Should American health care include assisted suicide?

Business & Health, Annual, 1997 by David Anderson

Timothy Quill, MD, wrote a prescription for barbiturates and made sure that his patient knew how much to take to induce sleep, and how much to die. As Quill passed the slip to Diane, he had the uneasy sensation of stepping beyond personal as well as legal bounds. Yet he was convinced that he would do wrong to refuse the middle-aged woman's firm and repeated requests for a means to kill herself.

Diane had declined cancer therapy that would have offered a 25 percent chance of cure. She was unwilling to accept the inverse of that hope: the 75 percent chance that the ordeal of radiation and chemotherapy would be useless -- that she would die without ever again experiencing a day in which pain and drug effects did not severely restrict her faculties and energy. Surely, Quill reasoned, it would be cruel to abandon her to agonies such as might attend the final onslaught of her acute myelomonocytic leukemia.

Not many weeks later, Diane retired to a room by herself and made use of Quill's prescription. Had anyone accompanied her, that person would have been subject to legal action for assisting in a suicide. Afterwards, Quill was so convinced that he had taken the only defensible course, and so upset by Diane's ultimate isolation, that he decided to challenge the law. In early 1992, he published his story in The New England Journal of Medicine. Soon after, together with two other physicians and three patients, he filed suit to challenge New York's law forbidding any person from helping another commit suicide. In January, the U.S. Supreme Court heard arguments on that suit, along with a second, similar one from the state of Washington.

The proposition to grant physicians a legal right to help patients die obviously has profound ethical implications-none of which is seriously encountered in the well-publicized activities of Jack Kevorkian. Does a person's right to self-determination extend to the point Of self-destruction? Is the injunction "Thou shalt not kill" absolute in all circumstances except for self-defense? Should we tolerate grim suffering -- either physical or psychic -- without hope of recovery or epiphany?

Ultimately, say many experts, we must consider these difficult issues not in the abstract, but in the light of what we know and intuit about ourselves and our institutions. Can we be sure that freedom rather than coercion, and compassion rather than socioeconomic motives, would drive the writing of legal prescriptions for death?

Is there a right to suicide?

Today's debate over physician-assisted suicide grows out of the right-to-die movement. With the coming of age of intensive-care medicine in the 1960s and 1970s, caregivers and the public became alarmed over the plight of some patients who were being kept alive by the new techniques. Some of these patients had no hope of ever leaving their hospital beds and wished to die. But the moral tenets of medicine, as traditionally understood by many physicians, forbade disconnecting ventilators and feeding tubes.

With a growing number of individuals tethered indefinitely to pumps and monitors in intensive-care netherworlds, patient advocates and ethicists argued that patient autonomy is a primary ethical principle in medical decision making. After intense professional and public debate, a consensus emerged that a patient's normal right of self-determination entails a right to refuse medical treatment or demand that it be stopped -- even if death is a sure result.

To proponents of assisted suicide, self-determination logically extends to taking one's life. "We all agree that it's all right to take the patient off the ventilator," says Peter Ubell, MD, an internist and bioethicist at the University of Pennsylvania School of Medicine. "But sometimes it's going to take 48 hours of slow, miserable respiratory failure before the patient dies. How many times have I been asked, `Is that really humane? If we know the patient is going to die in the next couple of days, why don't we help them?"'

From another perspective, however, suicide and refusal of treatment differ with respect to the issue of patient autonomy. The right to refuse treatment is important in large part because it enables patients to protect themselves from unwanted medicine. The catalyst for establishing this right was the sight of unlucky patients sentenced to semiperpetual dependency on machines. In some of the worst instances, individuals were allegedly preserved so that medical students could practice venipuncture and other techniques upon living human bodies.

Thus, asserting the ability to refuse treatment transferred power from the medical system to patients. In contrast, legalizing physician-assisted suicide will give the system more power.

In a similar vein, some advocates of assisted suicide point to the use of opiates to abolish pain even when the necessary doses are high enough to hasten the patient's demise. What ethically substantive difference can be drawn between this common practice and that of assisted suicide? they ask.