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Two views published online January 19 in JAMA (Journal of the American Association) illustrate the moral and ethical struggle of the medical profession when terminally ill patients want their physicians to help them die.
Prescribing self-administered medication intended to hasten death is now legal in Oregon, Vermont, Washington, Montana, and California. Prescribing lethal medication given by a clinician at patients' request is legal in Belgium, Colombia, Canada, Luxemburg, and the Netherlands.
Yes: Help Patients Keep Control
In their viewpoint article, Timothy E. Quill, MD, from the Palliative Care Division, Department of Medicine, University of Rochester Medical Center in New York, and colleagues say it should be an option in the continuum of care.
"Patients with serious illness wish to have control over their own bodies, their own lives, and concern about future physical and psychosocial distress. Some view potential access to physician-assisted death as the best option to address these concerns," they write.
Being willing to explore the options with patients is important for the physician–patient relationship. Many more patients are interested in the possibility and find comfort in the thought of a back-up than will actually use the prescription, their research finds.
The authors cite numbers from Oregon, the first state to legalize the practice. "In Oregon, where physician-assisted death has been legal for 18 years, 1 in 6 terminally ill patients talks with their families, 1 in 50 talks with their physician, and only 1 in 500 directly accesses this option," they write.
Slippery slope concerns and worries about coercion, the authors say, have not been borne out in the states where it has been legal.
Assessing the patient's emotional state and determining personal history and values with the patient and family are essential when considering the request, and the authors include guides in the paper for questions physicians can ask.
Still, the authors recognize the boundaries physicians wrestle with and note that those who cannot morally participate should help patients find an alternative approach that may include finding another physician.
No: It Goes Against Basic Oath
In their viewpoint article, Y. Tony Yang, ScD, LLM, MPH, from the Department of Health Administration and Policy, George Mason University, Fairfax, Virginia, and Farr A. Curlin, MD, from the Trent Center for Bioethics, Humanities & History of Medicine, Duke University, Durham, North Carolina, say it should never be an option.
Arguments that physicians should follow patients' wishes with respect to hastening death undercut the essential role of the physician, they say.
"If the medical profession accepts physician-assisted suicide, it will be declaring decisively that 'physicians' are mere providers of services, to be guided only by the desires of the individual patient, the will of the state or other third parties, and what the law allows."
They argue that patients already have the right to refuse life-sustaining treatment and the liberty to end their lives in ways that do not involve physicians.
It is also an issue of trust, they say, because since the time of Hippocrates, physicians are sworn only to heal, not to harm.
"That is why Doctors Without Borders treats injured Taliban soldiers. It is why physicians have refused to participate in capital punishment, or to be active combatants, or to cooperate with torture," Dr Yang and Dr Curlin write.
They urge physicians to fight legalization of the practice and refuse to participate in it.
Terminology Fuels Conflict
Some of the controversy comes in referring to the practice as suicide, some say, as calling it suicide suggests mental illness and a self-destructive action.
Arthur Caplan, PhD, director, Division of Medical Ethics, New York University Langone Medical Center in New York City, agrees, saying "hastening death" is better terminology. "I think hastening inevitable death has little to do with suicide. Using that language is spin and not accurate," he told Medscape Medical News.
One strength of the argument from Dr Quill and colleagues, he said, is that it notes the lack of evidence that abuses or coercion have happened in states where it is legal.
"Almost no one in these states wishes to overturn their laws. This is not a theoretical debating point: the facts and experience bolster the pro–assisted dying side."
In the argument by Dr Yang and Dr Curlin, he said, "The notion that doctors should not kill is wrong. Doctors must allow patients to die. If patients who are terminal wish to die without hospice, etc, then they should have the ability to get and take medicine that hastens their death. But [if] they choose to take pills not given by doctor, that is only providing the means, not killing. The argument about killing does not hold."
Dr Quill reports receiving honoraria from various institutions for speaking about end-of-life decision-making and the topic of physician-assisted death. Dr Caplan has served as a director, officer, partner, employee, adviser, consultant, or trustee for Johnson & Johnson's Panel for Compassionate Drug Use (unpaid position) and is a contributing author and adviser for Medscape.
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