The right time to choose to die

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On April 13, 1999, a Michigan jury convicted retired pathologist Dr. Jack Kevorkian of second-degree murder in the death of Thomas Youk, who suffered from Lou Gehrig’s disease. Kevorkian was sentenced to 10 to 25 years in prison, where he remains today, for actively assisting in Youk’s death.

The debate regarding end-of-life choices has not reached the degree to which Kevorkian subscribes – hands-on euthanasia. Rather, the discussion focuses on indirect measures that hasten one’s death, such as physician-assisted suicides, applicable at this time only in Oregon.

In a 2001 sampling of 1,011 American adults, conducted by The Harris Poll, 65 percent supported “doctors complying with the wishes of a dying patient in severe distress who ask that his or her life be ended.” Sixty-three percent disagreed with the 1997 Supreme Court ruling that people do not have a constitutional right to doctor-assisted suicides.

In 1994, Oregonians approved allowing doctor-assisted suicides for patients who have less than six months to live. The Harris Poll study reported that 61 percent of those interviewed would favor of the same type of law for their state.

During the last 20 years, hospices have taken on vital the roles as the comforters of the terminally ill. Through hospices and doctors, many of whom are now board certified in hospice and palliative care, the actively dying can choose a course of medicine that treats their pain, not their illness.

Still, if someone would rather die than continue life for the sake of dying naturally, is it wrong? Does a terminally ill person have the right to choose the time of his or her death?

Dr. Gil Porat, who practices hospital-based medicine in Colorado Springs, says the terminally ill should have the right to physician-assisted suicide. Porat moved here from Oregon two years ago. He said Oregon lawmakers incorporated safety measures into their legislation to prevent abuses and misuses of the law that allows physicians to write prescriptions for drug overdoses for terminally ill patients. Developmentally disabled individuals and people with advanced dementia, including Alzheimer’s victims, are two groups that are ineligible for physician-assisted suicides in Oregon.

According to the Oregon law, a patient must meet the following three conditions: He must request the prescription three times; he must get a second opinion; and if the first two conditions are met, he must adhere to a 15-day waiting period. “There has been no single case where the law has been abused,” Porat said. “I believe the main reason for supporting physician-assisted suicide is that it gives autonomy to the people; the second biggest argument is the relief of suffering.”

Porat said he believes the controversy is “100 percent” about religion. He said there are some religious people who support physician-assisted suicide, but the Catholic Church exemplifies the religious influence that is in opposition. On March 20, Pope John Paul II said that feeding and hydrating patients in vegetative states is “morally obligatory,” and withdrawing feeding tubes is “euthanasia by omission.” The pope’s statement has administrators from Catholic hospitals, bishops, priests and Catholics in general discussing the Holy Father’s intentions and the validity of living wills.

Despite religious convictions, Porat said that what matters is an individual’s choice and quality of life.

Dr. Jonathan Weston, medical director for Pikes Peak Hospice and Palliative Care and a member of the El Paso County Medical Society’s Ethics Committee and the Pikes Peak Forum for Health Care Ethics, agrees with Porat about the quality-of-life issues. “Quality of life varies from person to person,” Weston said. “I had a patient who, because of Lou Gehrig’s disease, was on a ventilator and could do nothing but blink his eyes, but he wanted to prolong his death so he could watch baseball.”

It was his choice, but others are not always aware of their choices regarding end-of-life care options because they are uninformed or have misconceptions about hospice care, Weston said. “We must have a proficient way for patients to communicate their wishes for end-of-life care,” Weston said. “When people have not written advance medical wishes in detail, the decisions are left up to the physicians or the next of kin, and family members may not be willing to make those decisions.”

Porat said that society has “lost it” when the use of ventilators and feeding tubes do not allow for a natural death. Although Weston said he believes that no one should take active measures to hasten death, he agrees that keeping people alive as long as possible when there is no hope is a flaw in medicine. The intent for the terminally ill is to relieve suffering, a course of action that sometimes results in an unintended side effect – a quicker death, Weston said.

Porat and Weston agree to disagree on the issue of palliative care. Weston said in 99.9 percent of his terminally ill patients, he promises they will have “no pain under any circumstances.” Porat said 99 percent is an exaggeration. He said Weston most likely factored in the use of terminal sedation, which medicates patients so they awaken every two to three days to allow the intake of nourishment. That kind of care is somewhat of a slippery slope, Porat said. “What’s the difference (between assistance and terminal sedation)?” he asked.

Brig. Gen. Mal Wakin is a doctor of philosophy, an internationally-known public speaker on ethics and serves on many ethics committees including the El Paso County Medical Society’s Ethics Committee and the Pikes Peak Forum for Health Care Ethics. Wakin spent 41 years on active duty in the U.S. Air Force teaching philosophy at the U.S Air Force Academy.

“Our enemy is pain, not death,” he said. Moral principals and a belief system in the hereafter are points of discussion in the right-to-die debate. Hastening death could jeopardize life after death, Wakin said. “I don’t want to do something that might be judged to be evil.”

Is the choice about religion? Wakin said one should never act based on “knowing something or thinking you know something that you could not possibly know.” Society may have the right to choose, he said, but if there is life after death, a concept that many religions adhere to, the believers may be tempting fate if they “play God” with their life. But Wakin said choosing life is not about a religious ethic. “I have a moral responsibility to myself and my community to persevere in my own human existence,” he said. “If doctors help their patients die when they want to die, the whole thrust of their profession is perverted.”

Wakin said there are four basic principals taught in medical school: nonmalfeasance – above all, first do no harm; beneficence – there is a moral obligation to prevent harm, remove harm and provide a benefit; respect for autonomy – the individual’s right to self-govern, including informed consent; and the just distribution of health care in the community.

“The third principal is troublesome,” Wakin said. The principal of autonomy could be in conflict with other principals when people decide their own course of treatment. “In 1968, 88 percent of the physicians in this country did not tell their patients when they diagnosed them with cancer because there was no cure or treatment,” Wakin said. “We’ve come a long way – everyone today has a right to know and a right to decide. People have the right to refuse treatment, but do they have the right to demand treatment?”

The fourth principal – health care distribution – is a modern-day hot topic. Wakin said there are tough questions to answer: Should health care access be based on an ability to pay? Should health care be equally distributed or distributed based on need? Does everyone deserve merit and value within the system?

Part of the problem with end-of-life decisions is the chaos that exists in the health care system,” said Martha Barton, president and chief executive officer of Pikes Peak Hospice and Palliative Care. “People fear they won’t be know
n, respected and supported in the context of their own values and priorities,” she said. The end-of-life care decisions include a gamut of issues, including finances, the loss of dignity and control, and the fear of suffering, Barton said. “We must embrace everyone, regardless of their choices for end-of-life care plans,” she said. “We are here to make a difference; it doesn’t start with a judgment.”

Any person who applies for care at Pikes Peak Hospice is considered for admission into the inpatient or outpatient program, Barton said. “We start with yes,” she said.

Barton also sits on the board of the Pikes Peak Forum for Health Care Ethics and is the president of the Colorado Hospice Association, which includes 39 statewide hospices. “Kevorkian’s actions caused a lightening-bolt reaction to these issues and ramped up the debate,” she said. Regardless of the differences of opinions, Barton applauds the open discussions. “Ideally, we will eventually wrap around the preparation for the end of life as we do the beginning of life,” she said.

Assisted suicide beyond a physician’s help is prosecutable in all states. A 60-year-old Green Bay, Wis., woman, Donna Trautman, spent two years in prison for suffocating, at his request, a 66-year-old friend. Raymond Krerowicz had suffered from terminal prostate cancer.

Is the system at fault because patients do not have adequate knowledge or access to proper end-of-life treatment? Is the issue strictly one of moral values and religious beliefs? Or, are we afraid of that slippery slope between individual choice and the doctors’ code to do no harm?

The debate continues.

The Pikes Peak Forum for Health Care Ethics distributes a brochure, “Decisions About the End of Life,” which includes a statement of principals and guidelines for end-of-life care decisions. The guidelines also are available on the El Paso County Medical Society Web site at www.epcms.org/forummain.htm. The Pikes Peak Forum for Health Care Ethics Web site is www.pikespeakforum.com.

- Editorial@csbj.com