Should California give its citizens a right to die?

(from this month, Assembly members Patty Berg, D-Eureka, and Lloyd Levine, D-Van Nuys (Los Angeles County), introduced a bill that would allow terminally ill, mentally competent adults with less than six months to live to end their own lives legally.

It is patterned after Oregon’s voter-approved law, which went into effect eight years ago. Oregon’s law permits physicians to issue lethal prescriptions to patients with terminal illnesses who request “aid in dying.”

Californians have twice before grappled with the emotional questions raised by such legislation. In 1992, state voters rejected by 54 to 46 percent an initiative that would have legalized both physician-assisted suicide and euthanasia (lethal injections by doctors).

In 1999, legislation introduced by then-Assembly member Dion Aroner, D- Berkeley, to legalize physician-assisted suicide reached the Assembly floor, but no vote was taken.

The coming debate is profoundly important, involving the value of life, the meaning of compassion and the proper balance that state law should strike between personal autonomy and protecting lives.

To learn more about the arguments for and against the right-to-die legislation, The Chronicle asked Assemblywoman Berg, whose primarily North Coast district includes portions of Sonoma County, and Wesley Smith, author of “Culture of Death: The Assault on Medical Ethics in America,” to debate the issue via e-mail. Here is their exchange, which began with this question from Insight: “Should California enact right-to-die legislation?

Berg: California already has some “right to die” legislation, in the form of advanced health care directives and durable powers of attorney. These are great to make sure a person’s wishes are honored if he or she becomes unable to express them.

But in the case of mentally competent, terminally ill adults, we can and should do more.

We should allow them to die on their own terms, with the peace and comfort of knowing they have a choice and that they could escape unbearable suffering if that were to occur.

This means that eligible, dying patients should be able to obtain a prescription for life-ending medication and administer it themselves.

Our neighbors to the north in Oregon have had this right since 1997, and their experience shows that it empowers patients and comforts them, while it improves end-of-life care.

Strict safeguards protect vulnerable people, and the medical community has accepted aid in dying as an option of last resort.

Californians deserve the comfort of having this choice at the end of their lives.

Smith: Whatever happened to suicide prevention? People who are dying should be given love, inclusion and proper medical care that treats pain and values their lives, not a poison prescription. This care is available through hospices — the true death with dignity.

As a former hospice volunteer, I was trained that a request for suicide by a patient means that a need exists that is not being met. As the history of the hospice movement demonstrates, once such unmet needs are fulfilled, suicidal desires often disappear.

On the other hand, placing the explicit seal of approval of the state of California on suicide would tell despairing patients that their worst fears —

that they are burdens on family, that their illness makes them less worthy of being loved, that they will die in agony — are true.

And it would send the insidious message throughout society, including to our young people, that killing is an acceptable answer to the difficulties associated with human suffering.

Berg: Wesley Smith’s inflammatory words — invoking “poison,” “killing” and “suicide” — have nothing to do with the gentle, voluntary and peaceful choice a handful of dying patients make each year to escape their intolerable suffering.

Smith and I agree that the hospice is the gold standard of end-of-life care. But medical experts of every persuasion admit that in 5 to 10 percent of cases, even the best comfort care cannot adequately address end-of-life suffering. Shall we simply abandon those whose suffering we cannot relieve?

Ninety-three percent of patients who legally hasten their deaths in Oregon are in hospice care. They turn to aid in dying as an option of last resort, after all comfort measures have failed.

But just the fact of choice, even if it is never exercised, brings peace of mind and hope to every dying patient. The message sent is that society will not abandon its dying, but will honor their choices, their values and convictions, even to their last dying breath.

Smith: According to suicide-assisting doctors in Oregon, hastened death is almost never requested because comfort care fails but out of the fear of being a burden or losing autonomy.

Assemblywoman Berg is the one playing word games, using gooey euphemisms such as “peaceful choice” to mask the harsh reality of assisted suicide.

In a debate as important as this, we must use accurate language. Webster’s defines “poison” as “a substance that through its chemical action kills,” which is precisely what happens in assisted suicide.

Legalizing assisted suicide would mark such a radical change in law and ethics that the burden of proof must be on Assemblywoman Berg. Ideological assertions are insufficient. Indeed, it is urgent that assisted suicide remain illegal.

Follow the money: California health services are being cut to the bone. Poor people don’t have health insurance, and those with coverage usually are in HMOs that make profits by limiting costs.

The drugs used in an assisted suicide would cost less than $100. Yet, it could cost $100,000 to provide quality care so the patient doesn’t want suicide.

Then there are issues of family coercion, inheritance and life insurance. Elder abuse is rampant. Legalizing assisted suicide in such a milieu would be the ultimate abandonment of patients.

Berg: If we’re going to follow something, let’s forget the fear and emotional rhetoric, and follow the facts. And the fact is, as we’ve learned through more than seven years’ experience in Oregon, that palliative care has improved since the adoption of the act.

A study published May 9, 2001, in the Journal of the American Medical Association illustrates this point.

A self-administered questionnaire was mailed to 3,981 physicians eligible to prescribe under the Oregon act. Of the 2,641 who responded, 30 percent reported that they had increased referrals to hospice care, and 76 percent reported that they made efforts to improve their knowledge of the use of pain medications for the terminally ill.

The conclusion was that “most Oregon physicians who care for terminally ill patients report … they have made efforts to improve their ability to care for these patients.” Those are the facts.

Smith: Assemblywoman Berg changes the subject rather than grapple with the disastrous consequences of permitting assisted suicide in California’s dysfunctional health care environment.

Even so, her data appears outdated. For example, a disturbing study published in the November 2004 Journal of Palliative Medicine reported that Oregon patients in the last week of their lives were “twice as likely” between 2000-2002 to be reported to be “in moderate or severe pain” than reported in the years 1996-1997 — a time
mostly prior to Oregon’s law going into effect.

These contrasting studies point to a rarely discussed fact about assisted suicide in Oregon: Nobody knows what is actually going on.

Rather than providing independent oversight, Oregon’s Department of Human Services gets its information from forms filled out by suicide-prescribing doctors, reviews a small sampling of these assisted suicides and then publishes a yearly statistical report without knowing for sure whether its contents are true.

Thus, a 1999 Oregon Health Division publication admitted that these physician reports “could have been a cock-and-bull story.” This is hardly an example for California to follow.

Berg: Oregon’s experience with aid-in-dying is more meticulously documented and studied than any community’s end-of-life decisions ever have been.

Information from the state is only a small part of the story. Researchers at the National Centers for Disease Control and Prevention in Atlanta and independent investigators at Oregon Health and Science University, the Portland Veterans Administration Medical Center and Providence Health System have published many scientific studies in respected medical journals.

None of these studies supports Smith’s claims. Palliative care specialists believe the study Smith cites reveals not falling pain care but rising expectations for pain relief at the end of life — surely a desirable effect.

Study after study demonstrates that the law has been carefully administered, and that 1 in 6 terminally ill patients in Oregon considers aid in dying, and only 1 in 1,000 ultimately takes medication to end his or her suffering legally and safely.

The truth is, aid in dying happens in every state, California included. Recently, the Journal of Clinical Ethics reported no aid in dying outside the law in Oregon and suggested that it probably occurs four times as often in states where it remains illegal.

The task of the California Legislature is to bring the practice out of the closet, impose legal safeguards and careful oversight.

Forcing physicians underground when their dying patients seek the comfort of choice is not only barbaric, it adds to needless end-of-life suffering.

Smith: End-of-life care is improving generally throughout the country without legalizing assisted suicide.

Moreover, very few doctors commit assisted suicide — even in Oregon, where many patients obtain their lethal prescriptions from doctors affiliated with assisted-suicide advocacy groups instead of from their own physicians. This is rank Kevorkianism.

Physician-assisted suicide is not only illegal throughout most of the world, it is generally considered a corruption of medicine and a profound violation of medical ethics.

Moreover, once the wolf is in the door, safeguards do not protect, they merely anesthetize the public to the dangers.

Just look at the moral abyss into which the Netherlands has fallen after 30 years of assisted suicide/euthanasia.

Today, Dutch doctors kill terminally ill patients who ask for it, disabled patients who ask for it, and infants born with disabilities who by definition can’t ask for it. Nonvoluntary euthanasia is rampant, with some 900 cases reported a year. Doctors also assist the suicides of depressed patients who have no organic illness.

This same trajectory will happen in the United States should assisted suicide ever become widely legalized and legitimized. No wonder a robust and diverse coalition made up of disability rights groups, medical and nursing professional organizations, advocates for the poor, hospice organizations and many churches steadfastly oppose the legalization of assisted suicide.

Berg: Jack Kevorkian focused the nation’s attention on patients’ enormous desire for compassion and control, but Oregon is no Kevorkian. In 2003, 42 Oregon doctors wrote prescriptions for life-ending medication. The doctors are specialists in family and internal medicine and oncology, and their average time in practice is more than 20 years.

They are affiliated with the finest clinics and institutions in the state. Hardly “Kevorkianism.” And no one is suggesting the Netherlands as a model for California.

But even so, the Dutch have no “slippery slope.” Their practices haven’t changed for decades. This month’s Journal of the American Medical Association adds another voice to the chorus of reasoned, objective experts supporting Oregon-style aid in dying.

Dr. Lawrence Schneiderman of UC San Diego at La Jolla writes that one of the “unexpected yet undeniable” consequences of Oregon’s assisted-dying law is that state’s leadership in excellent and compassionate palliative care.

Will you simply admit, Mr. Smith, that your opposition to end-of-life choice is rooted in religious teaching of the redemptive power of suffering?

For you, no amount of suffering, no matter how much it persists in spite of the best possible medical care, would permit a consciously chosen death. All your arguments are just a smoke screen.

I truly respect your religious beliefs. But I draw the line at imposing your beliefs on those who do not share them.

Smith: Jack Kevorkian’s ultimate goal, described in his book “Prescription Medicine,” was to experiment on people being euthanized. He once stripped the kidneys from one of his victims and offered them to the public, first come, first served. Is this what Assembly member Berg means by focusing the nation on compassion and control?

In Oregon, doctors affiliated with assisted-suicide advocacy groups often write lethal prescriptions for patients they have not treated. That is Kevorkianism.

Assembly member Berg is right: There is no slippery slope in the Netherlands — it is a plunge off a vertical cliff. Not only do Dutch doctors kill infants with disabilities — eugenic infanticide — but now they are seriously debating whether to reduce the age of consent for assisted suicide to 12.

A recent report sponsored by the Royal Dutch Medical Association recommended issuing assisted-suicide guidelines for those who are “tired of life.”

Finally, we see the usual desperate tactic of assisted-suicide advocates who can’t win on the facts. They trot out the tired old clich?that their opponent is pushing religion.

Well, Assemblywoman Berg, I have said nothing about religion. Nor do I think suffering is redemptive. I oppose assisted suicide because it is bad medicine and worse public policy, particularly in a milieu of family dysfunction, in which millions have no health insurance and services for the elderly are being ravaged.

The most dedicated opponents of assisted suicide are disability- rights activists who are explicitly secular in their outlook, liberal in their politics, and adamant that assisted suicide is a form of bigotry disguised as compassion. And they are right.

Making choices

The California Compassionate Choices Act would allow mentally capable, terminally ill adults with six months or less to live to legally obtain and use prescriptions to end their suffering. Its safeguards include:

— The patient must be evaluated by two physicians. Both must verify that the patient is mentally capable of making and communicating health care decisions. If either physician believes the patient’s judgment is impaired by a psychiatric or psychological disorder, the patient must be referred for a psychological examination.

— The patient must make two oral requests and one written request for the prescription. The written request must be witnessed by two individuals
who attest that the patient is competent, acting voluntarily and not being coerced.

— There are two waiting periods – 15 days after the oral requests and 48 hours after the written request.

— The patient must take the medication himself. No one can assist in administering drugs.

— Physicians may refuse to participate. No doctor would be required to write a prescription under the act.

— Both physicians must submit detailed reports to the Department of Health Services.