I Watched My Friend Choose Death. Physician-Assisted Suicide Needs More Guardrails.

“Have yourself a good life.”

That was my friend’s message informing me of his plan to end his life through physician-assisted suicide. His pancreatic cancer had progressed and was no longer responding to treatments. Weeks before, he shared he might soon enter hospice. He reflected upon his proudest lifetime accomplishment as my surgery scheduler: creating a new policy for clinic patients to expedite care.

The tumor soon caused a bowel obstruction requiring hospitalization. His surgeon said nothing more could be done. He planned to end his life before he could no longer be independent.

When I saw him in the hospital, he was upset to learn the costs for the morphine cocktail and physician to deliver the medications reached nearly $2,200. The social workers told him MediCal would only cover a hospice nurse, and he did not have the income to cover these extra expenses. He did not want his family or friends to be financially burdened.

Unfortunately, within days after discharge, he was readmitted with another obstruction. From his hospital bed, he resolved to end his life after returning home. Three of us were present at the end — he was grateful not to be alone as it takes great courage to drink the cocktail. What do you say to someone in the last 30 minutes of life? We talk about firsts in life (first job, first love) but not lasts. The conversation was as carefree as any other. I thanked him for his friendship and excellent patient care, and wished him well on his journey.

He sat in his favorite chair listening to his favorite song as the time arrived. Within 4 minutes of consuming the cocktail, he lapsed into unconsciousness. I held his hand 15 minutes longer until I could no longer feel a pulse. His complexion darkened, and then came the ominous death rattle that we dread to hear in the hospital. He passed an hour later.

All in all, it was a 12-day emotional roller-coaster — of being resolute, of fear of the unknown, of sadness, of concern for those left behind. In his final week, he reassured me that he was at peace with his decision, and spoke with a chaplain before death. Ultimately, his primary hope was there was something better in the afterlife compared to continued existence on this planet.

Sixteen days later, I chaired an American Medical Association (AMA) Committee regarding a request to rename physician-assisted suicide as “medical aid in dying.” There was also a discussion of whether physicians and patients who participate in physician-assisted suicide should be shielded from criminal or civil penalties. The testimony was passionate and touched on broad aspects of physician-assisted suicide. Some opposed physician-assisted suicide for ethical and religious reasons, or viewed it as violating the Hippocratic Oath; someone even invoked Jack Kevorkian. They noted that assisting in a suicide is illegal in every state (with physician-assisted suicide being the exception in some states). Others praised the intent to alleviate suffering and restore patient autonomy.

As I listened to the debate, I wondered: how many had ever actually witnessed the final moments?

Soon after the final vote to reject the name change and to maintain a stance against physician-assisted suicide, the AMA’s opposition was cited in a Wall Street Journal editorial against a New York bill to legalize physician-assisted suicide. The nation was watching and listening.

Thirteen states and Washington D.C. have legalized physician-assisted suicide, with Oregon enacting the first law in 1997; specific eligibility requirements vary by state. Data from 1998-2020 data show that 5,329 Americans have died using this method. By September, nearly a third of Americans will live in states with legal physician-assisted suicide. Another 16 states are considering legislation.

My friend gave me permission to share his story to make the system better. As I reflect on his experience, I would urge the strengthening of policy guardrails before expanding physician-assisted suicide to more states and more patients. First, we need to reduce the financial burden to spare others the exasperation my friend endured; a financial barrier to accessing this final treatment seems unfair.

Second, it is difficult for family and friends to witness a death by suicide, which is not a normal or natural death. Perhaps they should not be present, or be better prepared for the events to come. As a surgeon, I have seen death firsthand, but usually in intubated patients, not those you are chatting with minutes before. Some soldiers have had a similar experience, speaking to a comrade moments before they are killed in battle. This can be uniquely devastating.

Third, some patients never actually take the cocktail after it’s delivered to them. Ensuring safe storage and disposal of unused medications is essential.

Fundamentally, the question remains whether physicians should be involved at all. Perhaps one option is to end physician involvement after certifying that a patient qualifies, and delegate the remaining steps to others like a pharmacist or the coroner.

Physicians should instead focus on supporting terminal patients and finding new cures to push the limits of medical knowledge. A leading reason for physician-assisted suicide requests is Lou Gehrig’s disease. But imagine if Stephen Hawking had pursued this option: instead of going on to accomplish all he did, he may have ended his life at 21. In 2028, we will celebrate the 100-year anniversary of the discovery of penicillin, which cured many bacterial infections often considered fatal. Someday medical breakthroughs may cure cancers just as readily, and some will look back and wonder why we focused on ending lives instead of bringing new treatments into reality sooner.