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sides of euthanasia - «arch Angel JV YES The Supreme...

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Unformatted text preview: «arch Angel] JV» YES The Supreme Court and Physician- Assisted Suicide—The Ultimate Right mtmmeondmwmiawafphysicimassmm,mm mmwossuprmmemmarwrwmngmmm Wyomqmmgammmmmm [Idle mmsmrrwwm Dc tsunami mmmraoonxam Fate}; memes Pain «anemone CMWOIMQWW 31'me Cmmmmmmwmmm,mmmmm wm’mdmimafflmflfineirmaflm Wammtlhelpwmd- mammommms. ijeromeEKassirenMD. The US. Supreme Court “fill decide later this year whether to let stand iccisimubymoappmlsoourtspemfitfingdoctonmhelptermmaflyfllpaflmts :ommjt suicide.‘ The Ninth and Second Circuit Courts or Appeals last 5pm; field that state laws In Washington and New York that ban assistance in suicide were unconstitutional as applied to doctors and their dylng patients.2“3 If :he Supreme Court lets the decisions stand, physicians in 12 states, which nclude about half the population at the United States, would be allowed to grovide the means for terminally ill patients to talc: their own lives, and the remaining states would rapidly follow suit. Not sinceRoev. were has a Supreme Court decision been so fateful. The decision will culminate several years of intense national debate. fueled by a number of highly publicized events. Perhaps most important among them is Dnjack Kovorkian’s defiant assistance in some 44 suicides since [990. to the dismay of many In the medical and legal establishments, but with substantial public support, as evidenced by the fact that three iuries refined to convict him even in the face of a Michigan statute enacted for that purpose. Also since 1990, voters In three states have considered ballot [Initiatives that would legalize some form of physician-assisted dying, and in 1994 Oregon became the first state to approve such a measure.‘ (The Oregon law was stayed pending a court challenge.) Several surveys indicate that rough! two thirds of the American public now support physician-assisted suicide, -5 as do more Minimalism “ThesupmmeCotmanaPhyunan-amdmioes—m Lnumaremghc-ne memmormmdaafiuwa Ming. 50—53. Cometghtfllmbyflie .[tepdnlad MassadiusellsMedical Sodcty.AllrIgi‘ttsrer-e mutilation. rssr MardaAngell 83 than half the doctors in the United States,” despite the fact that lrtl'luentlal physicians organizations are opposed. It seems clear that many Americans are now so concerned about the Inability ofa lingering, [ugh-Ledanology death that they are receptive to the idea of doctors“ being allowed to help them die. Inthisedltoriallmllexplain whylbelievetheappealsoourtswereflght and why 1 hope the Supreme Court will uphold thelr decisions I am aware that this is a l'ljghlyooneentlous issue, with good people and su'ongarguments on both sides The American Medical Association (AMI? filed an amicus brief opposing the legalization of physician-assisted suicide, and the Massachusetts MedicaJSociety. whichownsthehumtwasasignatmytoit. But herelspeak fmmysdfinotthelwmoruieMassachusettsMedlcalSodetthelegal aspectsofthecasehayebeenwell discussed elsewhere, to memostcompel- lingly in Ronald vaorkin‘s may in the New York Review arm? I will focus primarily on the medical and ethical aspects. Ibegithhthegenerallyaooeptedprerrflserhatmeot‘themostlrnpon tent ethical principles In medidne ls respect for each patient‘s autonomy, and that when this principle conflicts with others, it should almost always take prev oedence.‘l'hlspremlse lsincorporated lntoourlaws gown-ling medicalpracdce and research, including the requirement of lnfonned consent to any treat- ment in medicine, patients exercise their self-deterrrunadon most dramatically when they ask that life-sustaining treatment be withdrawn, Although others may sometimes consider the request ill-fomded. we are bound to honor it if the patient is mentally competent—that Is, it the patient can understand the nature otthe decision and its consequences. A second starting point is the recognition that death is not fair and is orflen cruel. Some people die quickly. and others die slowly but peaoehrlly. Some find personalor religiousmearungtn theprocess, as wellas an opportu- nity for a final reconciliation with loved ones. But others, especially those with cancer, AIDS, or progressive nemoiogic disorders, may die by inches and in great anguish, despite every effort of their doctors and nurses. Although nearly all pain can be relieved, some cannot, and other symptoms. such as dyspnea, nausea, and weakness. are even more difficult to control. In addition, dying sometimes holds great indignities and existential sorta-mg Patients who hap— pentorequ‘rre some treatment tosustaln theirllves, suchasassisted ventilation or dialysis. can hasten death by having the life-sustaining treatment with- drawn, but those who are not receiving lifeasustaining treatment may desper- ately need help they cannot now get. ' [E the decisions of the appeals courts are upheld, states will not be able to prohibit doctors from helping such patients to die by prescribing a lethal dose of a drug and advising them on its use for suicide State laws baning euthanasia (the adrnlnlstration of a lethal drug by a doctor) and assisted suicide for patients who are not terminally Ill would not be affected. Furthermore, doctors would not be required to assist in suicide; they would simply have that option. Both appeals courts based their decisions on constitutional questions. This is important, because It shifted the focus of the debate from what the majority would approve through the politlcal process, as exemplified by the Oregon ini- tiative, to a matter of flmdamental rights, which are largely immune from the 34 ISSUES ! Should Physicians Befllowedtn Assist!!! Patient Suicide? political process. Indeed. the Ninth Circuit Court drew an explicit analogy between suicide and abortion, saying that both were personal choices pro- tected by the Constitution and that forbidding doctors to amist would in effect nullify these rights. Although states could regulate assisted suicide. as they do abortion, they would notbe permitted toregulateitoutofeidstence. [tlshatdtoquarrelwiththedesiteot‘agreatlyutfierurgdyingpatlehtiot a quicker, more humane dream or to disagree that it may be merciful. to help bringthat about lndtosecircumstances. lovedonesareoiften relievedwhen death finally comes, as are the attending doctors and nurses. As the Second Grudthurtsaid (in thecaseonulllu them), thestate hasnointetestmpro— longing such a llie. Why, then, do so many people oppose legalizing physidan- assisted suicide in these cases? There are a number of arguments against it, somesimngerthanothers. butlbelieve noneofthemcan oflsettheoverriding duties of doctors to relieve sullering and to respect their patients' autonomy. Beiow 1 list several of the more important arguments against physician-assisted suicide and discussle believetheyare in the last analyslsunpersuasive. Astittodsrdcldeisdfirrmofkillfrrg, whichisalwmwmnanmustuimwiqg lifesnsitu'm'rgirectrrieritsimplycllm tiredlsmwindrkeidmurse 'i‘hetearethree melhodsorl‘hasleningflredeathofadfingpafienl: Mflidtawinglile-sustaining treatment, assisting suicide, and euthanasia. The right to stop treatment has been recognized repeatedly since the 19% arse ofKaren aim Quinlan” and wasaffln'riedbythe U5. Supreme Courtinthe 199G t.“.r-u.mrrdecisionu and the us. Congress in its 1990 Patient Self-Determination Act.“ Although the legal underpinning is the right to be free of unwanted bodily invasion, the purpose ethane-13:13 death wasexpiicitly acknowledged. lnoontrast, assistedsuiddemd euthanasia havenotbeenacoeptedieuthanadatsiilegal inallslates, andassisted sudden meg] in most of them. Why the distinctions? Most would say they turn on the doctor's role: whether it is passive or active. When life-Mug treatment is withdraw the doctor’s role is considered passive and the cause of death is the underlying disease, despite the fact that switching off the ventilator of a patient dependent on it looks anything but passive and would be considered homicide it done without the consent of die patient or a proxy. In contrast, euthanasia by the injection of a lethal dnrg is active and directly causes the patients death Assist- his suicide by supplying the necessary drugs is considered somewhere in between, more active than swltdung oil a ventilator but less active than iniect- irig drugs, hence morally and legally more ambiguous. I believe, however, that these distinctions are too doctorcentered and not wifldenilypatient—centered. Weshouldaskourseivesnotso much whetherthe doctor'srcle upasfiveoracdvebutwhedierthepafientsroleispasshieoracfive. From that perspective, the three methods of hastening death line up quite differently. When lilosrmainlng treatment is withdrawn from an incompetent patientattherequestofa proxyorwheneuthanasiatsperformed, thepaiient maybeumerly passive. hideed, eitheractcan beperi'ormedeven ir‘thepadentis unaware of the decision. In sharp contrast, assisted suicide, by definition, cannot occur without the patients knowledge and participation. Thereiore, it YES i' Marcia Angeli 8: must be activevthat is to say, voluntary. That is a crucial distinction, becaus it provides an inherent safeguard against abuse that Is not present with th other two methods of hastening death. if the loaded term ”klli“ is to be user it is not the doctor who kills, but the patient. Primarily because euthanasi can be performed without the patients participation. 1 oppose its legalizatio in this ammo-y. Assisted suicide is riot necrssrrnt All summits! can be relieved ifccre givers or Wskdlfirlmdmrpasriwmh, as illrotruledbydwliaspienmt Ihav no doubt that ii expert palliative care were available to everyone who needed 1- therewouldbefewrequestsforassistedsiuddefwenunderfliebestotdrom stances, however, there will always be a few patients whose suffering stmpl tannctbe adequatelyalleviated. And there will be some whowouid prefer su cide to any other measures available, including thewithclrawal of liie-sustainln heannentordteuseofhmvysedafionSmehtmryeiiortslmuldbemadeb improve palliative care, as Iargued 15 years ago,13 but when those efforts ar unavalilrig and suffering patients desperately long to end their lives. Wdat assisted suicide should be allowed. The argument that permitting it woul. divert us from redoubling our commitment to comfortcu‘easlts these patient topaythepenaltyiorour failings. It isaiso illogical. Goodoomfortcateand th availability of physiclarrassisted sirldde are no more mutually exclusive that good cardiologic care and the availabilityof heart transplantation. Permitting assistedstdcide norrldprirus arr a moral 'sli'ppery superfdldrwglr in ilse. assisted suicide might be acceptable, it would lead inexorably to involution! eufirartoslc. [t is impossible to avoid slippery slopes in medicine (or In an: aspect of life). The issue is how and where to find a purchase. For example we accept the right of proxies to terminate life-sustaining treads-rent, despit the obviouspoteniiai ior abuse, because thereasons for doingsooutweigh th risks. We hope our procedures will safeguard patients. in the case of assistel suicide. its voluntary nature is the best protection against sliding down a slip pery slope, but we also need to ensure that the request is thoughtful and freel- made. Although it is possible that we may someday dodde to legalize voluri tary euthanasia under certain droimstanoes or assisted suicide forpatients whi are not terminally ill, legalizing assisted suicide for the dying does not in itsel make these other decisions inevitable. Interestingly, recent reports from thu Netherlands, where both euthanasia and physician-assisted suicide are permit ted, indicate that fears about a slippery slope there have not been born Out.“'15‘16 Assistodsuiddemdbeadmmflwemmimflymrdsaclallyndnemble. Th. marmaladrfleiymmbemmwa Adimttedly, overburdenet families or oostmnsdousdocwrsmight pressme vulnerable patients toreques suicide, but similarwrongdoing Isat least as likely in the (use cil‘wlthdrawiru life-sustaining tread-neat, sir-roe that decision can be made by proxy. Yet, their is no evidence of widespread abuse. The Ninth Clirwit Court recalled that i wasfearedRoenltbdewoiddleadtocoercionofpooranduneducatedwomer 86 ISSUE 5 r Should Physicians Be Allowed to Assist in Patient Suicide? no request abortions. but that did not. happen. The concern that coercion is more likely in this era of managed care. although understandable, would hold suffering patients hostage to the deficiencies of our health care system. Unfortu- nately, nohuman endeavor is immune to abuses. The question Is not whether a paiedsystemcanbedwisedbutwhetherabusesareflhelytobesuffidmfly raretobeoflsetbydiebenefitsto paflentswhoothervlrisewouldbeoondemned toiacetheendolftheirlives inpron'acted agony. Depend! patients “mid seek physician-assisted suicide miter than help flu- drelr depmtslhri Even in ammonium. «womammmmmpmr— able depression, nor inaudible slrflirl'ng. Patients suffering greatly at the end of life may also be depressed, but the depression does not necessanlyexplain their decision to commit suicide or make it inah'onal. Nor Is it sbnple to diagnose deprtusion In terminally ill patients. Sadness Is to beexpecbed. and some ofthe vegetative symptoms of depression are similar to the symptoms of rennIi-ial ill- mess The succefi of antidepressant treatment in these circumstances Is also not ensued. Although there are anecdotes about patients who diangcd their minds about suicide alter treatment.” we do not have good studies or how often that happens or the relation to an t beam-lent. Dying patients who request assisted suicide and seem depressed should certainly be strongly encouraged to accept psychiatric treatment. but [do not believe that compe- tent patients should be required to accept it as a condition of receiving assis- tance with nitride. 0n the other hand. doctors would not be required to comply with all requests; they would be expected to use their iudgment. just as they do in so many other types oflife-and-cleath decisions in medical practice. Doctorsshoiddmparfidpatein takirlgll'fl. lfdterefs to bemistedstdrideldoctms mlrsrrror be Emailed. Although moot doctors favor permitting assisted suicide under certain (1mm many who favor it believe that doctors should not provide the assistance.“ To them, doctors should be unambiguously com- mitted to Life {although most doctors who hold this view would readily honor a patient: decision to have life-sustaining treatment withdrawn). The AMA. too. seems to obiect to physician-assisted suicide primarily because it violates. the prodession‘s mission. Like others, I find that position too abstract.m The highiot ethical imperative oi docoors should be to provide care in whatever way best serves patients“ interests. in accord with each patient’s wishes. not with a theoretical commitment to preserve life no matter what the cost in suf- fearing.19 if a patient requests help with suicide and the doctor believes the request is appropriate, requiring someone else to provide the assistance would be a form of abandonment. Doctors who are opposed in principle need not assist. but they should make their patients aware of their position early In the relationship so thata patient whochooses toselect another doctor can do so. The greatest harm we can do is to consign a desperate patient to unbearable straining—or force the patient to seek out a stranger like Dr. Kevmidan. Con- trary to the hequent assertion that pemrltting physician-assisted suicide would lead patients to distrust their doctors. i believe distnlst is more likely to arise from uncertainty about whether a doctor will honor a patient's wishes. YES r' Marcia Ansell Physicinmsssldes‘ nitride may occasionally be mounted, but it should renmirr gal. ifdociorsriskplusecuiion, meme!" think Mosheforemisiing Mfirsui 11115 argument wrongly shifts the focus from the patient to the doctor. 111.51 of reflectingthe condition and wishes of patients. assisted suicide would rel the courage and compassion of their doctors Thus. patients with doctors Timothy Quizlii who described in a 1991 Journal article how he helped a pat take her life. would get the help they need and want. but similar pati- wlth less steadfaotdoctorswould not'lhal maltesno sense. People do normed assistance to commit suicide. Wink enough detemlirrafim, can do it chenueiws. This is perhaps the cruelest oi the arguments aga physician-assisted suicide. Many patients at the end of lite are. in fact, physir unable to commit suicide on their own. Others lack the resources to do s has sometimes been suggested that they can simply stop eating and drlnl and kill themselves that way. Although this method has been describe: peaceful under certain conditions.“l no one should count on that The fa- that this argument loaves most patients to their suffering. Some, usually it manage so commit suicide using violent methods. Percy Bridgman, a N: laureate in physics who in 1961 shot himself rather than die of metastatic l cur. said in his suicidenote. ‘It lsnot decent forSociety to makea man do to llimilelf.“'22 My father. who knew nothing of Percy Bridgman. committed sul- under similar circumstancen. He was 8] and had metastatic prostate car The night before he was scheduled to be admitted to the hospital, he shot t self. Lille Bridgman. he thought it might be his last chance. At the time. he notilleactreme pain. norwasheciosetodeath (hlsliieexpoctancywaspn bly longer than six months). But he was suflering nonetheless—horn mr and the side effects of antiemetic' agents, weakness. incontinence, and h: laziness. Was he depressed? He would probably have freely admitted tha- was, but he would have thought it beside the point. in any case. he war lrliensely private man who would have refused psychiatric care. Was he ov concerned with maintaining control at the circumstances of his life and do: Manypeople would sayso. but thatwas the my he was. it isthe job ofrn cinebodealwithpatientsastheyaie. notasvve would likethem lobe. I tell my father's story here because it makes an abstract issue very ( crete. if physidanassisted suicide had been available. I have no doubt father would have chosen it. He was protective of his family. and if he had he had the choice, he would have spared my mother the shock of finding body. He did not tell her what he planned to do, because he knew she wt stop him. I also believe my father would have waited I! physician-assisted (ride had been available. if patients have access to drugs they an take w they choose. they will not feel they must commit suicide early. while they still able to do it on their own. They would probably live longer and oerta more peacefully. and they might not even use the drugs. [mtg before my father‘s death. ] believed that physician-assisted sui ought to be permissible under some circumnances. but his death strengths my ccmiclion that it is simply a part of good medical Merl-ling t1 88 issues if ShmddPhyslcimBenllowedmAsslstinPatIentSulclde? done reluctantly and sadly. as a last resort. but done nonetheless. 'l'here should be safeguards to ensure that the decision is well considered and oonslstcnt. but they should not be so daunting or violative of privacy that they become obsta- cles instead ot‘ protections. in particular. they should be directed not tomrd reviewing the reasons for an automatons decision. but only toward ensuring that the dedslon is indeed autonomous. 1f the Supreme Court upholds the decisions of the appeals oouris. assisted suicide will not be [creed on either patients or doctors. but it will be a choice for those patients who need It and those doctorswiiiingnoheip.lt.om thcotherhand. the Supreme Consumer- turns the lower amuls' decisions, the issue will continue to be grappled with state by state. through the political prooefi. But sooner or iatet. given the need and the uddespread wblic hippest. phyncian-assisted sulcidewill he demanded of a compassionate profession. References l. Greenhmi. Highooust wsayiithedfinghavearighttowlcidehelp. New m‘nmes. October 2. 1996cA1. 2. ...
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