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Last Rights

Californians have just won a right that we all hope we will never need to use: The right to physician-assisted dying.

Governor Jerry Brown signed California’s End of Life Option Act last week after what was clearly deep consideration; he concluded that “I do not know what I would do if I were dying in prolonged and excruciating pain. I am certain that it would be a comfort to be able to consider the options afforded by this bill. And I wouldn’t deny that right to others.”   Wise and compassionate words, and Brown was also careful to also point out that he is a lifelong Catholic. That church has long opposed legalizing physician-assisted dying (PAD), but the California Council of Churches supported the bill. The other main opposition has come from certain disability rights advocates, but hardly all of them, and, most crucially, from organized medicine, in our state in the form of the California Medical Association. The CMA has defeated every attempt to legalize PAD in the past, for how could a "physician-assisted" process be legalized against the will of physicians themselves?

As it turns out, the opinion of physicians has evolved. Having conducted surveys of doctors' opinions and followed others, I saw that doctors appeared to support a legal option for PAD almost as much as the general public - by at least a plurality.  Thus the traditional "just say no" position of the AMA and CMA no longer represented the profession. It took years to convince the CMA of that, but when their membership and leadership was finally allowed to weigh in on the topic, it became clear that something had to change, and after a long process, it did. The CMA would not support a PAD bill but, if proposed legislation had all the "safeguards" against abuse contained in laws in other states where PAD has been legalized - and where problems have been minimal, contrary to scare stories from opponents - they would no longer oppose it and be neutral, thus letting proposed legislation move forward. This is what occurred with the bill Brown signed.

Physician-assisted dying is, in fact, a relatively rare occurrence even where legal; it is part of a spectrum of overdue efforts to improve care at the end of our lives. Contrary to some fears, such care has been demonstrated to improve where assisted dying has been legalized, and it can here as well. So, to borrow from a slogan in the abortion debate, the work now begins to make this right a “safe, legal and rare” one — but one available when truly a last resort.

For many of us who have followed this issue and have cared for dying patients, Brown’s compassionate action is welcome. For those strongly opposed to this option, of course, all will have the option not to request assisted dying. And the strict guidelines will make any such deaths among the most scrutinized of all, preventing coercion or other problems. In fact, most people with a terminal disease — the only ones who can request such a hastened death — will not follow through with that request. The irony observed by many who care for dying patients is that reassuring such patients that they will not be abandoned in this regard can actually lengthen their final days — for having some sense of control is a crucial issue, whether the right to die is utilized or not.

And it should be noted that this is not "suicide," as even the American Psychological Association has noted, but a hard decision made in the face of suffering and impending death. Suicide is a tragedy, most always brought about by depression, hardship, or other severe problems that have some possibility of being lessened or removed; PAD is, again, only for those undeniably already dying.

It is no accident that this right has been legalized due to a huge effort partly arising from San Francisco, and this new law is a tribute to thousands of AIDS, cancer, and other patients from the Bay Area who worked to make it become reality. What is crucial now is that the health care, legal and other professions continue to work on everybody’s behalf so that the best possible care is available to all; that each of us document our wishes in already available advance health care directives, living wills, and the newer Physician Orders for Life-Sustaining Treatment forms; that the “Palin Death Panel Amendment” to Obamacare be reversed so that more discussions about end-of-life-care planning will take place and be reimbursed; and that access to hospice care be expanded.  There is already organizing taking place to set up intensive monitoring of PAD in California, to ensure that problems are minimized.

With such progress, the need for actual PAD can be minimized, and people die "naturally" (if by natural one includes all the varied interventions of modern medicine). But alas, there will most likely always be a relatively few but tragic cases where suffering remains unrelieved, and this new right to die then becomes, in fact and practice, a part of what real healing can mean.

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