Physician-Assisted Dying: Honest Choices

Physician-assisted dying (not "suicide" - a term that is not truly relevant here) is a complex and emotional issue. Here is a new perspective done with a leading physician with much direct experience - and who has quit one of his professional medical associations due to their lack of integrity on the topic. Regarding religious opposition to the bill in question, we can only observe that there is supposed to be a "separation of church and state" in our nation, and that the California Council of Churches supports the legislation.

Donald Abrams and Steve Heilig

The California End-of-Life Options Act, SB128, which would legalize physician-assisted dying (PAD), has been front-page news and stirred much controversy.

One casualty of such emotional debates can be basic truths about the personal, clinical and policy decisions surrounding this issue. Both of us have much experience in these arenas and hope to shed some light here.

Approaching the end of their lives, patients most want two things from their doctors - that they have clinical competence and know everything that might be done to help a patient not suffer, and that they will be there for the patient no matter what.
Rarely - not often, but not never - that can include hastening the end to some degree, and always at the patient's own choice. Most of the time such requests are not carried out - but just knowing that one has some added control and choice at the end can actually extend life in some cases - ironic, but true.

The California Medical Association opposed PAD for many decades, until this year. Their change in position came for three main reasons. First, accumulating surveys of doctors' opinions on this topic - over 30,000 physicians in published surveys thus far - indicate that at least half, and likely more, physicians now support some legal options for PAD. Second, experience in states that have legalized PAD for years shows that the many fears about abuses have not come about, and that, again, the practice is uncommon and legalizing it can actually lead to improvements in general care at the end of life. And finally, the hallowed medical dictum "Do no harm" is now seen to include the possible harm of keeping patients alive and suffering longer than nature, their God, or first and foremost whatever they might want for themselves.

The CMA conducted a survey of its leadership and found that a substantial majority supported legalizing PAD, or at least not opposing it. While still working to ensure that all reasonable safeguards against abuse are in any PAD policy, the CMA then changed to a "neutral" position. This is how a democratic organization, which purports to represent the profession, should work.

The one vocal medical group against SB128, the Association of Northern California Oncologists, also conducted a survey of members on this topic. Their survey also came back with a majority supporting PAD legality. But the executive leadership of the Association felt otherwise and discounted the members' vote in deciding to continue to oppose SB128. We wish they would have had the integrity of the CMA in this regard and as a result, Dr. Abrams has terminated his membership in the Association. For those who care for patients coping with end-stage malignant disease, support of PAD, or at least neutrality, increasingly seems a humane option.

The PAD issue comes down to an issue of patient choice and control towards the end of life, when we are very vulnerable. Most of us will be such patients at some point, and hope that by that time, we and our doctors will be empowered to make ultimate choices without outside interference.

Dr. Donald Abrams is chief of Oncology at San Francisco General Hospital and a Professor of medicine at the University of California San Francisco.
Steve Heilig is co-editor of the Cambridge Quarterly of Healthcare Ethics, health policy director for the San Francisco Medical Society, a former hospice worker and director, and drafted the original resolution urging the California Medical Association to be neutral on physician-assisted dying.