Physician-assisted suicide

Aside from abortion, no there is no controversy in medicine more contentious or polarizing today than the controversy over physician-assisted suicide. Yet, it is not immediately obvious why this issue has become so acutely important.

Proponents of assisted suicide usually invoke a prototypical scenario to illustrate their position: Consider the patient riddled with widely metastatic cancer, facing imminent death, and suffering from severe, uncontrollable pain. Does not such a patient have a right to ask his or her physician to give them the means to end their suffering once and for all? And does the physician not have the right to respond without committing a crime?

It is an extremely compelling question. Accordingly, this scenario is the one that has been posed to the public in most polls whose results appear to show that the majority of Americans are in favor of physician-assisted suicide. Few would argue that this terminal, pain-wracked patient does not have a right to expect his physician to do whatever it took to relieve his suffering. Few would expect that physician to deny the desperate pleas of the patient. Most would believe it unethical for a doctor to deny those pleas.

But in real life, this very difficult clinical problem is dealt with frequently and effectively without having to invoke assisted suicide. What most knowledgeable and compassionate physicians do in such cases is simply to give as much pain medicine as it takes to make the pain go away, even if doing so runs the risk of hastening the patient’s death.

This course of action is not only ethical, it is also legal. Aggressive pain control in terminal patients is almost always effective in reducing pain to tolerable levels. It is entirely consistent with professional standards. It honors individual autonomy, and does so without impinging on the rights of society. Furthermore, the Supreme Court, which in 1997 unanimously struck down a constitutional right to assisted suicide, took that opportunity to stipulate specifically that physicians are encouraged to use aggressive pain control measures in terminal patients when necessary, even if those measures have a chance of hastening death.

Granted, there will be occasional cases where even extremely aggressive pain management fails to adequately control pain, and leaves the patient asking for death. So current medical science, laws and ethics do not adequately answer all possible situations. But fortunately, with adequate management these cases are very rare. (And in cases where management is not adequate, the solution is to better educate the physicians, not to kill the patients.) So, given that the prototypical scenario is uncommon, this leads us to wonder – why all the passion, at this particular time, about legalizing physician-assisted suicide?

Why all the passion?

In examining this question we should look at how assisted suicide is actually practiced. Consider the clinical practice of that celebrated pathologist, Dr. Kavorkian. For the most part patients with unrelenting pain are not the ones who have requested his assistance. Most who have sought him out wanted to end their life for other reasons, commonly because they suffered from disease-related depression, loss of control, or fear of becoming a burden to their families. Few had intractable pain, and some did not even have terminal illnesses. This is a pattern that holds up in Holland, too, where assisted suicide and euthanasia are acceptable as a matter of public policy. Pain is the motivator in a decided minority of Dutch patients who ask for assisted suicide.

Seeing this, one must conclude that the passion in the end-of-life movement for assisted suicide cannot reside primarily in the desire to relieve pain in terminally ill patients. One suspects that instead, the prototypical pain-wracked patient is invoked primarily to garner sympathy for their position. Their passion more likely derives from a general sense, within that movement, that individual autonomy needs to be rescued from the clutches of the unrelenting, unfeeling, smothering bio-medical-technical machine.

But these sentiments have been rumbling along in the background for decades, and never drew more than amused glances from the “establishment.” What’s new is that, for some reason, the “establishment” has seen fit in recent years to give voice to these sentiments, and to bring the issue of physician-assisted suicide (and its mate, euthanasia) to the fore. Obviously, I am suggesting that the reason for this is financial.

So in examining the assisted suicide issue, we need to consider not only the ethical debate (i.e., the rights of the individual to demand assisted suicide versus the rights of society to hold such activity illegal), but also what it means that this issue has become so urgent at this particular time.

Next: Physician-assisted suicide and autonomy

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