Whoever said that politics is not relevant should have been in my office last Wednesday. Jill* came in for an “urgent” appointment. Two days earlier the New Jersey Senate and Assembly ratified the Medical Aid in Dying for the Terminally Ill Act. This fulfilled a dream for which Jill had long waited. She rushed into the office to get the kind of medical care for which she longed. Jill wanted me to kill her.
Jill’s cancer is not out of control. She is without significant symptom. She is without pain. If Jill wishes, she can eat what she wants, go out of the house and even travel. The anti-cancer therapy is oral and does not cause nausea, profound fatigue or any of the myriad of side effects that often plague cancer patients. It is not the disease or treatment that overwhelms Jill. It is the uncertainty of living.
Jill has told me for years that she wants to die. She has seen therapists, had family meetings, taken antidepressants and talked through this difficult journey with me on many occasions. She has isolated herself, waiting for this special moment when New Jersey will finally allow me to end her life. The possibility that someday the state would provide her with the method to die has undermined her ability to cope. So, on Wednesday there she sat, demanding the terminal script.
As I was trying to figure out how to deal with Jill’s ultimate existential crisis, a husband and wife came into the office. He is under my care for cancer and also doing very well. However, they were terrified that because his therapy is expensive and because this new law “obviously was pushed by the insurance companies to save money,” soon payment for his critical treatment would be cut off.
They had been told that the New Jersey euthanasia legislation allows, perhaps even requires, that termination be proposed to all patients as a viable alternative to more complex and expensive therapy. My reassurance that this was not the intent or the letter of the legislation seemed to give pale comfort. They were quite frightened.
Both of these cases distort the intent of physician-assisted suicide. The goal is to give an alternative in the extremely rare situation that palliative care completely fails. This would be a reasonable goal if this was indeed a significant problem and if the possibility of doctor-directed death was without major side effect.
The problem is that in 38 years of oncology practice, having taken care of thousands of cancer patients at the end of their lives, I have never seen a situation where deliberately killing a patient was the indicated or needed therapy. There have always been ways to provide comfort and support. Therefore, while there is little apparent benefit to giving doctors the power to kill, I am already seeing the side effect of confused, undermined and scared patients. The medical mission is distorted. Patients will be harmed.
Many will say, the physician is not killing anyone—this is assisted suicide; the patient is the one who swallows poison. However, for the physician, it is about intent. The goal of a lethal prescription is to kill. In no other area of medical care is the intent of the doctor ignored. No clinician can ethically or legally justify saying, “But the patient takes the pill; I am not responsible.” Yes, patients consent to medical care, but the doctor orders it to happen. If I push someone off a cliff, it is no defense to say that gravity does the work.
Jill and I talked about her disease, which is stable, and her challenge in coping with that Damocles sword. Her fear of the natural dying process precludes her from either stopping treatment or continuing to wait for what will happen. For now, the discussion is moot because the bill is not yet a law, and the regulations and the process for legal medical suicide are not written. Therefore, Jill will continue therapy for now. As soon as the bill is signed by the Governor, as soon as the process is in place, Jill will find another doctor.
My frightened couple will be all right, as long as I keep my patient under care. They remain skeptical of the intent of a law, which they fear may push seniors or others on society’s “fringe” away from the doctor’s office and toward the mortician. I know that many patients will be having similar anxieties in the coming years, as the law causes bizarre distortion of the healing relationship. The oncologist, always a person to raise anxiety because of what he or she may find or say, now also has the power to take life.
Healthcare givers must be always committed to the beauty of life. Yes, life ends, and to deny that reality is folly and futile. We must make decisions in that clear, if harsh, light. Often comfort care is the indicated medicine. However, somewhere in the tough, challenging, complex journey of living, someone must stand for hope, healing and dignity. That person must be clear in his or her mission, whether it is cure or comfort. In our society we call that person doctor.
James C. Salwitz, MD, is board certified in internal medicine, medical oncology and hospice and palliative medicine and practices at Regional Cancer Care Associates – Central Jersey Division.