Agreement is possible in assisted suicide debate
Physicians suggest focusing on common ground
Rather than focusing on the contentious aspects of physician-assisted suicide, providers should concentrate on the common ground of good care for dying patients. That's the view researchers in a national survey on physicians and assisted suicide took in a recent article. "In our view, the common ground between the two sides of the physician-assisted suicide debate includes seven areas," says Diane E. Meier, MD, director of palliative care at Mount Sinai Medical Center in New York City. Meier and the other researchers published an additional article based on their national survey in the Annals of Internal Medicine.1
Ethics committees can improve the environment for physicians by promoting commonalities on both sides of the issue, she says. "It was our intention to help focus on the areas of agreement so that it would promote a better understanding of the issues behind a patient's desire to hasten death."
Here are the seven areas in which providers can find common ground:
1. A central goal of medicine is to relieve suffering by helping people die with comfort, support, and meaning. The "healer" has more than one role in the care of a dying patient. The healer is not only designated to cure or prolong life, but but also can help dying patients and their families make the best of the situation. All aspects of the person should be considered, including physical, mental, social, and spiritual.
Caregivers should respond with urgency, skill, and creativity, especially if the patient experiences suffering as death approaches. Also, goals and methods of management should be specific to individual patients, and patients should be given the opportunity to define meaning and comfort in the context of their illness and personal values.
2. Comprehensive, interdisciplinary palliative care is the standard of care, and the focus of medical management is quality of life. Palliative care should be given for progressive advanced disease with limited prognosis. Although palliation of symptoms should be offered during all stages of disease, it is increasingly important as death nears. Further, goals of care shift from attempted cure or prolongation of life to emphasis on quality of life. Hospice care, compared to conventional care, improves quality of life outcomes, such as pain relief and other symptoms, and offers psychosocial, existential, and spiritual support.
3. Physicians must provide adequate pain relief according to well-established standards. Pain management techniques generally are effective, and adequate pain relief can be achieved with minimum side effects by using widely available practice guidelines. Physicians should reassure patients that whatever opioid doses are needed to relieve suffering can and will be used, even if they cause sedation or indirectly hasten death. The patient should be the final guide for whether the level of pain relief is adequate and any side effects are bearable. Withholding effective pain relief due to unwarranted fears of addiction, tolerance, sedation, or legal consequences is unacceptable.
4. Patients have the right to refuse unwanted treatment or to stop treatment once it has been started. Patients have authority over what happens to their bodies, including the right to refuse or stop any and all medical treatments, even when a patient's wish is to hasten death. If patients are unable to express their wishes, clearly stated earlier preferences should be followed. When preferences are unavailable, decisions should be made by surrogate decision makers according to the principle of substituted judgment: the decision should reflect what patients would prefer if they could speak for themselves.
5. Patients who request that death be hastened should have their requests fully explored, and they deserve an exhaustive search for palliative alternatives. Death can be hastened by a variety of methods, including forgoing life-sustaining therapy, voluntary cessation of eating and drinking, terminal sedation, physician-assisted suicide, or active euthanasia. Requests should be viewed as a cry for help, and the meaning behind them should be explored carefully.
Requests could indicate unrecognized pain, depression, or psychosocial, family, or spiritual crises. A comprehensive evaluation should follow, and efforts should be made to relieve distress and make continued living desirable. Providers should ensure that a request is fully informed, autono mous, and a true reflection of the patient's values, based on the current clinical situation. Consultation with providers with expertise in caring for the dying also is recommended.
6. Even if physician-assisted suicide is justified under some exceptional circumstances, it doesn't necessarily mean it should be supported as public policy. Policy questions about assisted suicide, terminal sedation, and forgoing life-sustaining therapy require a complex analysis of how each act might be used in response to individual patients and the needs of specific groups, such as the disabled, poor, mentally ill, and incompetent. Public policy decisions must address the intended and potential unintended consequences of assisted suicide subject to regulation, as well as the consequences of the current underground, unregulated practices that are available.
7. Physicians should remain committed to skillful and compassionate care of the terminally ill throughout the dying process but should not be required to violate their own values. It is the physician's obligation to treat severely ill patients by providing palliative care. Physicians should not be obligated to assist in suicide if it violates their fundamental values, even if the practice becomes legal. When patients seek to hasten death, physicians should explore mutually acceptable alternatives and request consultation with experts in care of the dying. If common ground can't be established, physicians could offer to transfer care to a clinician or facility whose values more closely match those of the patient.
Reference
1. Quill T, Meier D, Block S, et al. The debate over physician-assisted suicide: empirical data and convergent views. Ann Intern Med 1998; 128:552-558.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content