Vermont Death with Dignity Act
Following Oregon's lead, the Vermont legislature is considering a bill (HB 168) to offer terminally ill patients the option of a prescription medication to hasten their death.. The law itself, in broad summary, provides that only the patient can initiate a request which must be in writing, there is a 15-day waiting period, two witnesses must attest the patient is acting voluntarily, two physicians must be involved, and counseling is required if the MD feels the pt is depressed or has any psychological pathology. The bill has the support of many people and institutions including the Burlington Universalist Church, the VT Alliance for Ethical Healthcare and others.
I'm not so enthusiastic. I greatly admire Timothy Quill and his work advancing a humane medical approach to the dying patient, but I feel that full-blown legalized physician assisted suicide will do more harm than good. Here's what former Surgeon General C. Everett Koop wrote about the Oregon law legalizing MD-assisted suicide, Measure #16:
As former United States Surgeon General, I have worked first hand in developing health care policies. Many proposed policies at first sound like good ideas, but in fact are very dangerous. Measure #16 is one of those policies...
Measure #16 prescribes suicide as a treatment for disease. A patient's request for suicide is a signal that certain needs are not being met. Most likely, the patient is suffering from unnecessary pain or treatable depression. Doctors too often fail to dispense adequate pain management. The solution is to provide mental health treatment or better pain management, not drugs for suicide. This is the time for the doctor to be the patient's support, not his/her killer.
Measure #16 is ripe for abuse. The so-called safeguards built into Measure #16 are inadequate. Patients remain vulnerable to outside pressures to choose suicide. Physicians are required only to suggest the patient notify family members, leaving many to choose suicide without the support of loved ones.
Measure #16 strikes at the most vulnerable. Cost containment is a positive and necessary step toward health care reform. However, in this environment Measure #16 is dangerous. Poor, elderly, frail and disabled patients will be the victims if the "choice" to die becomes the "duty" to die.
A patient's request for suicide is a signal that certain needs are not being met.
In my own experience, there are two types of relevant situations. In the acutely ill patient with a dismal long-term prognosis from a terminal illness, the wish to control uncomfortable symptoms becomes paramount to any life-prolonging treatment and the patient is treated accordingly--these are patients who might be termed 'actively dying' before your eyes. They routinely recieve pain and sedation medications at doses which may hasten their death, in an effort to provide comfort.
These situations are not where a Death-with-Dignity law will apply. Instead, it mostly will be invoked for the ambulatory patient with uncomfortable symptoms, who despairs of further deterioration. These are the patients that palliative care services can help so much, but often are connected to them too late. Rather than presenting them with the initially appealing option--and perhaps eventually, in some sense a duty--to choose controlled early death, these folks should be referred for hospice and other palliative services. Their needs often involve a desire for control over the circumstances of their death, and assurance they will not be exposed to extreme suffering--we have the means now to meet these needs without assisting them with suicide. And my experience is that when such needs are addressed, the wish for hastened death vanishes.
Sometimes the meaning that patients find in the end of life is as simple yet profound as facing what comes as an example to their families, or as a final task for themselves they wish to do right. These things are not possible while symptoms are not well controlled, but when they can be, the death of a family member surrounded by loved ones and perhaps a minister is part of the cycle that makes up a family's story.
When patients' requests for assisted suicide are understood as a communication that their needs are not being met, setting up a state mechanism to administer lethal prescriptions seems absurd. When the Vermont legislature returns from its recess, I hope this bill does not reach the floor.