ARTICLE:
Excerpted from "Redefining Physicians' Role in Assisted Dying," by Julian J.Z. Prokopetz, B.A. and Lisa Soleymani Lehmann, M.D., Ph.D. New England Journal of Medicine: N Engl J Med 2012; 367:97-99, July 12, 2012) - Under the Death with Dignity Act (DWDA), the patient's physician prescribes lethal medication after confirming the prognosis and elucidating the alternatives for treatment and palliative care. In theory, however, the prescription need not come from the physician. Prognosis and treatment options are part of standard clinical discussions, so if a physician certifies that information in writing, patients could conceivably go to an independent authority to obtain the prescription. We envision the development of a central state or federal mechanism to confirm the authenticity and eligibility of patients' requests, dispense medication, and monitor demand and use. This process would have to be transparent, with strict oversight. Such a mechanism would not only obviate physician involvement beyond usual care but would also reduce gaps in care coordination: in Oregon and Washington, patients whose doctors don't wish to participate in assisted dying must find another provider to acquire a prescription. Physicians who strongly object to the practice could potentially refuse to provide certification or could even alter their prognosis, but these possibilities yield the same outcome as permitting conscientious objection. Patients could also provide an independent authority with their medical record as proof of their prognosis.
Such a mechanism would make it essential for physicians to offer high-quality palliative care. The availability of assisted suicide in Oregon seems to have galvanized efforts to ensure that it is truly a last resort, and the same should hold true regardless of who writes the prescription. Usual care for terminally ill patients should include a discussion of life-preserving and palliative options so that all patients receive care consistent with their own vision of a good death.
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.
COMMENTARY:
CMDA Member Mark McQuain, MD: responded to this NEJM article: "Returning to Pre-Hippocratic Medicine - Margaret Mead has been quoted as saying (regarding the Hippocratic Oath), 'For the first time in our tradition there was a complete separation between killing and curing. Throughout the primitive world, the doctor and the sorcerer tended to be the same person. He with the power to kill had power to cure, including specially the undoing of his own killing activities. He who had the power to cure would necessarily also be able to kill...With the Greeks the distinction was made clear. One profession, the followers of Asclepius, were to be dedicated completely to life under all circumstances, regardless of rank, age or intellect - the life of a slave, the life of the Emperor, the life of a foreign man, the life of a defective child...'
"Amongst other things, Margaret Mead was talking about trust between the patient and her physician. Society should not want physicians and other health care providers to be placed in any position where this trust becomes questionable, particularly as other entities insert themselves into the decision-making process. This is particularly the case as physician's conscience protections are being challenged and arguably eroded via federal regulations."
COMMENTARY:
CMDA Senior VP Gene Rudd, MD: "This is 'reasonable' progression of the assisted suicide initiatives. 'Reasonable' in the sense that once you cross the moral boundary of facilitating death, you need only improve the efficiency of the process by removing impediments.
"Some see state laws as the greatest impediments to expanding assisted suicide. Actually, our experience in opposing expansion has shown resistance of the medical community as the most effective impediment. The opposition from individual doctors and state medical societies has been key to thwarting the agenda of death. So proponents of assisted suicide now want to bypass that impediment.
"The article states that the Oregon experience proves there is no slippery slope. However, the author’s proposal for government involvement in order to expand assisted suicide is evidence to the contrary. Since the great majority of physicians refuse to participate or even endorse assisted suicide, the author concludes we simply need the government to step in with a system to assist in dying. That’s all we need, another costly federal program and more bureaucratic control of our health care – or in this case, control of our dying. I used to think it inappropriate to make this comparison, but as I have seen events unfolding, I am compelled by the slogan in the wake of the Holocaust, 'Never again!' We must stop this descent into cultural insanity or the next proposal will be that we establish federal centers where people will be 'referred' for death."
Excerpted from "Redefining Physicians' Role in Assisted Dying," by Julian J.Z. Prokopetz, B.A. and Lisa Soleymani Lehmann, M.D., Ph.D. New England Journal of Medicine: N Engl J Med 2012; 367:97-99, July 12, 2012) - Under the Death with Dignity Act (DWDA), the patient's physician prescribes lethal medication after confirming the prognosis and elucidating the alternatives for treatment and palliative care. In theory, however, the prescription need not come from the physician. Prognosis and treatment options are part of standard clinical discussions, so if a physician certifies that information in writing, patients could conceivably go to an independent authority to obtain the prescription. We envision the development of a central state or federal mechanism to confirm the authenticity and eligibility of patients' requests, dispense medication, and monitor demand and use. This process would have to be transparent, with strict oversight. Such a mechanism would not only obviate physician involvement beyond usual care but would also reduce gaps in care coordination: in Oregon and Washington, patients whose doctors don't wish to participate in assisted dying must find another provider to acquire a prescription. Physicians who strongly object to the practice could potentially refuse to provide certification or could even alter their prognosis, but these possibilities yield the same outcome as permitting conscientious objection. Patients could also provide an independent authority with their medical record as proof of their prognosis.
Such a mechanism would make it essential for physicians to offer high-quality palliative care. The availability of assisted suicide in Oregon seems to have galvanized efforts to ensure that it is truly a last resort, and the same should hold true regardless of who writes the prescription. Usual care for terminally ill patients should include a discussion of life-preserving and palliative options so that all patients receive care consistent with their own vision of a good death.
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.
COMMENTARY:
"Amongst other things, Margaret Mead was talking about trust between the patient and her physician. Society should not want physicians and other health care providers to be placed in any position where this trust becomes questionable, particularly as other entities insert themselves into the decision-making process. This is particularly the case as physician's conscience protections are being challenged and arguably eroded via federal regulations."
COMMENTARY:
"Some see state laws as the greatest impediments to expanding assisted suicide. Actually, our experience in opposing expansion has shown resistance of the medical community as the most effective impediment. The opposition from individual doctors and state medical societies has been key to thwarting the agenda of death. So proponents of assisted suicide now want to bypass that impediment.
"The article states that the Oregon experience proves there is no slippery slope. However, the author’s proposal for government involvement in order to expand assisted suicide is evidence to the contrary. Since the great majority of physicians refuse to participate or even endorse assisted suicide, the author concludes we simply need the government to step in with a system to assist in dying. That’s all we need, another costly federal program and more bureaucratic control of our health care – or in this case, control of our dying. I used to think it inappropriate to make this comparison, but as I have seen events unfolding, I am compelled by the slogan in the wake of the Holocaust, 'Never again!' We must stop this descent into cultural insanity or the next proposal will be that we establish federal centers where people will be 'referred' for death."
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