On April 23, 2018, Dr. Sally White testified before the New York State Assembly Standing Committee on Health on proposed legislation that would legalize physician-assisted suicide. The following is a transcript of Dr. White’s testimony:
Chairman Gottfried and Honorable Members of the Assembly Health Committee, thank you for the invitation to present my testimony today. I am Dr. Sally White, a practicing physician who serves as Medical Director of a New York State Addiction Treatment Center. I am also a member of The American Medical Association and the Medical Society of the State of New York.
I come today to ask you to support more and better end of life care and to oppose Assembly bill A.2383.A.
This bill is dangerous and misguided.
No Protection from Abuse
The bill is dangerous not only because “safe suicide” is an oxymoron, or because doctors often make mistakes estimating life expectancy, but because the bill’s so-called “safeguards” are unenforceable. There is nothing to stop an abusive relative or caregiver from using the lethal medications on an unwilling or confused fragile patient. There’s nothing to ensure that the person taking the medicine knows what’s happening.
I’ve investigated many cases of elder abuse in my years as Medical Director of the Franklin County Department of Social Services and of the St. Lawrence Psychiatric Center Mobile Geriatric Unit. Too often, New York State agencies don’t prevent, protect, or prosecute, even when people suffer severe psychological and physical abuse.
New York State Protective Services workers don’t have the resources to address current cases. Removing people from abusive situations often takes months of intricate legal and logistical work. Administering lethal medication takes minutes.
If this bill is enacted, terminally ill patients prescribed lethal medicines would have no protection from abuse. Policing the use of deadly medicines by non-medical personnel in private homes simply isn’t possible, no matter how carefully crafted legal definitions and procedures may seem. This bill does not extend compassionate, sound medical care to dying patients. Instead, it protects caregivers from being prosecuted for euthanizing those who are elderly or terminally ill.
State Reports from Oregon demonstrate the lack of oversight created by legalizing assisted suicide. No one knows who was with half of the patients dying under Oregon’s so-called “Death with Dignity Act” when they ingested lethal medication. Did a sick, confused person take medicine by mistake? Was it crushed and put into apple sauce without the patient’s knowledge? Did someone hold the person’s shoulders and head until medicine was swallowed? No one knows.
Many Dying Patients Lack the Capacity to Make Medical Decisions—But Physicians Don’t Realize It
It’s possible everyone took the medicine willingly and knowingly. But I don’t think so, because there’s a second reality this bill can’t eliminate.
This bill can’t ensure patients have “capacity” to make this life or death decision. Capacity assessment is a complex skill set. It involves evaluating patient’s ability to make a specific decision about care according to legal competency standards. The more serious the decision, the more the patient needs to show he or she appreciates the benefits and consequences of alternatives. Few doctors have formal training in capacity assessment. This bill has no mandate for referral for capacity assessment and no mandated physician training in how to assess capacity.
More than two-thirds of patients show capacity impairment in the last week of life. If you’ve spent any time with dying people, you know this. So why would New York State send opioids and barbiturates home with patients we expect to lose decision-making ability?
And what about the patient with longer life expectancy? Chilling information comes from the first study of capacity in cancer patients expected to live less than six months. In the study, which was published in The American Journal of Geriatric Psychiatry in December 2017, researchers documented diminished capacity in the terminally ill compared to a control group. 85 percent of ill patients could express a choice, but less than half could describe their medical situation and treatment choices. Only 15 percent could answer questions about the consequences of treatment and alternatives.
Then the researchers looked at how often doctors’ capacity assessments agreed with a standardized test consistent with legal standards. The answer? Not often. Physicians regularly said patients’ capacity was intact, while the assessment tool identified numerous problems.
This means many terminally ill patients might verbally ask for lethal medication but wouldn’t meet the legal definition for competency. We can also assume that most New York State physicians need training in the intricacies of capacity assessment.
So not only is enforcement of the protective measures of this bill impossible, most people who would use it probably lack the capacity necessary to make an informed decision about taking lethal medication. This is a very flawed bill.
What Dying People Really Need
Humor me for a moment, and mentally throw out the text of the bill. Keep only its title. “Medical Aid in Dying.” Now consider what kind of help you want at the end of your life. Think of the two most important things you want as you get close to death.
I won’t ask for a show of hands, but I think I know what you want. You want to die without pain, and you don’t want to die alone.
We need more and better end of life care in New York. Let’s stop talking about physician-assisted suicide and work together to increase support at the end of life. The Medical Society of the State of New York has a few ideas for legislators. Last month, the organization unanimously passed a Quality End of Life Care resolution supporting increased funding for various services “which improve each person’s quality of life as it nears its natural end.” People wouldn’t feel so hopeless if they had access to mental health care, in-home care, hospice and palliative care, and family respite service.
Legislators, when it comes to end-of-life issues, if you can’t do better than Assembly Bill A. 2383.A, I ask you: please, do nothing at all.