Assisted suicide and the case of Dr. Quill and Diane.

• Author: Ubel, Peter A.
• Position: Response to Timothy E. Quill, New England Journal of Medicine, vol. 324, p. 691, 1991

Dr. Timothy Quill provoked a great deal of debate when The New England Journal of Medicine published his description of a woman named Diane, a patient whom Quill helped to commit suicide.(1) Among the responses published in a later issue of the journal was the comment of a physician who stated that "it is the role of a physician to prevent suicide attempts wherever there is a possibility that they may occur."(2) The moral principle seems clear. Physicians should never help patients commit suicide.

That physician, and many others, view the prohibition of physician-assisted suicide as a moral absolute. Such actions are always wrong. Indeed, the terminology surrounding suicide implies such a moral determination. People "commit" suicide, just as they commit other types of sins. It is wrong to commit a sin.

But we err when we view difficult moral dilemmas such as physician-assisted suicide as yes/no, pro/anti, or right/wrong issues. This type of dichotomous approach to moral reasoning strips away the complex ethical concerns that physicians face when dealing with terminally ill patients. Such dichotomous thinking also tends to separate people into opposite camps whose views are quite similar, for it deemphasizes those values that they share.

Such a dichotomous approach to moral reasoning, relying on strong principles or fast rules, contrasts with a method of moral reasoning described by Jonsen and Toulmin in their book The Abuse of Casuistry.(3) Casuistry is a method of reasoning that focuses on the complexity of particular cases as they arise in such disparate disciplines as law, medicine, and ethics. In casuistry, one compares the case at hand both to paradigmatic cases and to previous cases one has studied or been involved with. The skilled casuist expertly teases out the relevant similarities and dissimilarities between this new case and the others. Where relevantly similar, the new case should generate the same conclusion that the previous cases did (the conclusion being a verdict in law, a diagnosis or treatment plan in medicine, and a moral judgment in ethics). Where dissimilar, one must make judgments about how to factor these dissimilarities into one's final decision.

By applying casuistic methods to the case of Diane, I hope to reveal the complexity of the moral decisions Quill faced. In this article, I will compare Quill's actions to those taken by physicians in other well-known cases, such as the anonymous physician in the "It's Over, Debbie" case and the suicide specialist, Dr. Jack Kevorkian. In addition, I will explore the alternative actions available to Quill. Only by dwelling on these practical matters, as defined by the particular situation facing Quill, can we begin to judge the moral implications of his actions.

The Facts of the Case

Any good judge, physician, or ethicist must begin with the facts of the case at hand. When we meet Diane, Quill tells us that he has known her for more than eight years and has helped her battle both alcohol abuse and depression. However, Quill and Diane discover that they now face a problem greater than any they have faced together before: Diane has leukemia. After several long discussions with Quill, Diane decides that a 25% chance of long-term survival is not good enough for her to undergo the agonies of chemotherapy and bone marrow transplant. She chooses to accept certain death rather than suffer these additional agonies.

Quill brings an impressive background to the case, having training or experience in internal medicine, psychiatry, and hospice care. His background is ideally suited to taking care of terminally ill patients.

Quill now faces a difficult situation that, in this day of patient rights and informed consent, is becoming increasingly common. He wants to help Diane conquer her illness, but he knows he must respect her right to refuse. Thus, he pushes for her to consider treatment but ultimately bows to her consistent desire to forgo treatment.

Quill also takes the time to make sure she understands her decision. Like a textbook on informed consent, he makes sure she knows her treatment options and the consequences of refusing therapy. He gives her time to dwell on her decision and discusses it with her and her family on multiple visits. He does not accept ambiguous statements but makes sure he knows exactly what she is thinking.

Quill's actions up to this point, while impressive in their sensitivity and thoroughness, would not raise much excitement at a meeting of medical ethicists. Ethicists are in general agreement that competent patients have the right to refuse treatment. While health care workers, in return, may reason with patients, plead with them, or even threaten to stop taking care of them, they cannot force competent patients to undergo treatments against their will. Thus, Quill did what most ethicists would say he should have done--he regretfully respected Diane's decision to refuse chemotherapy.

At this point, however, Diane's narrative history takes a turn, as she states her desire to control the end of her life. She expresses her aversion to "comfortable lingering" and prefers to have the means to end her life painlessly when she feels ready. Quill considers the possible consequences of what she is considering and refers her to the Hemlock Society. He hopes such information will decrease her fear of a lingering death and thereby improve the quality of her remaining life. He also hopes to avoid the consequences Diane and her family would face were she to attempt suicide and fail.

Over the next few months, Quill provides Diane with additional assistance in ending her life. Most controversially, he prescribes barbiturates for her, ostensibly for sleep but in the full knowledge that she wants enough to be able to commit suicide. He talks to her about her plans and educates her regarding the proper dose of pills needed to end her life. He remains available to help her and provides a wide range of outpatient medical care to make her life as comfortable as possible. She finally calls him to say she is ready to end her life, and within a couple of days her family lets him know that after taking an overdose of barbiturates she has passed away.

Quill's Options

Before Quill wrote about Diane's case, the medical ethics community and the public at large (through the help of the media) debated the morality of assisted suicide and euthanasia largely on the merits of several well-known cases: the "It's Over, Debbie" case from The Journal of the American Medical Association (JAMA)(4) and the series of suicide-machine deaths organized by Dr. Kevorkian. Although these cases did wonders to unite ethicists who had rarely agreed on anything previously, they did little to advance debate on assisted suicide.

In telling Diane's story, Quill not only gave us a remarkable case to learn from, but he also redirected the debate on assisted suicide. Quill's actions differed significantly from those taken by Kevorkian and the Debbie author. And in every way that Quill was different, he improved on their actions. Because of this, physicians, lawyers, ethicists, and the general public have a better case with which to test the appropriateness of physician-assisted suicide.

In this section, I first want to describe how Quill differs from other well-known cases. Then I will discuss the other options Quill could have pursued with Diane.

Contrasts with Well-Known Cases

Quill's clinical experience and his long-standing relationship with Diane contrast sharply with that of Dr. Kevorkian, a physician widely known for his efforts to help patients kill themselves with his suicide machines.(5) Kevorkian is a retired pathologist, without any experience or training in caring for terminally ill patients. Kevorkian got to know his first suicide "patient," Janet Adkins, at the same time that he was preparing to help her end her life. He did not have a chance to...