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Minnesotans deserve better than the proposed death with dignity law

Physicians carry a duty to public health, and a duty to protect vulnerable patients from careless or negligent physicians.

I am writing in response to the Oct. 8 Community Voices article by Dr. David Plimpton regarding SF 1880, the "Minnesota Compassionate Care Act.” Dr. Plimpton presented many points commonly raised by proponents of assisted suicide or death with dignity laws; however there are many aspects of these laws that the public should be informed about that he did not address.

Dr. Annette Hanson

Over the past several months I have reviewed all existing laws and all proposed legislation submitted nationally on the right-to-die issue. I reviewed all available reports and studies regarding the Oregon practice. I listened to hours of testimony on bills introduced in Connecticut and Washington, D,C., and also testified myself in the Maryland general assembly regarding the death with dignity bill in that state.

I am concerned that the proponents of death with dignity legislation make repeated assertions, as Dr. Plimpton made, that there have been no documented abuses or problems with the Oregon law.

Weaknesses in Oregon law

What proponents fail to mention is that there is no independent mechanism to detect or investigate abuses of the Oregon law. While the health department gathers data and produces an annual report about the practice, it has no investigative authority. The law does not require any independent witness to the actual ingestion, and privacy laws protect patient records from outside review. The main mechanism for detecting abuse is entirely reliant on the self-report of a prescribing physician. In order to comply with this requirement, the physician only has to file certain forms with the health department in a timely fashion. Even with his minimal and pro forma standard, all Oregon physicians are not complying with the law.

Physicians who fail to comply with minimum reporting requirements — or who violate the law in other substantive ways — are entirely immune from professional liability since the law requires only “good faith” compliance. In other words, a prescribing physician only has to BELIEVE that he has followed the law properly to be immune from civil liability or professional sanction. This legal standard is even lower than that required to be liable for medical malpractice — which is absurd, given that the outcome of an error is the death of a human being.

Safeguards missing from SF 1880

Dr. Plimpton's ethical analysis of the death with dignity issues is limited only to the consideration of patient autonomy. However, as a member of a profession, physicians also carry a duty to public health, and a duty to protect vulnerable patients from careless or negligent physicians. To that end, SF 1880 carries no requirement for any prescribing physician to have any training or experience to recognize mental disorders, to access capacity for high-stakes medical decisions, or to be informed about all palliative care options. Two-thirds of the doctors prescribing fatal medication in Oregon now are family physicians with no specialty training in either oncology or psychiatry. The fiscal notes for the bills I've reviewed have not designated any funds for physician training, nor any requirement to be certified to prescribe fatal care. Adopting a law without these safeguards in place is analogous to selling a car without brakes. Minnesotans deserve better.

Legislators must also consider the public health impact of assisted suicide laws. This month, the first rigorous analysis of this issue was published in the Southern Medical Journal. In a paper entitled “How Does Legalization of Physician-Assisted Suicide Affect Rates of Suicide?” professors David Jones and David Paton documented that states which have death with dignity laws have a significant elevation in total suicides, both physician-assisted and unassisted. This refutes the proponents' contention that death with dignity laws provide only psychological comfort to the terminally ill; the law provides a ready means to die for people who wouldn't otherwise commit suicide.

Dr. Plimpton bases a right to fatal care upon a condition of “intolerable suffering.” The Compassionate Care Act allows a patient to request fatal care even in the absence of any pain or suffering. Most Oregon patients who are given a fatal prescription report that the request is based on fear of future disability or pain, not actual current circumstances. Nevertheless, some proponents have testified in favor of a “mental suffering” standard and would support assisted suicide for those diagnosed with psychiatric disorders even in the absence of terminal illness. I was particularly struck by the testimony of one proponent of the Washington, D.C., bill. He referred to that proposed law as “a good start” to the right-to-die movement. Similarly, the Senate sponsor of the Maryland bill told me that he felt his bill did not go far enough because he favored “euthanasia ... like Kevorkian.” People concerned about the expansion of aid-in-dying to euthanasia and to assisted suicide for non-terminal conditions have a valid basis for that concern.

The most vulnerable can't do phone surveys

I often hear that popular opinion polls favor death with dignity laws, but I disagree that popular opinion should determine medical standards and practice. Those most at risk from this practice — the severely disabled, and patients who are long-term residents of public institutions — are not able to express their wishes through telephone surveys. Physicians have a duty to speak up on their behalf.

I join the American Medical Association and numerous other medical and disability rights organizations in opposition to death with dignity laws. Thank you for this opportunity to provide accurate information to the public.

Annette Hanson, M.D., is a Maryland forensic psychiatrist, an assistant professor of psychiatry, and the director of the University of Maryland forensic psychiatry fellowship.

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If you're interested in joining the discussion, add your voice to the Comment section below — or consider writing a letter or a longer-form Community Voices commentary. (For more information about Community Voices, email Susan Albright at salbright@minnpost.com.)

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Comments (11)

Who controls our lives?

Sounds like another physician who knows better than her patients what they want.
Rather than toss out a lot of numbers, I'm providing a link to the Death with Dignity web site so those interested can get their point of view directly.
http://www.deathwithdignity.org/

Suicide Prevention, Abuse of Elders

I fear Dr. Hanson is raising issues regarding "death with dignity" for which the alternative she seems to favor,...

death WITHOUT dignity,...

is not a solution.

Minnesota does have serious problems, especially in rural areas, centered around the availability and affordability of well trained and qualified, effective mental health care practitioners for many who need their services.

Adequate mental health care and available care beds close to home for those who are going through mental health crises, including suicidal tendencies, are too often simply not available or affordable.

In far too many cases, county Health and Human Services personnel have caseloads that are too high to allow them to adequately monitor and track elders who may be at risk of abuse or neglect,...

especially when those people are living in private residences in the care of their own families.

They are often hard pressed to deal with documented abuse cases. Investigating cases where abuse or neglect might be suspected of developing, but is not yet externally evident, is often impossible.

These issues, though they may be related to "death with dignity" are, essentially a distraction. Their solutions lie elsewhere - in increasing funding for County HHS departments and supporting the recruitment and training of mental health professionals, especially Psychiatrists, to work in rural areas.

When it comes to "death with dignity," I can only say that, like many other people, if I were to fall terminally ill with no hope of recovery and the likelihood of rapidly increasing physical or mental disability or excruciating pain as my death approached, I would value the availability of my doctor's assistance in choosing when and how to move from this life to the next.

I would hope that the same would be available to any and all who might find it useful and helpful, as well.

Medical standards in death

Why should a physician advocate prolonged life without dignity over shortened life with dignity (and without excess pain and suffering) for a patient with a terminal illness? Call me cynical-- I can think of no humane reason, but I do know that dead people don't pay medical bills. I'm sorry if that's entirely off base, but I'm not convinced that a doctor should ethically deny a more comfortable death to someone who will die sooner rather than later, regardless of treatment. I agree that there need to be safeguards against abuse, but that's a social issue, not a medical one.

fear

While Dr. Hanson points are valid, I can't reach the same conclusion. It all seems to come down to demanding that people endure a significant period of intense, documented physical suffering before they're allowed to die - and also a requirement for yet another class of specialist to be called in. If people want to avoid this period of misery, I understand. Fear is suffering - in some ways the worst of all - as many of us have seen firsthand. We can't insist that someone first spend some time living in terror, followed by more time in actual agony, before we allow them to make this choice.

While I agree with Dr. Hanson that the situation created by this new law would be far from perfect, and has potential for abuse and mistakes, I still believe it would be, on balance, better than what we have today. When we see how things play out in reality, maybe we can create a better law in the future.

My rights....

How can anyone deny my right to die when I want and for whatever reason?

Those who defend "death with dignity," why do you refuse "death with dignity" to those who are not suffering and not terminally ill?

Choose for yourself

Dr Hanson is free to choose to end her own life in months of needless suffering and disability, but I sure don't want her having anything to do with MY end of life choices. My life, my choice, butt out, medical profiteers!

Loopholes eviserate intended safeguards, polling is contested

Dr Hanson, Thank you.
Note these loopholes and more work with each other to eviscerate intended safeguards.
By all these OR model laws all family members are not required to be contacted, hold that thought. A single predatory heir is allowed to steer the sign up and then execute the lethal process without a witness.
A witness is not required to confirm that the dose was so called “self administered” (you remember this was one of their lead selling points).
Even as the law provides immunity for all involved and demands the falsification of the death certificate (impossible to track trends for good public policy) it actually prohibits a public inquiry of any kind (remember the family members who were not contacted).
These loopholes and more are in the OR, WA, and CA’s laws and expand the scope of exploitation by predators and predatory corporations for windfall profits. However, it serves the health insurance corporations very well.
There is the Oregon Tami Sawyer Thomas Middleton case of abuse for assets.
Oregon and Washington should amend their initiative-sound-bite driven dangerous laws. California’s should be vetoed.
Also note how the promoters of assisted suicide cling to their verbally engineered polls that claim a majority is in favor. I polled thousands of Montanans one-on-one as I served 60 days at fair booths across the state. Once folks knew about the loopholes in all of the Oregon model bills, 95% were not for them. So much for their verbally engineered polls.

So you asked

leading questions
and got the answers that you wanted.

Author Response

I agree that lack of rural mental health services are a serious problem, however I would disagree that this is merely a distraction from the right-to-die debate. All existing laws and bills require a patient requesting lethal care to be competent to make this decision, and a mental health assessment is required only when an MD untrained in psychiatric diagnosis suspects there is a problem. In 2014, only four or five people were referred for evaluation out of the 104 who died in Oregon. Statistically speaking, this virtually guarantees that some patients have already died who were incompetent, or who had a potentially treatable psychiatric disorder.

Let's not forget that Minnesota has already experienced the actions of a rogue doctor acting in concert with the Final Exit Network to provide death on demand. If there are doctors willing to risk criminal prosecution now, why would they respect regulatory safeguards in a death-with-dignity law? This is particularly a problem since the fiscal notes for the California and Maryland bills did not provide any funding or additional human resources to do random chart reviews or investigation of noncompliant doctors. For physicians, this issue cannot solely be an issue of patient autonomy. And the general public would hardly be forgiving if our profession failed to stop a malicious or careless doctor providing fatal care.

Pulling at one thread leads to many others

Once we pick up one thread- death with dignity- we quickly end up talking about all the threads of health care because ultimately health care is about stopping death from happening for as long as possible. The dissonance between that and "physician assisted suicide" (or "death with dignity," the choice of terminology often reflecting which side of the debate one is on) is tremendous. Doctors try to stop people from dying, after all- it is what they are trained to do from the first day of medical school. Assisting them to die feels like the negation of that.

A key part of the discussion is "should you be allowed to choose when you die and how?" Many people believe that it is only up to a deity of some sort when you should die and that suicide abrogates that power. Often this subtext is cloaked in other, possibly more rational sounding argument, but most of the discussion really boils down to whether you believe you should be able to choose when to end your life. If you do not, for whatever reason, then you will likely not support "death with dignity" laws because those laws would contravene your values. Those who feel that you do, at least under some circumstances, have the right to end your life try to make different rational sounding arguments. I am not sure that rationality is really the way to resolve the discussion- the issues are really values and beliefs, not facts and figures. Do we end up with "good suicide" and "bad suicide?" If you're dying from something anyway, it is really suicide? Should you be able to end your life if the health problem is reasonably treatable? Do you have to even have a terminal health condition or intractable pain to be allowed access to doctor assistance in dying? Do the doctor's values and beliefs get taken into account? Some interesting discussion may be found at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1282180/

I frankly don't have a brilliant answer to the dilemma. Like many health care providers- I am not a doctor- I feel caught on the horns. I spent two hours of my morning taking steps to try to prevent someone from killing themselves only to have the suicidal person be turned away by the hospital twice in 24 hours, so as a health care provider I am sometimes engaged in trying to prevent suicide (that person is now in a supervised setting). I have also supported clients with terminal illnesses in making the decision to end the treatments that are prolonging their lives- or more accurately prolonging their dying. Some would argue that this is promoting suicide. On my mother's final day I made decisions with the hospital doctors that surely resulted in her death, based on the wishes she expressed and the values she held- as she put it that morning, she was "ready to go Home." Even with aggressive treatment she would have had at best a brief and unpleasant half-life of pain and disability. Her death was graceful and peaceful, for which I am profoundly grateful, but there are some religions that would see my actions as wrong. We are not good at knowing when to stop intervening- it is interesting to note that doctors tend to die differently than patients; doctors often do not start treatment for diseases that are not likely to be successfully treated. To my observation, in most cases we stop intervening due to exhaustion more often than anything else.

In the US and many other parts of the world we do have hospice care, covered by Medicare since 1983 and also by some other insurers. This is intended to promote the comfort of the person inexorably nearing the end of their lives within the next six months. The treatment is aimed not at prolonging life but at minimizing pain as much as possible and providing social, medical and spiritual support as needed. It is a middle ground between aggressive treatment and giving a life-ending drug or set of drugs. Hospice is not a perfect solution; it can often be provided in the person's home.

More than half of Americans die in the hospital, stuck full of tubes and surrounded by machines; 1 in 5 dies in a nursing home. 75% of Americans die in a health care institution of some sort- even though most of us want to die at home surrounded by our loved ones. To me the real death with dignity is being able to honor, as much as possible, the person's wishes about dying. That might include physician assisted suicide and it might not, depending on the individual.

AUTHOR RESPONSE

I share Mr. McNamara's concern about the conflict between a mental health professional's duty to prevent suicide and a proposed right-to-die as an expression of personal autonomy. This certainly presents a potential conflict of values, however I think that "rational sounding arguments" are the preferred way of resolving this, as a profession, rather than basing an opinion solely upon one's personal experiences and wishes.

This is particularly true of public officials who have a duty to consider broader issues, like potential impact upon public health general, distribution of fiscal and health care resources, and effects upon vulnerable groups. Sadly, the governor of California abrogated this responsibility and made his decision based upon his own personal preferences rather than these other factors in spite of the fact that he was provided with pre-publication results from the Southern Medical Journal study. I am hopeful that Minnesota legislators, and the govenor, will be more mindful of their political duties. This is truly not solely an issue of personal autonomy or medical privacy.