Dying: After the Court Ruling
By Ira Byock

Throughout my years of working as a hospice doctor, I have frequently argued against the legalization of physician-assisted suicide. And while I welcome the Supreme Court’s unanimous finding yesterday that there is no constitutional right to a lethal prescription, I feel little reason to rejoice. A crisis still surrounds the care of the dying in America. Earlier this month, a report from the Institute of Medicine detailed this crisis: Doctors neglect, even avoid, the patients they cannot cure. Doctors often ignore their dying patients’ preferences for care. Doctors often fail to address their dying patients’ physical suffering. Instead, continued, unnecessary medical treatment often contributes to the dying person’s pain.

Families of the dying routinely face financial devastation on top of their grief. And for elderly patients living alone or in institutions, poverty and isolation worsen the fear and suffering they naturally feel as they face the end of their lives. In the wake of the Supreme Court’s decision, the debate will shift to the states. But the legalization of physician-assisted suicide is a particularly dangerous proposition unless fundamental changes are made in the care of the dying. For many, the “choice” of physician-assisted suicide would become the only alternative to suffering. In these budget-weary, cynical times, legalization is an inhumane and illusory quick fix for the end-of-life crisis.

It is our cultural denial of death that lies beneath this emotionally charged debate. If you ask an American how he would like to die, he will typically tell you how he doesn’t want to die. People don’t want to die in pain. They don’t want to die alone. They don’t want to become a burden to their families. Our culture’s perspective on dying seems entirely defined by what we fear, utterly devoid of the color and texture of life.

Over the past 18 years, hospice patients have taught me that dying is, most simply, a part of living. When pain is adequately controlled, and people are assured that they are not too much of a burden on those they love, the time of dying can be a time of remarkable possibilities: the opportunity to strengthen bonds with family and friends; the chance for reminiscence; time for precious reconciliation. While the potential for suffering is palpable, the less-recognized potential for people to grow - within themselves and together - is perhaps even greater. As bleak as the possibilities for dying well in America may look, solutions are well within our reach. Both sides in the debate over physician-assisted suicide agree on 90% of the key points. We should begin building on this common ground. We could require that physicians are competent in pain management and adhere to high ethical standards in order to obtain or renew their medical licenses. We could insist that medical and nursing schools begin teaching state-of-the-art care for the dying and for their families. We could demand that accrediting agencies carefully assess the quality of end-of-life care provided in hospitals and nursing homes. Health insurance providers could be required to include hospice care as a standard benefit.

Today fewer than one in five Americans receive specialized palliative care as they die. Yet the best hospice programs have shown that in addition to being practical and cost-effective, end-of-life care can also help people feel dignified, worthy and loved. We should settle for no less, whether care is provided in the home, a hospital or a nursing home.

A political agenda uniting proponents and opponents of physician-assisted suicide would have overwhelming moral force. Above all, we must remedy the absence of competent, comprehensive care that leads too many patients to consider assisted suicide necessary.

Dr. Byock is author of “Dying Well” (Riverhead Books, 1997). He serves as president of the American Academy of Hospice and Palliative Medicine.