GRAY MATTERS: Assisted Death
Saturday, 19 June 2010
Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.
The poet Dylan Thomas said it best for those of us of advanced age: “Do not go gentle into that good night; rage, rage against the dying of the light.” But what if there is no good alternative to quietly turning out your light?
In Connecticut, the home state of insurance giants, a legal and moral battle rages that may have national implications as two physicians have sued the state for an action that could eventually allow patients to choose a peaceful, drug-induced death to avoid the pain and terrors of a terminal illness.
As CNN's Randy Kaye reported,
“While courts have addressed constitutional questions connected with aid in dying, no court has directly considered whether a mentally competent, terminally ill patient’s desire to bring about a peaceful death should be considered a ‘suicide.’”
That’s vital, for a suicide is generally against the law and the family of the person who dies may suffer spiritually and legally, including the loss of insurance and other claims.
Thus, Connecticut physicians Dr. Gary Blick and Ron Levine are suing the state, asking that the state’s laws restricting assisted suicides should not include cases in which mentally competent, terminally ill patients take their own lives to avoid pain and suffering.
The suit, which a superior court judge has dismissed on technical grounds, was prompted in part by several cases in which people have been punished for helping friends or relatives to die. Right to die advocacy groups are expected to appeal.
In the most publicized case, in 2004, John Welles, who was dying of cancer and suffering, pleaded with a friend, Hunt Williams, to give him a pistol. Williams did as his friend asked. As Welles walked away in the woods, Williams shouted “God bless” and heard the gunshot. Welles died and Williams was convicted of “assisting a suicide,” a felony in the state.
Blick’s suit was aimed, in part, to clear and free Williams and win permission to end a dying patient’s suffering. Said Blick,
“We’re not talking about hooking up a potassium chloride drip and have our patient’s heart stopped. We’re talking about terminally ill patients who I’ve counseled over the years and that I would like to give them prescriptions and help them die with dignity.”
Blick, the Medical and Research Director of CIRCLE Medical, is a specialist in infectious diseases and HIV-AIDS, which raised for me a question. Not a few years ago, AIDS was considered always fatal. Now it’s not. How many AIDS patients took their lives, rather than wait for the life-saving treatments now available?
Nevertheless, if Blick and Levine are successful in their campaign, Connecticut could join a growing number of states that recognize the right of a terminally ill patient to end his/her life with the help of a physician.
The recent HBO film, You Don’t Know Jack, was a sympathetic portrait of Jack Kevorkian who was jailed for helping a number of people die, most them not his patients. But he brought the issue to a life that is growing. Recent polls indicate that 60 percent of whites (38 percent of blacks) favor allowing physicians to assist the terminally ill to die.
By all accounts, Oregon’s pioneering “Death With Dignity” law has been doing what was intended. The 1998 law (which has been copied in Washington state) has survived legal challenges including protests by members of Congress because of its safeguards. A physician must determine that the patient has less than six months. and a second opinion is required. The patient must make repeated requests, waiting at least 15 days between requests.
If these procedures are followed, an Oregon physician can prescribe the life-ending drugs, which may be taken with or without a doctor present. In this way about 30 persons a year have gone through the process and died, usually with close family members present. Most of the patients were suffering from advanced cancer or ALS (Lou Gehrig’s Disease).
Leading medical institutions, Harvard Medical School and organizations such as the American Medical Women’s Association, the American Medical Student Association and the American Public Health Association support legislation permitting physicians to assist terminally ill patients to take their lives with drugs.
The American Medical Association stands opposed. And the American Academy of Hospice and Palliative Medicine is neutral, possibly because proper hospice care (in which I am now a participant) can avoid the need to take one’s life and even put off death.
But in the end, hospice provides for pain free and comfortable last days with the help of a hospice nurse to tend to the patient and a hospice social worker to work with the family.
Much of the opposition to assisted death also comes from the severely disabled and persons with serious chronic diseases. They fear, with some justice, that they and people like them will be vulnerable if, for example, their insurance companies balk at the cost of their care. Remember former Colorado governor Richard Lamm telling such people to “get out of the way” because they were costing Medicare too much money?
Other opposition comes from religious institutions and right-to-life organizations who also oppose elective abortions. I disagree, of course, but I believe that just as the state should stay out of a woman’s right to choose, so the state should not need to come between a dying patient and his/her right to choose the manner and time of his/her death.
Oregon’s statute, I admit, is a model of regulation for the safety of the patient’s rights and to guard against abuse - say by relatives who can no longer care for the patient. But the choice of hospice seems to be minimized. That’s why I’m uncomfortable with such organizations like Compassion and Choices, which seems to advocate an end-to-life as if it were a walk in the park.
They may encourage people to seek the alleged comfort of death for no good reason. A woman I know whose medical problems are serious but not life threatening seems to have given up on life because she’s despondent over the death of her husband.
End-of-life advocates seem to provide little encouragement to fight a disease, as I am, and the reasons for their despondency, the better to hang onto life and “rage against the dying of the light.”
As another, more gentle poet, Robert Frost. has written, “The woods are lovely, dark and deep. But I have promises to keep and miles to go before I sleep. Miles to go before I sleep.”
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When I was caring for my mother during her last months, she asked me to "help her die." There was no possibility of recovery or even being able to live with her liver cancer, and she wanted me to do something right away.
Although she wasn't in a lot of pain, she couldn't eat much without being sick and she could no longer get out of bed or care for herself.
I took 24 hours to think over her request and, of course, told her I would do so if that is what she really wanted. I say "of course" because she was my mother and because she asked, and because she wasn't going to live more than a few more weeks and she hated every day of being totally dependent.
There was no internet in 1992, and I had no idea what the penalty would be if I were caught, but I decided I would just have to face it if I were caught. Because she asked and because she was my mother.
It's not hard to find the right kind and quantity of drugs for someone to die peacefully, "to go to sleep one last time," as mom requested and I did so. I told her we had the drugs, but I wouldn't give them to her until she asked again. She never did and she died quietly in the afternoon about three weeks later.
Because of this, I've had reason to think about assisted suicide, assisted death, whatever to call it, a lot in the years since then. I agree with you that some of the organizations make it sound like too much a "walk in the park."
Such laws as Oregon's and Washington state's concern me too because, over time, assisted death comes to seem ordinary. And that can lead to acceptance of ideas such as Governor Lamm's.
In a culture where Pete Peterson and other deficit hawks want to kill Social Security and Medicare, I don't think it is a stretch to imagine him and others to begin suggesting that old people have an obligation in certain circumstances to move nature along, so to speak, and they would justify such suggestions as they do killing SS and Medicare - to save money.
Important, complicated and compelling topic today, Saul.
Posted by: Ronni Bennett | Saturday, 19 June 2010 at 06:14 AM
Thank you so much Saul. Hugs.....
Posted by: Mage B | Saturday, 19 June 2010 at 08:04 AM
I kid with my daughter about saying it's time for me to go out on the ice floe. She always tell me it is not time yet. But someday it will be time and I wish I lived in Oregon or Washington where I would have the option of ending my life if I were terminal.
The word 'terminal' must be a necessity for assisted suicide. The request for help should only be granted after two physicians have pronounced the patient to be terminal within a proscribed time.
I do not think, nor do most people, that assisted suicide should be granted easily or just to end pain. There are other remedies for that. The hospice program is wonderful and should be tried before assisted suicide is contemplated.
My husband was in the hospice program and I cannot say enough good about it. Although there were no beds available when he was within two weeks of death (It has now been expanded, but then there were only 9 hospice beds and you had to be two weeks away from death to be cared for there) the nurses were of so much help to me in aiding my husband that I bless them every day.
You are scaring me, Saul, when you say you are in the hospice program.
Posted by: Darlene | Saturday, 19 June 2010 at 08:35 AM
As an Oregonian, I strongly believe in Oregon's law and it really is not something most people will be using nor have they. Some have gotten the prescription but never used it finding comfort in just knowing they could. When it first came on the ballot, I voted against it for the fears that are mentioned; but the second time I voted yes and have felt it was a good choice. You cannot just have a terminal illness but there must also be a life span of less than 6 months. That doesn't happen all that often with doctors as they often don't know how long one might live.
I think it's a lot kinder than a gun or maybe taking the wrong number of pills and being worse off than before. It's not for the elderly or depressed, and it's only for those who request it themselves. I think to worry it might be abused is to face the reality nothing is fail safe, but in this case with several doctors involved and one of them about mental state, I think the risks are low. The stories I have read of those who used it, they knew what they were doing and got to die with their beloveds near them, something that you don't get if you don't have control. The very ones that some fear might force people to use it are the ones who disagree with it even being available and usually for religious reasons.
Posted by: Rain | Saturday, 19 June 2010 at 09:50 AM
My 91 year old father just signed up for hospice. I don't know as much about it now as I will in a few weeks, but I have seen research that suggests people who qualify for hospice live longer if they enroll in hospice (the earlier the better) than those who don't enroll.
Dad's hospice providers will come to him where he lives offering him another layer of care over and above what he already receives in assisted living.
Apparently people who join hospice these days do not sign away their right to go to a hospital when they become ill if that is what they decide to do at the time. Even treatments like chemotherapy are okay if they are intended for "comfort" rather than "cure".
I gather that the only iffy area might be what insurance or Medicare might cover once someone has signed on for hospice. Hospice is covered 100% by Medicare, but hospital treatments might be problematic.
Everything I hear about hospice is very positive. We are glad that my dad has chosen it, because we have begun to feel in over our head with regard to determining his medical needs. It is reassuring to us that the pros will be watching him closely and doing whatever can be done for his well being, comfort and quality of life.
By the way, I always thought that calling in hospice was a 6 month death sentence. However, I have a friend whose mother was under hospice care for 2 and 1/2 years. Lot's of people apparently forgo hospice until death is right there on the doorstep because of this and other misconceptions about hospice care.
Posted by: Carol | Saturday, 19 June 2010 at 09:59 AM
Saul, I read your essay informing “us” of your condition, and daily send you thoughts—hopefully there is something to thought-power or perhaps it will become part of genetic memory to help move our off-spring to a higher level of caring, one day.
I have died twice, clinically, and remember the last time asking the determined doctor why he brought me "back" only to have to go thought 'it' again. “Waking up” was not painless, or comfortable – it was terrifying.
Life comes, and it goes. Each time, I heard no violins or harps in spite of being a chamber music aficionado; saw no pastures, no people waiting who had "gone on" before me - no white light. Nothing in fact, it was like I had been asleep.
Hospice will not be in my future – I’m fiercely private about my friends, former colleagues, lovers, and am not in favor of the Hospice "interrogation" into our lives – if I have to move to Oregon or Washington to be able to move out of life with some shred of self-esteem, amen.
I’ve lived 60 years with a condition for which I am dependent on an external "force" to keep me alive – and that did not prevent me from living a full life educationally, and socially, thus, simply unplugging it and adding a little relaxant will do it; however, the medical profession has rendered me terminal many times because they didn’t believe me, or respect a condition that has taken millions of lives worldwide – us survivors have been at their mercy most of our existence on earth.
What’s all the ‘buzz’ about in Connecticut? That’s also the state that refused to permit women to have prescriptions for the BCP years back. There’s nothing new about a knowledgeable, caring physician medicating to primarily relieve pain, which may in turn result in death – that’s been happening since only plants were used for medicinal purposes, before Dr. Withering discovered the values of the digitalis plant. Pompous arrogance is the only possibly sane reason for any state to interfere with lives terminating -- more so one as Conservative as Connecticut wanting no government interferences.
This abject interference is rather like that which forces women to find back-alley surgeons, use wires, take overdoses of drugs, and worse, to end a pregnancy as soon as possible.
Kevorkian was the paradigm shift for humanity in the USA. Without Kevorkian, our nation will continue to slaughter people in other lands, control their home health services, indeed remove them without caring, take lives by lethal injection or electric shock (by physicians no less) but not allow people to die in peace.
Those who want to plan out their lives and their deaths have a right to our support, caring, and attention so they make be assured of control over their existence.
Posted by: ElderSpeak | Saturday, 19 June 2010 at 12:31 PM
I think Hospice is a great program, and one of the most important articles I ever wrote long ago was about the start-up in our local community. Since then my mother, my father-in-law and mother-in-law were in Hospice, eventually dying.
I do think individuals should be able to die with dignity, assisted by a doctor if that is their wish. And I I'm very impressed with Oregon's law and how it has evolved.
When I was 23, I nearly died, and went through a period of intolerable suffering/pain. But I was young, and survived. Yet that left me with the knowledge that one can be in such pain/suffering there is NO relief, and frankly, I do not want to live under those conditions. I've taken advantage of all the means of pre-planned suicide, if I should reach that point of suffering. Still, I wish there was a law here (Alabama) like that in Oregon, just in case I was unable to carry out my wishes myself.
Your posts are always thoughtful and insightful, Saul. Thank you for that!
Posted by: Cara | Saturday, 19 June 2010 at 02:56 PM
Thank you as usual, Saul, for your wise and insightful comments. None of us ever knows exactly how he will react when end-of-life is perhaps no longer an abstraction. That being said, I am a strong advocate of exercising some control over how and when I exit this world.
Speaking strictly for myself, retaining my personhood and dignity is way up there. Unless one is wealthy (I'm not) almost nothing risks compromising both more than end-of-life care as imposed on many old people by the U.S. health care system. If I find myself in that situation, facing no meaningful recovery, I would urgently desire a merciful exit and have signed every available document to that effect.
I'm a supporter of Compassion & Choices. They are a big reason why, as a resident of Washington State, I have the legal right to exercise a degree of control over my demise. The law isn't perfect and I may yet need a fallback plan. Like Cara in Alabama, I'm working on that. I also support the concept of hospice, but it can be intrusive and may not be enough, as other responders have noted.
It's always been a point of interest to me that conservatives--who vociferously insist at every turn that they want government out of our wallets and our lives--presume they have the right to decide for ME how I should end MY life. How arrogant! That's the most personal of decisions--or should be.
Posted by: Elizabeth Rogers | Saturday, 19 June 2010 at 06:58 PM
One of the interesting side-effects of our law here in Oregon--which doesn't quite go far enough for me, who would prefer it apply to those with conditions not necessarily terminal--is that it jump-started the hospice movement. Palliative care for the dying is much more advanced and available now than it was when I was trying to take care of my parents thirty years ago.
Posted by: murr brewster | Saturday, 19 June 2010 at 10:09 PM
Glad you keep on walking those miles, Saul. We need your thoughtful commentaries.
Posted by: Cynthia Friedlob | Sunday, 20 June 2010 at 01:19 AM
I will only add this to the topic. It is very helpful to those whose parents are "elderly", to have all the legally signed papers of their state, DNR's etc. when/if the time comes. My parents did this and when my 92 yr old Mother had a final stroke, she was kept comfortable, unconscious and I spent her final days with her. It appeared peaceful and I was at peace with that decision. Each situation is different and calls for difficult decisions, legally and morally. I, in a way, equate these decisions to having to put down a beloved pet. It isn't easy and making that decison is not: it comes with pain and perhaps playing God with that life. Knowing all the circumstances makes it right and should not the same be available for beloved family, friends and us? I am not totally certain, yet
Posted by: kate | Sunday, 20 June 2010 at 07:48 AM