A Debate on Physician-Assisted Suicide by znu21902

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									A Debate on Physician-Assisted Suicide
Lawrence Hartmann, M.D.
Arthur Meyerson, M.D.



Dr. Hartmann: This debate is a                                                            ing, and evolution of varieties of de-
small part of a large continuing Amer-                  s
                                                Editor’ note: As part of the              cent, balanced, and caring solutions.
ican and international debate on                ongoing discussion at many lev-              Let me cite an issue that, at least
physician-assisted suicide. I will ar-          els of our society about physi-           temporarily, displaced physician-as-
gue that physician-assisted suicide             cian-assisted suicide, a debate           sisted suicide as a topic of medical-
should be legal, and Dr. Meyerson               was held at the October 1997              ethical debate in 1997: cloning. A
will argue that it should not.                  Institute on Psychiatric Ser-             member of the medical-ethical panel
   The state of Oregon now has a law            vices in Washington, D.C. Dr.             immediately set up to deal with what
called the Death With Dignity Act. It           Hartmann argued in favor of               to do about cloning said of the panel’  s
narrowly passed by referendum in                physician-assisted suicide, and           discussions, “Logic was air-tight, but
1994 with 51 percent of the vote and            Dr. Meyerson argued in opposi-                                         s
                                                                                          it did not change anyone’ mind. . . .
was then put on hold by legal chal-             tion. Alan A. Stone, M.D., was            Logical arguments [were] only ratio-
lenges until October 14, 1997, when             the moderator. This article pre-          nalizations for gut feelings or reli-
the U.S. Supreme Court removed the              sents the opening statements of           gious viewpoints” (1).
final legal obstacle to its becoming            the two debaters, slightly edited            So let us be a bit modest about the
law. Energetic opponents attempted              and updated to reflect subse-             power of this debate. In physician-as-
to repeal the law in a referendum in            quent developments.                       sisted suicide, there are many obsta-
November 1997, but it was upheld by                                                       cles to real discussion, including peo-
a vote of about three to two.                                                                 s
                                                                                          ple’ general reluctance to get any-
   Under the Oregon law, a mentally                                                       where near making any exceptions to
competent adult suffering from a ter-        eas of special interest in physician-as-     “thou shalt not kill.” However, one
minal illness likely to result in death      sisted suicide, such as, “Is the wish to     large obstacle to discussion of physi-
within six months may choose to re-          die always a symptom of mental ill-          cian-assisted suicide is that people
ceive a lethal dose of medication, af-       ness?” Part of our potential useful-         have deep wishes not to be in conflict,
ter consulting with two doctors and          ness is also at what is probably a more      to have one simple, clear guiding phi-
waiting 15 days.                             general and preliminary level: to ac-        losophy or value or commandment or
   I favor that law and others like it.      knowledge and identify some psycho-          model that will settle difficult dilem-
   Good values clash with good values        logical obstacles to discussion and to       mas for us. We wish for the security
in the area of physician-assisted sui-       help clear some ground so that these         and beauty of simplicity. We human
cide. People often hold on to some of        emotion-laden areas can be open for          beings— including physicians and Su-
these values with firm feeling and           reasonable discussion, as opposed to         preme Court judges— are, on the
long-standing conviction— feeling            mere intellectual decoration on the          whole, uncomfortable with what is
and conviction not always fully rea-         surface of deeply held positions.            not perfectly resolved and with the
soned or reasonable, and certainly not          Laws simply criminalizing physi-          idea that some conflicts are not whol-
always stemming from advanced edu-           cian-assisted suicide do not help clear      ly resolvable— that some of our own
cation and training.                         such ground. Rather, the reverse.            powerful values necessarily and in-
   Part of our possible usefulness to-       They do affect practice, powerfully if       evitably clash with other of our own
day in considering this area, as both        always imperfectly, but they also fos-       powerful values.
citizens and psychiatrists or mental         ter passionate premature closure                Moreover, we are often uncomfort-
health colleagues, is not just to look at    rather than reasonable discussion, ac-       able even with acknowledging that
specific and legitimate psychiatric ar-      knowledgment of complexity, learn-           this discomfort or conflict exists, so
                                                                                          we tend to deny that there are major
                                                                                          philosophical as well as emotional
Dr. Hartmann is a past-president of the American Psychiatric Association and is on the    conflicts, and to deny that we often
faculty of Harvard Medical School. Send correspondence to him at 147 Brattle Street,      wish away conflicts by leaning unrea-
Cambridge, Massachusetts 02138. Dr. Meyerson is professor and vice-chair in the de-       sonably on authority and what seem
partment of psychiatry at the University of Medicine and Dentistry of New Jersey–New      to be familiar or simplifying solutions.
Jersey Medical School, 215 South Orange Avenue, Newark, New Jersey 07103 (e-mail,         At a level that I think is always in con-
meyerson@umdnj.edu).                                                                      flict with our most adult selves, we all
1468                                                                         PSYCHIATRIC SERVICES   o November 1998 Vol. 49 No. 11
still sometimes have wishes to have          one recent translation, the Hippo-          half century the American public has
good parents. Much of the strength           cratic oath says, “I will give no deadly    moved from a large minority who ap-
and irrational appeal of authoritative       medicine to anyone if asked.”)              prove of physician-assisted suicide in
guides or governments, and of many              Allied to, although not explicitly a     some circumstances to about two-
or most religions, have their roots in       part of, most versions of the Hippo-        thirds or three-quarters (1996 polls)
this psychological area.                     cratic oath is the excellent and power-     who now think that physician-assisted
   “Thou shalt not kill,” for instance, is   ful and perhaps most fundamental            suicide should be legal in some cir-
an extraordinarily powerful, appeal-         commandment to physicians, “Above           cumstances (2). Polls suggest that
ing, and all-but-universal ethical           all, do no harm.” Yet again, that is a      currently only about one-half of
guideline. Yet most of us do not often,      fine, but imperfect, commandment            American physicians favor physician-
or comfortably, examine too closely          for some difficult situations in real       assisted suicide in some circum-
its edges, where most human beings           life. We do, of course, use medicines       stances (3). No one knows what per-
allow some exceptions. (The excep-           that do harm if they also do what we        centage of American psychiatrists fa-
tions are in line with scholarly opinion     consider more good than harm.               vor it, although in Oregon a poll sug-
that considers “thou shalt not mur-             Although apparently wonderfully          gests that half to two-thirds of Oregon
der” a more accurate translation of          clear, “Above all, do no harm” does re-     psychiatrists favor physician-assisted
the Biblical Hebrew.)                        quire judgment and is open to differ-       suicide in some circumstances (4).
   Another deep and powerful ethical         ent interpretations. Some would say            A great many judicious people
guideline, also all but universal, and       that to help speed the death of a ter-      think something that wisely ought to
also deeply relevant to physician-as-        minally ill, severely suffering, mentally   be rare but possible ought to be legal
sisted suicide and of comparable             competent patient who asks for help in      rather than illegal. Many of us clearly
weight to “thou shalt not kill,” is the      dying is to do harm; others— many           do not think that “thou shalt not kill”
Golden Rule, in either its positive or       laypeople and many physicians—              ends the argument, or that “above all,
its more careful negative form: “Do          would say that to withhold help in          do no harm” ends the argument, or
not do unto others what you would                                 s
                                             speeding a patient’ end would be to         that the Supreme Court ended the ar-
not have them do unto you,” and that         do not only harm but more harm.             gument. Probably hugely more of us
may, in relatively rare cases, clash            Another source of deep values and        do not think that a position of the
with “thou shalt not kill.”                  commandments for many Americans,            American Medical Association, or the
   History, or tradition, is another         and, of course, for our laws, is the        American Psychiatric Association’      s
guide that seems absolute and over-          U.S. Constitution and Bill of Rights.       joining in an amicus brief with AMA,
riding to many people, but tradition is      But there, too, in not a few important      ends the argument.
often more complex than its pure ad-         areas, are found difficulties of inter-        There are dozens of good areas for
herents admit, while change, slower          pretation, disagreements, and even          discussion and argument in physi-
or faster, is not only traditional, but      significant changes of interpretation       cian-assisted suicide, and dozens of
also essential for civilization.             over time. That was clearly the case in     good people who have recently ar-
   More specific to physicians, includ-      the recent history of an emotional                         ll
                                                                                         gued them. I’ pick a few to comment
ing, of course, psychiatrists, is the        area related to physician-assisted sui-     on, while also giving a bit of a whirl-
Hippocratic oath, which— although it         cide— abortion— and it is also true in      wind tour of some of the many recent
has had various forms over the cen-          physician-assisted suicide, where rul-      issues and players and law cases and
turies, and various translations— is of-     ings in two cases decided in one di-        arguments.
ten used as if it were a clear, simple,      rection on constitutional grounds by           o A U.S. Supreme Court case,
single clinical guideline. It is not a       two appellate courts (the second and        Casey v. Planned Parenthood, al-
clear, simple guideline. A serious dis-      ninth circuits in New York and the          lowed people to make their own deci-
cussion of its problems and clashes          State of Washington, respectively)          sions about intimate matters.
with practice, with other ethical            were overruled in 1997 by the U.S.             o A U.S. Supreme Court case, the
guidelines, and with regulations, eco-       Supreme Court.                              Cruzan case, allowed the removal of
nomic pressures, and laws would be              So one of my major points is to          life supports.
timely and useful— far more so than          warn us against total reliance on any          o A Ninth Circuit Court of Ap-
is currently admitted by those who           simple, single statement or institu-        peals case, Washington v. Glucks-
have not read the Hippocratic oath or        tion, and to suggest that where seri-       berg, argued for a constitutional liber-
who only vaguely remember it, or             ous basic value conflicts exist, laws       ty right to physician-assisted suicide
those who want it to be above dis-           that in effect would silence and fore-      largely based on due process.
pute. Some people wish it to be above        close one-half of the values and of the        o A Second Circuit Court of Ap-
dispute perhaps partly because to            discussion and the hard work of de-         peals case, Vacco v. Quill, in New
doubt or correct or edit any part of it      veloping variety and experimentation        York, argued for physician-assisted
might throw it all into question, and it     with careful balanced, relatively good      suicide largely using the equal-pro-
is felt to be overall a good and sound       solutions— such laws are less wise          tection clause.
document, protective of patients and         than laws that allow more liberty and          o A U.S. Supreme Court decision
of medicine as a good profession.            careful variety and debate.                 in June 1997 overturned Washington
(That said, let me remind you that in           Recent polls show that in the past       v. Glucksberg and Vacco v. Quill and
PSYCHIATRIC SERVICES   o November 1998 Vol. 49 No. 11                                                                      1469
did not find a constitutional right to      ments, including as Alan Stone, Keith       euthanasia and greatly to increase the
physician-assisted suicide but allowed      Brody, L. Jolyon West, and David            likelihood of carefulness and minimal
state legislatures to deal with it.         Spiegel.                                    abuse and unfairness.
   o Comments by justices other than           o Medical ethicists have also en-           o Palliative care is useful and in
Rehnquist in the 1997 Supreme               tered the debate— for example, two          need of great improvement, but it is
Court case gave some support to             energetic opponents of physician-as-        not a solution. It is expensive and like-
physician-assisted suicide. For in-         sisted suicide, Linda Emanuel and           ly to remain grossly inadequate in the
stance, Breyer considered a “right to       Ezekiel Emanuel. Ezekiel Emanuel            U.S., and even where it is good and
die with dignity.”                          has frequently noted that depression        available, it does not fully solve the
   o Countless other comments               is the problem and that depression is       question of physician-assisted suicide.
about the ruling also supported physi-      treatable. (Not necessarily, and not al-       o The issue of fairness also arises.
cian-assisted suicide, including those      ways. The wish for a good death is of-      What would be the effect of more or
by Harvard law professor Lawrence           ten far from a depressed wish, and,         less legal physician-assisted suicide
Tribe, the New York Times, and many         separately, depression is not always        on fairness— for example, on the poor
other newspapers, journalists, and es-      treatable.) Linda Emanuel (7) helps         and vulnerable versus the rich and
sayists, as well as several amicus          AMA develop its positions, favors           powerful? This issue presents a mixed
briefs. I particularly commend the so-      better palliative care, and does admit      picture, but legal physician-assisted
called “philosophers’ brief,” which         that physician-assisted suicide is “jus-    suicide would be potentially fairer
bases much of the case for physician-       tifiable in rare cases.”                    than the present system.
assisted suicide on autonomy.                  o The issues involved in suicide it-        o The relationship of abortion and
   o Real-life experiments with phy-        self, not just physician-assisted sui-      the abortion debate to physician-as-
sician-assisted suicide have provided       cide, must be considered. Suicide has       sisted suicide should be considered in
a valuable experience, including            in this century been legalized in many      its emotional, ethical, legal, and polit-
those of many physicians over the           jurisdictions; physician-assisted sui-      ical dimensions. One large difference
centuries, some of which have been          cide has not. However, many religions       is the presence of adult choice— the
reported, but many not; those of            still flatly oppose all suicide. Yet, if    presence in physician-assisted suicide
provocative physicians such as Dr.          suicide is legal, the legal and moral       of a competent adult patient.
Kevorkian; and calmer and wider ex-         position of physician-assisted suicide         o The question of dying well mat-
periments, such as those in Holland,        is on different and narrower ground.        ters. Physician-assisted suicide is
Oregon, and Australia.                      (Laws against physician-assisted sui-       probably more urgent now and more
   o Another move is the current            cide seem to me to be used, often           popular now because modern medi-
AMA position accepting the Supreme          covertly, to buttress religious disap-      cine has made dying worse— often
       s
Court’ decision in the Cruzan case          proval of suicide itself by making sui-     both longer and worse.
and insisting that the right line to draw   cide as painful and difficult as possi-        o AIDS is a major example of doc-
is more or less between so-called pas-      ble, by refusing any help for dignified     tors often contributing to making dy-
sive pulling the plug (the AMA ac-          suicide to all those who ask for it.        ing worse.
cepts this) and so-called active pre-          o The issues of euthanasia versus           o There are many disadvantages to
scribing pills for a competent patient      physician-assisted suicide are often        criminalizing physician-assisted sui-
requesting them (the AMA rejects            blurred, especially by opponents of         cide, including huge potential risk
this) (5). The 1997 Supreme Court           physician-assisted suicide. It is possi-    and damage to individual doctors, to
decision (overturning Washington v.         ble to clarify the difference between       other persons, and to honesty, open-
Glucksberg and Vacco v. Quill) large-                                         s
                                            assisting death against a patient’ will     ness, trust, and respect in doctor-pa-
ly accepted that line.                      and assisting a patient to take some        tient relationships and medical care.
   o The APA has no official position       control of the time and way of death.          Doctors in general have all the
on physician-assisted suicide, but in          o The issue of euthanasia versus         above concerns and some more spe-
1996 its board of trustees, after a brief   physician-assisted suicide leads to         cific medical ones. For instance, can-
debate (that, oddly, hardly touched         questions of so-called slippery slopes,     cer specialists, AIDS specialists, and
on any issues of content), voted to         a catchy image used and abused to           many others have specific front-line
join the AMA amicus brief.                  blur physician-assisted suicide terri-      problems about how to be compas-
   o Other prominent psychiatrists          bly with giving the state power to kill,    sionate; how to cure when they can,
have furthered the debate. For in-          which is not at all what physician-as-      but when they cannot cure, how to
stance, Dr. Herbert Hendin, a suici-        sisted suicide is. Watch out for the        help as much as they can and harm as
dologist, went to Holland and wrote a       slippery-slope metaphor. In physi-          little as they can; how to help against
book saying that the Dutch experi-          cian-assisted suicide, it is usually a      pain; how to help preserve the pa-
ence shows physician-assisted suicide       dishonest slope sitting queasily on a              s
                                                                                        tient’ dignity and autonomy; and how
to be unworkable (6). Various Dutch         conceptual swamp.                           to do what the patient wishes. Physi-
psychiatrists have commented that              o Another serious question is            cians who are morally opposed to
                            s
they do not think Hendin’ book is ac-       whether good regulation of physician-       physician-assisted suicide should not
curate or fair. Other American psy-         assisted suicide would be possible,         have to take part in it. (No one that I
chiatrists have added their com-            both to separate it more clearly from       know of is proposing that they do so).
1470                                                                       PSYCHIATRIC SERVICES   o November 1998 Vol. 49 No. 11
   However, physicians currently are         ments for the decency and dignity of       cide. However, even if one accepts
also under such pressure from man-           physician-assisted suicide, and major      the premise of that argument, and we
aged care and have suffered such             public approval, let us carefully allow    should not, two essential questions
losses of professional autonomy— and         it to exist in various forms with vari-    remain. Should the humane and logi-
damage to the doctor-patient rela-           ous regulations in different states and    cal extension of relief of suffering be
tionship— that neither good palliative       countries, and encourage variety and       to require legalization of terminating
care nor good physician-assisted sui-        careful experiment and respectful de-      the life of a suffering person when
cide is likely to be widely and careful-     bate. If physician-assisted suicide        that requires an affirmative act on the
ly available. That our current Ameri-        were illegal in all relatively advanced    part of someone else? If assisted sui-
can model of medical care, which is          societies, that would discourage at-       cide is legalized, should the assisting
dominated by business and profit and         tempts to think through, discuss, and      person be a physician?
managed care, might see good pallia-         try out careful ethical guidelines for        That the act should be legalized if
tive care as particularly expensive,         something that is fairly rare, but is—     performed by someone can be ar-
and physician-assisted suicide as rela-      now and historically, nationally and       gued, but not convincingly, and the
tively cheap is, I think, a reason not to    internationally— present in the prac-      counterarguments are at least as com-
make physician-assisted suicide ille-        tice of many good physicians and the       pelling. The argument against physi-
gal but to reform our system of fi-          wishes of many good people.                cians’being the agents or even the an-
nancing health care.                            I do not think more and more life is    gels of death is compelling when the
   And what about psychiatrists? We          always better.                             art and science of medicine and par-
have all of the concerns I have de-             I do not think pulling the plug ver-    ticularly psychiatry are taken into ac-
scribed and some additional psychi-          sus prescribing pills is a morally         count. I will address each of the argu-
atric concerns about physician-assist-       strong boundary to draw.                   ments for the affirmative.
ed suicide. For instance, is depression         I value life, autonomy, dignity, med-      Before I get into the formal part of
the whole problem? No. Is depres-            ical compassion, liberty, and choices.     the negative case, I would like to
sion always curable? No. Can a psy-             I would not like the choice for phy-    share my personal reasons for believ-
chiatrist tell a reasonable wish to die      sician-assisted suicide to have to be      ing that there should be no legaliza-
from depression? Often yes. If physi-        everywhere covert and illegal, or          tion, or other formal acceptance, of
cian-assisted suicide is legal, how          available only to the educated and the     physicians’ending or terminating the
does it affect the treatment of other        rich.                                      life of a patient— killing someone.
depressed or suicidal patients? (This           I would myself like to have a lethal       Why did most of us go into medi-
is a serious but workable clinical area,     dose of sleeping pills and a good          cine? Perhaps that is an unanswerable
demanding honesty and toughness              physician and some choice available        question, but it is one that each of us
about our own educated, limited, but         to me if and when I have a painful ter-    has struggled with in some fashion.
relevant judgment and clinical cau-          minal disease. I think most people         For myself, and, I suspect, for many
tion about what is clear psychosis or        would. What do you want?                   others, the answer lies in a combina-
treatable depression; what is a shade           I think physician-assisted suicide      tion of personal experience of physi-
of gray and debatable, thus requiring        should be legal.                           cians and the public image of medi-
great caution; and what is a compe-                                                     cine as portrayed in biography and
tent and reasonable wish to die soon-        Dr. Meyerson: The debate on physi-         art, mainly fiction and films. My expe-
er rather than later.)                       cian-assisted suicide tends to focus on    rience involved Sidney Rosenfeld,
   Does deciding that a patient asking                    s
                                             the patient’ needs for relief from         M.D., who doctored my family from
for physician-assisted suicide is not        pain and suffering. By physician-as-       before my birth until his death about
depressed mean that the physician is         sisted suicide, one refers to the physi-   ten years ago. Sidney was a commit-
taking a direct part in killing? Or, as           s
                                             cian’ following the wishes of a patient    ted family doctor treating my cousin’ s
proponents of physician-assisted sui-        by actively and intentionally aiding       idiopathic thrombocytopenia purpu-
cide would say, is it letting patients       and abetting the death of that patient.                    s
                                                                                        ra, my father’ thyroid and prostate
have more control over their own             Physician-assisted suicide is distin-                                 s
                                                                                        conditions, my mother’ various ills
time and way of death— that is, not          guished from euthanasia, which in-         including depression and osteoporo-
being a direct gatekeeper of death           cludes cases in which the patient may      sis, and my own childhood and ado-
but a direct gatekeeper to more              be assisted by the physician to die but    lescent ailments. My earliest expo-
choice? Psychiatrists also face              not necessarily with the full knowl-       sure to medicine was in Sidney’ of-s
burnout with physician-assisted sui-         edge of the patient, as in the case of     fice, where he would show how fluo-
cide, and significant transference and       an unconscious, terminally ill person.     roscopy worked, how to listen
countertransference issues.                     The majority of physicians and lay-     through a stethoscope, and other
   In conclusion of this first part of the   persons believe that there should be a     magic of medicine. His goals were to
debate, what do we want for our-                     s
                                             patient’ right to die, at least under      share his love of medicine and to dis-
selves and for our society? What is          limited circumstances. This simple         tract me from the needle he was go-
ideal? Can we design it, in a complex        fact is presented, in the context of a     ing to stick in my little tush.
world where good values clash with           democratic society, as a reason for le-       When my mother became unremit-
other good values? Given major argu-         galization of physician-assisted sui-      tingly depressed in her sixties in re-
PSYCHIATRIC SERVICES   o November 1998 Vol. 49 No. 11                                                                     1471
sponse to growing deafness and in-         taining the essence of physicianhood.          cide; pain in conjunction with other
herited, sex-linked tendencies toward         I do not believe that those who ad-         factors still represents less than half
depression, which she shared with          vocate physician-assisted suicide main-        of requests. The majority are not pain
her mother and her two sisters, Sid-       tain the essence of physicianhood that         related. The relief of suffering should
ney first tried counseling and then in-    characterizes our ideals. Even the             not be achieved by ending the suffer-
sisted she see a psychiatrist. As she      withdrawal of life support appears to          ing life. One could argue that the end
grew older, my mother developed os-        follow the logic and passion of the            of life in an anaesthetic coma is not
teoporosis, and her multiple spinal                   s
                                           physician’ credo that I know— “Pro-            appealing, but it does provide mercy
fractures made her six inches shorter      long life, relieve suffering”— in that         without violating the moral and ethi-
at her death at 82 than when she was       these patients appear to have no via-          cal boundaries of society and physi-
in her 50s. As the back pain and her       bility and thus the relief of suffering is     cianhood.
narcissistic injuries became in-           paramount. Even when a physician                  Proponents also hold that some
tractable, she would talk of suicide       gives incremental pain medication to           mercy killing is justified as they be-
and on several occasions asked my fa-      patients who might use it to kill them-        lieve that acts of omission such as the
ther and Sidney to help her commit         selves a few hours or days premature-          withdrawal of life-sustaining equip-
suicide. On one occasion, she asked                   s
                                           ly, if one’ motivation is the relief of        ment are equated with acts of com-
me as well. In each case she received      suffering and not to help the patient          mission (physician-assisted suicide).
the same answer, in essence: “We love      die, then one remains a physician. But         Are acts of omission morally and eth-
              t
you, we don’ want to lose you, let us      to actively and intentionally kill a sen-      ically distinct from actively causing
help you.” The help was better pain        tient patient, whatever the motivation,        death? Triage medicine involves the
management, psychiatric treatment,         is an act outside of the profession.           potential choice of omission of care
and distraction of every kind.             One might find a way to justify it as a        for one who is sure to expire in favor
   Until her death my mother was not       human being but not as a physician.            of providing care for another whose
openly grateful to us for refusing. She       The 50 international doctors who are        chances of survival are greater. When
always longed for an end, but she          willing to risk injection with an attenu-      a physician or family member choos-
knew she mattered to her family and        ated, live AIDS virus are the living em-       es to withdraw life-sustaining care,
to her physician, whom she had             bodiment of the highest ideals of the          the motive may be to reduce suffer-
known for 70 years. My mother was          medical profession, the essence of its         ing. In a physician-assisted death or
fully able bodied despite her ailments     best identity. Killing patients is not. Dr.    suicide, the motive is to kill a patient
and could have killed herself at any       Kevorkian will not take his place beside       whose sentient life is still a reality, and
time. Perhaps our refusal to stop lov-     Koch, Pasteur, Lister, and the others in       the positive act to end it is the goal.
ing her and valuing her life, and Sid-     any medical pantheon I care to believe         The distinction between physician
     s
ney’ persistent offers of hope, new                           t
                                           in. One doesn’ have to condemn                 and executioner is a far cry from that
drugs, new consultants, plain support,                 s
                                           Kevorkian’ actions to think they are           of physician and triage officer.
and patience, also tilted the balance      not inherently medical.                           Advising a family and patient on
toward life.                                  Now for the less personal and for-          withdrawal of equipment or that, to
                        s
   Along with Sidney’ wonderful ex-        mal presentation of the negative posi-         be fully effective, a pain medication
ample, literature and movies were an       tion in this debate. Mercy is often the        may reach levels that will cause death
intermittent reinforcer of my belief in    basis for the pro argument, which as-          is also morally and ethically distinct
the life-giving and life-valuing core of   serts that the relief of pain and suffer-      from purposely killing a patient.
the medical profession. Semmelweis,        ing justifies the act of assisted suicide.     Emanuel (9) suggests that in circum-
Koch, Fleming, and, beyond all oth-        However, such a decision can often             stances in which palliative care can
ers, Pasteur as portrayed by Paul          be and perhaps always is misguided             eliminate physical pain, misery is re-
Muni and as described in two biogra-       when the assessment is made by peo-            duced to the point where one cannot
phies were the heroic figures around       ple other than the patient. It is analo-       choose physician-assisted death over
which my imago of physicianhood            gous to the difference between how             medication-induced coma, which
was formed. Dedicated men, alas            people with a disability value their           point does not justify mercy killing.
only men, committed to saving life         lives and how people without a dis-               The right to die with dignity is
and to prevention, diagnosis, and          ability value the lives of the disabled.       raised as a reason for physician-assist-
treatment of disease and suffering.           Palliative care in the U.S. is notori-      ed death. Dignity is a subjective and
   I remember the raging debate in         ously underused. Ideally, it can man-          culture-driven notion. Its use as a jus-
the great film about Pasteur with Paul     age almost all pain adequately. In the         tification for mercy killing requires
Muni. Should inoculations be given         few cases of unmanageable suffering,           one to accept the sense of dignity of
to patients even to save their lives?      anaesthetic coma can be induced un-            an elderly Eskimo or Native Ameri-
Could one risk the side effects of the     til death or new palliative or curative        can, for example, which involves al-
unproven sera even in cases of ex-         treatments can be developed. A study           lowing self-imposed isolation, starva-
treme illness? This debate in modern       by Van der Maas and colleagues (8)             tion, freezing, and exposure to ani-
guise still rages among institutional      indicated that in only 3 percent of            mals of prey, while also accepting an-
review boards all over the country. It     cases is pain alone the motivation for                         s
                                                                                          other person’ request for an over-
is a worthy one, with both sides main-     requests for physician-assisted sui-           dose to relieve his impaired sense of
1472                                                                         PSYCHIATRIC SERVICES   o November 1998 Vol. 49 No. 11
dignity. If the person in the first in-      argument for physicians’ assisting          and disability. You are already finan-
stance is exemplary of dignity and au-       death privately as part of the physi-       cially dependent on your family. As
tonomy, how can society set itself up        cian-patient relationship ignores the       time goes on, the cost of nursing care
to decide or relegate to the physician               s
                                             family’ interest, the societal interest,    will be added, or you will have to
the right to distinguish which person,       and, unfortunately, the issues im-          move to a costlier hospice or nursing
in which situation, and from which           posed by managed care with enforced         home. I want you to know that if you
culture should be assisted to die by         rationing. The cartoon of the physi-        wish to end your life, your pain, the
the doctor? Psychiatrists should be          cian informing the patient, “Your           indignity of loss of function, and the
most aware of the vulnerability of           HMO will not pay for your treatment         burden to your loved ones, I will assist
these value-laden motivations to be          but does cover physician-assisted           you in a painless death.”
irrational and ego-syntonic. Are physi-      death. Come back in the morning and                                           s
                                                                                            Has Dr. H added to Mrs. C’ sense
                                    s
cians to simply follow a patient’ val-         ll
                                             I’ kill you” may be bizarre humor,          of comfort, or has he eroded what lit-
ues and idiosyncratic notions of digni-      but it points to a real danger affecting    tle hope she had? By the power of his
ty and override our ethical positions        all of us. Should any active killing of     position and suggestive language, has
of “do no harm,” “preserve life,” and,       one individual by another be allowed                                     s
                                                                                         he reframed the patient’ sense of a
yes, “relieve suffering”?                    in a purely private setting? How dan-       loving connection to her family into
   I, says Grandma or Grandpapa, am          gerous, how cowardly, how grandiose.        one of clinging, resented depen-
no longer beautiful, wise, a leader,            Proponents of physician-assisted         dence? Has he tipped his profession-
able to provide materially for my fam-       suicide also assert that professions        al identity from healer, soother, pro-
ily, or continent. All of these situations                           s
                                             should serve society’ needs. Should         longer of life, and potential savior
are reasonable causes of a loss of a         the medical profession therefore ac-        (granted, lost in this case) into one
sense of dignity for some people. But                                s
                                             tively assist a patient’ death? This ar-    immutably tainted with fearful, judg-
a reason for dying at the hands of a         gument essentially ignores the long                                            s
                                                                                         mental rejection of the patient’ basic
physician requires a degree of certain-      traditions of medical ethics by assert-     value? If you are not sure of the an-
                           t
ty that the patient isn’ treatably de-       ing that ethics should be suspended         swers, that should prevent your ac-
pressed. Were physician-assisted sui-        in favor of legal decisions or the will     cepting the physician as the instru-
cide a professionally acceptable and         of the voters. As Emanuel (9) be-           ment of death.
legal practice, then a patient suffering     lieves, societal values can be defined         Legal trends are said to support
a loss of beauty or any other reason for     and applied to support or oppose            physician-assisted suicide. It is odd
loss of dignity could doctor-shop until      physician-assisted death based on the       that the only instances when it has
he or she found the right narcissistic       tradition that an appropriate profes-       been argued in law that citizens have
physician to empathize with the sense        sional position may be determined by        a right to physicians’assistance is for
of loss of dignity and kill out of a kind    assessment of overall benefit to pa-        abortion or physician-assisted suicide.
of empathic mercy.                           tients or society. However, this ap-        Although courts often fail to convict
   Autonomy, self-determination, and         proach largely ignores traditional          physicians of physician-assisted sui-
the right to privacy are also raised as      ethics and the insights that psychiatry     cide, including Kevorkian, the trend
arguments for the affirmative posi-          and psychoanalysis bring to bear.           in both public opinion and new legis-
tion. Autonomy does not require that            The profession of medicine lost          lation is to bar physician-assisted sui-
even freely given requests for physi-                             s
                                             much of society’ generally positive         cide or to fail to adopt it as law. The
cian-assisted death be followed. All         transference when from the 1950s on         Supreme Court has decided that the
autonomy rights are limited by the           we became tainted by the pollution of                                t
                                                                                         Constitution doesn’ include physi-
rights of others not to be interfered        the Hippocratic tradition with the ve-      cian-assisted suicide as a protected
with or injured. If a patient is to be al-   nality inherent in some physicians’ex-      liberty. The only state to pass a law on
lowed the right to die or be killed, un-     ploitation of Medicaid and Medicare,        physician-assisted suicide is Oregon;
der some restricted circumstances,           private hospitals and clinics laden         when it revisited its plebiscite last
does that equate with being able to          with conflicts of interest, machinery       year, the voters reaffirmed their be-
                             s
prescribe the physician’ role in that        medicine, and so forth. If we lost the      lief in its utility by a small majority.
killing? Arguably, attorneys in their                s
                                             public’ respect for those apparent             Fifty bills for physician-assisted sui-
role in adversary systems might find it      changes, imagine the distortion of our      cide have been introduced in the
closer to their ethical and psychologi-      benign imago if we assume the offi-                                       s
                                                                                         states, and only Oregon’ passed. A
cal essence to kill a patient than a         cial role of killer, even under the best-   1996 Washington Post poll indicated
physician would or should.                   intentioned rationale.                      that while a small majority of Ameri-
   The right to privacy is proffered as         Consider the following possible          cans favor some form of physician-as-
a basis for asserting that physician-as-     scenario. Dr. H, the internist, says to     sisted suicide, blacks, the elderly, and
sisted death should be a decision in-                          ve
                                             Mrs. C, “You’ not responded to              those earning under $15,000 were
volving only the physician and the pa-       chemotherapy. Further treatment             against legalization (10). Seventy per-
tient. Emanuel (9) argues that the           seems hopeless. You may live for sev-       cent of blacks opposed it, and 20 per-
public importance of this matter, its        eral years but more likely one or two.      cent were in favor. Among the elder-
private nature not withstanding,             In that time the tumor, already caus-       ly, these figures were 58 and 35 per-
seems to be a point of consensus. The        ing weakness, will cause headaches          cent, and among those earning under
PSYCHIATRIC SERVICES   o November 1998 Vol. 49 No. 11                                                                         1473
$15,000, they were 54 and 37 per-           spread availability of hospice care,         permit a terminally ill patient to die
cent. The Academy of Medicine has           and a legal distinction between illegal      when death is imminent. However,
recognized poverty, minority status,        and punishable acts; we do not. Com-         the physician should not intentionally
and age as the three most significant       pared with the U.S., Holland has no          cause death.”
correlates of mortality and disability      state-based legal system, a culture of                           t
                                                                                            In short, we don’ require doctors
in America (11). It appears that those      pragmatism mixed with Calvinism,             to kill. Anyone can do it. We need to
most likely to be shuffled off this mor-    less cultural and ethnic diversity, and      use the power of medicine to improve
tal coil would least appreciate our as-     far less violence.                           the care of the terminally ill. Legal-
sistance along the way.                        In addition, the Dutch approach to        ization of physician-assisted suicide
   Whatever the majority wishes,            physician-assisted suicide is fraught        does not represent an argument for
should physicians seek to join soldiers     with major problems. First, the law          adoption of the practice as ethically
at war, persons defending their lives,      includes psychiatric illness as well as      sound. o
police, and executioners as the instru-     medical illness; however, one criteri-
ments of societally approved killing?       on of the law is that the patient’ deci-
                                                                              s          References
Certainly, the movement toward le-          sion be “well considered,” and signif-        1. Kolata G: New cloning attempts meet no
galization and my parody of the fic-        icant controversy has arisen about               success so far. New York Times, Mar 18,
                                                                                             1997, p C9
tional Dr. H embody worthwhile val-         whether decisions by seriously psy-
ues, including a desire to maintain pa-     chiatrically ill persons can meet this        2. Brodie HKH, Banner L: Normatology:
                                                                                             abortion and physician-assisted suicide.
tients’ autonomy and alleviate their        standard. Second, another legal crite-           American Journal of Psychiatry 154(June
suffering. However, the opposing val-       rion is “incurability,” which may be             suppl):13–19, 1997
ues of “do no harm” and the preser-         impossible to determine in many cas-          3. Portenoy R, Coyle N, Kash K, et al: Deter-
vation of life should be compelling for     es, perhaps most of all in psychiatry,           minants of the willingness to endorse assist-
physicians when the good values can         where new and more effective drugs               ed suicide. Psychosomatics 38:277–287,
                                                                                             1997
be accomplished, as they can, by            are rapidly becoming available.
means other than the physician’ be-  s         Third, many Dutch psychiatrists            4. Ganzini L, Fenn D, Lee M, et al: Attitudes
                                                                                             of Oregon psychiatrists toward physician-
coming the agent of death.                  refuse to participate in physician-as-           assisted suicide. American Journal of Psy-
   Those holding the affirmative posi-      sisted suicide, feeling that the bound-          chiatry 153:1469–1475, 1996
tion argue that legalization permits        ary violations inherent in participa-         5. American Medical Association Council of
restraints and prevents us from slid-       tion taint their ability to form a thera-        Ethics and Judicial Affairs: Decisions near
ing down the notorious slippery             peutic alliance (12). These psychia-             the end of life. JAMA 267:2229–2233, 1992
slope. They argue that physicians al-       trists also believe that countertrans-        6. Hendin H: Seduced by Death. New York,
ready engage in physician-assisted          ference toward chronically ill patients          Norton, 1996
death and that legalization such as in      can intrude. Fourth, 60 percent of            7. Emanuel L: Physician-Assisted Death.
Holland would bring it into the open        Dutch physicians don’ report cases
                                                                       t                     Harvard Medical School Clinical Ethics
                                                                                             Lecture Series. Cambridge, Harvard Uni-
and provide a barrier against errors of     of physician-assisted suicide (13),              versity, 1996
judgment or malpractice. Opponents          which is perhaps related to the Dutch
                                                                                          8. Van der Maas PJ, van der Wal G, Haverkate
argue that the slippery slope to wide-      courts. Despite legalization, courts             I, et al: Euthanasia, physician-assisted sui-
spread misuse would be oiled by le-         have levied civil and criminal penal-            cide, and other medical decisions involving
galization.                                 ties in several cases in which family            the end of life in the Netherlands,
                                                                                             1990–1995. New England Journal of Medi-
   Concern about the slippery slope is      members or prosecutors filed actions             cine 335:1699–1705, 1996
real, but there are no empirical stud-      and physicians were deemed incor-
                                                                                          9. Emanuel EJ: Euthanasia: historical, ethical,
ies to determine which mechanism is         rect or negligent in agreeing to partic-         and empirical perspectives. Archives of In-
more effective in reducing unjustifi-                             s
                                            ipate in the patient’ death.                     ternal Medicine 154:1890–1901, 1994
able killing. Again, it is evident that a      In conclusion, I can think of no bet-     10. Colburn D: Survey reveals differences on
society that allows and even legally        ter way to end the argument for the              doctor-assisted suicide. Washington Post,
encourages physicians to kill patients      negative case than by quoting the                July 2, 1996, p Z8
will have a different group psychology      AMA guidelines (5), supported by             11. Institute of Medicine: A National Agenda
or ethos than one that doesn’ Re-  t.       APA: “Life should be cherished de-               for the Prevention of Disability in America.
                                                                                             Washington, DC, National Academy Press,
spect for life is a general good, and for   spite disabilities and handicaps except          1988
physicians it should not be eroded,         when the prolongation would be in-
                                                                                         12. Asmus FP, Schoevers RA: The role of the
even by “merciful” impulses.                humane and unconscionable. Under                 psychiatrist in suicide [in Dutch]. Maand-
   The Dutch experience is cited as a       these circumstances, withholding or              blad Geestelijke Volksgezonheid 50:131–
basis for U.S. physicians to carry out      removing life-supporting means is                143, 1995
physician-assisted suicide. Dr. Hart-       ethical provided that the normal care        13. Van der Wal G, van der Maas PJ, Bosma
mann argues that Holland should be a        given an individual who is ill is not            JM, et al: Evaluation of the notification pro-
                                                                                             cedure for physician-assisted death in the
model for the U.S. and assumes that         discontinued.” They go on, “For hu-              Netherlands. New England Journal of Med-
Holland and the United States are           mane reasons, with informed con-                 icine 335:1706–1711, 1996
sufficiently similar for us to adopt        sent, a physician may do what is med-
their position. However, Holland has        ically necessary to alleviate severe
universal health coverage, wide-            pain and cease or omit treatment to
1474                                                                        PSYCHIATRIC SERVICES   o November 1998 Vol. 49 No. 11

								
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