When Physicians Choose to Participate in the Death of Their Patients: Ethics and Physician-Assisted Suicide

It has become so problematic that some patients tell me they have approached their doctors about aid-in-dying in a non-threatening way, say, by talking with them about reading Kübler-Ross. The doctors respond: “Oh boy, we don't discuss that around here!” Clinically speaking, there is an enormous gap between proposed public policy legalizing PAS and doctors' willingness to back it with action.

There is almost complete unanimity among bioethicists about the morality of the double effect. For example, see Bresnahan J. , “The Catholic Art of Dying,” America, Nov. 4, 1995, 12–16.

This is the way Freud died, for example. When his cancer became too painful, he asked his friend to help him die. His friend administered an overdose of morphine. The next morning, Freud was still alive, so his friend gave him a fatal second dose.

In a comment on my suggestion, Dr. George Crile, a fellow of the American College of Surgeons, suggested, for the purpose of empowerment not for death itself, that the phrase by the physician be something like: “If you take [this high dose] you will most certainly die.” In this way, the physician does not encourage taking the medication (thus reinforcing the effort toward empowerment within the context of addressing the patient's suffering), yet acknowledges what the patient already knows: He/she has the power to take life. See the later discussion of Dr. Timothy Quill's original intention in his article on assisted suicide. See Quill T. , “Death and Dignity: A Case of Individualized Decision Making,” N. Engl. J. Med., 324 (1991): 691–94.

Singer P. , Rethinking Life & Death: The Collapse of Our Traditional Ethics (New York: Oxford University Press, 1995). See also Campbell C. , “The Crumbling Foundations of Medical Ethics,” Theoretical Medicine, (1997): Forthcoming.

Royko M. , “Widow Finds High Cost of Dying Lives on Long After Death,” Chicago Tribune, Aug. 14, 1996, at 1:3; Dr. Ezekiel Emanuel has argued that there is a constant conjunction between interest in euthanasia and PAS and economic fears. See Emanuel E. , “Cost Savings at the End of Life. What do the Data Show?,” JAMA, 275 (1996): 1907–14.

This use includes emotional responses to difficult cases, what Yale Kamisar calls the “compelling force of heartrending individual cases.” See Kamisar Y. , “The Reasons so Many People Support Physician-Assisted Suicide—And Why These Reasons Are Not Convincing,” Issues in Law & Medicine, 12 (1996): 113–32.

Quill T.E. Cassel C.K. Meier D.E. , “Care of the Hopelessly Ill: Proposed Clinical Criteria for Physician-Assisted Suicide,” N. Engl. J. Med., 327 (1992): 1330–84; Miller F.G. , “Regulating Physician-Assisted Death,” N. Engl. J. Med., 331 (1994): 119–23; and Baron C.H. , “A Model Statute to Authorize and Regulate Physician-Assisted Suicide,” Harvard Journal on Legislation, 33 (1996): 1–34.

Quill Cassel Meier , id.: And Ciesielski-Carlucci C. , “Physician Attitudes and Experience with Assisted Suicide: Results of a Small Opinion Survey,” Cambridge Quarterly of Healthcare Ethics, 2, no. 1 (1993): 39–44.

Associated Press/Media General, Poll no. 4 (Richmond: Media General, Feb. 1985).

Wanzer S.H. , “The Physician's Responsibility Toward Hopelessly Ill Patients: A Second Look,” N. Engl. J. Med., 320 (1989): 844–49.

Kushner T. , “Derek Humphry on Death with Dignity,” Cambridge Quarterly of Healthcare Ethics, 2, no. 1 (1993): 57–62.

McGough P.M. , “Washington State Initiative 119: The First Public Vote on Legalizing Physician-Assisted Death,” Cambridge Quarterly of Healthcare Ethics, 2, no. 1 (1993): 63–67.

Humphry D. , Final Exit: The Practicalities of Self-Deliverance and Assisted Suicide for the Dying (New York: Dell Paperbacks, rev. ed., 1992).

American Medical Association, Code of Medical Ethics: Current Opinions with Annotations (Chicago: American Medical Association, 1996).

Associated Press, “AMA Debates Policy Opposing Assisted Suicide,” Chicago Sun-Times, June 24, 1996, at 5.

American Nurses Association, Center for Ethics and Human Rights, Task Force on the Nurses Role in End-of-Life Decisions, Compendium of Position Statements on the Nurse's Role in End-of-Life Decisions (Washington, D.C.: American Nurses Association, 1992).

Asch D. , “The Role of Critical Care Nurses in Euthanasia,” N. Engl. J. Med., 334 (1996): 1374–79.

Scanlon C. , “Euthanasia and Nursing Practice—Right Question, Wrong Answer,” N. Engl. J. Med., 334 (1996): 1401–02; and Coffey R.R. , “Nurse Says Their Goal is to End Pain—Not Lives,” Chicago Sun-Times, June 13, 1996, at 6. A wide range of professional opinion and support for PAS can be found in Battin M.P. Lipman A.G. , eds., Drug Use in Assisted Suicide and Euthanasia (Binghamton: Pharmaceutical Products Press, 1996). Despite its title, only a few articles are devoted to drug use; the rest explore PAS from different professional perspectives.

Steinfels P. , “Help for the Helping Hands in Death,” New York Times, Feb. 14, 1993, at 1, 6.

See the debate over assisting the mentally ill to die occasioned by the Chabot case in the Netherlands. See infra note 28 and accompanying text. See also the issue of Cambridge Quarterly devoted to “Physician-Aided Death: The Escalating Debate,” with articles for and against the practice, including narratives by families whose loved ones chose euthanasia. Cambridge Quarterly of Healthcare Ethics, 5, no. 1 (1996): 7–166.

Playing on the famous battle for the bridge at Arnhem during World War II. See van Leeuwen E. Kimsma G.K. , “Philosophy of Medical Practice: A Discursive Approach,” Theoretical Medicine, 18, nos. 1–2 (1997): Forthcoming.

See the entire issue of Cambridge Quarterly of Healthcare Ethics, 2, no. 1 (1993): 9–80, which is devoted to descriptions and analyses of the Dutch euthanasia situation.

Dillman R.J.M. , “Euthanasia in the Netherlands: The Role of the Dutch Medical Profession,” Cambridge Quarterly of Healthcare Ethics, 5, no. 1 (1996): 100–06.

“Netherlands Eases Curbs on Euthanasia,” Chicago Tribune, Feb. 10, 1993, at 1, 13.

Kimsma G.K. van Leeuwen E. , “Dutch Euthanasia: Background, Practice, and Present Justifications,” Cambridge Quarterly of Healthcare Ethics, 2, no. 1 (1993): 19–31.

Los Angeles Times News Service, “Euthanasia Doesn't Always End Families' Pain,” Orlando Sentinel, Mar. 14, 1993, at A12.

Klotzko A.J. , “CQ Interview: Dr. Baudewijn Chabot on Assisted Suicide in the Absence of Somatic Illness,” Cambridge Quarterly of Healthcare Ethics, 4, no. 2 (1995): 239–49.

Colleagues and I have submitted a manuscript portraying all levels of the Dutch debate. Thomasma D.C. , Asking to Die: Inside the Dutch Debate about Euthanasia (Cambridge: Cambridge University Press): Under consideration.

Kevorkian was indicted on November 7, 1996.

“Kevorkian Cleared of Murder Charge,” Chicago Tribune, July 22, 1992, at 1, 3.

Hughes J. , “Coroner Finds No Illness in Kevorkian's Latest Suicide,” Chicago Sun-Times, Aug. 20, 1996, at 3; and Jouzaitis C. , “New Scrutiny for Kevorkian,” Chicago Tribune, Aug. 23, 1996, at 1:1.

See Hughes , id.; and Jouzaitis , id.

Anonymous, “Kevorkian Helps Another Woman Commit Suicide,” Chicago Tribune, Nov. 29, 1992, at 1, 5.

Bartholome W. , Post: Execution Case—Reply (visited Aug. 12, 1996), Medical College of Wisconsin Bioethics Network.

Prodis J. , “Kevorkian Aids Man, Ind. Woman in Suicides,” Chicago Sun-Times, Feb. 5, 1993, at 30(w).

Id.; and Bartholome , supra note 36.

Bartholome , supra note 36.

Bennahum D.A. , “Encounters with Death,” Cambridge Quarterly of Healthcare Ethics, 5, no. 1 (1996): 7–9.

Quill , supra note 4.

Brahams D. , “Euthanasia: Doctor Convicted of Attempted Murder,” Lancet, 340 (1992): 782–83.

Rosenblatt S.M. , Murder or Mercy: Euthanasia on Trial (Buffalo: Prometheus Books, 1992).

Kass L.R. , “‘I Will Give No Deadly Drug.’ Why Doctors Must Not Kill,” American College of Surgeons Bulletin, 77, no. 3 (1992): 7–17.

Compassion in Dying v. State of Washington, 79 F.3d 790 (en banc) reh'g en banc by full court denied, 85 F.3d 1440 (9th Cir. 1996).

Garrow D.J. , “The Justices' Life-or-Death Choices,” New York Times, Apr. 3, 1996, at 1. After an en banc hearing, by an 8-to-3 decision, the original appeals decision was overturned, and a judgment was made that the law violates the Fourteenth Amendment to the U.S. Constitution. See 79 F.3d 790.

Lee v. State of Oregon, 891 F. Supp. 1429 (1995).

Quill v. Koppell, 870 F. Supp. 78 (S.D.N.Y. 1994).

Quill v. Vacco, 80 F.3d 716 (2d Cir. 1996).

Id. Judge Calabresi argued that laws against assisted suicide are conceivable if they provide equal protection. He further argued that state representatives are best able to want and defend laws that may be constitutionally suspect.

Poweres J. Anderson L. , “Courts Give Boost to Assisted Suicide,” Chicago Tribune, Apr. 16, 1996, at 1:4.

Reuters , “Australia Split as Euthanasia Law Takes Effect,” Chicago Tribune, July 1, 1996, at 1:9.

Martin G.L. , “Northern Australia Legalizes Euthanasia—with Limits,” Chicago Sun-Times, Apr. 14, 1996, at 32.

Kerridge I.H. Mitchell K.R. , “The Legislation of Active Voluntary Euthanasia in Australia: Will the Slippery Slope Prove Fatal?,” Journal of Medical Ethics, 22 (1996): 273–78.

Schmetzer U. , “A Catch in Australia's Suicide Law: Doctors, Psychiatrists Refuse to Give Required Consent,” Chicago Tribune, July 27, 1996, at 1:1.

Battin M.P. , Ethical Issues in Suicide (Englewood Cliffs: Prentice-Hall, 1982); and Graber G.C. , “The Rationality of Suicide,” in Wallace S. Ester A. , eds., Suicide and Euthanasia: The Rights of Personhood (Knoxville: University of Tennessee Press, 1981): 51–65.

Meyer J.-M. , “The Sacredness of Life in Pagan Philosophy,” Dolentium Hominum, 11, no. 31 (1996): At 56.

Engelhardt H.T. Jr. , Bioethics and Secular Humanism (Philadelphia: Trinity Press International, 1992). See also Brandt R. , “The Morality and Rationality of Suicide,” in Rachels J. , ed., Moral Problems (New York: Harper and Row, 1975): 363–87.

Jochemsen H. , Euthanasia: A Christian Evaluation (Oxford: Latimer House Studies #49, 1995).

Choron J. , Suicide (New York: Scribner's Sons, 1972): At 100.

Prado C.G. , The Last Choice: Preemptive Suicide in Advanced Age (Westport: Greenwood Press, 1990).

Erikson E. , Childhood and Society (New York: Norton, 2d ed., 1963): At 268.

Moody H.R. , Ethics in an Aging Society (Baltimore: Johns Hopkins University Press, 1992): At 86.

Kane G.C. , “Suicide and Advance Directives: One Doctor's Dilemma,” Journal of Medical Humanities, 17, no. 3 (1996): 191–93.

Cruzan v. Director, Missouri Dep't of Health, 497 U.S. 261 (1990).

See Quill Cassel Meier , supra note 8.

“Study Puts High Cost on Care for Dying,” Chicago Tribune, Feb. 10, 1993, at 1, 12.

Battin M.P. , “Euthanasia: The Fundamental Issues,” in Battin M.P. , Least Worst Death: Essays in Bioethics on the End of Life (New York: Oxford University Press, 1994): At 101–29. Unlike Alexander Capron, Battin thinks that assisted suicide is a better first option than euthanasia, because it depends so thoroughly on the patient's own assessment of the relationship between suffering and continued existence or death. She would reserve euthanasia for those who choose it ahead of time but are no longer able to request it near the time of death.

Thomasma D.C. Graber G.C. , Euthanasia: Toward an Ethical Social Policy (New York: Continuum Publishing, 1990).

Capron A. , “Legalizing Physician-Aided Death,” Cambridge Quarterly of Healthcare Ethics, 5, no. 1 (1996): 10–23, esp. 17–18.

Gunn A.E. , “Risk-Benefit Ratio: The Soft Underbelly of Patient Autonomy,” Issues in Law & Medicine, 7 (1991): 139–54.

Cameron N.M. de S. , The New Medicine: Life and Death After Hippocrates (Wheaton: Crossway Books, 1992).

Cassell E. , “The Relief of Suffering,” Archives of Internal Medicine, 143 (1993): 522–23.

Anonymous , “Missouri and Kevorkian Continue to Provoke Controversy,” Hospital Ethics, 8, no. 6 (1992): 9.

Pellegrino E.D. Thomasma D.C. , For the Patient's Good: The Restoration of Beneficence in Health Care (New York: Oxford University Press, 1988); and Loewy E. , “Beneficence in Trust,” Hastings Center Report, 19, no. 1 (1989): 42–43; and Beauchamp T. Childress J. , Principles of Biomedical Ethics (New York: Oxford University Press, 3rd ed., 1994).

Gaylin W. , “Doctors Must Not Kill,” JAMA, 259 (1988): 2139–40.

Kass L. , “Arguments Against Active Euthanasia by Doctors Found at Medicine's Core,” Kennedy Institute of Ethics Newsletter, 3 (1989): 1–3, 6.

Muller J. Koenig B. , “On the Boundary of Life and Death: The Definition of Dying by Medical Residents,” in Lock M. Gordon D. , eds., Biomedicine Examined (Dordrecht: Kluwer Academic, 1988): 351–74.

Illich I. , Medical Nemesis: The Expropriation of Health (New York: Pantheon Boob, 1976): At 106.

Id. at 154.

Thomasma D.C. , “The Ethics of Caring for Vulnerable Individuals,” in Reflections on Ethics (Washington, D.C.: American Speech-Language-Hearing Association, 1990): 39–45.

Proctor R.N. , “Nazi Doctors, Racial Medicine, and Human Experimentation,” in Annas G.J. Grodin M.A. , eds., The Nazi Doctors and the Nuremberg Code (New York: Oxford University Press, 1992): At 23.

Kevorkian J. , Prescription—Medicide: The Goodness of Planned Death (Buffalo: Prometheus Books, 1991).

Pernick M.S. , The Black Stork: Eugenics and the Death of “Defective” Babies in American Medicine and Motion Pictures Since 1915 (New York: Oxford University Press, 1996).

Kilner J.F. Miller A.B. Pellegrino E.D. , eds., Dignity and Dying: A Christian Appraisal (Grand Rapids: W.B. Eerdmans, 1996).

Wiesel E. , “Preface,” in Annas G.J. Grodin M.A. , eds., The Nazi Doctors and the Nuremberg Code (New York: Oxford University Press, 1992): At vii.

Annas G.J. Grodin M.A. , “Introduction,” in Annas G.J. Grodin M.A. , eds., The Nazi Doctors and the Nuremberg Code (New York: Oxford University Press, 1992): At 3.

See Proctor , supra note 86, at 17–31.

Id. at 24.

See Wiesel , supra note 90.

Thomasma Graber , supra note 72.

Rachels J. , “Active and Passive Euthanasia,” N. Engl. J. Med., 292 (1975): 78–80.

Cassell E. , “The Nature of Suffering and the Goals of Medicine,” N. Engl. J. Med., 306 (1982): 639–45.

See Battin , supra note 71.

Kohl M. , “Altruistic Humanism and Voluntary Beneficent Euthanasia,” Issues in Law & Medicine, 8 (1992): 331–42.

Admiraal P. , “Justifiable Active Euthanasia in the Netherlands,” in Baird R.M. Rosenbaum S.E. , eds., Euthanasia: The Moral Issues (Buffalo: Prometheus Books, 1989): 125–28.

See Quill Cassel Meier , supra note 8.

Helme T. Padfield N. , “Safeguarding Euthanasia,” New Law Journal, Oct. 2 (1992): 1335–36.

Campbell C.S. , “Religious Ethics and Active Euthanasia in a Pluralistic Society,” Kennedy Institute of Ethics Journal, 2 (1992): 253–77.

Bresnahan J. , “Observations on the Rejection of Physician-Assisted Suicide: A Roman Catholic Perspective,” Christian Bioethics: Non-Ecumenical Studies in Medical Morality, 1 (1995): 256–84.

Gaylin , supra note 80.

House of Delegates of the American Medical Association, Dec. 4, 1973, as quoted in Rachels , supra note 96, at 97.

Welie J.V.M. , “The Medical Exception: Physicians, Euthanasia and the Dutch Criminal Law,” Journal of Medicine and Philosophy, 17 (1992): 419–37. See the objections raised to PAS and euthanasia in Newsletter of Evangelical Churches, “Legalized Physician-Assisted Suicide,” Discernment, 1, no. 3 (1992): 1–4.

Campbell C.S. , “Aid-in-Dying' and the Taking of Human Life,” Journal of Medical Ethics, 18 (1992): 128–34.

Pellegrino E.D. , “Euthanasia and Physician Assisted Suicide,” in Kilner J.F. Miller A.B. Pellegrino E.D. , eds., Dignity and Dying: A Christian Appraisal (Grand Rapids: W.B. Eerdmans, 1996): At 117.

As quoted in Wilkes P. Carter S.L. , “The Case Against Doctor-Assisted Suicide—The Next Pro-Lifers,” New York Times Magazine, July 21, 1996, at 22.

Brody H. , “Assisted Death—A Compassionate Response to a Medical Failure,” N. Engl. J. Med., 327 (1992): 1384–88.

Thomasma D.C. , “Models of the Doctor-Patient Relationship and the Ethics Committee, Part Two,” Cambridge Quarterly of Healthcare Ethics, 3, no. 1 (1993): 10–26.

Gevers J.K.M. , “Legislation on Euthanasia: Recent Developments in the Netherlands,” Journal of Medical Ethics, 18 (1992): 138–41; and Kimsma G.K. , “Clinical Ethics in Assisting Euthanasia: Avoiding Malpractice in Drug Application,” Journal of Medicine and Philosophy, 17 (1992): 439–43.

Kuhse H. Singer P. , “Euthanasia: A Survey of Nurses' Attitudes and Practices,” Australian Nurses Journal, 21, no. 8 (1992): 21–22. Note that the same percentage occurs among Australian citizens; about 76 percent of those surveyed supported allowing physicians to offer lethal doses of medication on request to “hopelessly ill” patients “in great pain.” Sixty-six percent of nurses surveyed said that patients had asked nurses to kill them at some time in their practice at least once, and 85 percent said that they participated in ending a patient's life directly when asked to do so by a doctor.

Evidence exists that hardship leads people to forgo long-term care and to opt for comfort care. See “Hardship Drives Patients to Forgo Long-Term Care,” Chicago Tribune, Aug. 12, 1996, at 1:3.

Anonymous, “Hospitals, Physicians Paying More Attention to Pain Control,” Medical Ethics Advisor, 7, no. 11 (1991): 133–37.

Winslade W. , “Teaching About Dying,” Choice in Dying News, 1, no. 4 (1992): 1, 6.

Selib Epstein S. , “What the Dying Give to the Living,” Chicago Tribune, Dec. 11, 1992, at 1, 21.

Kamm F.M. , Morality, Mortality (New York: Oxford University Press, vol. 2, 1996): At 58–59; and Tulsky J.A. Alpers A. Lo B. , “A Middle Ground on Physician-Assisted Suicide,” Cambridge Quarterly in Healthcare Ethics, 5, no. 1 (1996): 33–43.

Hutchcraft C. , “Doctors Belong with Patients to the End,” Chicago Tribune, Aug. 16, 1996, at 2:1–2. This is an excellent commentary on the AMA's position against PAS.

Miles S.H. , “Physicians and Their Patients' Suicides,” JAMA, 271 (1994): At 1786.

American Board of Internal Medicine, Caring for the Dying: Identification and Promotion of Physician Competency. Parts One and Two, Narratives and Educational Resource Development (Philadelphia: American Board of Internal Medicine, 1996).

Wilson Ross J. , “Review: The Future of Dying,” Western Bioethics News, July (1996): At 4.

Witsenburg B.C. , “Dood op Verzoek” (“Death on Request”), Medisch Contact, 50 (1995): 1293–94.

Thomasma D.C. , Human Life in the Balance (Louisville: Westminster Press, 1990).