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he final house call. A nagging back pain would not go away. It was diagnosed as metastatic cancer in the bones. At first he was determined to fight, with all that modern medicine could offer, and for a while things were better. But on the afternoon he requested the house call, they were much worse. His pain required large doses of medication that dulled his intellect, and he was barely able to get off the sofa to greet his physician.
He told his doctor what was on his mind. He did not want the indignity of physically and mentally failing in front of his wife, family, and friends. All that lay ahead were weeks of increasing distress before he died. He wanted help in ending his life on his own terms. His physician agreed to help.
Physician and patient wrestled with the details: the medication; the possible failure of the suicide and what might follow; when to act; who should be present; and the possibility of the medical examiner's finding out about the cause of death. The patient got his wish and died peacefully, and, since the secret was kept, the physician was not prosecuted. Nevertheless, the process and the violation of laws exacted a heavy emotional toll from both individuals.
There had been many questions and problems, but no accepted standards or guidelines. Each question had been addressed in an environment of legal uncertainty, and neither the patient nor the physician felt able to consult with anyone else because of these uncertainties. Their anxieties had come close to precluding any action on the part of the physician; had they done so, the patient would not have had his wish to end life on his own terms. He instead would have suffered the indignities and increasing distress he so wanted to avoid.
Public issues vary in prominence, and physician-assisted suicide (PAS) seems now to be at the forefront. Until a few years ago, most people thought about this issue only when newspapers or television reported on "mercy-killing." It was broadly assumed that doctors on occasion quietly acceded to a patient's wish to have death accelerated, but little was said. Only rarely would a prosecutor pursue someone who "aided and abetted" a suicide, and these infrequent prosecutions did not result in convictions.
The arrival on the scene of Dr. Jack Kevorkian changed this state of affairs. By repeatedly and openly assisting patients who wanted to kill themselves, and by asserting that he was right to do so and intended to continue, Kevorkian forced this issue on public officials and the public. It was clear he had hit a vulnerable and sensitive nerve. He became a controversial focus of litigation in Michigan, although he has so far won acquittal. Physician-assisted suicide narrowly won approval from voters in a 1994 initiative in Oregon, and lost in close votes in California and Washington. Most recently, the constitutionality of states' banning physician-assisted suicide was challenged by two federal courts of appeal and was argued before the U.S. Supreme Court on January 8, 1997; a ruling is expected this spring.
Too much of the debate has been in absolute terms, without recognition that what is often involved is the balancing of risks. The arguments for permitting physician assistance have been based largely on autonomy--the right to control one's own body--and draw strength from the Supreme Court's decision in the abortion cases and the Cruzan case, in which the court upheld the right to refuse life-prolonging treatment. But opponents argue that there is too great a danger that families or hospitals will pressure patients to agree to suicide and that it is too dangerous a precedent. Even proponents of physician-assisted suicide recognize the risks of an unwise or pressured decision in particular cases. And one cannot dismiss lightly the unease many doctors feel when they, who are trained to save life, assist in its termination.
We believe that PAS should be possible for certain individuals within a system with the following protections against an unwise or pressured decision.
There should remain no other way to relieve intolerable suffering, and all else must have been done with respect to basic therapy. The patient must have had the best pain control.
The patient must be competent to make the decision.
The decision must be a completely voluntary action that has been requested by the patient on more than one occasion.
The patient must be fully informed as to the nature of his condition, its prognosis, and all possible options for treatment of the disease.
A patient who requests assistance in suicide must be examined by a doctor other than the one to whom the request was made (to confirm the nature, prognosis, and seriousness of the illness) and by a psychiatrist, psychologist, or psychiatric social worker (to determine that the patient is not clinically depressed and is free from undue influence). The risks of abuse are heightened by the present situation, in which doctors acting on their own judgment--perhaps with private encouragement or pressure from family members--accede to a patient's request with no outside review.
Doctors who assist in a suicide must state in written records, reviewable by health officials, the circumstances that led them to assist.
Of course, such protections are not absolute guaranties that the patient's wishes will not be overborne, but in a situation in which the choices on both sides are daunting, it seems reasonable to us to give fair weight to what it means to force someone to live a life that has become intolerable (see Francis D. Moore, "Prolonging Life: Permitting Life to End," July-August 1995, page 46). And, if preserving life is our concern, we must recognize the risk that patients who fear they will lose the ability to kill themselves as their illness progresses may choose suicide prematurely.
The most important reason PAS is not more widely practiced now is that there are major risks for the physician, some only perceived and some real. These risks depend on the varying laws in the different states and whether or not the act is secret. If assistance is given in secrecy, the risks are very minimal, even in states in which such action is clearly illegal. Legal jeopardy for the physician then depends on discovery and an aggressive district attorney, and the vast majority of acts of PAS are in fact not discovered and not prosecuted. Many physicians, however, perceive the risks to be high and therefore decline to assist, even when they would otherwise be supportive. It seems to us unfortunate to drive decision-making by physicians--and also frequently by patients--underground, and to have the patient's ability to obtain relief from an intolerable situation depend on the physician's estimate of the risks they both face.
Legalization of physician-assisted suicide can come about through the courts or through state legislative action. Achieving change by court decisions has a disadvantage. The best procedures for developing safeguards are those to which courts do not have easy recourse--public hearings at which a variety of experts and nonexperts can be heard. The views of the people are particularly important; in states where the issue has faced a general referendum, close votes have followed spirited campaigns. If the Supreme Court does not recognize a right to physician-assisted suicide in its decision this spring, we hope it will at least leave a framework for continuation of the current public debate and the legislative process in the states.
Risks of patient abuse or physician legal jeopardy would be markedly reduced if PAS took place according to agreed-upon standards and procedures codified in law and regulation--a remedy for today's situation in which PAS is necessarily secretive, does not conform with any set rules, and generally occurs without consultation.
Such codification by statute is highly desirable. Assisted suicide does occur frequently--regardless of illegality--but the emotional cost of that illegality is high. The answer is not to drive PAS farther underground (that will fail), but to make it an open act that conforms with standards of good medical practice, modulated by guidelines that apply to any crucial medical decision. The patient who is suffering intolerably will then have the freedom to choose during that final house call.
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