As one with the letters “M” and “D” after my name, I get emails from a service called Medscape (subscription generally required), with links to a variety of articles on things medical. This week brings a link to a piece under the title “Inexact Science: is Patient Eligible for Medical Aid in Dying?” The upshot: physicians who provide assistance in suicide for their patients struggle with two common features of laws around assisted suicide: a requirement that the prognosis for survival be 6 months or less, and the requirement to confirm—usually with concurrence of a second doctor—the patient’s capacity to make decisions.
In the first case, it’s no secret that saying how long any one person, even one with a terminal illness, has to live cannot be done precisely, and there are many mistakes. A doctor can try three approaches: guess how long she thinks a patient will live, ask whether she will be surprised if the patient is alive after 6 months, or guess the probability of the patient’s living 6 months. These are three very similar, but logically non-identical, questions. Doctors’ estimates tend to be more accurate for patients with cancer than for other cases, but they still can be wildly inaccurate.
In the second case, patients’ limited ability to communicate can make it hard to tell whether they have the capacity to freely choose death, or they may have that capacity when the doctor provides the assistance, by prescribing a lethal dose of a drug to be taken later, yet the patient’s decision-making capacity may not be so good at the time the drug is actually taken.
Readers of this blog will know that the present writer is a staunch opponent of doctor-assisted suicide. One can sympathize with the difficult cases faced by physicians who disagree on the subject, yet still argue that their best course of action would not be to assist a patient’s dying, but focus on caring for the patient and alleviating symptoms and distress to the end. A poignant essay in this week’s New England Journal of Medicine (prescription also required) by a palliative care doctor whose patient, with bone cancer, had truly intractable pain, is a case in point. Here, the doctor did everything she could to control her patient’s pain, using higher doses of narcotics than she ever had or probably ever will again, with no success. Seeing her patient’s joy in interacting with his family and friends, she resisted sedating him to the point of unconsciousness to death—the last resort for controlling his pain. “Terminal palliative sedation” comes about as close as possible to active euthanasia without, I would argue, crossing the line because the primary intent is to alleviate suffering, not cause death, although the latter, because of suppressed breathing, may prove unavoidable. In the case in point, the patient was not sedated, but died over a weekend when the doctor was off; on reviewing his last moments when she returned on Monday, she learned that he had been able to “clink a glass of beer” with visiting friends before he died. She wondered whether she had treated him too much, tried to be too much of a hero(ine), because she wanted to preserve what was left of his consciousness. She thought she might be to blame for treating her patient too aggressively in the end. Reading her account, one must be reluctant indeed to level a charge like that at her. Her writing makes it clear that she discharged her duties admirably, in a difficult situation.
Finally, I note a headline in today’s USA Today: “Suicide prevention: Many not ready.” Who is not ready? Therapists. Psycohologists. Practitioners who do not know how to talk to someone who is suicidal, or who are worried about liability if a patient/client actually kills himself, or who are more concerned about assessing how likely a suicide attempt is than positioned to take on the burdens of identifying and addressing the underlying emotional pain. Better training is called for, the article says. Perhaps more awareness and caring from folks in general would help. Ten and a half million people seriously thought about suicide in 2018, it says. About a third of those made a plan to kill themselves. About a third of those actually tried. Over 48,000 died from suicide. Our goal should always be to care for suffering people, but in the process we should reject actively ending their lives.