right to die

The Right to Die

~ iduncun ~ Leave a comment

I’ve been trying to figure this one out for some time. My first reaction to physician assisted suicide was negative. After all, I took an oath to do no harm and that’s been hard enough to uphold in my regular practice since every treatment course I’ve prescribed has had the potential to cause harm. Prescribing medication sure to cause death seemed downright unethical.

There’s also the fact the medical community has done everything in its power to keep people from killing themselves. If a person expressed suicidal ideas we stripped them of their basic rights and held them captive in a medical or psychiatric facility until a psychiatrist deemed they had no more desire to end their life, usually after significant medical and counseling therapy. The patient had no right to refuse treatment-they were held involuntarily. The only other way a patient could get released was by a court order. Thus, for all intents and purposes, suicide was illegal.

But aside from the ethical and legal aspects of physician assisted suicide there was something else I’ve struggled to understand. Why did we need physician assisted suicide if we could already provide excellent end-of-life hospice care? No matter what the illness we should be able to keep people comfortable and at their highest quality of life until their natural passing. And wasn’t that the best death we could hope for?

Reading about Brittany Maynard and Jennifer Glass, who was quoted in an NPR article as saying “No one should have the right to prolong my death”, I can now answer my own question. Dying comfortably in hospice is not the best death we can hope for. The best possible death is one we have complete control over. It’s one where we haven’t let our bodies fail to the point we have no ability to carry out basic daily functions such as feeding and toileting, or where our bodies have become so wasted or swollen they are painful for our loved ones to see. It’s one where we can have one last, great day and say, ‘Yep, that was perfect, this is enough, I’m ready now.’ It’s one where the looming inevitability no longer remains a mystery, but something you can plan precisely. Should everyone have the right to die their best death? I think they should.

But I’m still struggling with how. Physicians may be doing more harm to their patients by preventing them from dying their best death, thus my ethical issue is solved, but I’m not confident we understand enough about the dying process to be its best dispensers. As it is we aren’t doing a good enough job preparing people for end-of-life. In a profession so heavily focused on treat-treat-treat with pill after pill after pill will this be just another pharmaceutical plan? And how should we treat patients with chronic major depression recalcitrant to treatment who have been begging us to have their best death for years?

Another issue that bothers me is the permanence of physician assisted suicide. There is no other medical treatment I know that is quite so permanent. The one constant in life is change. We age, we sicken, we improve, all in a never-ending cycle until the unknowable end. But to be responsible for making it knowable and unchangeable-maybe this frightens me most of all. I don’t know if I’m ready for that responsibility.

As the legality of physician assisted suicide changes my hesitancy toward it will also change. I’ve already come to believe we should have the right to die our best death. And even if I’m not convinced doctors are prepared to take on this awesome responsibility right now, one day with the right training and experience we just might be.

Legalize It, Soon!

~ iduncun ~ Leave a comment

Oregon recently became the fourth state to legalize recreational marijuana. There is a momentum behind the legalization movement I hope will mirror the same-sex marriage movement with increasing numbers of states following suit soon. Eventually, just like with same-sex marriage, the federal government will be forced to change its position on marijuana from tolerating its recreational use in states where it is legal to decriminalizing it nation-wide. This is, in my opinion, excellent and long over-due. Especially since the way states have eased restrictions on marijuana use has been by making medical professionals the new drug dealers.

Let me be very clear-I am one hundred percent for the legalization of recreational pot. What has bothered me about its evolution is the involvement of the medical community. Four years ago, stranded in Santa Barbara waiting for my VW bus to be fixed, I was shocked by the number of people I met who had marijuana cards. Actually, I think everyone I met had one. Young bohemian artist/fruit sellers, college students, middle-aged mechanics, yoga instructors, professional coffee shop hanger-outers (you can tell the crowds I traveled in). Up until then I had thought marijuana derivatives, such as Marinol, were only indicated in disease processes where the appetite is significantly diminished or in glaucoma. As far as I knew none of these people suffered from any of these problems. How were they all getting access to medical marijuana?

The answer became clear the more time I spent in California. I began to notice the many advertisements for medical marijuana clinics with young, attractive physicians promising quick and easy service. Then in Venice Beach I approached a very tall, sunglassed Eastern European man holding a huge sign with a pot leaf. He led me down a narrow street off the boardwalk and into a dark, bare store front. Sitting behind a dingy desk was a young woman dressed in club gear. Not your typical professional medical office. She smiled and handed me a sheet to fill out as my Eastern European escort slipped back into the street. Except for the list of medical questions on the sheet the whole experience had the aura of a shady drug deal. I confessed to the club kid I was a doctor just curious about the process and she happily told me the steps to getting a marijuana card. First I fill out the medical form, being sure to focus on the questions about anxiety since this was the most common ailment for which medical marijuana was prescribed. Then I go upstairs and see the physician who’ll read my form and give me a marijuana card. Just like that. I asked if anyone was ever denied a card and she said she didn’t think so.

So basically everyone who came through that back alley store front with enough money to buy their marijuana card got one. Call me old fashioned but that sounds like drug dealing. And it just doesn’t sit well with me. Doctors are educated and licensed to help cure illness, or at least give comfort when they can’t, not provide access to recreational drugs to the masses for money. I have no problem with the real use of medical marijuana, and I have no problem with the recreational use of pot, I just have a problem when those uses are inextricably blurred. In the end, its unethical and fraudulent.

I understand the legalization of medical marijuana is a means to an ends. The medical marijuana dispensaries have allowed legal marijuana farms and distribution networks to be established in the United States laying the groundwork for when recreational pot is legal. But I don’t believe the ends justifies the means. We need to be very careful to maintain the boundaries of what the physician’s role in society is. Unfortunately there are unethical opportunists amongst us, and instead of doing no harm we may be exploiting a situation for our own gain to the detriment of our patients. Marijuana is for most people a recreational drug, not a medication. To rename it as such makes its use a necessity instead of a luxury. And as we find out through more studies, just like another recreational drug alcohol, it is not entirely benign.

Hopefully Oregon’s example will spur other states to quicker action and marijuana will be taken out of the medical purview and put back into the category to which it belongs-a recreational drug to be used at the user’s discretion with full knowledge of all the potential negative consequences. Then the procurement of pot will not depend on compromising the ethics of the medical profession.