Tuesday, November 11, 2008

Landscape Evolves for Assisted Suicide

An article written by Jane Gross and published in the New York Times examines the landscape or the changes in relation to the issue of assisted suicide since 1991 when Dr. Timothy Quill published an account of his role in the death of one of his patients.

The article makes some very interesting points that need to be examined further if we are to effectively respond to future initiatives to legalize assisted suicide.

The article describes the conditions for assisted suicide in Oregon and in the Washington statute. The article states:
State residents requesting this assistance must be mentally competent, have six months or less to live according to two physicians, wait 15 days after their request and then repeat that request orally and in writing. They must be capable of administering medication themselves and agree to counseling if their physicians request it. The patients also must be told of alternatives.

Dr. Timothy Quill, who is the director of the palliative care program at the University of Rochester then states:
these options have gained acceptance over the past decade.

The article then comments on the 1997 Supreme Court Decision:
In 1997, the Supreme Court ruled that there was no constitutional right to physician-assisted suicide and upheld a prohibition against it. But in the ruling, the justices conceded that terminally ill patients were entitled to aggressive pain management, even if opiates or barbiturates had the “double effect” of hastening death.

This statement concerning the "double effect" principle is inappropriately worded because the use of opiates or barbituates for the aggressive management of pain when it is not intended to cause death, and therefore when properly administered, should not be associated with assisted suicide. A physician should not consider the "double effect" principle as an open window to euthanasia because that is an abuse of its proper use.

The article then quotes Quill concerning that options that should exist before one considers the "last resort" of assisted suicide. He states:
First and foremost, Dr. Quill and others say, all terminally ill patients should have access to palliative care, both to relieve pain and other symptoms and to provide emotional support to patients and families.

This statement begs the question, that is, when palliative care is not accessible for all people needing pain and symptom management, then is assisted suicide represents an abuse of the vulnerable person who is not actually seeking assisted suicide but rather relief from their suffering.

Quill recommends that a palliative care consultation be mandatory before anyone considers a "last resort" measure.

Quill suggests that other options be made known to the patient.
Pain management so aggressive that it may well hasten death, although that is not the primary intention. (This is the doctrine of “double effect.”)

Invoking a patient’s right to forgo life-sustaining therapies or discontinue them.

Voluntarily stopping eating and drinking. (Dr. Quill believes this is a “more morally complex” choice because over the last decade the practice has expanded beyond those with end-stage cancer or Alzheimer’s disease — who often lose interest in food or forget how to eat and drink — to people who are not “actively dying” but nevertheless have had enough of disability or dependence).

Sedation to the point of unconsciousness. (Although it was endorsed this year by a panel of the American Medical Association, Dr. Quill called it the “last, last resort.”)

Quill should acknowledge that people who voluntarily stop eating or drinking when they are not "actively dying" are often people who are suffering from undiagnosed clinical depression. Physicians should uphold a pledge that they will "do no harm" which should include protecting the vulnerable.

The primary concern around the sedation of a person to the point of unconsciousness is that usually sedation is done to intentional dehydrate of the person. It is sometimes necessary to sedate a person to the point of unconsciousness in order to relieve their neuropathic pain, but to intentionally dehydrate a person, who is not otherwise dying, is euthanasia by dehydration.

The article is correct when it states that the landscape has changed in relation to assisted suicide. What has not changed is the effect assisted suicide has on the attitude and treatment that is offered to people at the most vulnerable time of their life.

The question whether we need to strive for a culture that solves its difficult human problems by caring for the patient or a culure that solves its most difficult human problems by killing the patient?

I choose to care.

Link to the article on the New York Times:
http://www.nytimes.com/2008/11/11/health/11age.html?_r=1&oref=slogin

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