Redefining physicians’ role in assisted dying

An interesting read: Prokopetz & Soleymani Lehmann. Redefining Physicians’ Role in Assisted Dying. N Engl J Med 2012; 367:97-99.

Exerts:

“Terminally ill patients spend their final months making serious decisions about medical care and the disposition of their assets after death. Increasingly, they are also choosing to make decisions about the manner and timing of their death, and many are completing advance directives to withhold life-sustaining treatment…..”

“A controversial facet of this trend toward a more self-directed dying process is the question of assisted dying – whether patients should have the option of acquiring a lethal dose of medication with the explicit intention of ending their own life…..”

“Advances in palliative medicine have produced effective strategies for managing and relieving pain for most terminally ill patients, including the possibility of palliative sedation. Inadequate pain control therefore ranks among the least common reasons that patients in Oregon request lethal medication.Most say that they are motivated by a loss of autonomy and dignity and an inability to engage in activities that give their life meaning.” 

“This perspective is reflected in surveys of relatives of terminally ill patients in Oregon. In two studies comparing deaths from ingesting lethal medication with deaths from terminal illness, relatives gave similar ratings of patients’ medical and emotional well-being in the last days of life and of their own feelings about the patients’ dying process. The only reported differences were that patients who chose assisted dying had greater control of their symptoms and that they and their families were more prepared for and accepting of their death…” 

“Critics have voiced six primary objections to legalizing assisted dying, four of which have been largely invalidated by 13 years of data from Oregon. First, opponents fear that permitting patients to take their own life will worsen the quality of palliative care, but in Oregon, overall spending on and patient ratings of palliative care have risen since assisted dying was legalized…”

“Three concerns center on patient safety: discrimination — that assisted dying will disproportionately affect vulnerable groups; the slippery slope — that the practice will be expanded to include patients with nonterminal illness or even nonvoluntary euthanasia (a lethal injection from a physician without an explicit request by the patient); and abuse — that a patient’s request for lethal medication may stem from mental illness or coercion by unscrupulous relatives. These fears have not been borne out ….”

“The fifth objection holds that allowing assisted dying undermines the sanctity of life. This is a subjective moral question, commonly framed in terms of absolute preservation of life versus respect for personal autonomy — a divide that often falls along religious lines. There is no clear, objective answer, but as with issues such as abortion or withdrawal of life support, legalization would benefit those who want the option, without affecting care for those who object to the practice…”

“Finally, there are objections from the medical community. In a 2003 study of AMA members, 69% objected to physician-assisted suicide, a position officially held by various national and state medical associations. Even with allowances for conscientious objection, some physicians believe it’s inappropriate or wrong for a physician to play an active role in ending a patient’s life. We believe there is a compelling case for legalizing assisted dying, but assisted dying need not be physician-assisted.”

“Momentum is building for assisted dying. With an independent dispensation mechanism, terminally ill patients who wished to exercise their autonomy in the dying process would have that option, and physicians would not be required to take actions that aren’t already part of their commitment to providing high-quality care.”

“We have been here before, particularly in relation to the Debbie Purdy case, and have debated this topic on several occasssions on this blog. It is interesting to see it getting such prominent space in the NEJM.”

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