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.
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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