Insight into Physician Assisted Dying – 4/17/2017

Tonight I will explain what physician assisted dying is, who opposes it and why I think it is a human rights issue that we must address. At the conclusion of my talk, I will be happy to answer questions.

Many years ago, during a trip to San Antonio to visit with my elderly parents, my father took me aside and said to me, “Cindy, please get me a gun; I can’t go on like this.”  I recoiled with a gasp.  Hearing my reaction, he quickly said he didn’t mean it.  However, we both knew he did.  Eighty seven years old, blind, enfeebled and exhausted from lung problems and advanced Parkinson’s disease, no longer capable of walking but a few steps and never without a walker, my father yearned for death.  He was incapable of reading, volunteering, gardening, traveling, driving a car, watching TV, walking for any great length or caring for himself.  With most of his family and friends long dead, my father endured this diminished life day after day.  He was now broken from this endless cycle of misery and suffering.

I was a Daddy’s girl completely incapable of imagining him gone and totally helpless to improve the quality of his life. His situation lead me to think seriously about our responsibility to those in the throes of intractable pain and suffering, terminal illness or end stage half-lives.  A book that addresses this issue is entitled Must We Suffer Our Way to Death?  In this stage of our history, I believe that should be a resounding no.

Some of you may have seen spouses, parents or grandparents, a child or aunts and uncles or a sibling or a friend, die a difficult death. If you have not, count yourself among the lucky. Aid in dying gripped the national conscience in 2014 when a 29 year old California woman by the name of Brittany Maynard went public that she was dying of a serious brain cancer called glioblastoma and was moving to Oregon to avail herself of aid in dying because physician assisted dying was illegal in California. After treatments had failed and her doctors had told her that the end was coming and that it would get ugly, she decided that she wanted a compassionate, peaceful death in her own bed surrounded by her loved ones.

At that time, a death with dignity statute had been in place in Oregon since 1997 and had been upheld by the US Supreme Court. And because of Brittany’s advocacy and the work of so many others, her home state of California passed a death with dignity law in 2015. In his signing statement Gov. Brown wrote: “In the end, I was left to reflect on what I would want in the face of my own death. I do not know what I would do if I were dying in prolonged and excruciating pain. I am certain, however, that it would be a comfort to be able to consider the options afforded by this bill. And I wouldn’t deny that right to others.” Currently Oregon, Washington State, Vermont, Colorado, California and the District of Colombia all have laws permitting physician assisted dying also known as medical aid in dying. A judicial finding in Montana allows aid in dying also.
Physician assisted dying allows a mentally competent terminally ill adult who has been seen by two doctors who attest that the patient is mentally sound and within 6 months of dying, to obtain a prescription for a lethal pharmaceutical to end their lives when and if they so choose. It must be self-administered.

To me, aid in dying is a human rights issue. Although each day we hear of atrocities all over the world, I believe that as a species we keep evolving towards a greater good. We ended slavery as an accepted practice; women now have the right to vote in most but not all countries and civil rights laws have passed ending legal discrimination against minorities. Compassion toward others-in-need drove these changes. And now we face another form of discrimination and that is against those mentally competent, terminally ill adults who have intractable pain or unbearable suffering and are asking for help to end their lives peacefully through medical intervention and are denied the legal right to do so.

Texas and most other states in the union do not allow aid in dying. So if you or a loved one becomes terminally ill you have few options in Texas when death approaches. If you are lucky, hospice care sometimes known as palliative care can ease you into death but it does not prove helpful for some patients as hospice nurses and doctors admit and is unavailable for many. Hospice programs serve only around 42% of the people who die each year. Many areas in rural Texas don’t have hospice care at all. So in addition to improving and increasing hospice care in Texas, we should pass a death with dignity law to help those patients where hospice care is unable to ease their suffering.

Additionally, in Texas, you can also choose to stop eating food and drinking water, a difficult proposition but totally possible and legal. Or, if you qualify, where the terminal disease is irreversible and death is expected within two weeks, a doctor can administer terminal sedation. This treatment is used when other palliative efforts are not effective. High doses of sedation drugs like lorazepam or phenobarbital combined with an opioid drug like morphine used to ease pain and shortness of breath will sedate the person into unconsciousness sometimes for days or weeks. Terminal sedation slows one’s breathing to the point of death if the underlying disease does not end the patient’s life first. This medical intervention has sometimes been called “death by inches.”

You can choose undignified and barbaric forms of death like shooting yourself, hanging yourself, driving your car into an abutment, taking an overdose of barbiturates or drinking Drano or some type of poison. None of these acts are peaceful, compassionate or necessarily successful sometimes leaving relatives to pick up the pieces.

None of these choices are as humane as aid in dying. So the last choice for Texans could be to move to a state like Oregon and establish residency so as to avail oneself of physician assisted dying. In Oregon, there is no minimum residency requirements or a timetable according to the Death with Dignity National Center website. It states that one must simply be able to provide proof of residency to the attending physician in the form of a state issued ID such as a driver’s license or documents showing the patient rents or owns property in the state.

The important things to remember are that the patient makes the request for the lethal prescription, multiple times, not a doctor or third party, the patient must self-ingest the medication and that there are built in safeguards, approximately 13, to ensure that the patient is not being influenced by nefarious individuals with self-interested motives. I will pass out the Oregon guidelines at the end of my talk.

Statistics in Oregon and Washington show that not all people who obtain the lethal prescription end up using it. But what they do say is that it gave those people peace of mind, a “key to the exit” so to speak, sort of like an insurance policy, so that if and when they reach a point where they want and need to use it, it will be there for them. And no physician can be forced to participate.

In a democracy we enjoy many personal freedoms.  We may marry or not marry. We may have children or not have children. We may go to college or not go to college. We may travel or choose not to travel.  We may go to church, temple or mosque or not go.  I could go on and on where the government may not intrude on certain decisions we make in our lives, important decisions. I can certainly understand why some people would not avail themselves of physician assisted dying, because of religious or other personally held beliefs.  I respect that. My question is why a vocal minority wants to prevent others without such held beliefs from availing themselves of aid in dying during a terminal illness.  In the lawsuit filed in Montana which lead to their Supreme Court decision allowing physician assisted dying, it was written “The decision about how to cross the threshold to death when delivered there by terminal illness is a profoundly personal one. Some will choose to cling to life even in the face of unremitting agony. Others will seek a measure of control over the time and manner of death…If the Montana Constitution’s guarantees of privacy and dignity protect any decision, surely they protect this one.”

In 2014 a Health Day/Harris Poll found that 74% of American adults support DWD laws. 14% oppose it. A Health Day reporter wrote that “This poll found support for the RTD movement cut across all generations and educational groups, both genders and even political affiliations.” 64% of Republicans favor PAD, 78% of Democrats and 78% of Independents. Another national poll in 2015 revealed that 81% of 18-34 year olds support it. Regardless of these polls, these laws remain stalled in most state legislatures.  Why is this so?

The most used argument against aid in dying is that it diminishes the sanctity of life.

This argument supports the belief that only God can determine when a person should die and that the taking of one’s life is suicide, an act forbidden by all holy books. But aid in dying is not suicide. There is a significant difference between suicide and death with dignity. A person who wants to commit suicide wants to die. Following a suicide, family members and friends are shocked, bereft, angry, guilt ridden and filled with terrible sorrow. But terminally ill adults who avail themselves of aid in dying do not want to die, they want to live. But they have been given a medical death sentence and they do not want to suffer a lingering death from an illness or condition which was not of their own choosing. Following a death from aid in dying, the family of the patient grieves at their loss, of course, but not in the way that a family does following a suicide.  They are not shocked, angry or guilt ridden. Unlike the families of suicides, they were able to be with their loved one when they died, holding their hands, saying their goodbyes and watching their loved one gently and peacefully die.

Although the hierarchy of most religions do not support death with dignity statutes, the Unitarian Universalist Association does as reflected in its 1988 Resolution advocating the right to self-determination in dying and supporting aid in dying.  Other religions are beginning to debate this issue as more and more of their members are vocally supporting the law because of personal experiences they have witnessed with the death of loved ones.

Although most conservative religions oppose this law, the Catholic Church remains its greatest opponent. It pours millions of dollars into states to defeat these laws by financing boots on the ground and misleading political ads. They put pressure on legislators to vote against a law that is publicly popular. The church shamelessly calls it euthanasia which they know is absolutely illegal in every state in the USA, including every state which has legalized aid in dying. Euthanasia is defined as the putting to death of a patient by a doctor who injects a lethal pharmaceutical into the patient. In aid in dying, this pharmaceutical must be taken by the patient.

Every supporter of death with dignity honors an individual’s right not to choose aid in dying and asks the nationwide religions to return the favor by not precluding terminally ill patients the right to avail themselves of it.  As the Death with Dignity National Center has stated: “we don’t force you to do it so don’t force us to forbear it.

The American Medical Association opposes medical aid in dying.

It states that under no circumstances should a physician intentionally cause death. Physicians are healers. However, Hippocrates, the father of Western medicine, also said “Cure sometimes… comfort always.” And many doctors believe that relieving a terminally ill patient’s suffering is the highest form of comfort.  As one doctor noted, we should not look just to the quantity of life but to the quality of life.

The AMA claims to speak for the nations doctors however only 25% of physicians are AMA members. Furthermore, the latest survey by Medscape shows that in 2014, 54% of American doctors support aid in dying, up from 46% in a 2010 Medscape survey. Medscape is owned by WebMD and is an online resource for physicians.

In addition, the following medical organizations support death with dignity laws: American Medical Women’s Association, the American Public Health Association, the American Medical Students’ Association, and the American College of Legal Medicine.

Another popular argument against aid in dying is the potential for abuse within vulnerable populations: the elderly, the disabled, and the depressed.

However, strict records kept by the Oregon Public Health Division reveal that the majority of people who avail themselves of the Act are not poor, minority or disabled but white, middle income or above and well educated. If in the opinion of either the attending physician or consulting physician a patient may be suffering from a psychological disorder or depression causing impaired judgment such patient must be referred to a state licensed psychiatrist or psychologist.  No prescription may be given to the patient as long as that patient is mentally impaired.

And furthermore, various state polls reveal that a strong majority of voters living with disabilities support DWD: In Conn. 65%, Mass. 74% and in New Jersey 63%.

It is argued that terminally ill patients could be coerced into choosing assisted dying as a cost containment strategy by family members overwhelmed by the caretaking and financial burdens or by nefarious potential heirs who want a pay out sooner rather than later. However, the facts do not support this argument.  As stated earlier, this law has been on the books in Oregon since 1997 and in Washington State since 2009 and because of built in safeguards in the law there has been no evidence to show that the law presents these risks.

In his paper entitled “Ten Years of ‘Death with Dignity’ “ published in 2008 by The New Atlantis: A Journal of Technology and Society, Professor Courtney Campbell from Oregon State University, and an opponent of aid in dying, wrote: “The procedures embedded in the statute for ensuring informed and voluntary decisions by terminally ill patients have been substantially effective. The pre-implementation concerns of critics about coerced or compromised choices do not seem borne out in practice.” In 2015 Prof. Campbell was interviewed by a national Canadian newspaper and stated that “the Act has worked so well that the national media who put a spot light on this law when it was enacted and continued to do so at its 5 and 10 year milestone, paid scant attention to it at its 15th year milestone.”

In fact the truth is that very few people avail themselves of aid in dying as it is now written.  It is only those terminally ill adults who have found their condition to be unbearable who actually access this way of dying.

Opponents argue that death with dignity undermines Palliative and Hospice Care.

This has been proved to be false.  In Oregon and Washington State, their public health records show that 90% of patients who used aid in dying, die at home under hospice care, which is twice the national record. Although hospice organizations in Oregon initially opposed the DWD law, their experiences with the dying eventually caused a change in attitude where they now see the benefit of aid in dying for some patients and now work hand in hand with death with dignity advocates.  In an article by the Bellingham Herald, a Washington State paper, the writer stated that “end of life care improved in Oregon once this law went into effect. It increased hospice care with greater attention to pain management on the part of doctors and provoked a better relationship between the patient, their doctors and their families as they could now openly discuss end of life issues.”

The biggest hurdle in Texas, however, is with the Texas Republican Party which has stated in their Texas Republican State Platform: The sanctity of innocent human life, created in the image of God, should be protected from fertilization to natural death.

Under their Candidate Support plank it reads: The Republican Party of Texas should provide financial support only to those candidates who support the right to life planks. I have heard from several moderate Republicans that there are moderate Republican legislators who would like to support aid in dying but they know that right to life activists will run opponents against them in primaries if they file or support such a bill.

In conclusion, since Texas does not have a ballot initiative process our only avenue is to ask our state leaders to draft or support a DWD bill similar to the statute in Oregon.  Although an uphill battle, I remain optimistic because of the national polls that show a majority of conservatives are in favor of this law because they, like all Texans, believe in self-determination when it comes to our personal health decisions.

I ask all of you who would like Texas to have a physician assisted dying law to contact your state representative and senator and ask them to draft or support a Death with Dignity bill.  Edward Everett Hale once said “I am only one, but I am one. I cannot do everything, but I can do something. And I will not let what I cannot do interfere with what I can do.

Suffering from Lou Gehrig’s disease, an advocate of an aid in dying law once said, death is inevitable but suffering should be optional. Thank you.