Correspondence
Assisted Death and Physician-Assisted Suicide
N Engl J Med 1993; 328:964-966April 1, 1993
- Article
To the Editor:
The companion articles by Quill et al. and Brody (Nov. 5 issue)1,2 were well thought out and presented compelling arguments for the validity of assisted suicide or active euthanasia on rare occasions. The concern I have focuses on the aging population. There always has been a feeling among the elderly that their usefulness on earth is over and it would probably be best for them to pass on. Legalizing the practices of assisted suicide and voluntary euthanasia could increase this feeling and the compulsion of many to request an end to their lives, not so much out of an overwhelming desire, but out of a sense of duty to their loved ones or to society itself. . . .
The elderly must be reminded of their value to society and to family. Assuring suffering patients with a terminal disease that they are an inspiration, even to their health care givers, may give them a purpose for continuing to live, thus enhancing a concept of the “good death” expressed by Dr. Brody.
2 ReferencesRichard A. Gingrich, M.D.
10000 S.E. Main, Portland, OR 972161
Quill TE ,Cassel CK ,Meier DE . Care of the hopelessly ill -- proposed clinical criteria for physician-assisted suicide. N Engl J Med 1992;327:1380-1384
Full Text | Web of Science | Medline2
Brody H . Assisted death -- a compassionate response to a medical failure. N Engl J Med 1992;327:1384-1388
Full Text | Web of Science | Medline
To the Editor:
This society has neither the knowledge nor the wisdom to decide whether to effectuate the recent proposals for physician-assisted suicide and euthanasia. How do we die? How many have severe pain? How many are incompetent before death? Can we predict death or incompetence? How often are families avoidably impoverished?
We simply do not know. With the exception of a study involving one county in Connecticut,1 the last consecutive series describing dying was done by Osler2 at the turn of the century. The National Hospice Study described patients dying of cancer in hospices3 and suggested that severe pain in that setting is unusual. . . .
I have participated in the care of some 2000 patients who have died, and nearly all died outside of hospitals and in systems of excellent care (largely the Washington Home and Hospice in Washington, D.C.). I am impressed by how well people can live while dying, but also by how adverse the incentives of the care system are.
No one has the essential empirical information to judge whether we should violate centuries of moral tradition. To create policy without basic epidemiologic information would be outrageous. The question is too important to resolve without data, relying solely on the empathy engendered by competing tragic cases.
3 ReferencesJoanne Lynn, M.D., M.A.
Dartmouth-Hitchcock Medical Center, Hanover, NH 037551
Brock DB, Holmes MB, Foley DJ, Holmes D. Methodologic issues in a survey of the last days of life. In: Wallace RB, Woolson RF, eds. The epidemiologic study of the elderly. New York: Oxford University Press, 1992:315-32.
2
Osler W. Science and immortality. Boston: Houghton Mifflin, 1904:19.
3
Mor V, Greer DS, Kastenbaum R. The hospice experiment. Baltimore: Johns Hopkins University Press, 1988.
To the Editor:
[The articles by Quill et al. and Brody] present a program for killing by physicians that is a chilling reminder of how the unique contribution of Hippocrates and the lessons of the 20th century have been forgotten.
What distinguished Hippocratic physicians from their forebears, and the Aesculapian tradition, was their renunciation of killing.1 Physicians cannot serve both Aesculapius and Hippocrates. The acceptance of killing in one circumstance will undoubtedly allow or require physicians to kill in an increasingly inclusive way. Societies have always found killing a solution to varied problems. This includes “civilized and liberal” societies, which at best may restrict the killing. . . .
The error lies in assuming that physicians have the talent and the personal qualities to meet the proposed safeguards and policies. Can we be so arrogant about our abilities that we would allow ourselves to govern the distribution of death?
1 ReferencesStephen S. Lefrak, M.D.
Washington University School of Medicine, St. Louis, MO 631101
Mead M . From black and white magic to modern medicine: proceedings of the Rudolf Virchow Medical Society 1965, 131. In: Derr PG. Hadamar, Hippocrates, and the future of medicine: reflections on euthanasia and the history of German medicine. Issues Law Med 1989;4:487-495
Medline
To the Editor:
As a forensic pathologist and medical examiner, I deal almost exclusively with sudden, violent death. Over the years, I have noticed that people who kill like to use euphemisms in referring to their actions. Thus, the Mafia “hits” or “whacks” someone, intelligence agencies “terminate with extreme prejudice,” the Communists “liquidated,” and the Nazis had their “final solution.” Anything to avoid using that simple four-letter word “kill.” Medicine has now developed its own euphemisms. Thus, we have “assisted death” and “voluntary, active euthanasia.”1 No matter what terms are used, you still end up killing someone. I see no reason for the introduction of new terms to disguise the fact that physicians are going to “kill” patients (there, I said the dreaded four-letter word).
1 ReferencesVincent J.M. Di Maio, M.D.
Bexar County Forensic Science Center, San Antonio, TX 782071
Brody H . Assisted death -- a compassionate response to a medical failure. N Engl J Med 1992;327:1384-1388
Full Text | Web of Science | Medline
To the Editor:
I am employed as a medical secretary. The medical profession is here to prevent and to treat illness. I do not think it should get into the business of suicide. Most people who want to commit suicide can and will do so without the aid of their physicians. I can't imagine scheduling patient suicides along with other diagnostic tests and procedures.
Debra White
Beth Israel Hospital, Boston, MA 02215To the Editor:
... Quill et al. give an inadequate response to physicians who are morally opposed to participating in physician-assisted suicide. Although they state that no physician should be forced to assist in these acts, they go on to say that “the personal physician should help the patient find another, more receptive primary physician.” This clearly does not show respect for the physician's moral values, since it enforces moral complicity.
Robert D. Orr, M.D.
Christian Medical and Dental Society, Richardson, TX 75083To the Editor:
The proposals by Quill et al. are based on a utopian view of pain management in a world where physicians learn about pain and its management during their medical school and postgraduate training. This is a world that does not yet exist and, despite concerted efforts from a number of quarters to create it, is still far in the future. Instead of dedicating themselves to recognizing how physicians should assist patients in dying, they should apply themselves to ensuring that, as Brody states in his accompanying paper, “all patients should be confident that physicians will aid them with the latest palliative care.” Only after this is achieved can proposals such as those espoused by Quill et al. be viewed as anything more than intellectual discussions with limited application to clinical practice.
Steven A. King, M.D.
Jefferson Medical College, Philadelphia, PA 19107To the Editor:
Quill et al. state that “6000 deaths per day in the United States are said to be in some way planned or indirectly assisted.” That figure cannot possibly be right. That would mean that every death falls into this category.
Max Bader, M.D., M.P.H.
2 S.W. Del Prado, Lake Oswego, OR 97035Author/Editor Response
The authors reply:
To the Editor: We fully agree with Dr. Gingrich that the elderly and the terminally ill must in no way be devalued in any consideration of physician-assisted suicide. Supporting each person and helping him or her find a unique path in life and death are our primary purposes. We also agree with Dr. King that we must redouble our efforts to educate physicians about modern palliative methods because they tend to be underused1 and are usually effective. It is only when comprehensive palliative care fails that physician-assisted suicide becomes a legitimate option.
Dr. Lynn argues that it is irresponsible to act without more empirical data, yet it is difficult to study terminal suffering despite comprehensive palliative care because medical professionals are reluctant to acknowledge its existence. Similarly, physicians are unlikely to disclose their current roles in assisting death because the legal standing of this practice is uncertain. Limited studies suggest that comprehensive palliative care becomes ineffective for 2 percent to about 50 percent of patients (our experience is in the lower range)2,3. Only recently have alternatives for these patients been openly considered. The practice of anesthetizing patients to unconsciousness so they can die of “natural causes” evades the issue of physician-assisted death4,5.
Should we use the term “kill” to describe these practices? The technical definition of kill is to “cause the death of.” Physician-assisted suicide qualifies, but so could the well-accepted practices of withholding or withdrawing life-sustaining therapies, as might the “double effect” of pain treatment. Medical ethicists and patient advocates have assiduously avoided using the term “kill” in the latter circumstances because of its other potential meanings -- “to destroy the essence of” or “to murder.” Such definitions clearly do not apply to compassionate physician-assisted suicide. We want language to enhance understanding and increase patient options, not to polarize and politicize the debate further.
Now more than ever, Hippocratic and Aesculapian physicians are quietly making life-and-death decisions with patients. Eighty percent of the deaths in the United States occur in health care institutions (6000 per day); 70 percent of these deaths in hospitals involve less than the most aggressive care. (We thank Dr. Bader for helping correct these numbers.) We know very little about the range of negotiations and practices involved in deciding on such limitations.
Finally, if legislation sanctioning physician-assisted suicide is passed, what is the responsibility of physicians who morally disagree with the patient's decision and the law? Physicians should not participate in processes that they find morally unacceptable, yet they also cannot abandon patients who request assistance with suicide. Their obligation is to continue to search for mutually acceptable alternatives. Though our primary obligation is to our patients, Dr. Orr rightly reminds us that the physician's moral integrity must also be respected in any legislation or public policy.
5 ReferencesTimothy E. Quill, M.D.
University of Rochester School of Medicine, Rochester, NY 14607Christine K. Cassel, M.D.
University of Chicago, Chicago, IL 60637Diane E. Meier, M.D.
Mount Sinai School of Medicine, New York, NY 100291
Solomon MZ ,O'Donnell L ,Jennings B , et al. Decisions near the end of life: professional views on life-sustaining treatments. Am J Public Health 1993;83:14-23
Web of Science | Medline2
Saunders C. Pain and impending death. In: Wall PD, Melzack R, eds. Textbook of pain. New York: Churchill Livingstone, 1984:477-8.
3
Ventafridda V ,Ripamonti C ,DeConno F ,Tamburini M ,Cassileth BR . Symptom prevalence and control during cancer patients' last days of life. J Palliat Care 1990;6:7-11
Medline4
Truog RD ,Berde CB ,Mitchell C ,Grier HE . Barbiturates in the care of the terminally ill. N Engl J Med 1992;327:1678-1682
Full Text | Web of Science | Medline5
Coyle N ,Adelhardt J ,Foley KM ,Portenoy RK . Character of terminal illness in the advanced cancer patient: pain and other symptoms during the last four weeks of life. J Pain Symptom Manage 1990;5:83-93
CrossRef | Medline
Author/Editor Response
Dr. Gingrich and Dr. Lynn raise excellent cautionary points, particularly regarding the care of the elderly. I am sympathetic to the contention that our society should never embark on a policy of physician-assisted death until we have invested much more to make life worth living for all older Americans1. However, I fear the empirical data that Dr. Lynn demands will come only from practical experience, with the legalization of assisted death in one or more states accompanied by mandatory reporting and thorough study. Demanding these data before legalization will ensure that legalization never occurs, and that the assisted deaths that continue to occur will all be carried out furtively, removed from careful study.
Dr. Lefrak warns of physicians' arrogance in presuming to assist death. I fail to see how assisting death is necessarily any more arrogant than refusing to grant a suffering patient's request when all else has failed. The question of arrogance or humility gets to the heart of the reason why I insisted on using the rather inflammatory term “medical failure” in my article. If assisting a patient's death means that I must automatically defend myself against a presumption that I failed to use my healing skills sufficiently, this seems a ready antidote to arrogance.
Dr. Di Maio is quite correct that in assisted suicide, the patient kills himself or herself, whereas in voluntary active euthanasia the physician kills the patient. “Assisted death” is not a euphemism, but a shorter locution for “either killing the patient or giving him or her the means to kill himself or herself.”
I share Ms. White's horror of any routine assistance with suicide, scheduled regularly along with stress electrocardiograms. But, although many patients undoubtedly kill themselves without consulting physicians for help, numerous other patients do seek medical advice, if for no other reason than to ensure that death will occur painlessly and with a minimum of “mess” for the survivors. I support this approach, since medical consultation might dissuade many patients from suicide by showing them better, compassionate alternatives. Even in the Netherlands, where abuses of the mercy-killing policy now seem to occur, only one ninth of the patients who request euthanasia actually end up receiving it2.
2 ReferencesHoward Brody, M.D., Ph.D.
Michigan State University, East Lansing, MI 488241
Caplan A. We must find ways to ease life for older people. Detroit Free Press. January 5, 1993:4D.
2
van der Maas PJ ,van Delden JJM ,Pijnenborg L ,Looman CWN . Euthanasia and other medical decisions concerning the end of life. Lancet 1991;338:669-674
CrossRef | Web of Science | Medline
