Advances in medical technology have presented us with a paradox. We are able to maintain life dramatically longer than ever before. The capability of the medical sciences to intervene has brought increasingly complex decisions into the care of the terminally ill. Where once nature held sway, now doctors, patients, family and society must face the decisions about when life should end. The humanity of medicine may, at times, do battle with the science of medicine.

The issue, couched in the term “death with dignity,” is physician-assisted suicide. To some it is outright murder and the most flagrant violation of the physician’s duty to do no harm. To others it is a logical consequence of the concept of patient autonomy and the right to die. This latter concept seems firmly ensconced in medical practice when decisions are made about withholding therapies.

Legal Background
That was not always the case. It took the case of Karen Ann Quinlan to move the private debate to the public arena. In 1975, Quinlan suffered a respiratory arrest and entered the state we now clinically label as a persistent vegetative state. It took years of legal and ethical arguments before the respirator was removed and some months later Karen Ann eventually died. Our society has shown itself to be comfortable with policies that reflect the outgrowth of the Quinlan case.

We commonly honor a terminally ill patient’s request to withhold or withdraw certain aggressive medical treatments. In 1994, Oregon voters approved a ballot initiative allowing a physician to prescribe a lethal dose of medication for self-administration by a terminally ill patient. Thus, physician-assisted suicide was legalized in October of 1997 under the Oregon Death with Dignity Act (Or. Rev. Stat. § 127.800-127.897). The intent of the voters was affirmed in two referendums and passed muster before the United States Supreme Court.

Although the Supreme Court stated there was no constitutional right to assisted suicide, the advocates of physician-assisted suicide envision a gradual acceptance of the concept now that the Oregon act has been sustained.

The Debate
The lay public and the professional health community will be faced with additional debates around the issue for some time to come. Central to the debate will be several claims. On one side, individual patients want control over the final moments of their lives. On the other, society has a broad interest in protecting life and protecting the ability of medicine to cure and care for the ill.

In between are the personal ethical and moral judgments each must make. The issues are also further clouded by the perception of ulterior motives such as financial considerations and personal animosities of the burden of care.

The debate has centered on the moral and legal considerations that surround legalization. Much should and could be discussed around physician and patient attitudes. The official position of organized medicine has generally been opposed to the principles of physician-assisted suicide as contrary to the basic tenets of health care and the provider/patient relationship. The American Medical Association (AMA, 1992), the American Nurses Association (ANA, 1994), the American Geriatrics Society (AGS, 1995) and the American Osteopathic Association (Bergen, 1999), all oppose such initiatives. However, polls of physicians show there is increasing acceptance of the notion that there may be a role for physician-assisted suicide in terminal care.(Lee, 1996)

In the fall of 2000, the people of the state of Maine were asked to vote on a physician-assisted suicide referendum. It can be predicted that there will be similar efforts across the country. The issue generated a crescendo chorus of opinions. There was loud and intense debate. Thankfully, it was for the most part courteous and open.

However, by all accounts it was most certainly vigorous. The issue was couched in the term “death with dignity,” but it was most certainly physician-assisted suicide. There was no escaping that central issue.

While the most recent attempt for legalizing physician assisted suicide was made in Maine, make no mistake - it is coming to a ballot box near you, sooner rather than later. Those members of our society who believe in this as a right will be vocal advocates of patient autonomy. They will rightly point out the failure of “the system” to care for the terminally ill. They will have heart-rending story after heart-rending story illustrating the cold and unfeeling physician, hospital, nurse, or other member of the health care system.

The opponents will cite fears of Orwellian proportions- unchecked “duty to die” and inevitable slippery slope predictions affecting vulnerable populations. Fears and emotional reactions will be fermented on both sides of the issue.

Phrases like end-of-life care, terminal disease, medical futility, and end-stage illness contain strong words that evoke strong reactions. They are so final when uttered by physicians and so startling when heard by patients and family. They most certainly evoke strong emotions - mostly distressing thoughts. They are, however, all potential realities on the road of life and the continuum of care.

What do they signal to you? Perhaps it is simply avoidance of the issue and its unpleasantness. Perhaps it is a feeling of helplessness for the patient or impending loss for the survivors. Perhaps it is a sense of failure for the physician. Perhaps it is conflict for society. Perhaps it is something else.

But whatever it is, it is likely very strong and very heartfelt. It will be rooted as much in the visceral gut as it will be in objective intellectual thought. It will be shaped by your values, your experiences, and your religious beliefs. For you, it will be correct and appropriate. It will be straightforward and easily understood by you in the context of your life and your wishes, dreams and aspirations.

I wish I could be black and white about it. I wish every case could be just like in the books or on the TV drama show. I wish that the approach could be coldly clinical – “just the facts.” However, it is not that simple.

Every case, every person, and every situation is unique unto itself. Every case has a myriad of factors to consider. Every case has an ever-changing set of circumstances. There are competing emotions and competing thoughts. Thoughts of compassion run along with thoughts of anger. Thoughts of guilt are side by side with thoughts of futility or hope.

Individual Judgements
Our culture and our training teach us to rage against the dying of the light. It teaches that there is another option, another medication, and another procedure just around the corner if we but wait and persevere. We are taught that disease and death are the enemy and that doctors can play God.

Some of us have come to realize that death is not always necessarily a negative therapeutic outcome. Some of us have come to realize that often the best treatment is no treatment at all. In that realization we confront our own fears and come to champion care over cure. We wrestle daily in the practice of medical care with spiritual, ethical, legal, and professional conflicts. Certainly physician assisted suicide is one of them.

As a matter of course, most of us try to have a rational approach to those conflicts. It is not always possible. Our language and words show that we try to grade such a conflict with each new encounter depending on age: dying young is worse than dying old. This is reflected in phrases like: “She was so young,” and “He lived a good life”.

We try to grade it by the therapies involved. Each of us has a separate view of what is extraordinary. Is it the feeding tube or the chemotherapy? Perhaps it is the breathing machine or the pacemaker. Furthermore, we grade it depending on the quality of life being experienced. We think of pain or what the patient would have wanted. We use phrases like “She’s out of her misery” or “He never would have wanted to live like this.”

All of this is filtered by our own experiences, our own thoughts, our own personal perceptions, and our own values. No two are exactly alike.

Both osteopathic and allopathic physicians take oaths, which in part seem to proscribe physician-assisted suicide. The Hippocratic Oath states, “... I will give no deadly medicine to any one if asked...” The Osteopathic Oath reads, “...I will give no drugs for deadly purposes to any person, though it be asked of me...”.

The proponents of physician-assisted suicide may seem at odds with such oaths. However central to both oaths is the concept of deadly purpose. Is the release that comes with death a deadly purpose? Is the preservation of dignity a deadly purpose? Is the actualization of autonomy and independence a deadly purpose? Or are advocates of physician-assisted suicide playing for semantic cover?

If the request for physician-assisted suicide was always predicated on pain or depression, advocates might be less sympathetic to the arguments in favor. There is much we can and should do in these areas of care.

Survey Results
But as the report on Oregon’s “Death with Dignity Act” (State of Oregon, 1999) shows, that is not always the case. Of those seeking assistance, 81 percent cited loss of autonomy and 81 percent cited loss of enjoyment of life as motivating factors. Further, 74 percent of families reported that patients wanted to control the manner and time of their deaths.

We must acknowledge that 21 percent cited pain and another 21 percent cited being a burden as the motivation for requesting assisted suicide. For that 21 percent, we must do more and not let them become trapped in suicide as their only option.

The Education for Physicians on End-of-Life Care (“EPEC”) effort is supported by the Robert Wood Johnson Foundation and the AMA and is endorsed by members of the AOA. Its attempt to bring end-of-life issues to the forefront is making a significant impact in medical education. As the EPEC curriculum (Emanuel, 1999) points out, there are many subtle messages involved in the request for assisted suicide.

Physician’s Responsibility
It is incumbent on the physician to search out those issues. There are complicated dynamics of family interactions in which the issues may be pressures that are real or imagined by the patient. While depression is an obvious consideration, other masked psychopathologies may be revealed as the patient intent and request for assisted suicide becomes apparent.

The hidden and secret agendas of revenge, control, and self-deprecation may need to be explored. The feelings of potential abandonment and burden are ever present. As the Oregon experience demonstrates, a number of prescriptions requested for assisted suicide were never used. This would seem to indicate a desire to retain the option of control and/or power in the face of an unconquerable illness is as great if not greater than actual utilization as a central issue.

Terminal illness is, and always has been, as much a family illness as a personal one. The impact of the family on the illness and the decisions made is well recognized and is a part of family systems teaching. Likewise, the impact of illness on the family system is equally well recognized.

When faced with terminal end-stage illness, the family is as much the patient as is the individual. The larger community as well as the family are influenced by and influence the question of physician-assisted suicide. Which dynamic should hold sway- the family, the community, and the individual? What is the rational answer? Any of these parts of the whole may see the issue of assisted suicide as simply wrong and irrational. Is the desire for assisted suicide rational, and if so, to whom?

Whether by assisted suicide or “by nature,” death may not always be an irrational choice, especially for the cognitively intact and competent individual. We acknowledge this fact when we condone the withdrawal or withholding of treatments.

Why is it OK to refuse artificial feedings and starve to death? Why is OK to stop dialysis and die of gradual uremic poisoning? Is it because it is “natural”? Much of medical intervention is not natural. Is it OK because it is God’s will? Does a loving and benevolent God want me to suffer? All the major religions have an admonition that proscribes the taking of ones own life or that of another.

Consider the following scenario: A 66 year old, cognitively intact, chronic dialysis patient has undergone dialysis three times a week for several years after failing transplantation. Her day-to-day life is consumed with fluid restriction, the taking of medications, and either getting ready for dialysis or recovering from it. The patient requests to have dialysis discontinued.

After due discussion and deliberation, it is stopped. It will take the patient several days to die. After two days, she reports that the wait, the process to be psychologically unbearable, and that she would like to die by assisted suicide. She reiterates her resolve to proceed in any case. Is there a place for assisted suicide here? Would we deny her the right to refuse treatment but not the right to a self-determined end? After all, the outcome will be the same.

Why must she die alone? Why must there be deathwatch for it to be natural? Why must she be allowed to die in the middle of the night at a time and place unknown? Is it because death must come by “slipping away”? Why can’t she choose the time and place? Why can’t she plan to have loved ones at her side? Why can’t she choose to have those things she cherishes - poetry, art, and music - present? Why must she succumb to your values and your perceptions or to mine? Why not hers?

Most physicians are troubled by the thought of physician-assisted suicide. It is worthy and deserving of debate. In addition to the referenda that are being proposed, I am troubled because I believe it occurs now.

It occurs as a dark and silent conspiracy without acknowledgment and without safeguards. I am concerned about vulnerable populations who cannot speak for themselves. I am concerned that it is the first step on an accelerating course of other convenience solution to medical care and costs.

I am troubled about how independent second opinions might be. I am troubled about diagnostic accuracy and the lack of precision in the predictability of the course of disease in any one individual. I am troubled by the possible financial motivations inherent in the concept.

I remain convinced that we can do better and that assisted-suicide might possibly be an option for a selected few. Which few remains a question. I am so sure that medicine cannot predict accurately and I am so sure that the right course of action for some is wrong for others.

Easing the Conflict
Here is where the imperfect science of medicine meets the imperfect art of medicine. I continue to strive for the right answer and or the easy formula that will ease my conflict.

I remain conflicted within myself as to what safeguards are enough to prevent exploitation and abuse. I am heartened that the Oregon bill did not open a floodgate of activity and the numbers remain small. I am certain that the technology and science of medicine will outpace the art of medicine. I am convinced that we will be able to keep people alive longer and longer even if spiritually, morally, intellectually, and physically bereft.

Our aim as physicians is health - not disease. Central to health is mind, body AND spirit. We must attend to all three and not just the corporeal body. After all is said and done, we must respect the patient and not the disease.

Signs, symptoms, disease, diagnosis - these should not be our only concerns. We must be sure that our focus is not the disease that happens to occur in a patient. We must be sure our focus is the patient who happens to have a disease. As the patient would remind us – “There’s a person in here.”