Maine Assisted Suicide Proposal More Cunning than Caring

By Paul D. Doolan, M.D.

Should a terminally ill adult who is of sound mind be allowed to ask for and receive help to die? The question is cunning. It avoids the words "physician-assisted suicide," features the word "terminal" and offers it in the spirit of a plea. Dying without further inconvenience embarrassment or distress is equated with death with dignity and all that is needed is to "skip the dying" by taking a lethal amount of a drug prescribed by a physician and a law that proclaims this is not suicide, assisted suicide, homicide or mercy killing. So the patient is sensible, the physician merciful and it all occurs within a legal context of enlightened blamelessness and no- fault assurance. It is too slick and the guile of the question hides the danger contained in the act.

The title, "An Act to Enact the Maine Death with Dignity Act" is considered less alarming than its earlier edition, "An Act to Allow Physician Assisted Deaths for the Terminally Ill." Call it what you will, this is a civil rights act, a right to die act presented as a plea on behalf of an elite but intended to serve as a precedent. The elite are not the grim and very sad cases that one usually thinks of, the chemotherapy and other treatment failures, the organic brain syndromes, the severely disabled physically and-or neuromuscularly, for although worthier of sympathy they fail to qualify and are wide of the point. This escape route is not based on consent but a decision that amounts to an insistence. The patient must be physically able to empty 90 capsules and mix the cumulative 9,000 milligrams (nine grams) with apple sauce, pudding or some other vehicle. To avoid an awkward coma and die within minutes, the patient must be able to swallow fast enough to ingest a lethal amount before falling asleep. Death with dignity then becomes gulping to expire.

This act is death directed and the medical considerations are set at the level of legality, not best medical care. A physicians worries include: Does the patient get a prognosis or a sentence? Does the patient know that terminal is an elastic term depending on conditions and circumstances? A patient may have terminal (end stage) kidney disease and live 30 years on dialysis. Does the patient know that incurable is not untreatable or in the case of the heart, lungs, liver, pancreas, kidney and bone marrow, replaceable? Is the doctor who writes the prescription the same one who directed the medical work-up? Will there be any death reviews, autopsies, quality assurances and how will compliance be monitored and funded? The sponsors of this act can claim that these are medical details, not the implementation responsibilities of a civil rights matter. That may be, but patients must be reminded that high standards of medical practice are in their best interest and a part of the trust physicians have earned.

Physicians for centuries have honored an oath that includes not betraying confidences, seducing the vulnerable or poisoning the patient. These prohibitions and the goal of human wholeness are what the doctor-patient relationship is about, not death options. The doctor-patient relationship is already threatened by cost restraints verging on rationing, efficiency quotas, fractionalized authority and liability threats without urging execution as a therapeutic privilege.

This act should be rejected yet again. It has been rejected unanimously by the Judiciary Committee in the 119th session and 12 to 1 in the 118th session of the Legislature.

This citizens initiative is a last- resort tactic with the sponsors hoping it will be treated with the impulsivity and spontaneity of a polling phenomenon. In addition, some might enjoy the vicarious thrill of trumping our elected legislators who studied it. Rejection is not, however, restricted to the legislatures of Oregon and Maine. The select committee of the House of Lords in England heard oral and written or written submissions from 61 different groups and did a project site visit to the Netherlands in their study of life prolonging, brain-dead, life-shortening, death- as-a-process-rather-than-event, issues.

The New York State Task Force on Life and the Law reviewed the epidemiology of suicide in the general population; suicide in patients with cancer, AIDS and the elderly; clinical responses to pain and suffering; extant law and ethical debate. Both concluded that existing law not be changed to allow physician-assisted suicide. President Clinton signed HR 1003, the restriction act that prohibits the use of federal funds in connection with physician-assisted suicide in virtually every program from Medicare to medical care in federal prisons.

One would think since the question has been rejected by every formal group that has seriously studied it, the matter is settled permanently. Not so for the proponents demanding a "right to die" and eliminating this remaining taboo in an "enlightened" society. Relying on the fear of death, the suspicion with which it is fashionable to regard health care providers and the instinctive sense of sympathy in voters, they hope to win via the initiative especially if thinking can be confined to the spirit of a slogan or a bumper sticker. They would have you believe that giving the physician the right to kill (euthanitize is the word required if working with lab animals) will have no effect on the doctor-patient relationship. Lethal dosing will always be a mere accommodation carried out in good taste. The aged, the poor, the inner-city minorities, the physically disabled, the addict and others near or in lifes final chapter need not be frightened if the doctor or nurse appears at the bedside with a syringe or handful of different pills.

We must to be realistic, no system is perfect, and whatever mistakes are made will certainly be fewer than those occurring in our criminal justice system. That most patients will stay within the established tradition is understood and proponents deny it will encourage the notion of "dying as the decent thing to do" or simply a "get out of the way" gloom. These are the predictable opinions of sponsors of an act intended for a right-to-die elite who from a fortress of self-centered high-mindedness, dismiss slippery slopes, casualties and collateral damage to institutions and agencies.

Physicians and nurses never get used to death no matter how many witnessed. There is a special aura about the dying and one feels an instinctive surge of respect. There are many heroes among the dying, some of whom have contributed to major advances in medical care as well. We are humbled by the devotion of families and can be proud of the many agencies and programs dealing with the end-of-life care and take heart in the serious efforts being made to deal with the ethical concerns medical progress entails.

What is involved in this act is not the quiet desperation of the usual suicide but a less than brave defiance with the risk being taken by the physician and the consequences to be born by the system. This initiative should be soundly defeated.

Paul D. Doolan, M.D. lives in Phippsburg, Maine.

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