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A Time to Die: The Place for Physician Assistance

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Charles F. McKhann, MD
A Time to Die:
The Place for Physician Assistance

(New Haven, CT: Yale University Press, 1999)
(ISBN: 0-300-07631-2; hardcover)
(Library of Congress call number: R726.R355 1999)
(Medical call number: W50M47847t 1999)

A physician and professor at a medical school
discusses all perspectives on physician-assisted voluntary death.

First, some common situations in which the patient
wishes to reduce his or her suffering
by choosing the most appropriate time to die:
cancer, AIDS, Alzheimer's disease, pain.
The person who is inevitably dying
might not want to dissipate his or her estate
in futile medical care.
Being able to pass some wealth to the next generation
sometimes means more to the dying individual
than a few more days or weeks of low-quality 'life'.

Sometimes patients ask doctors
to help them to die for irrational 'reasons'.
The full situation should be assessed before
discussing the best timing of death.

Alternatives to voluntary death should be explored first:
comfort care, pain relief, hospice care.
If such methods do not handle the situation satisfactorily,
then the doctor has some other methods
which will assist the patient to the desired goal
--a peaceful, painless, & dignified death.
Some of these methods of assistance are now legal:

(1) The doctor can provide sleeping medication and/or pain-control drugs,
which have as a known side-effect shortening the dying process.
This could even take the form of 'terminal sedation',
in which the patient is kept unconscious until natural death.

(2) In the states of Oregon and Washington,
the doctor can even write a prescription for gentle poison
once several safeguards have been fulfilled.

(3) If the patient is being sustained by some form of life-support,
all concerned can agree to discontinue such supports.
Natural death will quickly follow.

(4) If all concerned agree that death by dehydration would be the best path,
then food and water can be withheld
and the doctor can order additional medications
which can eliminate the unpleasant aspects of this means of dying.

When considering legal methods of assisting a voluntary death,
completely open discussions can involve
all who care about the life and well-being of the dying patient.

Dr. McKhann discusses the Dutch experience
of voluntary death with doctor assistance.
The experience of the Netherlands has uncovered several problems,
which can be corrected in any new legislation in the United States.

What about people who have requested death
in an Advance Directive or other careful document
but who slip into a semi-conscious state
before they can request death one last time?
How realistic is it to require the patient
to be awake and capable up to the last moment before death?

Why should the law authorizing physician aid-in-dying
require reporting to the coroner and/or the public prosecutor?
A physician-assisted voluntary death is not a suspicious death.
And no crime has been committed.
Law-enforcement officials have no training in the right-to-die.
Whatever reporting to public authorities is required
should take place before the death, not after,
in case this death might be premature.
Reporting after the death could have no positive outcome.
Thus, many Dutch physicians do not correctly report
their physician-assisted voluntary deaths.
These deaths are just reported as deaths from natural causes,
which do not involve the police, the public prosecutor, or the courts in any way.

Physicians are rightly concerned about
the legal aspects of helping their patients to die.
Not only is it illegal in most states,
but they might also be sued by a distant relative
who did not approve of the voluntary death.
Also, doctors do not want to be publicly associated with assisted dying.
They have been trained to cure, not kill.
And most of the professional medical groups
are opposed to any physicians assisting in dying.

When Dr. McKhann asked other physicians for their opinions,
most said that they would be more willing
to help their patients die in the last weeks of life
if it were legal, moral, & professional to do so.

The public resists physician-assisted voluntary death
because of fears of abuse and mistakes.
Like all other human beings, doctors do sometimes make mistakes.
But the public does not call for an end to air transportation
because pilots sometimes make mistakes
that result in the deaths of everyone on board those planes.

However, most cases of physician-assisted voluntary death
are nowhere near the error zone.
There is no rush to achieve death this instant.
And if there are doubts about the wisdom of this voluntary death,
then other opinions can be obtained
--from other doctors and relatives not yet consulted.

Some public worries also relate to the possibility of greedy relatives,
who hope to get their hands on their inheritance a bit sooner.
But most can wait a few weeks for their money.
And if there is any such doubt,
the full situation should be brought into the open.

Even more unlikely is the rare case of the mad doctor,
who gets some kind of enjoyment out of killing people.
Occasionally doctors have been exposed as serial killers.
But outlawing the right-to-die is probably not much help
in dealing with any doctors who relish the power of killing their patients.
Physicians who wish to kill their patients
can already kill them in a thousand ways
without pretending that it has anything to do with the right-to-die.
Careful detective work is the best way to catch these doctors.
We already have good laws against murder.
The criminal-justice system should deal with this problem.

The public also worries that the 'right-to-die'
will be applied first to vulnerable people.
But the facts point in the opposite direction:
The vulnerable people get little or no health care at all.
Neglected patients will not get any special attention from doctors
who want to help them to die.
With respect to less-favored groups of people,
doctors are already wary of providing sub-standard care.

Dr. McKhann reviews the standard safeguards for life-ending decisions:
1. requests from the patient while still capable of making decisions.
2. doctors' opinions about prognosis and treatment options.
3. psychiatric evaluation of the candidate if there is any doubt.
4. waiting period to avoid impulsive death.
5. full reporting of all material facts.

Such safeguards can probably be improved,
perhaps even to the degree needed
to win over some opponents of the right-to-die
who raise the specter of people being put to death
for the benefit of the state.
The discussion of the right-to-die
should be kept completely separate
from the discussion about health-care costs.

Finally Dr. McKhann explores the legal basis for the right-to-die.
The US Constitution grants us privacy and the equal protection of the laws.
This includes reproductive freedom
and the right to refuse unwanted medical treatments.
But the US Supreme Court has resisted
finding a right-to-die in the Constitution.
This is a proper area for legislative change by the states.
Most of the laws against assisting suicide
are more than 100 years old,
written long before modern medical technology.
Such laws were intended to keep everyone
from assisting an irrational suicide.
We need new laws to allow physicians to assist in a voluntary death,
which is completely wise, compassionate, well-planned, & rational.

The present system of secret assistance in dying
is open to more mistakes and abuse
than if we made choosing the best time for death
an open, rational discussion
in which all concerned persons would have a voice.

For example, as long as assisting a patient to die remains illegal,
the doctor is not inclined to ask for a second professional opinion
about the advisability of choosing death now
rather than following the pattern for standard terminal care.
Most of the family members must be kept in the dark
about the life-ending decision because of the fear of prosecution.
Only informal, personal safeguards are applied.
Any new laws regarding the right-to-die
would bring the decision-making process into the open,
where public safeguards would be applied to every case.

A Time to Die: The Place for Physician Assistance
is a wise and compassionate book
about the prospect of physicians helping their patients to die.
It does not break any new ground in the discussion,
but the fact that it was published
shows that we are more open to the possibility
of making reasoned choices at the end of life.
Dr. McKhann believes that it is only a matter of time
before physician assistance in voluntary deaths will be approved.
How soon will we all have this right to choose?

If you would like to read other books on this subject,
search the Internet for this precise expression:
"Books on Helping People to Die".

James Leonard Park, advocate of the right-to-die with careful safeguards.