COMMENTARY

More States Approve Physician-Assisted Dying. Is This Risky?

Arthur L. Caplan, PhD

Disclosures

November 02, 2015

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Hi. I'm Art Caplan at the Division of Medical Ethics at the New York University (NYU) Langone Medical Center. Physician-assisted dying has been in the news a lot lately. The California state legislature passed a bill permitting assistance in dying to the terminally ill. This is the latest in a series of efforts to enact legislation. Oregon and Washington have had legal physician-assisted dying for some time. Vermont passed it last year; Massachusetts turned it down. Many other states, such as Colorado, have bills pending.

It is a tough issue with many close calls about whether it's right or wrong for physicians to assist with dying. Physician organizations have been moving from opposition to neutrality for this kind of legislation. This happened in California. The California Medical Association was opposed but shifted its opposition to neutrality, and that is part of the reason the bill was able to get through the legislature. Politically, the Catholic Church, conservative protestant organizations, Orthodox Jews, and many disability groups are on one side saying, "Don't enact this, it's too dangerous." On the other side, we have people like Brittany Maynard, a young woman who died at a very early age from a brain tumor. Her family was incensed that she had to go to Oregon for physician-assisted dying, and they and other families touched by this pushed very hard to get physician-assisted suicide legalized. It's interesting that these families are empowered. They are usually people who have health insurance and no problem getting to a doctor. This is a movement for legalization that is more by the "haves" than the "have nots."

One of the reasons why people say this legislation should not be enacted is they are worried about going down a slippery slope. If we permit it for the terminally ill, we are going to wind up permitting it for everybody and anybody who asks for it. We have seen a little bit of that behavior take place in Belgium and Holland. Belgium and Holland permit assistance in dying to people who are suffering. But suffering is a pretty vague concept. They have had people with mental illness, severe depression, disability, and people going blind or deaf saying they don't want to live that way, and they have been helped to die. And recently and most startlingly, someone was helped to die who said she could not stop grieving for her deceased husband. She was not terminally ill. She just said, "I can't stop this horrible sensation of grief," and someone helped her to die. Those are startling facts. When it's due to divorce, disability, mental illness, or financial misfortune, I would not want us to say, "If you say you are suffering, then a doctor can help you die."

In the United States, the legislation has very strong protection. You do not get assistance in dying unless you are terminally ill. You are supposed to be certified as terminally ill in the State of Oregon by two doctors who say you have less than 6 months to live. If they are worried about your mental status, they are supposed to get a psychiatric or psychological assessment done. You have to be competent to do this. You have to be over 18. You have to make the request orally twice and then once in writing. One person, who is not part of your family, has to witness the request, so there is no hanky-panky about trying to get your estate or money or anything like that. And, ultimately, you have to take the pills yourself. No one puts them in your mouth.

That system has worked in Oregon. We do not see big abuses. The only people who see problems in Oregon—after 20 years of experience—do not live in Oregon. There is no movement to change the law; the people in Oregon seem satisfied with it. The authorities write an annual report on who has used it, and only a relatively small number of people—in the hundreds—have actually availed themselves of requests to get lethal doses of pills over the past 20 years. Remarkably, even out of that small number, about 40% don't take the pills. They like having the parachute available to them, but they choose not to use it and probably live longer than they might have because they have this option of taking a lethal dose of medicine.

I'm not moved by the objections. States like California can enact this legislation. It requires a lot of regulation and requires us to be very careful in circumscribing how it can be implemented. You can't just open the door and say, "Anybody who is suffering can have assistance in dying." That takes us to places where Belgium and Holland are going—where I do not think it's prudent to go. At the same time, we ought to be giving patients the right—although they don't have to use it—to die less painfully, to die in a more dignified manner, to die in a way that they are comfortable with. It is a close call, but at the end of the day, the objections do not hold. States ought to enact legislation permitting the terminally ill to have the right to assistance in dying.

I'm Art Caplan at the Division of Medical Ethics at NYU's Langone Medical Center.

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