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Michael D. ConnellyFebruary 23, 2024
A hospice nurse (seated in a chair) cradles the hands of an elderly male hospice patient (sitting in a bed). (iStock)The current health care system undervalues hospice and palliative care. (iStock)

The French philosopher Albert Camus once said, “There is but one severe philosophical problem, and that is suicide.” It is a problem we are still grappling with today.

Ten states and the District of Columbia have legalized physician-assisted suicide, and there is momentum across the country to pass similar legislation. States like Arizona, Massachusetts, Minnesota, New York and Pennsylvania are now actively considering it.

To be clear, physician-assisted suicide is contrary to the teaching of the Catholic Church and to the American Medical Association’s ethical code. The vast majority of hospice care providers also oppose it. In 2015, a multiyear study by the Institute of Medicine, titled “Death and Dying in America,” outlined alternatives to physician-assisted suicide, but few of its recommendations have been adopted.

Instead, the political popularity of physician-assisted suicide persists. Advocates argue that it helps with pain management and supports individual autonomy. In Minnesota, state Representative Andy Smith, a Democrat from Rochester, justified its legalization by saying, “We’re trying to put more compassion into the medical system.”

There is pressure on groups like the A.M.A. and hospice associations to reverse their official positions that assisted suicide is contrary to their missions.

The media is another source of the momentum for assisted suicide. For example, Steven Petro contributed an essay to The New York Times last December titled “I Promised My Sister I Would Write About How She Chose to Die.The author’s younger sister, Julie, was diagnosed with advanced ovarian cancer; after surgery and chemotherapy, she said she was no longer interested in “‘Hail Mary’ treatments—drugs with many side effects, often used out of desperation or denial.” She told Mr. Petro, “I don’t want to die like that,” and said that physician-assisted suicide was “about taking control of my life.”

And in January, The Boston Globe published “Dying on Lynda’s Terms,” about a woman with terminal cancer who moved from Connecticut to Vermont to take advantage of latter’s physician-assisted suicide law. She challenged a residency requirement in the law, saying it violated the U.S. Constitution, and Vermont waived the requirement for her, then scrapped it altogether. This precedent could make physician-assisted suicide a legal option for anyone willing to travel to states that allow it. The article closes with a touching description of Lydia’s death with family and friends.

Such articles are putting pressure on groups like the A.M.A. and hospice associations to reverse their official positions that assisted suicide is contrary to their missions. There is also a new physicians’ association called the American Clinicians Academy on Medical Aid in Dying, whose mission is “developing, improving, and supporting best practices for the care of patients considering or completing medical aid in dying.”

Some respected medical ethicists are also changing their attitudes about physician-assisted suicide. Arthur L. Caplin of the New York University Medical School, in a recent interview with the website Medscape, said, “I think it is an option that makes some sense. I am well aware that we also need to make sure that people know about hospice.”

Dr. Caplin’s last point is a critical one. If the public and physicians better understood hospice and palliative care, these two options might well address all the concerns of patients about end-of-life care.

If the public and physicians better understood hospice and palliative care, these two options might well address all the concerns of patients about end-of-life care.

The real problem with physician-assisted suicide is that it attempts to treat symptoms (patients no longer wishing to live) and not the cause of their despair (a broken health care system). Patients are not educated about, nor referred to, hospice and palliative care in a timely fashion. So they end up receiving excessive and painful treatments that add unnecessary suffering. They turn to assisted suicide from fear of being “overtreated” by the health system.

One piece of evidence for this view is a recent study by the Penn School of Medicine showing that more than 70 percent of those who selected physician-assisted suicide over a 20-year period were cancer patients, who often undergo extensive chemotherapy and radiation treatments. In some cases, these treatments might be avoided by timely referrals to palliative care.

The experience of nations like the Netherlands, Belgium, Canada and Australia, which have offered physician-assisted suicide for decades, also raises concerns that safeguards against abuse of the practice have been weakened. These safeguards, such as requiring a terminal diagnosis and a careful assessment of a patient’s mental capacity, are intended to ensure that physician-assisted suicide is allowed only when appropriate.

What starts as a “compassionate” and rarely used option can metastasize into something like euthanasia, especially in certain populations.

Writing in the National Review last year, Alexander Raikin said that he has interviewed many health care professionals in Australia and Canada who are considering leaving their profession because of the increased social pressure for patients to consider physician-assisted suicide:

David D’Souza, a physician in Ontario, told me, “I think already there’s a lot of abuse going on, and I’m seeing it in my own practice,” including when families pressure loved ones to die so that estates or insurance payouts become available sooner. “It’s making me think twice about whether I should be continuing in geriatric care.”

In short, what starts as a “compassionate” and rarely used option can metastasize into something like euthanasia, especially in certain populations. The Penn School of Medicine study indicates that the people who have chosen physician-assisted suicide since it was legalized in their states tend to be white, male and religiously unaffiliated—and also that they most often cite a loss of autonomy and dignity as the reasons for choosing suicide, rather than for relief from physical pain.

Physician-assisted suicide does not adequately answer the problem of older citizens facing a dire death experience. State governments should focus their energy on meaningful reforms to real problems rather than on superficial solutions that start us down a slippery slope. Below are three opportunities to benefit dying patients by reducing bureaucracy and increasing real compassion in health care.

Stop using medical coding to determine compensation to primary care physicians. The biggest (but seldom discussed) problem in health care today is using medical coding to determine provider payments. Coding has made health care billing exceedingly complex, and it doesn’t recognize physician services that are difficult to quantify—like conversations with a patient. As a result, physicians spend twice as much time on administrative documentation as they do seeing patients. No wonder health care lacks compassion!

This coding system also discourages physicians from talking to other physicians regarding shared patients. So no one is paid to coordinate patient care, much less discuss delicate end-of-life issues. This payment system has also driven physicians away from primary care, geriatrics and palliative care. But we need physicians in these areas to care for a growing aging population with multiple chronic illnesses.

Code-based payments to primary physicians are a major cause of fragmented health care. Federal legislation to change how we compensate primary care physicians will improve compassion and reduce fragmented care.

Improve access and education about palliative care and hospices. These two important care options are clinically, economically and legally designed to be underutilized by the health system. Simple changes to the payment model would help address this flaw. In addition, palliative care should be taught more in medical school, and patients should educate themselves about this option. State governments could also require patients to complete advanced directives in order to receive Medicaid, or provide financial incentives for patients to take classes in palliative and end-of-life care.

Help families manage their fear of death. Everyone—patients, families and physicians—fears death. As with many things, education is the best medicine to address this fear, but education requires extensive dialogue, and, as noted above, insurance companies do not compensate physicians for crucial conversations surrounding end-of-life care. Again, state Medicaid policy is another opportunity to encourage patients to learn about viable alternatives to physician-assisted suicide.

It is always difficult to change such a complex system, but as we wait, health care becomes increasingly expensive and far less compassionate. Unfortunately, physician-assisted suicide follows in that flawed tradition.

The real solution to the problem is to implement proven practices for improving end-of-life care. Of course, those familiar with the wisdom of Catholic teaching and the ethical code of the A.M.A. already know that.

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