One’s biography may be considered the writing of one’s history. What happens if one exists, but has nothing further to contribute or write about their “being”? The “godmother” of nursing care of patients in pain, Margo McCaffrey, stated that her definition of pain is whatever the experiencing person says it is, existing whenever the experiencing person say it does”. Shouldn’t we apply the same criteria to suffering?
In October of 2015, California governor Jerry Brown signed into law the End of Life Act. This will allow physician assisted suicide in the state of California. In considering this bill, he contemplated his own life and surmised that he would not want his own choices to be limited, and hence did not want the choices of others to be limited either. Opposition groups tried to collect enough signatures to overturn this legislation by ballot, but failed to collect enough by the deadline.
Many ethical considerations apply here. Physicians take a vow to “do no harm”, but does that mean they should stand by as a patient is feeling harmed by their circumstances? Likewise, a physician can act according to his/her own moral imperatives, sometimes referred to as “conscience clauses”: hence the “opt out” option with participating, just as it is in the case of abortion.
The Netherlands offers a longstanding experience on physician assisted suicide (PAS) that we can look to as a model. Their experience shows us how this may play out logistically. The legal standard for a Dutch physician who participates in assisting a patient in dying is referred to as force majeure. This translates into “a situation of necessity or last resort”.
Much of the legislation in the United States around physician assisted suicide focuses on a narrow legal acceptability of this as a situation of last resort. For example, in the states where PAS is legal, common threads include the following criteria:
- Mentally competent (i.e., also often includes that the patient is not depressed)
- Repeated request which includes a waiting period
- Patient is able to self-administer medication
- Patient is an adult (at least 18 years old)
- Patient must be a resident of the state where PAS is legal (this could simply mean getting a state ID…there is no time requirement i.e., the case of Brittany Maynard who moved from California to Oregon in 2014)
- Terminally ill with less than six months to live and two doctors may be required to sign off on this
A thesis could be written on this topic, however, for the sake of argument, let’s just assume the following:
A) Legislation exits to safeguard vulnerable populations and to avoid the slippery slope of those who may be coerced into this choice or feel like they have no other options or fear that someone else will make this decision for them with less than altruistic intent.
B) Laws are written to address the rules, not the exceptions. Let’s consider that exceptions to the rules do not make good law, but in limited circumstances are equally legitimate.
Consider these simple exceptions to the above and ask yourself if these circumstances are any less worthy of eliminating suffering:
1. What if the patient’s primary diagnosis is depression and they have tried every form of treatment including electroconvulsive therapy?
2. What if a patient suffers an unexpected burn injury in a fire and their chance of survival is 0%?
3. What if a patient meets all other criteria, but is paralyzed therefore cannot “self administer a medication? Does prescribing significantly differ from administering in its end result?
4. What if a patient is terminally ill, suffering, and is 17 years old?
This is by no means a simple topic. Here are some key takeaways:
OPTIONS ARE HEALING!
The experience in requests never carry out a physician assisted death. This theme was found in The Netherlands as well. Simply knowing one has control over the timing and nature of one’s death can be comforting alone. Having an option in hand in case things become intolerable presumably allows a patient to carry on with confidence that if circumstances become intolerable, then an end is in sight.
So what options are available prior to opting out?
Medical Cannabis applies here as do many other treatment options. It is simply unpalatable on many levels to allow a patient to make a choice to opt for PAS because they have symptoms that are not being addressed. This includes issues of inequity – like access to care. If a patient is having pain, nausea, seizures, depression, or the like that is not being addressed, any consideration of PAS is called in question. If we use the situation of last resort as a criteria, all patients should be as symptom free as possible. It is not rocket science to assume that if a patient’s intolerable symptoms are being adequately managed, that the likelihood of them asking for PAS would be reduced. Legislation that allows medical cannabis as a therapeutic option could eliminate symptoms that drive a patient to make such a request.
Hospice or Palliative Care This often allows the patient to forego aggressive treatment options and allows the patient to receive care at home. They are both similar in that they are primarily concerned with addressing a patient’s comfort and not focused on a cure. One difference is that hospice care usually addresses those patients who are terminally ill whereas palliative care does not have that same shared strict time frame.
This option allows a patient to be medicated to the point of unawareness. Usually many of the PAS criteria must apply, but not strictly so. During this time, food and water is withheld. The patient does not usually resume consciousness, and death is expected within days. This option is legally available even where physician assisted suicide is not. The timing of death is not certain, however, it allows loved ones to say good bye and to know that sedation will be enough to end their suffering until they pass away.
Let your family and your health care providers know your preferences. It is never too early to communicate these. Even if you are healthy, you can document a durable power of attorney for health care or advance directives for your health care preferences.
Find out where your preferences differ from others. As we mentioned earlier, your physician is not obligated to honor your PAS request, so find out before you need a doctor if they share your views. Also, in addition to having your wishes legally documented, communicating and discussing your preferences with loved ones beforehand is essential.
Be true to yourself. No one else can know how much pain or suffering you can endure. BE OPEN.
Alternative therapies or healing avenues such as cannabis may relieve or improve the symptoms that may be driving a request for physician aid in dying. Choosing death must mean that you have tried everything at your disposal and it has failed to eliminate your suffering and eliminate the impetus for a request to die. We are fortunate to be in a time where cannabis is an option to relieve such suffering over a choice to die could genuinely be an option.
For more information, please contact United Patients Group at 415-524-8099.