December 18, 1998

By Samuel Greenberg, M.D.

The professional landscape of medicine is changing. In all parts of the country physicians receive requests from patients for aid in dying and respond to a significant number of them. Since these actions are illegal everywhere in the U.S. but Oregon, they avoid publicity and rarely consult other physicians. Most feel they relieved suffering and did the right thing, but many fear possible prosecution. This is a sad state of affairs.

APA does not have an official position on physician-assisted suicide (PAS) but seems inclined to go along with the American Medical Association, which strongly opposes it. Most medical organizations oppose it, but individual physicians are about equally divided, for and against.

In my opinion, APA should have an independent position on PAS. Psychiatrists know as much about human character and motivation as any group and should speak out on this contentious issue.

The issue is complicated, but the central problem is an ethical one. Does self-determination include the right of the terminally ill to ask for help in dying when their suffering becomes unbearable? Those opposed to this option feel that PAS is "self- determination running amok," is bad for the medical profession, and threatens respect for human life.

Last year the U.S. Supreme Court ruled that the privacy and due process rights of the Constitution's 14th Amendment do not encompass the right to receive aid in dying. The issue was left to be decided by the legislatures of the various states.

Opponents of PAS maintain that this is a radical step and contrary to Hippocratic tradition that has guided physicians for centuries. They argue that it distorts the image of the medical profession: doctors are healers, preservers of life, dedicated to the cure of disease.

Furthermore, if patients receive good palliative care and their depression is treated adequately, they will no longer seek to end their lives. What is acceptable, in some instances, is stopping life-support systems. This is "letting die" and not "killing"; the disease-not the doctor-ends the patient's life. PAS opponents concede that there are tragic cases that seem to justify PAS, but insist that these rare cases and should not determine policy.

Those who favor PAS insist that there are quite a few patients whose symptoms are not controlled even by the best care-patients who are bedridden, totally dependent, have no control over bodily functions, and nothing left of the components that make life meaningful.

In addition, from an ethical standpoint there is little difference between stopping life support and taking part in PAS. Many doctors rationalize that the two are quite different, but the reality is that they are only comfortable with the more passive role.

The essential element is the relationship between patient and physician when the two reach an understanding about the wisdom of further treatment. The patient can say "no" at any time up to the very end.

Both opponents and proponents of PAS point to the Netherlands, where euthanasia has been permitted since 1973. Psychiatrists will not be surprised that the same data are interpreted quite differently by the two sides.

The majority of Dutch physicians approve of the policy and believe patients receive good and compassionate care. They feel that turning off life support and allowing the patient to die a lingering death, as happens in this country, is barbaric. Those opposed to the Dutch practice point to abuses and instances in which the guidelines were not followed.

Oregon's Death with Dignity Act has been operative since November 1997, and 10 patients have applied for PAS in that time. There are practical problems involving pharmacists, nurses, and hospice, but so far, all the guidelines have been followed and no abuses reported.

There are good people on both sides of the issue. They include clinicians, ethicists, lawyers, clergy, and prominent laypersons. Some religious groups feel very strongly that PAS is morally wrong for everyone. Advocates of PAS hold with Professor Lawrence Tribe of Harvard Law School that: "When facing imminent and inevitable death, a person would have some voice in the way the final chapter of his life unfold." Dr. Alan Stone, professor of psychiatry and law, also at Harvard, opposes legalizing PAS. However, he is quoted also as saying that he feels no obligation to suffer needlessly when the medical situation is hopeless. This may indicate a pragmatic solution: at times, bend the law a little.

The remarkable advances of medical technology have prolonged the process of dying and presented physicians with ethical dilemmas that they cannot avoid. I hope that APA does not avoid this troublesome issue, but faces it squarely and comes up with some guidelines or principles that will give support and comfort to clinicians at the bedside of terminally ill patients. If APA doesn't provide this expert guidance, who will?

Dr. Greenberg is clinical professor in psychiatry at the University of Florida in Gainesville.