Physician-Assisted Suicide and Euthanasia   Kenneth J. Simcic, M.D., FACP, FACE

Euthanasia and Physician-assisted Suicide                 

Kenneth J. Simcic, M.D., FACP, FACE

E-mail: simcic@uthscsa.edu

“You’ve [senior citizens] got a duty to die and get out of the way. Let the other society, our kids, build a reasonable life.”

                                           -Richard Lamm, former governor of Colorado

                                            Minneapolis Star Tribune, 3/29/84:13A

"You will never get accustomed to killing somebody. We are not trained to kill. With euthanasia, your nightmare becomes true."

                                           -Dr. Pieter Admiraal

                                            Dutch physician and pro-euthanasia activist

A. Important Definitions

     1. Assisted suicide: providing a person with the means to end his or her life,

         usually by an overdose of an oral prescription medication.

     2. Euthanasia: taking a direct and specific action to intentionally end another

         person's life, most commonly by giving a lethal intravenous injection.

     3. Euthanasia can be voluntary (at the patient’s request), or involuntary

         (without the knowledge or consent of the patient)

     4. Doctor-assisted death: this term includes both physician-assisted suicide

         and euthanasia performed by a physician.

     5. It is important to note that a person can refuse potentially life-saving

         medical treatment at the end of life without committing assisted suicide or

         euthanasia.

     6. Palliative sedation: giving a dying patient a potentially lethal dose of a

         narcotic or sedative drug with the intention of relieving pain, shortness

         of breath or other discomforts. This is done with the patient's consent

         and shortening the patient's life is not intended.      

B. The Hippocratic Oath (350 B.C.)

     1. "…I will neither give a deadly drug to anyone if asked for it, nor will I

         make a suggestion to this effect…"

C. Social and Cultural Factors Promoting Doctor-assisted Death in the U.S. in 2006

     1. Secularism-God is no longer respected as the only giver and taker of

         life.

     2. Moral relativism-the lack of moral absolutes in American society.

     3. Radical personal autonomy…"my body, my right".

     4. Modern medical technology-sick people live much longer.

     5. Families have fewer children-there are fewer family members to care for

         sick and aging relatives.

     6. Divorce is common-many dying people are alone.

     7. We have become a very busy, utilitarian society that no longer has the

         time to care for our elderly and disabled members.

     8. The traditional doctor-patient relationship is in trouble; when sick

         patients are admitted to the hospital, they rarely receive care from their

         personal or family doctor.

     9. There is now a tremendous emphasis on reducing the cost of healthcare;

         end of life care is expensive, but the pills for assisted suicide cost only

         about $40. 

D. Legal Overview: United States

     1. November 1994: in a statewide referendum, Oregon voters legalize

         assisted suicide (51%-49%) but the law is immediately blocked by a

         judicial injunction. Shortly before the vote, the Oregon Medical Society

         changed its position on assisted suicide from “against” to “neutral”.  

     2. 3/6/96: The 9^th Circuit Court of Appeals rules that Washington state’s

         ban on assisted suicide is unconstitutional.

     3. 4/4/96: The 2^nd Circuit Court of Appeals rules that New York state’s

         ban on assisted suicide is unconstitutional.  

     4. 6/26/97: U.S. Supreme Court ruling...

         a. there is no constitutional right to assisted suicide; there is a

             constitutional right to palliative care for the dying. 

         b. assisting suicide is not the same as removing life support.

         c. assisting suicide is not the same as giving dying patients “palliative

             sedation” with narcotic or sedative drugs.

         d. state bans against assisted suicide are constitutional (Washington,

             New York) because states have a valid interest in protecting the

             integrity of the medical profession and in protecting vulnerable

             patients: the elderly, disabled and the terminally ill.

         e. states are also free to legalize assisted suicide if they so choose

     5. 1997: The Florida State Supreme Court rules that there is no

         constitutional right to assisted suicide.

     6. 11/4/97: The Oregon "Death with Dignity Act" becomes law.

          a. Oregonians vote against repealing the original law: 60%-40%.

          b. the law allows an Oregon physician to write a lethal drug prescription

              for a patient.

          c. the Drug Enforcement Administration (DEA) rules that the Oregon

              law violates the federal Controlled Substances Act (federally

              controlled substances can only be used for a “legitimate medical

              purpose”) but the DEA is overruled by Attorney General Janet Reno

              who allows the Oregon law to stand.

          d. 3/25/98: Oregon’s first death resulting from assisted suicide.

          e. 11/6/01: new Attorney General John Ashcroft rules that the Oregon

              law is a violation of federal law (Controlled Substances Act) and that

              the use of federally controlled substances to assist in a suicide is not a

              “legitimate medical purpose”.

          f. 11/9/01: Federal judge Robert E. Jones blocks Ashcroft’s ruling.

          g. 5/26/04: the Ninth Circuit Court overrules Ashcroft by a 2:1 vote and

              upholds the Oregon law.

          h. 2/22/05: U.S. Supreme Court agrees to hear the Oregon case

             (Gonzales v. Oregon, 04-623)

          i. 1/17/06: U.S. Supreme Court upholds the Oregon law by a 6-3 vote.

          j. as of 1/07, 292 Oregonians have died as a result of assisted suicide

             (1998: 16, 1999: 27, 2000: 27, 2001: 21, 2002: 38, 2003: 42,

             2004: 37, 2005: 38, 2006: 46).      

         k. ballot initiatives similar to Oregon’s have failed in the states of

             Washington (1991: 54%-46%), California (1992: 54%-46%),

             Michigan (1998: 70%-30%), and Maine (2000: 51%-49%).

      7. 1999: A Michigan court sentences Jack Kevorkian to 10-25 years in

           prison for the (videotaped) lethal injection of ThomasYouk, a 52 year

           old man with Lou Gehrig's disease. Kevorkian assisted in the deaths of

           130 people prior to his imprisonment (he was acquitted on 3 previous

           occasions by Michigan courts).

      8. 2001: Alaska State Supreme Court rules that there is no

          constitutional right to assisted suicide.      

      9. 5/02: Hawaii state legislature votes against legalization by a 14-11

          margin.

    10. 2/04: Wyoming state senate votes 19-8 against legalizing assisted

          suicide.

    11. 2006: Legislative bills similar to Oregon's law fail to pass in Vermont

          (HB 168) and California (AB 651).

    12. 3/07: Another legislative bill (H.44) fails to pass in Vermont by an     

          82-63 vote (the 6th failed attempt in Vermont since 1995). 

    13. As of 4/05: 38 states had statutes prohibiting assisted suicide and 6

          states prohibit it by common law.  Only 5 states other than Oregon did

          not have laws criminalizing assisted suicide: North Carolina, Utah,

          Wyoming, Ohio and Virginia (reference 28).

    14. 6/1/07: After 8 years in prison, Jack Kevorkian is granted an early

          release at age 79 for "good behavior".

    15. 6/7/07: Another legislative bill fails to pass in California (the 8th failed

          attempt in California since 1995). 

    16. Since passage of the Oregon Death with Dignity Act in 1994, more than

          80 legislative efforts to legalize assisted suicide have failed in other

          states.     

E. The Oregon Death with Dignity Act

     1. The patient must be older than 17.

     2. The patient must be mentally competent and able to take the lethal

         prescription orally.

     3. The patient must also be terminally ill with life expectancy < 6 months.

     4. The request for suicide must be communicated both orally and in writing.

     5. A second physician must confirm the diagnosis & prognosis and that the

         patient is competent and not depressed.   

     6. Psychiatric consultation is only required if the patient’s competency is

         questioned by either physician; it is not otherwise required, even if

         depression is suspected.

     7. The patient must self-administer the lethal dose with no assistance from

         anyone else.

     8. The state has no authorization to investigate unreported cases or cases

         of non-compliance.

     9. The law contains no penalties for non-reporting or non-compliance.

   10. 1999: the assisted suicide of Kate Cheney raises concerns about the

         supposed "protective guidelines" in the Oregon law (see reference 30). 

F. Oregon Update

     1. Oregon 2006: 46 assisted suicide deaths reported; total of 292 since

         1998.

     2. Most common reasons given by patients for wanting to end their lives

         in 2006:

         a. losing autonomy (96%).

b. decreased ability to participate in enjoyable activities (96%).

c. loss of dignity (76%)  

     3. Previous data from 1998-2004: most common reasons given by

         Oregon patients wanting to end their lives (from reference 28):

         a. losing autonomy (>80%).

b. decreased ability to participate in enjoyable activities (>80%).

c. losing control of bodily functions (>80%).

d. fear of being a burden to family, friends, or caregivers (36%).

e. fear of inadequate pain control (22%).

         (Note that “pain” itself was not one of the top 5 reasons; in fact,

         uncontrolled pain has not been clearly documented in any of the assisted

         deaths in Oregon.)

     4. Most common medical conditions of Oregon patients dying by assisted

         suicide

         a. cancer

         b. amyotrophic lateral sclerosis.

         c. AIDS.

     5. Lethal medications most commonly used

         a. drinking 10 grams of liquid pentobarbital or…

         b. swallowing the powder from 10 grams of secobarbital capsules

             dissolved in water or applesauce.

     6. Less than 5% of Oregon patients dying by assisted suicide have been

         uninsured.   

     7. Psychiatric consultation was obtained in 31% of cases who died in 1998

         but in 5% or less of those who died in 2003, 2004, 2005 and 2006 (2

         of 46 patients in 2006).   

     8. Research published in 2004 reported that the prevalence of family-

         reported moderate to severe pain or distress for people dying in Oregon

         increased from 31% in 1996-1997 to 48% (after legalization) in 2000-

         2002 (25).

     9. 10/06: The Oregon Health Department announces that it will use the

         term "assisted death" in place of "assisted suicide" in official reports. 

G. The Netherlands (Holland)

     1. Although not technically legalized until 1/1/02, doctor-assisted death has

         been permitted in the Netherlands since 1973 when a Dutch physician

         was given only a suspended sentence for assisting in the death of her

         terminally ill mother.

     2. In 1984, the Dutch Royal Society of Medicine issued "rules of careful

         conduct" for euthanasia (“safeguards”): consult another physician, keep

         written records, etc.    

     3. 1991, the Remmilink Report (prepared from a confidential survey of

         Dutch physicians): 11,800 doctor-assisted deaths occured in Holland in

         1990 (9% of total deaths); 50% of these were involuntary (without the

         consent of the patient or family); 60% of assisted deaths were not

         reported.

Doctor-assisted Death in the Netherlands, 1990 (table obtained from www.euthanasia.com on 12/1/03)

Sources:

(1.) Medische Beslissingen Roknd Het Levenseinde: Rapport van de Commissie Onderzoek Medische Praktijk inzake Euthanasie (Medical Decisions About the End of Life: Report of the Committee to Investigate the Medical Practice Concerning Euthanasia) The Hague, 1991;  (2.) 1993 World Almanac and Book of Facts, New York, 1992.

     4. 1991: a Dutch psychiatrist gives a lethal dose to a depressed 50 year old

         woman with no other medical problems who was “suffering

         unbearably”.  She had recently gone through a bitter divorce and the

         deaths of her only 2 children.  She received no treatment for her

         depression prior to her assisted death.

     5. 1992: a 3 day old infant with spina bifida and limb abnormalities is given

         a lethal injection by a Dutch gynecologist.

     6. 1995: at least 1 in 5 cases of assisted death in Holland occur without the

         patient’s consent; almost 2/3 of cases of assisted death are not reported.

     7. 1998: the suicide of 86 year old Edward Brongersma is assisted  

         because he is “tired of life” (but otherwise in good health).       

     8. 4/1/02: The Netherlands formally legalizes assisted suicide and

         euthanasia after allowing these practices since 1973.

         a. law requirements: pt. persistently requests euthanasia; hopeless pain

             or "suffering"; another physician is consulted; a written report is made

             to a regional committee

b. “physical” suffering is not required and neither is psychiatric

    consultation

c. the patient’s disease need not be terminal

d. patients as young as 12 are eligible; those ages 12-16 need parental

    consent

    9. 2/27/03: the Dutch TV program “Reporter” reveals that thousands of

        life-shortening acts are not being reported by physicians because the

        reporting requirements are “too time consuming” (requiring extensive 

        paperwork and a second opinion).

  10. While there are only 3 hospices in Holland, Great Britain has more than

        200.

  11. In 2005, 1933 cases of euthanasia and/or assisted suicide were reported

        in Holland (47 more than the previous year).

  12. 2006: In the New England Journal of Medicine, two Dutch physicians

        announce that euthanasia of newborn babies is a regular occurence in the

        Netherlands (30).

        a. the authors announce that 22 cases were reported to district attorneys'

            offices from 1997-2004 and none of the responsible physicians were

            prosecuted (4 of the babies were euthanized by the authors)

        b. all of the euthanized newborns reportedly had severe spina bifida and

            parental consent was obtained in all cases

        c. the authors estimate that up to 20 newborns are euthanized every year

            in the Netherlands but only 3 cases per year are reported 

        d. they propose that their "Groningen protocol" be followed for newborn

            euthanasia 

  13. No Dutch physician has ever served a prison term for assisting suicide or

        performing euthanasia.

H. Doctor-assisted Death in Other Countries

     1. For a short time in 1996-1997, assisted suicide and euthanasia were

         legalized in Australia's Northern Territory (7 doctor-assisted deaths

         occurred before the law was repealed). 

     2. Belgium (5/02) has also legalized assisted suicide and euthanasia, and

         assisted suicide is legal in Switzerland. In 2007; it was estimated

         that approx. 350 assisted suicides were occuring in Switzerland every

         year. Swiss physicians are not permitted to participate in assisted suicide

         (it is left to designated "groups" like Dignitas) and assisted suicide

         cannot be performed in Swiss hospitals. 

     3. 12/03: Belgian Federal Health Ministry announces that 203 deaths

         by euthanasia were reported in the first year of legalization.

     4. 2004: Lawmakers in Belgium declare that the “right to euthanasia” must

         exist in all hospitals including Catholic hospitals that have previously

         refused to allow it due to religious objections. (Critics comment that in

         Belgium, patients have a "duty to die" and doctors have a "duty to kill".)

     5. 10/05: The Canadian Parliament begins debate on a bill that would

         legalize euthanasia (Bill C-407).  The bill did not pass. 

     6. 5/06: An assisted dying legislative bill fails to pass in Great Britain. 

     7. 6/06: the British Medical Association (BMA) votes overwhelmingly to

         reverse its year-old neutral position on euthanasia and assisted suicide

         and go back to a policy of strong opposition to any assisted-dying

         legislation.  

    8. 11/06: England's Royal College of Obstetricians and Gynaecologists 

         calls for open debate on legalization of euthanasia for "seriously

         disabled" newborn babies. 

    9.  6/07: Ludwig Minelli, who runs the Dignitas assisted suicide clinic in

         Zurich, Switzerland announces that he wants Swiss law to change,

         allowing him to extend his clinic's services to the non-terminally ill.  He

         would like all people, including the mentally ill and depressed, to be

         given the "marvelous opportunity" to end their lives at his clinic.

   10. 7/07: retired Swiss psychiatrist Peter Baumann is sentenced to one year

         in prison for assisting the suicides of 3 depressed patients.  He may be

         the only person besides Kevorkian to serve a prison sentence for

         violating assisted suicide laws.  

I. Providing Better Options for Suffering Patients

     1. It is important to remember that, first and foremost, doctor-assisted

         death is about suffering human beings.  We must offer these patients

         better alternatives:

         a. ethical hospice services should be readily available to all dying

             patients

         b. more doctors should be trained as palliative care ("comfort care")

             specialists

         c. comfort care must also include treatment of other discomforts such as

             nausea, shortness of breath, constipation, diarrhea, anxiety and

             insomnia

         d. all doctors should be better trained in the treatment of pain and

             depression

         e. in dying patients with incurable diseases: as curative treatments like

             chemotherapy are withdrawn, palliative care measures should be

             intensified

         f. remember: we may withdraw treatment but we never “withdraw care”

     2. Doctors need more training, time, and compensation for care of the

         dying.  All medical schools and residency programs should include

         palliative care as part of their training. All hospitals should have palliative

         care/pain mgmt. programs. Pain is now considered the “5^th vital sign”.  

     3. Families who care for sick or elderly relatives need more support. 

         Better funding for home care: currently, 75% of long-term care money

         goes to nursing homes.

     4. Responding to requests for doctor-assisted death: "PPD"

         a. Pain control (Palliative care)     b. Pastoral care services    

         c. Treat Depression                         

J. Medical, Nursing and Disability Organizations Opposed to Doctor-

    assisted Death

    (This list was last updated in May 2006)

     1. National medical organizations    

           American Medical Association

           American College of Physicians/American Society of Internal Medicine

             (116,000 members)

           American Cancer Society

           American Psychiatric Association

           American Geriatrics Society

           American Osteopathic Association

           American Neurological Association

           American Academy of Neurology

           National Spinal Cord Injury Association

           American Academy of Physical Medicine and Rehabilitation

           American Academy of Pain Management

           American Academy of Pain Medicine

           National Hospice and Palliative Care Organization

           Society of Critical Care Medicine

           Christian Medical and Dental Association (13,000 members)

           American Hospital Association

           American College of Legal Medicine

           League of United Latin American Citizens (LULAC)-California

           World Medical Association

           British Medical Association 

           Royal College of Physicians

           Royal College of General Practitioners

           Association of Palliative Care Medicine (Great Britain)  

           Australian Medical Association

           New Zealand Medical Association

           Canadian Medical Association

     2. National nursing organizations

           American Nurses Association

           Royal College of Nursing

           American Association of Critical Care Nurses

           Hospice Nurses Association

           American Society of Pain Management Nurses

           Oncology Nurses Society

           American Nursing Leaders

   *3. National Disability Groups

           Not Dead Yet (formed by disability activists in 1996 when Jack

           Kevorkian was acquitted after assisting in the suicides of 2 women with

           non-terminal disabilities)

           National Council on Independent Living (NCIL)

           National Council on Disability (NCD)

           American Disabled for Attendant Programs Today (ADAPT)

           Justice for All

           The Association for Persons with Severe Handicaps (TASH)

           Disability Rights Education and Defense Fund (DREDF)

           Association of Programs for Rural Independent Living (APRIL)

           American Association of People with Disabilities (AAPD)

           National Spinal Cord Injury Association

           Society for Disability Studies

           (at least 5 of these organizations filed amicus curiae briefs in support

           of the federal government’s position in Oregon vs Gonzales)

           British Council of Disabled People

           World Institute on Disability

           World Association of Persons with Disabilities (WAPD)

   *4. Local Disability Groups

           Vermont Coalition for Disability Rights (represents 26 Vermont

             disability rights groups)

    5. Quotes from Diane Coleman, J.D. (founder of Not Dead Yet)

          a. “Isn’t assisted suicide about individual autonomy and rights, they

              ask?  No, we say, it’s about discrimination and a profit-driven health

              care system.”

          b. “An individual’s right to refuse treatment is one thing, but legal

              immunity for your doctor, caregiver or someone else to kill you is not

              a right, it’s a threat.”  

K. The Best Arguments against Doctor-assisted Death

   *1. Look at what's happened in Holland where doctor-assisted death has

         been permitted since 1973.  This is the only hard "data" on the long-term

         consequences of legalization.

         a. assisted suicide leads to euthanasia

         b. euthanasia for the terminally ill leads to euthanasia for the chronically ill

             and the disabled

         c. euthanasia for physical suffering leads to euthanasia for psychological

             suffering

         d. voluntary euthanasia leads to involuntary euthanasia (what about

             “choice” for these patients?)

         e. euthanasia for adults leads to euthanasia for adolescents, children &

             newborns

             (there is no better example of the "slippery slope")

         f. the Dutch have a socialized medical system where everyone is insured;

            the economic incentives encouraging assisted death would be far

            greater in the U.S. where not everyone has health insurance (see #3

            below)

   *2. You can't legalize assisted suicide without eventually legalizing

         euthanasia.

         a. what about those patients who are too sick to ask for or swallow a

             lethal dose?; to deny them assisted suicide would be 

             "discrimination"            

         b. a "back-up" treatment is needed for failed cases of assisted suicide

             (5-20% of cases); what should emergency personnel do if called to

             the scene of a failed assisted suicide?  If there are problems with

             capital punishment by lethal injection, there will be more problems

             with assited suicide and euthanasia

         c. quote from Dutch physician P.V. Admiraal: "In spite of these

             measures every doctor who decides to assist in suicide must be aware

             that something can go wrong with the result being a failure of the

             suicide. For this reason one should always be prepared to proceed to

             active euthanasia..." (ref. 32)

   *3. Doctor-assisted death is the ultimate form of "cost-containment".  Derek

         Humphrey of the former Hemlock Society (now renamed “Compassion

         & Choices”) has claimed that “economic necessity” is the ultimate force

         driving the assisted suicide movement: “the hastened demise of people

         with only a short time to live would free resources for others.”

   *4. What about "choice" for doctors, nurses, and pharmacists who are

         morally opposed?  Any involvement makes them morally complicit: a.)

         nurses assisting at bedside; b.) pharmacists filling a lethal prescription; c.)

         morally opposed physicians who are forced to refer patients to a willing

         doctor.

     5. Doctors must remain healers and not killers; don't corrupt the medical

         profession.

     6. Patients already have the "right to die" naturally: they can refuse any

         medical treatment.  Legalizing doctor-assisted death will give doctors the

         "right to kill".

     7. We now have better treatments for pain and depression than ever

         before.

     8. Doctor-assisted death puts vulnerable groups of people at risk; the "right

         to die" can become the "duty to die" for the elderly, disabled, poor, and

         the mentally ill.             

     9. We can already offer "palliative sedation" to dying patients with severe

         pain or discomfort. The principle of "double effect” makes this an ethical

         option.

   10. It is discriminatory to describe some suicidal wishes as “rational”

         indications for assisted suicide when they occur in terminal or disabled

         patients, but other suicidal wishes as “irrational” and worthy of life-

         saving interventions when they occur in healthier patients.

   11. Physician involvement in capital punishment is considered unethical by all

         of organized medicine’s governing bodies.  Physician involvement in

         assisted death is unethical for the same reasons.  It is interesting that

         assisted suicide is legal in Switzerland but it is illegal for physicians to be

         present when it is performed. 

   12. The disability community is almost universal in its opposition to

         legalization of any form of doctor-assisted death. 

L. Answering Popular Arguments in Favor of Doctor-assisted Death

     1. Doctors already give lethal doses of pain medication to some dying

         patients.

         When this occurs, it is done with the intention of easing the pain, not

         killing the patient. According to the "principle of double effect", this is

         competely ethical and is not the same as assisted suicide or euthanasia. 

     2. Patients on life support such as kidney dialysis or a respirator have

         the “right to die” by stopping the life support treatments, so others

         not on life support should have assisted suicide available.

         Patients are removed from life support to respect their wishes and allow

         a natural death when the time has come.  Patients don’t always die when

         treatment is withdrawn (Karen Quinlan lived many more years).  This is

         a totally different situation from assisted suicide and euthanasia where

         death is always intended and death is always the result.

     3. You may not agree with it, but dying patients deserve this "choice".

         Legalizing this choice for some people puts others at serious risk.  This is

         why the disabled community feels threatened and is up in arms. The

         Supreme Court has ruled that states have a compelling interest to limit

         this choice in order to protect “vulnerable” groups of people such as the

         elderly, the disabled, and the terminally ill. Involuntary euthanasia gives a

         patient no choice.  And what about the “choice” of morally opposed

         doctors, nurses, and pharmacists who may be forced into complicity if

         they are required to refer or transfer the patient to a willing colleague? 

         Morally-opposed Catholic hospitals in Belgium now have no “choice”.

     4. You can't force your religion on the rest of society (the “Religion vs.

         Modernism” argument).   Religious arguments are not necessary to

         effectively argue against assisted suicide.  None of the arguments in the

         preceding section are based on religious principles.  Numerous

         organizations that support legalized abortion (such as the AMA) oppose

         doctor-assisted death.  The disabled community is heavily in

         opposition to assisted death and none of their arguments are

         religious.

     5. We need legalization for those few hard cases of uncontrollable

         pain; safeguards/guidelines  will prevent abuses.  We already have

         palliative sedation for hard cases.  Abortion was originally intended for

         “hard cases’ of unwanted pregnancy (rape, incest, life of the mother). 

         There are now at least 1.3 million abortions/year performed in the U.S. 

         "Safeguards/guidelines" have not limited abortion in the U.S. or assisted

         deaths and euthanasia in the Netherlands.

         Quote from Wesley J. Smith, author of Forced Exit: Euthanasia,

         Assisted Suicide, and the  New Duty to Die: “Adopting killing as an

         acceptable answer to human suffering eventually changes popular

         outlooks...once killing is redefined as medical treatment, it becomes

         transformed from ‘bad’ to ‘good’.  Thus, the guidelines

         intended to ‘protect against abuse’ eventually are viewed not as

         protections but instead as hurdles separating sick and dying patients

         from the beneficence of death. In such an intellectual and cultural milieu,

         it becomes easy to justify ignoring or violating ‘guidelines’ ”. 

Responding to Other Popular Arguments in Favor of Doctor-Assisted Death

"Why must people suffer if they are going to anyway within a short period of time?"

Response: Like living, the reality of dying is that it will often involve a component of suffering. But there is no reason for this suffering to be excessive or inappropriate. With the technology that we now have available for the control of pain and other discomforts, pain that cannot be completely relieved can at least be made tolerable. If a dying patient is suffering, the solution to this problem should be better medical care, not killing the patient. Modern palliative care involves a holistic approach that addresses the physical, psychological, and spiritual dimensions of a patient's suffering.

     "Palliative sedation" (see below) is a valid option for those rare patients whose pain cannot be relieved by conventional doses or analgesic and sedative drugs. A short period of palliative sedation prior to death is a much more dignified option than doctor-assisted death.

     The idea that there is compassion in killing is a truly radical notion that goes against the Hippocratic tradition that has guided medicine for more than 2,000 years. The original meaning of the word "compassion" is "to suffer with", and this is what we are called to do as family members and healthcare workers. We are called to share in the patient's suffering and provide as much comfort and support as possible. This includes providing the best palliative care that medicine has to offer. Doctor-assisted death is much closer to abandonment than it is to true compassion.

"Assisted suicide should be made legal for those few hard cases where pain cannot be controlled. Safeguards will prevent any abuses." 

Response: The "few" hard cases argument was used to legalize abortion. There are now 1.3 million abortions yearly in the U.S. As for safeguards, they have not worked for abortion in the U.S. and they have not worked in the Netherlands for euthanasia. Cases where pain cannot be controlled are indeed very few. Palliative sedation is a valid and ethical option for these patients (see below). In Oregon, "safeguards" in the law apparently failed to protect Kate Cheney (see reference 30).  

"Doctors already give lethal doses of pain medications to some dying patients; why not just legalize the practice for all dying patients?"

Response: Intention is everything. This is why there are different degrees of murder and manslaughter. If a physician's intention is to relieve a patient's pain, and the patient or the patient's family* is properly informed and in agreement, then it is ethical to give a potentially lethal dose of pain medication and accept the risks. However, if the intention is to bring about death, then the act is not ethical. Traditionally, this is called the "principle of double effect". It was recently supported by the Supreme Court. In those rare cases where pain cannot be controlled, the principle of double effect allows for "palliative sedation".

     Palliative sedation consists of giving very large and potentially fatal doses of narcotic pain medications such as morphine in order to induce a coma-like state of sedation.  In these cases, death sometimes results if breathing stops from over-sedation. As long as the physician's intention is to relieve pain, the risk of hastening death is acceptable and ethical if the patient (or the patient's family) agrees to take the risk. Organized medicine has accepted this practice as ethical for a very long time. The principle of double effect is invoked almost every time that cancer chemotherapy or emergency surgery is performed since sometimes patients do not survive these treatments.

     Some proponents of doctor-assisted death call palliative sedation "undignified"--a death without dignity. They feel that death by assisted suicide or euthanasia is somehow more dignified. This has certainly not been the case with many of the assisted suicides performed by Jack Kevorkian where bodies have been left in cars next to hospitals or morgues.

(*When a patient is unconscious or otherwise unable to make his/her decisions, these decisions are usually made by the patient's family.)  

"Suffering patients deserve to have this choice. You may not agree with doctor-assisted death but you can't force your morality on society."

Response: Issues of life and death cannot be arbitrary matters of "choice". Legalization of doctor-assisted death will have implications far beyond the individual patient. Although some citizens might feel that they would benefit from legalization, it would put other citizens at risk for coercion and possible involuntary euthanasia. This would be especially true for "vulnerable" citizens such as the elderly, the disabled, and the mentally ill-the "right to die" could become the "duty to die". This was one of the reasons given by the U.S. Supreme Court when they ruled that there was no constitutional right to assisted suicide in June 1997. The point should also be made that dying patient's considering assisted suicide don't really have a "choice" unless they have access to quality end-of-life palliative care. Laws can be viewed as restrictions on personal freedoms for the good of society as a whole. For this reason, 35 states now have statutes that prohibit assisted suicide.

     The involuntary euthanasia that is occurring in the Netherlands gives patients no choice. It is the ultimate absence of choice--the ultimate insult to a patient's autonomy.

     Many who favor doctor-assisted death also favor forcing doctors who morally object to it to refer patients to a willing physician. What about the doctor's choice in these situations?  Patients have a "duty to die" and doctors have a "duty to kill". Similar issues arise when pharmacists are forced to find the patient a willing pharmacist if they are unwilling to fill the prescription for the obvious lethal dose. There is no reason why a patient can't find another doctor or pharmacist on their own if their own provider objects on moral grounds.

     Every American has first amendment rights on this important issue. This includes the right to attempt to persuade others within the limits of the law. This is the very essence of the American political system. It is not "forcing one's morality" on America-such phrases “poison the debate” and are inappropriate rhetoric.

     And finally, the case of Oregonian Kate Cheney is very troubling (see http://www.findarticles.com/p/articles/mi_qa3798/is_199910/ai_n8870779%20-%2034k). It seems that Cheney's assisted suicide was more the choice of her family rather than her own decision or desire.   

"You are making this a religious issue--you can't force your religion on the rest of society."

Response: None of the objections to doctor-assisted death that I have stated thus far are based on religion. The American Medical Association, the American College of Physicians, and more than 40 other medical organizations oppose doctor-assisted death. None of these organizations have religious affiliations and most of them support legal abortion. Nearly every disability rights organization in the United States opposes doctor-assisted death for reasons that have nothing to do with religion. 

     Legislation or public policy that happens to parallel religious teachings is not automatically made irrelevant. Our laws against stealing, lying, and murder also coincide with certain religious teachings (the Ten Commandants). It would be absurd to suggest that such laws be eliminated because of this.

     I'm not "forcing my opinion" on anyone.  Don't poison our debate with such accusations and rhetoric.  Just like you, I'm exercising my right to free speech on this important issue.  Please don't insinuate that my position is radical or extreme. You are the one who is trying to change not only the law, but over 2,000 years of Hippocratic tradition in the practice of medicine. 

Response: These are totally different situations. Patients are removed from life support equipment to respect their wishes regarding unwanted medical care and to allow a natural death if and when the time has come. The patient does not ALWAYS die: Karen Quinlan lived 9 years after her mechanical ventilation was discontinued. Doctor-assisted death is intended to give the patient no chance at survival. Previous "right to die" legislation (Quinlan, Cruzan) was successful because withdrawing life support was portrayed as being very DIFFERENT from euthanasia. When we remove a patient from a ventilator we do not also remove all oxygen from the patient's hospital room. (The only "right to die" is the right to die NATURALLY.)

     The U.S. Supreme Court recognized this difference as "a distinction widely recognized and endorsed in the medical profession and in our legal tradition". The Court also cited 34 prior legal decisions that upheld this distinction.

"Opinion polls have repeatedly shown that the majority of the American public and the majority of American doctors are in favor of legalization. This is America: give the people what they want."

Response: It is very important to specify the exact question that was asked in an opinion poll since the wording of the question can be very misleading. Because of this, the accuracy of various opinion polls has been questioned. If the public strongly favors doctor-assisted death, they why did referendums for assisted suicide fail in California, Washington, Michigan and Maine and only pass by the narrowest of margins (51%:49%) in Oregon in 1994 (these are all fairly liberal states). In California, there have been 5 attempts to legalize euthanasia and/or assisted suicide by either referendum or legislative bill since 1988.  All 5 attempts have failed.  

     It should be noted that certain subgroups of Americans are strongly opposed to doctor-assisted death. These include nursing home patients, the disabled, and some minority groups. The majority of oncology (cancer) physicians are opposed to euthanasia and so are the majority of hospice workers. These are the health care workers that work most directly with the dying. If the majority of physicians favor legalization, then why did the physicians of the Oregon Medical Society vote 121-1 to support the repeal of the Oregon Death With Dignity Act in 1997? (American Medical News, 5/19/97). In November 1997, the people of Oregon voted NOT to repeal this act by a 60%:40% margin, but no other states have legalized assisted suicide.

     Furthermore, "consensus ethics" is a dangerous practice. It has given us slavery and the Nazi Holocaust. If a majority of Americans were ever to support pedophilia, should we then make it legal?

"I am personally opposed to doctor-assisted death, but I don't want to force my beliefs on other people."

Response: I find your position confusing and morally contradictory. Why do you personally oppose doctor-assisted death? If you feel that it is evil or immoral, then why don't you feel a responsibility to stand up against it? This same kind of attitude allowed the Holocaust to happen. How many good German people were personally opposed to the killing, but...? Since when do Americans tolerate evil and immorality in the name of pluralism? We do not take this approach with other evils such as child abuse and pedophilia. It is a tradition in America for individuals to fight for what they think is right and fight against what they feel is wrong. You must not feel very strongly about this important issue.

"Legalizing physician-assisted suicide will probably result in fewer actual cases of it in the U.S. If patients know that they have the option available, they will be less likely to attempt suicide out of fear when they are in the early stages of an illness."

Response: The logic of this argument seems inherently faulty-that legalizing assisted suicide will actually make it less common. The data from the Netherlands does not support this contention and neither does the data from Oregon. In the Netherlands, legalization of doctor-assisted death has clearly led to more doctor-assisted death.  I know of no situation in history where legalizing a previously illegal activity actually made it less common.  

"If a woman has a right to an abortion, then a suffering patient has a right to doctor-assisted death."

Response: This argument has actually been used by a circuit court judge. 

It is perfect example of the slippery slope of immorality. The right to life is the most fundamental of the human rights. Like legal abortion, legalization of doctor-assisted death will lead to its own slippery slope (just as we have seen in the Netherlands). Many medical organizations that fully support legal abortion are strongly opposed to doctor-assisted death (i.e., the American Medical Association).

     The "right" to an abortion is predicated upon the misguided reasoning that the unborn child is a human life but "not a person". Even if this thinking was accurate, how could it be applied to adults with terminal illness? It is worth noting that, at the time of Roe vs. Wade in 1973, proponents of abortion scoffed at the prospect of legal abortion eventually leading to legal euthanasia.

Closing thought: If a mother can kill her innocent, unwanted daughter for the sake of convenience, then why can't a daughter kill her innocent, unwanted mother for the same reason?

References:

1. Gianelli DM. Once again, Oregon voters ponder fate of assisted suicide. American Medical News. 8/25/97:9.

2. Shapiro JP. On second thought...Oregon reconsiders its pioneering  assisted-suicide law. U.S. News & World Report. 9/1/97:58-60. 

3. Gianelli DM. Dutch euthanasia expert critical of Oregon approach. American Medical News. 9/15/97:10.

4. Monod P. Insurance companies making a financial killing off assisted suicide. Today's Catholic. 1/2/98:17.

5. Groenewoud JH, van der Wal G, et al. Physician-assisted death in psychiatric practice in the Netherlands. N Engl J Med 1997; 336:1795-1801.

6. Ganzini L, Lee MA. Psychiatry and assisted suicide in the United States. N Engl J Med 1997; 336:1824-26.

7. Hammack JE, Loprinzi CL. Use of Orally Administered Opiods for Cancer-Related Pain. Mayo Clinic Proc 1994; 69:384-90.

8. Foley KM. Competent Care for the Dying Instead of Assisted Suicide. N Engl J Med 1997; 336: 54-8.

9. Emanuel E. Euthanasia: Historical, Ethical, and Empiric Perspectives. Arch Intern Med 1994; 154:1890-1901.

10. Gianelli DM. Dutch data indicate doctor-assisted death on the rise. American Medical News. 1/13/97:4.

11. Annas GJ. The Bell Tolls for a Constitutional Right to Assisted Suicide. N Engl J Med 1997; 337:1098-1103.

12. Marker R. Euthanasia: Answers to Commonly Asked Questions (in "Euthanasia: Implications for Hospice" published by the International Task Force, P.O. Box 760, Steubenville, OH 43952; Phone 614-282-3810)

13. Willing R, Castaneda CJ. Protesters see no mercy in assisted suicide. USA TODAY. 1/9/97:3A.

14. Emanuel E, Fairclough DL, Daniels ER, Clarridge BR. Euthanasia and Physician-assisted Suicide: Attitudes and Experiences of Oncology Patients, Oncologists, and the Public. Lancet 6/29/96; 347:1805-10.

15. Gianelli DM. Michigan doctors change stance on assisted suicide. American Medical News. 5/19/97.

16. Van Der Mas PJ, Van Delen JJM, Pijnenborg L, Looman CWN. Euthanasia and Other Medical Decisions Concerning the End of Life. Lancet 9/14/91. 338:669-674.

17. Van Der Mas PJ et al. Euthanasia, Physician-Assisted Suicide, and Other Medical Practices Involving the End of Life in the Netherlands, 1990-1995. N Engl J Med 1996; 335:1699-1705.

18. Spanger M. Mental Suffering as Justification for Euthanasia in the Netherlands. Lancet 6/25/94; 343:1630.

19. Shapiro JP, Bowermaster D. Death on Trial. U.S. News and World Report. 4/25/94:31-39.

20. Jochemsen H. Euthanasia in Holland: an Ethical Critique of the New Law. Journal of Medical Ethics 1994; 20:212-217.

21. Spanjer M. Nurses Cannot Assist Suicide in the Netherlands. Lancet 4/1/95; 345:849.

22. Orlowski JP, Smith ML, Zwienen JV. Pediatric Euthanasia. American Journal of Diseases of Children 1992; 146:1440-46 (page 1441, 1443).

23. Spanjer M. Terminating Life of Severely Handicapped Dutch Baby. Lancet 4/15/95; 345:975.

24. Terry PB. Euthanasia and Assisted Suicide. Mayo Clinic Proceedings 1995; 70:189-92.

25. Fromme EK, et al. Increased Family Reports of Pain or Distress in Dying Oregonians: 1996 to 2002. Journal of Palliative Medicine 2004; 7:431-442.

26. Verhagen E, Sauer PJJ. The Groningen Protocol-Euthanasia in Severely Ill Newborns. New Engl J Med 2005; 352:959-962.

27. Okie S. Physician-Assisted Suicide-Oregon and Beyond. New Engl J Med 2005; 352:1627-1630.

28. Golden M. Guest Editorial: Why Progressives Should Oppose the Legalization of Assisted Suicide. Beyond Chron (San Francisco's Alternative Online Daily) 4/12/05. Accessed at  www.beyond chron.org on 5/22/05.

29. Sheldon T. Dutch approve euthanasia for a patient with Alzheimer’s disease. BMJ 2005; 330:1041.

30. Smith, Wesley. Suicide unlimited in Oregon. Weekly Standard. 11/8/99:  11-14.   This article can be accessed at: http://www.findarticles.com/p/articles/mi_qa3798/is_199910/ai_n8870779%20-%2034k.

31. Stevens KR. Emotional and Psychological Effects of Physician-Assisted Suicide and Euthanasia on Participating Physicians. Issues in Law and Medicine 2006; 21:187-200.

32. Admiraal PV. Toepassing van euthanatica. Ned Tijdschr Geneeskd 2/11/95;139(6):267.

About the Author:  Dr. Kenneth J. Simcic was born in Pittsburgh, Pennsylvania.  He attended Duquesne University in Pittsburgh before obtaining his medical degree from Temple University Medical School in Philadelphia.  He then joined the United States Army and completed his internship, residency and fellowship at Fitzsimons Army Medical Center in Denver, Colorado.  

     Dr. Simcic's specialty is adult endocrinology.  He served for 20 years as an Army physician before taking his current position at the University of Texas Heatlth Sciences Center/San Antonio.  He was a member of the Bioethics Committee at William Beaumont Army Medical Center in El Paso, Texas, and served as Chairman of the Bioethics Committee at Brooke Army Medical Center in San Antonio.

     Dr. Simcic is a Fellow of both the American College of Physicians and the American College of Endocrinology.  He has also been awarded the "A" Proficiency Designator-the Army Medical Department's highest award recognizing professional expertise, exceptional ability, and outstanding achievement. 

  Dr. Simcic is the father of 3 daughters and he and his wife Mary will celebrate their 25th wedding anniversay in June 2007.