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Tuesday, June 12, 2018

ANALYSIS/OPINION:

As a physician specializing in oncology and hematology since 1975, I am pleased that the American Medical Association (AMA), American College of Physicians, American Psychological Association and many other medical organizations have, to this point, recognized the real danger associated with assisted suicide, and hope that they continue to distinguish between assisted suicide and authentic medical care.

After two years of carefully studying the issue, the AMA’s Council on Ethical and Judicial Affairs (CEJA) recommended that the AMA remain opposed to assisted suicide. For whatever reasons the AMA House of Delegates sent the matter to the CEJA for further consideration. The policy of opposing assisted suicide remains in effect.


Care at the end of life is a primary concern for most of my patients and I can say without hesitation that terminal patients need quality hospice and palliative care — not assisted suicide. In 1978, I co-founded the Hospice of Pasadena and, in 1981, I testified before Sen. Edward Kennedy’s subcommittee considering making hospice a Medicare benefit. As a board-certified physician in hospice and palliative medicine, I have seen firsthand that these specialized fields can alleviate suffering at the end of life.

And, in fact, physical pain is seldom the reason patients request assisted suicide. Most often patients list psychosocial factors such as concerns over the loss of autonomy, inability to participate in activities they found enjoyable, and fear of being a burden when choosing assisted suicide. This fact frightens many in the disability community because being burdensome or demoralized should have no bearing on medical care.

But suffering is far more than physical pain or other medical symptoms. Depression, demoralization and family dysfunction all cause suffering and can provoke suicidal thoughts. Chronically ill patients are at greater risk of developing a condition known as a “demoralization syndrome” in which overwhelming hopelessness and self-blame eventuate in suicidal thinking. Most patients with a terminal prognosis likewise experience depression at some point in the course of their illness.

Why then would I endorse handing a lethal overdose to a terminal patient? This issue is called “counter-transference, the physician projecting his/her feelings (fears of dying) on the patient. Other than psychiatrists, most doctors are clueless in dealing with this phenomenon. I queried noted psychiatrist Glenn Gabbard and he agreed. If you’re a patient with a fatal disease you don’t want a physician willing to consider your life “not worth living” and acting on it because that physician can’t handle the emotions associated with your situation. What everyone needs is commitment and compassion.

Most patients under my care who in some way requested assisted suicide responded promptly to counseling and changed their mind. Only a few required medications to relieve depression. Psychological suffering in terminal illness is a challenge for highly trained mental health professionals and well beyond the scope of most physicians.

Assisted suicide forces physicians who don’t specialize in mental health to diagnose mental illness, clinical depression and other psychological conditions, thereby putting vulnerable patients at the risk of going undiagnosed, untreated and receiving the means to kill themselves. Psychiatrists agree that even physicians within their own discipline need more than a one-hour session with a patient repeated in one week to diagnose and manage the forms of depression that can affect terminally ill patients, yet this is all assisted suicide laws recommend. These laws require instead the establishment of “competence,” which is a non-medical concept.

A further problem with all existing statutes is that they require that a patient have six months or less to live to “qualify” for assisted suicide. But a six-month prognosis doesn’t accurately predict end of life. I recently cared for a woman whose lethal prescription was written more than two years ago under the California assisted suicide law. She remains reasonably functional and comfortable. Prognostication is not an exact science. Very good, experienced physicians can be wrong about the time a person has left, by months, years, and even decades.

Terminal illness is no different than not being terminally ill when it comes to suicide. As medical professionals, we are always obliged to prevent suicide — regardless of the patient’s underlying diagnosis. Palliative care specialists appreciate this more than others. There is no good reason to treat terminally ill patients with different medical standards — they like everyone else deserve suicide prevention.

These laws stigmatize terminal illness as something different from other illnesses in which transient urges for self-destruction can occur. Within medicine, however, assisted suicide is nothing short of incompetent palliative care. We need to improve the care of the dying, not terminate them.

• Henry Rex Greene, a physician, has more than 35 years of experience in medical oncology/hematology, both in cancer centers and a private oncology/hematology practice. He has also served in academic roles at the University of California’s Keck School of Medicine and at Huntington Memorial Hospital in Pasadena, Calif.


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