A California doctor ponders assisted suicide

August 6, 2017 • 1:00 pm

California is now the fifth state in the U.S. that allows doctor-assisted voluntary suicide (the others are Delaware, Colorado, Washington, and Oregon), but apparently the details of the procedure have not been worked out, nor how it should be paid for. In the article below, in today’s New York Times, Dr. Jessica Zitter shows the dilemmas facing doctors who now can suddenly be asked to help terminate the life of a patient but haven’t thought about it much. Zitter is identified as “a critical care and palliative medicine doctor at Highland Hospital” (California) and “is the atuhor of Extreme Measures: Finding a Better Path to the End of Life.”

I don’t have much to add to her article, which raises the very real complexities of putting such a measure into practice. Let me just say that it’s about voluntary euthanasia of adults, and deals not with when to withdraw care, like turning off a respirator, but when to prescribe medications for terminal patients that can end their life. She does not discuss, nor does any American law allow, the possibility of euthanasia for terminally ill, malformed, or permanently unconscious newborns, something we’ve discussed here recently:

Here’s how Zitter describes the law:

California’s law permits physicians to prescribe a lethal cocktail to patients who request it and meet certain criteria: They must be adults expected to die within six months who are able to self-administer the drug and retain the mental capacity to make a decision like this.  

But that is where the law leaves off. The details of patient selection and protocol, even the composition of the lethal compound, are left to the individual doctor or hospital policy.

One problem is that some patients, like those with ALS, will be unable to self-administer the “lethal cocktail” but deserve such euthanasia anyway.  It’s unconscionable that a doctor could not help these patients with an injection. After all, yes, an injection is a deliberate act, but so is giving a patient a prescription that they know will be used to kill them, and standing by to make sure it works properly. (And, by the way, so is turning off a respirator, which is legal if the patient or her family requests it.)

Second, Zitter notes (and I did not know) that the American Medical Association is opposed to such doctor assisted suicide. To me that shows a failure to even consider whether, when a patient requests a prescription or an injection, fulfilling that request might be more merciful than forcing the patient to endure up to six months of intolerable suffering. Click the screenshot to see the article.

The questions that Zitter discusses involve these issues:

  • Should a patient who wants to die because he or she is depressed, and not physically suffering very much, also be offered this alternative? (My answer, as was that of another expert discussed in the piece, is “yes”, but I’d offer them antidepressants first.)
  • What about doctors who are uncomfortable, as is Zitter, helping carry out such a procedure? (My view is that if they are, they must refer the patient to a doctor who can help.) Physicians who often assist the dying by turning of respirators or removing feeding tubes need to think about whether those acts are substantively and morally different from prescribing medication for a patient to use for euthanasia.
  • What should hospitals do about formalizing the procedure and deal with paying for it? (I have to admit that I found the last bit a little churlish in such an article, but it’s a genuine issue.) Doctors need to be trained in this procedure and its ethics now if they intend to practice in one of those five states.
  • What about palliative care as an alternative? Zitter says it’s underused, and somepatients aren’t offered it. Of course they should be. But there are cases where palliative care doesn’t relieve suffering, and when patients prefer to die before they require respirators and other assistance (e.g., as in cases of ALS). So yes, the alternative of a cocktail or injection needs to be available for patients who are informed of the alternatives (part of any decent set of regulations) and still choose euthanasia.

It is a crime that only five out of fifty states allow assisted suicide. They all should—with proper regulations and conditions—and then the states need to consider active euthanasia (i.e, an injection) for those patients who aren’t able to take the “cocktail” themselves. That is what’s done in the Netherlands and Belgium.

Here is a graphic map about the states that have assisted suicide, ones that are considering it, and ones that have banned or criminalized it (all from the sidebar of the article):


53 thoughts on “A California doctor ponders assisted suicide

  1. Having recently updated my medical directive, I couldn’t be happier to be in one of those states where death with dignity is an option. Shameful the rest of the nation is so far behind.

    1. one of those states where death with dignity is an option.

      I thought America had the Second Amendment to guarantee access to “death with dignity”.
      Do gun shops sell bundles of gun, single bullet, and several rolls of wallpaper? Yet?

  2. Thank you for this very thoughtful article (and I did read the article by the doctor.) Thanks you also for your thoughtful posts on dying newborns. I’ve had such a situation in my family, and I do support you. I think it’s interesting that the doctor suggests certification in death and dying–I think she’s right. It takes a special kind of person to go with what a patient wants, even if you yourself may oppose it. That would not be the only thing that doctors get special certification for. When I wrote my will, in 2007 right after my dad died (his dying was botched despite his clearly stated wishes) I did something that may surprise some people. I asked that my body be donated to UC San Francisco, for use by medical students or whoever needs it. I came to that decision both on financial grounds (I am on a low fixed income and this process, as well as the following cremation and scattering of ashes is free to people who donate their bodies,) but also because I’d read that in catholic countries like Argentina, so few people donate their bodies to medical schools that often classes of over 200 students have to use the same cadaver. This was my chance to give back to the scientific and medical community to make sure this shortage never happens in our country. I’d recommend this to all readers, as it is a simple process and proceeds with dignity to the person who makes the donation. The catholic church, of course, is against it.

    1. Good post Dianne, I totally agree and have done the same. Another factor, in the UK anyway, is that with the amount of people donating organs there is a shortage of cadavers for students to use.

      There is also a nice option here that when they finally dispose of the remains if you choose there will be no religious mumbo jumbo.

    2. Congratulations on your decency and concern for others. I’ve willed my organs or body as well. It’s a great feeling to think you might contribute, physically, to allowing others, who might die, to live.

    3. My mother, who died of breast cancer, donated her body to science. My favorite family member has filled out the paperwork to do the same. Now I have to get off my butt and get that paperwork happening. I’d rather have my body put to good use than to be cremated and creating more air pollution.

      If my body turns out to be unacceptable, I’d rather have a “natural” burial and biodegrade back into the earth from which I came. I don’t want to be embalmed and put in an expensive box and buried in a concrete vault and kept from decay as long as possible.

      1. “I’d rather have my body put to good use than to be cremated and creating more air pollution.”

        I do suspect they cremate the left-over remains, so that’s not a reason.

        But your other reasons are good.


    4. My father did that (donate his body). I was there when they came to pick him up, and it all went very smoothly. Some months later we received notice of the annual cremation of donated remains, with ashes buried at sea. It seems like a good idea to me.

      1. What might be an interesting aside – on my PVR I have a couple of recorded programmes from BBC4 on dissecting “The Incredible Human [Hand | Foot]”, where donated remains were obviously used. Unlikely to have been anyone you knew, but I found them fascinating for showing the true biomechanical complexity of building such structures, and a genuinely educational use of the donations.
        You can probably tube them on YouVideo using the description above. The presenter is worth noting too – Dr George McGavin, who seems to be on a “charge” for a late career in TV presenterhood.

        1. A further aside – Creationists who tout the “gdly perfection of the human hand”, typically do not, literally, know what they’re talking about.

  3. This is an area where the religionists are causing a lot of trouble and where they should be ignored.

    I have witnessed a lot of people suffer needlessly when they had no hope of survival. I can remember a time not long back in the UK where a doctor would try to help patients if they requested death by gradually increasing morphine to an OD level, this was about the best they could do but at least it saved some suffering. Unfortunately that has become more difficult with evangelical colleagues trying to make sure they do not and threatening them with legal action.

    Unfortunately the highly religious love suffering, just look at the Albanian Poison Dwarf and her torture clinics in India. I have even heard UK nurses say that the suffering helped to bring the patient closer to Jesus/god – I think that remark was supposed to be a comfort to them although I do not see how. A translation would be “The psychotic overlord who is now torturing you is getting ready for you to live with him for eternity.”

    I have been lucky with my haemophilia now very controllable and can live a fairly normal life but the joint damage was done before there was good treatment and at some stage little or no analgesia will work, I already swig a good amount or Oramorph daily. The simple fact is I am 58 having been born with a life expectancy of less than 20, so I can be very happy with the way things have gone. However, there will come a time when I am bed ridden and in constant pain and at that time I should be allowed to die if I so wish and not have to endure pain and uselessness just because someone else believes in a strange, malevolent and out-dated mythology.

    I certainly know other haemophiliacs who feel the same, plus there are many other conditions, MS is one, where the same death option should be available.

    1. I can remember a time not long back in the UK where a doctor would try to help patients if they requested death by gradually increasing morphine to an OD level,

      In the 1980s I knew several medics going through the transition onto the wards, all of whom had experience of prescribing and installing a “diamorph drip”. Heroin, of course being diacetyl morphine, but the families didn’t like the idea of their dieing kin being given heroin. So they were given diamorph instead.
      And yes, it upset the trainee doctors too.

  4. Aid in dying is legal in five states, not four. This is all fairly new, so there are details to be worked out that will help to hasten legalization in more states. The insurance and payment issue is important. I found it interesting that the doctor who wrote the article freely admits to wanting the option for herself but is still uncomfortable about extending that choice to others.

      1. From your graphic above it looks as if there are 5 states (see Vermont–easy to overlook) plus D.C., but not Delaware.

    1. @Rita “…I found it interesting that the doctor who wrote the article freely admits to wanting the option for herself but is still uncomfortable about extending that choice to others.”

      It is easier to make ones own life decisions than to do so for others. She is faced with new situations she hasn’t had to consider before professionally & she’s still working through her ambivalence.

      Here’s an article she wrote a while back on ‘Death Ed.’ & it’s clear she’s learning still.


    2. “The insurance and payment issue is important.”

      Surely it should be simple, almost a non-issue. The sooner someone dies, the LESS the cost to the family/hospital/insurance company.

      Of course, ‘should’ be simple is not always realised in practice, with bloody-minded people always ready to introduce complications.


  5. I am very much in favour of assisted suicide, euthanasia, or whatever you want to call it. However, I do think that these options place a heavy burden on doctors, quite regardless of religious or moral objections. There is a psychological difference between letting someone die and killing them, a difference evidenced in the “trolley problem”: in this thought experiment, it has been found that a majority of people will be prepared to take an imaginary decision to allow one person to die in order to save five, but in an extension to the problem, called the “fat man dilemma”, only a minority will be prepared to kill one person in order to save five, despite the fact that the outcomes are exactly the same. In addition, it is fairly well known that doctors do “hasten” the end of terminal patients by adjusting the doses of drugs such as morphine. However, I suspect that, in the majority of cases, such patients are unconscious or heavily tranquillised. There is a big psychological difference between this and looking a conscious person in the eye as you deliver a lethal dose of drugs.

    1. I think euthanasia should be legal for those that want it, but that doctors should have a choice whether they do it. If they don’t want to, they should be obliged to refer the patient to a doctor who will do it.

      That’s basically how abortion works in NZ. Doctors who don’t want to get involved are required to refer patients who want an abortion to a doctor who will help.

  6. The AMA and the doctors need to get with it on this subject. They need training and specific guidance on this and I suppose it has to be at state level since the states license the doctors. Not as easy as in many countries. You could just count the number of Nursing homes in a state and say, we need at least that many doctors who know what to do and how to do it.

    People should also plan ahead, after all, everyone dies. It should not be a surprise when mom or dad or whoever it may be is suddenly in very bad shape and needs the care that cannot be had at home. As you grow older you will experience more of these things all the time. You will also be surprised that there are many nursing homes that are not particularly good at handling the end of life patients in their care. We are really behind the curve on this issue in America. Our pets in general have it much better.

  7. I don’t know why these issues should cause so many problems. I’m in Oregon where the Death With Dignity Act was passed 20 years ago (I well remember the difficulty in overcoming the fierce opposition of the Catholic Church) and, as a new study shows, it has been working as intended. One in three people who request prescriptions never use them, yet, from several people I’ve talked to in that situation, the peace of mind that it brings immediately improves their quality of life. To me, this is one of the biggest benefits of the law. Shamefully, the study shows that about 3 percent of patients used the law because the cost of chemotherapy was too high.

  8. I’m in favor of it, but it is difficult to distinguish when it is justified.

    My mother is 93 and mentally as alert as ever but physically deteriorated to the point of constant suffering and difficulty in taking care of herself. She has to take prescription painkillers on a daily basis. But her ailments will not be fatal, and she could go on living for another decade – her sister lived to 106.

    She lives in Washington State, but certainly doesn’t qualify for assisted suicide. But from her point of view, the small pleasures she still gets out of life are increasingly being outweighed by pain and discomfort. At what point would her desire to end her life be morally justified? I don’t know the answer.

    1. This is exactly why I have always opposed the six month requirement that all these assisted dying laws have. A person could be in intolerable pain for a lifetime, yet not qualify for aid. To my mind the six month terminal illness requirement is simply a salve to the conscience of physicians and others who feel guilty. If they can say, “they were about to die anyway,” they can justify their actions.

      Many of the difficulties that are built into these laws are to overcome the opposition of the religious.

      1. I agree about the baleful influence of the religious on these laws.

        I suspect the ‘six-month life expectancy’ – which depends on a medical judgement – may well be interpreted leniently by sympathetic doctors. (Just as the ‘probable detrimental effects to the physical or mental health of the mother’ used to be in countries where such clauses were in the abortion laws).

        But the fact that such clauses can be circumvented in many cases is still no excuse for encumbering the laws with them.


      2. Totally agree with tomh and cr. I should be up to the individual to decide his/her fate. Arguably there is a stronger case to cut short suffering if otherwise it will go on for years.

    2. Now here’s one to think hard about! I’m thinking about it because I could very well get Alzheimer’s.

      Even if I go to a state where assisted suicide is allowed, I wouldn’t qualify if I had Alzheimer’s. I would no longer be in my right mind by the time I had only six more months to go.

      Alzheimer’s is an ugly way to go…

      There was a piece in the New York Times magazine. This is really good and well worth reading:


      I’m sorry Jerry is getting kicked around by people who just don’t get it about life and quality of life. The issue of hideously deformed and nonviable newborns is related to the issue of suffering old people who have had enough. And the Death with Dignity issue is big-time related to what Alzheimer’s people can and cannot do.

      Both grandparents on my father’s side died of Alzheimer’s. It could happen to me, too. I’m 75 now, and I’ve been having some memory issues. We don’t know if what I’m experiencing is normal aging, or if it’s the beginning of Alzheimer’s.

      And then on July 29th I had An Incident. I was out for a drive with my Sweetie and was on a road I hadn’t been on since the 1970’s. There’s been lots of building and development in these decades, and things weren’t familiar.

      And suddenly I didn’t remember where I live.

      No, I don’t mean nominal aphasia about a street name. I mean, I. Didn’t. Know. Where. I. Live. I fumbled around in my mind, around this weird empty spot that had suddenly appeared in my head, and came up with the address of the house I’d moved from back in 1984…but that’s not right, is it? Is that where I live? I know the address, but I’m not sure that’s where I’m supposed to be…

      For some two or maybe three minutes I was LOST. Oh, I could have found my way to the old house, but where do I live now?? I came to an intersection and a road that I know. Oh, okay, now I know, now I know where I live and can go home.

      I’m thinking a lot about this magazine article. I don’t know if this Incident is just a one-off happening, or if it’s the beginning of something. I do support Death With Dignity and Compassion and Choices, but this six month stuff may well not apply to me.

      Jerry and everybody, let’s keep talking about these things and not let ourselves be bamboozled into silence.

      1. I understand your fears. You have my sympathies, for whatever that’s worth. I also understand the terrible choice you might have to make, and it makes my heart heavy.

      2. Laurance, I understand your worry. Both my parents had dementia, and it is a concern for me as well. My late wife, when dying with cancer, made good use of The Peaceful Pill Handbook, and I can recommend it to you. Like Sandy Bem, she resorted to buying sodium pentobarbital from Mexico.

        I feel for you right now, and thank you for your comment. We need to keep talking about death.

    3. “At what point would her desire to end her life be morally justified? I don’t know the answer.”

      Her desire to end her life is surely justified the moment she decides, after due consideration**, that the pluses outweigh the minuses. Nobody else (and certainly nobody else’s ‘morals’) should have any standing in the matter. In fact I’d find it totally immoral to impose any outside constraints on her decision.

      ** She might well take into account the family’s feelings, but that’s up to her.

  9. Zitter notes (and I did not know) that the American Medical Association is opposed to such doctor assisted suicide.

    I think more or less all medical associations are. It is certainly the massive opposition from the associations here in Sweden that has made it more or less a taboo issue. The problem is claimed not be so much that they want to put their own potential suffering before the patient’s, though that cannot be ruled out in some, but the concern about regulation problems as described by Zitter. (Which, as far as I understand, is solved in Netherlands by using informed committees.)

    But there are doctors fighting for doctor assisted suicide. One of the questions on the table, if I remember correctly, is if not doctors themselves when put in that situation can get around the very problem other patients have.

  10. Physicians who often assist the dying by turning of [sic] respirators or removing feeding tubes need to think about whether those acts are substantively and morally different from prescribing medication for a patient to use for euthanasia.

    It’s the trolley problem in hospital-gown clothing.

    I’m of the opinion that anyone who wants to commit suicide ought to have a lawful, painless way to do so. There should be a series of checks and balances, of course, to ensure that that’s truly the person’s desire, that it’s not just a temporary whim. But if it’s their considered opinion to check out, that decision ought to be respected.

    (Damn, now I’ve got the movie version of the theme from M.A.S.H. rattling around my head.)

  11. Something I don’t understand (and if it’s set forth in the linked article, pardon me, I haven’t taken the time to read it) is, what is the “expense” that hospitals would incur if they provided euthanasia? Wouldn’t it just be administering a week’s worth of the medication the patient is taking daily, in many cases?

    There are many quick, painless, and cheap ways to die. I have a number of suicide plans on the back burner — my worry would only be that if I lost the necessary mental and physical faculties, I couldn’t perform any of them. So be sure to do it before it’s too late.

    If our legislatures and medical organizations are intransigent, the rest of us could at least be discussing suicide as a reasonable alternative for people to perform on their own.

    1. In Oregon the prescriptions – usually for 100 capsules of secobarbital that the patient must empty into water – aren’t cheap, ranging from $3,200 to $7,700 depending on the pharmacy. Another possibility involves a triple cocktail of much cheaper drugs and costs about $400 total, but it’s acidic and the patient stays in a coma for much longer.

      1. Not not all Oregon pharmacies participate. The cost of the prescription for this purpose is not covered by or reimbursed by medical plans and can’t be itemized as a medical expense on income tax insofar as I was advised.

        1. The cost of the prescription for this purpose is not covered by or reimbursed by medical plans and can’t be itemized as a medical expense on income tax

          Fee fi fo fum, I smell the gangrenous stench of religion inserting it’s bony fingers wherever it can to make people suffer.

    2. @Peter N

      It’s not just the drugs. And the drugs would not be more potent versions of the patient’s standard prescription.

      The medical protocol to authorise the death of a patient is complex – review of patients medical records by an expert in the area of assisted dying. This may raise other questions such as the patient’s ability to make decisions or perhaps there’s disagreement about whether the patient falls inside the 6-month criteria. All this is expense.

      Then there’s this from the article:

      “What about payment? Providers can bill for an office visit and the cost of the medication. But because there are no specific codes established for this procedure, reimbursement doesn’t come close to covering any effort to do this well. On top of that, many insurers won’t cover it, including federal programs like Medicare and the Veterans Health Administration.

      And will this new “right” be available to everyone? Most communities won’t have a Dr. Shavelson, who offers steep discounts to low-income patients. I worry that public hospital patients like mine will not be able to afford this degree of care. These are inequities we must address.”

      1. As I see it, these are the growing pains of a system in it’s infancy. Give them another 10 or 20 years and it should have been all worked out. Just like setting a fracture or cataract surgery. 10 or 20 years is about when I will likely need the service.

  12. So many Americans are afraid of either guilt or the sin of a decision that may land them an eternity of agony. And yet, the majority of Americans see fit to end anyone’s life so long as that person is already on ‘death row’.

    Vengeful barbarians? Maybe, but certainly hypocritical.

  13. Answers to the questions:

    1. No.
    2. Refer to a different doctor.
    3. Following in the footsteps of pioneer, Dr. Jack Kevorkian, no charge. Procedures should be in place.
    4. Palliative care and a cocktail/injection should both be options.

    Active euthanasia should be legal. The case of Thomas Youk was a huge setback. My view is that Dr. Kevorkian let his pride get in the way and decided to defend himself with no legal experience instead of letting the attorney he had been working with all along defend him. The family of Thomas Youk was not allowed to testify in front of the jury. That was possibly a make or break factor and in the end he lost.

    I think Vermont may have been missed.
    Thank you!

  14. ” It’s unconscionable that a doctor could not help these patients with an injection. After all, yes, an injection is a deliberate act, but so is giving a patient a prescription that they know will be used to kill them, and standing by to make sure it works properly. (And, by the way, so is turning off a respirator, which is legal if the patient or her family requests it.)”

    The trolley car dilemma. If they don’t pull the switch, the trolley kills the six pedestrians, but if they do pull the switch, they have killed the one lone pedestrian on the other track. If they pull the plug, the disease kills the patient, so why not believe that if you give an injection and the drug kills the patient, not the physician?

  15. “Second, Zitter notes (and I did not know) that the American Medical Association is opposed to such doctor assisted suicide.”


    To me, that just says that they’re afraid to tackle any issues and put their own convenience ahead of the patients’ best interests.


    1. I disagree. Doctors are often blamed for things for which responsible adult patients have given informed consent. They are fed up with patients requesting or declining procedures against medical advice and then suing the doctor for the natural consequences.
      In the “Skeptical OB” bl*g of Dr. Amy Tuteur, there are at least a dozen cases of brainwashed women who refuse C-section or another recommended intervention and then blame the doctors when the baby ends up dead or disabled.
      In the case of assisted suicide the patient of course cannot blame, but maybe his relations could.

  16. As I wrote in an earlier comment, I have some experience with this since I live in Oregon and my husband availed himself of Oregon’s Death with Dignity option in January of last year.

    None of the medical appointments associated with this process were unpaid by insurance. I don’t know if doctors were paid any less for helping my husband with this than they normally are paid.

    I was told that insurance would not pay for the drug (which cost over $3000) and that it couldn’t be itemized under pharmaceutical expenditures on income tax returns. I would have paid any amount for a drug that met my husband’s need, but agree that it’s gouging to charge so much for a drug that has been available for so long, seemingly, just because of the purpose for which it was used in this case.

    My husband’s primary physician was unable to assist him for personal ethical reasons but made certain he found a doctor who could help. The whole process went very smoothly. The primary physician maintained contact throughout and made a personal visit to my husband at home in Lebanon from the doctor’s home in Portland, 90 to 100 miles each way.

    The end can occur much more rapidly than anyone is prepared for. My husband was within a week to ten days of being too weak and too medicated with morphine for pain to be able to down the Seconal in water by himself. He chose the date and time and was able to accomplish his painless death as he desired. I will forever be grateful to this man for his caring above and beyond. I will remain his patient as long as he is a doctor and I yet live.

    Many doctors who treat aged geriatric patients
    who experience much pain are often asked for help to terminate their lives. Anyone who has extremely aged family members or friends in exceedingly poor health and pain are familiar with being told that the relative wishes they hadn’t lived so long. Sometimes, they ask family members to help them die. Unfortunately, Alzheimers, ALS patients and numerous others do not have the ability to express wishes of this sort after they become too ill and are in no position to self-medicate. I hope this will be thought about more fully and carefully.

    Sometimes, there are worse things than dying if it can be accomplished at the patient’s behest without pain. Sometimes, living in great pain is much worse, and those who must stand by unable to do anything suffer as well.

    1. Rowena, Thank you again for sharing such a difficult memory.

      I was told that insurance would not pay for the drug (which cost over $3000)

      That is appalling. I know from experience that 200ml of veterinarian sodium pentobarbital from Mexico costs $600, and I expect the supplier is making a good markup, knowing that desperate people have nowhere else to go.

    2. Thanks for sharing that, Rowena. I’m sure it must have been emotionally draining, but it’s reassuring that your husband was able to avoid unnecessary pain and suffering.

  17. Agree with most of the points in this article. It is instructive that looking back over 40 years in practice, the only complaint ever raised was by a relative distressed at how long her terminally husband (who was comatose, on an opiate infusion and not distressed) was taking to die – she made the comment that many years previously, another relative in a similar position was given an injection and it was all over in an hour. I had every sympathy with her point of view and it would have been infinitely more compassionate to have given a bolus dose of morphine or similar, than to go through the pantomime of increasing the doses in the continuous infusion pump, thus ensuring the same outcome but in slow motion.

    I have some reservations about euthanasia in depression – that is a whole can of worms and raises issues of a ‘sound’ mind. There is no doubt that existential angst is a form of suffering as extreme as any, and both emotional and physical pain can more than cloud your judgement. Although not in the same context, I remember as a young intern admitting an elderly man with a bowel obstruction who (initially) balked at signing the consent form as he announced in a sepulchral stage whisper “I don’t want an operation, I just want to die!” As it was, he eventually did agree to a laparotomy, his condition was benign, and three days later he was sitting up in bed, eating and drinking and reading the newspaper.

    Most of my practice has been in one form or other of cancer medicine, and terminal and palliative care has always been part of the treatment spectrum, but there are large gaps in access to expert palliative care services.

    However, the most challenging and distressing patients for me, earlier in my general medical training, were those with chronic neurological conditions especially motor neurone disease and its variants. Advanced directives are one way that those who know that they are likely to lose the ability to communicate clearly are one approach to addressing the issue, but there are still not good practices and procedures surrounding end of life care in those with end-stage non-malignant conditions.

    I was impressed by one of our old school physicians in Cambridge, UK who was admitted in extremis following a severe myocardial infarction, who had written across his chest in biro – “Not for resuscitation.” At least he was tackling the problem head on and making clear his wishes, but this does not provide a satisfactory model.

    It is important that professional medical bodies address this issue, as many are now committed to now doing. I know from sitting on committees how much more difficult it is to address this issue from within the profession than to comment from outside, but this makes it all the more important that those outside the profession make their voices heard.

  18. I believe that society should allow people to commit suicide whenever and however they want, regardless of whether they are sick or healthy- and doctors should be permitted to offer assistance in this endeavor contingent on the individual giving full informed consent.

    Choosing when and how to end one’s life is the ultimate expression of individual freedom (isn’t personal liberty a core American value?). There is no vice in paying someone to help you do it, properly and painlessly.

    1. @YF You do not mention regulation nor social consequences. You do not mention what U.S. laws exist at the moment that make suicide a criminal offence [none mostly everywhere].

      You want doctors to have the legal right to assist in any suicide as long as there’s some paperwork giving informed consent? Have you thought this through?

      You go to baloney “freedom” & “personal liberty” without any examination of the other pan on the set of scales you’re using. You write “…allow people to commit suicide whenever and however they want” – do you want to be that subway train driver?

      Forgetting about the doctor side of things… What about the chap who decides to off himself without assistance, as a ‘revenge suicides’? “I’ll show her! I’m gonna stand outside her house & blow my head off!” Should the passing patrol car police officers just ignore this developing drama? Check he has a permit for that firearm & then leave him to it? Cite him for littering? What?

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