Refuting Arguments Against Medical Aid in Dying

(Editor’s Note: David Leven is Executive Director Emeritus and Senior Consultant for End of Life Choices New York — KTB)

Introduction

Before there was experience with medical aid in dying (MAiD), many arguments were made opposing it and concerns were raised, some understandable at the time. Unfortunately, some of these same arguments and concerns are still being expressed. Below are some arguments against MAiD and some informed responses based on more than 50 years of cumulative experience.

MAiD is the same as assisted suicide and should not be permitted.

Suicides are done by those, usually with a mental illness, who can continue to live but choose not to; are done in isolation, often impulsively and violently; and they are tragic. In contrast, MAiD is available only to terminally ill patients who will soon die; their disease is killing them. The process usually takes at least several weeks from the time that a request is made for a prescription of life-ending medicines. It occurs after consulting with two physicians and almost always with family support; and it is empowering. The term “assisted suicide” is rejected by the American Public Health Association, American Academy of Hospice and Palliative Medicine, American Medical Women’s Association, the American Psychological Association, American Academy of Family Physicians, and other highly respected healthcare organizations. In 2017, the American Association of Suicidology issued this statement: “Suicide is not the same as physician aid in dying”. The statement lists 15 points of discussion, which you can read here.

Palliative or hospice care is enough to relieve the suffering of dying patients.

In fact, those who die by MAiD are far more often receiving hospice care than others — over 90% on average in Oregon, where MAiD has been legal over 20 years. The implication is that even hospice care is unable to sufficiently relieve the suffering of some dying patients. We certainly do not want patients to die prematurely if there are things which could be done to improve their quality of life. However, once desired treatment and care run their course, it should be up to the patient to decide how life will end.

We should not allow MAiD until patients have adequate access to palliative care.

The concern about lack of access to palliative care is absolutely legitimate, particularly for poor people, people of color and those who live in rural areas. However, there is no evidence that patients who use MAiD have been deprived quality care. As mentioned above, most patients are enrolled in hospice when they die by MAiD, receiving the gold standard of end-of-life care.

Most people who end their lives by MAiD do not do so primarily because of uncontrollable pain or other symptoms.

This is true but the argument is not valid. People suffer in different ways at the end of their lives. All who are dying and have decision-making capacity should be able to decide if and when their suffering has become intolerable, whether because of pain, other uncontrollable symptoms or other reasons that cause suffering. Mentally competent patients are currently permitted to reject any life-sustaining treatments or to stop them at any time, with the understanding that death will ensue. Decisions are made everyday to withdraw a feeding tube, stop dialysis, or turn off a pace maker. And they may do so regardless of the nature of their suffering. That being the case, denying terminally ill patients the right to access MAiD cannot be justified simply because in some cases the suffering is not due to intolerable physical symptoms.

Prognostications by physicians are not always accurate so patients might end their lives prematurely by MAiD.

Doctors far more often predict that patients will live longer than they actually do. More importantly, patients who choose the option of MAiD almost always wait until they are in fact quite close to death. The process usually takes some seven weeks from the time the first request is made until the drugs are taken, if ever (about one third of patients never take them). Clearly, patients should be able to make end-of-life decisions based on the prognostications of two doctors, just as they can make similar decisions to hasten their deaths by stopping or never starting life-sustaining treatments, even if the prognostication is inaccurate, as long as the decision is based on adequate information.

Patients might be coerced into dying by MAiD.

This would be an understandable concern if there were not over 50 years of combined experience with legal MAiD, without any substantiated court or administrative cases proving coercion or any other abuses. Even if coercion is theoretically possible, that is not a sufficient reason to withhold access to MAiD. Patients might also potentially be coerced to stop or never start life sustaining treatments, and there is actually more opportunity for coercion in those cases than with MAiD due to the strict safeguards in the law.

Vulnerable populations are at risk and may be abused or coerced.

The concern expressed here was quite understandable before there was evidence. But, there has in fact been no disproportionate impact on vulnerable populations such as the poor, people of color, people with disabilities, or the elderly (see “Legal physician-assisted dying in Oregon and the Netherlands: evidence concerning the impact on patients in ‘‘vulnerable groups”, Journal of Medical Ethics 2007; 33;591–597.) There are no contrary studies to our knowledge. With regard to those with disabilities, consider a February 2016 letter from the Executive Director of Disabilities Rights Oregon where he categorically states that “DRO has not received a complaint of exploitation or coercion of an individual with disabilities in the use of Oregon’s Death with Dignity Act.”

Doctors should not be involved in intentionally causing the death of their patients.

We actually do not know what the intent is of any doctor who prescribes the medications for a patient who chooses MAiD. The doctor may not want the patient to die but is acting to support and respect the wishes of the patient when prescribing the drugs. Similarly, we do not know what the intent of a doctor is when a ventilator is withdrawn. The doctor may actually want the patient to die or not. We do know that in both situations the patient will die regardless of the doctor’s intent. But the intent of the doctor is not really the point. The intent of the patient is what clearly matters.

MAiD is fundamentally incompatible with the doctor’s role as healer.

When a patient is terminally ill, healing the illness itself may not be possible. The relief of suffering might be considered another form of healing, compatible with a doctor’s role. And it is, of course, extremely important to the doctor that the patient has the best possible quality of life, usually with the provision of palliative or hospice care. But, when suffering becomes intolerable, the relief of that suffering may include a hastened death if that is what the patient decides. Doctors must have the ability to act in accordance with the wishes of their patients and to prescribe life-ending medications to eligible patients. If they cannot do so because of their own ethical or religious values, none of the laws authorizing medical aid in dying requires doctors to directly participate in the process.

Conclusion

With more than five decades of data, it is clear that there are no longer any compelling arguments in opposition to MAiD. There are no justifiable reasons why this medical option should not be available to adult, mentally capable, terminally ill patients.

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(P.S. Last week’s post included the news that a MAiD bill was introduced in the Minnesota legislature. A similar bill has now been approved by the New Mexico House of Representatives and the first of two required Senate committees, and the Connecticut version has finally cleared the Public Health Committee. Supporters of MAiD living in those states are encouraged to contact their elected officials. Also, an attempt to criminalize doctors for helping their patients end their suffering was struck down in the Montana Senate. — Kevin Bradley, Editor)