Monday, January 13, 2014

Unintended Consequence: Obstructing Patient Choice for Death with Dignity

By: Sue Dessayer Porter

Oregon was the first state to legalize aid-in-dying. Since 1998 it has implemented “Death With Dignity (DWD),” which allows eligible terminally ill people to end their lives peacefully with a legal prescription. 

Contrary to fears asserted by the opposition, there have been neither slippery slopes, nor granny panels, nor hordes of people clamoring to Oregon to die. With over sixteen years of experience, DWD has demonstrated successfully that cautious adherence to the law provides safe choice and dignity with aid-in-dying.

In spite of this flawless record, there is ever-increasing obstruction against choosing this autonomous and personal end-of-life option. The problem? As religious hospitals merge with financially imperiled medical centers or acquire independent medical practices, they are enforcing policies which prohibit doctors from participation with DWD. This restriction applies to all doctors; therefore, a Muslim physician treating a Jewish patient is dictated by another religious doctrine. Doctors are not even allowed to have a conversation with their patients about DWD, so the “duty to refer” is not a consideration.

An unintended consequence?  Oregon’s DWD Act, Section 127.885 s.401 (5) (a), allows a health care provider to prohibit another health care provider from participating in DWD. [1] This was intended as a well-meaning compromise to appease the opposition and move the law forward. In retrospect, lawmakers in the early 1990’s could not have predicted the merger activity by religious hospitals twenty years into the future. However, the state of medical economics has changed so dramatically in the last two decades that private practitioners cannot sustain independently. Therefore, doctors who previously supported patients through DWD can no longer do so, because they are now employed by religious medical organizations. 

Washington state voted DWD into law in 2008 and is facing the same obstacles.

These health care leaders state that they are in savior mode, in that if it were not for them, many communities would be bereft of medical care. They say that they are “driven by a mission to serve the underserved,” with a commitment to help every human being. [2] However, patients requesting end-of-life choices are being denied lawful alternatives. This pervasive barrier to aid-in-dying affects increasing numbers of qualified terminally ill patients who try to avail themselves to DWD. Because their states voted DWD into law, residents of Oregon and Washington reasonably assume that health policy, combined with their doctor-patient relationship, entitles them access to aid-in-dying. Although this is a credible expectation, it is proving to be false too frequently.

Doctors are individually protected by conscience clauses to deny services that are in conflict with their personal beliefs.  Alternatively, as long as freedom of choice is protected for doctors who do not want to participate in specific procedures, the same principle of choice should be guaranteed for doctors who do choose to offer what they consider responsible, ethical, legal and dutiful medical care.  And logically, patients should be assured their rights to legitimate choice and self-determination.

Medical beneficence should be defined by the doctor and patient; it should not be dictated by a separate entity which controls with economic power by acquiring medical practices that cannot sustain independently, due to the current medical business model.

Sue has been a client case manager for Compassion & Choices since 2001, stewarding patients through Oregon’s Death with Dignity Act. She has a Masters of Science in Bioethics from Union Graduate / Mt. Sinai Med. Center (NY), a Masters in Business Admin. from St. Mary's College (CA)  and a diploma from Yale's Interdisciplinary Center for Bioethics (2013). Sue is also a national board member for Compassion and Choices, the leading advocacy organization for end-of-life issues.

 1. http://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Pages/ors.aspx

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