Correspondence
Physician-Assisted Suicide
N Engl J Med 1997; 336:439-441February 6, 1997
- Article
To the Editor:
At no point in Dr. Orentlicher's article on the legalization of physician-assisted suicide (Aug. 29 issue)1 is there any mention of the Hippocratic oath, which states: “You will exercise your art solely for the cure of your patients, and will give no drug, perform no operation for a criminal purpose, even if solicited, far less suggest it.”
Dr. Jack Kevorkian was indeed on a slippery slope when he recently assisted in the suicide of a woman in her 40s with the chronic fatigue syndrome. It is just this sort of action that makes me oppose physician-assisted suicide.
Doctors may be given the legal right to assist in a suicide, but this does not mean they have a moral right to do so.
One part of Orentlicher's article is particularly distressing. He states, “If we view physicians fundamentally as relievers of discomfort or disease, . . . then assistance with suicide is not only compatible with the physician's role but quite possibly an obligation inherent in it.” Since Kevorkian was not convicted of assisting in suicides, I trust that I will not be convicted of declining to assist in suicides. Will the next law in Oregon require that all doctors assist in suicides? Some forces, once set in motion, cannot easily be reversed.
1 ReferencesWilliam B. Sembrot, M.D.
921 Plymouth Rd., Norristown, PA 194011
Orentlicher D . The legalization of physician-assisted suicide. N Engl J Med 1996;335:663-667
Full Text | Web of Science | Medline
To the Editor:
What will be the ethical and moral responsibility of a physician asked to provide assistance with suicide if he or she feels it is wrong? Will physicians ethically be required to suggest others who might provide such assistance? If they do not, and the patient allegedly suffers, will the physician be liable legally for wrongful life?
How will the managed-care physician, whose income depends on lowering the costs of medical care, react when a patient who is depressed and seriously ill, but maybe not terminally so, asks for help with suicide? Will the physician be able to resist the lure of the enhanced income that accompanies the hastened death of the patient?
The physician should not be in a position in which issues other than patient advocacy guide decision making, but in this era of managed care and physician-assisted suicide, many physicians will be.
John R. Corboy, M.D.
University of Colorado Health Sciences Center, Denver, CO 80262To the Editor:
Legalizing active assisted suicide would be more thinkable if physical and psychological prognoses by physicians were reliable and not subject to fatigue, frustration, family pressure, health-maintenance-organization finances, and, yes, even a fascination with death itself. Although Dr. Orentlicher may not see a moral difference between assisted suicide and the withdrawal of treatment, a practical difference — premature death in many patients — will remain as long as this policy is in the hands of fallible physicians.
Howard J. Swanson, M.D.
Marshfield Clinic, Marshfield, WI 54449-5777To the Editor:
What we are witnessing is a profession already well down the slippery slope, trying desperately to rationalize why we now support what we formerly opposed. Twenty years ago, proponents of a terminally ill patient's right to discontinue treatment argued that there was a fundamental distinction between withdrawing treatment and assisting in suicide and that permitting the first would not lead to the second. Now Dr. Orentlicher is arguing that the distinction is artificial: because we permit the first we must logically permit the second. Given this history, we should remain skeptical about the claim by advocates of assisted suicide that the practice will remain restricted to the terminally ill and mentally competent. There remains a very valid moral distinction between withdrawing treatment and assisting in suicide. A patient's decision to discontinue life-sustaining treatment in the face of an inevitably terminal illness constitutes a humble recognition of the limits of medicine, of forces beyond our control.1 By contrast, the option of assisted suicide — a final attempt to manipulate the time and circumstances of death — is the epitome of moral hubris.
1 ReferencesThomas J. Gates, M.D.
Lancaster General Hospital, Lancaster, PA 17604-35551
Capron AM . Euthanasia in the Netherlands: American observations. Hastings Cent Rep 1992;22:30-33
Web of Science | Medline
To the Editor:
Dr. Orentlicher did not mention that the laws regarding the withdrawal or refusal of treatment do not require the safeguards often suggested for physician-assisted suicide. The patient who refuses treatment does not have to be terminally ill; two doctors are not required to agree on the diagnosis or prognosis; no mental-health professional has to be involved in determining the person's competence or whether he or she is depressed; the family does not have to be notified or involved; and the death is reported as resulting from the underlying condition, not from “withdrawal of treatment.” Although these provisions have been included in various proposals to regulate physician-assisted suicide, still opponents argue a priori that they are inadequate and that there would be abuses.
Faye Girsh, Ed.D.
Hemlock Society USA, Denver, CO 80250-1810To the Editor:
Although Orentlicher claims that case-by-case decisions on physician-assisted suicide are “infeasible,” there is legal precedent to support case-by-case adjudication of important social issues. Family courts adjudicate custody issues, public guardian courts adjudicate financial competence, conservatorship courts in California and other states adjudicate commitments to institutions for mental illness on a case-by-case basis, and even personal bankruptcies are adjudicated case by case. It is quite feasible and most appropriate to handle the issues associated with physician-assisted suicide, and even euthanasia, in a court system set up for that purpose.
Arnold Sterne Leff, M.D.
103 Green St., Santa Cruz, CA 95060To the Editor:
It is important to acknowledge the latent link between legally sanctioned physician-assisted suicide and the care-control issues driven by capitulation to patient autonomy and the demands of the marketplace.1,2 However, killing oneself does not require a physician. To cede this point can only further divert medicine from its historically charted course toward scientific and altruistic care for the infirm.
2 ReferencesVincent J. Kopp, M.D.
University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-70101
Levinsky NG . The purpose of advance medical planning -- autonomy for patients or limitation of care? N Engl J Med 1996;335:741-743
Full Text | Web of Science | Medline2
Callahan D . Controlling the costs of health care for the elderly -- fair means and foul. N Engl J Med 1996;335:744-746
Full Text | Web of Science | Medline
To the Editor:
In his article on physician-assisted suicide (Aug. 29 issue),1 Annas says, in effect, that patients should be given what they need to hasten death, but it should be intended for legitimate purposes, and “prescriptions under these very limited circumstances are not assisted suicide by definition.” This seems ethically dubious. Physicians do what they do because they know what will happen, regardless of the stated intent. The Ninth Circuit Court treated pain relief and death as equally intended under the principle of the double effect, because death, the second effect, is a foreseen consequence. If physicians can foresee an effect, whether of a drug or of the withdrawal of treatment, is it not intended?
The courts did not say that assisted suicide is the same act as withdrawing life-sustaining treatment; they said it amounts to the same thing. Confusion arises from the mistake of giving meaning to a name for an isolated act at the end of life rather than to total medical treatment that first prolongs life and then helps to end the terminal stage of dying. Ironically, it is because the courts do “distinguish real causes of death from various medical tools and techniques” that they have equated the refusal of treatment with the taking of lethal drugs, because the purpose, intent, and consequences of the two acts are the same. The courts understand that physicians are deeply involved in helping patients die in a variety of ways, and that cloaking acts in ambiguous intent and linguistic camouflages obscures the real issues.
Editor's note: The author is a plaintiff in Compassion in Dying v. Washington, 79 F.3d 790 (9th Cir. 1996).
1 ReferencesThomas A. Preston, M.D.
University of Washington, Seattle, WA 981441
Annas GJ . The promised end -- constitutional aspects of physician-assisted suicide. N Engl J Med 1996;335:683-687
Full Text | Web of Science | Medline
Author/Editor Response
The authors reply:
To the Editor: As Sembrot observes, the Hippocratic oath is an important source of moral authority. Yet its precepts often reflect anachronistic attitudes. For example, the oath's prohibition of abortion has generally been rejected by contemporary codes. In any event, the issue here is whether a physician's assistance in suicide should be viewed as entailing a “criminal purpose.”
Sembrot's and Corboy's concern about physicians who oppose assisted suicide is important, but legalizing assisted suicide would not mean that physicians must participate. Advance-directive statutes permit physicians who object to the withdrawal of life-sustaining treatment to transfer the patient to another physician, and obstetricians who object to abortions need not perform them.
Corboy and Swanson appropriately worry that physicians may be too willing to assist in suicide, given the difficulties of caring for the dying and especially the financial pressures of managed care. However, we cannot distinguish assisted suicide in terms of these concerns. Indeed, finances are more problematic with the withdrawal of treatment, since the patient dependent on a ventilator or dialysis is generating higher health care costs than the terminally ill patient who is not dependent on life-sustaining treatment.
I do not agree with Gates that, once we permit assisted suicide for the terminally ill, it is inevitable that we will permit it for others. As I argued, the law has drawn its lines for the right to die to limit that right to persons who are hopelessly ill and suffering greatly. Previously, society limited the right by restricting it to patients dependent on life-sustaining treatment. Restricting assisted suicide to the terminally ill also helps ensure that people can end their lives only when they are hopelessly ill and suffering intolerably.
Girsh correctly notes that assisted-suicide proposals generally have more safeguards than laws regulating the withdrawal of treatment. However, the distinctions are not as great as she suggests. New Jersey typically requires the concurrence of two independent physicians and, in some circumstances, the involvement of hospital prognosis committees or the state's ombudsman for the elderly before life-sustaining treatment can be stopped.1
Leff misconstrues my argument. I claimed that case-by-case decisions are infeasible for all end-of-life decisions, including withdrawal of life-sustaining treatment. The courts agree. In its first opinion on the withdrawal of treatment, Saikewicz, the Massachusetts Supreme Court required that all such cases be heard by a probate judge.2 However, the court eventually abandoned the requirement.3 Other courts have regularly stated that these issues should be decided at the bedside.4,5 More important, as I argued, representatives of the state should not be making case-by-case decisions about who shall live and who shall die.
Kopp believes that we can permit assisted suicide without involving physicians. Many physicians, however, believe it is their professional duty to stay with their patients to the end and provide relief of their patients' suffering, especially when the suffering is a result of previous treatments.
5 ReferencesDavid Orentlicher, M.D., J.D.
Indiana University School of Law–Indianapolis, Indianapolis, IN 46202-51941
In re Conroy, 486 A.2d 1209, 1237-1242 (N.J. 1985).
2
Superintendent of Belchertown State School, 370 N.E.2d 417, 433-435 (Mass. 1977).
3
Meisel A. The right to die. 2nd ed. Vol. 1. New York: Wiley, 1995:238.
4
In re Lawrance, 579 N.E.2d 32, 41-42 (Ind. 1991).
5
In re Farrell, 529 A.2d 404, 415 (N.J. 1987).
Author/Editor Response
As these correspondents attest, there are medical, legal, ethical, and practical differences between the right to refuse treatment and any purported right to request or demand that a physician write a prescription for lethal drugs with the intent that the patient use them to commit suicide. These are explored both in my article and in a subsequent amicus brief to the U.S. Supreme Court on the decision of the Second and Ninth Circuit Courts of Appeals that was submitted by me and my colleagues Leonard Glantz and Wendy Mariner on behalf of a group of bioethics professors.1 Drs. Swanson, Gates, Girsh, Corboy, and Sembrot all properly note some of the differences. Drs. Corboy and Kopp also make reasonable points about managing death under managed care. They could have gone further. Since assisted suicide will always be the cheapest “treatment,” and since it will cure literally every disease, declaring it a constitutional right could make promoting it as a new choice irresistible to those for-profit managed care companies that are more dedicated to enhancing their bottom lines than caring for their patients.
Dr. Preston's amazing assertion that “physicians do what they do because they know what will happen, regardless of the stated intent” is breathtaking. Medicine is filled with uncertainty, and virtually every treatment has risks that are accepted but certainly not intended. The fact that a known and quantifiable risk occurs (such as death during surgery) does not mean it was intended. This is why it is not murder. Preston himself declared in the Compassion in Dying case that he had refused to prescribe drugs to a terminally ill patient of his who was “suffering terribly, and the suffering could not be relieved” because, “under the statute prohibiting assisted suicide, fulfillment of this professional responsibility might expose me to criminal prosecution”2 (emphasis added). So Preston appears to think that the concepts of uncertainty and risk should apply only to patients, not doctors. But no statute or court decision can remove uncertainty and risk from life, death, or the practice of medicine. The quest for absolute legal immunity in the care of the dying is illusory and distracts us from the real challenge of providing quality care to all patients.
2 ReferencesGeorge J. Annas, J.D., M.P.H.
Boston University Schools of Medicine and Public Health, Boston, MA 021181
Brief for the Bioethics Professors Amicus Curiae Supporting Petitioners, Vacco v. Quill and Washington v. Glucksberg, Nos. 95-1858 and 96-110, November 12, 1996.
2
Declaration of Thomas A. Preston, M.D., Compassion in Dying v. Washington, No. C94-119, Feb. 1, 1994 (reprinted in Joint Appendix, Washington v. Glucksberg, No. 96-110, filed November 12, 1996, 53-57).
- Citing Articles (1)
Citing Articles
1
L. M. Cohen. (2000) Psychiatric Evaluation of Death-Hastening Requests: Lessons From Dialysis Discontinuation. Psychosomatics 41:3, 195-203
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