General MedicineApril 10, 2015

Suicide: The rattlesnake in the hat

By James Salwitz, MD

The theater darkens; children stop laughing, adults sit forward in their chairs. Framed by a single light in the center of the stage, he stands; tuxedo, white shirt, black tie. He stares into the silent crowd, slowly turning his head, lips touched with the slightest, smallest, cruelest of smiles. His gaze fixes upon you; he is just feet away. His hand rises to the brim of his tall hat and in a single motion, it sweeps from his head; he holds it, pointing at you.

The magician spins the hat end-to-end, showing emptiness. Pushing in the top, he turns the hat inside out. Empty. He carefully returns the hat to its normal shape and shakes. Empty.

He extends the hat forward, upright. Slowly, smoothly, mysteriously, he reaches into the hat, to his elbow. There is pause. Then, in an instant, in a flash, with a quick flip, his arm pulls from the hat and in his hand he holds…. A hissing, rattling, squirming, furious, diamond-painted snake. The children scream.

Suicide. Physician-assisted suicide is that snake. We desire, we expect, a white rabbit; we are given, death.   We are told state sanctioned suicide is choice; it is infinite loss of control.

To understand this macabre trick, one must understand two words. Freedom and Right. These words we use interchangeably. We say the “right to bear arms” or “the freedom to bear arms,” as if they mean the same thing. They do not. Those who want legal physician-assisted suicide depend on us not knowing the difference.

Freedom is having the power to choose or act without government interference. A freedom means to be left alone. Freedom of religion, speech or association mean that we can think, say or be with whomever we want; no one, especially not the government, can interfere.

A right means that the government must act in order to provide a service or protection. The right to education, right to health care, right to a fair trial or the right to feel secure. You have the right to demand action from government.

The main argument to support physician-assisted suicide is that each of us should be able to control our bodies and decide whether it is worth continuing to live. No one should interfere if we decide that we have too much pain or if we believe we are so damaged that there is no quality or hope. We are entitled to die, as we decide.

This argument makes a lot of sense. The only thing each of us can really control is our own thoughts, soul and body. Only we can decide for ourselves whether life is worth living. We should have the choice to end our lives, if we so judge. This is hard logic to counter.

The desire to decide our fate is clear support for the freedom to commit suicide. The freedom to be left alone; the government and no one else should interfere. Many have said taking one’s life is the ultimate display of choice and freedom.

The trick is that none of the “death with dignity” proposed or active laws are about “freedom.” If they did, the words would be short and simple. They would say, “The government will not interfere with someone who wishes to end their life.” This sort of law would establish a “freedom to die.”

However, even though the logic used is a “freedom” argument, what is written in each law, is a “right.” Proponents want the government to do something. They want the government to act. What action do they want from the government? Well, if you have a right to an education, the government sets up schools, hires teachers. A right to health? Medicare, Medicaid and a healthcare system to heal. A right to be safe? Police and army. A “right to die?” These laws give the government the power to kill.

The government kills by setting up a system that results in the death of citizens. It establishes rules and regulations that require doctors to kill. Since a right cannot be denied, if doctors refuse to poison their patients, then the government will find someone else to do the killing.

Many will argue that no one is killed, that the final act is taking one’s own life, suicide, even if proponents are frightened by that word and mask it with phases like “death with dignity.” This is magical thinking.

If a doctor, following the law as directed by the government, writes a prescription for a chemical that kills his patient, the doctor is responsible for this action. If he were not responsible, if the system does not depend on him or her to make a decision and to perform that fatal action, then suicide laws would not need a doctor to ”assist”at all. While the patient is also involved, as he/she is in all health decisions, the doctor bears the major burden and blame.

We are told we are getting a white rabbit, the freedom to choose, but we are given a deadly righteous snake; a government and doctors who, because it is a right, which therefore cannot be denied, must kill us. The horror of a government with the power to kill is obvious. The destruction and potential damage to doctors, patients and their relationships, cannot be overstated.

One key difference between a freedom and a right is how they are justified and derived. Freedom is inalienable; it is the natural result of the human condition. We are individual, separate beings, and therefore we must be allowed self-determination. No one, no person nor government, can command our thoughts, dreams or the decisions which mark our private lives.

A right is sanctioned by the agreement and demand of the governed and it may differ across societies. A right must answer an important need or crisis. Education, housing, and public safety are vital societal goals. However, there can be no doubt that the quality of life, near the end of life, in this era of pain medications, sedatives and palliative techniques, is better than at any time in human history. Other than the high cost of unneeded end-of-life care, there does not seem to be any new crisis requiring terminal governmental intervention.

Canada is further along this frightening path than the United States. There, the Supreme Court has ruled that euthanasia, a doctor putting a needle into a patient’s arm and personally injecting a toxin, is legal. The problem is that doctors are not trained to kill and Dr. Kevorkian is not available to teach, as he died several years ago.

Therefore, medical schools in Canada are starting to teach this horrendous subject. Think of that; 23 year old, fresh faced, enthusiastic, naïve men and women show up to class. First, physiology, how does the body work? Then, microbiology, the danger and complexity of infections. After lunch, surgery, repairing the most complex machine. Later in the day, perhaps after a brief tour of the anatomy lab, “killing your patient, 101.”

It is hard to image anything more twisted than compromising medicine with this terrible mission. It would be like telling priests the 10 commandments are given by God and therefore are pure and perfect … except when one of your flock has to shoot a neighbor or sleep with his wife. Or perhaps bankers should learn to be careful with the money of their customers, keep complete records and return each dollar invested … except, occasionally, if they think it is unfair that Mr. Jones has more money that Mr. Smith. And politicians? Honesty is an important quality unless taking a bribe will help.

Physicians are about life. This is a sacred trust and oath. They are about life, healing and treating suffering, without reserve. Race, creed, religion, or any subjective measures do not matter. Every life is precious. In every society, physicians stand for and must always support life. This does not mean extending life to the point of suffering, but it definitely means that taking life, government directed or not, is an abomination.

If we believe, and many do, that we have a “freedom to die,” then those are the laws we should pass. The government should not interfere with how we live or how we decide to end. Each of us is given a single precious body and it is our responsibility to take care of it and decide our fate.

Some will ask; how will people who want to commit suicide take their own lives, if the government will not kill them? If we grant the “freedom to die,” the solution will appear. Perhaps we will allow pharmacies or specially trained thanatologists to supply the fatal dose… at the patient’s written request. Perhaps the Compassion & Choices lobby, descendent of the Hemlock Society, will again publish suicide guides. However, we must not be hubristic. As a society, it is not our place to dictate. Like all true freedoms, granting unqualified choice to the individual, each person must decide.

We are being tricked and in an awful way. We ask to be left alone to decide our fate. Instead, we are given government with the power to destroy it. At the same time, we corrupt those that stand for life, the healers. We must accept responsibility for our own lives. The only snake we should allow is the one that is not tread upon and the cry of freedom must be, “leave me alone.”

 

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33 Comments

  • Liz
    You and I will NEVER agree on this. My father committed assisted suicide. His breathing tube was pulled (he could breath on his own but not well with only 1/3 of his lung capacity). He was given a normal dose of morphine, which of course with compromised lung capacity was too much. He died 7 hours later. My uncle had his lungs destroyed by chemo for colon cancer. He made the same choice. My aunt was given, at her request, morphine she could give herself (stage 4 ovarian cancer) she chose to stop eating and died. Another aunt stopped the chemo for stage 4 ovarian cancer and died 5 months later. None of these choices are really any different from each other - ALL had chosen to die from what ailed them but their methods were different. ALL had committed suicide. You would condone all but how my father died. The only difference is that without the morphine my father would have been in far more pain and died a bit slower - maybe in14 hours rather than 7 or whatever. In your arguments you are not separating out murder (eg killing a patient against their will) from a reasoned decision to die by stopping treatment, pulling tubes, and yes choosing to commit suicide by drugs. Perhaps a better solution is to allow the patient to bring a gun to the hospital to shoot themselves? Using inflammatory language, as you are doing, cheapens the entire issue and works to prevent a rational discussion on the issue of death and dying. You are assuming the Canadian medical schools do not talk about the issues, and anguish, dying with dignity… rather "here is how to murder your patients". Using inflammatory language does not strengthen your arguments and it does not contribute to reasoned discussion on the underlying ethics, etc. of the issue and further polarizes the discussion diverting it from the issues to murder or not. The underlying issue is that you think it is morally wrong (the best I can tell from these and other posts you have made). As a doctor you have the right to your beliefs. A patient has the right to theirs. You do NOT have the right to push your beliefs on a patient. And because changing doctors at that time in one's life is just too hard you have the *ethical* responsibility to let your patients know *at the very beginning* of their relationship with you that you will, under no circumstances, help facilitate a patient who choses to die from cancer; if they want that choice open to them in the future they need to chose another oncologist. You need to tell any patient you take on that you will actively refuse assisted suicide or anything that hastens their death that involves your hand directly. There are some patients where it is important enough for them to know that they won't have to change doctors if they finally chose that choice. Incidentally I see that you are willing to allow "passive" suicide - allowing a patient to stop treatment. On the ethical level how is that any different than any other approach, You know what they are doing will hasten their death. Using your logic if you don't talk them out of it, go to court to force treatment, then you are, in effect, killing them too. You are just one step removed from the "act" this way. How do you morally justify that? It is on the same "slippery slope" of decisions that can or will kill a patient. If you argue that they will die anyway then how is that any different than allowing them to die anyway using another method of death?
    Reply
    • D Someya Reed
      And, to your point on "passive suicide" and to those who claim that hospice & palliative care are so good now as to have removed any need for suicide (assisted or not), how do they explain that hospices allow patients to stop eating and/or drinking? That's just as much suicide as any other method but that seems to be OK. Why?
      Reply
  • cherie79
    Liz, I agree with everything you say. I seem to be ok for now after surgery for Cancer but, should the need arise it would be a great comfort to know that the means to end my life successfully was available. Unfortunately I am in the UK and although several attempts have been made to change the law, it does not look likely any time soon though I hope it will in my lifetime. My mother starved herself to death which was very painful for us and I would hate my family to go through that. If you can obtain the means of course you can try but without expert knowledge of what and how much. You would also have to ensure your family wasn't present in case they were charged with assisting suicide. The only other option is to travel to Switzerland which is very expensive and, since you have to be fit to travel, it probably means going before you really need or want to. Of course every Dr. should have the right to refuse on ethical grounds but that should be made clear to their patients. I found the above use of language to be exaggerated and lacking in compassion. I can't understand a society that happily permits the abortion of millions of healthy foetuses while denying the terminally sick a peaceful death at the time of their choosing. I am not anti abortion in some circumstances or fanatical about it but the logic escapes me.
    Reply
  • Carolyn Thomas
    Dr. Salwitz, I feel dismayed and alarmed that you are actually preaching deliberately inflammatory inaccuracies throughout this essay - like all those fresh-faced med students being forced to learn “Killing Your Patient 101.” You do a serious disservice to your readers by falsely claiming that in Canada. "the Supreme Court has ruled that euthanasia, a doctor putting a needle into a patient’s arm and personally injecting a toxin, is legal." You are misinformed, and such sweeping claims do little to support your own personal argument. Our Canadian Supreme Court did not, of course, sanction "euthanasia" - which, as you must clearly already know, is not at all the same as assisted death. It's irresponsible (and confusing to your patients!) to throw around terms like euthanasia as if you honestly don't know the difference. What our Supreme Court here in Canada DID in fact say was that those who are severely and irremediably suffering, whether physically or psychologically, “may be condemned to a life of severe and intolerable suffering” by our government’s former absolute ban on assisted dying. “A person facing this prospect has two options: she can take her own life prematurely, often by violent or dangerous means, or she can suffer until she dies from natural causes. The choice is cruel.” Their ruling also adds: "We do not agree that the existential formulation of the right to life requires an absolute prohibition on assistance in dying, or that individuals cannot ‘waive’ their right to life. This would create a ‘duty to live'." The Court did not repeal the Canadian Criminal Code’s prohibitions on assisted suicide, but ruled that, as already in place in your U.S. states of Washington and Oregon, they will no longer apply “to the extent that they prohibit physician-assisted death for a competent adult person who: (1) clearly consents to the termination of life, and (2) has a grievous and irremediable medical condition that causes enduring suffering that is intolerable to the individual in the circumstances of his or her condition.” In other words, each person WILL decide on their own. Assisted dying - as has been well-documented in Washingtong and Oregon - is NOT a "government-directed" action as you say, nor is there any expectation that physicians like you will be somehow forced to "kill" your patients against your personal or religious beliefs. It's highly irresponsible for you to be claiming that it is.
    Reply
    • Kathleen
      Thanks for this, Carolyn. Sounds like Canada is moving toward getting it right. A friend's father recently chose to end his life. He was in his 90s and financially-secure, but had lost his beloved wife and was distressed by signs that he was losing his intellectual acuity, which had defined his life, his very notion of himself. He wanted the end to be as quick and painless as possible, as well as certain (no maiming, thank you very much). But, in our state, that was no simple matter. Not without putting his children or caregivers in legal danger. He was still sharp enough to do copious research into the matter, and, for a time, was rather excited about drowning as a method. His son pointed out that access to the ocean would be difficult with his walker, and that he may be rescued, and his children arrested for neglect. In the end, he went for starvation, having made it absolutely clear that this was his own choice. That really was the best option for him, given the lack of legal medical assistance. But it took 2 weeks, a rather long time, and was painful, though people did the best they legally could to relieve his pain. Dr. Salwitz - Please read all of these. Reality is so very, very far from the specter of killer-doctors that you raise.
      Reply
  • Penny H.
    My goodness, did nobody actually read this article? It's an excellent presentation of the danger (!) of giving the government the "right" to kill you. This isn't just about y.o.u. (or me) deciding we've had enough and it's time to exit stage left at our own descretion ... this is about other people deciding it for you and that, imo, is not a good thing. My "freedom" to commit suicide, should I ever get to that point, is what I want. The freakin' government is way too intrusive into our private lives as it is. Lord, how I hate the nanny-state. Let's keep them the heck out of it and not have "rights" in this scenario ... just freedom from the government interfering with our choices. Good article, Dr. S.
    Reply
    • meyati
      But when I'm denied the right to receive help, I don't have the freedom to decide. A doctor that would be willing to help is prevented from helping- how does that make the patients' decisions either a 'right' or a 'freedom'. I have neither.
      Reply
    • Geri
      This blog in no way represents the truth of the government deciding who dies and when. The right to die laws in Oregon and Washington do not give any governmental body or person acting on behalf therof to take anyone"s life. Just as the good Doctor has chosen to define the right to die as a "right" enforced by government, this is a descriptive personal interpretation. What the doctor had failed to mention in this day's blog is the many decisions and overwhelming influence a doctor's recommended line of treatment will have little impact on the actual progression of certain illnesses and cancers. So many people have suffered extreme pain, anxiety, nausea and other side effects in an attempt to shrink a tumor, minimize or limit metatases, only to still be terminal. The result, they are dying anyway. And extremely weaken physically, psychically, and sometimes, emotionally. So a quality death becomes impossible. Make no mistake, I work in the field. So many people benefit from many of these treatments. But the idea that we should hold your profession and its tenets to a higher level of righteousness than the individual's is dangerous. When tenet's such as you describe are held far and above what is actually in the best interest of the individual, it demonstrates your point exactly - except not in the way you intended - that the government or some one acting therof is keeping you alive against your expressed wishes, both written and spoken. This happens in hospitals everyday. I see people in trauma units, hooked up to life support totally against their wishes. It is well documented. But one fiamily member can verbally protest and an ethics panel is assembled and the process begins. The result far too many times are people "living" on life support in a skilled nursing facility without the capacity to truly espress themselves any more I any meaningful way. So, doctor, if you want to argue this point, be sure you have your backside covered. When the ethics panel and the doctor's agree to such extreme measures, hence revoking the individual's expressed wishes, they are doing the very same thing you are protesting against. You are then acting as an agent of the government! I have been a reader for years, but sometimes, you need to be a person first and a doctor second!
      Reply
    • D Someya Reed
      I seem to have missed the part where someone else is deciding for me. The government will license (authorize) doctors to write lethal prescriptions if asked by someone who is competent enough to realize what they are asking. Then there is a waiting period. The only decision of others will be as to your competency. I don't see that as a bad, nanny-state thing. Nanny-state is that I can't have a large soda with my burger because I might get fat. And I don't even drink soda. What statistics do you have that people are being turned down in droves as incompetent in States where this is legal? I'm more afraid of doctors deciding what they consider to be "acceptable losses" from a previous post. I certainly wouldn't want to overhear two doctors saying, "Well, Bob, we haven't hit our acceptable loss total this month so if we lose a few more that's OK." Would you?
      Reply
      • meyati
        My state legislator and governor just decided last week that it is illegal for a doctor to even write a prescription that would assist in a person taking too many pills.. So where is my choice? They decided to start supervising veterinarians now too. what does you not drinking soda pop have to with a person not being able to stand pain any more. What part of incurable don't you understand? I'm not wasting money on burial insurance, I'm buying a plan that's not negated by suicide, and I have a savings just for my funeral expenses. A state judge ruled that doctors could assist patients this summer, but as I said, the state legislature voided that. I do not understand why people cannot realise that different states have different values and laws. We drive 80 MPH here.
        Reply
    • red pear puppets
      This is exactly where you are sadly incorrect Penny..it is not about others deciding for you it is about stopping the decision process for the individual..and freeing those left behind from the fear of prosecution. Too many have taken a violent end simply because they don't want to risk the prosecution of family and friends who otherwise could have sat holding them as they died. Keep the nanny state out I agree Highly trained individuals who understand the ending of life don't necessarily need to be government officials.
      Reply
  • meyati
    Thank you for supporting an upside down triage medical system. First care for the government and its administrators. Next meet the needs of hospital systems and insurance companies that want to appease the government and not loose funding, be in an investigation, etc. Last, comes the needs of patients, Sort of sounds like Germany from 1938 to 1945, doesn't it? Dr. you aren't thinking of family members or friends that end up in court for assisting their loved one to pass. Then lets go to the gun-haven't you ever been on a reservation, and seen people with bandit style bandanas over the faces? I guess the other commentators haven't either. If a gun isn't angled correctly, they just shoot off the lower jaw. Too much NSAIDs, OXY whatever, can just make a person throw up. Our traditional way was the long walk, where a person took off. Found a place, and talked to their gods, while passing. I know that you'll call that premature, but can't a person decide on their own. It helps the regional cancer center keeps being sued. The family has to notify the police for a lost elder or face criminal charges. GPS, helicopters, federal laws make this walk almost impossible. I know a cancer patient that was awarded over a million dollars from the state cancer center. I've told my family that if anything happens to me- take off to the coast with my coonhounds and stay for 3 weeks. They go fishing all of the time anyway. For me, it probably will be agony, but you are trying to prevent humane treatment and care for people like me. Suicide isn't as portrayed in movies. When done as a suicide effort- alone or without the family's help-it's often unsuccessful, messy, and the family members are accused of trying to murder their loved one, elder abuse and neglect, practicing medicine without a license, possession. I'm supposed to get a special DNR, because in this state, if anybody gets a weak stomach and calls 911, patients become wards of the state, and their lives must be saved. Summer of 2014, a court decided that it was a civil right for a patient to request assistance from a physician, and receive assistance. A state senator decided that it should be a state law, and a judge can't dictate things like this. There have always been times where doctors wrestle with their consciences. Many of the Catholic saints became saints, because physicians abdicated their responsibilities to their patients. Epidemics and wars usually set this up.
    Reply
  • janice mancuso
    I'm with Penny on this, only my focus primarily revolves around the role of the doctor, not the government. What Dr. Salwitz has written is the most thoughtful and enlightening piece on "doctor-assisted suicide" I've ever read. By distinguishing between "freedom" vs "right" to die he helped clarify my own opposing views. I was 35 years old when I first read, "Last Wish" by Betty Rollins in which she chronicled her mother’s choice to die on her own terms instead of enduring further last-ditch-effort chemotherapy for ovarian cancer. My now-grown sons were barely in grade school at the time, yet I decided I would make that same choice when/if similar end-of-life circumstances presented themselves…rather than prolong the painful inevitability for all of us. Fast forward to a few years ago when I heard Dr. Ira Byock speak forcefully and eloquently about his position against doctor-assisted suicide. He rattled my firmly-held, long-standing position...or so I thought. In fact, thanks to Dr. Salwitz, it never was either-or. It's about "freedom to die” vs “right to die with the help of a doctor.” I can exercise my "freedom" if the need arises for such an end-of-life decision (see Dr. S's 2nd last paragraph) without having it be a "right" assigned by the government allowing, even protecting, the right to avail the services of a doctor... who pledged an oath to heal and treat suffering, not to help kill. Doctors should not be put in that position. We should NOT want doctors to be put in that position; we may end up with that snake. PS Dr. Salwitz, I realize you’re an oncologist and may not want to answer my question, but I wonder if you would weigh in on "right to choose" vs "freedom to choose" regarding abortion. Could your reasoning apply to this hot-button issue as well?
    Reply
    • meyati
      I would have to move to Oregon for the freedom or the right. Doctors here won't help, because this state is under strict supervision by the DEA. A doctor can believe anything he wants, but is he willing to be under investigation, and possibly lose his license and practise? When I had part of my nose and lip removed, it never dawned on me to ask if the plastic surgeon was under investigation. I'm allergic to Tylenol, and the only painkiller that she was allowed to dispense had Tylenol in it. I can't take aspirin. The ER could not believe that this happened to me-I seldom talk about it, because it sounds so crazy. My surgery was done on Friday, and my PCP didn't get in until Wed. The government is a factor in the end of life choices in the real world in America. It doesn't help to be in a state with the highest or one of the highest OD rates from prescription meds. Semantics don't help me one way or the other, I just know that it's not even moral to ask any of my doctors or dentists to help me. Why should I ruin their lives?
      Reply
    • janice mancuso
      Meyati, just as pharmaceutical companies no longer provide drugs to prisons for the purpose of killing people—because that was not why the drugs were created—doctors should not enter the realm of helping people to die because it goes against all they were trained to do. And they took an oath. Prisons are still killing people; they have found alternatives. I just googled "Compassion and Choices" (https://www.compassionandchoices.org/) mentioned in Dr. Salwitz's essay. "Our End-of-Life Consultation (EOLC) program provides free, confidential, professional support anywhere in the country. 800-247-7421" This info brings me comfort, knowing that there are committed individuals who can—and choose to—provide information and support to those in need. Doctors do not have to fill that role.
      Reply
      • meyati
        You don't understand. They do not have to fulfill that role, but they should not be prevented from fulfilling that role. The state has removed their choice of how to practice medical care. For a short while, it was legal to have Dr. assisted death, and several of my doctors said that they would help me, because I a rare incurable, that different specialists said is one of the most painful and agonizing cancers they saw. They say that there isn't a painkiller that works. A judge made assisted death legal, and dozens of different specialists, doctors, showed up to testify and beg for this right-and this is a catholic state. A state legislature said that only the state could pass this law. It was a local judge, so the state legislature passed a law making it illegal to supply meds for this. Even veterinarians are now being supervised. These are good compassionate people that could go to prison for helping me. Then my family could face prosecution if the DA thinks that they helped me pass. The DA for this county is out to have everyone live up to her moral code. I do thank you for the link---
        Reply
      • meyati
        I went to the link for my state, and I've already filled out a DNR, my advanced directive-and those are the only things that I can do-so how does your opinion or link help me? The state monitors pharmacies, and pharmacies report any unusual large amounts of drugs. My plastic surgeon did skin transplants-8 hour surgeries for her part on the team. She didn't take care of bad backs, whatever, but she was put under investigation. About supplying prisons- what about Tylenol? At least at this VA, it is recognised as a toxin that destroys livers. If you read pediatrics or internal medicine, they complain about how kids 10 and up are starting to have liver complications caused by Tylenol. No matter the warnings, almost every OTC med for coughs, colds, flu, sinus, headaches, sleep has Tylenol in it. You don't see pharmaceutical companies removing that poison from the shelf. The prison death cocktails is just a PR ploy to make the companies look good. .They never spent that much money of the cocktails. The production was so low, they probably lost money anyway. Doctors ask me why I have such a sound liver, no spongy tissue, nice and solid, no cysts, no scar tissue, etc. I'm allergic to Tylenol- Surfer's Ear or Diver's Ear. I was lucky, Navy ENTs diagnosed this early in my life. It was odd sitting in a waiting room with SEALS, UDT, and surfer boys. So, I don't thank you for the link, as I've already taken these great steps on my own. What I need is a law with compassion, so I can die here, and not have to travel to oregon.
        Reply
    • D Someya Reed
      Everyone has the freedom to die and the right to die. But no one has the right to die with the assistance of a doctor even where that phrase is used. You can only die with the assistance of a willing doctor where the privilege has been passed into law and carries no punishment or penalty. If it's anything else, you are impinging on the rights of the doctor. None of us have the right to take away the rights of another, in this case, the doctor.
      Reply
      • meyati
        Didn't you see that I wrote that it would be immoral for me to ask or beg that a doctor help me in anyway. In this state, the doctor could lose his license and even be sent to prison. What part of that don't you comprehend? I have no right to harm another person or cause another person to be sent to prison. There the law of the government denies me the freedom or the right to die somewhat decently, not spend 2 weeks starving to death as one commentator described Think about that.
        Reply
  • janice mancuso
    More about/from Dr. Byock...in support of Dr. Salwitz's position: http://www.latimes.com/local/california/la-me-ira-byock-20150406-story.html#page=2
    Reply
    • D Someya Reed
      Do you suppose Dr. Byock would be interested in our story (see below...sorry for the length) or just chalk it up to "anecdotal" evidence. That doesn't mean it's not true but the word has taken on a connotation that the subject to which it refers is irrelevant. Will he say, like so many other doctors, that he supports hospice because he's heard more "good than bad?" Seems wrong to promote something so vigorously while truly knowing that there are just as many problems in hospice as there are in "our broken" medical system. Many of those problems are just the same. He follows the same path as so many others by saying that larger reimbursements will solve the problem. Hardly. Hospice is not the overall answer to suicide, assisted or not. And how much is decided for you by hospice? You can't even decide to go to the hospital yourself. The hospice will decide if you can or can't. Not because it's beneficial to you but because they will be paying the bill with or without Medicare reimbursement. They will decide what treatments and what medications you can have for the same reason. How free is that? Many will say that that's the government's decision. Maybe, but early hospices were doing this all voluntarily long before the government got involved and with no reimbursement from Medicare. The government is supposed to protect your rights. It can't take them away. It lists them but it still can't take them away. Governments can make them difficult to exercise, that's all. Anything the government can take away is a privilege, not a right. You can pursue either suicide or assisted suicide if you find a willing partner. The government can't take away your right to do so, just as it can't stop you from doing so. It can, however, punish you for doing so, if it chooses. Governments, or so we've been told, legalized abortion to protect the rights (and safety) of women not to be preyed upon by some creature with a coat hanger in an alley. No one has mentioned Atul Gawande and his new book, 'Being Mortal.' The dust jacket claims "he follows a hospice nurse on her rounds." Kinda neglected to mention that the rounds were with his Dad's hospice nurse. Do you suppose his Dad got the same level of care we did? Why don't any of these people go to a hospice and ask to be taken to the homes of their worst, most difficult patients/cases to see how good they really are at what they do; not just the expertise they claim? When will people realize that hospice is not the answer to everything end-of-life? When will they realize that hospice is only as good as the way it treats its most difficult patients. Just as doctors are only as good as the way they treat theirs. Governments are only as good as the way they treat (not indulge) their weakest and most vulnerable citizens and protect their rights/freedom. Each of us is only as good as the people we choose NOT to step on especially when doing so would give us something more than we have now. If each of us were like this, what would the Dr. Byocks of the world have to talk about?
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  • D Someya Reed
    Here’s my thoughts… You say that the government will set up a system that forces students to learn “killing your patient 101” but that same government still can’t seem to set up a system that forces every doctor to learn how to tell a patient they are terminal? You say assisted suicide grants the government the power to kill but doctors who perform legal abortions are the ones seen as killers, not the government? How clever the government must be. Every licensed veterinarian has the legal ability to euthanize an animal. Do all of them do it? The government set up that system too. Are any of them “forced” to do it? And, how strange that veterinarians don’t seem to have a problem telling anyone their pet is terminal even though we, largely, see our pets as family and, in some cases, more so than our human family. Where do they learn that skill that most seem to do remarkably well? You say that the government will set up rules and regulations that require doctors to kill? Which doctors? Are you saying ALL doctors? Does the government’s system of legalized abortion now require ALL doctors of any discipline to do abortions? Has it ever? Are you required if asked? Because it’s “assisted” suicide and there is that segment of the populace that feels we have too many people for the resources (and climate changes) we have now, will they take special interest group control of the government and authorize the wholesale slaughter of the sick and elderly? Is this the fear? Where has something like this happened that could even begin to form any basis for concern? Is there any system established by the government that requires doctors to do anything that either they or the patient don’t want to do or have done to them? Note: The court system’s rulings are a different matter. Doesn’t the government set up the system and then those doctors who want to participate seek licensing? If a doctor doesn’t want to do something and feels pressured to do so, aren’t they always free to surrender their license? No one can make an unlicensed physician do anything. Now, of course, all these rules and regulations and licenses and ethics and morals and conscientious and religious objections go right out the window when you talk about money, don’t they? If the cost is too high, we’re not doing it. The plug will be pulled whether wanted or not. Even your (claimed beloved and beyond reproach) hospice will find a way. I was standing right there when hospice staff in our own home (so much for the “castle” idea) told me that their instructions from management were to literally and physically “drop her” if I should try to interfere no matter what they were doing or if either of us objected to anything that they were doing. But this same hospice, to this day, advertises that they care for their patients in a spirit of “loving service.” But this hospice's nursing director told me, directly to my face, that she didn’t accept patient refusals which in this case meant refusing to be turned on her side. After many failed, illegal attempts to induce our “voluntary” revocation of hospice, both the hospice nursing director and medical director (without any contact or input from our attending physician and against all CMS and State medical regulations for patient care, patient autonomy, patient safety and basic human “rights” and apparently not applicable to hospice) authorized and approved that a terminal, quadriplegic, metastatic breast cancer patient with over 30 tumors in her lungs, tumor masses outside her lungs, both legs completely severed from the hips (no femoral neck bones remaining), with a spine cracked into three pieces at the T12 and C7 vertebrae and the resulting spinal cord compression and lastly, a backed up, overdue for flushing chemo port and a left arm filled with edema swollen to 2-3 times its normal size and rock-hard should be turned and held on her side (while she SCREAMED she couldn’t breathe). This was done so that they could take as much time as they chose to inspect a radiation burn to her tailbone area and, more importantly and I’m certain they felt potentially litigious, where their staff had carelessly scraped her bare back and the exposed tumors growing out of her spine just after they were warned (by both me and her) to be careful of her back (and why) when transporting her home from hospital to die. Oh, I’m sorry; I forgot to add “with dignity.” You’ve got it wrong…it’s not freedom vs. rights. They are the same thing. George Carlin said it best in his bit about “rights vs. privileges.” He said a right is a right simply because no one can take it away from you. Now that would be freedom. But we don’t have rights, he continued. We have privileges. Those can be taken away at any time and for any reason. The government does not grant rights. We already have those and have had them from birth. The government grants privileges. Finally, you say that proponents claim no one is killed; yet, they are afraid of using the word “suicide” so they say “death with dignity.” You claim this to be “magical thinking.” How so? This is EXACTLY the same thing that hospice claims. Why is it not “magical thinking” for them? Is it because they simply stand by and watch you die “a natural death” while they “relieve” your physical pain with drugs and your mental pain with trite, pointless banter because they can’t possibly know much of anything about who you are in the short time they have known you? So please tell me…no, correct that…PLEASE TELL MY WIFE that what she had done to her at the “loving” hands of hospice was “true” death with dignity. TELL HER that what they did to her pales in comparison to the agony she would have felt, the suffering she would have endured if some misguided, sadistic, medical professional stuck a needle in her arm, at her request, and just let her go to sleep, forever. Or maybe he would have been a nice medical professional who was afraid not to comply because the government was threatening him with prison time. Remember, my wife was paralyzed and would have been unable to do the Kevorkian thing even had it been offered. And just for the record, here is the policy of the hospice that we used which they don’t have in writing, of course, but as it was explained to us on the 2nd day of the hospice’s refusal to provide any care including the potentially life-threatening (although they already told me to “get over it” because she was “going to die anyway”) overdue flushing of the chemo port. Keep this in mind as you read #2 because it turned out that the port flush was actually on their sorry excuse for a “plan of care” but they chose to simply ignore it without consequence. Here’s the policy as explained to us (paraphrased): 1. Patients cannot refuse to do as told by any hospice staff member, especially the nurse. 2. Patients must not deviate at any time from the plan of care whether or not the patient and/or caregiver have ever been given a copy of the POC or have ever been told of its content. A copy or knowledge of the POC doesn’t matter anyway because staff will tell you what you need to know. 3. Patients who do refuse any hospice staff request(s) will have all services suspended until compliance is achieved or the patient “voluntarily” revokes hospice. 4. The original contract will be voided, unilaterally, at the discretion of the hospice with or without notification to patient’s chosen attending physician. Keeping attending physicians involved is not the job of hospice but patients/caregivers are free call their attending if they so choose. (Ours, they informed us, was on vacation when they chose the timing of the suspension of services.) 5. A new, replacement contract will be presented and require both patient and caregiver signature within whatever time frame the hospice deems appropriate and allows for them to do so (we were allotted, for example, one hour at the end of which no signature from both or either would result in immediate discharge and removal of all equipment). Note: Paralysis was not an excusable reason for not signing. They also stated, "We do this all the time." How many elderly patients or any for that matter do you suppose refused to sign? 6. If a new contract is signed, patient, caregiver and all family members are barred from refusing any future services chosen by hospice staff to be applied to the patient (whether wanted or not) and any interference, even a single verbal negative reaction, will result in patient’s immediate discharge from hospice and all equipment being removed from the patient’s home. Makes you want to run and sign up, doesn't it? There is a postscript to this story. Just recently, this hospice acquired new management from out of the area. One of the first major (and highly controversial) things done was the termination of the individual responsible for overseeing patient care. The reason stated was management was not comfortable that this individual could properly perform the duties of that position any longer. Pretty vague until you know that this was the same individual that promoted the above policy towards patients when we had the service. This is also the same individual who actually held my wife on her side as she SCREAMED. This individual was also well aware, at the time, of all that was wrong with my wife. Not only had I voiced it to her directly but it was in her medical record. The rumors are out that this individual may sue for wrongful termination. I never thought I’d say this but I will voluntarily testify on behalf of this hospice to all I know and experienced if their reasons are to stop the above practices from occurring any longer. I tried to make an appointment with the new management to explain how I could support them in their decision. They’ve refused to meet. The board of directors has refused to make any comments to media inquiries. Maybe you’re right that our government are killers, Dr. Salwitz. But maybe not the way you think they are or you think they might want to be. Follow the money, follow the savings. Who costs government the most in their eyes? There’s your target. The hospice Medicare benefit was done purely to save money. It will remain as it is until someone shows that the government no longer saves roughly $2,500 per head over traditional end-of-life care. Assisted suicide will find its way into law only if they can get the numbers to pencil out.
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  • D Someya Reed
    Bottom line is that those who oppose assisted suicide tend to misrepresent and/or blur the line between the freedom to do something (because we have the physical ABILITY to do it...which society labels "natural rights") and "legal rights" which societal based law allows us to do in order to remain in that society. But "legal rights" are nothing more than "temporary and revokable privileges." "Natural rights" cannot be revoked by law and are universal regardless of which society we live in. Fear mongering happens when opponents use the logic that: 1) All physicians can write prescriptions 2) Dr X is a physician 3) Therefore, Dr X can write ANY prescription even those he will be forced to do by societal law against his will This is an aberration of what is called "syllogism." In my opinion, syllogism often leads to erroneous conclusions. Proponents of assisted suicide are usually those who have been touched by suffering (of themselves or a loved one or a friend) but tend to believe that because they know true suffering they have a right to force another (in this case, a physician) to do as they want them to (i.e., prescribe and/or assist in a method of ending a suffering life). Societal law calls this a "claim right" of the proponent over the doctor. The doctor, of course, does not want to be forced to do anything...wanted or not. That's where it gets muddy. Doctors don't want to be forced to write lethal prescriptions and patients don't want to be forced to live in further suffering. Doctors, and you heard it in this blog's conversation and links to others (Byock), claim that hospice and palliative care are so good that they can relieve almost all suffering. For those whose suffering they can't relieve, they claim they can put you in an induced coma. Now hospice won't feed you because it costs money and they claim it will cause dyspnea in the dying though predicting death is still in its infancy. Further, doctors say that most "suffering" is actually nothing more than depression and they can fix that. Tell that to someone with real physical suffering. Shouldn't these same doctors have already "fixed that" if their claims are true and their mantra is "to relieve suffering?" But what if you, as patient, don't want any part of this "solution?" Does the doctor have the right to force you to live as they would have it? Isn't that the same "claim right" they don't want you to have over them? And what of suicide among doctors themselves? Medscape printed an article last year that some 400 physicians (equivalent to a full medical school) commit suicide every year. Do you suppose that they use only those same methods available to the rest of us outside of the medical field? This blog could lead you to believe that's true. What doctor would say to a patient seeking an abortion that she could either have the baby or buy a coat hanger? What kind of choice is that and is that any different than a doctor telling those who are dying in suffering that either you can use our hospice (which we know has problems but we won't admit to them) or you can find your own method of killing yourself? While all the time knowing that assisted suicide happens anyway for some and doctors, off the record, have admitted to doing it. Their problem is "they" don't want to "have to" do it. They seem, however, more than happy to have you "have to" choose their option only. Even when they know there's really nothing they can do which is why most doctors (so hospice claims) ultimately sends patients to them. What is the fair, middle of the road solution?
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  • red pear puppets
    Although doctors are part of the process in diagnosing a terminal illness they are most certainly not necessary for the last loving part of ending life. In Switzerland there are strict checks to ensure there is no coercion and that the diagnosis is terminal..this of course involves a willing doctor but the final enabling of a peaceful end is made possible by a highly trained nurse who makes space for loved ones to surround and hold their relative or friend as they administer to themselves the drug to cease living..die..end life. Like birth, death need not be bound to doctors.
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    • cherie79
      Switzerland is fine if you are fit to travel and have the roughly £10,000 it costs plus of course being able to self administer the final drink. It should be available in the UK with the same safeguards.
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      • meyati
        Agreed- here in the US, you have to have a ton of money to move to Oregon or Washington state, get housing- find a doctor- go through evals, etc. I don't have the money for that. The poor should be able to die with dignity at home or in a medical facility, but not have to travel and move thousands of miles.
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      • red pear puppets
        YES!!!!!! A thousand times yes! It should not be just for those who are lucky enough to be able to afford it..So glad our campaign is going well
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    • meyati
      I really don't understand what the others are saying. They say-freedom or right and argue about semantics. They don't understand that the government is a 'nanny' state' when it doesn't allow people to choose. They talk about "doctors being forced", but it's doubtful that a law will be passed to make a doctor do anything they don't believe in. A doctor can say 'NO", but currently a doctor cannot say, "Yes my friend. I will prescribe these pills for you." Right now, in many states the doctor would loose his license and probably his freedom. I'm sure that when somebody reads that a highly trained nurse may assist, they read that as Big brother and his death panel is killing people. They don't realize that a person applies for help in passing. A positive point that people point out is are the safeguards, being evaluated, a waiting time. It took me two years to get a DNR from my HMO type advantage plan. The system took the view that only suicidal people would want a DNR, and then my PCP felt like he would be complicit in killing me.. We'll fill this out at teh end of the visit, I don't have one around, the office is out of them, No, I have to see the next patient, the nurse forgot to bring a DNR form. Then when I filled out the final directive-they were appalled that I didn't want to be tubed; that I didn't want to have oxygen-part of that is that I had surgery inside my nose, and part of my nose is gone, and I'm not talking about the tip. They had to let me fill out a final directive. I had to go through a psych eval to finally get the DNR. Then I had to fill out the final directive 3 times, and have counseling each time. part of the counseling was why are you suicidal since your cancer is in remission? I had a DNR in my military records, when I was a military wife. Part of that was for my husband and our children would be able to get on with their lives-a new wife- a mother for the kids. 2014 the tumor board decided that I shouldn't have any biopsies, as a cut in the area creates-sets off new cancers. I'm terrified to wake up from an accident- be revived, and have the cancers pop out and start drilling into my brain. Also the state and this HMO has strict lab guidelines to even get hospice. My doctors told me that I probably won't meet those guidelines. Being allowed to ask a doctor and talk about this shouldn't fill me with fear. Any doctor that might help and my family shouldn't be taken to court. We should stop semantics about freedom, right, and allow doctors to make a medical decision. Doctors and families should not be punished for having compassion and anguish. I belong to a cancer blog and these Christians are terrified their doctor will kill them. They spend every penny and focus their family's efforts to live another day. To me that's a conundrum. If you believe in heaven-religious values, why aren't you accepting your time line and fearing death so much? Why can't doctors be free to say- yes or no? Why can't patients be free-not in fear-of having a discussion with a doctor?
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      • cherie79
        Well said and I agree. I too have noticed that with devout Christians on the Cancer forum and it always puzzled me. Surely going to Heaven is not to be feared for them?. For me I think we are all date stamped and can only hope that someone will help make it peaceful and psinless.
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        • meyati
          Then the Christian doctors that don't want to murder somebody, but they do everything to interfere with God's angel. It has to be pride and power disguised as compassion. They don't realize it. I adore every word Dr. Salwitz says, but on this he is wrong. He's entitled to his views and feelings, but he shouldn't interfere with doctors that feel the opposite. I cannot think of why such an intelligent manwould think that any law would be passed that would force him to murder his patients
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          • red pear puppets
            Thankyou so much for sharing your shockingly painful stories. I am humbled and ashamed that we have let you down so badly. We may live in separate countries but on some level we are one. James you carry a weight that comes from years of experience and I can feel your anguish but surely you can see it is not comparable with the stark uncomforted depths that the brave contributors to your blog are going through Please...such a lightweight thin slip of a word...please find a way to support a way forward that gives intelligent men and women the choice to help others in their decision to die when they are already labouring each day with a terminal diagnosis. As others have said there must be no forcing...no obligation but please let there be the choice for one human being to reach out and help another without fear of retribution Heartfelt and sincere thanks again to Meyati, Cherie, D Somaya Reed and everyone who has written but most of all to you James for giving us the opportunity to share the dialogue. You are without doubt an exceptional caring doctor who is passionate to uphold the highest standards in practice and in teaching. Please keep looking because there has to be another way to engage with dying...what we have now is simply not working
  • red pear puppets
    Previous post seems to have turned into a long one word/line ribbon so here it is again. Thankyou so much for sharing your shockingly painful stories. I am humbled and ashamed that we have let you down so badly. We may live in separate countries but on some level we are one. James you carry a weight that comes from years of experience and I can feel your anguish but surely you can see it is not comparable with the stark uncomforted depths that the brave contributors to your blog are going through Please…such a lightweight thin slip of a word…please find a way to support a way forward that gives intelligent men and women the choice to help others in their decision to die when they are already labouring each day with a terminal diagnosis. As others have said there must be no forcing…no obligation but please let there be the choice for one human being to reach out and help another without fear of retribution Heartfelt and sincere thanks again to Meyati, Cherie, D Somaya Reed and everyone who has written but most of all to you James for giving us the opportunity to share the dialogue. You are without doubt an exceptional caring doctor who is passionate to uphold the highest standards in practice and in teaching. Please keep looking because there has to be another way to engage with dying…what we have now is simply not working
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  • jane
    My greatest fear is becoming demented, and I'll be ready to shoot myself or choose VCED/VSED (Voluntarily Stopping Eating and Drinking, read up on it, folks) well before I wind up in an institution tied to a bed. But what if some catastrophe unexpectedly renders me simultaneously miserable enough, or at great enough risk of imminent incompetency, to want to die, but also incapable of going home and shooting myself? Or what if I was one of the many people who can't get or can't properly use a handgun in the first place? I'd be asking for drugs, you bet, so that I could die as well as my beloved pets. You say you and no other doctor should be obliged to provide them for me. That's fine. If you don't want to field those requests, you should seek to change the law so I can order them for myself without a prescription. And if that were done, the obvious question would become: why should I be able to get a sedative without prescription to kill myself, but not to relieve my insomnia? Why should users of Western medicine have to kowtow to a Learned Intermediary for birth control pills or thyroid supplementation but not for euthanasia? Why don't we just pay doctors to give us advice, but then have the freedom to go down to the pharmacy and buy and put in our bodies whatever we like? That would hurt oncologists more than most specialties, I believe.
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