Written Testimony of Dr. Omega Silva Retired Physician, Former President, American Medical Women’s Association Albany, New York April 23, 2018

My name is Dr. Omega Silva. I am an 81-year-old retired physician living in Washington, D.C. with three cancer diagnoses.

I have taught and practiced medicine in D.C. for 50 years. I was the first woman president of the Howard University Medical Alumni Association and I am a former 1 president of the American Medical Women’s Association, which supports medical aid in ​ ​ dying.

I came here to testify today to share some important information that I learned as a 2 3 vocal advocate for the D.C. Death with Dignity Act that took effect last year. It may ​ ​ ​ 4 help you decide if you want to support the New York’s Medical Aid in Dying Act and ​ how to ensure the law works if you pass it. Like the law in D.C., the New York bill would authorize doctors to write a prescription for medication for mentally capable, terminally ill adults who request it, so they can decide whether to take it to end unbearable suffering, by dying peacefully in their sleep, at home, surrounded by their loved ones.

You will hear the same false claims by opponents of medical aid in dying here in New 5 York that were made in Washington, D.C. Opponents make identical arguments to ​ ​ lawmakers across the country to inspire fear among them not to give their constituents this compassionate end-of-life care option. That said, I understand your hesitation as lawmakers. This is a matter of life and death quite literally, and you are right to be concerned about misuse of this law and the impact it might have in communities of color.

1 American Medical Women’s Association, Excerpted from: Position Paper on Aid in Dying. No date, available from https://www.amwa-doc.org/wp-content/uploads/2013/12/Aid_in_Dying1.pdf. ​ ​ 2 District of Columbia, Death with Dignity Act, Enacted February 2017, available from: ​ https://code.dccouncil.us/dc/council/laws/21-182.html 3 Compassion & Choices, District of Columbia Becomes 7th Jurisdiction to Authorize Medical Aid In Dying, Death with Dignity Act to Take Effect Tomorrow, February 18, 2017, available from: https://www.compassionandchoices.org/district-of-columbia-becomes-7th-jurisdiction-to-authorize-medical -aid-in-dying/ 4 The New York Medical Aid in Dying Act, A02383A/S03151A, available from: http://assembly.state.ny.us/leg/?default_fld&leg_video&bn=A02383&term=2017&Summary=Y&Memo=Y& Text=Y 5 Compassion & Choices, Sponsor of Bill to Repeal D.C. Medical Aid-in-Dying Law Fails Fact Check Test, Video Analysis Shows Physician Congressman Made False Claims about D.C. Law, July 27, 2017, available from: https://www.compassionandchoices.org/sponsor-of-bill-to-repeal-d-c-medical-aid-in-dying-law-fails-fact-ch eck-test/

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But let me tell you—as a woman of color, as a doctor, and former president of the American Medical Women’s Association—none of the concerns raised by opponents, 6 the same concerns that your Task Force on Life and the Law warned of in its 1994 ​ report on this issue, have come to pass. Keep in mind that the Task Force on Life and the Law report was 24 years ago, three years before the nation’s first medical 7 ​ aid-in-dying law took effect in Oregon in 1997. ​

The reality is the District of Columbia, Oregon and six other states have safely utilized this medical practice for a combined 40 years. In fact, according to a 2007 Journal of 8 ​ Medical Ethics report about the Oregon Death with Dignity Act:

“Rates of assisted dying in Oregon...showed no evidence of heightened risk for the elderly, women, the uninsured...people with low educational status, the poor, the physically disabled or chronically ill, minors, people with psychiatric illnesses including depression, or racial or ethnic minorities, compared with background populations.”

9 More recently, Disability Rights Oregon testified in 2016 that it: “has not received a ​ ​ complaint of exploitation or coercion of an individual with disabilities in the use of Oregon's Death with Dignity Act.”

There has never been a disciplinary action against any physician for practicing medical aid in dying.

The data from the public health authority in Oregon, in hand: they experience a sense of ​ ​ relief, a reduction of fear, and a peace of mind. Providing that kind of psychological relief is also doing the right thing for our patients.

In addition, Oregon’s medical aid-in-dying law has helped spur the state to lead the nation in hospice enrollment, according to the report published in the New England ​

6 The New York State Task Force on Life and the Law, When Death is Sought, Assisted Suicide and ​ Euthanasia in the Medical Context, May 1994, available from: ​ https://www.health.ny.gov/regulations/task_force/reports_publications/when_death_is_sought/taskforc.ht m 7 Oregon Death with Dignity Act. Oregon Revised Statute. Chapter 127. Enacted October 27, 1997, ​ available from http://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Page s/ors.aspx. ​ 8 M​ argaret P. Battin, Agnes van der Heide, Linda Ganzini, Gerrit van der Wal, Bregje D. ​ Onwuteaka-Philipsen, Legal physician-assisted dying in Oregon and the Netherlands: evidence concerning the impact on patients in “vulnerable” groups, Journal of Medical Ethics, Volume 33, Issue 10, 2007, available from http://jme.bmj.com/content/33/10/591 ​ 9 Letter from Disability Rights Oregon Relating to Abuse or Coercion, February 10, 2016, available from: https://drive.google.com/file/d/1vMdcyYv-V0LP_lQcuRNOc0jzjJUXHME5/view?usp=sharing

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10 Journal of Medicine. More than 40 percent of terminally ill patients in Oregon were ​ enrolled in home hospice in 2013, compared with less than 20 percent in the rest of the United States. Nearly two-thirds of Oregonians who died in 2013 did so at home, compared to less than 40% of people elsewhere in the nation. Research shows more 11 ​ ​ ​ than 85 percent of Americans say they want to die at home.

12 I believe a medical aid in dying is consistent with the Hippocratic Oath, an oath that I ​ ​ have taken. Though medicine has changed dramatically in the 2,500 or so years since Hippocrates, the concept remains valid today: Do what is right for the patient. I am not alone in this belief. A 2017 Medscape survey of physicians in states without a medical aid-in-dying law showed 58 of them said had “been in a situation where [they] wished the patient could have taken advantage of such a practice.”

When my best friend, who graduated from Albany Medical College, was dying of breast cancer, and had uterine cancer as well, she would have utilized this option had it been available in Virginia where she lived at the time.

As she was dying, she looked up at me and said: “This is taking too long.”

After seeing decades of evidence that these laws are safe, many leading medical and health groups have either endorsed medical aid in dying, including the New York State 13 14 ​ Academy of Family Physicians, American Academy of Neurology, American College 15 ​ 16 ​ ​ of Legal Medicine, American Medical Student Association, American Medical ​ ​ ​ ​

10Tolle, Susan W. M.D., and Teno, M.D., Joan M. Lessons from Oregon in Embracing Complexity in End-of-Life Care, New England Journal of Medicine 376:1078-1082, DOI: 10.1056/NEJMsb1612511 (2017), available from: http://www.nejm.org/doi/full/10.1056/NEJMsb1612511 ​ 11 Amber E. Barnato, MD, MPH, Brooke Herndon, Denise L. Anthony, Patricia M. Gallagher, Jonathan S. ​ Skinner, PhD,7Julie P. W. Bynum, MD, and Elliott S. Fisher, MD, MPHWII, Are Regional Variations in End-of-Life Care Intensity Explained by Patient Preferences? A Study of the US Medicare Population, available from: https://www.documentcloud.org/documents/3517028-Med-Care-Vol-45-Regional-Variations-in-EOL-Care. html 12 Jackie Rosenhek, Is the Oath outdated? Hippocrates’ legendary tract was first implemented in 1508. Are his guidelines still relevant today? Doctors Review, December 2009, available from: http://www.doctorsreview.com/history/is-the-oath-outdated/ 13 New York State Assembly of Family Physicians, 2016 Congress of Delegates, Actions. June 18-19, ​ 2016, available from ​ http://www.nysafp.org/getmedia/95417f97-5c38-4dc1-82c9-6d31dfeb114b/17-15-Medical-Aid-in-Dying.as px 14 American Academy of Neurology, Position Statement on Lawful Physician Hastened Death, Neurology 2018;90:420-422. doi:10.1212/WNL.0000000000005012, available from: http://n.neurology.org/content/neurology/90/9/420.full.pdf 15 American Academy of Legal Medicine, Excerpted from: Policy on Aid in Dying. October 6, 2008, available from http://c.ymcdn.com/sites/aclm.site-ym.com/resource/collection/Policy_On_Aid_In_Dying.pdf

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17 18 Women’s Association, American Nurses Association of California, American Public 19 ​ ​ ​ ​ 20 Health Association, GLMA: Healthcare Professionals Advancing LGBT Equality. In ​ ​ ​ addition, 10 state medical societies have dropped their opposition to medical aid in ​ ​ 21 dying and adopted neutral positions, nine of them in the last three years. ​

Opponents argue that people of color do not support medical aid in dying. But polling shows two-thirds of D.C. residents, the majority of whom are people of color, support 22 ​ this end-of-life care option. I support it as both a woman of color and physician who ​ has treated dying patients. Five of the six African-American D.C. council members voted 23 for the D.C. Death with Dignity Act when it passed by an 11-2 supermajority. Our 24 ​ ​ African-American Mayor Muriel Bowser signed the bill and our African-American representative in Congress, Eleanor Holmes Norton, has vigorously fought 25 ​ congressional attempts to veto the law. ​

16 American Medical Student Association, Excerpted from: Preambles, Purposes, Principles: Principles Regarding Physician Aid in Dying. 2008, available from http://www.amsa.org/wp-content/uploads/2015/03/PPP-2015.pdf 17 American Medical Women’s Association, Excerpted from: Position Paper on Aid in Dying. No date, available from https://www.amwa-doc.org/wp-content/uploads/2013/12/Aid_in_Dying1.pdf ​ ​ 18 American Nurses Association of California, Statement of Support, May 6, 2015, available from: https://www.compassionandchoices.org/wp-content/uploads/2016/10/ANA-support-SB-128-.pdf 19 American Public Health Association, Excerpted from: Patient’s Rights to Self-Determination at the End. Policy # 20086. October 28, 2008. Available from https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/29/ 13/28/patients-rights-to-self-determination-at-the-end-of-life 20 GLMA Letter of Support in AB X2-15, October 2, 2015, available upon request from Compassion & Choices. 21 Compassion & Choices, Mass. Medical Society Drops Opposition to Medical Aid in Dying, December 2017, available from: https://www.compassionandchoices.org/mass-medical-society-drops-opposition-to-medical-aid-in-dying/ 22 D.C. Council Holds First Hearing on Death with Dignity as New Poll Shows 67% Support in District. Death with Dignity. July 2015, available from https://www.deathwithdignity.org/news/2015/07/dc-hearing-poll/ 23 Compassion & Choices, D.C. Council Passes Death with Dignity Act on Second and Final Vote, D.C. Is 3rd Diversely Populated U.S. Jurisdiction in Last Year to Authorize Aid in Dying; November 15, 2016, ​ available from: https://www.compassionandchoices.org/d-c-council-passes-death-with-dignity-act-on-second-and-final-vo te/ 24 Fenit Nirappil, Fenit, Bowser quietly signs legislation allowing terminally ill patients to end their lives, Washington Post, December 20, 2016, available from: https://www.washingtonpost.com/local/dc-politics/bowser-quietly-signs-legislation-allowing-terminally-ill-pa tients-to-end-their-lives/2016/12/20/2b68dda6-c6ca-11e6-8bee-54e800ef2a63_story.html?noredirect=on& utm_term=.c36fcf8ad917 25 Norton Prepared to Defend D.C.’s Death with Dignity Law after Republican Announces New Attack, Apr ​ 17, 2018, Press Release, available from: ​ 4

I understand your desire to be careful. Maybe you think that this law needs more safeguards. But New York's Medical Aid in Dying Act is the best of the best. I commend the sponsor of the bill, Assemblymember Paulin, for her careful consideration of the evidence across the jurisdictions that have now adopted medical aid-in-dying laws. And I appreciate the recent amendments to the bill, which I think make it the strongest in the nation.

But a word of warning: too many safeguard amendments will make it difficult, if not impossible, for terminally ill patients with six months or less to access the law. The last thing you want to do is pass a meaningless law that cruelly promises dying people unobtainable relief from unbearable suffering.

Two examples come to mind.

26 The D.C. law took effect 14 months ago, but The Washington Post recently reported ​ that not one terminally ill adult has been able to access it even though district officials estimated about 10 people would do so during the first year. I testified that the problem is the law’s administrative rules, which are too burdensome and complicated for both doctors and patients.

In addition, Kaiser Permanente Southern California published a report in the March 27 Journal of the American Medical Association (JAMA) showing that about one-third of the terminally Ill Californians who requested medical aid in dying either died before completing the process or were too ill to complete it. It also worth noting that the Kaiser report also showed that about one-fifth of the people who requested medical aid in dying did not qualify to receive it, demonstrating these laws’ core safeguards work.

I have seen palliative care and hospice programs provide extraordinary care to patients. They work wonders for many dying people and their loved ones. But there are times even the best palliative care cannot alleviate pain and suffering. Patients may suffer from physical and emotional pain, from a loss of autonomy, and from an inability to engage in enjoyable activities. These issues are legitimate.

https://norton.house.gov/media-center/press-releases/norton-prepared-to-defend-dc-s-death-with-dignity-l aw-after-republican 26 Fenit Nirappil, A year after D.C. passed its controversial assisted suicide law, not a single patient has used it, Washington Post, April 10, 2018, available from: https://www.washingtonpost.com/local/dc-politics/a-year-after-dc-passed-its-assisted-suicide-law-only-two -doctors-have-signed-up/2018/04/10/823cf7e2-39ca-11e8-9c0a-85d477d9a226_story.html?noredirect=on &utm_term=.bc7e20097f5d 27 Nguyen HQ, Gelman EJ, Bush TA, Lee JS, Kanter MH. Characterizing Kaiser Permanente Southern ​ California’s Experience With the California End of Life Option Act in the First Year of Implementation. JAMA Intern Med.2018;178(3):417–421. doi:10.1001/jamainternmed.2017.7728, available from: ​ https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2665731?redirect=true

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Ironically, while less than one percent of terminally ill adults in authorized jurisdictions ​ 28 utilize medical aid in dying, it improves care for most terminally ill adults, including ​ 29 people who oppose medical aid in dying, by spurring them to talk with their physicians ​ about all end-of-life care options and better utilize them. No terminally ill person has to utilize this option and no healthcare professional, physician or pharmacist has to participate in it if they object to it for any reason. In short, if you pass this law, those who oppose it won’t have to participate, but those who do want this option will be free to ask for it.

I love my work . . . and my life. But if the time comes that my weekly Thursday chemo treatments are no longer working and my suffering becomes unbearable, I would want medical aid in dying as an option for myself, and for the sake of my loved ones.

For those individuals who have terminal illnesses and are experiencing physical pain and emotional suffering, we doctors should be able to give them relief from that suffering. If a mentally capable adult who is dying wishes to end their life, in a controlled and reassuring manner, with family and friends around them, medical aid in dying should be an option for them.

Medical aid in dying is one option among several that can be available to people facing a terminal prognosis of six months or less to live. It is a humane and compassionate option that gives people peace of mind whether they use it or not. I urge you give this option to your terminally ill constituents, so they don’t have to suffer needlessly at life’s end.

I will be glad to answer any questions you have for me.

Thank you.

28 Oregon Death With Dignity Act: 2017 Data Summary. Oregon Public Health Division, Feb. 9, 2018, available from: http://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATH WITHDIGNITYACT/Documents/year20.pdf 29 Soumya Karlamangla, California's physician-assisted death law has an unforeseen benefit, Los ​ Angeles Times, August 21, 2017, available from: http://www.latimes.com/health/la-me-end-of-life-care-20170821-htmlstory.html

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