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Physicians and Californians Support Aid in Dying, but the California Medical Association Doesn’t

CMA ignores evidence, experts, and physicians’ views

By Richard Ikeda, M.D.

When cure is no longer possible, the majority of Californians, and the majority of California physicians, want dying patients to have the right to make end of life choices in accord with their own values and beliefs. I am disappointed that my own professional organization, the California Medical Association (CMA), continues to oppose terminal patients’ end of life choices. As a physician caring for the poor and vulnerable elderly, I can tell you cancer and other terminal patients need better end of life care and choices. This week completed ten years’ experience with Oregon’s death with dignity law, and all studies show end of life care has improved for all Oregonians.

The CMA leadership continues to ignore the evidence that patient choice helps all those facing the end of life. It’s time for CMA to join other medical groups in changing its position on aid-in-dying. Peer-reviewed research from Oregon shows that after almost 10 years, there is no evidence of a slippery slope or that vulnerable populations have been harmed. A study published last month in the Journal of Medical Ethics by five researchers who exhaustively examined the effects of aid in dying in Oregon and the Netherlands debunks opponents’ arguments that legalized aid-in-dying harms disabled people and other at-risk groups. The researchers concluded that there was no evidence of harm to the elderly, the uninsured, the, poor, or the disabled. The most recent study found that no vulnerable populations have been harmed in any way from the Oregon law. Yet CMA ignores this evidence and continues to base its opposition to patient choice on a fear of a “slippery slope.” But there is no slippery slope. CMA appears to be making policy based on conservative Christian doctrine instead of relying on peer-reviewed studies and the opinion of end of life experts.

The CMA opposition ignores the views of most physicians. A national survey of 677 physicians and 1,057 members of the general public by HCD Research in October 2005 revealed that the majority of both groups believe that physicians should be permitted to dispense life-ending prescriptions to terminally ill patients who have made a rational decision to die due to unbearable suffering. The survey indicated that nearly two-thirds of physicians (62%) and the general public (64%) believes that physicians should be permitted to dispense life-ending prescriptions. The CMA policy contradicts that of the Academy of Hospice and Palliative Care Medicine (AAHPM), the organization that represents physicians on the front line of end-of-life care - changed its position from opposition to “studied” neutrality: “Excellent medical care . . . can control most symptoms . . . near the end of life. On occasion, however, severe suffering persists; in such a circumstance a patient may ask his physician for assistance in ending his life by providing Physician-assisted Death (PAD).”

The American Medical Women’s Association (AMWA) “supports the right of terminally ill patients to hasten what might otherwise be a protracted, undignified, or extremely painful death.
AMWA believes the physician should have the right to engage in practice wherein they may provide a terminally ill patient with, but not administer, a lethal dose of medication and/or medical knowledge, so that the patient can, without further assistance, hasten his/her death. This practice is known as Aid in Dying.”

In addition, the American Public Health Association has parted ways with the CMA on this issue, and “urges health educators, policy-makers, journalists and health care providers to recognize that the choice of a mentally competent, terminally ill person to choose to self-administer medications to bring about a peaceful death is not "suicide," nor is the prescribing of such medication by a physician "assisted suicide."

The choice of whether to hasten death at the end of a terminal illness should belong to the patient. I have always been in favor of a patient’s right to a dignified death. Medically hastened deaths – which happen already - should be done in the best of circumstances under true safeguards instead of botched attempts and violent suicides we see now. At a minimum, allowing the patient to control their own pain management allows for more comfort than a doctor can provide in some cases.

Control over a dying patient’s death should belong to the patient, not the federal or state government. It is the patient who is suffering. It is at this time, as in other pivotal times in the lives of our patients, that physicians should feel safe in serving their patients, protected and free to discuss all medical options at the end of life. The more choices patients have, the better.

Caring for dying patients includes the sacred duty to listen to their fears, communicate their options, and honor their choices for end of life care. It’s time for CMA to abandon its opposition to patients’ end of life choices.

For more information, visit: compassionandchoices.org

Dr. Richard Ikeda cares for elderly, low income patients as medical director of Health For All community clinics, a non-profit organization providing quality medical health and social services to low income families.

Posted on November 02, 2007

Comments

The California Medical Associations's position is not -- and should not be -- based on counting the number of hands raised in a classroom. The discussion is about more than the flavor of seasoning on popcorn.

Among other aspects of his article that seem biased, the author fails to note the rest of the American Academy of Hospice and Palliative Medicine's position statement: "Whether or not legalization occurs, AAHPM supports intense efforts to alleviate suffering and to reduce any perceived need for PAD....For physicians practicing in regions where PAD is legal, AAHPM advises great caution before instituting PAD..." This is hardly a ringing endorsement. Indeed, the position is more a recognition that in some states PAD is legal and that it is the moral obligation of the physician to do everything in their power to avoid that extreme by giving the best end-of-life care possible. Read the position statement!

As to the study cited in the Journal of Medical Ethics, their focus was the effect upon certain population groups. The idea of The Slippery Slope deals with more than just the possible impact on certain population groups. It is the general acceptance of suicide and the use of physicians as a means to that end - something that the good doctor seems to have few concerns about. Moreover, in the use of physicians to accomplish the deaths of certain populations, we hardly need the study he cites: We have abundant evidence from our not so distant past.

Let it be said that the position of this comment is not one of meekly tolerating suffering, either. We endorse the use of whatever pain medicine is needed, in the amount needed, to ease suffering even if that leads to death. We do not, however, endorse the use of medications for the purpose of ending the life. While that may seem a semantic difference to those who are biased towards physician-assisted suicide, it is a notable and significant distinction. Hospice physicians understand the distinction completely.

The broader question, the one that does and should give pause to the CMA and all other such organizations is the ethical status of PAD. It is not only the effects of PAD on particular population groups: It is the broad-ranging impact of employing those who have chosen the calling of healing in the instrumentation of killing. The position endorsed by Doctor Ikeda would rob patients, families and their heirs of many opportunities for healing and growth in the days, months and generations that will follow them.

Posted by: Michael Davis at November 3, 2007 05:22 PM

I am a documentary filmmaker in Atlanta, Ga. I've produced a short documentary about end-of-life decision making, caregiving and hospice. It's called 203 Days.
You can view it in it's entirety at the following University of Connecticut website along with a study guide.

http://fitsweb.uchc.edu/days/days.html

If you'd like more information please go to my website

http://bbarash.com/bb_203days.htm

I hope this film is helpful to people who want to know more about the most common experiences for caregiver and patient at this difficult time.

Bailey Barash

Posted by: Bailey Barash at November 4, 2007 05:15 PM

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