Correspondence
Physician-Assisted Suicide — The Ultimate Right?
N Engl J Med 1997; 336:1524-1526May 22, 1997
- Article
To the Editor:
A key point in Dr. Angell's case for allowing physician-assisted suicide (Jan. 2 issue),1 a practice many believe is immoral and contrary to a physician's oath, is that it does not differ from withdrawing certain forms of life-sustaining care (i.e., food, fluids, and mechanical ventilation). Others have drawn the same conclusion,2,3 including both the Second and Ninth Circuit Courts of Appeals.4,5 In addition, the Catholic Church, in its Charter for Health Care Workers,6 approved by the Congregation for the Doctrine of the Faith, states, “The administration of food and liquids, even artificially, is part of the normal treatment always due to the patient . . . their undue suspension could be real and properly so-called euthanasia.”
Although Dr. Angell does not approve involuntary euthanasia, it will certainly follow if physician-assisted suicide is allowed. The Ninth Circuit Court has already ruled that a proxy's decision is the same as the patient's decision,5 and there is precedent for allowing involuntary euthanasia by dehydration at a proxy's request.7 Where will the slippery slope end? In the current medical economic climate, brought on in part by the Medicare funding crisis, third-party payers are dictating standards of medical care. It seems likely that in the future, physician-assisted suicide and involuntary euthanasia will be forced on countless patients by the refusal of third parties to pay for the care of those with certain disorders.
A major flaw in Dr. Angell's case for assisted suicide is her assumption that we should continue and expand on the moral error of killing patients through the withdrawal of life-sustaining care by allowing doctors to provide drugs and advice to accomplish the same end. An ethical conclusion that can be drawn from her arguments is that physicians should abandon both forms of assisted suicide and return to fidelity to their oath.
7 ReferencesWilliam J. Burke, M.D., Ph.D.
Saint Louis University, St. Louis, MO 63110-02501
Angell M . The Supreme Court and physician-assisted suicide -- the ultimate right. N Engl J Med 1997;336:50-53
Full Text | Web of Science | Medline2
Burke WJ . The dying patient. Neurology 1996;47:1611-1612
Web of Science | Medline3
Orentlicher D . The legalization of physician-assisted suicide. N Engl J Med 1996;335:663-667
Full Text | Web of Science | Medline4
Quill v. Vacco, 80 F.3d 716 (2d Cir. 1996).
5
Compassion in Dying v. Washington, 79 F.3d 790 (9th Cir. 1996).
6
Pontifical Council for Pastoral Assistance. Charter for health care workers. Boston: Pauline Press, 1995:105.
7
Busalacchi v. Busalacchi, No. 093-799 (St. Louis County Cir. Ct. Jan. 16, 1991).
To the Editor:
The value of human life cannot be overstated. Our society has understandably introduced the concept of autonomy, which allows the patient to refuse further care. Autonomy refers to a person's right to avoid further bodily invasion, whether by instrument or medication, not to the right to kill oneself. Medical care will become corrupt if physicians begin to assist in the suicide of ill or elderly persons who are afraid of being a burden in terms of finances, time, or emotion to their families.
Compassion must not be confused with suicide or homicide. Suicide or homicide should not become an acceptable solution to illness, handicap, or any of life's troubles. Hospice care is compassionate. It can maintain an adequate level of pain control and dignity. We should err on the side of treating the symptoms of pain and worthlessness rather than kill the person. Physicians need better training to preserve the quality of life during illness rather than to cut life short.
Our Hippocratic oath challenges us not to give deadly medicine to anyone if asked. If we begin to advocate physician-assisted suicide, we will give up the public's long-standing trust that we will do no harm.
Scott M. Seaton, M.D., Lt., U.S.N.
U.S.S. LHA-4, FPO AE 09557-1615To the Editor:
Dr. Angell stipulates that the decision to commit suicide must be thoughtful and freely made. Is this an autonomous decision, freely made? Are we so easily assured that the patient understands the nature of the decision and its consequences, free of emotional, spiritual, or financial duress? At the risk of paternalism, I think not. End-of-life decision making takes place within the context of a patient's experience of serious illness, described and framed by physicians in unfamiliar words and concepts. As physicians, we often base our counsel on imperfect knowledge of a disease process. Our communication of treatment options and prognosis is not free of bias or, occasionally, misinformation. Physician-assisted suicide is not a decision considered with equanimity among peers. The patient, as victim, is called to choose death thoughtfully and freely in the throes of depression, loneliness, grief, and sadness. There are family issues and relationships to address, spiritual issues, and often financial worries for a spouse, children, or surviving parents.
Frank Earnest, IV, M.D.
Mayo Clinic, Rochester, MN 55905To the Editor:
To justify physician-assisted suicide, it would need to be very clear whether a patient is suffering from clinical, treatable depression or, rather, has an “appropriate” response to a terminal illness with a consequent desire to commit suicide. These two situations are not easy to differentiate. In addition, patients with clinical depression are usually competent; they have the capacity to understand the consequences of their actions and are able to provide informed consent. Therefore, one cannot differentiate between these two situations on the basis of competency. In either case, I as a psychiatrist see these patients as treatable; that is, I would attempt to treat the suicidal ideation with a variety of methods, including, if necessary, electroconvulsive therapy.
Comprehensive care of the depressed patient involves assessing and, if possible, modifying the patient's social, functional, psychological, and environmental circumstances. This approach may also be appropriate for the terminally ill patient for whom physician-assisted suicide is advocated.
Mayana Golomb, M.D.
39 Sky View Cir., Newton, MA 02159To the Editor:
. . . With governmental concessions to physician-assisted suicide in the Netherlands1 and Michigan,2 treatable patients died; depressed, anxious, ambivalent feelings were discounted; the threshold for killing fell; conflicts of interest among patients, families, and clinicians increased. None of these evils can be avoided by writing safeguards into law because, as was the case with eugenics, the very accessibility of physician-assisted suicide evokes them. To put it simply, legalizing physician-assisted suicide or euthanasia, as with eugenics, brings out the worst in doctors, not the best.
2 ReferencesPaul R. McHugh, M.D.
Johns Hopkins Medical Institutions, Baltimore, MD 21287-74131
Hendin H. Seduced by death: doctors, patients, and the Dutch cure. New York: W.W. Norton, 1997.
2
McHugh PR . The Kevorkian epidemic. Am Sch 1997;66:15-27
Web of Science
To the Editor:
By legalizing assisted suicide we would be condemning patients to death because of the tragic inadequacy of physicians' education about pain during medical school and residencies. As Dr. Foley indicates (Nov. 14 issue),1 the reason that so many physicians and other health care professionals involved in the field of pain management oppose legalizing assisted suicide at this time is not a lack of compassion for the patients to whose care we have committed our professional lives, but, rather, our knowledge of the poor quality of pain management for so many terminally ill patients.
1 ReferencesSteven A. King, M.D.
Temple University School of Medicine, Philadelphia, PA 191401
Foley KM . Competent care for the dying instead of physician-assisted suicide. N Engl J Med 1997;336:54-58
Full Text | Web of Science | Medline
To the Editor:
Who is qualified to be the expert in managing terminal illness? Who is qualified to decide that optimal financial counseling has been obtained to alleviate financial pressures that led to depression and a consequent request for assisted suicide? These questions lead us back to recommendations in the Sounding Board article by Miller et al. (July 14, 1994, issue),1 which addresses both the regulation of physician-assisted death and the specialized management of terminal illness. The authors refer to “certified palliative-care consultants” who would be consulted when any complex decisions about palliative care arise, not merely when optimal, or suboptimal, care has led to a question of physician-assisted death. The identification and certification of such “palliative-care consultants” would be handled in a similar way to certification in other medical specialty areas. The ties between certified consultants and government agencies would ensure that all instances of physician-assisted suicide would involve an expert and be appropriately reported.
1 ReferencesFrancis C. Wood, Jr., M.D.
University of Washington School of Medicine, Seattle, WA 981951
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:
If forms of assisted dying, such as assisted suicide, are to become legal, then the laws and rules of professional conduct should be in place before the legalization of assisted suicide. Otherwise, their implementation may be hampered by institutionalized reluctance to abolish the profit in assisted-dying-for-profit, including the benefits that can accrue to care givers from the assisted suicide of their patients.1 The Dutch have public laws and rules of professional conduct that solve this problem.2,3
3 ReferencesGeorge Hug, M.D.
Children's Hospital Medical Center, Cincinnati, OH 45229-30391
Hug G . Sterbehilfe und Interessenkonflikte. Schweiz Med Wochenschr 1997;127:79-81
Medline2
Beoordeling geneesheren e.d. In: Burgerlijk Wetboek. 4th ed. Book 4. Title 12. Article 953. Nijmegen, the Netherlands: Ars Aequi Libri, 1995:284.
3
Gedragsregels voor artsen. Utrecht, the Netherlands: Koninklijke Nederlandsche Maatschappij tot Bevordering der Geneeskunst, 1994.
To the Editor:
When the time comes when constant misery and a fogged mind are all that's left and hope is gone, many patients feel life has no further meaning. Especially those who have spent their lives helping others see no reason to prolong their own and their family's suffering if they can give nothing in return — not even intelligent conversation or a heartfelt smile. Pain control is a worthy clinical science, but it must not preclude the release and peace of death for those who declared their intent when their minds were clear.
H. Phelps Potter, Jr., M.D.
208 Ivy Ln., Haverford, PA 19041To the Editor:
Perhaps the most robust formulation of the Golden Rule has been Immanuel Kant's: “Treat others as ends-in-themselves, and not as a means only.” I believe that Angell's perspective is highly resonant with that imperative. Those who oppose assisted suicide patronize the patient by presuming to know what is best for him or her, thus treating the patient as a “means” in the service of their own religious views, or “oaths.”
M. David Tilson, M.D.
Columbia University, New York, NY 10025Author/Editor Response
Dr. Angell replies:
Medicine is rife with slippery slopes that simply cannot be avoided, nor should they be. By permitting the cessation of life-sustaining treatment, we stepped on a slippery slope, but the alternative would have been indefensible. The problem is to craft policies and procedures to stop us from slipping. I do not share Dr. Burke's belief that physician-assisted suicide is especially vulnerable to slippage; on the contrary, I believe its essential voluntary nature is a very strong protection.
Dr. Earnest's logic would permit us to discount virtually any decision a patient made by questioning whether it was really autonomous. Unless there is evidence to the contrary, the presumption should be that patients know what they want.
Dr. Golomb asserts that depression is “treatable” in terminally ill patients who wish to end their lives. Certainly treatment can be offered, but whether it is generally successful is a question that cannot be answered with the data we now have. Golomb acknowledges that it is difficult to differentiate between “appropriate” and inappropriate depression in these circumstances. I think we should be cautious about dismissing the desire of dying patients for physician-assisted suicide as clinical depression, with the implication that it can be successfully treated. Anecdotes about such patients' changing their minds are not very persuasive, especially since terminal illness would itself lead over time to a loss of the energy required to persist in requests for assisted suicide.
The unsubstantiated alarm of Dr. McHugh and Dr. Seaton does not, in my view, justify the continued harm of forcing dying patients to endure protracted, meaningless suffering.
I strongly agree with Dr. King that we must redouble our woefully inadequate efforts to treat pain. But, as I pointed out in my editorial, terminally ill patients do not just suffer from pain. Furthermore, it seems doubly cruel to ask them to endure a system in which pain relief is notoriously inadequate and use that as a justification for denying them the option of assisted suicide.
Dr. Hug's concern about conflicts of interest is legitimate, but the problem is at least as great when life-sustaining treatment is withheld.
Dr. Wood asks, “Who is qualified to be the expert in managing terminal illness?” My answer is that only the dying patient is “qualified” to make the ultimate judgment about the trade-offs between a longer life and the suffering it brings.
Marcia Angell, M.D.
