Category: Assisted Dying

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Two state medical societies drop opposition to medical aid-in-dying

by Joanne Finnegan

[T]wo state medical societies have dropped their opposition to medical aid-in-dying, a position that mirrors growing acceptance of the practice among many doctors.

The Massachusetts Medical Society on Saturday became the 10th chapter of the American Medical Association to depart from the profession’s long-standing opposition to physician-assisted dying, according to an organization announcement.  

The Vermont Medical Society also recently joined the list of medical associations that have voted to take a neutral stance on physician-assisted death. Massachusetts and Vermont joined medical societies in California, Colorado, Maryland, Maine, Minnesota, Nevada, Oregon and the District of Columbia in dropping opposition to what was once called physician-assisted suicide. Supporters of legislation that allows doctors to write a prescription for a lethal dose of medication that terminally ill adults can use to end their lives now prefer the term medical aid-in-dying.

The shift in position is a new one, as nine of those medical societies adopted a neutral stance in the last two years, according to the group Compassion & Choices. The group praised the action by the Massachusetts physicians’ group, which it hopes will improve the chances for passing legislation in the Bay State to legalize aid-in-dying.

The society’s House of Delegates voted to adopt a position of “neutral engagement,” which it says will allow it to serve as a medical and scientific resource as part of legislative efforts that will support shared decision-making between terminally ill patients and their physicians. The change followed the release of a survey of the society’s members that showed they supported the aid-in-dying bill the state legislature is considering by a 2-1 margin, Compassion & Choices said.

Also applauding the decision was Roger Kligler, M.D., a retired doctor who has stage 4 metastatic prostate cancer and filed a lawsuit against the state seeking the right to die using self-administered medication. Compassion & Choices and a fellow physician, who wants the right to prescribe medications to help patients die without fear of prosecution, have joined in that lawsuit.

“I am excited about this decision because the legislature greatly respects the medical society’s positions on healthcare issues and its previous opposition to medical aid-in-dying was a serious roadblock to passing legislation authorizing this end-of-life care option. I’m extremely grateful for the society’s change of heart,” Kligler said in the group’s announcement.

The Massachusetts society’s vote came after considerable discussion, as aid-in-dying raises ethical questions for many physicians.

Six states, including California, Colorado, Montana, Oregon, Vermont and Washington, as well as the District of Columbia, have explicitly authorized medical aid-in-dying

In Vermont, the medical society’s action caught up with existing law. The society dropped its opposition to the state’s 2013 death with dignity law, adopting a resolution at its annual meeting that says doctors have a right to decide if they should assist their patients in ending their lives.

While some physician groups have changed their stance, others have held firm. The American College of Physicians published an updated position statement in September reaffirming its opposition to legalization of what it still calls physician-assisted suicide.

Complete Article ↪HERE↩!

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Drug commonly used for self-administered death now available in Canada

By Joan Bryden,

[O]nly a tiny percentage of Canadians who’ve received medical assistance to end their lives has chosen to self-administer a lethal drug cocktail.

But that could change now that secobarbital — the drug most commonly used for assisted suicide in other countries — is available in Canada.

Secobarbital is considered the best way for suffering individuals who want to control the manner of their death as much as possible, including administering the medication themselves.

“It’s kind of the barbiturate of choice because (its) quicker onset and duration is such that the dying period is reduced,” said Dr. Stefanie Green, president and co-founder of the Canadian Association of MAID Assessors and Providers.

“Much of the other recipes cause an extended dying period to happen, which is not always successful.”

Health Canada reports that from June 2016 to June 2017 — the first year in which medical assistance in dying (MAID) was legal in Canada — a total of 1,982 individuals received an assisted death. Of those, just five were self-administered deaths.

Green said the unavailability of secobarbital may, at least in part, explain the small number of self-administered deaths.

In general, orally ingested drug cocktails present some difficulties that are not associated with those injected intravenously: they taste bad, they can induce nausea and vomiting, the patient can fall asleep before the entire dose is consumed, which can ultimately cause it to be ineffective.

“You want to mitigate those factors as best as possible,” Green said. “So if you’re going to choose to use a barbiturate and an oral cocktail, this (secobarbital) would be the best one.”

Among other things, she said secobarbital is more soluble than other barbiturates, meaning it can be dissolved in a smaller volume of liquid, thereby reducing the risk that patients won’t consume the entire dose.

Green expects that self-administered deaths will increase somewhat now that secobarbital is available.

“There are certainly a significant amount of people who want to be the ones to have the control, who want to be the ones with the medication in their hand, who want to say, ‘I’m going to take this to my backyard and drink it when I darn well please, thank you very much,”‘ she said.

The drug may be particularly helpful in rural or remote areas where it may be difficult to find a nearby physician or nurse practitioner willing to provide an assisted death, Green added. Individuals in those areas may find it easier to get a prescription for a lethal dose of secobarbital that they can administer themselves.

Because it is fast-acting, secobarbital may also make the self-administration option more viable in a province like British Columbia, where Green practices and which requires a physician to be present throughout the assisted dying process, even when the patient self-administers the medication. That was not feasible when the barbiturates used could take hours, or even days, to work, she said.

Secobarbital, once widely used as a sedative decades ago, has not been available in Canada for years. That it is now is largely due to Jocelyn Downie, a professor of law and medicine at Dalhousie University and a passionate advocate of medical assistance in dying.

When she realized few people were using the self-administration option, Downie said she explored ways to make secobarbital available. She discovered that the cost and time required to get the drug approved for marketing in Canada was a big obstacle so she found “an alternate path:” persuading a pharmaceutical products company to provide the active ingredients for the medication that can be compounded, or mixed, by a pharmacist to produce secobarbital.

Since the company doesn’t want its name publicized, Green said her organization is acting as “the middleman.” It will provide the necessary contact information to health care providers and pharmacists who are helping patients who choose the self-administered death option.

“For those of us in the field, it’s good news, it’s very good news to be able to offer this extra option to our patients, some of which we know will take it and we’ll be happy to provide a better quality product for them,” said Green.

Complete Article ↪HERE↩!

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The fear that dare not speak its name:

How language plays a role in the assisted dying debate

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[A]rguments in the “euthanasia debate” (as it is colloquially referred to in Australia) hinge in part on the language used to describe “death”.

The inevitability and permanence of death make it a taboo fraught with fears (such as fear of losing loved ones, fear of the afterlife, fear of what happens to the body after death).

When it comes to fear, politicians are slick verbal smugglers, sneaking messages under our noses. Conservative pollsters found “global warming” was scary so they gave us “climate change”. Richard Nixon knew white voters afraid of minorities would respond well to “law and order”.

Those involved in the “euthanasia debate” draw on similar tactics. Are we talking about “assisted dying” – as the name of the bill suggests – or are we talking about “assisted suicide”? Does it even matter?

Debating a ‘good death’ in the Victorian parliament

Three terms loomed large a few weeks ago in the debate in parliament: “euthanasia”, “assisted dying” and “assisted suicide”.

Those who supported the Voluntary Assisted Dying (VAD) Bill tended to use the phrase “assisted dying” throughout the debate. A preliminary token count (factoring out references to the name of the bill) shows 678 references to “assisted dying” from October 17-19. The lion’s share of these were made by the bill’s proponents.

Conversely, those who opposed the bill favoured the terms “euthanasia” and “assisted suicide”. There were 264 references to “euthanasia” and 205 to “assisted suicide” across the three days. These terms were most often used by the bill’s opponents.

In fact, the bill’s opponents took issue with its euphemistic tone. Deputy Premier James Merlino argued in the debate that “language is important” and pointed out the reticence of the bill’s proponents to use “confronting words” like “euthanasia” or “suicide”.

Also during the debate, opponents made multiple references to comedian/actor Liz Carr and her show Assisted Suicide: The Musical.

Liberal MP Robert Clark highlighted one particular scene in Carr’s play in which societies engaging in euthanasia seek the most “palatable term” for what they do. These societies acknowledge, in Clark’s words, “to call it by its true name would be a big setback for their cause”.

Why do these words matter to politicians? Should they matter to us?

To name the tiger or to not name the tiger?

Cultures avoid naming the things they fear the most.

The Batek, a nomadic group inhabiting peninsular Malaysia’s tropical forests, fear and revere tigers. Consequently, hunters often use avoidance terms like “animal of the forest” or the mocking “smelly paws” to discuss them.

Modern English speakers linguistically dance around the concept of death with the same care and mocking humour as the Batek do the tiger. Among other things, we frame death in terms of “rest” (“rest in peace”), “loss” (for example, “my condolences on your loss”) and “a journey” for “the departed” (“pass away” originally referred to the soul’s “departure” from the body for the “journey” to heaven or hell).

We can also, with an irreverent nod to dark humour and idiomatic expression, “buy the farm”, “push up daisies” or “kick the bucket”. These seemingly frivolous statements can often have dark origins. For instance, “kick the bucket” is likely either a reference to suicide by hanging or an old way of killing of pigs (in both cases, the living thing is tied to a beam, and a bucket kicked from under them).

Such dark humour perhaps enables us to cope with death by downgrading its significance.

Returning to the current debate, opponents of Victoria’s VAD bill most commonly use the terms “euthanasia” and “assisted suicide”. They are sometimes used interchangeably, but also separately, as they have differing meanings (the former entails more direct involvement of a doctor or another person).

The Oxford English Dictionary (OED) traces the earliest uses of “euthanasia” to the mid-17th century, deriving from the Greek eu- “good or well” and thanatos “death”. It is worth noting in light of the current debate that this eu- also appears in “euphemism” – loosely, “good speaking”.

Euthanasia originally had this general sense of “good death” until the 18th and 19th centuries when it came to signify the “means” or “actions” to bring on a good death.

Words associated with taboo topics often taken on negative connotations, and euthanasia is no exception. We see similar processes at work with “coffin”, which once meant a “small basket” in French, and was originally a reference to the container in which we place our dead.

Opponents of the VAD bill also draw on the negative connotations of “assisted suicide”. Suicides are, of course, highly stigmatised. Moreover, the use of “suicide” conjures up a series of other negative words containing the element –cide (from the Latin “slayer of”), including “homicide” and “fratricide”.

Many of these –cide words are first noted in English in the 15th century but “suicide” (from the Latin suī “of oneself”) did not appear until the 18th century. Before this, the act was known, among other things, as “self-destruction”, “self-homicide”, “self-murder” and “self-slaughter”. The OED notes the first appearance of “assisted suicide” in 1976.

Proponents of the VAD bill favour “assisted dying”, which, of course, is in the name of the bill itself. The OED shows the first appearance of “assisted dying” in 1988 in the British magazine The Contemporary Review. It appears in an article referencing Sigmund Freud’s request that his life end early rather than suffer unduly from his inoperable cancer.

The term “dying” is arguably the more neutral of the two terms (though how accurately it represents the act will relate to one’s philosophical or religious viewpoint).

While we are squeamish about the concept of death, we may be coming to terms with the use of the word “death” itself. Linguists Keith Allan and Kate Burridge studied obituaries and “In Memoriam” notices in the early 2000s, and found only a single of these contained the verb “die” or the noun “death”.

However, last year PhD scholar Pawel Migut studied online obituaries and found “died” to be the most common reference to the process in 12 US states (“passed away” seemingly remains the most common euphemism across the US on the whole).

Naming the tiger or slick political strategy?

Politicians’ choices to use “euthanasia” and “assisted suicide” or “assisted dying” have demonstrable political impact, as evidenced by a 2013 Gallup poll.

This poll found that 70% of Americans supported ending “a patient’s life by some painless means” when they were suffering from an incurable disease. However, support dropped to 51% when Americans were asked whether they supported a request to “assist the patient to commit suicide.”

So then, it is worth noting that the selection of “assisted dying” or “assisted suicide” might reflect our pollies’ attitudes. But it just as equally may be an effective political act, playing to our fears of death, and those words we use to name, or either to not name, our cultural tiger.

Complete Article ↪HERE↩!

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We need to address questions of gender in assisted dying

Gendered risks challenge the idea that women will always be acting autonomously.

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[O]ne of the principal motivations behind current efforts to legalise assisted suicide in Victoria and New South Wales (and most jurisdictions) is patient autonomy. However, research suggests “gendered risks” may thwart women’s autonomy in end-of-life decisions, making them uniquely vulnerable to assisted suicide laws.

While eligibility under the Victorian and NSW bills requires that a patient must be suffering from a terminal illness from which they will likely die in 12 months, the concern for women is that the final decision to end their lives may nevertheless be influenced by risk factors that challenge the rhetoric of “choice”. Here are some of those “gendered risks”.

Longer life span

Women tend to live longer than men. This means they are more likely to develop diseases and disabling conditions, or experience elder abuse and discrimination, both of which could motivate the desire for assisted suicide.

The Australian Law Reform Commission’s report on elder abuse recognised that women are significantly more likely to be victims than men, and that the rate of neglect of older women could be as high as 20%.

More likely to experience their partner’s death

Women are also more likely to experience the death of a partner or spouse due to their relative longevity, and to be deprived of this support and companionship in older age. A 2013 Australian study found that living alone is an important predictor of suicide in older adults.

A 2016 US study found that loneliness was a key motivation for assisted suicide requests of patients with “psychiatric” disorders in the Netherlands. Of the cases reviewed, 70% were women and 76% were 50 years or older. One women in her 70s “without health problems” said she experienced life without her husband as a “living hell” and “meaningless”.

Fewer economic resources in old age

Women have fewer economic resources when they are older, the time when decisions about assisted suicide are most likely to occur.

This entrenched economic disadvantage limits their options for care and means they are more likely to face other financially related adversities.

Women are also more likely to have to pay for care than men due to their male partners and families being less likely to care for them.

All these factors could influence a decision on assisted suicide.

More self-sacrificial and less assertive

Women are arguably more self-sacrificial and less assertive than men, whether by nature, socialisation or simply in terms of society’s ideals about femaleness.

So, they may be more likely to request assisted suicide to spare their loved ones the burden of caring for them, or be persuaded that their life is unworthy of others’ care and their family’s resources.

In a study of assisted suicides where the majority of cases were women, the fear of being a burden was a prominent reason for deciding for death. The ethic of self-sacrifice was summed up by a friend of one of the suicides, who said:

She felt it was a gift to her family, sparing them the burden of taking care of her.

Preference for passive suicide methods

Women demonstrate a stronger preference for more structured, passive methods of suicide, with significant physician participation.

It is clear that increasing numbers of women decide to die when offered the more passive options of assisted suicide. The rate of assisted death of women in the Netherlands, Oregon and elsewhere is nearly four times that of the usual female suicide rate.

One explanation might be that decisions for assisted suicide fit in with cultural expectations of women as passive and compliant, and play out gender expectations of subordination and dominance in a profession where physicians are still predominantly male.

More likely to attempt suicide

Women are more likely to attempt suicide than men, as they are more prone to psychological problems such as depression.

While mental illness does not qualify a person for assisted suicide under the Victorian and NSW bills, neither does it disqualify them.

If assisted suicide is legalised, women’s greater propensity to attempt to take their lives as a result of psychological problems, coupled with their preference for more passive methods of suicide, could have a harmful compounding effect on women’s decisions to die. This may already be evident in the 2016 American study.

Entrenched patterns of violence against women

Female assisted suicide needs to be considered in light of pervasive male violence against women, particularly against intimates. Research indicates striking similarities between the broader patterns of male violence against women and at least one kind of assisted death: “mercy killing”.

American and Australian studies indicate that there are more female mercy killings in those countries, mostly by men, who are most often the woman’s partner, and these are characterised by the same themes of domination, possessiveness and control as other gender-based violence.

The prevalence of violence against women in Australia (particularly intimate partner violence) is a serious problem, and so it is vital that we understand whether the dynamics underlying other forms of gendered violence that result in the deaths of women may sometimes also underlie female assisted suicide.

Taking into account gender differences in health care is important. And if there is potential for gendered risks in legalising assisted suicide, this requires further consideration and research in advance of any legislative change.

These insights challenge the presumption that women who decide for assisted suicide are always exercising autonomy. Legalisation could in fact compound oppressive sociocultural influences and facilitate the last of many non-choices for some women.

Complete Article HERE!

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Dying a good death—what we need from drugs that are meant to end life

There are a few drugs that can end life, and how we want to die should be considered.

by And

[G]enerally speaking, health care is aimed at relieving pain and suffering. This is also the motivation behind euthanasia – the ending of one’s own life, usually in the case of terminal illness characterised by excruciating pain.

There has been debate in Victoria about the drugs that should be used to end life if euthanasia is legalised. So which medications can we ensure would facilitate the best, medically-supervised death?

Medicine as poison

When it comes to the question of which medicines can, or even are meant to, kill us, the most important thing to remember is the old adage:

“The dose makes the poison.”

This concept is one on which the whole discipline of toxicology and medicines is founded. This is the meaning of the well-known symbol of the snake, wound around the bowl of Hygeia (the Greek goddess of health), representing medicine, which you see in pharmacies and medical centres around the world. The intertwining of poison and is a longstanding concept in the therapeutic use of medicines.

This is a very intricate science, and the reason we conduct clinical research. We need to trial different doses of new drugs to meticulously establish a safe but effective threshold for use.

In more practical terms, this means too much of any medicine can cause harm. Take, for example, the humble paracetamol. When taken following correct guidelines, it is a perfectly safe, effective pain killer used by millions of people worldwide. But taken in excessive quantities, it can cause irreparable liver damage, and if the patient is not given an antidote in a hospital, could lead to death.

What drugs are used in assisted dying?

The group of drugs most commonly used to end life is called the barbiturates. They cause the activity of the brain and nervous system to slow down. These drugs, used medicinally in small doses, can be taken short-term to treat insomnia, or seizures in emergencies. In different doses and administration techniques, these preparations can also be used as anaesthesia, to make us sleep through surgery.

An overdose of barbiturates is fatal. A large dose will effectively make the brain slow down to a point where it stops telling the body to keep the respiratory system working, and breathing ceases.

Both secobarbital capsules and pentobarbital (usually known as the brand name, Nembutal) liquid – (not to be mistaken for epilepsy medication phenobarbital) have been used either alone or in combination for physician-assisted suicide or euthanasia. They are also used in injectable forms for animal euthanasia.

These two products are tried and tested, have the advantage of years of use with the benefit of knowing the exact dose range needed, and with few adverse effects reported (such as unexpected pain, drawn-out death or failed death).

Their safety and efficacy in inducing a peaceful, swift and uneventful death has been proven around the world. They are the preferred drugs in the Netherlands, Belgium, Switzerland and some USA states where euthanasia is legal.

Other options exist, whether in combination or alone, but have limited evidence of use in euthanasia. Some drugs that cause excessive muscle relaxation and respiratory distress can end life, as can some pain killers commonly used in palliative care.

Drugs can also be used that fatally lower , cause heart attack, or block messages from the brain to the muscles, causing paralysis.

While all of these drugs are legally available in Australia, they could cause a long, protracted , with many more side effects that could cause distress and suffering at the end of life. Nembutal and its relatives are less likely to do so, with greater evidence from international practices than any other drugs that can end life.

The ‘best’ death

In Australia, Nembutal and secobarbital can be used for animals, but are illegal for human use. This makes implementation of the newly proposed euthanasia law in Victoria slightly more difficult. The proposed legislation does not seek to legalise the use of Nembutal and its relatives – but suggests a “drug cocktail” be concocted by a compounding pharmacist.

The Victorian government has reportedly approached Monash University’s pharmacy department to research the kind of pill that could be developed if the legislation passes. Therefore, no final description of this product has been released.

Some have suggested the mixture will be in powder form made with to induce a coma and eventually cause respiratory arrest. It may also use sedatives and muscle relaxants, a drug to slow down the heart, and an anti-epileptic to prevent seizure and induce relaxation of muscles. The constituents and doses are yet to be determined.

It’s difficult at this early stage to predict how this concoction would work and whether it would be easier or safer to use than drugs already tried and tested. This proposed product would need to be tested and results compared, as all are.

What is needed is a or a mixture of drugs that produce a painless, relatively quick and peaceful passing. We do not wish to see further suffering in the form of seizures, prolonged distress and pain. If no solution is certain, it would be wise to fall back on simply legalising what is already tried and tested.

Complete Article HERE!

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De-Medicalizing Death

By Jessica Nutik Zitter

[T]here’s been an unexpected, and excellent, consequence to California’s new medical aid-in-dying law. For many terminally ill patients, immersion in the process of securing lethal drugs ultimately renders them unnecessary. How did this come about?

Passed by the California legislature in late 2015, the End of Life Option Act allows physicians to prescribe a lethal concoction of drugs to some patients with terminal illnesses who meet certain criteria. The law, commonly described as providing “medical aid in dying,” took effect on June 9, 2016. It stipulates only that the requesting patient be considered terminal (less than six months away from death), possess full decision-making capacity, and be physically able to self-administer the life-limiting drugs. Although the physician is obligated by law to inform the patient of alternative care options, such as psychological counseling or symptom management with palliative care services, there is no direct requirement that the physician arrange or provide them. In its barest form, the option can serve as a dispensary for life-ending medications.

California’s medical community was taken by surprise by the rapid passing of the law in late 2015. It came on the heels of the dramatic case of Brittany Maynard, a young woman with terminal brain cancer who elected to move from California to Oregon to access medical aid in dying under that state’s Death with Dignity Act. Hospital systems and physicians in California suddenly found themselves with an urgent need to rapidly formulate policies around this new right of patients. Some, such as the Catholic Health Systems, opted out on religious grounds. Others scrambled to put basic policies in place for patients who met inclusion criteria. And some institutions decided to put significant time and resources into supporting this new legal reality in the most comprehensive way possible.

One standout example is the University of California, Los Angeles (UCLA) Health Centers. After literally thousands of hours of discussion, the working group determined that the intake process for patients requesting medical aid in dying should be conducted by trained psychotherapists (psychologists and clinical social workers) instead of physicians. Dr. Neil Wenger, director of the UCLA Health Ethics Center, led the effort to create processes and infrastructure to respond to this law. “We wanted to be able to offer a service that doctors tend to gloss over,” he said, when asked why they chose to lead with talk therapy. The intake consisted of an extensive set of questionnaires designed to assess all possible sources of distress. Any patient with physical or psychiatric needs was referred on to the appropriate services. But as the UCLA committee expected, most of what patients needed was to discuss their feelings about their approaching death and process their grief and sense of loss. This mirrors data from the entire state of California as well as Oregon, which suggest that the distress prompting patients to request these lethal medications primarily stems from their fear over losing control at the end of life. It is not, as many may think, due primarily to physical suffering.

The intake questions explored goals of care, quality of life, and patients’ emotions around their impending deaths: Were they ready? What scared them? What made them anxious? Did they feel their lives were complete? What did they feel makes life meaningful? What decrements in quality of life are too great? What haven’t they said and to whom? Anne Coscarelli, psychologist and founding director of the Simms/Mann–UCLA Center for Integrative Oncology, described the conversations that came from this intake process as revelatory and comforting for the patients. Several patients ultimately completed legacy projects, such as video or written messages and stories, for their children and grandchildren. This invitation to talk, which opens up a discussion that most of us are taught to avoid, turned out to be a game-changer.

Only a quarter of the patients ultimately went on to ingest the lethal drugs they came requesting. The actual data is more complex: Some who requested this service did not meet the basic requirements to receive it. Others died before they had a chance to ingest the medications. But the staff from UCLA reported case after case in which patients’ goals shifted from wanting to hasten their deaths to deciding to live out the remainder of their lives.

Ours is a culture that does not talk about death, even when it should be impossible to ignore. Despite the fact that 89 percent of people think that it is a doctor’s responsibility to discuss end-of-life care with their patients, in reality, only 17 percent of patients report having had such a conversation, according to a 2015 survey from the Henry J. Kaiser Family Foundation. As a doctor who practices both critical care and palliative care medicine, I have presided over thousands of deaths. Most of my patients have suffered with chronic illnesses for years: metastatic cancers, failing lungs, and progressive debilitation from dementia. And yet almost none of them have discussed their own death with their doctors, or even their families. Most have no idea that they are actually dying. In this culture that operates on a fantasy of immortality, with unrealistic promises made by television shows and advertisements, doctors see themselves as failures if they are unable to cure their patients. We physicians are trained to lead patients into battle after battle, into the next procedure or intervention, banking always on that magic pill or miracle cure.

This broad cultural unwillingness to acknowledge death results in a phenomenon I call the “End-of-Life Conveyor Belt,” where high-tech treatments are automatically attached to bodies as they progress through the stages of dying. As the baby boomers age and our treatment options blossom, more are being exposed to the suffering brought about by these protocols. The tremendous anxiety we see over loss of control is understandable. It is no wonder that people in many states have asked for, and finally won, the right to take back that control with a pill.

The effort by UCLA Health seems to be working. Placing highly trained psychologists and clinical social workers in the critical role of “first responder” to a patient’s request to hasten death has rendered many of these requests obsolete. In choosing this approach, UCLA is effectively “de-medicalizing” the experience of dying by prioritizing the need for deep reflection. In this way, the program provides patients with an option that doctors are not primarily trained for.

Patients requesting support to hasten their deaths are only a small subset of the population of the dying. They are in some ways canaries in a coal mine, their request for medical aid in dying is alerting us to the unmet needs of the wider population of dying patients. And what I am seeing is that our new legal responsibility to steward these patients responsibly through this rocky terrain will build practices and skills that will help all of those at the end of life.

Where goes California, thus goes the nation. California was the fourth state to legalize medical aid in dying and has since been followed by two more. And UCLA’s approach, with trained psychologists guiding patients through this tricky terrain, shows us the way. Let’s take advantage of this wave to take better care of all our seriously ill patients. And let’s make sure we give patients what they really need and hope that lethal drugs are always the last tool in the toolbox.

Complete Article HERE!

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When a ‘good death’ was often painful: euthanasia through the ages

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[T]oday, a primary goal of both movements aimed at care of the dying – palliative care and euthanasia – is to eliminate suffering. These are underpinned by the idea that a good death is a painless death. But it wasn’t always so.

The term “euthanasia” is derived from the Greek for good death, but it only began to be used in a modern and familiar way in the late 19th century. For centuries in Western societies, “euthanasia” referred to a pious death blessed by God.

The means of achieving a good death was set out in the enormously popular ars moriendi (art of dying) guides that offered prayers, attitudes and actions intended to guide the dying towards salvation. This wasn’t necessarily a painless process. Far and away the most reproduced image of good dying was Christ’s crucifixion.

The pain that could accompany dying was seen as punishment for sin and ultimately redemptive: a chance to transcend the world and flesh through imitation of Christ’s suffering. It was also a test of the compassion and charity of friends, relatives and even strangers.

The Christian injunction to minister to suffering meant visiting and caring for the dying were seen as communal duties. Children as well as adults were expected to offer physical and moral support to those who were gravely ill.

Doctors did not typically attend the deathbed. They did not have an obvious role in the central spiritual business of dying, but nor were they particularly associated with the mitigation of suffering.

Indeed, in the pre-anaesthetic era, doctors were more likely to be associated with the infliction of pain. Surgery, of course, was excruciating, but other now infamous “heroic” remedies (such as blistering, excessive bleeding and the application of caustic chemicals to the skin) were based on the belief that pain had healing properties and involved doctors deliberately inducing it.

In the 19th century, pain began to be seen as a discrete and aberrant physiological phenomenon. Both dying and suffering were increasingly medicalised. Doctors gradually took over from the clergy and family as carers of the dying.

At the same time, the word “euthanasia” took on a new meaning. It began to refer to this new medical duty to assist the terminally ill – but not to hasten death.

In the wake of the mid-century revolution in anaesthetics and aided by innovations such as the hypodermic syringe, doctors began to “treat” the dying with painkillers as well as prayers.

In 1870, Samuel Williams, a Birmingham businessman and amateur philosopher, proposed a more definitive form of this new medical treatment for the terminally ill. In an essay called Euthanasia, published by the local Speculative Club, he wrote:

That in all cases of hopeless and painful illness, it should be the recognised duty of the medical attendant, whenever so desired by the patient, to administer chloroform or such other anaesthetic as may by-and-by supersede chloroform – so as to destroy the consciousness at once, and put the sufferer to a quick and painless death.

Williams sparked a debate that has waxed and waned but never gone away. But how had this come to look like a good way to die?

Changing meanings of pain

In 1901 psychologist and philosopher William James wrote of the “strange moral transformation” that had taken place regarding attitudes to pain:

It is not expected of a man that he should either endure it or inflict much of it, and to listen to the recital of cases of it makes our flesh creep morally as well as physically. The way in which our ancestors looked upon pain as an eternal ingredient of the world’s order, and both caused and suffered it as a matter-of-course proportion of their day’s work, fills us with amazement.

Historian Stephanie Snow observes that as anaesthetics and other methods of pain relief became available in the 19th century, people began to see pain – the experience but also the sight of it – as more damaging and demoralising.

A new generation of comfortably off Victorians who considered anaesthesia commonplace could no longer stomach physical suffering. Now pain was something that could not just be eliminated but struck as cruel, unusual and degrading: “an alien force which undermined man’s very humanity”.

Dying and suffering became things from which people, particularly children, should be shielded.

A modern paradox

Medical methods aimed at eliminating the pain of the dying process developed as the fear of death – a fear that for centuries dwelt on the post-mortem horrors of hell – began to centre on the horror that could precede it.

Paradoxically, this fear arose and gained momentum as most people in Western cultures became increasingly insulated from such suffering. As mortality declined, more people died in hospital under the care of specialists, and doctors’ ability to control pain advanced in ways previously unimaginable.

This very modern anxiety can be historically tracked from Williams’s 1870 proposal to the assisted dying bill soon to be debated in the Victorian parliament.

Our ancestors would be amazed.

Complete Article HERE!