March 1998
Volume 62 |
Number 3
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| Physician-Assisted
Suicide: Con/Pro |
Douglas G. Merrill, M.D., Chair, Committee on Pain Management
David B. Waisel, M.D., Committee
on Ethics
Medicine, as practiced in the United States, is an often rapidly
evolving art. Suddenly, a large
torque has been applied to it by the recent passage of the physician-assisted
suicide initiative in Oregon. This law permits prescription of
oral medication that is designed to end the life of a terminally
ill patient.
That event has taken the issue of physician-assisted suicide
from the darkly caricatured realm of Dr. Jack Kevorkian's death
machines to the forefront of reasoned debate on public policy.
The great majority of ASA members have encountered terminally
ill patients in their practices. Most also have had to consider
the issue of those patients' desires regarding resuscitation in
the operating room and the ethics of honoring or ignoring such
directives.
Fewer members have provided primary care for patients
with cancer pain or other suffering who may have sought us out
to control or even end that pain. All of us must contemplate what
we as individuals and as a specialty might expect to occur in
the coming months and years as the physician-assisted suicide
debate evolves into legislation that will directly affect us.
Prior to the Oregon initiative's passage, various bodies
of organized medicine (including the American Medical Association
and the American Pain Society) had already created policy statements
that delineated a stand against physician-assisted suicide. In
the spring of 1997, the ASA Committee on Pain Management crafted
a document on end-of-life issues that also spoke against physician
involvement.
However, with the passage of the initiative and evidence
of divided medical opinion in Oregon, it was recognized that writing
a statement on physician-assisted suicide that was to represent
the opinion of ASA's 34,000 members would be a complex task. Thus,
that aspect of the "Statement on Quality End-of-Life Care" has
been deleted until the ASA House of Delegates has an opportunity
to consider the issue in October 1998. The remaining
portion of the statement is appended to this article.
In recognition, then, of the importance of holding a discussion
on the issues of physician-assisted suicide in a forum to which
the ASA membership has specific access, the authors would like
to initiate (only initiate) that dialogue in this edition
of the ASA NEWSLETTER. Dr. Merrill offers CON comments
against physician-assisted suicide, while Dr. Waisel presents
PRO comments supporting certain arguments for it. These would
seem to be the salient dilemmas and arguments as they affect the
role of the anesthesiologist/physician:
Should Physician-Assisted Suicide Be Legalized
and Used in Our Practices?
CON:
Patient safety is our motto ...
A physician is supposed to heal and comfort. The definitive spirit
and mandate of our particular specialty is the relief of discomfort
in the safest manner possible. This would seem to be incontrovertibly
in opposition to any deliberate effort to terminate life prematurely.
The physician-patient relationship ...
This is a fragile entity which could only suffer from the additional
suspicion in most patients' minds that this new option might be
used without patient consent. All of the legal safeguards will
not eradicate the fears that often accompany the use of opioids.
More often than not, we cannot get patients with cancer pain to
use enough now! The new possibility (in their minds) that we (or
their managed care company) might be euthanatizing them legally
will not decrease that fear.
Only your personal physician ...
How do we ensure that, once physician-assisted suicide is accepted
and allowed, only the responsible and caring physician who personally
knows the patient will be involved? This tenet, so dear to those
who advocate physician-assisted suicide, has already been horribly
subverted by the specter of Kevorkian. Those of us who see physician-assisted
suicide as a dangerous perversion of the physician-patient relationship
need look no further than this pathologist who kills those whom
he does not know. We fear that his actions will pale in comparison
to the euthanasia mills that might be spawned by the creation
of legal physician-assisted suicide.
PRO:
Do not abandon those who need you most ...
It would be wrong to suggest that physicians' roles are unchanging.
Society and medicine have rewritten the job description of physicians
often over the past 100 years. The new use of physician-assisted
suicide would be simply another change in that description.
The goal of a physician is to help a patient live life
as the patient defines it. One of the requirements to do that
is to minimize suffering. If necessary, this can be done by embracing
the concept of a "good death." Thus, the oft-cited idea that causing
death is always wrong is an abdication of our responsibility as
physicians. What is wrong is to abandon our responsibility to
help alleviate suffering, to hinder the right to self-determination
and to throw barrier after barrier in front of a good death.
Surely, a patient in such distress as to desire the termination
of his or her life is most in need of our care. That patient should
be allowed the benefits of our skills and abilities at that most
crucial time of life. Otherwise, we consign a patient only to
the painful, often ineffective and disfiguring methods of suicide
that are available to nonphysicians. That could be considered
a peculiarly unmerciful act on our part.
An irrational fear ...
There is no historical or otherwise rational experience to ground
the belief that the legalization of physician-assisted suicide
would result in the creation of "death mills." It could be just
as well argued that allowing physician-assisted suicide will bring
about a greater respect for the quality and sanctity of human
life, because of the ability to choose when to use physician-assisted
suicide.
Is Physician-Assisted Suicide Necessary?
CON:
Let us treat the disease ...
The legalization of physician-assisted suicide, indeed even the
contemplation of its legalization, diverts attention from the
real need to ensure good treatment for patient pain and suffering.
If a patient is in pain or is depressed, or both, we have remarkable
methods to help them with that pain and depression.
The elevation of physician-assisted suicide to accepted
therapeutic status will at the least obscure our efforts to convey
the existence of these multiple treatments to our suffering patients.
At worst, it might allow third-party payers to push patients away
from more expensive therapy toward the cost-saving step of suicide.
The only fear we have to fear ...
When scrutinized closely, it is apparent that the healthy public's
interest in physician-assisted suicide is a response borne out
of fear and ignorance. Certain that their physicians would not
be able to relieve their potential future suffering, they want
an insurance policy that it will not last long.
Yet, most patients who already have cancer and have an
approximately known "end date" to their lives do not desire physician-assisted
suicide. Instead, they want their physicians and nurses to concentrate
on relieving their suffering and thereby improve those days that
remain to them.
It is the public's paranoia (and traditional medicine's
failure to assuage it with both information about available therapy
and more liberal employment of it) that fans the fire of physician-assisted
suicide. Like most insurance policies, the mandated, legal availability
of physician-assisted suicide may, in the end, be far more costly
in the purchase than rich in the reward.
PRO:
Physician paternalism ...
This paternalistic view of physicians is one of the reasons that
the public is frightened. Just because some patients do not desire
physician-assisted suicide does not mean that it should not be
available. Who are we to weigh benefits and burdens for others?
Perhaps, if we did a better job with hospice care, fewer patients
would desire physician-assisted suicide. However, even when it
is available, high quality hospice care does not solve all problems.
Many times the issue is not solely pain but is likely
to be suffering, an indefinable sense of loss and perhaps embarrassment
regarding a decline in basic body functions. Frequently given
reasons by patients requesting physician-assisted suicide are
loss of dignity, pain, fear of pain, dependency and "tiredness
of life." Those are not always treatable problems.
Cancer is not the most difficult ...
Those cancer patients whose lives are only measured in months
or weeks surely may wish more for relief
than for death. But what about the patient with quadriplegia or
the ALS sufferer who can only look forward to a long life of declining
health and, often, sheer torture? Trapped for years in bodies
that are often wrapped in pain and warped by disease, they have
no "acutely" terminal illness. That is their misery. Shouldn't
they be allowed to die sooner?
What Are the Practical Problems With Legalization
of Physician-Assisted Suicide?
CON:
Another invitation to let the government into the physician-patient
relationship ...
Early attempts by some state governments to deal with physician-assisted
suicide and "self-determination" at the end of life have included
some remarkably onerous legislation. One example requires physicians
to obtain second opinions before offering any "life-extending"
therapy to the terminally ill (based upon the remarkable notion
that patients will not be able to recognize that their lives are
being extended).
What do you think the result will be when a physician
must arrange a second opinion before a lung cancer patient can
be offered oxygen or even an aerosolized breathing treatment?
These legislative efforts could be expected to multiply
rampantly (as all governmental efforts do) and to form significant
barriers to patient access to even the most basic care.
PRO:
Simply because some legislatures bring in potentially difficult
legislation does not mean that the idea of physician-assisted
suicide is wrong. The same problem of dire predictions and poor
implementation plagued the early attempts to implement the "do
not resuscitate" legislation. Physician-assisted suicide can be
successfully managed.
The experience in the Netherlands, where euthanasia was
decriminalized, is our best source of information in this regard.
The 1990 Remmelink study1 found
that 2,700 of the 130,000 deaths in the study period resulted
from physician-assisted suicide. Nearly all of the patients who
received physician-assisted suicide had a life expectancy of less
than one month. Physicians there were cautious, rejecting over
two-thirds of the requests they received for physician-assisted
suicide.
However, an additional 1,000 patients were euthanatized
by a physician without the explicit request of the patient, thereby
not fulfilling an essential requirement of the policy. In a follow-up
1995 study, physician-assisted suicide requests increased from
8,900 to 9,700 while the rate of rejected requests increased slightly.2
As in the earlier study, nearly all the patients who received
physician-assisted suicide appeared to have had a short life expectancy.
The incidence of physician-assisted suicide in patients not explicitly
requesting assistance declined from 0.8 percent to 0.7 percent
of all deaths.
These studies can be interpreted several ways. One way
is that the consistency exhibited suggests that there is no slippery
slope toward increased misuse of physician-assisted suicide. Another
is that insufficient time has passed to make this assessment.
The fact is that the implementation of physician-assisted suicide
will need to be done carefully, as was the case with the living
will legislation.
Conclusion
These are but some of the questions which are raised by
the legality of physician-assisted suicide. It is a prospect that
for some of us seems as dangerous as the words which Despair spoke
to the Red Cross Knight in The Faerie Queene, which almost
drove him to take his own life not yet half-way through his quest.
For others of us, the possibility of physician-assisted
suicide is merely another item on the list of available therapeutic
options that we can offer to our most afflicted patients.
It is an issue that is likely to specifically affect anesthesiology,
the primary pain management medical specialty. In the coming months,
it would behoove each of us to think hard on our own and then
to let our ASA delegates know how we feel about what may be one
of the most important topics we may encounter in our professional
lives.
References:
- van der Maas PJ, van Delden JJM, Pijnenborg
L, et al. Euthanasia and other medical decisions concerning
the end of life. Lancet. 1991; 338:669-674.
- van der Maas PJ, van der Wal G, Haverkate
I, et al. Euthanasia, physician-assisted suicide, and other
medical practices involving the end of life in the Netherlands,
1990-1995. N Engl J Med. 1996; 335:1699-1705.
Statement on Quality End-of-Life
Care
by the American Society of Anesthesiologists
Committee on Pain Management
Patients developing incurable diseases frequently experience
more pain and distressing symptoms than necessary near the end
of life. This circumstance is distressing because adequate pain
and symptom management in most cases is not dependent upon future
medical discoveries but can be achieved with contemporary management
methodologies. Quality end-of-life patient care requires that
palliative (or comfort) treatment concepts be integrated into
the care of these patients.
The American Society of Anesthesiologists Committee
on Pain Management believes that opportunities exist to improve
our patients' end-of-life care. Education and training of patients,
families, health care workers and physicians should be undertaken
to promote available, compassionate, comprehensive and interdisciplinary
end-of-life care.
Further, the American Society of Anesthesiologists Committee
on Pain Management believes that the improvements in palliative
care should be based on value-based advance care planning. This
advanced care planning should attempt to minimize the sense
of abandonment often described by patients near the end of life
and the loss of control that patients feel.
Anesthesiologists should always strive to relieve suffering,
address the psychological and spiritual needs of patients at
the end of life, add value to a patient's remaining life and
allow patients to die with dignity.
This document has been developed by the ASA Committee on Pain
Management but has not been reviewed or approved as a practice
parameter or policy statement by the ASA House of Delegates. Variance
from the recommendations contained in this document may be acceptable
based on the judgment of the responsible anesthesiologist. The
recommendations are designed to encourage quality patient care
and safety in the workplace but cannot guarantee a specific outcome.
They are subject to revision from time to time as warranted by
the evolution of technology and practice.
Douglas G. Merrill, M.D., is Director
of Valley Analgesia Service, Valley Anesthesiology Consultants,
Phoenix, Arizona.
E-mail the author.
David B. Waisel, M.D., is an Attending
Anesthesiologist, Wilford Hall Medical Center, San Antonio, Texas.
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