As the Supreme Court recently heard oral arguments regarding the constitutionality of states' prohibitions regarding physician-assisted suicide, it is worth reiterating that in today's cost-conscious health care environment there may exist subtle pressures on the capitated physician to inadvertently overlook occult depression and other painful but treatable conditions and all too readily to assent to the patient's expressed desire while ignoring that it is neither an autonomously expressed nor authentic interest.

As I have previously set forth in my published essays based on my experience as a physician specializing in psychiatry called to the bedside of dying patients, under such conditions it is a tragic fallacy to equate enabling such a patient to die with respecting a patient's liberty interests. Patients can and do change their minds about how to say goodbye to life when their suffering is addressed, and in doing so they leave the physician on the healing side of the healing/killing divide.

Assisted-suicide proponents' proposed safeguards, such as protocols or practice guidelines, are of doubtful value in the emotionally charged, and now increasingly cost-sensitive, crisis ambiance attendant to decisions to end a patient's life in the current third-party-structured health care landscape. In contrast, there is no evidence that to criminalize such decisions will be helpful in creating the atmosphere of deliberation, comfort, and decency that dying patients and their caregivers have a right to have the state help protect.

A "bright line" that leaves the relevant health care corporation and physician open to reasonable state and individual civil and administrative remedies--although protected from criminal sanctions--may be the wisest public policy position for protecting both state and personal liberty interests, even amid potentially conflicting corporate health, professional, and patient priorities.

Harold J. Bursztajn, M.D.
Cambridge, Mass.

(Psychiatric News, April 18, 1997)