What makes a good death?
Perhaps it is time for Connecticut to allow patients and families to decide
I support the perspective articulated by Paul Bluestein in “It is time for Connecticut to pass an Aid-in-Dying Bill.”
I want to express my gratitude and admiration for the efforts of Connecticut State Medical Society President Dr. Claudia Gruss, the Ethics Committee led by Dr. Henry Jacobs and EVP/CEO Matt Katz “who undertook thoughtful and careful clinical and ethical discussions” to arrive at a new policy on medical aid-in-dying:
“… the CSMS approved a change in their policy concerning medical aid-in-dying from opposed to engaged neutrality, meaning ‘The CSMS is committed to protecting its members’ freedom to decide what medical aid-in-dying options to provide to patients in accordance with each physician’s personally held values, beliefs and ethical standards, including the decision whether or not to write a prescription for a lethal dose of medication, if legalized in Connecticut.’”
I participated in the discussion as member of the Ethics Committee and in an online survey. I testified to the Judiciary Committee in March 2015 on HB 07015. “To allow a physician to dispense or prescribe medication at the request of a mentally competent patient that has a terminal illness that such patient may self-administer to bring about his or her death.”
To provide a reliable foundation for decision-making on this issue I want to share:
1. The statement of the American Public Health Association on the patient’s rights to self-determination at the end of life:
Empirical and anecdotal evidence reflect that health care providers do not inform terminally ill patients of all options legal in the state in which the patient is receiving care. As a result, patients are not able to make fully informed decisions about care at the end of life. APHA rejects providing only partial information on which to base health decisions.
2. This Pros and Cons Debate on the right to die as one chooses.
Whatever the decision, for a physician who participates in the process with a patient, family members, chaplains, hospital staff or in some cases with members of the bio-ethics committee of a Health Care entity, it is important to know the actions proposed are consistent with the code of medical ethics, Belmont Principles, and are morally permissible when measured against the four principles of the Doctrine of Double Effects.
1. The nature-of-the-act condition. The action must be either morally good or indifferent.
2. The means-end condition. The bad effect must not be the means by which one achieves the good effect.
3. The right-intention condition. The intention must be the achieving of only the good effect, with the bad effect being only an unintended side effect.
4. The proportionality condition. The good effect must be at least equivalent in importance to the bad effect.
Finally, I want to provide a context for the discussion about aid-in-dying by providing information from three sources on what is spoken of as “good death:”
1. Defining a Good Death (Successful Dying): “According to an Institute of Medicine report, a good death is ‘Free from avoidable distress and suffering for patient, family and caregivers, in general accord with the patient’s and family’s wishes, and reasonably consistent with clinical, cultural and ethical standards.'”
According to Dr. Dilip Jeste, one of the above research article’s authors: “Death is obviously a controversial topic. People don’t like to talk about it in detail, but we should. It’s important to speak honestly and transparently about what kind of death each of us would prefer.” Dr. Jeste and I are friends and colleagues for several years.
The team’s literature search returned 32 relevant papers. From these sources, the team uncovered 11 core elements to consider when contemplating a good death.
Across all of the groups being studied, the categories considered most important were preferences for a specific dying process, being pain-free and emotional well-being.
However, certain discrepancies between the groups came to light. For instance, spirituality and religiosity were deemed more important by patients than family members. Family members were more likely to put emphasis on life completion, quality of life and dignity.
Meanwhile, health care professionals tended to occupy the middle ground between the patients and family members.
3. This, from Medical News Today: What does a “good death” really mean?
“Although many individuals shy away from contemplating the inevitability of death, most would agree that they would like to die well. A new review of existing literature, published in the American Journal of Geriatric Psychiatry, asks what makes a ‘good death’ according to those involved in the process,” — namely patients, family (prior to and during bereavement) and health care providers.
I should also point out that in its recently revised Code of Medical Ethics, the American Medical Association is opposed to an Aid in Dying role for any physician:
“It is understandable, though tragic, that some patients in extreme duress—such as those suffering from a terminal, painful, debilitating illness—may come to decide that death is preferable to life. However, permitting physicians to engage in assisted suicide would ultimately cause more harm than good.
Physician-assisted suicide is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks.
Instead of engaging in assisted suicide, physicians must aggressively respond to the needs of patients at the end of life.”
This role is not mutually exclusive from the role of being just as caring and compassionate as physicians who participate in the somber and momentous Aid-In-Dying process.
Physicians: (a) Should not abandon a patient once it is determined that cure is impossible, (b) Must respect patient autonomy, (c) Must provide good communication and emotional support, (d) Must provide appropriate comfort care and adequate.
Given the complexity of this issue, you can now see why I expressed my gratitude and how proud I was of the courageous decision of the CSMS leadership and members to adopt the “Engaged Neutrality” position.
Dr. Velandy Manohar is a member of the Community Advisory Board of the Office of Health Strategy. A native of India, he has been a physician in the U.S. since 1967.
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