Dr. Robert Macauley of Charlotte is medical director of clinical ethics at Fletcher Allen Health Care.
There are many thoughtful arguments both for and against legalization of physician assisted death (PAD). Many commonly heard assertions, however, are either not relevant to the proposed law or are based on misperceptions. I hope that laying these to rest will foster respectful and informed discussions.
• Patients should have the right to die naturally, rather than being hooked up to machines: A competent patient already has the right to refuse any treatment he doesn’t want, even if he will die without that treatment.
• Patients who suffer from conditions such as chronic pain, advanced dementia, or ALS (Lou Gehrig’s Disease) need a way to end their suffering: The proposed legislation (following laws adopted in Oregon and Washington by voter referendum) would limit PAD to competent, terminally ill patients who can self-administer the lethal dose of a pharmaceutical, and therefore none of the patients noted above would qualify.
• There is no other way to help terminally ill patients in extreme pain: Contrary to popular opinion, fewer than 1-in-4 Oregonians who ended their lives through PAD cited “inadequate pain control or concern about it” as a reason for doing so. The most commonly cited reason was loss of autonomy, highlighting the fact that pain at the end of life can be controlled through intensive interventions which are already medically available and completely legal. The drug used to cause the patient’s death through PAD has absolutely no effect on pain.
• Legalizing PAD is a logical next step to the noble work already being done in palliative care: A great deal of attention has been paid to palliative care since PAD legislation was defeated in the Vermont House in 2007, by a vote of 82-63. Yet while hospice care in Vermont is of the highest quality, only 20 percent of Vermonters utilize hospice in the last six months of life, which places our state in the bottom 10th percentile nationally (source: Dartmouth Atlas 2008). There is a great deal more work to do, and here it is important to note that palliative care “intends neither to hasten or postpone death” (source: World Health Organization). PAD, by definition, is not palliative care.
• People who are opposed to legalization shouldn’t be able to revoke the right of others to PAD: On the contrary, legalization would establish a right that has never existed in Western medicine. Doctors who take the Hippocratic Oath vow that they “will not give a lethal drug to anyone if I am asked, nor will I advise such a plan.” The U.S. Supreme Court has ruled unanimously (twice) that there is no constitutional right to hastened death, although states may choose to establish such a right. Bills legalizing PAD have been introduced in 23 other state legislatures, but none of them have passed.
• If legalized, a lot of Vermonters would end their lives through PAD: Based on data from Oregon, we can anticipate that three Vermonters would obtain a lethal prescription in the first year of legalized PAD (two would use it), subsequently reaching a maximum of 15 prescriptions per year (up to nine patients would use them).
• Making PAD a legal option would provide many more Vermonters with peace of mind, knowing they would have the means to end their lives, if it came to that: The odds of obtaining a lethal prescription are actually very poor. Oregonians who seek a lethal prescription have only an 18 percent chance of ever obtaining one, through a combination of not meeting the requirements of the law, changing their mind, the doctor’s refusal or dying before the prescription can be written (source: New England Journal of Medicine). It’s debatable how much reassurance patients might derive from knowing there’s less than a 1-in-5 chance of obtaining the means to end their life through PAD.