Euthanasia and assisted suicide: a family practice perspective

Author: Thomas J. Gates
Date: May 15, 1997

Since the passage of Oregon's Death With Dignity Act by voter initiative in November 1994, the campaign to legalize euthanasia and physician-assisted suicide has gained considerable momentum. Indeed, recent events give the impression of a headlong rush toward legalization. Dr. Jack Kevorkian continues to assist in suicides, and three separate juries have been unwilling to convict him. In early 1996, two federal Courts of Appeals overturned Washington and New York state laws that prohibit physician-assisted suicide; both courts asserted a new constitutional right to assisted suicide.[1] Both cases were appealed to the U.S. Supreme Court, which heard oral arguments on January 8, 1997, and is expected to issue its ruling by mid-1997.

The Supreme Court review has generated widespread publicity and debate in both the lay and medical press.[2,3] As one commentator observed, "This is a highly contentious issue, with good people and strong arguments on both sides."[2]

This essay discusses the controversies surrounding the dual issues of euthanasia and assisted suicide, emphasizing the arguments that prompted the Congress of Delegates of the American Academy of Family Physicians at its annual meeting in October 1996 to reaffirm its opposition to the legalization of euthanasia and assisted suicide.

Historical Perspective

With its roots in both the Hippocratic tradition and the Judeo-Christian ethic of the sanctity of life, Western medicine has long opposed the practice of euthanasia. However, the controversy over euthanasia is not new. Beginning about 1870 (after the introduction of chloroform and ether) and continuing until the 1930s, there was widespread public debate over euthanasia in both Great Britain and the United States, leading to two serious proposals, one in Ohio in 1906 and the other in Great Britain in 1936, for the legalization of euthanasia.[4] However, the eventual disclosure of grievous crimes during the Nazi regime in Germany led to a virtual moratorium on further discussion.[5]

The modern debate on euthanasia can be traced to a 1973 court case in the Netherlands, when a Dutch physician was tried for giving a lethal injection to her debilitated mother. The physician was convicted of murder, but given only a one-week suspended sentence. Subsequently, the Royal Dutch Medical Society proposed guidelines for physician participation in voluntary euthanasia, and the state agreed not to prosecute if these were followed. The guidelines (given statutory force in 1993) specify that the request for euthanasia must be voluntary, the patient must be experiencing suffering that cannot be relieved by any means other than death, and a consulting physician must agree that euthanasia is warranted.[6] Although euthanasia and assisted suicide remain technically illegal in the Netherlands, an estimated 3,600 cases occurred in 1995, representing approximately 3 percent of all deaths.[7,8] Sixty-two percent of general practitioners in the Netherlands report that they have participated in euthanasia.[9] The majority of cases take place in the home, presided over by the patient's general practitioner.[10]

In this country, public debate was stimulated by two case reports published in the medical literature--one in a 1988 issue of JAMA and the other in a 1991 issue of New England Journal of Medicine.[11,12] Dr. Kevorkian began to publicly assist suicides in 1990. The following year, Derek Humphry's book Final Exit[13] sold over 500,000 copies, demonstrating widespread public interest in the issue. Voter initiatives to legalize euthanasia narrowly failed in Washington in 1991 and in California in 1992, before the Oregon initiative (which is restricted to physician-assisted suicide) passed in 1994.[14]

Arguments For and Against Euthanasia

In the contemporary debate over legalization of euthanasia and assisted suicide, proponents and opponents disagree on at least four controversial issues: the nature of autonomy, the role of beneficence, the distinction between active and passive euthanasia, and the public and social implications of legalization.[6]

Because individual self-determination is so highly valued in our legal and cultural tradition, the attempt to justify euthanasia usually starts with an appeal to the principle of autonomy. Proponents argue that decisions about the end of life are among the most intimate and personal issues that anyone will ever face, that no one can possibly be more qualified than the individual person to make such decisions, and that the individual therefore ought to have the freedom to decide when the burden of further suffering outweighs the benefits of continued life.[6,15]

Opponents of euthanasia argue that, whatever the status of autonomy, it is not sufficient to override absolute prohibitions against the taking of a life (or at least the taking of a life by physicians).[16] Others point out that respect for autonomy, rightly understood, demands a higher standard than simply acceding to the subjective desires of the individual. They contend that it is self-contradictory to appeal to autonomy as the highest ethical principle, in order to justify an act that abolishes life, the necessary condition of all future autonomy.[6,17,18] Furthermore, if the right to assisted death is grounded in the principle of autonomy, there is no logical reason for restricting these practices to the terminally ill. If self-determination is the sole consideration, then we have no rational basis on which to question the motive behind any autonomous request for assisted suicide, such as a request from a patient who is chronically but not terminally ill, or even a request from a patient whose suffering is psychologic rather than physical.[18-20]

Beneficence, in the context of the euthanasia debate, involves the physician's duty to relieve suffering, with proponents arguing that death from euthanasia is sometimes necessary to prevent unbearable pain.[15,21] All family physicians have seen cases in which death, when it finally comes, can only be seen as a blessing. Yet many of us are troubled by the notion that the way to deal with suffering is to do away with the sufferer. Such an approach would also seem contrary to the fundamental premise of hospice care, which holds that even in the midst of tragic terminal illness, there is value in "suffering through" the dying process, that it should not be artificially cut short. Furthermore, if relief of suffering is our primary concern, it will be difficult to restrict these practices to only competent, terminally ill patients. Suffering is ubiquitous, and eventually some will argue that handicapped, demented and mentally retarded persons deserve the same "rights" (exercised through surrogates) as the terminally ill.[18,19]

The third area of controversy is the distinction between active and passive euthanasia, between killing and allowing to die. Proponents of legalization argue that there is no important moral distinction between the two practices; because we allow one, we ought logically to allow the other.[15,22] Opponents argue that to equate the two practices is to confuse causality with culpability; when life support is withdrawn, the cause of death is the underlying disease, not the actions of the physician.[19] Regardless of the technical arguments, the two practices would be emotionally very different for most practicing physicians. When we decide with a patient or family that the time has come to withdraw life-support measures and allow a patient to die, it represents a humble recognition of the limits of medicine and a submission to forces beyond our control. By contrast, in administering a lethal injection, even to a consenting patient, we seem to overstep our bounds, as though wresting from nature something that is not properly ours.[23]

The final area of controversy has to do with the social and public consequences of any change in the legal status of euthanasia. Proponents argue that euthanasia and assisted suicide already occur; legalizing them would allow safeguards and public accountability which are now lacking.[21] Opponents counter that, even if these practices seem justified in individual cases, the social consequences of legalization would be profoundly negative. This often involves some variation of the "slippery slope" argument--once these practices are legalized, it will be impossible to restrict them to competent, terminally ill patients.[18,19] This view is given some credence by the experience of the Netherlands, where it has been claimed that in as many as 40 percent of euthanasia cases, the published guidelines are not followed and euthanasia is performed either nonvoluntarily or involuntarily.[6,7,9,24,25]

[31.] Brody H. The physician's role in determining futility. J Am Geriatr Soc 1994;42:875-8.

[32.] Callahan D. The troubled dream of life. New York: Simon and Schuster, 1993.

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

Thomas J. Gates, M.D., is associate director of the Lancaster (Pa.) General Hospital family practice residency program. He practiced for eight years in New Hampshire and three years in the Republic of Kenya before joining the faculty at Lancaster in 1995. Dr. Gates is a graduate of Harvard Medical School, Boston, and completed a family practice residency at the University of Utah in Salt Lake City.

The author thanks Keith Dobyns, D.O., Jeffrey Kirchner, D.O., Nikitas Zervanos, M.D., Murray Wagoner, Ph.D., Richard Davis, Ph.D. and Elizabeth Gates, MEd. for their assistance and encouragement in the preparation of this paper.

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