Thursday, April 5, 2012

Second Thoughts grow on Assisted Suicide

The risks of mistake, coercion and abuse are too great to warrant legal immunity for doctors who help end lives.

An initiative to legalize assisted suicide will be on the November ballot in Massachusetts. Last month, advocates on both sides of the issue testified at a legislative hearing in Boston. Although the debate about assisted suicide is often portrayed as part of the culture war—with typical left-right, pro-con politics—the largest number of witnesses at the hearing were 10 disability-rights advocates who oppose the initiative.

In Massachusetts, the disability advocates call their opposition group "Second Thoughts." They say that assisted suicide may sound like a good idea at first, but on second thought the risks of mistake, coercion and abuse are too great to warrant legal immunity for doctors or others who assist suicide.

Proponents of assisted suicide claim that 14 years of data from Oregon—which legalized assisted suicide for people who are predicted to die in six months, with purported safeguards to ensure that it's voluntary—prove that such mistakes or abuses do not materialize. How would they know?

Oregon's annual reports tell us very little. For one thing, assisted-suicide laws like the one in Oregon and the one proposed for Massachusetts lack teeth. Doctors who fail to report giving a lethal prescription face no penalty. The state does not talk to doctors who denied a request to prescribe lethal drugs in order to find out why, or to families to learn why the person requested assisted suicide and what happened after the lethal drugs were obtained. No form of noncompliance with the law's relatively flimsy safeguards is monitored or investigated.

Assisted-suicide proponents have been pushing the term "aid-in-dying," hoping to get people to view a life-ending prescription as merely one option on a continuum of palliative or "end-of-life" care.

People already have the right to refuse unwanted life-extending treatments, and they have the option of using advance directives to determine their care when they can no longer express their wishes. But death that results from withholding or withdrawal of life-sustaining treatment has always been separated by a bright line from active measures to cause death. Assisted-suicide proponents seek to blur this line, while opponents want to hold the line against increased medical authority to end life.

The Massachusetts Medical Society and the Massachusetts Hospice and Palliative Care Federation testified against the ballot initiative. The Medical Society has stated that "allowing physicians to participate in assisted suicide would cause more harm than good."

Proponents say that assisted suicide increases self-determination, but actually it puts one's life in the hands of others. It gives doctors the power to issue a lethal prescription with blanket legal immunity for any mistake as long as they claim "good faith." It gives insurers a cheaper option than providing the care you need.

People assume there are safeguards to ensure that withdrawing life-sustaining treatment is voluntary or at least consistent with the patient's directive. Few are aware that most states have laws granting doctors a "safe harbor" for denying care the patient wants if the doctor feels that it's "futile" or inconsistent with local standards of care. Aside from such futility policies, studies show that the protections people expect have proven unreliable.

A recent study in the Journal of Emergency Medicine found that having a living will might give people a false sense of security about getting the treatment they want. Based on survey responses from more than 700 physicians in 34 states, researchers from the University of Pittsburgh Medical Center found that over 50% of physicians misinterpreted a living will as having a "do not resuscitate" (DNR) order when it did not. About the same percentage over-interpreted DNR orders as meaning no treatment except "comfort care" or "end-of-life" care.

The study shows that there is a frighteningly high likelihood that having a living will or DNR order will result in physicians withholding curative treatment that a patient actually wants.

A March 10 Wall Street Journal article, "What You Lose When You Sign That Donor Card," raised questions about the determination of death. What most people are unaware of is that, under the Uniform Determination of Death Act (UDDA), hospitals get to set their own standards and specific protocols to use in making that determination. A study published in 2008 in the journal Neurology found widespread variation in protocols used in top neurology centers.

Imagine allowing individual housing contractors to decide what parts of the plumbing code they choose to implement. That's what the UDDA has done with hospitals and determination of brain death—and it leads to the possibility that someone could be determined "brain dead" and eligible for organ procurement in Hospital A, and diagnosed as a severely injured person needing evaluation and treatment in Hospital B.

Family members are also major players when someone is sick enough to be unable to make his own health-care decisions. If you do not appoint someone you trust, state law designates a sequence of potential surrogates to whom doctors can turn for health-care decisions, usually the spouse first, then adult children, then parents, and so on down to the government's public guardian.

Unfortunately, elder-abuse data show that the perpetrators are frequently the spouse or an adult child. But neither surrogacy laws nor real-life practices in medical facilities are designed to prevent an abusive or even merely self-interested surrogate from deciding to pull the plug sooner than you might prefer.

In the face of such irrefutable evidence that safeguards to protect people from the involuntary withholding of life-sustaining treatment are not working, disability advocates see assisted suicide and the broken, profit-driven health-care system as a deadly mix. Today's risks of mistake, conflict of interest, coercion and abuse are too great.
Diane Coleman and
Stephen Drake
Ms. Coleman, a lawyer, is president and CEO, and Stephen Drake is research analyst, for Not Dead Yet, a national disability rights organization that opposes legalization of assisted suicide.
A version of this article appeared April 6, 2012, on page A13 in some U.S. editions of The Wall Street Journal, with the headline: 'Second Thoughts' Grow on Assisted Suicide.

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