Seriously ill
need compassion
-- and assistance

Hawaii must continue to press for
legalization of physician-assisted dying

Suicide is not illegal in the United States, but assisting someone to end his or her life is against the law everywhere except Oregon, and then only under rigorous safeguards and controls.

About the author: Roland L. Halpern is executive director of Compassion In Dying of Hawaii.

While efforts are being made to pass legislation in Hawaii, California and Vermont, progress has been slow, in large part due to fierce opposition from the Catholic Church, whose bottomless coffers (nationally the church has spent more than $11 million) enable it to influence legislators and launch misleading advertising campaigns.

Some proponents, understandably discouraged by this lack of progress, have opted to ignore legislative efforts and instead concentrate on improving the availability of nonmedical methods of self-deliverance.

However, while this may provide a humane and dignified alternative for those who are suffering intolerably, we should not abandon efforts to legalize physician-assisted dying, for it is only through legalization that we can assure that proper controls and safeguards are in place.

Removing the physician from the equation is problematic because the physician is the person best qualified to make a candid evaluation of both the patient's condition and mental competency, and is the only source a patient has for legally obtaining the most effective drugs to bring about a peaceful death without undesirable side effects or botched attempts that might leave the patient in an even worse situation.

In addition, the safeguards required under legalization ensure that the patient's decision is an informed one. Under the Death With Dignity bill proposed for Hawaii, the terminal diagnosis must be confirmed by a second physician, two oral requests and one written appeal must be made, and should either physician suspect the request is motivated by depression or coercion, the patient must be referred for psychological evaluation. Finally, the patient must be counseled on alternative forms of treatment.

Absent the physician's involvement, the process is usually carried out in secrecy, requiring elaborate plans to protect the patient and his or her loved ones, and following death additional efforts often must be made to dispose of whatever container or apparatus was used, which could cross the line between an autonomous act by the patient and "assistance" by a third party.

A study among elderly suicides on Oahu found 78 percent involved patients who had recently been diagnosed with a serious illness. In order of frequency they ended their lives by jumping, hanging, firearms and overdosing. Coming in fifth was drowning, although the actual number is probably higher. Absent a suicide note, drowning rarely shows any obvious signs of violence, and thus is likely to be classified as "accidental."

Compare this with the experience in Oregon where one study found that 90 percent of those initially seeking a hastened death changed their minds after having talked with their doctor. Because the law encourages an open discussion between doctor and patient on end-of-life concerns, many commonly held fears, such as being institutionalized for having suicidal thoughts, simply disappear.

For some, merely being able to talk about their illness is enough to alleviate the desire for death. Others are willing to explore alternative therapies including pain management, hospice and treatment for depression, provided the assisted dying option remains open. Still others are comforted in knowing there is a final option if all else fails. And for the few who ultimately decided to end their lives, they do so in a nonviolent way surrounded by friends and loved ones.

During the six years that Oregon's law has been in effect, only 171 patients hastened their deaths out of 53,544 patients who died from the same underlying illnesses. As opposed to dire predictions of "mass suicides" if the law passed, legalization has actually resulted in fewer deaths. In Oregon assisted deaths represent only 1 per 1,000, compared to studies of other states where the rate averages 1 per 250 -- four times higher.

Legalization also brings about considerable improvements in end-of-life care, even for those who would never choose the option for themselves. Following passage of the Oregon law a survey among physicians found they had increased hospice referrals by 30 percent, 69 percent reported taking steps to improve their knowledge of mental conditions including depression, 76 percent reported taking steps to improve knowledge of pain management, and the use of medical morphine -- considered the "gold standard" for treating pain -- increased by 70 percent.

But this only occurred as a result of legalization. Before the Oregon's law, when the Oregon Health & Science University along with 27 other organizations offered a pain treatment seminar, only eight physicians signed up. One year following passage of the law, 150 physicians signed up, and more were turned away for lack of space.

Would that we were as fortunate in Hawaii. At the 1999 hearing on the Death With Dignity bill the Hawaii Medical Association's testified that within two years it would teach physicians about better pain control; arguing that once pain is managed the desire for assisted dying will disappear. Three years later Hawaii would receive an "E" rating, the lowest grade possible, for its failure to have any pain control policies in place, and within a few months of that, be ranked 51st, dead last, for failing to have adequate medical disciplinary oversight.

Competent adults who are dying and suffering should have the right to ask a physician for help in hastening their death. This is not about a patient choosing death over life -- the patient is already dying. Instead, it is about patients who want control over the way they die, a peaceful and humane death versus a prolonged and intolerable one.

While opponents often argue there is no constitutional right to die, a Harris poll found 65 percent of Americans think there should be, and Supreme Court Justice John Paul Stevens has stated, "In my judgment, it is clear that the so-called 'unqualified interest in the preservation of human life' is not itself sufficient to outweigh the interest of liberty that may justify the only possible means of preserving a dying patient's dignity and alleviating her intolerable suffering."

Hawaii, and all states, eventually will have an assisted dying law. Baby boomers used to having their own way are not going to be complacent relinquishing control over this most intimate final stage of life and their vote will influence future laws. But in the meantime many terminally ill adults are suffering. Some will find the means to end their lives. Others will suffer intolerably, tethered to the tubes and wires that are technology's answer to medicine's failure.

While it is true that nonmedical methods of hastening death have improved greatly and are readily available via the Internet, they are not a substitute for legalization. By prohibiting physician-assisted dying we only encourage this underground network to grow, with the unfortunate consequence that often those who are not terminally ill have access to this information as well.

It is only through legalization that we will improve end-of-life care through an open process that encourages discussion, contains safeguards to prevent abuse, and offers the alternative of a humane, peaceful and dignified death when all other efforts to relieve pain and suffering have failed.