Residential Space A creative outlet during residency, turned ongoing virtual soap box

Posted on Wednesday, January 18th, 2006 at 6:32 pm. About News and Politics.

Oregon’s “Death with Dignity” Law Upheld

I learned from NPR upon awakening this morning that Oregon’s “Death with Dignity” law was upheld in a 6-3 decision by the U.S. Supreme Court this week. I have been intrigued by this law ever since I declared my medical humanities minor at the University of South Carolina in 1999. It is now interesting to be practicing medicine in a city three hours from Portland, Oregon, as the issue seems even closer.

In 1994 Oregon citizens approved the Death with Dignity Act in the form of a state-wide ballot initiative. The law allows physicians to prescribe lethal doses of medication to patients who A) are terminally ill and are assessed by two different physicians to have less than a six month life expectancy, and B) make the formal request, are found to be of sound mind, and repeat the request at least two weeks from the initial date. The same initiative was reintroduced on the ballot in 1997, and again Oregonians approved it. Physicians who feel uncomfortable with the law are not obligated to participate in this practice.

President Bush took the state of Oregon to court over the issue, claiming that the law violates federal drug regulations (ie, drugs are not approved by the FDA for the purpose of killing patients, therefore prescribing drugs for this purpose embodies an off-label use). I think many of us recognize that the actual purpose behind the lawsuit was to keep patients from being able to end their lives; the motive is obviously of a strongly religious overtone consistent with the president’s self-proclaimed fundamentalist Christian beliefs. In any case, the Supreme Court disagreed with the president. Justice Anthony Kennedy stated in writing the majority opinion that federal regulations are to prevent drug trafficking, and that the state of Oregon’s practices are not in conflict with this federal regulations.

My views on this issue have changed somewhat over my past seven months as a physician. Before my residency began, I was in favor of the Death with Dignity Act, believing that patients should have the right to say “enough is enough” and bow out gracefully. I always claimed that *I* would never do it, but who was I to say that others couldn’t? I also believed that, as a physician, my role was to “do no harm,” and that I would not participate in such practice, despite my support of the law’s principle.

At this point, I have spent a month on the University of Washington’s oncology service. Every fourth night, I was the sole physician in charge of 40+ cancer patients, entrusted with the duty of keeping everyone alive and comfortable throughout the night until their primary teams returned in the morning. The first patient I ever pronounced dead was a leukemic woman I met during that difficult month. I thought I knew suffering until I spent sleepless nights with these people. It is pain beyond what is imaginable – needing to cough because one can’t breath well, but being too weak to do so; intense oral and gingival burning and bleeding because the tissue in the mouth is destroyed from radiation therapy, and being mostly unable to stop it because the body’s platelet stores are wiped out; around-the-clock vomiting from chemotherapy; being unable to speak because yeast has completely overtaken the throat and esophagus; infections involving the eyes and vagina and skin. I once had a patient that did not sleep for seven days because of an unremitting severe headache that would not respond to even our strongest narcotics. Who among us can begin to empathize with what it must be like to live like this not for hours or days, but months and perhaps years? Several patients told me they were just waiting to die, if only the process could be sped along. The best option I could offer them was “comfort care,” to keep them sedated with heavy doses of medications while withholding food and hydration (at their request), allowing them to die slowly over two weeks.

As one might imagine, I am now not only a supporter of Oregon’s law, but were I practicing medicine in Oregon, I believe I would be doing my patients a service by honoring their wishes. I have never even withdrawn care on a patient without discussing it with at least two other physicians, going back through all of the patient’s legal documents, and having a lengthy discussion with the patient to ensure that he fully understands the consequences of deciding to remove life-sustaining medications. At times, if I have had the slightest doubt as to decision-making capacity of a patient, I always call the psychiatry team to evaluate the his mental status formally before withdrawing care. The decision to assist a patient in ending his life is not one I would take lightly, but I can say with confidence that I would save him the despair of wasting away painfully if he requested this of me.

One time I investigated the meaning behind “I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect” in the Hippocratic Oath, and what I found was this: physicians used to be hired assassins in ancient Greece. A wealthy family would pay a physician to assassinate a member of a rival family when the sick person had believed the doctor was giving medication. Physicians also mixed poisonous substances using their knowledge of plants and would sell these concoctions to interested parties. Physicians were used to induce abortions in the wives of rivals under the false pretense of providing care. Hippocrates was not thrilled with this, and it motivated him to create his now famous Oath for physicians as a means of establishing a code of conduct. We are not talking about assassinating people in the Death with Dignity law. Besides, I believe it is doing a great deal of harm to a patient to strip him of self-determination during the final days of his life and force him to endure pain beyond what any of us know.

So I send a relieved “thank you” to six of our Supreme Court justices for ensuring that terminally ill people can maintain a sliver of dignity during the dying process, an experience that is quite personal and, I believe, really not the business of the powers-that-be in DC.

 

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