Should We Aid The Dying, or Aid Their Dying?

By: Jacob Dahlke

Having previously worked in a state during the time that they passed legislation permitting physician aid in dying, I recall a story from one of the testimonies. A woman recounted her experience with her husband, a former state legislator who was dying from a terminal disease. It left him in pain, and more importantly to the both of them, it left him in suffering. He had lost all control: of his daily living, of his bodily functions, of his mental capacities, of his future. He felt he had lost all of his dignity as a person. The widow advocated that although at the time (a couple of years prior) it was illegal for the visiting home health care practitioners to have knowingly prescribed a lethal dose of any medication, she pleaded with them to do so. When her husband finally died at home, she claimed it was in suffering, and unnecessarily so.

Similar stories have recently been told in Nebraska, and opposing anecdotes as well. State Senator Ernie Chambers’ bill proposed legislation that would have permitted what is now legal in five other states: it expands the role of a physician to allow them to write a lethal prescription to a particular category of patients who are near the end of their lives due to terminal illness. Although it has failed to advance this current session, Sen. Chambers has assured that this topic isn’t going anywhere any time soon. In this he is correct. Five states permit legislation, and nineteen states considered bills in 2016. Four of those states neighbor Nebraska.

Defining the Issue

In my line of work in bioethics, words matter. Specific words, carefully chosen, can serve to clarify issues, and others, sometimes just as carefully crafted, can serve to obfuscate a discussion. Such it is here: “physician-assisted suicide”; “death with dignity”; “physician aid in dying”; all of these terms are used to describe the same type of action. I find it helpful to use “medical aid in dying”. To say that a physician is assisting in a suicide attempt is inaccurate: that would mean the physician participates in the act of suicide. No one, to my knowledge, is advocating for this in these discussions. (Euthanasia, ending the life of a person to alleviate pain and/or suffering, is legal in some countries. A narrow part of it could be considered assisted suicide, if the desire to die is expressed by the patient. That discussion, although important, is not relevant here.) Conversely, “death with dignity” seems too exclusive in claiming that this kind of death is the only kind that can be dignified. It focuses less on the act and more on the motivation – to be dignified in the dying process as much as one was dignified in life. This can be countered relatively easily by providing examples – dying in one’s sleep, for one – which a person could consider dignified. Instead, “aid in dying” acknowledges that dying is already occurring, prematurely and against the person’s wishes (which also counters the use of “suicide”). The underlying disease has overtaken the person’s organs and body to the point that our medical interventions, however advanced they may be, are no longer effective. To “aid” in this is to acknowledge its happening, and to ensure that suffering and pain are minimized by it, even if it means that death comes sooner than if the disease is left alone.

Supporting All Patients with All Options

To say that this option – medical aid in dying – provides a broad solution to dying patients is perhaps grandiose. It is particularly true in a state like Nebraska, which lacks the medical infrastructure to provide qualify end-of-life care to all suffering or dying patients, not just ones that may qualify for aid in dying. An accurate, robust “death with dignity” law would be one that provides support to all mechanisms for supporting such patients. For example, promoting advance directives can compel people to thoughtfully consider their options before a crisis. Palliative medicine services provide therapy and symptomatic relief (such as for pain and suffering) during the course of a long-term illness, regardless of the aggressiveness that a person may wish to pursue. Finally, the state has no standardized mechanism for communicating patient wishes about end-of-life treatments as they travel between their various healthcare facilities such as a hospital, rehabilitation facility, or nursing home. Documentation of patient and physician conversations about such treatments – which are used in nearly every other state – could help promote a more efficient and more effective method of considering options. These structures, in addition to educating patients about other legal and ethical options at the end of life, ought to be considered the horse to physician aid in dying as the cart.

To echo Sen. Chambers, this topic is not going anywhere any time soon. It will be important that as we consider what is best for the people of Nebraska, we engage in thoughtful, civil discourse about the balance of a patient’s rights to self-determination and our society’s interests in promoting sound medicine. Where we Nebraskans fall into that conversation is still undetermined, but I remain hopeful about the possibilities.

 Jacob Dahlke is a clinical ethicist for Nebraska Medicine in Omaha, Nebraska, and an instructor and associate for the Center for Health Policy and Ethics at Creighton University. The views shared here are his own and do not represent those of the organizations.