Physician-assisted suicide: a very personal issue - Editorial

Author: Howard Brody, Gregg K. Vanderkieft
Date: May 15, 1997

An elderly patient in the late stage of decline from multiple chronic conditions recently inquired, "If I become so incapacitated that I no longer see any reason to go on, would you help me if I choose to end my life?"

A recently retired maintenance man came to the office because of somatic complaints, but his main concern was the care of his wife, who had become bedridden as a result of diabetes and renal failure. All efforts to obtain social services assistance had failed, and he faced the dilemma of either managing her total care by himself or losing all of his retirement savings to qualify for public assistance. He expressed both anger and hopelessness. At the end of one visit, he said over his shoulder as he was leaving the room, "You wouldn't by any chance have Dr. Kevorkian's phone number, would you?"

The two cases illustrate the "helpless hopelessness" many patients--and many physicians--feel when faced with terminal or debilitating illness. Even physicians who engage abstractly in debates about the ethics of physician-assisted suicide may be ill-prepared for encounters with patients such as these. Yet it is how we handle these encounters, not whether we can provide elegant answers in the policy debate, that tests our skill and character as family physicians.

At the level of law, ethics and public policy, the battle lines have been drawn and the barricades erected. Seven years of often acrimonious debate and analysis have changed the mindset of very few committed partisans. But the polarized and contentious nature of this debate has tended to obscure a more important reality: no matter whether the individual physician is morally opposed or in favor of physician-assisted suicide, the basic approach to a patient who requests suicide assistance should be very similar no matter what the physician's beliefs are.[1]

Even the strongest advocates of physician-assisted suicide acknowledge that in the majority of cases, something else short of death might relieve the patient's suffering.[2] Thus, physicians on both sides of the debate can approach the patient with the same basic agenda--hear the patient out nonjudgmentally, be sure lines of communication remain open, find out in the greatest of detail what led to the decision that death is preferable to life and start exploring alternatives to death as a means of relieving the patient's suffering.[3]

The physician must obtain from the patient an explanation of what it is about the patient's current health status that led to the request for physician-assisted suicide and what are the patient's unmet needs--physically, emotionally, socially and spiritually. A somewhat harder question to ask may be what are the underlying values that form the basis of the patient's present stance on suicide. The question that should dominate, at least at first, in the physician's mind is: What would it take for this patient to reconsider or rescind the request for assisted death? In the name of both honest disclosure and enhanced communication, it is probably best that this question be stated candidly to the patient.

One of the most difficult questions to ask the patient, and one that likely is unanswerable for the patient, is: What attitude, either for or against suicide assistance, would reassure the patient the most? At least two possibilities must be kept in mind. Some patients might raise suicide as a trial balloon, wondering whether their caregivers are sufficiently committed to try to talk them out of suicide. Physician acquiescence in the suicide request would simply reconfirm and deepen that patient's sense of depression and abandonment.[4] But one must also be alert for what could be called "Quill's paradox"--that a promise to assist suicide at a later time, if things become really extreme, is the "security blanket" the patient needs to better face present adversity and, in all likelihood, to go on to die naturally as the disease takes its course, without ever reopening the request.[2]

To engage in this sort of searching and forthright exploration, the physician must have self-confidence based on a thorough self-examination of one's own values, commitments and fears. An analysis of suicides assisted by Dr. Jack Kevorkian shows that, in many of the cases, individual physicians or the medical care system in general obviously failed in the care of the patient. A careful analysis of the reasons a patient is requesting suicide assistance is therefore likely to reveal, at the least, some ways in which the patient's physician or other physicians have let the patient down. If one is not prepared to accept this possibility, one can hardly ask the right questions or listen carefully for the answers.

Physicians with ambivalent feelings about suicide assistance might be reluctant to engage in a searching dialogue with the patient for fear of having to reveal their own doubts or of being challenged in new and uncomfortable ways. Advocates of suicide assistance are obviously in danger of being so eager to declare an ideologic alliance with the patient that they do an inadequate job of searching for practical alternatives to suicide. And devout opponents are in danger of hating both the sin and the sinner, of allowing their distaste for the practice to turn into judgmentalism or abandonment of this highly needy and vulnerable patient. It may be difficult for a physician opposed to assisted suicide to say, "I am as a matter of conscience unable to provide the specific sort of assistance you are asking, but I promise you that I will stand at your side as long as you are alive and always try as hard as I can to bring you greater comfort."

Two groups in our society that are most steadfastly against physician-assisted suicide are hospice workers and advocates for persons with disabilities. Their opposition should prompt all physicians facing a request for suicide assistance to re-examine their basic attitudes and skills. Far too many of us know too little about the latest hospice techniques, and we need to be watchful to never tell a patient that a symptom cannot be relieved simply because we personally do not have the skills to treat it.

Because hospice represents an interdisciplinary-team model of care, we must also guard against the illusion that we, by ourselves, can supply the same quality and breadth of care as a skilled hospice team. Further, we must accept that we have been brought up in a society that signals in all sorts of ways the devaluation of persons with disabilities. We must be alert for any prejudices that would lead us to agree prematurely that a request for death is "rational" simply because a person is handicapped. And we must be alert to the possibility that a request for death arises more from a lack of adequate social services and support than from the inexorability of the disease itself.

Ira Byock, a national spokesperson for hospice medicine and the author of the book Dying Well: The Prospect of Growth at the End of Life,[5] describes a series of moving vignettes of patients allowed to "die well" with excellent palliative care and emotional support. Some of the patients started out looking like ideal candidates for suicide assistance, certain to suffer miserable and painful deaths if the disease were allowed to unfold. Byock seems to suggest that the best hospice care is the answer for everyone--that no patient would continue to ask for assisted suicide if a hospice team were providing quality care.

While we do not agree with the generalization that hospice care can ever achieve a 100 percent success rate, we share Byock's optimism that something very special can occur when a patient and a physician come together in an open dialogue about impending death. By requesting assistance with suicide, the patient, ironically, has handed the physician a special privilege and gift. The patient has bared his soul in a way that few others will, even in the intimacy of the medical encounter, and has shown the highest possible level of trust in his physician. The physician may now repay that trust by joining the patient in a journey to look squarely in the face of things that frighten away most onlookers--death, dependency and medical "failure."[6] Along that journey may come enhanced comfort, spiritual peace and a better sense of how death can be a sad but fitting final chapter in one's life story.

For this patient-physician journey to have a reasonably happy ending, we must become much more comfortable engaging with our patients in conversation about the deep and ultimate meaning of life and death. Currently, very little in our medical training prepares us to address these issues. There can be few harder tasks in family practice and few tasks as potentially rewarding.


[1.] Supanich B, Brody H, Ogle KS. Palliative care and physician- assisted death. In: Berger A, Levy MH, Portnoy RK, Weissman DE, eds. Principles and practice of supportive oncology. Philadelphia: Lippincott (in press).

[2.] Quill TE. Doctor, I want to die. Will you help me? JAMA 1993;270:870-3.

[3.] Block SD, Billings JA. Patient requests to hasten death: evaluation and management in terminal care. Arch Intern Med 1994;154:2039-47.

[4.] Miles SH. Physicians and their patients' suicides. JAMA 1994; 271:1786-8.

[5.] Byock I. Dying well: the prospect of growth at the end of life. New York: Putnam, 1997.

[6.] Brody H. Assisted death--a compassionate response to a medical failure. N Engl J Med 1992;327:1384-8.

Dr. Brody is a professor of family practice and director of the Center for Ethics and Humanities in the Life Sciences at Michigan State University. He has served as chair of the Committee on Bioethics of the Michigan State Medical Society and as chair of the Michigan Commission on Death and Dying. Dr. Vandekieft is assistant professor of family practice at Michigan State University. He was active in the debate over physician-assisted suicide within the Washington State Academy of Family Physicians.

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