Re: Chuck Thomas' June 9 column, "California's legal limit on compassion":

Mr. Thomas wrote an interesting essay as a reaction to the recent defeat in the California Legislature of the "Compassionate Choices Act." He emphasized the compassionate angle, but failed to clarify the issues involved. I was particularly concerned about his use of "choices" as a link to a tired debate about abortion.

Unfortunately, confusion, rather than compassion, is what colors the tone of the discussion about euthanasia — the good death — or what is referred to here as assisted suicide. Clear-cut issues such as brain death are not as clear to most. It took a neurosurgeon, in a recent case in Fresno, to determine that a patient who was already declared brain-dead by two physicians was, in fact, not!

One of the problems is definitions.

Most people and many physicians do not draw a distinction between withholding life support, managing pain in dying patients and assisting in ending a life. And I maintain that until a clear understanding of these issues is accomplished, we will continue to have a debate about assisted suicide that will take us nowhere. Let us look at the facts:

Withholding life support

Today, the concept of withholding life support is well-accepted. There are no moral issues, except for withholding food and water.

A patient has an illness that makes his expected life unproductive, even painful and very likely dependent on others and hopeless, and he does not want that. Before ventilators and intensive-care intervention, such a patient died with dignity at home.

If this is what he wants, then this is what he should get. Advanced directives have helped very much, but have not solved the problem entirely.

Not having an advanced directive when admitted to a hospital remains a major issue. Whatever happens, a case like Terri Schiavo's should be avoided.

Managing pain

Managing pain and suffering during our dying days is a little less clear. There are some moral issues to be considered. Everyone agrees that pain and suffering should be treated with compassion. We, California physicians, are expected to take continuing medical education classes in pain management in order to maintain our medical license. This came after the celebrated case in San Francisco, where a family filed a civil suit (not malpractice) against a physician for failing to give enough narcotics to their dying father. They won their lawsuit. Such patients should be given enough pain medications, realizing that respiratory suppression and death may follow.

Giving more and more narcotics to patients who are on hospice is becoming more acceptable, but questionable. Often, increasing the dose of narcotics does not necessarily correspond exactly to the amount of pain a patient is experiencing; a regimen of gradually increasing doses is devised and it results in hastening the death of a hospice patient. Some people have problems with that. I do. I am in favor of controlling pain, but not in increasing the amount of pain medication for the sole purpose of suppressing respiratory effort. This issue and how to handle it should be left to the discretion of patients, their families and individual physicians.

Assisted suicide

Helping a patient end his life does raise many moral, ethical and religious issues.

Here we are dealing with a patient who suffers from a terrible illness with no known cure, an illness that robs such a patient of his independence and dignity. A perfect example is ALS, better known as Lou Gehrig's disease.

Do such patients have the right to make a decision not to go on living? I think they do; it is their life, after all. Their upbringing, philosophical inclinations, family, friends and clergy play a major role in their decision-making. We should respect that.

Should they expect help from their physicians and the medical profession? Yes, but only to the extent of making sure the diagnosis is accurate and that they are not depressed and that they, in fact, are competent to make such a life-and-death decision.

Should they expect their physicians' help with the actual suicide? No, physicians should refrain from the intentional act of ending a life. It is not our job; we will experience major ethical conflicts if we start doing that, not to say anything about our moral and religious convictions.

If and when our society agrees that patients have a right to end their own lives, and after having gone through all the proper medical investigative steps, there could be a mechanism devised for them to end their lives, a mechanism from which physicians are excluded entirely.

Society and freedom

In the final analysis, we must never forget that physicians wear two different hats: their individual hat first and their physician hat next. Our society should not impose on physicians a behavior that is not appropriate for them, much like it avoids imposing a behavior that is morally objectionable on any other individual.

The all-important debate about assisted suicide will be better-served if editorial writers such as Mr. Thomas were to clearly articulate the issues involved, without appealing to the emotions that we experience when we face pain and suffering. Calling legislation that attempts to regulate how people end their lives the "Compassionate Choices Act" does not make it compassionate. And, frankly, it has very little to do with choice.

— Moustapha Abou-Samra, M.D., lives in Ventura.