Bioethics

Thoughts on Assisted Suicide.

By Chris Rangel MD ⋅ December 30, 2005 ⋅  Email this post ⋅  Print this post ⋅ Post a comment

Q&A on assisted suicide - In life there are two absolutes; Death and taxes. Actually there is a third; suffering. Many things cause suffering in life but often none more so than terminal illness (usually cancer). When death is certain within a short amount of time and suffering is expected to continue unabated (only incompletely relieved with standard treatment) within this time period should a patient have the right to request help (usually from a physician) in arranging a painless and effective suicide?

Continuing my discussion on this topic with Moof, one commenter, Dr. Crippen (from the UK), proposed the following excellent questions that need to be considered before any “right-to-die” legislation is proposed. I will answer each in turn.

1. There would have to be legislation allowing euthanasia. Under UK law, you cannot consent to being murdered. You therefore have to legislate. Supposing, therefore, you do legislate and allow patients to ask a doctor to kill them. Under what circumstances?

First off, assisted suicide is not direct euthanasia under either the Oregon or the Netherlands laws. The term “assisted suicide” is not just a euphemism. Patients are “assisted” by a medical professional in obtaining a lethal combination of medications and the means by which to administer them. The Oregon law prohibits anyone other than the patient from directly administering the medication(s) but requires a “health care professional” to be present.

The Netherlands law is less clear on who would administer the medications (probably to avoid discriminating against patients who are able to give consent but because of their illness would not be able to do it themselves) but several conditions must exist; The patient must be a mentally competent adult. The request by said patient for assisted suicide must be voluntary and persist over time. The patient must have intolerable suffering without any hope for relief. The physician must consult with another physician not involved in the case.

2. Could they ask to be killed because of intractable depression that has not responded to treatment? Of course not, you will say. But why not? If that is what [they] really want, why not?

Depression and other psychiatric illnesses do not fulfill generally accepted criteria for assisted suicide; i.e. that the patient is suffering from intractable physical pain and suffering and that death resulting from the same illness causing the suffering is considered to be inevitable. Both the Oregon and the Netherlands laws do leave it up to physician evaluation to determine if the appropriate criteria exist but the Oregon law makes it very clear that if the physician suspects that the patient’s judgment is impaired by depression or other psychiatric illness, a psychological examination must be done. More about the depressed terminally ill patient on question # 4.

3. How terminally ill do you have to be to be allowed to request euthanasia? Life expectancy 5 years? 1 year? Less than a year? One month? You would surely have to draw a line . .but where?

A terminal patient is commonly defined by hospice programs and by the US Medicare program as having six months or less of expected lifespan. I prefer the inclusion of this criteria in being eligible for assisted suicide because it underscores the futility in continuing palliative care when suffering is incompletely relieved, quality of life is poor and death is inevitable.

However, not everyone includes this criteria because there exists the possibility of suffering chronic severe pain/discomfort and/or debilitation from one or more conditions that are not necessarily terminal. This is a valid point but also a source of a lot of alarm from critics of assisted suicide. In particular, they worry about the possibility that non-terminal patients who have debilitating disease will be put to death by society under the pretext of humane relief of suffering from lives that are deemed to be not worth living. But such a slippery slope would have to cross a huge speed bump in that it violates a critical tenant of assisted suicide; that the patient request must be fully voluntary, persistent, and be free of coercion or other undue influence such as depression or substance abuse.

However, the possibility that a patient with a non-terminal illness may be allowed to chose assisted suicide is of continued concern to opponents of such laws (advocates for the disabled are vehemently opposed). How do we know that a cure or effective treatment for their disability and/or source of suffering won’t soon be discovered? How do we know that their lives will not improve with effective treatment and even how do we truly know that a terminal illness is truly terminal (the case of Stephen Hawking who has ALS is often invoked)?

These are valid concerns however opponents assume that these theoretical hypotheticals (the possibility that a cure will be found, for example) usurp the importance of patient autonomy and the reality of human suffering due to physical illness. Opponents have never provided a good argument to why patient autonomy should stop at how, when, and where a terminal/suffering patient decides to die (hence the “right-to-die” debate). Again I raise the question; Does the importance of life always trump the relief of suffering and of patient autonomy?

4. Should the patient have to have an independent psychiatric assessment?

Dealing with psychiatric conditions in terminal illness is tricky for any proposed assisted suicide law. Depression is very common in terminally ill patients and as such I think it’s very important that the patient be evaluated for impaired judgment resulting from such depression or other psychiatric illness. The problem is that an automatic requirement for a psychiatric evaluation may amount to an undue hindrance and delay for the patient who will not benefit from it. Such a requirement will also suggest to these patients that the system (and society) automatically considers them to have some degree of “mental imbalance” for wanting to die. After all, what sane person wants to die? Only depressed or crazy people want to commit suicide! This requirement seems reasonable on the surface but can become quite problematic.

5. Does the family have to consent? If they do, is it just the partner? Or the children? Or the parents? Supposing there is a disagreement; would you have a vote? Simple majority required, or maybe two thirds?

Since this is a question of patient autonomy and self-determination the concerns and wishes of the family are not taken into account in most cases. In addition, the Oregon law makes very clear that the family cannot make a request for assisted suicide on behalf of the patient in the event that the patient is unable to communicate (i.e. in a coma). The request must be voluntary and come from the patient and the patient alone.

6. Having signed a document requesting euthanasia, does the patient have to be conscious at the time he is killed? Supposing he is unconsciousness. Does the doctor still kill him? Supposing at that stage, the wife/husband changes her/his mind and withdraws consent? To whom does the physician owe the greater duty?

Both the Netherlands and the Oregon laws make it clear that a request for assisted suicide be voluntary and be made by a competent and well informed patient and that such request persist over time. The Oregon law specifically states that the patient can resend the request at any time. If the patient is not conscious then obviously he/she cannot continue to give consent nor are they able to resend the request if so desired. In Oregon the patient must self-administer the medication(s), which is another protection against involuntary euthanasia.

In the event that the patient is no longer able to give consent then from a legal aspect it appears that the request is no longer considered to be valid. As mentioned above, consent for assisted suicide cannot be given nor rescinded by anyone other than the patient. Ergo, the physician’s duty is strictly to follow the request of the patient so long as the patient is able to give consent.

7. If he does not kill the patient and the patient regains consciousness, could he then sue the doctor for breach of contract? You can just see the lawyers buzzing round that one!

Considering that this is America (which means “Land of the Lawyers” in Potawatomi) this is a very important question. If the assisted suicide does not work and results in additional pain and suffering of the patient and it can be proven that this was a result of improper procedure, prescribing, and/or monitoring then it should fall into the venue of medical malpractice (ironically). As with question #6 if the patient is unable to give consent for any reason then the physician cannot be held liable for not going through with the assisted suicide in accordance with the law.

8. Do you take the patients financial standing into account? What has that got to do with it you may say, well, supposing the patient knows that the on-going medical bills are going to reduce the whole family to poverty (and it happens) and so decides to ask for euthanasia rather than soldier on?

Ahh. Excellent question. Or to put it another way; What if the patient has reasons other than intractable pain and suffering that are pushing them to request assisted suicide? Many an elderly or terminally ill patient may not want to subject their family not only to the expense of their illness but also to the pain of seeing their loved one suffer and slowly die.

But then again, financial considerations or other concerns not directly related to intractable pain and suffering in a terminal patient do not fulfill the accepted criteria just as depression alone does not (see question #2). What if a terminal patient does have intractable pain and suffering but other concerns like the financial well being of the family do play a part in the patient’s reasoning and decision to request assisted suicide?

If this is known to the physician then a request for a psychological evaluation should be made to ensure that the patient is making the request for assisted suicide appropriately and not under undue influence or pressure. But just because the family may save money from the patient’s early demise does not necessarily mean that this alone supercedes that patient’s right to self-determination!

There are still so many more questions that need to be asked with regard to assisted suicide.

Is it appropriate for the physician to FIRST bring up the option of assisted suicide to a terminal patient who is obviously suffering? Just what is the family’s role in this? What if the family approaches the physician with a request to “convince” the patient to consider assisted suicide? Can family members sue or get a court order to stop the assisted suicide? Exactly how do we determine and document “pain and suffering” in a terminal patient? What does the physician do with a patient who is not in any pain yet but has been diagnosed with a terminal illness and who wants assistance with suicide before the inevitable pain and suffering start? Should we require patients to endure pain and suffering first before we consider a request for assisted suicide?

Yes, euthanasia and assisted suicide is a can of worms waiting to be opened. But in my opinion it needs to be opened and these questions need to be asked because intractable pain and suffering is a very real issue and patient autonomy needs to be discussed and debated within this context. If you believe that we can make the issue of assisted suicide go away by not opening that Pandora’s box then you must believe as well that the issues of futile human suffering at end of life and patient autonomy and the right of self determination will also go away with it. Obviously this will not happen. It is a box that we must open.