Correspondence
Regulating Physician-Assisted Death
N Engl J Med 1994; 331:1656-1658December 15, 1994
- Article
To the Editor:
The Sounding Board article “Regulating Physician-Assisted Death” by Miller et al. (July 14 issue)1 nicely reveals, though unwittingly, what a charade such regulation would quickly become. First, the article fails to acknowledge the most difficult, indeed insuperable, regulatory problem: How would it be possible to monitor agreements and conversations between doctors and patients, given the privacy of the doctor-patient relationship? Are we to station a police officer at every bedside and in every doctor's office? The plan advanced in the article is, in effect, nothing other than a self-regulatory scheme, requiring that physicians voluntarily subject themselves to oversight; only at that point does the scheme kick into operation. Moreover, if the practice of physician-assisted suicide is already widespread but currently carried out with legal impunity, why should we expect doctors who now freely break the law to pay attention to new regulations any more than they do to the present one? If they now feel they can violate a long-standing moral prohibition in medicine to assist a suicide, why should we expect a sudden new respect for medical morality in the future?
Second, the notion of “independent and impartial oversight” of an issue as morally and emotionally volatile as this one would be merely amusing if the authors were not serious. Or maybe their plan shows that they really do have a sly sense of humor. Presumably, no physician or lay person opposed to physician-assisted suicide would be allowed to serve as a palliative-care consultant or be a member of the palliative-care committee. By definition, such people would lack the requisite impartiality, as would the many hospice workers who believe that pain and suffering can be relieved in all but the rarest cases and who claim never to have seen such cases anyway. In short, only those who passed an initial ideological test could be certified as independent and impartial. How convenient that would be.
Third, the authors combine a liberal conception of who would be eligible for assistance with a view that the “situation and values” of prospective candidates should be determinative. It is thus hard to see how any reasonably determined patient could fail to get what he or she wanted. Indeed, it would take an uncommonly dense patient not to be able to figure out how to play the game with such a system.
The authors of this article have created a regulatory Potemkin village -- all facade, with nothing behind it.
1 ReferencesDaniel Callahan, Ph.D.
Hastings Center, Briarcliff Manor, NY 105101
Miller FG ,Quill TE ,Brody H ,Fletcher JC ,Gostin LO ,Meier DE . Regulating physician-assisted death. N Engl J Med 1994;331:119-123
Full Text | Web of Science | Medline
To the Editor:
Miller et al. state that public-opinion polls show that the majority of Americans favor legalizing physician-assisted suicide. Yet the voters of Washington State were asked their opinion and clearly stated their opposition to this practice by defeating Initiative 119 in 1991. Because this decision was contrary to the authors' view, they assume that the feeble-minded populace of Washington could not grasp the complexity of the proposed public policy and that the outcome must have been influenced by moneyed interest groups. The authors express much greater confidence in the thoughtfulness and character of our elected legislators and the future “certified palliative-care consultants.”
Where do the authors find support among physicians for assisted suicide? The Washington State Medical Association, representing 75 percent of the physicians in our state, opposed Initiative 119. A telling finding in the study by Cohen et al. (July 14 issue)1 was that physicians who “had the most exposure to terminally ill patients [were] the strongest opponents of euthanasia and assisted suicide.”
Miller et al. mention the need for evaluative research to assess the “personal and cultural meaning” of physician-assisted death. We would do well to remember such culturally accepted and meaningful practices as the sacrifice of virgins to the gods by the Aztecs, the exposure of unwanted female infants in ancient Rome, and the mass extermination of eugenically “impure” peoples in Nazi Germany. What is the basis for the authors' ethical stance? Is it contemporary sentiment? Is it the arbitrary determinations of an elite few? We assert that there are higher laws and principles that prevail throughout time.
1 ReferencesKenneth A. Feucht, M.D., Ph.D.
Douglas R. King, M.D.
Robert C. Wright, M.D.
302 14 Ave., S.E., Puyallup, WA 983721
Cohen JS ,Fihn SD ,Boyko EJ ,Jonsen AR ,Wood RW . Attitudes toward assisted suicide and euthanasia among physicians in Washington State. N Engl J Med 1994;331:89-94
Full Text | Web of Science | Medline
To the Editor:
The article by Miller et al. mentions the need to promote comfort care, but neither the authors nor the public and professional debate now raging takes seriously the need to ensure good supportive and palliative care before there is consideration of removing the legal barriers that prevent physicians from causing death. Hospice providers have shown that the physical suffering of dying persons can always be relieved, although sometimes the patients require continuous sedation. The suffering that does occur results mostly from choices the community makes about which services to fund and which skills to disseminate widely, not from immutable biologic facts.
Deficiencies in the provision of comfort care profoundly affect the review procedures that Miller et al. would establish for physician-assisted deaths. Consider the role of a physician counseling a person near death whose family is being bankrupted, whose symptoms persist because needed medications cannot be made available for at-home care, and whose home is too cold and vermin-infested for the person to die there comfortably. The physician cannot fix these problems, and they certainly can be harsh enough to make a deliberately hastened death appear “rational.” However, endorsing the suicide of many persons who are suffering precisely because our community does not provide the care they need should be a terrifying prospect. Making available a way for such patients to die may well also attenuate the demand to right the fundamental social wrong of giving inadequate care at the end of life.
Are we entering this debate at the right point? Surely not. We should not even consider how to regulate physician-caused deaths until our society effectively does what can readily be done to ensure the relief of suffering while people are dying.
Joanne Lynn, M.D.
Dartmouth-Hitchcock Medical Center, Hanover, NH 03755-3863To the Editor:
We would like to stress the importance of psychiatric consultation for any candidate for physician-assisted death. Depression, a potentially reversible cause of a patient's wish to accelerate dying, is notoriously difficult to recognize in advanced cancer and is frequently overlooked or improperly managed.1,2 Determining decision-making capacity in the late stages of a terminal illness often requires a sophisticated assessment of mental status, psychodynamic issues, and psychiatric diagnoses.3
In addition, neither physicians nor the public has deliberated adequately about the profound ramifications of offering physician-assisted death to persons with incurable, debilitating illnesses who are not terminally ill. A new consensus may be developing on hastening death for people who will inevitably die in 6 or 12 months. But should young people who are intractably depressed or suffering from extensive, treatment-resistant psoriasis be helped to kill themselves? Do we want to offer euthanasia to people with the earliest manifestations of terminal illness, such as an incurable but indolent cancer, or the onset of Parkinson's disease or AIDS? Let us first get some experience in dealing responsibly and openly with assisted suicide and voluntary euthanasia for patients who are quite near death.
3 ReferencesJ. Andrew Billings, M.D.
Susan D. Block, M.D.
Harvard Medical School, Boston, MA 021151
Depression Guideline Panel. Depression in primary care: detection and diagnosis. Vol. 1. Clinical practice guideline no. 5. Rockville, Md.: Department of Health and Human Services, 1993. (AHCPR publication no. 93-0550.)
2
Depression Guideline Panel. Depression in primary care: treatment of major depression. Vol. 2. Clinical practice guideline no. 5. Rockville, Md.: Department of Health and Human Services, 1993. (AHCPR publication no. 93-055l.)
3
Block SD ,Billings JA . Patient requests to hasten death: evaluation and management in terminal care. Arch Intern Med 1994;154:2039-2047
CrossRef | Web of Science | Medline
To the Editor:
In Great Britain and Ireland, palliative medicine already exists as a distinct specialty. It is represented by the Association for Palliative Medicine, whose 283 specialist staff physicians and more than 300 doctors in training or working part-time are firmly opposed to euthanasia.1 Palliative-medicine physicians work alongside the acute care specialists in medicine, surgery, and oncology to control symptoms and provide psychosocial support for patients with advancing disease and those approaching death. Methods of symptom control, medical ethics in decision making, ability to communicate, and skill in handling psychosocial issues are actively taught. In some areas up to 80 percent of dying patients have some form of palliative care given by a specialist, often in the form of advice to the clinical team, who continue to be the principal professional care givers. Requests for euthanasia come out of despair and hopelessness, often through ignorance. In our experience, patients who first wish to die can go on to enjoy lives of good quality after effective intervention by a specialist; they no longer want their deaths hastened.
The House of Lords Select Committee on Medical Ethics decided unanimously in 1993 to oppose any change in the law in the United Kingdom so as to permit euthanasia.2 They were “concerned that vulnerable people -- the elderly, lonely, sick or distressed -- would feel pressure, whether real or imagined, to request early death.”3 By permitting the previously unthinkable and allowing people to be killed,4 society states an unwillingness to fulfill its duty to care for them and implies that it considers those who depend on others for care a burden and of no intrinsic worth.
We respectfully suggest that there is an urgent need to establish the specialty of palliative medicine in the United States and to avoid the temptation to view physician-assisted death as an alternative to meticulous palliative care.
4 ReferencesIlora G. Finlay, M.D.
James Gilbert, M.D.
Fiona Randall, M.D.
Association for Palliative Medicine of Great Britain and Ireland, Southampton SO17 1DL, United Kingdom1
Submission from the Ethics Group of the Association for Palliative Medicine to the Select Committee of the House of Lords on Medical Ethics. Southampton, England: Association for Palliative Medicine, 1993:21.
2
Report of the Select Committee on Medical Ethics, House of Lords. HI Paper 21-I. London: Her Majesty's Stationery Office, 1994:26, 48.
3
Walton J House of Lords Official Report 1994;554:1345-13454
Cessation of treatment, non-resuscitation, aiding suicide and euthanasia. In: British Medical Association, Ethics, Science and Information Division. Medical ethics today: its practice and philosophy. London: BMJ Publishing, 1993:175-7.
Author/Editor Response
The authors reply:
To the Editor: Callahan erroneously concludes that our recommended policy for regulating physician-assisted death would be a charade. We expect that physicians who are now prepared to risk legal, professional sanctions by responding to their patients' requests for help in dying will welcome a legal option and comply with stipulated safeguards. Furthermore, we recommend serious penalties for physicians found to assist in patients' deaths without complying with regulatory procedures. We do not propose any ideological test for palliative-care consultants charged with oversight, but they must have open minds about the reasonableness of physician-assisted death in particular cases. Their independence and impartiality would derive from their lack of collegial affiliation with treating physicians and their responsibility for ensuring that physician-assisted death occurred only in the context of a thorough palliative-care assessment and the careful consideration of alternatives.
Feucht et al. question the ethical basis of our position. We focused our article on the design of public policy rather than on the ethical grounds for physician-assisted dying, which we have addressed in detail in other publications.1-3
We join Lynn in deploring the lack of adequate health care and social services for disadvantaged Americans. Improving access to palliative care should be a high priority, and we have much to learn about this from the United Kingdom, as Finlay et al. indicate. We disagree, however, with their statement that the time is not right to debate the regulation of physician-assisted death. Dying patients who suffer intolerably without obtaining satisfactory relief with palliative treatment currently face the unacceptable alternatives of enduring needless torment, attempting suicide by themselves, or secretly seeking the aid of physicians prepared to risk helping them end their lives. The status quo is unfair to these patients, their families, and their physicians. Furthermore, the recent referendum in Oregon legalizing physician-assisted suicide and pending judicial review elsewhere of laws prohibiting this practice make it timely to debate the optimal regulatory policy.
We agree with Billings and Block that psychiatric consultation is an important consideration in assessing requests for physician-assisted death. Although we do not favor limiting this option to patients who are imminently dying, we agree that it should not be made available in the early stages of terminal conditions, when patients can still maintain a decent quality of life with the help of competent medical care.
Palliative care works very well for most dying patients, but neither clinical experience nor research indicates that such care can adequately relieve the pain and suffering of all such patients.4 Physician-assisted death is justifiable only for the minority of competent, incurably ill patients who resolutely prefer death to an intolerable quality of life. The aim of our recommended policy is both to promote palliative care and to make available as a last resort the option of voluntary physician-assisted death, subject to appropriate safeguards.
4 ReferencesFranklin G. Miller, Ph.D.
University of Virginia School of Medicine, Charlottesville, VA 22908Timothy E. Quill, M.D.
Genesee Hospital, Rochester, NY 146071
Quill TE. Death and dignity: making choices and taking charge. New York: W.W. Norton, 1993.
2
Brody H . Assisted death -- a compassionate response to a medical failure. N Engl J Med 1992;327:1384-1388
Full Text | Web of Science | Medline3
Miller FG ,Fletcher JC . The case for legalized euthanasia. Perspect Biol Med 1993;36:159-176
Web of Science | Medline4
Kasting GA. The nonnecessity of euthanasia. In: Humber JM, Almeder RF, Kasting GA, eds. Physician-assisted death. Totowa, N.J.: Humana Press, 1994:24-45.
- Citing Articles (1)
Citing Articles
1
Roger S. Magnusson. (2004) "Underground Euthanasia" and the Harm Minimization Debate. The Journal of Law, Medicine & Ethics 32:3, 486-495
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