Rob Spencer, M.D. lives in Concord.

As a physician, I want to apologize to the citizens of New Hampshire with regard to end-of-life care. I do this in response to a Medical Aid in Dying (MAID) bill introduced in the legislature which allows healthcare providers in the state to prescribe lethal substances to patients with terminal illnesses.

In the past, like most physicians specializing in hospice and palliative medicine, I have opposed such bills because we believe we can do better. Working as a team of physicians, nurses, social workers, chaplains, and volunteers, we can address physical, emotional, and spiritual/existential suffering at the end of life at least to the extent that people would not choose to intentionally end their own lives.

So, why the apology now? Because, as a medical community and as a society, we have failed to accomplish the goal of making such optimal end-of-life care freely available to everyone in need. Recently, due to COVID and other factors, our system of medical care has become increasingly fragmented and, in some cases, inaccessible. Having the tools to make MAID unnecessary does us no good if we don’t fully use them. Hence, my apology.

With regard to the recently introduced MAID legislation (House Bill 1283), I have mixed feelings. The bill includes some important improvements over previously introduced legislation. For example, it allows prescribers of MAID to be held accountable if they don’t do it well. (Some prior bills have prohibited civil action or criminal prosecution for any negligence.) The current bill claims to define a “standard of care” which may provide legal cover for prescribers. However, this is medically inappropriate because there have not been good studies to determine whether any particular drug (or combination of drugs) self-administered by mouth will uniformly work as intended to bring about a “peaceful” death.

The current bill includes language requiring patients who request a prescription to acknowledge that, “most deaths occur within 3 hours, my death may take longer” (following ingestion of a drug). However, in fact, even when given anti-nausea medication, any drug administered by mouth can cause vomiting, potentially before enough drug has been absorbed to cause death. A more appropriate warning would be that, “No orally administered drugs are guaranteed to work as intended.”

Other concerns remain: What happens if the patient vomits, becomes unconscious, does not die, and the prescriber is not present and can’t even be reached? (I know of one such case.) What if a terminally ill woman’s teenage daughter finds and takes the drugs herself because she can’t imagine living without her mother? What if a patient obtains the drugs voluntarily (when cognitively intact and able to self-administer) but then comes under undue influence or coercion only after becoming more frail as the illness progresses? What if a patient has regrets after swallowing the drugs and wants more time with loved ones?

Currently, there is no good way to collect data regarding adverse outcomes of the MAID procedure as long as no registry or mechanism for review is included in the law. Surveys of providers who are eligible to prescribe may have inadequate response rates as prescribers may be reluctant to self-report failures. And no studies to date have evaluated the potential psychological impact on loved ones, prescribers, or others involved in the procedure.

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One way to address many of these issues is to require that the prescriber (or an appropriate surrogate) be given and maintain possession of any drugs until shortly before their intended use. The prescriber (or an appropriate surrogate) would then be in attendance to confirm that 1) the ability to self-administer is still present and 2) no undue influence is being applied. This would enable the prescriber to intervene if adverse events occur and also to report them to a mandatory data registry that could facilitate proper study of the practice.

In conclusion, I believe that HB 1283, as introduced, may help some individuals. But it has real potential for inadvertently harming others. I still think we can do better than MAID. However, to the extent that we have not actually done so, for all who are in need, I sincerely apologize.