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Is Physician-Assisted Suicide Ever Justified?
Physician-assisted suicide and euthanasia (PAS/E) are contrary to the 2,500-year-old historic and vitally important professional ethic of caring and healing. The professional ethic of medicine is to care for the patient. Francis Peabody said in 1927, “The secret of caring for the patient is in caring for the patient.”1 This is not a tautology, but a truism. The proper response to a request for physician-assisted suicide or euthanasia is excellent end-of-life care.
The American Medical Association maintains an unequivocal position on this issue: “Physician-assisted suicide is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks. Instead of participating in assisted suicide, physicians must aggressively respond to the needs of patients at the end of life ... .”2
In both ancient and modern times some physicians have, on occasion, secretly assisted patients with suicide or have even administered lethal medication themselves when they felt extenuating circumstances justified an exception to the societal standard and the professional rule. Until Jack Kevorkian, MD, it was done in secret because this rule was recognized as valid.
Historically, there have been several periods of time when euthanasia was given serious public debate. But until 1984, when the Royal Dutch Medical Association took the revolutionary position that it was professionally acceptable for a physician to give a lethal injection to a patient under certain clearly defined circumstances, that debate was always silenced by returning to the professional ethic of healing and not killing.
Arguments in Favor of Physician-Assisted Suicide/Euthanasia
In the current debate about the legalization of assisted suicide, supporters offer three major arguments:
- A patient has a right to self-determination;
- It is the compassionate thing to do; and
- It is working in the Netherlands and in Oregon, so we should allow it elsewhere, too.
The first two arguments have remained the same for more than 200 years.3
The right to self-determination: Proponents maintain, correctly, that a patient has a right to accept or refuse any treatment—even if that refusal leads to death. They go on to maintain that the patient should then have the right to request any treatment they want, even medical assistance with bringing about death.
Though a patient has a negative right to be left alone, I believe this does not translate into a positive right (an entitlement) to whatever he or she wants. If that were the case, there would be no need for laws to regulate prescription drugs; a patient could just buy whatever he or she felt was appropriate. Patient autonomy is not absolute any more than is a generic right to personal freedom. The U.S. Supreme Court has found there is no constitutional right to assisted suicide.
Compassion: Supporters of PAS/E often point out that “we shoot horses, don’t we?” implying that our compassionate response to animal suffering should be extended to include human suffering. This is only tenable in a worldview that concludes that there is no moral difference between humans and animals. If you believe, as do most people in Western society, that a) we have a greater obligation to human beings than we do to animals, and that b) human life is special and should be respected and protected whenever possible, then we are obligated to find a better solution to terminal suffering in humans.
Compassion, while perhaps more compelling than self-determination, is still not determinative. As Pellegrino has said, “ ... compassion is a virtue, not a principle. Morally weighty as it is, compassion can become maleficent unless it is constrained by principle.”4 Compassion means “to suffer with.” Compassionate patient care involves coming alongside patients who are suffering, being with them, and doing all we can to alleviate that suffering.
The Dutch example: Other supporters of PAS/E offer a more pragmatic defense of their position, suggesting that the Dutch have proven that regulated euthanasia can work; however, it is not always used as a “last resort.” In nearly 20% of cases available palliative measures were declined by the patient; 60% of cases were not reported truthfully; 50% of cases did not have the required consultation; and—most worrisome of all—25% of patients who were given a lethal injection did not request euthanasia.5
Conversely, only about one-third of patient requests for euthanasia are carried out by Dutch physicians. Thus, two-thirds of patients who request euthanasia are denied it, and one-quarter of patients who are euthanized did not request it, suggesting that it is not patient autonomy that drives the Dutch euthanasia program, but physician autonomy. We must conclude that the Dutch experiment with regulated euthanasia has failed.
Arguments Opposing Physician-Assisted Suicide/Euthanasia
In addition to these rebuttals to those arguments in favor of PAS/E, there are several specific arguments in opposition. These have been well articulated elsewhere.6-8 They will merely be summarized here in two groups:
- Rule-based arguments: PAS/E goes against longstanding professional virtue and would change the nature of the patient-doctor relationship, perhaps even detracting from efforts at palliative care; and
- Consequence-based arguments: PAS/E would be bad public policy because regulations cannot prevent abuses and expansions of the “indications” to include coerced “voluntary” PAS/E, surrogate non-voluntary PAS/E for those who have lost decision-making capacity, requests from patients who are suffering (but not terminally ill), and even discriminatory involuntary euthanasia as a cost-control measure.9
The Moral High Ground
If we accept that PAS/E are contrary to physician virtue and moral tradition, and further that legalization of such activities would be bad public policy, what then is the alternative? The alternative is excellent end-of-life care. This requires a commitment to compassion, a willingness to “suffer with” the patient. Good palliative/hospice care has the goal of helping the patient to live each day as well as possible. Patients who receive good end-of-life care rarely request that their physicians hasten death.10
If a terminally ill patient does make such a request, the physician must elicit the reason by saying, “I’m sorry you are suffering. How can I help to make it better?” In addition, the physician should give the patient as much control as possible over treatment options when the patient is ready to shift goals to comfort care. The physician must never say, “There is nothing more I can do for you.” Such a statement represents an immoral abandonment of the patient. Instead the physician should say, “There is nothing more we can do to stop or slow the disease process, but there is a lot more we can do for you.”
All of the patient’s physical needs must be thoroughly addressed. This means intensive symptom control of pain and dyspnea, the two most feared symptoms at the end of life, as well as the multitude of other symptoms experienced by patients as they approach death.
Psychological symptoms are almost universal in dying patients. Anxiety about the future is understandable. Depression is likewise to be expected in a significant percentage of patients. Both need treatment, whether that be drugs, counseling, or someone to sit with the patient. Ramsay has said that people who are dying need only two things, comfort (symptom control) and company (human presence).11
Social issues also need assessment and treatment. Many dying people are lonely. Friends often stop visiting because they are uncomfortable and do not know what to say. Even family members may distance themselves physically and emotionally from a patient who is approaching death. Patients may have “unfinished business” that causes them unspoken distress. Byock has observed that a person who is dying often needs to say one or more of the following five things: “Will you forgive me?” “I forgive you,” “Thank you,” “I love you,” and “Goodbye.”12
The final dimension in whole person care is the spiritual. While this is important in caring for any patient who is seriously ill, it becomes imperative in dying patients. When facing death, patients often ruminate on guilt about how they have lived their lives. Others may develop uncertainty or doubts about even longstanding beliefs. They may have many questions about the meaning of life and the meaning of death.
It is rare indeed that one professional is able to address all of the physical, psychological, social, and spiritual needs of dying patients. It requires a multidisciplinary team including nurses, physicians, therapists, counselors, pastoral care workers, social workers, and lay volunteers. Such a team is usually best mobilized through a formal hospice or palliative care program, but may at times be coordinated through a primary care physician’s office or a community or church organization.
The Imperative for Good Pain Management
In spite of excellent resources too numerous to cite, and in spite of practice guidelines and quality improvement guidelines, pain management is often inadequate.13-15 JCAHO has issued pain management standards that affirm both the patient’s right to appropriate assessment and management of pain and the institution’s responsibilities.16
Perhaps the most commonly asked ethical question about pain management at the end of life is concern about the inadvertent—or even the intentional—suppression of respiration with the use of high doses of opioids that could lead to an earlier death. Experts in pain management maintain that this rarely—if ever—happens because pain is a good respiratory stimulant. Even with good empiric evidence that narcotic use does not hasten death, this myth continues to discourage many physicians from fulfilling their obligation to relieve suffering.17
But let us consider the worst-case scenario: What if a terminally ill patient with overwhelming pain requires rapidly increasing doses of narcotics and does actually suffers from respiratory depression. Is the physician morally obligated to use ventilatory support to overcome this side effect? Thomas Aquinas (1224-1274) answered this question with his “rule of double effect”: It is morally permissible to do an act that has both a good effect and a bad effect if all of the following conditions exist:
- The act must be inherently good, or at least morally neutral;
- The bad effect may be anticipated, but not intended;
- The good effect must not be achieved by means of the bad effect; and
- There must be a proportionately grave reason for allowing the bad effect.
Using high doses of narcotics to relieve pain fits these criteria.
Terminal Sedation
Because of the continued legal and professional proscription against PAS/E, some have proposed the use of “terminal sedation”: the practice of giving sedation to a patient who is dying, expecting that he or she will die more quickly of dehydration. If the intention is clearly to hasten death, then this is euthanasia and, in my estimation, it is an immoral end-run around the current legal and professional prohibitions. If, however, maximal efforts have failed to adequately relieve the suffering of an imminently dying patient, it would be ethically permissible to render the patient unconscious in order to relieve pain, accepting the unintended side effect of an earlier death from dehydration. This too would be justifiable using the rule of double effect.
Conclusion
PSA/E have been outside the bounds of acceptable behavior for physicians for hundreds of years. The moral, legal, and professional acceptable alternative is excellent end-of-life care. TH
To cure, sometimes; to heal, often; to comfort, always.—15th century French proverb.
Dr. Orr is a clinical ethicist at the Fletcher Allen Health Care in Burlington, Vt.
References
- Peabody F. The care of the patient. JAMA. 1927;88:877-882.
- Code of Medical Ethics, AMA (1994). Opinion 2.211 “Physician Assisted Suicide”: 51.
- Emanuel EJ. The history of euthanasia debates in the United States and Britain. Ann Intern Med. 1994;121(10):793-802.
- Pellegrino ED. Compassion needs reason too. JAMA. 1993;270(7):870-873.
- Jochemsen H, Keown J. Voluntary euthanasia under control? Further empirical evidence from the Netherlands. J Med Ethics. 1999;25(1):16-21.
- Kass LR. Neither for love nor money: why doctors must not kill. The Public Interest. 1989;94:25-46.
- Callahan D. When self-determination runs amok. Hastings Center Report. 1992;22(2):52-55.
- Singer PA, Siegler M. Euthanasia—a critique. N Eng J Med. 1990;322(26):1881-1883.
- Hendin H. Selling death and dignity. Hastings Center Report. 1995;25(3):19-23.
- Brown JH, Hentelheff P, Barakat S, et al. Is it normal for terminally ill patients to desire death? Am J Psych. 1986;143(2):208-211.
- Ramsay P. The Patient as Person. New Haven, Conn.: Yale University Press; 1970:113-164.
- Byock I. The nature of suffering and the nature of opportunity at the end of life. Clin Geriatr Med. 1996;12(2):237-252.
- Agency for Health Care Policy and Research. Management of Cancer Pain. Rockville, Md.: U.S. Department of Health and Human Services, 1994
- American Pain Society Quality of Care Committee. Quality improvement guidelines for the treatment of acute pain and cancer pain. JAMA. 1995;274(23):1874-1880.
- Cleeland CS. Undertreatment of cancer pain in elderly patients. JAMA. 1998;279(23):1914-1915.
- Phillips DM. JACHO pain management standards are unveiled. JAMA. 2000;284(4):428-429.
- Thorns A, Sykes N. Opioid use in the last week of life and implications for end-of-life decision making. Lancet. 2000;356:398-399.
Physician-assisted suicide and euthanasia (PAS/E) are contrary to the 2,500-year-old historic and vitally important professional ethic of caring and healing. The professional ethic of medicine is to care for the patient. Francis Peabody said in 1927, “The secret of caring for the patient is in caring for the patient.”1 This is not a tautology, but a truism. The proper response to a request for physician-assisted suicide or euthanasia is excellent end-of-life care.
The American Medical Association maintains an unequivocal position on this issue: “Physician-assisted suicide is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks. Instead of participating in assisted suicide, physicians must aggressively respond to the needs of patients at the end of life ... .”2
In both ancient and modern times some physicians have, on occasion, secretly assisted patients with suicide or have even administered lethal medication themselves when they felt extenuating circumstances justified an exception to the societal standard and the professional rule. Until Jack Kevorkian, MD, it was done in secret because this rule was recognized as valid.
Historically, there have been several periods of time when euthanasia was given serious public debate. But until 1984, when the Royal Dutch Medical Association took the revolutionary position that it was professionally acceptable for a physician to give a lethal injection to a patient under certain clearly defined circumstances, that debate was always silenced by returning to the professional ethic of healing and not killing.
Arguments in Favor of Physician-Assisted Suicide/Euthanasia
In the current debate about the legalization of assisted suicide, supporters offer three major arguments:
- A patient has a right to self-determination;
- It is the compassionate thing to do; and
- It is working in the Netherlands and in Oregon, so we should allow it elsewhere, too.
The first two arguments have remained the same for more than 200 years.3
The right to self-determination: Proponents maintain, correctly, that a patient has a right to accept or refuse any treatment—even if that refusal leads to death. They go on to maintain that the patient should then have the right to request any treatment they want, even medical assistance with bringing about death.
Though a patient has a negative right to be left alone, I believe this does not translate into a positive right (an entitlement) to whatever he or she wants. If that were the case, there would be no need for laws to regulate prescription drugs; a patient could just buy whatever he or she felt was appropriate. Patient autonomy is not absolute any more than is a generic right to personal freedom. The U.S. Supreme Court has found there is no constitutional right to assisted suicide.
Compassion: Supporters of PAS/E often point out that “we shoot horses, don’t we?” implying that our compassionate response to animal suffering should be extended to include human suffering. This is only tenable in a worldview that concludes that there is no moral difference between humans and animals. If you believe, as do most people in Western society, that a) we have a greater obligation to human beings than we do to animals, and that b) human life is special and should be respected and protected whenever possible, then we are obligated to find a better solution to terminal suffering in humans.
Compassion, while perhaps more compelling than self-determination, is still not determinative. As Pellegrino has said, “ ... compassion is a virtue, not a principle. Morally weighty as it is, compassion can become maleficent unless it is constrained by principle.”4 Compassion means “to suffer with.” Compassionate patient care involves coming alongside patients who are suffering, being with them, and doing all we can to alleviate that suffering.
The Dutch example: Other supporters of PAS/E offer a more pragmatic defense of their position, suggesting that the Dutch have proven that regulated euthanasia can work; however, it is not always used as a “last resort.” In nearly 20% of cases available palliative measures were declined by the patient; 60% of cases were not reported truthfully; 50% of cases did not have the required consultation; and—most worrisome of all—25% of patients who were given a lethal injection did not request euthanasia.5
Conversely, only about one-third of patient requests for euthanasia are carried out by Dutch physicians. Thus, two-thirds of patients who request euthanasia are denied it, and one-quarter of patients who are euthanized did not request it, suggesting that it is not patient autonomy that drives the Dutch euthanasia program, but physician autonomy. We must conclude that the Dutch experiment with regulated euthanasia has failed.
Arguments Opposing Physician-Assisted Suicide/Euthanasia
In addition to these rebuttals to those arguments in favor of PAS/E, there are several specific arguments in opposition. These have been well articulated elsewhere.6-8 They will merely be summarized here in two groups:
- Rule-based arguments: PAS/E goes against longstanding professional virtue and would change the nature of the patient-doctor relationship, perhaps even detracting from efforts at palliative care; and
- Consequence-based arguments: PAS/E would be bad public policy because regulations cannot prevent abuses and expansions of the “indications” to include coerced “voluntary” PAS/E, surrogate non-voluntary PAS/E for those who have lost decision-making capacity, requests from patients who are suffering (but not terminally ill), and even discriminatory involuntary euthanasia as a cost-control measure.9
The Moral High Ground
If we accept that PAS/E are contrary to physician virtue and moral tradition, and further that legalization of such activities would be bad public policy, what then is the alternative? The alternative is excellent end-of-life care. This requires a commitment to compassion, a willingness to “suffer with” the patient. Good palliative/hospice care has the goal of helping the patient to live each day as well as possible. Patients who receive good end-of-life care rarely request that their physicians hasten death.10
If a terminally ill patient does make such a request, the physician must elicit the reason by saying, “I’m sorry you are suffering. How can I help to make it better?” In addition, the physician should give the patient as much control as possible over treatment options when the patient is ready to shift goals to comfort care. The physician must never say, “There is nothing more I can do for you.” Such a statement represents an immoral abandonment of the patient. Instead the physician should say, “There is nothing more we can do to stop or slow the disease process, but there is a lot more we can do for you.”
All of the patient’s physical needs must be thoroughly addressed. This means intensive symptom control of pain and dyspnea, the two most feared symptoms at the end of life, as well as the multitude of other symptoms experienced by patients as they approach death.
Psychological symptoms are almost universal in dying patients. Anxiety about the future is understandable. Depression is likewise to be expected in a significant percentage of patients. Both need treatment, whether that be drugs, counseling, or someone to sit with the patient. Ramsay has said that people who are dying need only two things, comfort (symptom control) and company (human presence).11
Social issues also need assessment and treatment. Many dying people are lonely. Friends often stop visiting because they are uncomfortable and do not know what to say. Even family members may distance themselves physically and emotionally from a patient who is approaching death. Patients may have “unfinished business” that causes them unspoken distress. Byock has observed that a person who is dying often needs to say one or more of the following five things: “Will you forgive me?” “I forgive you,” “Thank you,” “I love you,” and “Goodbye.”12
The final dimension in whole person care is the spiritual. While this is important in caring for any patient who is seriously ill, it becomes imperative in dying patients. When facing death, patients often ruminate on guilt about how they have lived their lives. Others may develop uncertainty or doubts about even longstanding beliefs. They may have many questions about the meaning of life and the meaning of death.
It is rare indeed that one professional is able to address all of the physical, psychological, social, and spiritual needs of dying patients. It requires a multidisciplinary team including nurses, physicians, therapists, counselors, pastoral care workers, social workers, and lay volunteers. Such a team is usually best mobilized through a formal hospice or palliative care program, but may at times be coordinated through a primary care physician’s office or a community or church organization.
The Imperative for Good Pain Management
In spite of excellent resources too numerous to cite, and in spite of practice guidelines and quality improvement guidelines, pain management is often inadequate.13-15 JCAHO has issued pain management standards that affirm both the patient’s right to appropriate assessment and management of pain and the institution’s responsibilities.16
Perhaps the most commonly asked ethical question about pain management at the end of life is concern about the inadvertent—or even the intentional—suppression of respiration with the use of high doses of opioids that could lead to an earlier death. Experts in pain management maintain that this rarely—if ever—happens because pain is a good respiratory stimulant. Even with good empiric evidence that narcotic use does not hasten death, this myth continues to discourage many physicians from fulfilling their obligation to relieve suffering.17
But let us consider the worst-case scenario: What if a terminally ill patient with overwhelming pain requires rapidly increasing doses of narcotics and does actually suffers from respiratory depression. Is the physician morally obligated to use ventilatory support to overcome this side effect? Thomas Aquinas (1224-1274) answered this question with his “rule of double effect”: It is morally permissible to do an act that has both a good effect and a bad effect if all of the following conditions exist:
- The act must be inherently good, or at least morally neutral;
- The bad effect may be anticipated, but not intended;
- The good effect must not be achieved by means of the bad effect; and
- There must be a proportionately grave reason for allowing the bad effect.
Using high doses of narcotics to relieve pain fits these criteria.
Terminal Sedation
Because of the continued legal and professional proscription against PAS/E, some have proposed the use of “terminal sedation”: the practice of giving sedation to a patient who is dying, expecting that he or she will die more quickly of dehydration. If the intention is clearly to hasten death, then this is euthanasia and, in my estimation, it is an immoral end-run around the current legal and professional prohibitions. If, however, maximal efforts have failed to adequately relieve the suffering of an imminently dying patient, it would be ethically permissible to render the patient unconscious in order to relieve pain, accepting the unintended side effect of an earlier death from dehydration. This too would be justifiable using the rule of double effect.
Conclusion
PSA/E have been outside the bounds of acceptable behavior for physicians for hundreds of years. The moral, legal, and professional acceptable alternative is excellent end-of-life care. TH
To cure, sometimes; to heal, often; to comfort, always.—15th century French proverb.
Dr. Orr is a clinical ethicist at the Fletcher Allen Health Care in Burlington, Vt.
References
- Peabody F. The care of the patient. JAMA. 1927;88:877-882.
- Code of Medical Ethics, AMA (1994). Opinion 2.211 “Physician Assisted Suicide”: 51.
- Emanuel EJ. The history of euthanasia debates in the United States and Britain. Ann Intern Med. 1994;121(10):793-802.
- Pellegrino ED. Compassion needs reason too. JAMA. 1993;270(7):870-873.
- Jochemsen H, Keown J. Voluntary euthanasia under control? Further empirical evidence from the Netherlands. J Med Ethics. 1999;25(1):16-21.
- Kass LR. Neither for love nor money: why doctors must not kill. The Public Interest. 1989;94:25-46.
- Callahan D. When self-determination runs amok. Hastings Center Report. 1992;22(2):52-55.
- Singer PA, Siegler M. Euthanasia—a critique. N Eng J Med. 1990;322(26):1881-1883.
- Hendin H. Selling death and dignity. Hastings Center Report. 1995;25(3):19-23.
- Brown JH, Hentelheff P, Barakat S, et al. Is it normal for terminally ill patients to desire death? Am J Psych. 1986;143(2):208-211.
- Ramsay P. The Patient as Person. New Haven, Conn.: Yale University Press; 1970:113-164.
- Byock I. The nature of suffering and the nature of opportunity at the end of life. Clin Geriatr Med. 1996;12(2):237-252.
- Agency for Health Care Policy and Research. Management of Cancer Pain. Rockville, Md.: U.S. Department of Health and Human Services, 1994
- American Pain Society Quality of Care Committee. Quality improvement guidelines for the treatment of acute pain and cancer pain. JAMA. 1995;274(23):1874-1880.
- Cleeland CS. Undertreatment of cancer pain in elderly patients. JAMA. 1998;279(23):1914-1915.
- Phillips DM. JACHO pain management standards are unveiled. JAMA. 2000;284(4):428-429.
- Thorns A, Sykes N. Opioid use in the last week of life and implications for end-of-life decision making. Lancet. 2000;356:398-399.
Physician-assisted suicide and euthanasia (PAS/E) are contrary to the 2,500-year-old historic and vitally important professional ethic of caring and healing. The professional ethic of medicine is to care for the patient. Francis Peabody said in 1927, “The secret of caring for the patient is in caring for the patient.”1 This is not a tautology, but a truism. The proper response to a request for physician-assisted suicide or euthanasia is excellent end-of-life care.
The American Medical Association maintains an unequivocal position on this issue: “Physician-assisted suicide is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks. Instead of participating in assisted suicide, physicians must aggressively respond to the needs of patients at the end of life ... .”2
In both ancient and modern times some physicians have, on occasion, secretly assisted patients with suicide or have even administered lethal medication themselves when they felt extenuating circumstances justified an exception to the societal standard and the professional rule. Until Jack Kevorkian, MD, it was done in secret because this rule was recognized as valid.
Historically, there have been several periods of time when euthanasia was given serious public debate. But until 1984, when the Royal Dutch Medical Association took the revolutionary position that it was professionally acceptable for a physician to give a lethal injection to a patient under certain clearly defined circumstances, that debate was always silenced by returning to the professional ethic of healing and not killing.
Arguments in Favor of Physician-Assisted Suicide/Euthanasia
In the current debate about the legalization of assisted suicide, supporters offer three major arguments:
- A patient has a right to self-determination;
- It is the compassionate thing to do; and
- It is working in the Netherlands and in Oregon, so we should allow it elsewhere, too.
The first two arguments have remained the same for more than 200 years.3
The right to self-determination: Proponents maintain, correctly, that a patient has a right to accept or refuse any treatment—even if that refusal leads to death. They go on to maintain that the patient should then have the right to request any treatment they want, even medical assistance with bringing about death.
Though a patient has a negative right to be left alone, I believe this does not translate into a positive right (an entitlement) to whatever he or she wants. If that were the case, there would be no need for laws to regulate prescription drugs; a patient could just buy whatever he or she felt was appropriate. Patient autonomy is not absolute any more than is a generic right to personal freedom. The U.S. Supreme Court has found there is no constitutional right to assisted suicide.
Compassion: Supporters of PAS/E often point out that “we shoot horses, don’t we?” implying that our compassionate response to animal suffering should be extended to include human suffering. This is only tenable in a worldview that concludes that there is no moral difference between humans and animals. If you believe, as do most people in Western society, that a) we have a greater obligation to human beings than we do to animals, and that b) human life is special and should be respected and protected whenever possible, then we are obligated to find a better solution to terminal suffering in humans.
Compassion, while perhaps more compelling than self-determination, is still not determinative. As Pellegrino has said, “ ... compassion is a virtue, not a principle. Morally weighty as it is, compassion can become maleficent unless it is constrained by principle.”4 Compassion means “to suffer with.” Compassionate patient care involves coming alongside patients who are suffering, being with them, and doing all we can to alleviate that suffering.
The Dutch example: Other supporters of PAS/E offer a more pragmatic defense of their position, suggesting that the Dutch have proven that regulated euthanasia can work; however, it is not always used as a “last resort.” In nearly 20% of cases available palliative measures were declined by the patient; 60% of cases were not reported truthfully; 50% of cases did not have the required consultation; and—most worrisome of all—25% of patients who were given a lethal injection did not request euthanasia.5
Conversely, only about one-third of patient requests for euthanasia are carried out by Dutch physicians. Thus, two-thirds of patients who request euthanasia are denied it, and one-quarter of patients who are euthanized did not request it, suggesting that it is not patient autonomy that drives the Dutch euthanasia program, but physician autonomy. We must conclude that the Dutch experiment with regulated euthanasia has failed.
Arguments Opposing Physician-Assisted Suicide/Euthanasia
In addition to these rebuttals to those arguments in favor of PAS/E, there are several specific arguments in opposition. These have been well articulated elsewhere.6-8 They will merely be summarized here in two groups:
- Rule-based arguments: PAS/E goes against longstanding professional virtue and would change the nature of the patient-doctor relationship, perhaps even detracting from efforts at palliative care; and
- Consequence-based arguments: PAS/E would be bad public policy because regulations cannot prevent abuses and expansions of the “indications” to include coerced “voluntary” PAS/E, surrogate non-voluntary PAS/E for those who have lost decision-making capacity, requests from patients who are suffering (but not terminally ill), and even discriminatory involuntary euthanasia as a cost-control measure.9
The Moral High Ground
If we accept that PAS/E are contrary to physician virtue and moral tradition, and further that legalization of such activities would be bad public policy, what then is the alternative? The alternative is excellent end-of-life care. This requires a commitment to compassion, a willingness to “suffer with” the patient. Good palliative/hospice care has the goal of helping the patient to live each day as well as possible. Patients who receive good end-of-life care rarely request that their physicians hasten death.10
If a terminally ill patient does make such a request, the physician must elicit the reason by saying, “I’m sorry you are suffering. How can I help to make it better?” In addition, the physician should give the patient as much control as possible over treatment options when the patient is ready to shift goals to comfort care. The physician must never say, “There is nothing more I can do for you.” Such a statement represents an immoral abandonment of the patient. Instead the physician should say, “There is nothing more we can do to stop or slow the disease process, but there is a lot more we can do for you.”
All of the patient’s physical needs must be thoroughly addressed. This means intensive symptom control of pain and dyspnea, the two most feared symptoms at the end of life, as well as the multitude of other symptoms experienced by patients as they approach death.
Psychological symptoms are almost universal in dying patients. Anxiety about the future is understandable. Depression is likewise to be expected in a significant percentage of patients. Both need treatment, whether that be drugs, counseling, or someone to sit with the patient. Ramsay has said that people who are dying need only two things, comfort (symptom control) and company (human presence).11
Social issues also need assessment and treatment. Many dying people are lonely. Friends often stop visiting because they are uncomfortable and do not know what to say. Even family members may distance themselves physically and emotionally from a patient who is approaching death. Patients may have “unfinished business” that causes them unspoken distress. Byock has observed that a person who is dying often needs to say one or more of the following five things: “Will you forgive me?” “I forgive you,” “Thank you,” “I love you,” and “Goodbye.”12
The final dimension in whole person care is the spiritual. While this is important in caring for any patient who is seriously ill, it becomes imperative in dying patients. When facing death, patients often ruminate on guilt about how they have lived their lives. Others may develop uncertainty or doubts about even longstanding beliefs. They may have many questions about the meaning of life and the meaning of death.
It is rare indeed that one professional is able to address all of the physical, psychological, social, and spiritual needs of dying patients. It requires a multidisciplinary team including nurses, physicians, therapists, counselors, pastoral care workers, social workers, and lay volunteers. Such a team is usually best mobilized through a formal hospice or palliative care program, but may at times be coordinated through a primary care physician’s office or a community or church organization.
The Imperative for Good Pain Management
In spite of excellent resources too numerous to cite, and in spite of practice guidelines and quality improvement guidelines, pain management is often inadequate.13-15 JCAHO has issued pain management standards that affirm both the patient’s right to appropriate assessment and management of pain and the institution’s responsibilities.16
Perhaps the most commonly asked ethical question about pain management at the end of life is concern about the inadvertent—or even the intentional—suppression of respiration with the use of high doses of opioids that could lead to an earlier death. Experts in pain management maintain that this rarely—if ever—happens because pain is a good respiratory stimulant. Even with good empiric evidence that narcotic use does not hasten death, this myth continues to discourage many physicians from fulfilling their obligation to relieve suffering.17
But let us consider the worst-case scenario: What if a terminally ill patient with overwhelming pain requires rapidly increasing doses of narcotics and does actually suffers from respiratory depression. Is the physician morally obligated to use ventilatory support to overcome this side effect? Thomas Aquinas (1224-1274) answered this question with his “rule of double effect”: It is morally permissible to do an act that has both a good effect and a bad effect if all of the following conditions exist:
- The act must be inherently good, or at least morally neutral;
- The bad effect may be anticipated, but not intended;
- The good effect must not be achieved by means of the bad effect; and
- There must be a proportionately grave reason for allowing the bad effect.
Using high doses of narcotics to relieve pain fits these criteria.
Terminal Sedation
Because of the continued legal and professional proscription against PAS/E, some have proposed the use of “terminal sedation”: the practice of giving sedation to a patient who is dying, expecting that he or she will die more quickly of dehydration. If the intention is clearly to hasten death, then this is euthanasia and, in my estimation, it is an immoral end-run around the current legal and professional prohibitions. If, however, maximal efforts have failed to adequately relieve the suffering of an imminently dying patient, it would be ethically permissible to render the patient unconscious in order to relieve pain, accepting the unintended side effect of an earlier death from dehydration. This too would be justifiable using the rule of double effect.
Conclusion
PSA/E have been outside the bounds of acceptable behavior for physicians for hundreds of years. The moral, legal, and professional acceptable alternative is excellent end-of-life care. TH
To cure, sometimes; to heal, often; to comfort, always.—15th century French proverb.
Dr. Orr is a clinical ethicist at the Fletcher Allen Health Care in Burlington, Vt.
References
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- Code of Medical Ethics, AMA (1994). Opinion 2.211 “Physician Assisted Suicide”: 51.
- Emanuel EJ. The history of euthanasia debates in the United States and Britain. Ann Intern Med. 1994;121(10):793-802.
- Pellegrino ED. Compassion needs reason too. JAMA. 1993;270(7):870-873.
- Jochemsen H, Keown J. Voluntary euthanasia under control? Further empirical evidence from the Netherlands. J Med Ethics. 1999;25(1):16-21.
- Kass LR. Neither for love nor money: why doctors must not kill. The Public Interest. 1989;94:25-46.
- Callahan D. When self-determination runs amok. Hastings Center Report. 1992;22(2):52-55.
- Singer PA, Siegler M. Euthanasia—a critique. N Eng J Med. 1990;322(26):1881-1883.
- Hendin H. Selling death and dignity. Hastings Center Report. 1995;25(3):19-23.
- Brown JH, Hentelheff P, Barakat S, et al. Is it normal for terminally ill patients to desire death? Am J Psych. 1986;143(2):208-211.
- Ramsay P. The Patient as Person. New Haven, Conn.: Yale University Press; 1970:113-164.
- Byock I. The nature of suffering and the nature of opportunity at the end of life. Clin Geriatr Med. 1996;12(2):237-252.
- Agency for Health Care Policy and Research. Management of Cancer Pain. Rockville, Md.: U.S. Department of Health and Human Services, 1994
- American Pain Society Quality of Care Committee. Quality improvement guidelines for the treatment of acute pain and cancer pain. JAMA. 1995;274(23):1874-1880.
- Cleeland CS. Undertreatment of cancer pain in elderly patients. JAMA. 1998;279(23):1914-1915.
- Phillips DM. JACHO pain management standards are unveiled. JAMA. 2000;284(4):428-429.
- Thorns A, Sykes N. Opioid use in the last week of life and implications for end-of-life decision making. Lancet. 2000;356:398-399.