hard not to imagine what those patients who required 48 hours to die might have experienced — suffering over and above that brought on by the terminal illness.

A shame, when stepped palliative care would relieve pain as it grows in a kind way.  Physician assisted suicide intrudes on palliative care and tries to replace it with patient death.

Indeed, this has been the experience in the Netherlands, with a report from 2000 showing that so called “problems with completion” (a longer-than-expected time to death, failure to induce coma, or induction of coma followed by awakening of the patient) occurred in 16% of cases, prompting physician intervention 18% of the time, which of course blurs the line considerably between suicide and euthanasia10.•

Even though 80% of patients had cancer, only 23% of the prescribing physicians were oncologists. Most were family practitioners, who may have had minimal training in palliative care. Oncologists are the physicians best suited to care for cancer patients at the end of life.•

Few patients requested suicide because of inadequate pain control or concern about it (24% in 2006), consistent with the findings discussed above.

Loss of autonomy and decreased ability to engage in pleasurable activities were cited in excess of 78% of cases.

What percentage of these cases might have been helped by aggressive psychiatric intervention or spiritual counseling

The percentage of patients referred to a specialist for psychological evaluation beyond that done by a hospice team decreased from 27% in 1998 to 5% in 2005. It seems implausible that over that same time period physicians prescribing lethal medications were 22% more capable of diagnosing depression or psychiatric illness.•

The median duration of the patient-physician relationship in 2005 was eight weeks, and for all patients between 1998 and 2004, it was twelve weeks. This means that the attending physician in the majority of cases would have had little more than a passing relationship with the patient and in all likelihood was not the treating oncologist. Furthermore, it strongly implies that “doctor-shopping” is occurring in Oregon.

Not having longitudinal follow-up of a patient’s individual case deprives the physician of important insights into that patient’s emotional and spiritual condition and makes it more likely to miss a diagnosis of depression.

Only 6% of Oregon psychiatrists are “very confident” they can determine in a single visit when depression may be affecting decisions to commit assisted suicide in the absence of a long-term relationship.11 10Groenewoud JH et al. Clinical problems with the performance of euthanasia and physician-assisted suicide in the Netherlands.N!Engl J Med. 2000; 342:551-556.11 Ganzini L. et al. Attitudes of Oregon psychiatrists towards assisted suicide. American Journal of Psychiatry. 1996; 153:1469-14755

..  The bill is silent as to the nature of the relationship between the patient and the physician who will ultimately prescribe the lethal medication.

There is no safeguard that says

* the attending physician must have anything longer than a 15-day relationship with the patient, * let alone any requirement whatsoever that a physician trained in palliative care must be involved in the assessment of the patient.• Section 7196.1.

Note from Eileen:  If the law has been being circumvented, like these doctors say it has, that means there is no enforcement of it with severe penalties that match the crime; adding any new safeguards would be meaningless.

Physicians are wrong about a given patient’s prognosis “more often” than they are right. A consulting physician who examines the patient and reviews the medical records is prone to the same errors in judgment that the attending physician may make when faced with the same data.

Despite skill and experience, physicians often make errors in estimating a patient’s prognosis, not because of a lack of information, but because new information (test results, observations of interventions, etc.) comes to light. As oncologists, every week in our practices we see patients surviving many months or even years longer than originally estimated because of variability in disease manifestations or unanticipated benefits from treatment, and we rejoice with our patients in these “errors.” But if our prognosis were wrong in regards to a patient choosing a lethal ingestion, the patient pays the ultimate penalty.• Section 7196.2.

If, in the attending or consulting physician’s “opinion” the patient suffers from a disorder impairing his judgment, the patient will be required to under go counseling. The same requirement will apply to patients not enrolled in a hospice program. In other words, formal counseling by a mental health professional is not mandated in all circumstances. This is most unfortunate, since there is no question that depression, mood and thought disorders, dementia, and existential distress will be missed. Even hospice workers and physicians expert in end of life care frequently fail in this regard, let alone generalist physicians who will likely be the ones caring for these patients …  For example, in one study of 25 oncology clinics, oncologists markedly underestimated the level of depression in the most severely depressed patients.12

Moreover, the fact that the language of the bill states that the psychiatric disorder must “impair judgment” means that there is no requirement for a profoundly depressed patient to receive a trial of antidepressant medication or psychotherapy if they do not have a co-existing thought disorder impairing their judgment or reality testing. This alleged safeguard is indeed flimsy when closely examined.• Section 7196.4.

Patients requesting PAS are not required to notify their next of kin, which means that those patients already socially isolated will remain so through their death.• Section 7196.8.

As with the Oregon statute, there is no requirement that the physician be present at the time of ingestion.. 12 Passik SD. Oncologists’ recognition of depression in their patients with cancer. J Clin Oncol. 1998;16:1594-1600. 6dying. Documentation

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Dr. Marshal Mandelkern, Chief of Psychiatry at the Hospital of Saint Raphael

http://www.healthgrades.com/physician/dr-marshal-mandelkern-2vbpj

It’s not always obvious when someone is depressed, especially if the person is not used to revealing his feelings. When a person feels helpless, hopeless and has no pleasure in usual activities, he could be in a depressed state and should be treated, either by medication or psychotherapy, Mandelkern said.

“People can deal with grim situations, but most choose not to die when they are depressed. These things are relatively rare,” he said.

“If someone says there’s no point in going on, I would first ask ‘How depressed is this person?’

If you let somebody die when they’re depressed, they don’t have a chance of getting better.” …..

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Dr. Marije van der Lee, of the Helen Dowling Institute in the Netherlands

Oregon Health and Sciences University

http://health.usnews.com/health-news/family-health/brain-and-behavior/articles/2008/10/08/oregons-assisted-suicide-law-may-overlook

Oregon’s Assisted Suicide Laws
may Overlook
Depressed Patients

WEDNESDAY, Oct. 8 (HealthDay News) — Oregon’s physician-assisted suicide law may not adequately protect the one in four terminally ill patients with clinical depression, a new study says.

The Death with Dignity Act was passed by the state in 1997, and there’s been intense debate about the extent to which potentially treatable psychiatric disorders may influence a patient’s decision to hasten death, according to a news release about the study, published online Oct. 8 by the British Medical Journal.

The act does contain several safeguards to ensure patients are competent to make the decision to end their life, including referral to a psychologist or psychiatrist, if there’s concern that a mental illness may be impairing a patient’s judgment. However, depression is often overlooked in mentally ill patients. In 2007, none of the 46 people in Oregon who used physician-assisted suicide were evaluated by a psychologist or psychiatrist, the news release said.

For the new study, researchers at Oregon Health and Sciences University checked for depression or anxiety in 58 terminally ill patients who’d requested physician-assisted suicide or had contacted an assisted death organization. * Fifteen of the patients met the criteria for depression and * 13 for anxiety. * By the end of the study, 42 patients had died. * Of those, 18 received a prescription for a lethal medication, and * nine died by lethal ingestion. * Of those who received a prescription for a lethal medication, three met the criteria for depression. All three died by lethal ingestion within two months of being assessed by researchers. ….”

The authors called for “increased vigilance and systematic examination for depression among patients who may access legalized aid in dying.” While it’s important to protect vulnerable patients, it can be difficult to determine if depression is impairing the judgment of terminally ill patients, Dr. Marije van der Lee, of the Helen Dowling Institute in the Netherlands, wrote in an accompanying editorial.

Depression doesn’t necessarily impair judgment, van der Lee said. “We should focus on trying to ‘protect’ patients from becoming depressed in the first place, rather than focus on protecting patients from assisted suicide,” she wrote. …..

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Best AMA Quotes Opposing Assisted Suicide

The AMA strongly opposed assisted suicide in an amicus brief in the 9th Circuit case regarding doctor-assisted suicide.

In this brief, the AMA stated, “There is, in short, compelling evidence of the need to ensure that all patients have access to quality palliative care, but not of any need for physician-assisted suicide …”   see:  http://www.pregnantpause.org/euth/amagomez.htm

 

From its Online Library, the AMA reject assisted suicide and recommends a multidisciplinary approach which would also address patient psychological needs:

“Considering the complexity of care for incurable patients, a multidisciplinary approach is a prerequisite to balance curative and palliative intervention options. Optimal functioning of a team requires excellent training, communication and a description of the tasks and responsibilities of each team member….More and more advanced care planning is introduced in palliative care, focusing on an early identification of patients in a palliative trajectory and on the prevention of annoying symptoms, hoping that this approach results in an improved quality of life for the individual patient, less useless technical investigations and a better end-of-life care on the place the patient and his family desires.”  See:  http://onlinelibrary.wiley.com/doi/10.1111/papr.12025/abstract

 

In its Opinion 2.211 Column, entitled “Physician Assisted Suicide”, the AMA reported that:

“Instead of participating in assisted suicide, physicians must aggressively respond to the needs of patients at the end of life.  Patients should not be abandoned once it is determined that cure is impossible.  Multidisciplinary interventions should be sought including specialty consultation, hospice care, pastoral support, family counseling, and other modalities.  Patients near the end of life must continue to receive emotional support, comfort care, adequate pain control, respect for patient autonomy, and good communication.” http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/ opinion2211.shtml

 

AMA:  Palliative Medicine Update:

A Multidisciplinary Approach –  Abstract Palliative medicine is a young specialty that is officially recognized in relatively few countries. The World Health Organization published an adapted definition in 2002, describing palliative care as an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness. When the accent is shifting from curative to palliative, the goal of management is the maintenance or improvement of the patient’s quality of life. The different dimensions of palliative care and the multitude of types of care to be provided require a multidisciplinary, well-functioning team, effective communication and a clear task division between primary and hospital care. Considering the complexity of care for incurable patients, a multidisciplinary approach is a prerequisite to balance curative and palliative intervention options. Optimal functioning of a team requires excellent training, communication and a description of the tasks and responsibilities of each team member. More and more advanced care planning is introduced in palliative care, focusing on an early identification of patients in a palliative trajectory and on the prevention of annoying symptoms, hoping that this approach results in an improved quality of life for the individual patient, less useless technical investigations and a better end-of-life care on the place the patient and his family desires. http://onlinelibrary.wiley.com/doi/10.1111/papr.12025/abstract

 

A re-assuring AMA mission statement

When doctors join the American Medical Association, they help support causes that affect your health—causes such as reducing infant mortality, improving access to care for minorities, halting childhood obesity, preventing substance abuse and stopping underage drinking. In becoming your advocate, your physician gains access to cutting-edge clinical advances that help you get the best medical care available. Our publications, such as The Journal of the American Medical Association (JAMA) and Archives specialty journals, are widely recognized for propelling the state of medicine. As a member of the nation’s largest medical society, your doctor can spend less time worrying about administrative hassles and more time providing care. Our powerful presence in Washington, D.C., leverages your physician’s support into positive change on a number of medical causes—causes that might otherwise distract your physician from the main task of caring for you and your family. AMA members also promise to abide by the highest ethical standards for medicine—meaning our doctors commit to being professional, fair and compassionate to you, the patient. https://www.ama-assn.org/ama/pub/about-ama/your-doctor.page

AMA on Physician Services In becoming your advocate, your physician gains access to cutting-edge clinical advances that help you get the best medical care available. Our publications, such as The Journal of the American Medical Association (JAMA) and Archives specialty journals, are widely recognized for propelling the state of medicine. As a member of the nation’s largest medical society, your doctor can spend less time worrying about administrative hassles and more time providing care. Our powerful presence in Washington, D.C., leverages your physician’s support into positive change on a number of medical causes—causes that might otherwise distract your physician from the main task of caring for you and your family. AMA members also promise to abide by the highest ethical standards for medicine—meaning our doctors commit to being professional, fair and compassionate to you, the patient. Make sure the doctor you choose supports quality patient care and the very future of our nation’s health. Choose an AMA-member physician or encourage your nonmember physician to join the AMA today.

 

Dr. Lisa Honkanen, MD,

Geriatrician Long Island, New York

http://hartfordfavs.com/ethics/death-and-dying/physician-asisted-suicide-patients-mistakenly-lose-years-or-life

It is never acceptable to end the suffering by ending the sufferer. The root of “compassion” is to “suffer with” – to walk the journey with him who suffers. It is the ultimate abandonment to assist in causing the death of another even if guided by a false sense of altruism. Experience shows that patients do not request physician assisted suicide (PAS) when physical pain and mental suffering are adequately treated. These are legitimate areas of a physician’s healing duty, but causing or assisting in death is not. However, when PAS is a legal option, these issues are much less well addressed, because there is a simpler, but far less humane and compassionate option – intended death. PAS violates the physician’s traditional oath to “first do no harm.”

Additionally, legalizing PAS allows many abuses, indeed many “safeguards” are abandoned, e.g. in 2010 and 2011, less than 2% of patients requesting PAS in Oregon had a mental health evaluation.

Medicine has come a long way in managing pain and mental suffering with medications, devices, procedures and technology that can bring great comfort and relief to patients with symptoms that in the past would have been unmanageable. It is incorrect to say that patients without the ability to express their desires “have no rights” just because PAS is not a legal option. The Declaration of Independence tells us that we are endowed by our Creator with certain unalienable rights, including the right to Life. There is an expectation of death, but not a right to choose to kill oneself. One might be frustrated and downtrodden by debility, but it is our human responsibility to comfort and care for that person, not eliminate a perceived burden by assisting in killing him. Does that not convey the sentiment “you’re better off dead to me?”

Furthermore, we cannot agree that suicide is a tragedy, but also say that if it is assisted by a physician it will be tolerated. We cannot agree that some lives are not worth living until their natural end, and then be surprised when suicide rates in general increase (as seen in Oregon), or there becomes a strong sense of a societal duty to die despite opposite core beliefs. In the end, PAS is just another step along the slippery slope of a culture of death – legitimizing that which we know in our hearts is wrong.

As a physician, I am deeply saddened that the healing art of medicine is being distorted by the rhetoric of misguided compassion. I commend Ms. Bianchini for defending patients’ rights, and I beg Rev. Peary (comments) to rethink his position. I hope the CT legislature will use the experience of Oregon, Washington, and the Netherlands to see the direct and unintended consequences of PAS do not advance our humanity, but rather diminish our capacity to love and care for each other.

 

Quote by the then St. Raphael Healthcare Sys VP & Councel

On Connecticut Bill, Right to Die, 1995,

17e4b0f852622291051.txt

In response to a to a 1995 bill proposed in Connecticut to legalize the right to die, Jane Ann Lubin Sfranski, the then vice president and general councel for the St. Raphael Healthcare System, speaking on behalf of the Connecticut Catholic Hospital Council, told the Judiciary Committee,

“A legislative license to kill will not assist physicians or other caregivers in the delivery of these vital services.  She said, “The cornerstone of this bill is fear” …and further explained that “It will complicate, confuse, and contaminate the dying process.

Our attention must be drawn to dignified end of care, end of life care and a way from ending life. As the chosen representatives of the citizens of the State of Connecticut, it is incumbent upon you to redirect this process”.  A similar 2009 bill never made it to public hearing…..

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National Cancer Institute

http://www.cancer.gov/cancertopics/factsheet/support/end-of-life-care

How do doctors know how long a person will continue to live? Patients and their family members often want to know how long a person who has cancer will continue to live. It’s normal to want to be prepared for the future. But predicting how long someone will continue to live is a hard question to answer. A number of factors, including the type of cancer, its location, and whether the patient has other illnesses, can affect what will happen. Although doctors may be able to estimate the amount of time someone will continue to live based on what they know about that person, they might be hesitant to do so. They may be concerned about over- or under-estimating the person’s remaining life span. They also might be fearful of giving false hope or destroying a person’s will to live…..

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Kenneth R. Stevens, Jr. M.D. Assisted Suicide: Conspiracy and Control Wednesday,

September 24, 2008, 7:10 PM By Rick Attig, The Oregonian Newspaper,  The Oregonian

http://www.oregonlive.com/opinion/index.ssf/2008/09/
assisted_suicide_conspiracy_an.html

Rick Attig shares Dr. Stevens comments on the group controlling assisted suicide in Oregon which is also the group that promotes assisted suicide and has authored its laws,  “Compassion and Choices (C&C)” to the extent that they participate in 75% of Oregon’s PAS deaths.

…We must comment on two realities:

* First:  the group controlling assisted suicide in Oregon is also the group controlling what the public is told; * Second, the claim that Oregon is a leader in improved end-of-life care because of assisted suicide is inaccurate.

The editorial board correctly notes “a coterie of insiders run the program, with a handful of doctors and others deciding what the public may know”.

The group promoting assisted suicide, so-called “Compassion and Choices (C&C)”, are like the fox in the proverbial chicken coop; in this case the fox is reporting its version to the farmer regarding what is happening in the coop. Members of C&C authored and proclaim they are the stewards of Oregon’s assisted suicide law. They call it “their law”. They have arranged and participated in 3/4ths of Oregon’s assisted suicide cases.

* Their medical director reported she’d participated in more than 100 doctor-assisted suicides as of March 2005.

* A physician board-member reported in 2006 that he’d been involved with over forty such patients.

* Their executive director reported in September 2007 that he has attended more than 36 assisted suicide deaths. He has been involved in preparing the lethal solution. Yet, he is not a doctor.

In 2006, C&C’s attorneys intimidated the Oregon Department of Human Services (DHS) to change to euphemisms in referring to Oregon’s assisted suicide law. The limited DHS reports of assisted suicides is another indication of this organization’s influence. Information that is damaging to the “good public image” of Oregon’s assisted suicide law is hidden or glossed-over in the DHS reports. As such, we believe the initials “C&C” of this organization more properly reflect its repeated public behavior —that is, “Conspiracy & Control”.

Regardless of one’s perspective on assisted suicide, all citizens should be concerned about the controlling influence of this death-promoting organization. In all other areas of medicine, we are striving for increased transparency—not conspiracy and control.

Second:  What about assisted suicide causing improved end-of-life care?

There is improved end-of-life care in Oregon. In training physicians, we have sought to improve patient-physician communication, and improve patient care at many levels. We have made improvements. However, similar improvements have occurred in other states that have not legalized assisted suicide (Note from Eileen – because of the work the AMA and other medical organizations have done to perfect pain management so that no patient, not even dying, would suffer great pain and to expand palliative care to include multidisciplinary care.) Many states do better than Oregon in this area.

The latest data ranks Oregon 9th (not 1st) in Medicare-age hospice-utilization; 4 of the top 5 states have criminalized assisted-suicide. The Wisconsin Pain Policies Studies Group issues grades regarding states’ pain-policies.

While Oregon & Washington both have high grades on their pain-policies, an OHSU study documented that after 4 years of assisted suicide in Oregon there was a decline in end-of-life pain-control.

This doesn’t prove that the pain-control decline was due to assisted suicide. At the same time, the data doesn’t support the claim that legalization of assisted suicide improved care at the end-of-life.

In summary, we should all be wary of the false “C&C” claims…..

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Kenneth R. Stevens, Jr., M.D.,  VP, Physicians for Compassionate Care Education Foundation. William L. Toffler, M.D., is National Dir, Physicians for Compassionate Care Education Foundation.

 

David W. Hafer, M.D.

Assisted suicide not legal in state, needs clarification Montana Standard, November 21, 2012 12:15 am

http://mtstandard.com/news/opinion/mailbag/our-readers-speak-assisted-suicide-not-legal-in-state-needs/article_6d1ca724-337f-11e2-9eee-001a4bcf887a.html

Dr. Hafer sets the record straight – Montana has not legalized Physician Assisted Suicide, and discusses some of his concerns,   about the bill, including — that it goes against the physicians mission to cure,  is “A Recipe for Elder Abuse”, and that doctors are fallible and often wrong in their prognosis.

A recent Associated Press article, which appeared last Friday in most major newspapers in our state, incorrectly stated that Montana is the third state to allow assisted suicide, along with Washington and Oregon.

Attorneys Greg Jackson and Matt Bowman did an extensive analysis of the case and concluded it “did not legalize assisted suicide and it continues to carry both criminal and civil liability for any doctor, institution, or lay person involved.” [ Click here to see Jackson/Bowman article]

The Montana Lawyer, the official publication of the Montana State Bar concluded the issue is open to argument, confirming that the Legislature needs to clarify the issue this coming session.

As a retired doctor and Montana representative for CMDA, your readership needs to know that there are problems inherent in passing a law that would allow a physician to kill their patient. People need to understand that we are talking about a physician writing a prescription for the express purpose of one taking their own life.

The very oath that physicians take in stepping into this profession states that they “shall do no harm.” Their purpose is to cure, to heal, to provide comfort and care at the end of life, but not to aid in facilitating the end of that life through active means.

Physicians are fallible human beings and often are wrong in their prognosis concerning how long a patient will survive their illness. Often, it is depression that prompts one to think that life if not worth living or perhaps the feeling that because of their illness they are a burden to their family.

The whole matter is a recipe for elder abuse.   This is a topic that requires much more discussion and education concerning what it really entails and what is at stake.

The Montana Medical Association has drafted its position statement, stating that boards (e.g. Montana Medical Examiners Board) should not be making position statements without clear statutory authority. I appreciate the opportunity to set the record straight and hope that you continue to report on this vital topic.

David W. Hafer
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William Reichel, M.D.

Abuses are Inevitable with Assisted Suicide

Georgetown University, School of Medicine, Washington, D.C.

Published:  Thursday, October 15, 2009

http://www.nashuatelegraph.com/apps/pbcs.dll/article?AID=/20091015/OPINION02/910159975/-1/opinion

I am a physician who has studied assisted suicide and also euthanasia since 1988, in Oregon, and especially in the Netherlands. Your recent editorial is correct in raising the concern that New Hampshire’s proposed assisted suicide bill cannot be drafted to prevent abuse.

Dutch doctors have practiced assisted-suicide and euthanasia for decades. Although the law calls for performing assisted-suicide and euthanasia with the patient’s consent, it is often involuntary. The law also calls for obtaining a second opinion of another physician, but this is often never done.

By 1991, the Remmelink Report showed that 1,040 people (an average of three per day) were actively killed by Dutch doctors without the patient’s knowledge or consent. In addition, 8,100 patients died as a result of doctors deliberately giving them overdoses of pain medication, not for the primary purpose of controlling pain, but to hasten the patient’s death. This pattern continues to this day.

Early death can save money for health-care systems as well as for surviving family members. Once assisted suicide and euthanasia are accepted, abuses are possible and difficult to control. Those who believe that the proposed bill will assure their control over the “time, place and manner” of their death, are naive.

William Reichel, M.D.
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Dr. Charles Bentz, M.D. Internist in Portland

http://www.wrtl.org/
assistedsuicide/personalstories.aspx

Dr. Bentz reports – his opinion was ignored. Two week later, his patient was dead. Dr. Charles Bentz, an internist in Portland, Oregon, diagnosed a malignant melanoma in a 76-year-old man who had been under his care for over ten years. Unfortunately, the cancer had already spread to his shoulder at the time of diagnosis, so it was not curable.

Dr. Bentz referred this active man to both radiation oncology and medical oncology, using two methods to slow the cancer and prolong the man’s life. When the patient finished the radiation therapy, the radiation oncologist informed Dr. Bentz that the patient was depressed due to his diminished physical stamina. At almost the same time, he finished his chemotherapy and asked his medical oncologist for a prescription so he could take his own life by suicide. The medical oncologist called Dr. Bentz, asking him to act as the required second physician to confirm the diagnosis and prognosis before he wrote the prescription, saying secobarbital “works very well” and indicating he had used it many times. Dr. Bentz responded that he could not do this; the man had a documented depression and needed therapy for this.

The oncologist then found another physician to render the required “second opinion” and did not refer the man back to his primary physician. Two weeks later the patient was dead from a lethal prescription.

Dr. Bentz obtained permission from the man’s family and obtained a copy of the death certificate which falsely said death was from malignant melanoma.

[Note; How physician assisted suicide safeguards failed the patient of Dr. Bentz: * The patient’s well-documented depression was not evaluated by a mental health specialist, nor was it treated. * The patient’s primary physician was excluded from helping him with his end-of-life concerns. * The patient’s oncologist falsified a public document by lying about the cause of death.] …..

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Affidavit by Dr. Ken Stevens of Oregon. The Oregon Health Plan Steers Patients to Suicide http://www.ravallirepublic.com/news/opinion/mailbag/article_34acbde8-3686-11e2-b260-0019bb2963f4.html  

To view a hard copy of his affidavit with supporting documentation, click here.

AFFIDAVIT OF KENNETH R. STEVENS, JR., MD

THE UNDERSIGNED, being duly sworn under oath, states:

1. I am a doctor in Oregon USA where physician-assisted suicide is legal. I am also a Professor Emeritus and a former Chair of the Department of Radiation Oncology, Oregon Health & Science University, Portland, Oregon. I have treated thousands of patients with cancer.

2. In Oregon, our assisted suicide law applies to patients predicted to have less than six months to live. I write to clarify for the court that this does not necessarily mean that patients are dying.

3. In 2000, I had a cancer patient named Jeanette Hall. Another doctor had given her a terminal diagnosis of six months to a year to live, which was based on her not being treated for cancer. I understand that he had referred her to me.

4. At our first meeting, Jeanette told me plainly that she did not want to be treated and that was going to “do” our law, i.e., kill herself with a lethal dose of barbiturates. It was very much a settled decision.

5. I, personally, did not and do not believe in assisted suicide. I also believed that her cancer was treatable and that her prospects were good. She was not, however, interested in treatment. She had made up her mind, but she continued to see me.

6. On the third or fourth visit, I asked her about her family and learned that she had a son. I asked her how he would feel if she went through with her plan. Shortly after that, she agreed to be treated and she is still alive today. Indeed, she is thrilled to be alive. It’s been twelve years.

7. For Jeanette, the mere presence of legal assisted suicide had steered her to suicide.

8. Today, for patients under the Oregon Health Plan (Medicaid), there is also a financial incentive to commit suicide: The Plan covers the cost. The Plan s “Statements of Intent for the April 1, 2012 Prioritized List of Health Services,” states:

“It is the intent of the [Oregon Health Services] Commission that services under ORS 127.800-127.897 (Oregon Death with Dignity Act) be covered for those that wish to avail themselves to those services.”

9. Under the Oregon Health Plan, there is also a financial incentive towards suicide because the Plan will not necessarily pay for a patient s treatment. For example, patients with cancer are denied treatment if they have a “less than 24 months median survival with treatment” and fit other criteria. This is the Plan’s “Guideline Note 12.”

10. The term, “less than 24 months median survival with treatment,” means that statistically half the patients receiving treatment will live less than 24 months (two years) and the other half will live longer than two years.

11. Some of the patients living longer than two years will likely live far longer than two years, as much as five, ten or twenty years depending on the type of cancer. This is because there are always some people who beat the odds.

12. All such persons who fit within “Guideline Note 12” will nonetheless be denied treatment. Their suicides under Oregon’s assisted suicide act will be covered.

13. I also write to clarify a difference between physician-assisted suicide and end-of-life palliative care in which dying patients receive medication for the intended purpose of relieving pain, which may incidentally hasten death. This is the principle of double effect. This is not physician-assisted suicide in which death is intended for patients who may or may not be dying anytime soon.

14. The Oregon Health Plan is a government health plan administered by the State of Oregon. If assisted suicide is legalized in Canada, your government health plan could follow a similar pattern. If so, the plan will pay for a patient to die, but not to live.

Terminal Uncertainty Quote by: Nicholas Christakis, Professor of Medicine & Sociology, Harvard University By Nina Shapiro http://www.seattleweekly.com/2009-01-14/news/terminal-uncertainty/

Washington’s new “Death With Dignity” law allows doctors to help people commit suicide—once they’ve determined that the patient has only six months to live. But what if they’re wrong?

She noticed the back pain first. Driving to the grocery store, Maryanne Clayton would have to pull over to the side of the road in tears. Then 62, a retired computer technician, she went to see a doctor in the Tri-Cities, where she lived. The diagnosis was grim. She already had Stage IV lung cancer, the most advanced form there is. Her tumor had metastasized up her spine. The doctor gave Clayton two to four months to live. That was almost four years ago. Prodded by a son who lives in Seattle, Clayton sought treatment from Dr. Renato Martins, a lung cancer specialist at Fred Hutchinson Cancer Research Center. Too weak to endure the toxicity of chemotherapy, she started with radiation, which at first made her even weaker but eventually built her strength. Given dodgy prospects with the standard treatments, Clayton then decided to participate in the clinical trial of a new drug called pemetrexate. Her response was remarkable. The tumors shrunk, and although they eventually grew back, they shrunk again when she enrolled in a second clinical trial. (Pemetrexate has since been approved by the FDA for initial treatment in lung cancer cases.) She now comes to the Hutch every three weeks to see Martins, get CT scans, and undergo her drug regimen. The prognosis she was given has proved to be “quite wrong.” “I just kept going and going,” says Clayton. “You kind of don’t notice how long it’s been.” She is a plain-spoken woman with a raspy voice, a pink face, and grayish-brown hair that fell out during treatment but grew back newly lustrous. “I had to have cancer to have nice hair,” she deadpans, putting a hand to her short tresses as she sits, one day last month, in a Fred Hutchinson waiting room. Since the day she was given two to four months to live, Clayton has gone with her children on a series of vacations, including a cruise to the Caribbean, a trip to Hawaii, and a tour of the Southwest that culminated in a visit to the Grand Canyon. There she rode a hot-air balloon that hit a snag as it descended and tipped over, sending everybody crawling out. “We almost lost her because she was having too much fun, not from cancer,” Martins chuckles. Her experience underscores the difficulty doctors have in forecasting how long patients have to live—a difficulty that is about to become even more pertinent as the Washington Death With Dignity Act takes effect March 4. The law, passed by initiative last November and modeled closely on a 14-year-old law in Oregon, makes Washington the only other state in the country to allow terminally ill patients to obtain lethal medication. As in Oregon, the law is tightly linked to a prognosis: Two doctors must say a patient has six months or less to live before such medication can be prescribed. The law has deeply divided doctors, with some loath to help patients end their lives and others asserting it’s the most humane thing to do. But there’s one thing many on both sides can agree on. Dr. Stuart Farber, head of palliative care at the University of Washington Medical Center, puts it this way: “Our ability to predict what will happen to you in the next six months sucks.” In one sense, six months is an arbitrary figure. “Why not four months? Why not eight months?” asks Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania, adding that medical literature does not define the term “terminally ill.” The federal Medicare program, however, has determined that it will pay for hospice care for patients with a prognosis of six months or less. “That’s why we chose six months,” explains George Eighmey, executive director of Compassion & Choices of Oregon, the group that led the advocacy for the nation’s first physician-assisted suicide law. He points out that doctors are already used to making that determination. To do so, doctors fill out a detailed checklist derived from Medicare guidelines that are intended to ensure that patients truly are at death’s door, and that the federal government won’t be shelling out for hospice care indefinitely. The checklist covers a patient’s ability to speak, walk, and smile, in addition to technical criteria specific to a person’s medical condition, such as distant metastases in the case of cancer or a “CD4 count” of less than 25 cells in the case of AIDS. No such detailed checklist is likely to be required for patients looking to end their lives in Washington, however. The state Department of Health, currently drafting regulations to comply with the new law, has released a preliminary version of the form that will go to doctors. Virtually identical to the one used in Oregon, it simply asks doctors to check a box indicating they have determined that “the patient has six months or less to live” without any additional questions about how that determination was made. Even when applying the rigid criteria for hospice eligibility, doctors often get it wrong, according to Nicholas Christakis, a professor of medicine and sociology at Harvard University and a pioneer in research on this subject. As a child, his mother was diagnosed with Hodgkin’s disease. “When I was six, she was given a 10 percent chance of living beyond three weeks,” he writes in his 2000 book, Death Foretold: Prophecy and Prognosis in Medical Care. “She lived for nineteen remarkable years…I spent my boyhood always fearing that her lifelong chemotherapy would stop working, constantly wondering whether my mother would live or die, and both craving and detesting prognostic precision.” …..

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Nancy Valko Assisted Suicide Shouldn’t Be Option Missouri Nurses for Life and National

Association of Pro-Life Nurses, May 2010 Courant, May 22, 2010, St. Louis, Mo http://www.courant.com/news/opinion/editorials/hc-digbrflets0522.artmay22,0,1107533,print.story

Suicide is like a nuclear bomb dropped on a family [Opinion, May 16, “Elders Deserve Choices, Not Just A Bitter End”]. Besides the tragic loss of a loved one, suicide complicates the grieving process and can even increase the risk of suicide for survivors.

I know this both professionally, as a registered nurse, and personally, as a mother. Last October, my 30-year-old daughter, Marie, died by suicide using a “textbook final exit” technique, according to the medical examiner. Marie was not terminally ill and was under treatment for substance abuse and mental health issues at the time of her death.

As a nurse for more than 40 years, I have always supported suicide prevention and treatment. I oppose any form of suicide, especially assisted suicide. I know how to control pain and other symptoms for dying people, and I will do anything for my patients except kill them or help them kill themselves.

Right now, we have more than 33,000 known suicide deaths per year in the United States. How can we have a functional society that recognizes suicide as a tragedy always to be prevented, if possible, while also legalizing assisted suicide as a personal right for some people who demand both medical participation and society’s approval?

We cannot discriminate when it comes to suicide prevention and treatment.

Nancy Valco, St. Louis, Mo. Copyright © 2010, The Hartford Courant http://www.chninternational.com/valco.htm …..

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Statement by Physicians for Compassionate Care

http://www.pccef.org/articles/art16.htm
www.pccef.org

FROM: BRIEF OF AMICUS CURIAE PHYSICIANS FOR COMPASSIONATE CARE IN SUPPORT OF APPELLEE, STATE OF ALASKA Kevin Sampson and Jane Doe, Appellants, v. State of Alaska, Appellee SUMMARY OF ARGUMENT Experience with doctor-assisted suicide in the state of Oregon, as in the Netherlands, reveals that assisted suicide allowed in the medical setting is not a private act. Doctor-assisted suicide takes place in a complex medical, social, and economic system, making the individual patient vulnerable to adverse influence. It creates conditions allowing family members and others to pressure the patient to commit assisted suicide, as has already happened in Oregon.

Institutionalization of assisted suicide unfairly discriminates against vulnerable individuals and puts seriously ill individuals contemplating suicide at dangerous and unequal risk of death by failing to provide equal protection of their lives. If Alaska were to relinquish its right to prohibit physician-assisted suicide, one vulnerable class of individuals, those labeled “terminally ill,” would thereby be devalued and would no longer be afforded the same protection against assisted suicide which other Alaskans enjoy. This failure to assure equal protection would result in some of the depressed and mentally infirm who are labeled terminally ill receiving assisted suicide instead of medical care, which has already happened in Oregon, and as is common in the Netherlands, even among those who are not labeled “terminally ill.”

Institutionalization of assisted suicide not only has an adverse effect on a particular individual who may feel like giving up on life; it also has a harmful effect on society and its general welfare and puts other individuals at risk. The harmful effect on society derives from the fact that physician-assisted suicide is not a private act, but takes place in a complex medical, social, and economic system. Within this delicate, interactional context, as observed in the Code of Medical Ethics, Sec. 2.211, overthrowing laws protecting the public against doctor-assisted suicide is destructive to the doctor patient relationship, proves impossible to control, and poses serious societal risks. It creates an economic environment with institutional incentives favoring suicide over medical care. It is impossible to adequately monitor, as demonstrated by failed attempts to monitor the experience in Oregon.

Lacking adequate monitoring, it is impossible to regulate and control. Any illusion that assisted suicide could be confined to self-administered oral overdose quickly dissipates once the practice is allowed. Lethal injection must necessarily also be allowed for those who cannot quickly swallow the contents of 90 or so capsules it takes to commit assisted suicide or who have failed in their assisted-suicide attempt, as has been demonstrated in the case of Patrick Matheny in Oregon and previously in the Netherlands.

The inevitability of the introduction of lethal injection or infusion, once the protection against assisted suicide is overridden for one class of patients, makes it even more clear that institutionalized assisted suicide gives power and control to the doctor and to a complex medical, economic, and social system, not to an individual in an hypothetically “private” and “autonomous” act. Arguments supporting overthrow of Alaskan law protecting the lives of vulnerable individuals from assisted suicide are to some extent based on a verbal blurring of the clear and rational boundary between “suicide” with “assisted suicide.” The interchangeable use of these words and concepts fails to make clear the central issue of what is being done to who by whom. This usage obfuscates the fact that assisted suicide is a complex interaction taking place in a medical, economic and social system and is not an action carried out in a hypothetical “private” setting solely by an “autonomous” individual.

Arguments supporting overthrow of the protections provided by Alaskan law against assisted suicide also rely heavily on the spurious contention that the refusal of an unwanted medical treatment by a patient is somehow equivalent to a doctor carrying out an action clearly intended, not to provide medical care, but to make the patient dead. These arguments again are based on the failure to recognize the social nature of the doctor-patient relationship and to distinguish who is doing what to whom. In one case, a patient is declining to do something, that is, to accept an offer of medical treatment from a different person, the doctor. In the other case, an entirely different person, the doctor, is actively doing something, that is, writing a lethal prescription intended to actively kill the patient.

The clear and rational distinction between a patient refusing unwanted medical treatment and a doctor actively and intentionally taking steps to make a patient dead has been upheld by the United States Supreme Court, which stated “we think the distinction between assisting suicide and withdrawing life sustaining treatment, a distinction widely recognized and endorsed in the medical profession (n. 6) and in our legal traditions, is both important and logical; it is certainly rational.”

Once a patient involves a physician in assisted suicide, it becomes abundantly clear that the assisted suicide is not a “private” and fully “autonomous” action. Doctor-assisted suicide takes place in a complex medical, social and economic setting and opens discouraged or anxious patients to adverse influence and coercion. It discriminates against a vulnerable class of individuals, those labeled “terminally ill.” It further endangers the mentally ill and infirm and/or alcoholics and other groups with a differentially high suicide rate. And, it endangers not only the individual contemplating assisted suicide, but also proves harmful to society. It is destructive to the doctor-patient relationship, is impossible to control and poses serious societal risks. Clearly, Alaska has the right and the responsibility to uphold its laws protecting its citizens against the danger doctor-assisted suicide poses to vulnerable individuals and to the general welfare of society. N. Gregory Hamilton, M.D. President, Physicians for Compassionate Care Portland, Oregon May 14, 2000 Erin Hoover Barnett, Is Mom Capable of Choosing to Die? Oregonian, October 17, 1999 at G1&2. Wesley J. Smith, Suicide Unlimited in Oregon. WEEKLY STANDARD, November 8, 1999, at 11-14. Catherine Hamilton, The Oregon Report: What’s Hiding Behind the Numbers, BRAINSTORM, March 2000 at 36-38 (appended). Washington v. Glucksberg, 117 S.Ct. 2258 (1997). United States v. Rutherford, 442 U.S. 544, 558 (1979) “…Congress could reasonably have determined to protect the terminally ill, no less than other patients, from the vast range of self styled panaceas that inventive minds can devise”; N. Gregory Hamilton, MD, The Doctor-Patient Relationship and Assisted Suicide: A Contribution from Dynamic Psychiatry, 19 AM. J. FORENSIC PSYCHIATRY (1998) 59, (appended).

Hamilton, supra note 2 at 70. AS 11.41.120. Glucksberg, supra note 2, “Those who attempt suicide–terminally ill or not–often suffer from depression or other mental disorders.” Herbert Hendin, MD et al., Physician-Assisted Suicide: Reflections on Oregon’s First Case, 14 ISSUES IN LAW &MED. 243-269 (1998). N. Gregory Hamilton, MD et al., Therapeutic Response to Assisted Suicide Request, 63 BULL. MENNINGER CLIN. 191-201 (1999). Kathleen Foley et al. The Oregon Report: Don’t Ask, Don’t Tell, HASTINGS CENTER REPORT, May-June, 1999 at 37; Wesley J. Smith, J.D., Storm Warning over Oregon 171 WESTERN J MED. 220 (1999). New York State Task Force on Life and the Law, When Death Is Sought: Assisted Suicide and Euthanasia in the Medical Context (1994) 13-22, 126-128. Herbert Hendin, SEDUCED BY DEATH: DOCTORS, PATIENTS, AND ASSISTED SUICIDE (1998). Washington v. Glucksberg, supra note 2. Ravin, 537 P.2d at 504. (“Indeed, one aspect of a private matter is that it is private, that is, that it does not adversely affect persons beyond the actor…” State v. Erickson, 574, p.2d 1 (Alaska 1978). American Medical Association, Code of Medical Ethics (1997) at 56-57. N. Gregory Hamilton, MD, Testimony of Dr. N. Gregory Hamilton to the Subcommittee on the Constitution of the House Committee on the Judiciary, 106th Cong., (June 24, 1999). See also Joe Rojas-Burke, Oregon’s Poor Slip from Safety Net of Health Coverage: Although More Money Went to the Oregon Health Plan, the Percentage of Uninsured Poverty-Level Residents Climbed Last Year to 23 Percent, OREGONIAN, March 29, 1999, A1; Joe Rojas-Burke, Insurers Still Unfair with Mentally Ill, Study Says: Despite a Law Meant to Curb Coverage Bias, the Share of Plans Limiting Office Visits and Hospital Stays for Mind Disorders Jumps, OREGONIAN, April 30, 1999, D1; Joe Rojas-Burke, Senate Bill Proposes Increase in Mental Health Benefits, OREGONIAN, June, 19, 1999, D1; Theodore C. Falk, What Price Dying? The Debate over How to Die Now Can Shift to How Much Money We Think It’s Worth, OREGONIAN, December 31, 1997; Kathleen Foley, A 44-Year-Old Woman with Severe Pain at the End of Life, 281 JAMA 1937 (1999); Jeanette Hamby, The Enemy Within: State Bureaucratic Rules Threaten the Spirit of Oregon Health Plan’s Founding Principles, OREGONIAN, January 21, 1998. Hamilton, supra note 1; Foley, supra note 5. See also Glucksberg supra, note 2. “”Thus, it turns out that what is couched as a limited right to ‘physician assisted suicide’ is likely, in effect, a much broader license, which could prove extremely difficult to police and contain.” See also Charles T. Canady, Physician Assisted Suicide and Euthanasia in the Netherlands: A Report of Chairman Charles T. Canady to the Subcommittee on the Constitution of the House Committee on the Judiciary, 104th Cong., 2d, 10-11 (Comm. Print 1996); Hendin supra note 6; New York State Task Force supra note 7; American Medical Association supra note 10. See appended letter of Oregon Deputy Attorney General David Schuman to Oregon state Senator Bryant, claiming that “persons who are unable to self-medicate will be denied access to a ‘death with dignity,” therefore making Oregon’s “Death with Dignity Act” vulnerable to challenge under “title II of the Americans with Disabilities Act…” — a challenge which would allow for lethal injection for those who cannot swallow. See also Catherine Hamilton, supra note 1; N. Gregory Hamilton, supra note 11. Canady, supra note 13. Opening Brief of Appellants (fn4) states “Alaska criminalizes suicide in two separate statutory provisions: AS 11.41.100 and AS 11.41.120. The ban against physician assisted dying is codified in AS 11.41.120 (a) provides that any person who ‘intentionally aids another person to commit suicide'” and also later states “the challenged statute outlawed suicide for all Alaskans. Exc. 11, pp. 26-27. The court found the primary reason for the categorical prohibition against assisted suicide …” (emphasis added). Vacco v. Quill, 117 S.Ct. 2293 (1997). See also American Medical Association Council on Ethical and Judicial Affairs, Decisions Near the End of Life, 267 JAMA 2229 (1992). See supra note 2. See also, Hendin supra note 7, at 199-202. See supra notes 5-7. See Eve K. Moscicki, Identification of Suicide Risk Factors Using Epidemiologic Studies, 20 PSYCHIATRIC CLIN. N. AM. 499 (1997). See supra note 10. See Id. …..

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William L. Toffler M.D., Professor of Family Medicine OHSU—FM, Portland, OR

Physicians for Compassionate Care – Educational Foundation

Oregon’s law doesn’t work

[Note: There are many discrepancies between what is promoted about Physician assisted suicide, and the actuality being experienced in Oregon. Dr. Toffler focuses on several of them – opportunities for family members to coerce a patient to sign up for PAS and then to actually help the patient take the lethal dose.]

Dear Editor:

I am a doctor in Portland Oregon where assisted suicide is legal. I disagree with Kathryn Tucker’s rosy description of our assisted suicide law, which she terms “aid in dying.”

In Oregon, the so-called safeguards in our law have proved to be a sieve. Although we are reassured that “only the patient” is supposed to take the lethal dose, there are documented cases of family members administering it. Family members often have their own agendas and also financial interests that dovetail with a patient’s death. Yet the true extent of such cases is not known as the only data published comes from second-and even third-hand reports (often from doctors who themselves who were not present at the death and who are active suicide promoters).

What we do know about assisted suicide in Oregon is essentially shrouded in secrecy. The scant information provided by the “official” Oregon statistics report that the majority of patients who have died via Oregon’s law have been “well educated” with private health insurance. See official statistics at http://www.oregon.gov/DHS/ph/pas/docs/year12.pdf  . In other words, they were likely people with money. Was it really their “choice?”

Preserve choice in Idaho. Reject assisted suicide.

William L. Toffler MD Professor of Family Medicine OHSU–FM Portland, OR
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 Dr. Jad kebbe, MD  PGYIII, Internal Medicine

Yale New Haven Hospital – St Raphael Campus, CT

Dear representative,

Senator Meyer proposed Senate Bill No. 48 to legalize Physician Assisted Suicide in Connecticut.

It seems the Public Health and Judiciary Committee will consider this bill. If passed, all Connecticut citizens will have to live with it, and I have serious concerns.

Physician assisted suicide might be one of the most controversial topics of all nowadays. It is directly aimed at the moral and ethical core of medicine and of human nature. It is a direct attack on principles that have been standing and defended for more than 2 millennia, reasons why I decided to pursue a lifetime career in medicine.

On one hand, euthanasia is a direct insult to any doctor-patient relationship for it undermines trust, as the person who holds the treatment and possibly cure, would also hold the power to kill. How can our patients trust we will be doing the best to treat them if they carry the fear we might suggest a lethal medication instead? How will they know if our ultimate goal is to treat them or kill them?

On the other hand, it is not needed. For I believe it to be a failure of proper palliative care for people who suffer from debilitating conditions, as the urge would be to hasten demise rather than focus on comfort. No physician can accurately predict the exact timeline before death. Medicine is to cure sometimes, to relieve often but to comfort always, and physician assisted suicide will replace proper comfort measures with murder. Most physician assisted suicide victims have asked for this option because of uncontrolled pain: let us not accept our failure to control pain, and instead improve our practice and kill the pain not the patient.

I can only start to imagine the grounds for abuse this might make room for. Relatives might push toward this end if they harbor ulterior motives of their own or if they have financial incentives. This is all the more true if the patient is impaired or unable to participate in decision making, such as an infant or an elderly with dementia. And even if that’s not the case, a patient might feel so overwhelmed by emotional or financial burdens imposed on loved ones that said patient may feel it’s his/her “duty” to die so as to abridge those burdens.

Furthermore, physicians and patients may be subtly coerced to choose this “cheaper” option by insurance companies as these might remunerate better for physician assisted suicide than proper palliative care. Improper financial incentives may ensue which could dramatically change physicians’ approach to healthcare as the focus will be more on further cutting costs by expediting demise rather than treating appropriately.

Dear representative, I beseech you to compassionately choose to reject this bill that jeopardizes the moral and ethical principles of medical practice. Instead, I respectfully implore you to support truly compassionate legislation promoting palliative and hospice care—measures that will protect and advance life with dignity. Let us not legalize suicide by making it a “medical treatment” but rather continue to fight and discourage it.

Thank you.

Jad Kebbe, M.D. PGYIII, Internal Medicine Yale New Haven Hospital – St Raphael Campus 1450 Chapel Street, New Haven, CT, 06511 – USA ~ The fear of the Lord is the beginning of wisdom ~
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