rainy fall

http://picasaweb.google.com/ebrandt/20081101RainyFall

thinking about I-1000

I've filled out all of my ballot except for one bubble. That's I-1000, the assisted-suicide initiative. I'm deeply conflicted about I-1000, and looking for other people's thoughts on it.

I am definitely in favor of everyone's right to control their medical care, and to die without suffering. Everyone deserves effective palliative care, and effective control of pain and suffering, even if that control hastens their death. This is the medically and legally accepted standard, and if you aren't getting it, that's poor medical or insurance practice that ought to be fixed. If you kill yourself because you're not getting adequate care, I think it's a damned shame. (And I do have some concern that if the medical/insurance system has that "out", it will tend less to be fixed.)

Still, all of that only covers present suffering. People may want to end their lives for other reasons, like future suffering, or wanting to control how and where they die, or knowing they'll lose their mental competence to decide later. I am fundamentally agreed on your right to kill yourself (whether you're terminal or not, IMO) if that's your free and informed choice.

But I'm not convinced I-1000 does a good job on free and informed choice. Here are my concerns:

The economic conflict of interest:
Your insurance company makes more money if you die before receiving expensive treatment. Now, it's not obvious to me how they'd have a ton of pull in this system -- the worst I can see immediately is to make lethal drugs and consultations covered 100% and no copay. Which is despicable, but not going to kill a lot of people all else being equal. But it still worries me to have this incentive present.

Whether the patient appreciates their other choices:
The doctor prescribing the lethal drugs is required by I-1000 to inform the patient of alternatives, which I presume includes palliative care, etc. But are they any good at this? First, the patient may be distraught, overwhelmed by their prognosis, may have seen a parent die suffering in a hospital before the hospice existed in this country. Negotiating this is a serious job of counseling, and the prescribing doctor need have no training or skills in that. Second, the *doctor* doesn't necessarily appreciate the other choices. If they don't do end-of-life care themselves, and if they haven't been reading up on palliative care, how can they communicate the options concretely and persuasively, beyond flimsy handwaving? Any doctor either should have the counseling skills and the palliative-care knowledge, or should know they don't, but... there are imperfect doctors.

(Oregon has a similar requirement of informed choice. Hendin and Foley's excerpt of a transcript of one physician's conversation is disturbing. (Yes, they selected it to be, but still.) See below the cut.)

By the way, one possible concern that doesn't seem to have played out in Oregon is that assisted suicide hasn't cut into delivery of palliative care. There just aren't enough exercises of assisted suicide to show up in the numbers, for one thing. Also, most exercises are by people who *are* in hospice care. (Which I would like to understand better -- is there anything lacking in their care, or is this an argument that hospice care in itself just doesn't offer people control they want over their own death?)

Whether the patient is in a limiting mental state:
The prescribing doctor has to certify that the patient is competent, and a consulting doctor confirms this. But again, are they any good at it? As far as I know they are not required to have any psychiatric skills whatsoever. They can be nephrologists. And they don't have to have known the patient previously. And are they trying to make this decision based just on an office visit? And to separate "depression" from "has been given six months to live"? To me it seems very difficult, under these conditions, to pick up when a patient may intellectually know all about their options but not be in a position to make balanced emotional valuations of them.

(I was hoping that Werth and Wineberg would provide some refutation of this concern, but their attempt is pretty weak. See below.)

Tempering all of the above, in terms of outcome there's no point in building infinitely high barriers to uninformed or ill-judged assisted suicide. For the assisted-suicide system to turn someone down is no guarantee they won't do it themselves.

If I were writing the law, I think I'd say:

1. The prescribing doctor is a palliative-care specialist. (I think this mostly-ensures they know how to counsel about death and choices.)
   
2. Consultation with someone with a certain level of expertise in psychiatric evaluation.
   
3. If either of these says no, their reasons are made available to the next one the patient may go to.
   
4. And I'd think about balancing patient privacy with possible record-keeping to tell whether the system is failing; I'm not satisfied with Oregon's record-keeping despite Werth and Wineberg's defense.

But I didn't write I-1000. So here we have it, and is it good enough that I should vote for it? If you read this far, thoughts on all this?

Also a couple of concrete questions, if anyone knows:
Does WA Basic Health have good hospice coverage and palliative care coverage?
How about Medicare and Medicaid?

( references below the cut )

in lighter news. flat hexagonal crystals of guanine!

http://en.wikipedia.org/wiki/Tapetum_lucidum
A classification of anatomical variants of tapeta lucida[2] defines 4 types:

* Retinal tapetum, as seen in teleosts, crocodiles, marsupials and fruit bats. The tapetum lucidum is within the retina; in the other 3 types the tapetum is within the choroid behind the retina.
* Choroidal guanine tapetum, as seen in elasmobranchii (skates, rays, and sharks). The tapetum is a palisade of cells containing stacks of flat hexagonal crystals of guanine.[3]
* Choroidal tapetum cellulosum, as seen in carnivores, rodents and cetacea. The tapetum consists of layers of cells containing organized, highly refractive crystals. These crystals are diverse in shape and makeup.
* Choroidal tapetum fibrosum, as seen in cows, sheep, goats and horses. The tapetum is an array of extracellular fibers.