I have been privileged to practice medicine in Buffalo for nearly four decades, 35 of those years in hospice and palliative care. I have had the “bad news” discussions with innumerable patients and families, sat vigils at bedsides and “rescued” patients in crises of pain and faith.
More importantly, I have listened to my patients, now in the thousands, heard of their hopes and fears and loves, their goals and values and hates, as they faced the trials of progressive illnesses I was incapable of altering, not for all my effort or earnestness. From this experience, I have become a firm believer in the professional and ethical legitimacy of physician aid-in-dying and the need to decriminalize it as a stigmatized aspect of medical care.
In truth, this is not about me save as a clinical player in the human drama of every patient with terminal illness and the overarching, overriding ethical commandment of competent patient autonomy in medical decision-making. Debate over labeling is distracting and unhelpful if our focus is on the definition of physician assisted suicide rather than the suffering of the patient. Please, do not quote me the Hippocratic Oath, now in one of 42 adaptations and revisions, except to refer to its spirit rather than its letter. Instead, stay with me at the bedside.
I find it more helpful to consider suffering from a clinician’s view rather than from the theoretical Kabuki dance of legalistic cataloging. Suffering is that which exists when what we are enduring serves no meaningful or helpful purpose in our lives, is inconsistent with our values and what we would want to avoid. It is what I have sworn to alleviate to the best of my ability knowing that the enemy isn’t death, but inhumanity.
In that context, the practice of which we speak is for a patient with whom I have a supportive, professional relationship over time; a patient thought by two physicians to have a life expectancy of less than six months; a patient with full decision-making capacity; a patient free of coercion in decision making; a patient who wishes to avoid a burdensome final days or weeks in the throes of soon-to-be fatal illness; one who is legitimately given a prescription for medication, to be taken at a time and place and circumstances of his/her desire, or not at all. Understand, the intent here is to provide release from his/her suffering, real and anticipated, achievable by no other means acceptable to the patient.
I see this as no different in practice than my acquiescence to remove my patient from a ventilator at his/her request, knowing that death is likely shortly to ensue; no different from ordering discontinuation of dialysis at the patient’s demand, fully aware of the consequences of that decision; no different from assuring my patient with Lou Gehrig’s disease that he will never need to be tethered to the ventilator he dreads to be relieved of his inability to breathe. And, I believe, my patients are reassured knowing I will not abandon them or their families in accompanying them through this most difficult part of their care, as they desire it. I cannot, will not, tell them what they must endure. Nor should anyone else.
I am reassured that the decades of documented experience in Oregon and the other states that have decriminalized physician aid in dying, with the same safeguards as the proposed New York State legislation, have shown that the fears of abuse are overblown or not substantiated by a single case in decades of practice. The “slippery slope” of abuse has proved to be more of theoretic concern than real, an unhelpful distraction from the realities or needs of care. In short, the sky is not falling. Further, no legislation or proponent of physician aid in dying has advocated mandatory endorsement of or participation in the practice – the entirety is optional and participation is voluntary, both by patient and practitioner.
The endorsement of the pending New York legislation to decriminalize physician aid in dying is ethically consistent with the tenets of modern medical practice. It gives deserved ethical primacy to patient autonomy while shining the light of regulated, monitored, evidence-based, patient-centered practice onto a secretive practice that has lurked in the shadows far too long.
For those who oppose its practice, so be it; you need not subscribe or submit. For those patients and caregivers who would avail themselves of the option should need be, we must impress on our legislators the imperative of passage of the enabling legislation.
That done, we need to encourage all our fellow citizens, by survey more than 75 percent of us, to pursue with our caregivers our desires regarding this and all aspects of our end-of-life care.
Robert A. Milch, M.D., is a physician in Western New York.