Correspondence

The Oregon Death with Dignity Act

N Engl J Med 1995; 332:1174-1175April 27, 1995

Article

To the Editor:

Professor Annas's review of the Oregon Death with Dignity Act (Nov. 3 issue)1 again illustrates the potential for serious gaps between theoretical ethics, the law, and clinical reality. Professor Annas argues that there is no need to change existing laws prohibiting physician-assisted suicide because a physician is currently permitted to prescribe potentially lethal medications intended to relieve a patient's suffering as long as it is not the physician's explicit intention to contribute to the patient's death. When a patient requests a potentially lethal drug in order to “live better,” it appears to be morally and legally permissible for the physician to respond as long as the physician does not know too much. If the suffering patient made explicit his or her intention to take a lethal amount of a drug, then the physician would presumably cross the forbidden line of intention by providing that same prescription. Physicians must keep their intentions pure, always having a purpose other than helping suffering patients achieve a wished-for death.

Such laws and ethical distinctions reinforce pseudoconversations that are dangerous for patients and doctors, involving deception and unclear thinking at a time when honesty and openness are essential. Requests for physician-assisted death should be seen as cries for help,2,3 the meaning of which should be discovered through careful exploration. Many such requests, once fully understood, lead to interventions other than physician-assisted death. These requests may be signs of undertreated pain, unrecognized depression, fatigue on the part of a care giver, or a spiritual crisis. How tragic and dangerous to have such a request handled superficially with a prescription for barbiturates to help a patient “live better.” If we are to assist such patients, the process should be open and honest, ensuring fully informed consent, the competency of the patient, consideration of all alternatives, and the involvement of an independent consultant.4,5 For patients who meet agreed-upon criteria, the process must then include the provision of explicit information about and access to effective medication. How inhumane that such a patient should be left to die alone, in order to protect the intentions of the physician and family, or to end up half-dead from a failed effort that resulted from insufficient medication or ambiguous information.

Timothy E. Quill, M.D.
Genesee Hospital, Rochester, NY 14607-4055

5 References

1. 1

   Annas GJ. Death by prescription -- the Oregon Initiative. N Engl J Med 1994;331:1240-1243
   Full Text | Web of Science | Medline

2. 2

   Quill TE. Doctor, I want to die: will you help me? JAMA 1993;270:870-873
   CrossRef | Web of Science | Medline

3. 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

4. 4

   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 | Medline

5. 5

   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:

Despite appeals by Professor Annas and the American Medical Association to defeat the measure, Oregonians made a wake-up call to medicine by passing Ballot Measure 16, the Death with Dignity Act. It is not that society is unable to accept death, but that Oregon is no longer willing to accept prolonged suffering and loss of dignity and control in the process of dying.

Susan W. Tolle, M.D.
Oregon Health Sciences University, Portland, OR 97201-3098

Author/Editor Response

Professor Annas replies:

To the Editor: Dr. Tolle is correct in stating that I oppose the Oregon measure. I am opposed, however, not for the reasons Dr. Quill outlines but because on balance I believe, as I state in my article, that the measure “is likely to do more harm than good for terminally ill patients.” As for current law, my point is much more precise than Dr. Quill indicates. In my words, “No changes in current law are needed to legalize the prescription of lethal drugs that have a legitimate medical use to terminally ill patients.” Dr. Quill seems to support the Oregon measure, even though he has previously written, in an article he cites, “Dying patients need more than prescriptions for narcotics . . . from their physicians.”1 The “more” Dr. Quill seems to want is “open and honest” discussion. But the Oregon measure applies only to prescriptions. Physicians should be aware that there is no gag rule relating to suicide. Physicians can (and should) discuss openly and honestly with their patients all issues regarding suicidal thoughts, desires, and intentions. Discussing death is difficult for both patients and physicians, but it is a fantasy to think that making it lawful for physicians to prescribe lethal drugs with the intention that their patients use them to commit suicide is what is needed to permit honest conversations between doctors and patients.2,3

George J. Annas, J.D., M.P.H.
Boston University Schools of Medicine and Public Health, Boston, MA 02118

3 References

1. 1

   Quill TE. Doctor, I want to die: will you help me? JAMA 1993;270:870-873
   CrossRef | Web of Science | Medline

2. 2

   Katz J. The silent world of doctor and patient. New York: Free Press, 1984.
   

3. 3

   Annas GJ. Informed consent, cancer, and truth in prognosis. N Engl J Med 1994;330:223-225
   Full Text | Web of Science | Medline

Citing Articles (2)

Citing Articles

1. 1

   Carlos Camps Herrero, Joaquín Gavilá Gregori, Javier Garde Noguera, Cristina Caballero Díaz, Vega Iranzo González-Cruz, Asunción Juárez Marroquí, Ma José Safont Aguilera, Ana Blasco Cordellat, Alfonso Berrocal Jaime, Ma Godes Sanz de Bremond. (2005) La eutanasia en el paciente con cáncer y los cuidados continuos. Clinical and Translational Oncology 7:7, 278-284
   CrossRef

2. 2

   Fabrizio Starace. (1998) Medical decisions at the end of life: epidemiological and psychiatric aspects. Epidemiologia e Psichiatria Sociale 7:02, 135-146
   CrossRef