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.