A rebuttal to criticism of the Oregon Death with Dignity Act.

Abstract

To the Editor, Wesley J Smith, an attorney with the International Anti-Euthanasia Task Force, condemns the care provided to the first recipient of physician-assisted suicide under the Oregon Death with Dignity Act.1,2 I was the physician who monitored the patient's care. Mr Smith states that I described the patient as merely “frustrated.” I made careful notes at the time of my involvement with the patient. I had 4 prolonged telephone conversations with her, her 2 children, and a granddaughter. She had repeatedly asked her primary physician to help her die. This physician referred her to another physician, who thought that she was depressed. None of the other 4 physicians who saw the patient during the terminal phase of her illness believed that she was depressed. Her primary physician specifically noted at the time of her last visit that he believed her to be competent. When the second physician refused to help her, she felt powerless and desperate. The patient told me that she could no longer exercise, that her symptoms of breathlessness and paroxysmal cough were rapidly getting worse, and that she was afraid that she would soon be too sick to make a competent request. Her daughter said that her mother could spend only 10 minutes gardening, her favorite recreation, before becoming exhausted. I had telephone conversations with her second physician after each of the 2 visits the patient had with him. An x-ray film he had ordered at the time of the second consultation showed tumor infiltrates in both lungs. The physician who eventually provided her with the lethal prescription referred her to a psychiatrist, even though he thought that she was fully competent, and to an independent pulmonologist to confirm that she was terminally ill, competent, and acting voluntarily. He visited her at her home, consulted with her children, and was with her and her family when she took the prescription and died peacefully. This care Mr Smith labels as “pure Kevorkianism.” Joanne Lynn's commentary raises equally controversial points about physician-assisted suicide.3 Far from being a barrier to reform, debate during and after the campaigns that legalized physician-assisted suicide in Oregon was followed by measurable improvements in the care of the dying. Many hospitals and health care agencies made organizational changes to cater to dying patients' needs. There has been a large increase in the percentage of terminally ill patients dying at home. Oregon now has Hospice caring for proportionally more of these patients than any other state, except Arizona (A Jackson, Oregon Hospice, oral communication, March 2000). Lynn suggests that if the option were widely available, it would become “ordinary.” To the contrary, all of the physicians whom I know to have helped patients die have been deeply moved by the experience and deeply involved with their patients. The answer to Dr Lynn's question about why physicians should be involved in assisting patients to die is that they need our skills. Dying patients do not ask for “the mantra of acceptability granted by `the white coat.' ” We physicians delude ourselves if we believe that we “grant” acceptability. That is a verdict for the larger society. Dr Lynn worries that the poor and the socially deprived will be forced by circumstances to “choose” assisted suicide. This has not been the experience in Oregon. Physician-assisted suicide is to a great extent a privilege, exercised by patients who feel powerful enough to make their voices heard. Unfortunately, in our society the poor, the disabled, and the chronically ill seldom see themselves as having the power to significantly affect the thinking of their physicians. Dr Lynn refers to my “strange” use of the term “starve to death.” Her opinion that the time to dying of the patient was probably unaffected by the patient's decision to starve to death is irrelevant. She gives the impression that the decision was inconsequential. The patient understood what was meant, and his decision to starve to death gave him the control that eased his dying days. We all agree that care of the dying should be improved. Dr Lynn maintains that discussion of physician-assisted dying only diverts attention from that goal but provides no evidence to support that claim. The public dissatisfaction with terminal care, and the clamor that arose as a result, including widespread support for aid in dying or physician-assisted suicide, has goaded the medical profession to address the deficiencies in care of the terminally ill. I agree that physician-assisted suicide is not the most important issue concerning us, but it has encouraged us to confront those more important issues.