The Case against Assisted Suicide The Case against Assisted Suicide For the Right to End-of-Life Care Edited by Kathleen Foley, M.D. Professor, Department of Neurology, Weill Medical College of Cornell University Attending Neurologist, Pain and Palliative Care Service, Memorial Sloan-Kettering Cancer Center Director, Project on Death in America, Open Society Institute, Soros Foundation New York, New York and Herbert Hendin, M.D. Professor, Department of Psychiatry and Behavioral Sciences, New York Medical College Medical Director, American Foundation for Suicide Prevention New York, New York The Johns Hopkins University Press Baltimore and London © 2002 The Johns Hopkins University Press All rights reserved. Published 2002 Printed in the United States of America on acid-free paper Johns Hopkins Paperbacks edition, 2004 9 8 7 6 4 3 2 1 The Johns Hopkins University Press 2715 North Charles Street Baltimore, Maryland 21218-4363 www.press.jhu.edu The Library of Congress has cataloged the hardcover edition of this book as follows: The case against assisted suicide : for the right to end-of-life care / edited by Kathleen Foley and Herbert Hendin p. ; cm. Includes bibliographical references and index. ISBN o-8018-6792-4 (hardcover : alk. paper) 1. Assisted suicide. [DNLM: 1. Suicide, Assisted—legislation & jurisprudence— United States. 2. Terminal Care—United States. W32.5 AM. C337 2002] I. Foley, Kathleen M., 1944— II. Hendin, Herbert. R726 .C333 2002 174%24 — dc21 zool000823 ISBN 0-8018-7901-9 (pbk. : alk. paper) A catalog record for this book is available from the British Library. Contents Preface vii Acknowledgments ix List of Contributors xi Introduction: A Medical, Ethical, Legal, and Psychosocial Perspective Kathleen Foley and Herbert Hendin 1 Autonomy, Compassion, and Rational Suicide 1. "I Will Give No Deadly Drug": Why Doctors Must Not Kill Leon R. Kass 17 2. Compassion Is Not Enough Edmund D. Pellegrino 41 3. Reason, Self-determination, and Physician-Assisted Suicide Daniel Callahan 52 4. The Rise and Fall of the "Right" to Assisted Suicide Yale Kamisar 69 Practice versus Theory 5. The Dutch Experience Herbert Hendin 97 6. Palliative Care and Euthanasia in the Netherlands: Observations of a Dutch Physician Zbigniew Zylicz 122 7. The Oregon Experiment Kathleen Foley and Herbert Hendin 144 8. Oregon's Culture of Silence N. Gregory Hamilton 175 9. Deadly Days in Darwin David W. Kissane 192 vi _., Contents Reason to Be Concerned 10. Not Dead Yet Diane Coleman 213 11. Vulnerable People: Practical Rejoinders to Claims in Favor of Assisted Suicide Felicia Cohn and Joanne Lynn 238 12. Depression and the Will to Live in the Psychological Landscape of Terminally Ill Patients Harvey M. Chochinov and Leonard Schwartz 261 A Better Way 13. A Hospice Perspective Cicely Saunders 281 14. Compassionate Care, Not Assisted Suicide Kathleen Foley 293 Conclusion: Changing the Culture Kathleen Foley and Herbert Hendin 311 Notes 333 Index 365 Preface he debate over physician-assisted suicide has drawn attention to the T complex issues of end-of-life care. This edited text brings together a group of authors — ethicists, lawyers, clinicians, health care policy experts—who have argued thoughtfully and cogently against physician- assisted suicide as a social policy. We hope that this book serves as a resource for facts, opinions, and general discourse while offering a com- prehensive perspective on the case against physician-assisted suicide and for palliative care. To date there is no such book. One of our major goals is to draw attention to the vulnerability of the dying population and the evidence that legalizing assisted suicide increases that vulnerability. That evidence is drawn largely from the Dutch and Oregon experiences with physician-assisted suicide. A driving force in this publication is our own clinical experience in caring for patients with serious life-threatening illnesses such as cancer and suicidal depression. Such patients, who are often elderly, are pro- foundly vulnerable in our current social and health care system, which devalues their quality of life and inadequately assesses and treats their pain, their psychological symptoms, their emotional distress, and the associated burden to their caregivers. We join with each of the authors in seeking to advance an open and tolerant discussion to address how we as a society can provide better health care and social support to those who are uniquely vulnerable and suffering. Acknowledgments e gratefully acknowledge the contributions of several individ- Wuals who helped with the publication of this edited text. We are indebted to each of the authors, who patiently addressed the questions posed in reviewing their manuscripts and in formatting their chapters to reflect a coherent discussion of the physician-assisted suicide debate. We particularly thank Bette-Jane Crigger of the Hastings Center, for her editorial review of the text before it was submitted for publication; Yale Kamisar, who, in addition to contributing a chapter, read the entire manu- script and provided his legal expertise, encouragement, and enthusiasm for the project; and Bridget King, for her help in preparing the manu- script and researching references. Josephine Hendin, professor of English at New York University, helped with the writing and rewriting of the introduction and conclusion. We are grateful for help from col- leagues at our respective institutions, but the views expressed in the book are those of the authors and do not necessarily reflect the opinions or policies of their institutions. Finally, we wish to thank Wendy Harris, our editor at the Johns Hopkins University Press, for her confidence in the project and her guidance in bringing it to fruition. Contributors Daniel Callahan, Ph.D., Director of International Programs and Co-founder, The Hastings Center, Garrison, New York Harvey M. Chochinov, M.D., Ph.D., Professor of Psychiatry and Family Medicine, University of Manitoba, Winnipeg, Canada Felicia Cohn, Ph.D., Program Officer, Institute of Medicine/ National Research Council, Washington, D.C. Diane Coleman, J.D., President, Not Dead Yet, Forest Park, Illinois N. Gregory Hamilton, M.D., Clinical Associate Professor, Department of Psychiatry, Oregon Health Sciences University; and President, Physicians for Compassionate Care, Portland, Oregon Yale Kamisar, LL.B., LL.D. (hon.), Clarence Darrow Distinguished University Professor of Law, University of Michigan Law School, Ann Arbor, Michigan Leon R. Kass, M.D., Ph.D., Addie Clark Harding Professor, the Committee on Social Thought and the College, University of Chicago, Chicago, Illinois xii Contributors David W. Kissane, M.B., B.S., M.P.M., MD., ER.A.C.G.P., F.A.Ch.P.M., F.R.A.N.Z.C.P., Director of Palliative Medicine at the University of Melbourne and the Center for Palliative Care, St. Vincent's, Victoria, Australia Joanne Lynn, M.D., M.A., M.S., Director, RAND Center to Improve Care of the Dying, Arlington, Virginia Edmund D. Pellegrino, M.D., John Carroll Professor of Medicine and Medical Ethics and Director, Center for Clinical Bioethics, Georgetown University, Washington, D.C. Cicely Saunders, 0.M., F.R.C.P., Founder and President, St. Christopher's Hospice, London, United Kingdom Leonard Schwartz, LL.B., LL.M., M.D., Department of Psychiatry, University of Manitoba, Winnipeg, Canada Zbigniew Zylicz, M.D., Fellow in Palliative Care, University of Nijmegen; and Director, Hospice Rozenheuvel, Rozendaal, the Netherlands Introduction: A Medical, Ethical, Legal, and Psychosocial Perspective Kathleen Foley, M.D., and Herbert Hendin, M.D. hould we legalize physician-assisted suicide and euthanasia? Few Sissues have the potential to divide society as much as this one. Polls show that opinion divides old against young and black against white and sets the disabled apart. In the spring of 1997 the U.S. Supreme Court rejected a federal constitutional right to assisted suicide, essentially re- turning the struggle over legalization to the states and to the court of public opinion. Assisted suicide is an issue about which the public needs to be informed, one whose importance will only increase with the in- creasing percentage of elderly people in the population. The conditions peculiar to our age have made those who are dying in our culture profoundly vulnerable. The bonds of community are weak, and insistence on individual rights is strong. Advances in high-technol- ogy life-support systems, growing numbers of cancer and AIDS patients struggling with fatal diagnoses, the aging population, and increasing limitations on health care resources create an environment that particu- larly threatens patients with terminal illnesses. Such patients have mul- tiple physical and psychosocial symptoms compounded by a substantial degree of existential distress. Physicians have increasingly identified their own attitudinal, behav- ioral, educational, and economic barriers to providing humane, com- passionate, appropriate care to such patients. Such barriers make us seriously concerned that physicians inadequately equipped to care for those who are dying would substitute physician-assisted suicide for rational, therapeutic, psychological, and social interventions that could 2 -0 KATHLEEN FOLEY AND HERBERT HENDIN enhance the quality of life for dying patients. Health care professionals need to take the lead in developing guidelines for good care of the dying in the management of pain, the treatment of psychosocial distress, and the provision of social support for caregivers. Surveys of both the general public and health care professionals con- clude that our society provides woefully inadequate care for those who are dying and that we need to improve the care of such patients. We en- dorse the World Health Organization recommendation that govern- ments not consider the legalization of physician-assisted suicide and euthanasia until they have demonstrated the full availability and prac- tice of palliative care for all citizens. In the United States, we have a long way to go to reach this goal. Given public awareness of the inadequacies of care for those who are dying, it is not surprising that if asked "Are you in favor of euthanasia?" most people reply that they are.