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Cents and sensitivity--teaching physicians to think about costs.

99 Finally, there are objections from the medical community. In a 2003 study of AMA members, 69% objected to physician-assisted suicide,1 a position officially held by various national and state medical associations. Even with allowances for conscientious objection, some physicians believe it’s inappropriate or wrong for a physician to play an active role in ending a patient’s life. We believe there is a compelling case for legalizing assisted dying, but assisted dying need not be physicianassisted. Under the DWDA, the patient’s physician prescribes lethal medication after confirming the prognosis and elucidating the alternatives for treatment and palliative care. In theory, however, the prescription need not come from the physician. Prognosis and treatment options are part of standard clinical discussions, so if a physician certifies that information in writing, patients could conceivably go to an independent authority to obtain the prescription. We envision the development of a central state or federal mechanism to confirm the authenticity and eligibility of patients’ requests, dispense medication, and monitor demand and use. This process would have to be transparent, with strict oversight. Such a mechanism would not only obviate physician involvement beyond usual care but would also reduce gaps in care coordination: in Oregon and Washington, patients whose doctors don’t wish to participate in assisted dying must find another provider to acquire a prescription. Physicians who strongly object to the practice could potentially refuse to provide certification or could even alter their prognosis, but these possibilities yield the same outcome as permitting conscientious objection. Patients could also provide an independent authority with their medical record as proof of their prognosis. Such a mechanism would make it essential for physicians to offer high-quality palliative care. The availability of assisted suicide in Oregon seems to have galvanized efforts to ensure that it is truly a last resort, and the same should hold true regardless of who writes the prescription. Usual care for terminally ill patients should include a discussion of life-preserving and palliative options so that all patients receive care consistent with their own vision of a good death. Momentum is building for assisted dying. With an independent dispensation mechanism, terminally ill patients who wished to exercise their autonomy in the dying process would have that option, and physicians would not be required to take actions that aren’t already part of their commitment to providing high-quality care.