Response to: ‘What should we tell medical students and residents about euthanasia and assisted suicide?’

To the Editor

In a recent edition of the Australian and New Zealand Journal of Psychiatry, Leo Sher asks: ‘what shall we tell them (medical students, residents, fellows and other trainees) about euthanasia and assisted suicide?’ (Sher, 2012). He claims that we should tell them that the majority of individuals desiring death are suffering from a diagnosable psychiatric disorder and that, when a request to hasten death is made and heard as a call for help (instead of an authentic desire to die), the wish to die usually vanishes.

However, we should also tell them that modern medicine cannot control all pain. While it is true that multimodality approaches to pain relief have advanced tremendously over the past two decades, evidence indicates adequate pain relief will not be achieved for cancer patients in at least 5% of patients (Deepak et al., 2011), with other studies indicating that 10–30% will continue to suffer (van den Beuken-van Everdingen et al., 2007). Thus, in spite of often heroic efforts on the part of clinicans attempting ever more risky and toxic doses of analgesics and other medications, a number of patients at the end of life die in significant pain.

We should also tell them that some requests for assistance to die may be rational and reasonable in the patient’s particular context at the end of life. In the last few months of his life, Dr Ethan Remmel (who was terminally ill) wrote that choosing to die under the US state of Oregon’s Death with Dignity Act was not a choice between living and dying but between different ways of dying (Remmel, 2011).

Sher states that ‘we do not solve problems by getting rid of people to whom the problems happen. The more difficult but humane solution to human suffering is to address the problems, such as depression or pain’. The challenge, however, is to respond humanely to those whose deep suffering is not grounded in depression or who do not suffer pain. Tony Nicklinson, a severely disabled man with locked in syndrome whose request to the UK’s High Court to allow doctors to hasten his death without the threat of prosecution, died recently of pneumonia. In the week preceding his death, Tony had refused to eat. Unable to communicate except by blinking, Tony argued that staying alive in his circumstances was worse than dying. Neurologist Stelio Doris, commenting on Tony’s situation, said that ‘death is more normal than to stay alive in this condition’ (Ward, 2012).

We should be telling medical students, residents, fellows, and other trainees that medical assistance to hasten death may be more than a cry for help; it may be a considered and rational response to a life that has become intolerable for some individuals. While the law is clear that medical assistance to die is illegal in Australia and New Zealand, ethics tell us we need to think deeply about the reasons why someone wants to die. Depression and pain may be behind many requests to die, but they do not account for all requests and should not be understood as such.

For some patients at the end of life who are suffering intolerably, euthanasia or assisted suicide may be an appropriate last resort when all other options have been exhausted (Ganzini and Block, 2002).