The debate on assisted suicide - redefining morally appropriate care for people with intractable suffering.

• Author: Reitman, James S.

The recent passage of Oregon Measure 16, which would permit physician-assisted suicide under certain conditions, has forced a reevaluation of the proper role for caregivers of patients who are dying or otherwise intractably suffering from "non-terminal" illness.(1) Even before the recent spate of legislative initiatives, several highly respected ethicists and physicians began to advocate physician-assisted suicide whenever such patients see no further hope of meaningful life.(2) The justification for such a role for physicians has continued to evolve in the face of growing ambiguity and uncertainty over whether the capacity of modern technology to prolong life has any real meaning for severely incapacitated or dying patients with intractable suffering.(3)

Modern American Paradigms

The dilemma has been graphically depicted in several high-profile accounts of severely incapacitated or dying patients whose suffering has driven them to seek aid in dying from the courts(4) or from sympathetic physicians.(5) Two cases in particular that exemplify these approaches to aid in dying have attracted much attention and sparked prolonged debate about the legality and morality of actively responding to such appeals: the case of Elizabeth Bouvia and that of Timothy Quill's patient "Diane":

Elizabeth Bouvia is a woman with severe lifelong neuromuscular

impairment from cerebral palsy who at one time was able to control a

motorized wheelchair and even completed college. After a series of

psychosocial crises in her life she became depressed and entered a

hospital in California expressing a desire to commit suicide. Her

request to be allowed to starve herself was denied, and a judge

permitted the hospital to tube feed her. She then filed a suit three years

later at age 28 to have her feeding tube removed and be treated for any

discomfort as she starved. The trial court decided against her--since

fulfilling such a request was seen as tantamount to 'suicide by

starvation'--but the decision was reversed by the Court of Appeals,

which refused to label her request suicide and opined that such a life

`has been physically destroyed and its quality, dignity and purpose

gone.' She is still alive, years after the decision.(6)

Diane' was a woman with a family history of alcoholism and a past

medical history of vaginal carcinoma and depression who was

diagnosed as having leukemia by a former hospice physician, Timothy

Quill. She was referred to an oncologist but then became enraged at his

apparent presumption that she would accept his offer of chemotherapy

and proceed with the treatment. She expected the worst and was

initially convinced she would die. She repeatedly expressed her need to

be 'in control' and her fear of becoming dependent. Initially skeptical,

Dr. Quill was eventually convinced of her need to `maintain dignity and

control.' He referred Diane to the Hemlock Society and ultimately

prescribed a fatal dose of barbiturates. After several `tumultuous'

months--including a brief period of hope for a miraculous cure--Diane

finally said good-bye to Dr. Quill, her closest friends, and her husband

and son, then took the pills and died.(7)

Bouvia's case has become a paradigm for the rights of severely disabled but non-terminally ill individuals to hasten death by refusing life-prolonging medical treatment. As a result of an increasing number of such cases with similar outcomes in several different states, "it is virtually indisputable that competent patients have a right to refuse treatment whether terminally ill or not."(8) However, even though the courts have refrained from labeling such requests suicide, the caregiver who is confronted with a patient asking to hasten death is still faced with the dilemma of whether that request should in fact be treated as a suicide. For the purposes of this discussion "competent" refusals of life support by patients who are not dying--typified by the case of Bouvia--will be considered prima facie suicides.(9)

"Diane" has become a paradigm for the right of terminal but not imminently dying patients to hasten their dying through the active assistance of physicians because of the fear of future loss of control and dignity in the dying process. Championing such a position, psychiatrist Michael Kligman asserts that modern medicine must face the challenge "to allow terminally ill and intractably suffering patients to die with as much dignity, control, and comfort as possible."(10) He argues that, despite all efforts, including effective pain relief, some patients will be left with "the prospect of losing control and independence, and dying in what for many seems an undignified, helpless, and ultimately unacceptable condition."(11) The problem may even be aggravated, he points out, by a rigid, unreflective adherence to Hippocratic tradition and "the prior application of high technology medical intervention."(12)

Such concerns underscore the need to reevaluate the existential impact of intractable suffering and the related question of what kind of care can deal most effectively with such suffering. Behind the drive to legalize assistance in the types of cases exemplified by Bouvia and Diane is the powerful urge to relieve suffering, perhaps at any cost. But the currently acceptable "remedy" for intractable suffering of persons who are severely disabled and who happen to require life support, namely, the withdrawal of that life support,(13) is not legally accessible by the "terminally ill" who are neither imminently dying nor dependent on artificial life support.

Physician-Assisted Suicide and Ethical Individualism

This dilemma has led some activists to justify physician assistance in suicide on the basis of patients' rights and the correlative duties required of the caregiver in order to guarantee the free exercise of those rights. Such reasoning has promulgated the following moral assertions in one form or other to guide the ethical care of intractably suffering, dying patients:(14)

* The highest value for suffering, terminally ill patients is to maintain control and dignity in dying by preserving the right to self-determination.

* When there is no longer any reasonable possibility of otherwise maintaining control or dignity, there is no significant moral distinction between allowing such a patient to die and actually causing death.

* When cure is no longer possible, the most important aspect of the physician's care of the patient is the relief of suffering.

The first of these assertions is based on an individualistic ethical framework in which the preservation of patient rights(15) trumps all other values and is guaranteed by "correlative" duties of the caregiver.(16) The second assertion follows logically from the first, in that maintaining a distinction between allowing to die and causing death fails to provide equal protection for the right of dying individuals like Diane to exercise autonomous choice: If the highest value remains the preservation of control and dignity in dying, then it is discriminatory to deny such patients the same right retained by persons who are severely disabled, simply because they have no similar requirement for artificial life support that could conveniently be withdrawn.(17)

The third assertion logically follows the first two and stems from a contractual model for the patient/doctor relationship--in essence, the caregiver provides those services dictated by the "consumer's" autonomous choice.(18) Consequently, if the physician's ultimate role is viewed as the relief of suffering, then he can in good conscience continue to fulfill his contractual obligation to the patient by providing the autonomously chosen "service" of assisted suicide.(19) As long as the intent of such "therapy" is the relief of suffering, it would therefore be just as ethical for a physician to withdraw life support from one patient as to' prescribe lethal drugs for another.(20)

Callahan, among others, has argued vigorously against the moral justification that underlies these assertions(21) but has been accused of "abstract moralizing" in justifying his own position.(22) In my view Callahan's argument raises some very important questions that have significant bearing on the appropriate role of the physician in dealing with intractable suffering, and these questions must be addressed before we can be confident that any proposed approach is morally sound. Any framework based primarily on considering rights and correlative duties appears ill-suited to address these questions,(23) which have more to do with existential concerns than individual rights:

Do We Understand the Nature and Causes of Suffering Well Enough to Determine Confidentiy When a Given Life Is No Longer Worth Living?

What is it about suffering that makes some people like Diane sincerely want to die, while others continue to endure intractable suffering and never express such wishes and still others like Bouvia change their minds? How could we possibly tell the difference before the fact?

What Is the Relative Moral Value of Maintaining "Human Dignity" and Control over Death by Preserving the Right to Self-Determination?

Is the right to self-determination important enough to trump other values such as respect for human potential or the sanctity of life? When a physician chooses to actively assist a suffering patient's choice to hasten death, who is morally accountable for the decision?

How Well Do We Understand the Impact of Varying Degrees of Suffering on Rational Decisionmaking?

How can we be sure that requests for assistance in suicide are rational, whether or not they seem reasonable? Is there any basis for community attempts to influence such an individual's perspective to make more meaningful choices? Is it possible to avoid coercion--even with the best of intentions--when attempting to influence such choices?

What Is the Ultimate Role of the Physician When Cure Is No Longer Possible Or Meaningful?

Is this role, in fact, to...