Euthanasia and physician-assisted suicide
It was Tuesday night, and I was on the ambulance that had just transferred a patient from one hospital to another. Along the way, the ambulance ran over something. We pulled over to check the ambulance, but the paramedic was afraid it might have been a poor animal and decided to drive back to check. It indeed was – there on the road was a small kangaroo hobbling across the road, seemingly in pain. We had run over its lower body, and while it was still alive, it was apparent that it has lost most of its mobility. One of the paramedics was adamant that we should run over its neck to end its pain. Unfortunately, when we had turned back it was by the side of the road and we could not. The paramedic was staunch in her belief and persisted we did something. In the end, she called Animal Services and requested their help to put it down.
As I looked back, and examined my feelings at that point in time, I thought that we would leave the injured animal alone and let nature take its course. The thought of running over its neck was new to me, and in fact turned me off. Was it our right to end its life? Was it our call? Who were we to decide? Why couldn’t we send it to a veterinary hospital instead? Was its life not worth saving?
This incident prompted me to research further into the topic of euthanasia and physician-assisted suicide (PAS). I felt it was critical to get different perspectives to this controversial issue and have a personal stand. This is to prepare for the eventuality of me facing a similar incident in a healthcare environment. Would I be prepared to make the appropriate and sensitive comments? Would I be ready to answer the patient’s questions regarding available options? Would I be ready to participate in passive euthanasia and pull the plug for the life support machine, or administer high dose intravenous (IV) morphine?
When the incident happened, I felt nonchalant. “It was merely an animal, and we should just leave it alone. Let nature takes its course.” However, as I look back, I realised that my reaction was totally inappropriate and antithetical to the instincts of a doctor (thanks Sid for the input). After all, it was not natural that the kangaroo was run over in the first place. As a future doctor, I will probably be trying my best to stop nature’s course in the natural history of diseases, hence it is unacceptable to take insouciant approaches, especially when pertaining to the sanctity of life. This has changed my perspective and reminded me of the important responsibilities and role I bear when I graduate.I also recall feeling angry with the paramedic insisting that we kill the kangaroo, instead of trying to save it. I feel she had no right to decide what lives and what does not. However, she probably felt a sense of duty as an animal lover, or as a humane person. Perhaps I should have suggested sending it to a vet instead. She might have her own beliefs to this matter, and only after trying to put myself in her shoes, can I truly understand her. I can now appreciate the sociology lectures I used to attend, and the concepts of holistic health care for patients. I quote Harper Lee in the famous “To kill a mockingbird”, “You never really understand a person until you consider things from his point of view, until you climb into his skin and walk around in it.” This I will keep in mind.
A future possible scenario very similar to this would be in an intensive care unit. A patient is undergoing palliative treatment and is in pain. Prognosis is poor, and he probably only has a few months left. All medical and surgical management has been explored. As a physician, I could participate in PAS, administering high dose IV morphine to hasten death and alleviate pain . Physicians are generally protected in these cases under the established principle of “double effect”, wherein one act produces two inseparable effects: one good (relieving pain) and one bad (opiate sedation to the point of death) . Alternatively, for a patient in comatose, I could switch off the life support system.
Would I struggle with that? If I did struggle with ending a kangaroo’s life, chances are high that I would with a human. How would I deal with it? Would I not be acting against the first cardinal principle of biomedical ethics, ‘to first do no harm’? By assisting suicide, would that not be harm to the patient? Or is that good medical practice?
A little out of point but thought would be cool: Civil war morphine kit
Further research reveals that there are two approaches to this matter:
1. Thomas Aquinas documented traditional Christian beliefs well regarding all forms of suicide and he condemned it (whether assisted or not) because it violates one’s natural desire to live, and harms other people. Life is the gift of God and is thus only to be taken by God.
2. Michel de Montaigne3 argued that suicide should be considered a matter of personal choice – a human right. He indicated that it is a rational option under some circumstances. In his “A defence of legal suicide” (1580), he wrote: “Death is a remedy against all evils: It is a most assured haven, never to be feared, and often to be sought… The voluntary death is the fairest.”
To explore this, we go back in time to 1989, when a group of physicians published a report in the New England Journal of Medicine in which they concluded that it would be morally acceptable for doctors to give patients suicide information and a prescription for deadly drugs so they can kill themselves . Such situations would be for patients in terminal conditions. Oregon’s assisted suicide law defines “terminal” as a condition, which will “within reasonable medical judgment, produce death within six months”.
However, the use of a six-month prognosis to qualify a patient for assisted suicide or euthanasia was challenged in the World Federation of Right to Die Societies’ newsletter , “The six-month standard not only calls on doctors to make an unreliable prediction, but prescribes a pointless time limit: The longer the life expectancy the greater the patient’s suffering. The essential elements for legislation are that the condition is irremediable by medical treatment and the suffering is intolerable to the patient.”
Even the Dutch, who describe “terminal” as a “concrete expectancy of death,” have made no attempt to predict when that concrete expectancy will be fulfilled, because any estimate of the extent of shortening of life can only be very general” and this has no “absolute value”.
Personally, I will stand by Hippocrates. The art of medicine should continue to be passed on. Without empirical evidence on a patient’s prognosis, it will be irresponsible to give a death sentence. Even when needed to do so, I am of the opinion that one should not give it without hope. It is important to not give false hope. However, it would mean the world to a patient to know that their doctor has not given up on them, and that “you never know”. That is how I will choose to communicate with my patients in the future, believing that there are just some things that are unfathomable and it would never hurt to let your patient know that you are a doctor who, despite all medical training and logic, still believe in the impossible.
In conclusion, the American Medical Association has taken a firm stand for life, filing an amicus brief in the 9th Circuit case regarding doctor-assisted suicide. In this brief, the AMA stated, “There is, in short, compelling evidence of the need to ensure that all patients have access to quality palliative care, but not of any need for PAS.” My take is that as doctors, we perform a crucial act of healing and saving life. Accepting a dual role of taking life, while at the same time protecting life, would undermine one’s credibility and the sacred trust that exists between a patient and doctor. If I could do more to adequately manage pain, then that is my duty, because I also hold to the Scottish Parliament view , amongst other authorities, that the sanctity of life trumps autonomy.
A simple incident of running over a kangaroo has led to this brief exposition of passive euthanasia and a physician’s role in patients’ lives, which I believe will certainly prepare me as a physician to encounter these controversial issues with a firm yet sensitive stand.
References:
1. House of Lords (Session 1993-94), Report of the Select Committee on Medical Ethics, Volume 1-Report, p. 10, paragraph 20, London. Available at: http://www.ama.com.au/web.nsf/doc/SHED-5FK3DB. Accessed 19 May 2007
2. Vacco v Quill, 521 US 793 (1997).
3. New York State Task Force on Life and the Law.. When Death Is Sought: Assisted Suicide and Euthanasia in the Medical Context. New York, NY: New York State Task Force on Life and Law; 1994.
4. RCGP Statement on Assisted Dying. 21 September 2005. Available at: http://www.rcgp.org.uk/press/2005/0067.asp. Accessed 10 May 2007
5. David I Jeffrey of APM, “Time to legalise assisted dying? Response from the Association for Palliative Medicine”, BMJ 2005;331:841
6. D.J. Wilkie & TNEEL Investigators of the Cancer pain and symptom management nursing research group, “Comfort and pain management”. Available at: http://www.tneel.uic.edu/tneel-ss/demo/comfort/outline4.asp. Accessed 20 May 2007
7. Religious tolerance website, “Euthanasia and physician assisted suicide”. Available at: http://www.religioustolerance.org/euthanas.htm. Accessed 19 May 2007
8. Sidney H. Wanzer, M.D. et al., “The Physician’s Responsibility toward Hopelessly Ill Patients: A Second Look,” The New England Journal of Medicine (March 30, 1989), p. 848.
9. Oregon “Death with Dignity Act” [ORS 127.800 §1.01 (12)].
10. Jane Cys, “HCFA won’t punish doctors for long-living hospice patients,” American Medical News, October 9, 2000.
11. Eric Gargett, “Changing the Law in South Australia,” World Right-to-Die Newsletter, May 2001, p. 3.
12. Paul J. van der Maas et al., II Euthanasia and Other Medical Decisions Concerning the End of Life,”(English Translation, the Remmelink Report) (Elvesier 1992), p. 23.
13. “AMA: Anti-Euthanasia, Pro-Pain Control” (9 Sept 2000) Available at: http://www.pregnantpause.org/euth/amagomez.htm. Accessed 19 May 2007
14. Calum MacKellar, “Scottish Assisted Suicide Bill – An opportunity to show that sanctity of life trumps autonomy”. Available at: http://www.cmf.org.uk/literature/content.asp?context=article&id=1639. Accessed 20 May 2007.
Good on y’ for taking up the subject. It’s either really complex or really simple, depending on how able a person is to look at it strictly from the patient’s point of view. That, of course, is also very complex. But in my view, one needs, as a physician, to try as hard as possible not to inflict one’s own personal/religious views in these situations. I recognize that if a doctor sees any form of euthanasia as morally indefensible, he/she would have a problem proceeding. Yet in a sense, being a physician means one must accept the need to enter grey areas: it may not be euthanasia, but nearly all physicians will face a situation wherein a patient is suffering intractable pain and is dying: giving narcotic is nearly universally agreed upon, but there’s no doubt doing so will hasten death, even if it’s not the overt aim.
It’s easy to say: we must try only to do what’s best for the individual patient. It’s less easy to do. Yet when a patient is dying and has no hope of coming out otherwise, and when that patient is suffering and is asking for relief, it seems obvious to me that no matter what my personal religious beliefs are, my obligation is to provide that relief. It happens every day; and it need not be a Kevorkianesque delivery system. Stopping life-prolonging treatment for that which provides comfort only ought not to be a difficult decision if that’s what the patient wants. Of course there are areas in which the outcome is less clear; yet if most would agree that in the conclusively terminal situation we would try to alleviate suffering, then the rest is in the details.
Frankly, the thought that one might — in the case you describe — feel that letting “nature take its course” in the example of the kangaroo is shocking to me: it wasn’t natural that the animal was run over. The instinct to avoid any sort of action at all strikes me as antithetical to the insticts of a physician. I can understand recoiling from killing the animal; I’d have thought that, if it was possible, taking it to a vet would be the most desirable. Calling animal control seems fine as well, as was done. My point here is that I think if we are to do what it is we are charged with, there are situations in which we must overcome certain instincts to avoid difficult situations and to do what’s right for those in our care. It takes being able to do what many — if not most — would rather not do: disregard our own religious beliefs in favor of those of our patients. Because, to me, the only reason not to provide comfort for those who are dying is a particular religious view of life which may or may not be shared by everyone. Ideally, as a physician, my religious views ought not interfere with my ability to treat: whether it’s in this most difficult of areas, or in the more mundane matter of prescribing birth control. It’s the ultimate “liberal” view: my patient’s religious views have validity equal to mine. If I don’t believe in euthanasia, then when my time comes, I won’t ask for it. If another person has another view, then within the law (which ought to allow it, in my opinion), I ought to grant that I have no right to impose my views on another.
Thanks for inviting my comments. I’m sort of firing it off from the hip: maybe not the best way to address such an issue.
yeap. i agree with you totally. i may seem to portray strong religious views in my approach to matters, especially expressed in this blog as an outlet to share with my readers, but i will only keep it within it me and not let it affect the way i will treat and communicate with my patients in the future.
while i don’t believe in euthanasia, i think i might succumb to a patient’s wishes eventually, especially when i witness first hand his/her suffering and that all other palliative methods are not working or effective enough. that is why i suppose US doctors are protected by the law, which is what i gather from:
New York State Task Force on Life and the Law.. When Death Is Sought: Assisted Suicide and Euthanasia in the Medical Context. New York, NY: New York State Task Force on Life and Law; 1994.
have you personally come across such a situation and did you struggle to do it, or did you feel apprehensive, for the very first time?
I think you’ve written a great essay about a very sensitive (if not the most sensitive) topic of medicine. Both points and points of views are represented. Well done, Jeffrey!
You should submit it for the next edition of Grand rounds!
hey bertalan. thanks. i have submitted it and hopefully it gets featured. i thank you for your comments previously about IV morphine. i have researched more about that and found that it is indeed something permissible as i have reflected above in the main article. thanks a lot for your input.
I have, as have most, been in situations where I made decisions that I knew would hasten death. I’ve never actively performed what would be defined as “euthanasia,” having never lived in a place where it was legal. The closest was a patient who had incurable cancer who requested that I allow her to stockpile meds at home so that if she chose to take her own life at some point, she could. We talked many times about it; I assured her that when the time came I could hospitalize her and see to her comfort. But she wanted the peace of mind that would come from knowing she had the means to be in control on her own if she so chose. (As a general comment, I recognize that there are issues, if it were generally so, about people making such a choice improperly.) In the case of this woman whom I knew to be facing a cancer-related death within a very few months, the concept seems not inappropriate. The Hemlock Society provides people with recipes…
Oh , your post was very interesting.
hyaa
it is a wee shame on the people its dieing
i hope u can help thm
hyaa
it is a wee shame on the people its dieing
i hope u can help thm
i now it is a teribble thing but just try and help the people how is dieing
euthanasia is my project so i want to help too?
Thank you for posting on this moral dilemma. I posted on Euthanasia as well recently and I will probably be struggling with it for a while to find some clarity. I am a minister who also needs to have some clarity in my own position if I am going to provide spiritual counsel to families attempting to make these hard decisions.
What I did not mention in my post was the suicide of my granduncle. He was a farmer who also had a natural knack at doctoring horses. He knew when a horse had more living to do or had to be put down. He had an accident on the farm which left him with a brain injury and a seizure disorder. The medication he took to control the seizures had severe side effects and with out the medication he could not function on his work. He sought out the doctor for another medication. He was told there was none, to live with it and give up farming. This was more he could bear and took his life in a most gruesome manner. Had we had assisted suicide, he could have ended his life gracefully with family around him and not the manner he had and after his life partner went out to do her errands.
It cloudys the waters a bit on whether euthanasia is a moral choice… yet, I do not begrudge my uncle’s choice only that he felt he had no options left for him to preserve his dignity.
Blessings on your medical calling…
Rev. Fred L Hammond
i think euthanasia is funny why are people making a big deal about just let the sick people do what they want.
Please do not commit suicide, if you need help just say out loud now please Jesus I believe and I receive you in my heart please help me if you need more help please go to leroyjenkins.com
I think it is sad how anybody can just unplug someone knowing that they are going to die i think thats just wrong i think they should make people sign a paper saying that if they have to be on life support unplug me and if they dont that fine every one should have a changes to live