End-of-Life Choice, Palliative Care and Counseling

Montana

Montana Bill Would Obstruct Baxter Decision and Roll Back End-of-Life Choices

by Compassion & Choices staff
February 19, 2013

HELENA – Legislation that would make aid in dying a homicide will be heard in the
House Judiciary Committee on Wednesday, Feb. 20, at 8 a.m. House Bill 505 would
change the legal landscape established in a 2009 state Supreme Court decision, which
found that a physician could not be prosecuted for prescribing medication that a
terminally ill person could take to bring about a peaceful death. HB505, sponsored by
Rep. Krayton Kerns (R-Laurel), seeks to “clarify the offense of aiding or soliciting
suicide” and would deny Montanans’ the right to choose aid in dying.

Before the Supreme Court’s ruling in Baxter v. Montana it was unclear whether
physicians could face prosecution for helping terminally ill patients who wished to end
their suffering. On December 31, 2009, the Baxter decision made Montana the third U.S.
state in which aid in dying is a safe and legal medical choice. The ruling strengthened
the 1991 Rights of the Terminally Ill Act, which allows mentally competent adults to
make a declaration – Montana’s term for a living will. In 2009 the Court ruled that the
Rights of the Terminally Ill Act specifically deferred to a patient’s own decisions and
affords patients the right to control their own bodies at the end of life. HB505 would
take that right away and weaken the Rights of the Terminally Ill Act.

“The fact that Senate Bill 220 was tabled and House Bill 505 exists is really
disappointing,” said Dustin Hankinson, a disability rights activist. “This bill is part of a
continuing effort to deny rights established in 1991 by the Rights of the Terminally Ill
Act and reaffirmed by Baxter three years ago.”

HB505 goes beyond just prohibiting aid in dying by putting a physician at risk of
prosecution for answering a patient’s questions about any of a variety of deathhastening
options, such as directing deactivation of a cardiac device, directing
withdrawal of a ventilator or feeding tube, or provision of palliative sedation; and a
spouse, child or friend could be prosecuted for driving the patient to the doctor’s office
for the discussion.

“The complex issues surrounding how we die represent the most critical and sacred
moments of our individual lives,” said Dr. Stephen Speckart, a Missoula cancer
specialist. “For a very small number of patients experiencing intolerable end-of-life
suffering and who have received maximal palliative support and who meet specific
criteria, physician aid in dying should be an option as an appropriate and compassionate
end-of-life decision.”

Assisted suicide: New Mexico court asked to redefine the term

By Diane Carman
DenverPost.com
August 19, 2012

The question before the court in New Mexico is absurdly simple and yet impossibly complex. What is the meaning of “assisting suicide”?

If a terminally ill patient refuses a ventilator or a feeding tube and the physician yields to that decision, is that assisting suicide? If the patient is in excruciating pain and requests total sedation and no nutrition or fluids, can the doctor be held accountable for his death? What if the patient seeks a prescription from her physician so that when the pain of dying is overwhelming she can seek the ultimate relief on her own?

Two oncologists from the University of New Mexico Health Science Center and a patient with advanced cancer are the plaintiffs in a lawsuit filed in New Mexico District Court designed to clarify the legal definition of assisting suicide. That decision, likely to come in the next year, could send reverberations through the medical establishment in the Rocky Mountain West and across the country.

Morris vs. New Mexico contends that the statute outlawing “assisting suicide” never was intended to apply to physicians treating patients in the late stages of terminal illnesses. The plaintiffs believe that “patients who are dying and finding themselves trapped in an unbearable dying process should be able to choose aid in the dying process,” said Kathryn Tucker, director of legal affairs for Compassion & Choices, a nonprofit organization that works to expand choices in end-of-life care. She is one of the attorneys representing the plaintiffs in the case.

Compassion & Choices advocates for physicians to be allowed to prescribe medication to mentally competent terminal patients who can administer the drugs to themselves “to bring about a peaceful death,” Tucker said.

The organization contends that it’s fundamentally different than the commonly held idea of suicide, which presumes that without the suicidal acts, the person would be able to live. Opponents say it is exactly the same, an affront to human dignity, false compassion and highly susceptible to abuse.

If anyone had asked 48-year-old Aja Riggs a year ago for her opinion on assisting suicide, chances are she would have supported it. “I would have said, ‘Sure, I think people have the right to choose at the end of their lives if they’d like a physician’s aid in dying.’ ” She’d never had a particularly keen interest in the issue, though.

That changed 11 months ago.

Now, the self-employed professional organizer from Santa Fe said, “It’s really important to me.”

Riggs was diagnosed with uterine cancer last August. Surgery in October revealed that her condition was at stage 3c, far more advanced than doctors had expected.

After she recovered from the surgery, she underwent chemotherapy, during which another tumor developed. Then she had radiation treatments and now is receiving chemotherapy again.

“When I was diagnosed, I decided I wanted the most aggressive treatment that’s going to be effective. I thought, if I can get another 20 years in this life or so, wouldn’t that be great,” she said.

But Riggs is realistic.

“If my disease progresses, more difficult individualized decisions will be coming up,” she said. “If this disease does look like it will end my life, I can’t say for sure how I will make those decisions. … I can’t tell you for sure that I would get that prescription, fill it and use it. But I absolutely want to have that choice.”

Morris vs. New Mexico is modeled on Baxter vs. Montana, which was decided by the Montana Supreme Court in 2009. In a 5-to-2 ruling, the Montana court said that physician aid in dying was protected under the law providing for living wills.The court said that the state’s Rights of the Terminally Ill Act “very clearly provides that terminally ill patients are entitled to autonomous, end-of-life decisions, even if enforcement of those decisions involves direct acts by a physician.”Laws on assisted suicide are the purview of the states. In a case challenging Oregon’s assisted suicide law, the U.S. Supreme Court ruled in 2006 that the federal government does not have the power to overrule state statutes in this area.

Colorado’s assisted suicide law states that it is considered manslaughter if a “person intentionally causes or aids another person to commit suicide.”

While the specific statutes across the country are not identical, states generally protect the rights of terminally ill patients to give advance directives and make decisions on their care at the end of life. Tucker, who was among the lead attorneys litigating Baxter vs. Montana, maintains that the long-standing statutes outlawing assisting suicide were never intended to apply to physicians providing end-of-life care for terminally ill patients.

These statutes were “enacted at a time when medicine didn’t prolong the dying process as it does today,” said Tucker. “It’s pretty clear that that was not on the minds of legislators who introduced or voted on these measures.”

Instead, the laws were aimed at people who might provide a distraught teenager with the means to end his life after a bad breakup, or the friend who helps someone make a noose after he lost his job, she said. “There is an appropriate role for these statutes, but I don’t think they have anything to do with aid in dying.”

Professor Robert Schwartz of the University of New Mexico School of Law said that the argument in the New Mexico case is that “the court should defer to physicians in defining what constitutes appropriate care.”No one is going to argue that a physician couldn’t, for example, prescribe palliative sedation. No one is arguing that a patient couldn’t decide not to take nutrition and hydration, at least under New Mexico law. That’s entirely the patient’s decision,” he said. “This is one of the arrows in the doctor’s quiver, one way to provide adequate care at the end of life.”The Colorado Medical Treatment Decision Act, signed by Gov. Bill Ritter in 2010, explicitly provides for persons to refuse medical treatment, nutrition and hydration, and to execute advance directives outlining the circumstances under which they want such measures to be taken on their behalf.

Tucker and Schwartz said that momentum for physician-assisted suicide is strong across the West. Legislation that legalized it in Oregon and Washington, along with the Montana court decision, have generated growing support for the practice, and both advocates and opponents are watching the New Mexico case closely.

The most outspoken opponents to physician-assisted suicide have been leaders in the disability rights community. Diane Coleman, president and CEO of the nationwide disability rights organization Not Dead Yet, said there already are sufficient means for terminally ill patients to end their lives without providing immunity from prosecution for physicians who prescribe lethal drugs.

“The risks to many outweigh the alleged benefit to the few,” she said. Those risks include people succumbing to coercion from heirs or other family members, or to pressure from health insurers who deny services needed to cope with limitations caused by their conditions.

Rather than assisting people in ending their lives, Coleman suggests that physicians should help patients access the support they need to live well.The public response to Aja Riggs’ stand on assisted suicide has been “overwhelmingly positive,” Riggs said. “People have said, ‘Thank you so much for speaking out on this.’”It’s important to remember, she said, that the only patients who would be allowed to obtain physician assistance in suicide would be those who are terminally ill and mentally competent.

“This is something the patient chooses and does for herself. It’s not the doctor doing it,” she said. “It’s not a choice between life and death. It’s a choice about what kind of death.”

Exit Strategy

By Scott McLemee
Inside Higher Ed
July 25, 2012

Of the many strange things in Gulliver’s Travels that make it hard to believe anyone ever considered it a children’s book, the most disturbing must be the Struldbruggs, living in the far eastern kingdom of Luggnagg, not covered by Google Maps at the present time.

Gulliver’s hosts among the Luggnaggian aristocracy tell him that a baby is born among them, every so often, with a red dot on the forehead — the sign that he or she is a Struldbrugg, meaning an immortal. Our narrator is suitably amazed. The Struldbruggs, he thinks, have won the cosmic lottery. Being “born exempt from that universal Calamity of human Nature,” they “have their Minds free and disengaged, without the Weight and Depression of Spirits caused by the continual Apprehension of Death.”

The traveler has no trouble imagining the life he might lead as an immortal, given the chance. First of all, Gulliver tells his audience at dinner, he would spend a couple of hundred years accumulating the largest fortune in the land. He’d also be sure to master all of the arts and sciences, presumably in his spare time. And then, with all of that out of the way, Gulliver could lead the life of a philanthropic sage, dispensing riches and wisdom to generation after generation. (A psychoanalytic writer somewhere uses the expression “fantasies of the empowered self,” which just about covers it.)
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The Evolving State of Physician-Assisted Suicide

By Jaime Joyce
The Atlantic
July 16, 2012

Should terminally ill patients have the right to kill themselves? Voters in Massachusetts will soon decide. Last Wednesday, the Secretary of the Commonwealth announced that on November 6, 2012, when Bay State voters go to the polls to pick the next President, they will also have their say on a ballot measure called the Death with Dignity Act. If passed, the law would make Massachusetts the third state to give adults diagnosed with six months or less to live the option to end their lives using a lethal dose of doctor-prescribed medication.

Last year, volunteers from across the state began a petition drive to collect the 68,911 signatures needed to introduce the act for consideration by the state legislature; by the time they were done, they’d gotten more than 86,000 voters to sign on to show their support. Lawmakers had until the beginning of May to address the issue, but they declined to do so. In response, volunteers fanned out for a second wave of signature gathering. An additional 21,000 people from the state’s 14 counties signed on to support the Act. That’s nearly double the number needed to bypass the statehouse and bring the issue directly to voters via ballot measure.

Oregon and Washington were the first states to enact Death with Dignity laws. (In Montana, the state’s Supreme Court ruled in 2009 that physician-assisted suicide was legal, but Montana has no guidelines in place to regulate and monitor the practice.) Since 1997, when Oregon’s Death with Dignity Act went into effect, more than 900 people have received prescriptions to their end their lives. Not all have used the drugs. The Oregon Public Heath Division reports that more than 600 individuals have taken the dose, while the remainder either decided against using the prescription, or succumbed to their diagnosed illness.

In Oregon and Washington, patients must first make two requests of their doctor for medication, fifteen days apart. The patient then has to make the request in writing. In order to prevent potential abuses, patients are required to sign consent forms in the presence of two witnesses to whom they are not related. Once approved, patients must self-administer the drugs. Typically, it’s a deadly dose of Seconal, a barbiturate often prescribed by doctors to treat insomnia or to calm patients before surgery. The contents of the capsules are stirred into a glass of water or a serving of applesauce, to dull the taste. Statistics compiled and released annually by the Oregon Department of Health show that in the majority of cases, people lose consciousness within five minutes of swallowing the drugs. It can take anywhere between one minute and four days to die, but for most people death comes in just 25 minutes.

Ninety-eight percent of people who have made use of the law in Oregon are white. Eighty-one percent had cancer. Fifty-two percent were men. The median age of those who died using the law was 71. Most patients were enrolled in hospice and privately insured. They cited loss of autonomy, loss of dignity and the fact that they were “less able to engage in activities making life enjoyable” as the top three end-of-life concerns. In Washington State, where a Death with Dignity Act was approved by ballot initiative in 2008, and went into effect the following year, patients fit a similar profile. According to the latest figures released by the state, 135 people have died from the lethal prescription. The Death with Dignity Act that will go before Massachusetts’s voters this fall is modeled after laws in place in Oregon and Washington.

A survey conducted in May by Western New England Polling Institute showed that 60 percent of Massachusetts’s voters supported the rights of terminally ill patients to legally obtain and ingest life-ending drugs. Still, the measure faces tough challenges from powerful factions within and beyond the state. The Massachusetts Medical Society opposes the Act. The American Medical Association does too. “Physician-assisted suicide is fundamentally incompatible with the physician’s role as a healer,” the AMA states in its Code of Medical Ethics. “Patients should not be abandoned once it is determined that cure is impossible.”

Disability-rights activists have also spoken out against physician-assisted suicide. So has the Catholic Church. Noting a resurgence of interest in the topic and a renewed push by advocates of physician-assisted suicide to extend the practice beyond Oregon and Washington, the United States Conference of Catholic Bishops last year issued an impassioned statement against the practice. In Massachusetts, the Roman Catholic Archdiocese of Boston, anticipating the ballot measure, created a website, suicideisalwaysatragedy.org. “Our society will be judged by how we treat those who are ill and infirm,” Archbishop of Boston, Cardinal Sean O’Malley, says in a video address that appears on the site. “They need our care and protection, not lethal drugs.”

But it’s the people of Massachusetts who will ultimately decide the law’s fate, not religious leaders, lawmakers or medical professionals. Dr. Marcia Angell, former editor of Massachusetts Medical Society’s New England Journal of Medicine, and one of the Act’s lead sponsors, puts little stock in what physicians have to say about the matter.

“I am less concerned with what doctors want than with what patients want,” Angell said in an interview that aired on WGBH, in Boston. She continued, “I think doctors sometimes have a too-narrow idea of what their own obligations are. They feel they have an obligation to extend life even when it can’t be extended significantly. And even if you have that situation, then it seems to me they have two obligations. One is to support the autonomy, the self-determination of their patients. And the other is to relieve suffering. If you can’t extend life significantly, then you must relieve suffering.”

A study released by the Health Research and Education Trust shows that Americans are living longer lives than ever before. As a result, more individuals and families will face difficult questions about end-of-life care. In 2011, the oldest Baby Boomers turned 65. By 2030, the number of Boomers between 66 and 84 years old will climb to 61 million, and six out of 10 will be managing chronic health conditions. For the elderly and others facing terminal illness, doctors have numerous ways to prolong life. Palliative and hospice care are available to help patients find peace and comfort in their final days. But there are some people who want another option, which is the right to end suffering by taking their own life at a time and place of their choosing.

Doctors, patient challenge New Mexico assisted suicide ban

By Diane Carman
HealthPolicySolutions.com
July 11, 2012

The question before the court in New Mexico is absurdly simple and yet impossibly complex. What is the meaning of “assisting suicide”?

If a terminally-ill patient refuses a ventilator or a feeding tube and the physician yields to that decision, is that assisting suicide? If the patient is in excruciating pain and requests total sedation and no nutrition or fluids, can the doctor be held accountable for his death? What if the patient seeks a prescription from her physician so that when the pain of dying is overwhelming she can seek the ultimate relief on her own?

Two oncologists from the University of New Mexico Health Science Center and a patient with advanced cancer are the plaintiffs in a lawsuit filed in New Mexico District Court designed to clarify the legal definition of assisting suicide. That decision, likely to come in the next year, could send reverberations through the medical establishment in the Rocky Mountain West and across the country.

Morris v. New Mexico contends that the statute outlawing “assisting suicide” (NM Statute 30-2-4) never was intended to apply to physicians treating patients in the late stages of terminal illnesses.

The plaintiffs believe that “patients who are dying and finding themselves trapped in an unbearable dying process should be able to choose aid in the dying process,” said Kathryn Tucker, director of legal affairs for Compassion & Choices, a nonprofit organization that works to expand choices in end-of-life care. She is one of the attorneys representing the plaintiffs in the case.

Compassion & Choices advocates for physicians to be allowed to prescribe medication to mentally competent terminal patients who can administer the drugs to themselves “to bring about a peaceful death,” Tucker said.

The organization contends that it’s fundamentally different than the commonly held idea of suicide, which presumes that without the suicidal acts, the person would be able to live. Opponents say it is exactly the same, an affront to human dignity, false compassion and highly susceptible to abuse.

Patient’s story

If anyone had asked 48-year-old Aja Riggs a year ago for her opinion on assisting suicide, chances are she would have said that she supported it. “I would have said, ‘Sure, I think people have the right to choose at the end of their lives if they’d like a physician’s aid in dying.’ ” She’d never had a particularly keen interest in the issue, though.

That changed 11 months ago.

Now, the self-employed professional organizer from Santa Fe said, “It’s really important to me. I feel strongly about it.”

Riggs was diagnosed with uterine cancer last August.  Surgery in October revealed that her condition was at stage 3c, far more advanced than doctors had expected.

After she recovered from the surgery, she underwent chemotherapy, during which another tumor developed. Then she had radiation treatments and now is receiving chemotherapy again.

“When I was diagnosed, I decided I wanted the most aggressive treatment that’s going to be effective. I thought, if I can get another 20 years in this life or so, wouldn’t that be great,” she said.

But Riggs is realistic.

“If my disease progresses, more difficult individualized decisions will be coming up,” she said. “If this disease does look like it will end my life, I can’t say for sure how I will make those decisions. . . . I can’t tell you for sure that I would get that prescription, fill it and use it.

“But I absolutely want to have that choice.”

Lawsuit based on Montana case

Morris v. New Mexico is modeled on Baxter v. Montana, which was decided by the Montana Supreme Court in 2009. In a 5-to-2 ruling, the Montana court said that physician aid in dying was protected under the law providing for living wills.

The court said that the state’s Rights of the Terminally Ill Act “very clearly provides that terminally ill patients are entitled to autonomous, end-of-life decisions, even if enforcement of those decisions involves direct acts by a physician.”

Laws on assisted suicide are the purview of the states. In a case challenging Oregon’s assisted suicide law the U.S. Supreme Court ruled in 2006 that the federal government does not have the power to overrule state statutes in this area.

Laura Schauer Ives, legal director for the ACLU of New Mexico and co-counsel on the New Mexico case, said the Montana ruling serves as a precedent for Morris v. New Mexico.

“We have an unclear assisted suicide statute,” she said. “A number of states have taken the further step to prohibit physician aid in dying in addition to the assisting suicide prohibition.” New Mexico hasn’t.

The litigation is designed to determine what – if any — end-of-life care procedures by physicians are prohibited.

While the specific statutes across the country are not identical, states generally protect the rights of terminally ill patients to give advance directives and make decisions on their care at the end of life. Tucker, who was among the lead attorneys litigating Baxter v. Montana, maintains that the longstanding statutes outlawing assisting suicide were never intended to apply to physicians providing end-of-life care for terminally ill patients.

Colorado’s assisting suicide law states that it is the crime of manslaughter if a “person intentionally causes or aids another person to commit suicide.”

These statutes were “enacted at a time when medicine didn’t prolong the dying process as it does today,” said Tucker. “It’s pretty clear that that was not on the minds of legislators who introduced or voted on these measures.”

Instead, the laws were aimed at people who might provide a distraught teenager with the means to end his life after a bad breakup, or the friend who helps someone make a noose after he lost his job, she said. “There is an appropriate role for these statutes, but I don’t think they have anything to do with aid in dying.”

Professor Robert Schwartz of the University of New Mexico School of Law said that the argument in the New Mexico case is that “the court should defer to physicians in defining what constitutes appropriate care.

“No one is going to argue that a physician couldn’t, for example, prescribe palliative sedation. No one is arguing that a patient couldn’t decide not to take nutrition and hydration, at least under New Mexico law. That’s entirely the patient’s decision,” he said. “This is one of the arrows in the doctor’s quiver, one way to provide adequate care at the end of life.”

The Colorado Medical Treatment Decision Act,  signed by Gov. Bill Ritter in 2010, explicitly provides for persons to refuse medical treatment, nutrition and hydration, and to execute advance directives outlining the circumstances under which they want such measures to be taken on their behalf.

The Montana court endorsed the argument that prescribing a lethal drug for patients at the end of life is appropriate medical care. In its ruling, it stated, “A physician who aids a terminally ill patient in dying is not directly involved in the final decision or the final act. He or she only provides a means by which a terminally ill patient himself can give effect to his life-ending decision, or not, as the case may be. . . . The patient’s subsequent private decision whether to take the medicine does not breach public peace or endanger others.”

A similar lawsuit filed in Connecticut was dismissed by the state Superior Court in 2010. In its ruling, the court said, “taking one’s life even for a sympathetic reason is suicide” and therefore physician immunity from prosecution does not apply.

Tucker and Schwartz said, however, that momentum for physician-assisted suicide is strong across the West. Legislation that legalized it in Oregon and Washington, along with the Montana court decision, have generated growing support for the practice, and both advocates and opponents are watching the New Mexico case closely.

The doctors’ dilemma

Twice in his 40-year career, patients have asked Dr. Aroop Mangalik to write them prescriptions for drugs to, as he put it, “take care of their misery.”

“I said, ‘No. I can’t,’ ” said the oncologist, clinical researcher and professor of medicine at the University of New Mexico Cancer Center, who is among the plaintiffs in the lawsuit. (Mangalik is quick to emphasize that he is speaking for himself – not as a representative of the university.)

The New Mexico statute defines assisting suicide as “deliberately aiding another in the taking of his own life.” It makes no mention of physicians, but anyone convicted under the statute is guilty of a fourth-degree felony.

Oncologists frequently are faced with the challenge of helping patients cope with difficult decisions about continuing treatment or accepting that it is no longer productive.

“My mentor in medical school in Salt Lake City was very clear about being open and very sympathetic with patients,” said Mangalik. “He would not continue treatment without an open discussion with the patient.”

Mangalik said he has always tried to be open and honest with patients, no matter how tough the news might be. “It’s not something that becomes easy,” he said. “But I know if I don’t do it, the patient will be in a worse state.”

He became convinced of the need for physicians to be able to help terminal patients in the dying process about 15 years ago. “I realized that there were more patients being hurt not just by cancer or by chemo but by unnecessary ongoing treatments. I started working on ways to cut down on futile treatments through educational methods, counseling and also trying to develop policies for doctors to stop treating when the treatments were tortuous and not going to change anything.”

Mangalik said that oncologists know which types of cancer in which stage are likely to respond to treatment – and which do not.

“I’m not going to tell a patient or a physician how to lead their lives, but an honest discussion should be a minimum requirement,” he said. “That’s the least I’m advocating for.”

But he also said when the disease is no longer responding to treatment, “if the patient wants to end his life in the face of a terminal illness, he should be allowed to have that option.”

Dr. Katherine Morris, the named plaintiff in the case, is among the relatively few doctors nationwide who have been able to prescribe lethal medications to terminal patients legally.

Morris, a surgical oncologist, cancer researcher and professor of medicine at the University of New Mexico Cancer Center, practiced medicine in Oregon until 2010. Oregon was the first state to legalize medical treatment to assist in suicide under the Oregon Death with Dignity Act in 1997.

In announcing her support for the lawsuit that bears her name, Morris spoke of her experience with the procedure.

“A couple of years ago, a patient of mine in Oregon asked me for aid in dying, and because she lived in a state where it was already affirmatively legal, I had no fear of supporting her request… I wrote her a prescription, she got medication and she held onto it for a long time. After many months of good times and hard times, she decided – she decided – not to endure any further suffering. I hope the court will rule that patients in New Mexico have the same autonomy over their end-of-life choices.”

Morris also appeared in a documentary, “How to Die in Oregon.”

The opposition

The United States Conference of Catholic Bishops calls the efforts of Compassion & Choices “a corruption of the healing art” and a “threat to human dignity.” In an official statement released in 2011, the bishops condemned physician assisted suicide in all cases.

But the most outspoken opponents to physician-assisted suicide have been leaders in the disability rights community.

Diane Coleman, president and CEO of the nationwide disability rights organization Not Dead Yet, said there already are sufficient means for terminally ill patients to end their lives without providing immunity from prosecution for physicians who prescribe lethal drugs.

“The risks to many outweigh the alleged benefit to the few,” she said. Those risks include people succumbing to coercion from heirs or other family members, or to pressure from health insurers who deny services needed to cope with limitations caused by their conditions.

For patients seeking physician-assisted suicide in Oregon, Coleman said one of the most frequently mentioned reasons is that they feel that they are a burden on their families, either because of the care they require or the financial burden of their treatment.

“Home care is the No. 1 issue in the disability community,” she said. “We understand what that’s about and why home care is so important.”

With competent, reliable assistants, people with severe disabilities can lead full, productive lives, said Coleman. Physicist Stephen Hawking, who has amyotrophic lateral sclerosis and has been called the “Nelson Mandela of the disabled community,” may be the most famous example.

Rather than assisting people in ending their lives, Coleman suggests that physicians should help patients access the support they need to live well.

“…The disability community has always been concerned that assisted suicide costs a lot less than ongoing health care,” Coleman wrote in a blog post last year.

“…People with disabilities have long been denied many forms of needed health care for cost reasons. … People who claim that cost would never be an issue are naïve, privileged, dishonest or some combination of those.”

For those whose pain becomes unbearable, she said palliative sedation “takes care of that issue.” Patients can execute advance directives that say in the case of extreme pain, doctors are instructed to sedate them and withhold food and water. “They will be unconscious and die in their sleep. There’s no need to cross the line and apply active measures to cause death.”

Part of an ethical continuum

Mangalik understands opponents’ concerns, but questions the ethics of giving terminally ill patients false hopes and treatments that have no chance of success.

“Optimism is good,” he said. “But I’m a very strong believer that everything has a limit, including optimism.”

Too often he sees doctors who encourage patients to submit to experimental treatments when there is no hope of extending life. “In many cases, this is unethical,” Mangalik said. “If the doctor is optimistic in his tone, the patient goes into it.”

Mangalik said patients should be fully aware of the potential risks and benefits before they are asked to accept experimental treatments.

It’s even more important, Mangalik said, to help terminally ill patients live what’s left of their lives fully.

“It’s a process,” he said. “The physician clearly states, ‘Let’s focus on you and not your cancer. Let’s focus on how best to achieve comfort for you.’

“Many a time, when a patient has been coming in for active treatment and we have this discussion and he decides to stop, he’ll come back in two weeks and say, ‘Life is so much easier now.’”

For Riggs, that kind of straightforward talk is critically important.

“I can’t say for sure how I will make these decisions,” she said. If treatment no longer is productive, she anticipates she will be “weighing the facts. I will look at them very clearly and have people around me to give me an honest picture of what’s going on. I’ll be sitting with that information, waiting for my heart to respond.”

The public response to her stand on this issue has been “overwhelmingly positive,” Riggs said. “People have said, ‘Thank you so much for speaking out on this.’”

It’s important to remember, she said, that the only patients who would be allowed to obtain physician assistance in suicide would be those who are terminally ill and mentally competent.

“This is something the patient chooses and does for herself. It’s not the doctor doing it,” she said.

“It’s not a choice between life and death. It’s a choice about what kind of death.”