Correspondence

Disability and Physician-Assisted Suicide

N Engl J Med 1997; 337:1852-1854December 18, 1997

Article

To the Editor:

In his article on physician-assisted suicide (June 5 issue),1 Mr. Batavia fails to address the issue of the “slippery slope,” which is the point of the analogy with Nazi Germany. The scenario there was that initially the state passed laws that allowed physicians, by order of the state, to sterilize the criminally insane. Then, during a period of unanticipated social and political upheaval, the definition of “sterilize” was gradually broadened to include “euthanize.” Simultaneously, the definition of “criminally insane” became broadened to include “enemies of the state,” which eventually included members of most religious orders and Jews.

A major fear of the opponents of physician-assisted suicide is that once this legal power is let loose, physicians will slip down a similar slippery slope of political and social pressures, ultimately assisting with suicide for reasons ulterior to sound medical judgment. Definitions and criteria will become blurred and then broadened, regardless of the safeguards imposed. Social and government pressure will be exerted to encourage taxpayers and the insured to live but mercifully allow those on welfare, Medicare, and Medicaid to die. Pressure may also come from family members, some of whom may have financial gain in mind.

Physicians are hardly immune to pressure. Indeed, in the same issue of the Journal, Asch and Ubel2 describe well the present influence of social and political pressures on medical judgment in the context of rationing medical care. The bottom line is that we, and our system, are too imperfect and too vulnerable to trust ourselves with this power.

Edgar P. Kowalski, M.D., J.D.
7736 Rye Canyon Dr., Las Vegas, NV 89123

Susan D. Kowalski, R.N., Ph.D.
University of Nevada, Las Vegas, Las Vegas, NV 89154

2 References

1. 1

   Batavia AI. Disability and physician-assisted suicide. N Engl J Med 1997;336:1671-1673
   Full Text | Web of Science | Medline

2. 2

   Asch DA, Ubel PA. Rationing by any other name. N Engl J Med 1997;336:1668-1671
   Full Text | Web of Science | Medline

To the Editor:

Roderigo: “It is silliness to live when to live is torment; and then have we a prescription to die when death is our physician.”

Shakespeare, Othello

Cleopatra: “. . . if knife, drugs, serpents [have]

Edge, sting, or operation, I am safe.”

Shakespeare, Antony and Cleopatra

“The thought of suicide is a great consolation: by means of it one gets successfully through many a bad night.”

Nietzsche, Beyond Good and Evil

These quotations epitomize the value of the perceived availability of suicide as a means of release, as a safe haven if circumstances become intolerable. A personal acceptance of suicide as an option does not necessarily lead to action; the idea itself may suffice.

A key point about such an option is that most persons do not require the assistance of a physician to end their lives. For those with severe disabilities, however, it may be a different matter. The inability to drive, pull a trigger, or even ingest an overdose of some surreptitiously obtained drug makes assistance of some type essential. It is therefore disturbing and somewhat confusing that some disability organizations oppose physician-assisted suicide, even for mentally competent persons. Denying this option to persons who are physically unable to commit suicide smacks of discrimination.

As a person with paraplegia (due to traumatic T7 injury) since 1975, I have no fear of the “slippery slope” envisioned by these disability organizations. If I ever considered suicide, I could manage it alone, but I am close enough to the situation of more severely disabled persons that I have an empathic understanding of the frustration they would feel if unable to commit suicide on their own.

Larry R. Kirkland, M.D.
Emory University School of Medicine, Atlanta, GA 30322

To the Editor:

In his discussion of the arguments for and against physician-assisted suicide for persons with disabilities, Mr. Batavia did not mention an important argument against this practice. Many physicians and nonphysicians in our country attend worship services every week and have strong beliefs about what is right and what is wrong. If numbers mean anything, then arguments based on religious convictions ought not to have been omitted.

Gerald F. Falasca, M.D.
Robert Wood Johnson Medical School at Camden, Camden, NJ 08103

To the Editor:

As a young physician, I was interested in the recent editorials about the financial and legislative limitations in medicine.1,2 As a young physician with a disability (paraplegia), I was also interested in the Sounding Board on disability and physician-assisted suicide. Many of the controversies discussed in these pieces, from medical rationing to the attempted legislative restrictions on the use of medical knowledge (in the cases of late-term abortions and physician-assisted suicide), are perceived, by physicians, laypeople, and the media, as restraints on physicians' rights. We certainly lose the right to practice medicine in the way we were trained to do and according to the ethics that inspire us. What we often forget is that physicians' rights are nothing more than codified patients' rights.

In the case of physician-assisted suicide, I agree with Batavia's conclusion that many disabled persons feel disenfranchised by the medical community and are worried that physicians might use physician-assisted suicide indiscriminately. What people, physicians and laypeople alike, do not appreciate is whose right is at stake in the debate over the right to physician-assisted suicide. It is my belief that this right is the right of patients: a right to feel comfortable asking their physicians about the end of life, a right to know that their concerns will be respected and valued, and a right to know that fear of prosecution will not hinder their physicians' participation in the most profound and reflective moments of a person's life. The right of physician-assisted suicide is not the right of physicians to decide who lives and who dies but rather the right of every person to choose the fate of his or her own body. Furthermore, a right does not mandate an obligation. A patient has the right to dismiss such an option, and a physician has the right to decline to participate in a patient's decision.

As a profession, we have not done enough to demonstrate that limiting physicians' rights in the cases of physician-assisted suicide, late-term abortion, and the ordering of additional tests or treatments is really limiting patients' rights.

Elizabeth A. Bancroft, M.D.
New York Hospital–Cornell Medical Center, New York, NY 10021

2 References

1. 1

   Kassirer JP. Our endangered integrity -- it can only get worse. N Engl J Med 1997;336:1666-1667
   Full Text | Web of Science | Medline

2. 2

   Kassirer JP. Practicing medicine without a license -- the new intrusions by Congress. N Engl J Med 1997;336:1747-1747
   Full Text | Web of Science | Medline

Author/Editor Response

Mr. Batavia replies:

To the Editor: Soon after my article was published, the U.S. Supreme Court ruled that the states may prohibit terminally ill persons from obtaining a physician's assistance in hastening death.1 A few weeks later, the Florida Supreme Court similarly ruled that the Florida constitution's privacy amendment does not encompass a right to physician-assisted death.2

These decisions were disappointing to many of us who believe that the state should not be allowed to interfere unduly with our most personal decisions (e.g., end-of-life decisions emanating from the physician–patient relationship). Most affected is Mr. Charles Hall, the person with AIDS in the Florida case, who is now dying in precisely the manner that he wished to avoid — in a morphine-induced stupor necessary to alleviate his unbearable pain.

Perhaps the most disturbing aspect of the U.S. and Florida Supreme Courts' opinions is that both relied in part on disability-related justifications to deny the right to physician-assisted suicide. Ironically, one group of people with disabilities provided the arguments to deny another group of disabled people — those who are terminally ill — autonomy over their lives. Mr. Hall does not want to live under his current circumstances and has no way to end his suffering without assistance. I agree with Dr. Kirkland that prohibiting assistance has a discriminatory effect on such persons.

I also agree with Dr. Bancroft that although the right should protect physicians from prosecution, it fundamentally belongs to the terminally ill person and is based on that person's right to autonomy and self-determination. I would never support a right for physicians to determine whether a person should live or die. That is precisely what the Nazis did in 1939, when they authorized their “euthanasia” program. However, I disagree with Drs. Kowalski and Kowalski that a slide toward the immorality of Nazi Germany could ever occur in this country, precisely because of our commitment to individual autonomy. Hugh Gallagher, the foremost expert on the Nazi program 3 — and a person with a disability himself — supports the right to physician-assisted suicide.4,5

Finally, in response to Dr. Falasca, my article did not address religious arguments because it focused exclusively on disability issues. However, it should be noted that there are moral and religious arguments both for and against the right of a person in the process of dying to avoid unnecessary pain by hastening death with a physician's assistance.

Andrew I. Batavia, J.D.
Florida International University, North Miami, FL 33181-3600

5 References

1. 1

   Washington v. Glucksberg, 65 U.S.L.W. 4669, and Vacco v. Quill, 65 U.S.L.W. 4695 (decided June 26, 1997).
   

2. 2

   Krischer v. McIver, Florida Sup. Ct. No. 89,837 (decided July 17, 1997).
   

3. 3

   Gallagher HG. By trust betrayed: patients, physicians, and the license to kill in the Third Reich. Arlington, Va.: Vandamere Press, 1995.
   

4. 4

   Brief for the Amici Curiae: Gay Men's Health Crisis and Lambda Legal Defense and Education Fund and five prominent Americans with disabilities in support of respondents: Washington v. Glucksberg (No. 96-110) and Vacco v. Quill (No. 95-1858).
   

5. 5

   Brief for the Amici Curiae: A coalition of Floridians and other Americans with disabilities in support of respondents: Krischer v. McIver (Florida Sup. Ct. No. 89,837).