Special A rticle

Legalizing Physician-Assisted Suicide: Some Thoughts and Concerns

Harold G. Koenig, M D, M HSc Durham, North Carolina

Surveys show that most Americans favor the decrimi­ medicine in unpredictable ways, yet physicians are par­ nalization of phvsician-assisted suicide in certain cir­ ticipating relatively little in deliberations concerning cumstances. Several states are now considering legisla­ this issue. The problem o f suffering in persons with tion to bring this about and make the United States chronic and terminal illness cannot be ignored. C om ­ the first place in the civilized world where physician aid passionate, effective, and ethical solutions must be in dying is sanctioned. In the Netherlands, where phy­ found. As a former family physician and now geriatric sician-assisted suicide is practiced but officially remains psychiatrist, I review the pros and cons of physician-as­ illegal, 85% o f assisted suicides occur in the elderly, sisted suicide (emphasizing arguments against legaliza­ and most involve the help o f general practitioners. In tion) and encourage family physicians to debate this the United States, family physicians provide health care matter. to many older adults with chronic or terminal illness whose numbers will increase as the elderly population Key words. Suicide; aged; euthanasia; ethics; patient expands. The legalization o f physician-assisted suicide advocacy; quality' o f life. ( / Fam Fract 1993; would affect the way American physicians practice 37:171-179)

Most physicians have had patients with advanced cancer, Clarification of Terms end-stage heart failure, severe chronic obstructive pulmo­ To discuss this topic intelligently, one must carefully nary disease, or other disabling and painful diseases. define one’s terms, or risk ambiguity and confusion. Many of these persons experience great physical and First, withdrawal of life support, or passive euthanasia, emotional suffering during the final few weeks or months involves the removal of tubes, respirators, or any other of their lives. In such circumstances, it is our professional, type of artificial support that may prolong life. The excess ethical, and moral duty to do everything possible to use of medical technology to extend apparently meaning­ relieve such apparently meaningless suffering. Should less life and prolong suffering, especially in cases of physicians be allowed to honor requests by terminally or terminal or near-terminal illness, is one of the factors that chronically ill patients to assist them in ending their lives? have stirred a public outcry for physician assistance in This subject has special relevance for older adults, who dying. Physician-assisted suicide occurs when a physician are most likely to be affected by terminal or chronic intentionally and willfully takes actions that help a sui­ diseases, and for family physicians who care for them. In cidal patient to end his or her life. This may involve the Netherlands, more than 85% o f euthanasia cases providing information on ways of committing suicide, occur in medically ill persons aged 50 years or over, and supplying a prescription for a lethal dose of medication, most are performed by general practitioners.1 providing a syringe filled with a lethal dose o f medica­ tion, inserting an intravenous line so that the patient can Submitted, revised, April 15, 1993. inject the drug, or providing a suicide device that the

From the Departments o f Medicine and Psychiatry, Duke University Aledical Center, patient can operate (such as the “suicide machine” in­ Durham, North Carolina. Requests for reprints should be addressed to Harold G. vented bv Jack Kevorkian, MD). Active euthanasia in­ Koenig, MD, MHSc, Bax 3400, Duke University Medical Center, Durham, NC 27710. volves a physician willfully and intentionally performing

6 1993 Appleton & Lange ISSN 0094-3509 171 The Journal of Family Practice, Vol. 37, No. 2, 1993 Physician-Assisted Suicide

an action that directly and immediately results in the would consider some option to end their life if they had patient’s death. Here, the physician is the actor, but acts an incurable illness and were in a great deal of pain.5 at the patient’s request. Leading and organizing the effort to legalize phvsi- Watts and Howell2 argue that there are clear philo­ cian-assisted suicide is the Hemlock Society, founded it sophical distinctions between passive forms of assisted Los Angeles in 1980 and now numbering over 40,000 suicide (providing information), more aggressive assisted members. Englishman Derek Humphry, its principal suicide (providing a lethal dose of medication or appa­ founder, was the organization’s leader and spokesman ratus to inject it), and active euthanasia (physician inject­ until 1992 when, following adverse publicity surround­ ing a lethal drug), pointing to the differing degrees of ing the suicide of his second wife,7 he stepped down as physician influence or control over the process leading to executive director. Hum phry’s most recent book, Ftnii death. Others, however, contend that legalizing any form Exit,8 marketed as a “how to do it” manual for those of physician-assisted suicide may open a door that is not wishing to commit suicide, sold over 500,000 copies easily closed. They refer to the strategy taken by advo­ within 6 months of publication. cates of euthanasia in the Netherlands, who gradually The Hemlock Society has led initiatives to legalize won widespread acceptance of active euthanasia by first assisted suicide in Washington and California that were endorsing more palatable, less offensive categories.3 only narrowly defeated (both by a 54% to 46% margin; Making distinctions between forms of assistance, while The issue, however, remains very much alive, and similar easy in theory, is difficult in practice. If one can justify measures are expected to qualify for the 1994 ballot in providing support and advice, a lethal dose of medica­ California, O regon, and W ashington.9 In a speech to the 1992 annual meeting of the Academy of Psychosomatic tion, or a suicide device to a patient who is both intent on and capable of killing himself or herself, it becomes Medicine, Humphry emphasized that he hoped that fu­ difficult to ignore the desperate pleas o f another severely ture legislation would be as carefullv considered and wel ill patient who needs assistance to die but cannot com­ reasoned as the California initiative. A number of Cali­ plete the act because of problems with swallowing, phys­ fornia psychiatrists, on the other hand, argued that Ini­ ical frailness, or a lack o f emotional fortitude. tiative 161 was “a potential disaster” because of a lack of safeguards to prevent persons with treatable mental ill­ If one can justify that it is ethical and safe for a nesses, eg, depression, from committing suicide. physician to assist the suicidal patient, then it is difficult to argue against more active interventions in more com­ plex, and perhaps more appropriate, circumstances. Phy­ sicians in the Netherlands acknowledged this obvious Proponents’ View conclusion almost a decade ago, when the Roval Dutch Medical Association (KNMG) recommended that the Almost two decades ago, philosopher James Rachels1* distinction between euthanasia and assisted suicide be argued that there was no ethical distinction between passive and active euthanasia. If one can justify not treat abolished on grounds that the intent in both cases is to bring about the patient’s death.3 For these reasons, the ing or withdrawing treatment from hopelessly ill patient arguments proposed in this article will apply to all forms to quicken death and reduce suffering, then providing of assistance in dying, including active euthanasia. them with more active assistance in ending their live should pose no moral or ethical dilemma. In a more recent article, W eir11 argues that assisted suicide is mor­ ally justifiable. Rather than harm the patient, physician- Proponents o f Assisted Suicide assisted suicide benefits him or her by relieving intolera­ ble and useless suffering, some of which may not be Between one half and two thirds of Americans todav amenable to even the most expert palliation. Assisted favor the legalization of physician-assisted suicide in cer­ suicide enhances patient autonomy and reduces fear bv tain circumstances.4’5 The public’s attitude toward as­ giving the person control over the dying process. The sisted suicide has changed during the past 15 years. In argument for physician-assisted suicide has also beer- 1975, a Gallup poll showed that 41% of respondents presented in several recent articles by Timothy Quill and believed that persons in great pain without hope of Christine Cassel in The New England Journal of Medi­ improvement had a moral right to commit suicide; in cine. 12~14 Death with dignity and control is seen as better 1990, the figure had increased to 66%.6 Similarly, a than an agonizing, prolonged, and unpredictable death survey by the Harvard School of Public Health reported Furthermore, the right to die is guaranteed in the first that 61% of all Americans would vote for an initiative and fourth amendments to the Constitution, and there­ legalizing physician-assisted suicide; 52% said they fore the right to end one’s life is seen as being as imp

172 The Journal of Family Practice, Vol. 37, No. 2,199-' Phvsician-Assisted Suicide Koenig

tant as the right to life.15 Finally, assisted suicide can (former director of the federal Alcohol, Drug Abuse, and benefit society by reducing the use of scarce medical Mental Health Administration) voices considerable con­ resources on hopeless cases. The latter argument is sel­ cern within the psychiatric community about phvsician- dom stressed, since proponents believe that if assisted assisted suicide.22 I focus here on four major groups that suicide became available, it would be chosen by relatively tend to oppose physician-assisted suicide: physicians, few persons, and thus have little impact on resource bioethicists, the elderly, and religious organizations. conservation or on discouraging efforts by society to care for the needs o f persons with debilitating illnesses.2 Dr Physicians Quill has recently published a book entitled Death with dignity,16 which poses a very serious challenge to all Information on physicians’ attitudes toward assisted sui­ physicians who would oppose physician-assisted suicide cide was sparse until recently. Evidence for opposition across the board. comes from the state of Washington, where the state Proponents believe that guidelines can be developed medical society in 1990 voted 114 to 22 against Initiative that would protect the safety of patients and prevent 119, which would have legalized physician-assisted sui­ physicians, patients, and society from abusing this priv­ cide. Similarly, the majority of the members o f the Cal­ ilege.12 Such guidelines, according to Quill et al,14 in­ ifornia state medical society voted to oppose Initiative clude the following: (1) the patient must have a condi­ 161, which also failed to gain the majority vote from the tion that is incurable (not necessarily terminal) and public in the November 1992 election. A survey of associated with severe suffering without hope o f relief; Florida internists in 1991 found that 87% would not (2) all reasonable comfort-oriented measures must have administer a lethal dose o f a drug under anv circumstanc­ been considered or tried; (3) the patient must express a es.23 Opposition, however, is not uniform. A survey by clear and repeated request to die that is not financially or the American Board of Family Practice found that 90% emotionally coerced; (4) the physician must ensure that of 300 internists, family physicians, and psychiatrists the patient’s judgment is not distorted; (5) physician- agreed that terminally ill patients had a right to choose to assisted suicide must be carried out only in the context of die; however, this opinion primarily reflected support of a meaningful physician-patient relationship; (6) consul­ withdrawal of life-sustaining therapy (passive euthanasia) tation must be obtained from another physician to ensure rather than assisted suicide.23 However, evidence o f in­ that the patient’s request is voluntary and rational; and creasing support within the medical community for phy­ (7) there must be clear documentation that the previous sician-assisted suicide comes from a recent decision by six steps have been taken and a system of “reporting, Michigan physicians to reverse their stand against the reviewing, and studying such deaths” must be practice, preferring that it not be considered a felony. established. 14

A number o f these guidelines are Perhaps the best data arc available from a study already in place in the Netherlands, where proponents conducted by Watts and colleagues,24 who surveyed 727 believe the system works quite well.17 As a final safeguard internist geriatricians on their attitudes toward assisting in the United States, ethics committees could be estab­ suicide among dementia patients. Fourteen percent of lished to remove the responsibility for such decisions physicians said Dr Kevorkian’s assistance o f Janet Adkins’ from any one physician. The practical aspects of exactly suicide in 1990 was morallv justifiable; 26% favored how monitoring would take place to ensure that guide­ easing restrictions on assisted suicide for competent, lines were being followed, however, have yet to be nondepressed dementia patients; and 21% would them­ worked out to everyone’s satisfaction. selves consider assisting in the suicides o f such patients. Again, these findings suggest that only a minority of physicians support physician-assisted suicide. Finally, a recent survey of hospice physicians, nurses, and volun­ Opponents o f Assisted Suicide teers found overwhelming opposition to assisted sui­ Those who oppose physician-assisted suicide include cide.25 Hospice physician David Cundiff provides an many influential and respected groups in America, articulate and well-reasoned case against physician-as­ among which are several professional organizations. The sisted suicide in his book entitled Euthanasia Is Not the American Medical Association,18-19 the American Geri­ Answer.26 atrics Society,20 and the American Bar Association21 have all spoken out against the practice and legalization of Medical Ethicists physician-assisted suicide. A recent article in the Ameri- wn Journal o f Psychiatry by Herbert Hendrin (director, A number of medical ethicists oppose the legalization of American Suicide Foundation) and Gerald Klerman physician-assisted suicide in the United States.27 33 Lead-

173 Th“ Journal of Family Practice, Vol. 37, No. 2, 1993 Physician-Assisted Suicide

ing this group is Daniel Callahan, director of the Hast­ sen to live rather than die may be made to feel gui ings Center of Bioethics.34 In his book Setting Limits,35 because they are consuming their family’s inheritance • Callahan warns against the legalization of physician-as­ placing a burden on their caregivers. Besides guilt, this sisted suicide, arguing that such an action may send likely to arouse feelings o f resentment toward those (fan. unintended messages to older persons in our society. ily members or others) who would put them in a position Callahan fears that elders will come to feel that “old age of having to choose between life and the more “heroic can have no meaning and significance if accompanied by or “dignified” option of assisted suicide.28 The current decline, pain and despair.” He is also concerned that law provides a buffer against pressures that might prompt younger persons will come to believe “that pain is not to elders to end their lives for others’ sake. Legalizing phi be endured, that community cannot be found for the old, sician-assisted suicide could subject the 998 out of 10® and that a life that is not marked by good health, by hope terminally or chronically ill older persons who choose I and vitality, is not a life worth living.”35Judaism sake of justice (as in capital punishment), and not for the sake and Islam oppose the killing o f oneself to avoid persona of saving a life (as in self-defense), but rather to satisfy private pain or suffering, and no major world religion condones wants and desires.35

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tors will be touched on only briefly. These concerns, patient may interpret this as a confirmation of his or her which are hardly exhaustive, include the following: (1) worst fears: that life is indeed without purpose, meaning, ambiguous indications, (2) physician biases, (3) the or value, and cannot become otherwise during the patient’s “slippery slope,” (4) failure to follow guidelines, and (5) time remaining.36'44 the existence o f sensible alternatives. Terminal illness. The accuracy of diagnosis for many diseases is imprecise. Even when the diagnosis is correct, Am biguous Indications predictions about the timing of death are quite unreli­ able. This is true for Alzheimer’s disease, cancer, and Most agree that three conditions must exist for physician- many other disorders. After a complete medical evalua­ assisted suicide to be justifiable: (1) intolerable suffering tion, including extensive bloodwork and brain scans, and intractable pain, (2) terminal illness, and (3) a re­ physicians correctly diagnose Alzheimer’s disease only quest by a rational patient. None of these conditions are about 75% to 80% of the time.45 Cognitive impairment easily verified. may be reversible with the treatment o f various medical Intolerable suffering and intractable pain. We all suffer or psychiatric conditions, or at least mav not progress if to some extent over losses, failures, unmet expectations. appropriate medical measures are taken (control blood There comes a point, however, when the severity of pressure, stop excess alcohol use, replace thyroid medi­ suffering crosses a threshold from tolerable to intolerable. cation, remove toxic drugs). Thus, it is hard to say when That threshold varies widely from individual to individ­ an illness is terminal and prospects for reversal or stabi­ ual for a given level o f physiological pain. There is reason lization are no longer present. to believe that this “toleration threshold” can be affected Unimpaired reasoning. This condition requires that a without changing the level o f physiological pain, since person is rational, has no significant impairments in the psychological aspects o f suffering often far outweigh judgment, and can freely choose between alternatives. the physical aspects. Suffering includes emotions such as Psychiatrists report that at least 95% o f suicide victims fear, hopelessness, discouragement, fatigue, anger, and have a preexisting mental illness.46-47 In a study of ter­ feelings of entrapment. Even if the level of pain remains minally ill patients, Brown and colleagues48 found that it unchanged, suffering can still be lessened, at least to the was not “normal” for even severely ill patients to either point that it is tolerable, by addressing emotional ele­ desire death or wish to end their lives. Other studies ments through psychological or psychosocial interventions. indicate that a high proportion of elders with chronic or Next, one must establish the intractability of pain or terminal illness experience depression, with rates as high other physical discomforts such as nausea or breathless­ as 40% to 45%.4950 When emotional pain reaches a ness. According to Saunders,43 approximately 10% to certain level, consciousness becomes constricted to the 15% of terminal cancer patients die with pain that cannot point where choices other than suicide cannot be appre­ be entirely eliminated. Many of these patients, however, ciated by the patient. In such cases, treatment that lessens choose to tolerate pain to maintain mental alertness to take the emotional pain will broaden consciousness so that care of “unfinished business” in their final days. “Intrac­ alternatives may be considered. Rather than infringe table pain” is actually a misnomer, since pain can always upon autonomy, the prevention of suicide and treatment be reduced or even eliminated, if by no other means than of undcrlving emotional illness act to preserve and re­ by continuous anesthesia. Under such circumstances store autonomv Requests for assistance in committing (when food and fluids are not forced), death quickly suicide, then, often mean more than a simple expression follows. of autonomy or individual choice. Although cases prob­ It is hard to say exactly how much suffering might be ably do exist, “rational” suicidal thinking in the setting of made tolerable, given adequate pain relief, support, and chronic and disabling medical illness is not common.51 nurturance from others, and maximization of autonomy On the other hand, one study by Lee and Ganzini52 by providing personal control over health care decisions. examined attitudes toward life-sustaining therapy in 50 Unspoken personal and interpersonal issues are com ­ depressed and 50 nondepressed elderly veterans hospital­ monly involved in a request for assisted suicide: fear of ized with medical illness. They found that depressed loneliness or abandonment, fear of dependency on oth­ subjects desired fewer interventions (nasogastric tubes, ers, frustration over a dismal situation, and anger toward kidney dialvsis, ventilator support, etc) than control sub­ family members or health care providers over unmet jects in hypothetical scenarios with a good prognosis and expectations. It may also represent a cry' for someone to in their current state of health; however, there were no demonstrate that this patient’s life is important, valuable differences between groups in poor prognosis scenarios. to others, and worth the struggle to continue living. It Based on the latter finding, one might conclude that the phy'sician agrees to assist in the suicidal plan, the depression does not have a major effect on the decision

175 The Journal of Familv Practice, Vol. 37, No. 2, 1993 Physician-Assisted Suicide ______Koenjj making of chronically or terminally ill patients. Note, Physician Biases however, that failure to document attitudinal differences between depressed and nondepressed patients occurred Quill and colleagues14 see safety for the patient in the stipulation that the physician involved ought to have ® only for hypothetical poor-prognosis scenarios, not real- life situations. Furthermore, attitudes toward acceptance ongoing and, ideally, long-standing personal relationship with the patient. Indeed, it is precisely that relationship or rejection of painful or cumbersome life-sustaining that will aid the physician in identifying intolerable suf­ procedures may be quite different from attitudes toward fering and unimpaired reasoning. Nevertheless, as the suicide. physician weighs the various factors noted above, his or During the Durham Veterans Administration Men­ her personal attitudes, feelings, and other factors invari­ tal Health Survey,53 we examined the relationship be­ ably come into play. From a young healthy physician- tween psychiatric disorder and suicidal thoughts in 444 standpoint, the disabled, chronic or terminally ill elder consecutively admitted younger and older hospitalized may appear to lack an acceptable “quality of life.” If so, medical patients. Among those under age 40 (n = 115), the physician may be more likely to agree that it is 19% of 57 patients with depression or other psychiatric “reasonable” and “rational” for that patient to choose to disorder had at least fleeting suicidal thoughts at the time end his or her life, while ignoring symptoms suggestim of evaluation; none of the 58 patients without mental a reversible depressive illness. disorder had such thoughts. Among patients aged 70 Other factors that may influence a physician’s deci­ years or older (n = 329), 14% of 159 patients with sion include experiences within his or her own familv. depression or other psychiatric disorder had suicidal personal ethical and moral values, anxiety over death, thoughts, compared with 1% of 170 patients without feelings about the patient, and burden of treating that mental disorder (author, unpublished data, 1991). This patient. The physician’s objectivity- may be further com­ suggests that suicidal thoughts almost always occur in the promised by pressure from the patient’s family (who arc setting of psychiatric disorder. often paying the bills) whose motivations may not reflea Ruling out depressive illness and establishing ration­ the patient’s best interests. Leaving the physician as the ality, particularly in the setting of chronic pain, suffering, sole person responsible for deciding the patient’s compe- or terminal illness, is a challenge for even the most expert tence and rationality-, then, can be problematic. clinician. Studies have shown that only 9% to 20% of One solution, noted earlier, is to require that all such depressed, medically ill older patients are diagnosed with decisions either be reviewed by a hospital ethics com m it­ this disorder by their medical physicians.54'55 Part of the tee or be reassessed by a second physician. Ethics com­ reason is that depression is very difficult to identify in mittees, while preventing a single professional from tak­ these patients. Many symptoms of physical disease are ing full responsibility for such decisions, do not solve the identical with those of psychological distress. For exam­ central problem— that is, establishing with some degree ple, chronic pain is usually accompanied by insomnia, o f certainty- that the conditions necessary- to justify phy­ fatigue, decreased concentration, and other psychological sician-assisted suicide are present. It is also unclear who and physiological symptoms that are indistinguishable would be chosen to sit on such committees or how these from depression and can impair judgment and reasoning. committees would be monitored and regulated. Many Adding to this problem is that depression in the final decisions would ultimately rest on judgments made elderly may present without sadness or dysphoria. Approx­ by the personal physician who knew the patient best. If imately 50% of all depressed persons seen by physicians that physician also had an active role in choosing the come in complaining about physical symptoms, aches consultant who would provide a second opinion, consul­ and pains, that either have no organic basis or represent tation would become a farce. an exaggeration o f real but minor physical problems.56 This syndrome has been called “masked” depression.56-57 Physical symptoms are often more acceptable to elders Slippery Slope than emotional ones, which are seen bv many as embar­ The “slippery- slope” argument contends that once the rassing and indicative of weak or unstable character. legal barrier to physician-assisted suicide is broken, there Thus, deciding whether mental illness is present in a will be little justification for limiting this practice to the suicidal patient with chronic illness often boils down to terminally ill. Wennbcrg37(P 194> notes that “once volun­ subtle perceptions, distinctions, and judgments. Such tary active euthanasia for the terminally ill is legalized, decisions are almost always made subjectively and with one can reasonably expect pressure to mount to secure some degree of uncertainty, and are therefore easily legalized euthanasia for those with illness or physical swayed by the physician’s own biases. impairment that is incurable, of a distressing character

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but not terminal.” This would include the nonterminal argue that similar abuses could not occur in the United accident victim who, unlike terminally ill patients, has to States. face suffering for the rest o f his or her lifetime. The same Generation effect. While the current generation may argument could be used to justify physician-assisted sui­ be reluctant to liberalize conditions necessary to justify' cide for those suffering from chronic, degenerative dis­ physician-assisted suicide, the next generation and the eases like Alzheimer’s disease and other disabling condi­ one following that may' have other ideas, especially' if they' tions associated with old age. have been reared in a society' where assisted suicide In Holland, where physician-assisted suicide has among the chronic or terminally ill is the norm. been tolerated since 1 9 73, 3% to 15% o f all deaths occur Wennberg37(P 202 > notes that “It is hard to introduce for by this method. Physician assistance with dying has now the first time a practice that conflicts with long-standing extended from terminal patients with cancer to chroni­ moral, social, and legal prohibitions; it is easier the cally ill patients with paraplegia, multiple sclerosis, and second time.” “gross physical deterioration at advanced age.”58 Accord­ ing to Dr T. van Berkestijn, secretary general of the KNMG, this Dutch medical organization is now opcnlv F a ilu re to Follow Guidelines preparing guidelines for terminating the lives of incom­ If physician-assisted suicide were legalized in America, petent patients: the demented elderly, the mentally hand­ how likely would it be that physicians would follow (or icapped, and defective newborns.3 The eight cases of could follow) established guidelines for this practice? assisted suicide by D r Kevorkian between 1990 and This is not a moot point. Dutch physicians have had 1992 involving middle-aged or elderly women suffering many problems in this regard. In Holland, the only from chronic but not terminal illnesses demonstrate that safeguard for assisted-suicide is the review of deaths by a such things can happen in America, too.59 coroner (a requirement by law). If physician-assisted Social and financial pressures. Powerful social and suicide accounts for between 2 0 0 0 and 10,000 deaths financial forces exist that could influence the circum­ per vear in that country, then one would expect a similar stances in which physician-assisted suicide could be car­ number of reports to coroners. Dutch coroners, how­ ried out in the years ahead if it were legalized. The cost of ever, say that they receive only about 200 reports erf health care in this countrv has been spiraling upward, and physician-assisted suicide per year.36 Enforcing laws that the pressure to contain costs has been accelerating. With standardize physician-assisted suicide has proven difficult these trends, we can expect an increasing tendency to in Holland, as it likely would in America. Because of the limit the provision of health care for those who are less negative attitudes our society' has toward suicide, main­ productive or seen as profiting least from such expendi­ tenance of privacy has been a central component erf tures.35 Physician-assisted suicide, then, would provide inititatives for physician-assisted suicide in the states erf an all too expedient solution to the problem of an ex­ Washington and California. Balancing this need with the panding, chronically ill elderlv population. need to control the practice and monitor for abuses Substituted judgment. H ow might a society' imple­ would be a difficult task. ment physician-assisted suicide for incompetent patients? “Substituted judgments” made by either the physician or Sensible Alternatives family member might be called on to justify' such acts. Substituted judgments would have merit if it could be Rather than assist and support patients in ending their established that physicians and relatives accurately pre­ lives, physicians may choose to seek the underlying dict how patients might feel in such circumstances. U n­ causes for suffering and then aggressively implement fortunately, evidence for this is lacking.60 Proponents of measures to correct them. This may include arranging for physician-assisted suicide argue that assisting the death of companionship to alleviate loneliness, mobilizing family incompetent patients or of patients against their will members to dispel a sense of abandonment, providing would never happen; the situation in Holland, however, assistive devices to help limit disability, or allowing the speaks loudly to the contrary. A recent survey of Dutch patient’s participation in medical decision making to physicians’ participation in patient deaths found that maximize autonomy and self-care. More research could about 3% of all deaths in Holland could be attributable be directed into improving medical control of distressing to physician-assisted suicide.1 Physicians admitted, how­ symptoms such as pain, nausea, and breathlessness, and ever, that nearly 28% of such deaths (500 to 1000 per conditions such as constipation, incontinence, and other year) were performed “without an explicit and persistent intolerable physical problems associated with dying. request” bv the patient. Given this fact, it is difficult to Likewise, comprehensive psychological and spiritual care

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could be offered to help lessen emotional discomfort, this setting may even cause a release into the bloodstream- relieve anxiety or depression, and convey hope. Each of of natural analgesic substances that act to relieve these actions requires more effort, more money, and pain.62-63 Similarly, limiting fluids will minimize secre­ more time than simply allowing patients to terminate tions, ease respirations, decrease incontinence, and cause their lives. Nevertheless, these actions preserve the tradi­ little discomfort to the patient.64-65 Thus, forcing food0- tional role of the physician as healer, sustainer of life, and fluids into terminally ill patients who have little desire for afforder of comfort. Furthermore, such efforts prove to these substances is not only counterproductive but cruel our elderly and young people that disabled and chroni­ Instead, all efforts should be directed at simple com­ cally and terminally ill persons are valuable to society, fort measures, such as providing good skin and oral care, that life is worth fighting for, and that tough problems maintaining a fresh and clean environment, and album, sometimes require tough answers. the patient as much freedom as possible in deciding how Improving care for the dying. With good hospice care, and where to spend his or her final days. A narcotic most terminally ill patients can be made comfortable, analgesic such as morphine should be used freely and even if pain cannot be entirely eliminated.43-61 Adequate unrestrictedly to relieve pain, nausea, or shortness ol analgesia can be maintained with high doses of narcotics breath. In some cases, an excess dose of such medicatior that are either self-administered by patient-controlled may inadvertently hasten or cause the patient’s death infusion devices or administered by a continuous intra­ This risk should be acknowledged and is unavoidable venous drip monitored by health care providers. The emotional aspects of suffering (feelings of isolation, dys­ phoria, and anxiety) can be greatly diminished by having Need for Research and Ongoing a close relationship with another person (family, friend, or hospice staff'member), by supportive counseling, or in Debate cases of severe depression, by use of antidepressants, Sensible alternatives to physician-assisted suicide do exist tranquilizers, or sometimes, electroconvulsive therapy. and must be pursued. Nevertheless, the case for legaliz­ Allowing to die. Humane care for the dying includes ing physician-assisted suicide is a strong one that cannc: recognizing when provision of comfort must become the be ignored. Further research is needed on attitudes to­ primary goal. This is particularly true for terminally ill ward physician-assisted suicide held by the elderly auc patients with only a few weeks or months to live who are those with chronic or terminal illness, with and without suffering to the point that life has lost its meaning. This mental illness. In addition, this topic needs continuin' may also be true for certain patients with severe and debate among those within medicine so that all sides o: irreversible dementia, those with irreversible coma, and the question can be carefully considered. If we decide to those who exist in a persistent vegetative state (alive but legalize physician-assisted suicide, then guidelines shout with only minimal brain activity). Family members and be carefullv established, with physicians having an activ; friends should be encouraged to visit and spend time role in the process. Family physicians must enter this with their loved one. If suspected, depression or anxiety debate and voice their support or concerns, since they ait should be vigorously treated in conscious patients. the physicians who would assist patients in commit®: After arriving at a consensus by patient (when con­ suicide if the practice were legalized. scious), family, and health care providers (in that order), an agreement can be made to use whatever means nec­ essary to provide comfort and relieve symptoms, even at Acknowledgments the risk o f hastening death. This plan should be clearly documented in the chart. Advanced directives may guide Funding for this work was provided by the Center for the Study Aging and Human Development, Duke University Medical Centc family and health care providers in making such decisions (grant #A G 00371), and by the Geriatric Research, Education, it: for unconscious or incompetent patients. At this point, Clinical Center (GRECC), VAMC, Durham, NC. all life support measures, including administration of food and water, may be withdrawn and interventions to prolong life avoided in circumstances where death is References imminent and suffering is intolerable, or where con­ 1. Van der Maas PJ, Van Delden JJ, Pinenborg L, et al. Euthaw sciousness has been obliterated by continuous anesthesia. and other medical decisions concerning the end of life. L» While the popular press portrays starvation and de­ 1991; 338:669-74. hydration as the epitome of neglect, medical experts arc 2. Watts DT, Howell T. Assisted suicide is not voluntary 2® euthanasia. J Am Geriatr Soc 1992; 40:1043-6. aware that when death approaches, discomfort from hun­ 3. de Wachter MAM. Euthanasia in the Netherlands. Hastings C; ger or thirst becomes minimal or absent. Starvation in Rep 1992; 22:23-31.

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