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Physician-Assisted Death in the United States: Are the Existing "Last Resorts" Enough?

Although there has been relatively little activity in the last ten years with regard to legal access to physician-assisted death, this fall a citizen's initiative in the state of Washington is proposing an Oregon-style law that would allow legal access to potentially lethal medication for terminally ill patients, subject to defined safeguards. As the rhetoric inevitably heats up, this seems like a good time to review areas of progress in palliative and end-of-life care and to consider whether laws like the one on the table in Washington are either needed or desirable. Several things are clear: (1) Palliative care and hospice have improved in terms of access and delivery, and they remain the standards of care for addressing the suffering of seriously ill patients; (2) Despite state-of-the-art palliative measures, there will remain a relatively small number of patients whose suffering is insufficiently relieved; (3) Several "last resort" options, including aggressive pain management, forgoing life-sustaining therapies, voluntarily stopping eating and drinking, and sedation to unconsciousness to relieve otherwise intractable suffering, could address many of these cases. The question remains as to whether physician-assisted death--that is, providing terminally ill patients with a potentially lethal prescription that they could ingest on their own to directly hasten death--should be one of these last resort options. The author's own answer to this last question is a cautious "yes": open access to physician-assisted death, subject to the safeguards of excellent palliative care and access to other last resort options, gives patients an important additional option, and the benefits of legalization outweigh the risks. When unacceptable suffering persists for terminally ill patients despite state-of-the-art palliative care, four options have emerged as last resort possibilities. The first two are widely accepted and relatively uncontroversial. First, patients may choose intensive pain and symptom management. Pain can almost always be sufficiently relieved without any significant risk of hastening death, but there will be a few cases where pain accelerates severely toward the very end of life and pain medicine must be proportionately increased, bringing an increasing risk of hastening death. Second, patients may choose to forgo life-sustaining treatment. Medicine has made great strides in prolonging life, and a small but significant part of this progress has been the availability of life-sustaining technologies. …