Assisted suicide and Euthanasia: the illusion and façade

Why are the long-standing ethics of our health care system suddenly so threatened? Maybe it is all about money, or is it? HMO's already induce physicians to keep costs low, using a combination of financial rewards or punishments, which create in my opinion an implicit conflict of interest between doctors and some patients. After the Supreme Court decision in 1997 states took it upon themselves to change the terrain re: legalizing physician-assisted suicide. Is it merely coincidence that the first state to approve a program of explicit health care rationing is also the first state to approve physician-assisted suicide? Maybe it is courage and not coincidence, but at the same time, it is interesting to find the first operational assisted suicide law so plainly juxtaposed against "the first openly acknowledged system of health care rationing." I was talking about Oregon. The physician assisted suicide ballot initiative in Maine was not approved.    

A study soon to be published in JAMA (Journal of the American Medical Association) indicates that interest in euthanasia and PAS (physician assisted suicide) among dying patients is more often related to psychological distress than physical symptoms. This study was done with private funding from the Commonwealth Fund and the Nathan Cummings Foundation. According to the study about one in ten terminally ill patients said they seriously considered using physician-assisted suicide or euthanasia to end their own lives, and "just a fraction of these attempted to act on their thoughts." The findings point out that despite the highly charged public debate surrounding PAS and euthanasia, the majority of dying patients would not consider this option for themselves. As I pointed out in a previous Commentary many people change their minds and this was confirmed in the Commonwealth/Cummings study. The research is the first major assessment of terminally ill patients' attitudes about assisted suicide and euthanasia. The authors of this study caution physicians who receive requests for euthanasia or PAS to think first about depression and "other psychological stressors."

When I began to investigate Oregon's first year and the claim that "no abuses were reported" my spontaneous reaction was "Wow! No kidding?" Wouldn't common sense dictate the greatest care by proponents to put their best foot forward, to pick as PAS candidates those who would most easily pass public inspection? Would any physician be foolish enough to step forward and confess violating the law? Since there is no statutory requirement that abuses be reported by doctors or lay people, nor strong incentives to do so, why should we expect to hear about them?

The debate about guidelines continues without resolution. In the Netherlands where euthanasia and physician assisted suicide were decriminalized guidelines were established but very little can be learned from the Dutch experience. The force and legality of their guidelines are questionable. Many physicians do not follow the guidelines and high rates of noncompliance have been reported. This would be different I'm sure were the practice completely legal. Perhaps the harshest indictment of efforts to construct guidelines comes from Callahan and White who dismiss all efforts at constructing guidelines as "an elaborate regulatory façade concealing a poverty of potential for actual enforcement." The main reason for thinking that the slope around physician-assisted suicide might be too slippery even for the most carefully crafted guidelines, is that the presumptions behind the guidelines are inherently slippery in ways that no amount of regulatory precision can fix. Doctor patient relationships are private and sacred and cannot be monitored, and what cannot be moderated cannot be regulated. Callahan and White are very exacting in their long (83) pages Univ. of Richmond Law article "the Legalization of Physician Assisted Suicide: Creating a Regulatory Potemkin Village." The title implies that a façade would be erected with the regulations and guidelines, but behind the façade or illusion of regulation there would be nothing at all.

Perhaps PAS (physician assisted suicide) is not, as many like to put it, simply a logical extension of the physician's duty to relieve pain and suffering, an old obligation in a new garment. Maybe PAS appeals to those who must be in control. It may turn out that catering to this compulsion for control represents far greater abuse than a failure to adhere to the law. A study in the New England Journal of Medicine (February 24, 2000) about physicians' experiences with the Oregon Death with Dignity Act pointed out that 46% "of the patients for whom substantive interventions were made, changed their minds about assisted suicide." The conclusion and data suggest that in Oregon physicians grant about 1 in 6 requests for a prescription for a lethal medication and that 1 in 10 actually culminate in suicide. Substantive palliative interventions (pain relieving) lead some - but not all - patients to change their minds.

Society and the media have focused primarily on the importance of personal autonomy in the context of the "right to die", little attention has been paid to concurrent efforts to disregard autonomy when a dying or disabled person wants care that bioethicists, moral philosophers, doctors, and above all managed-care health insurance executives deem "futile'. Futile Care Theory goes something like this. When a patient reaches a certain "predefined stage of illness, or injury, any further treatment other than comfort care shall be deemed "futile" and shall therefore be withheld, regardless of the desires of the patient or family." The personal values and morals of the patient are no longer relevant. End of story, and often, end of life. Physicians must place the patients' interests above the cost considerations of third party payers or their own monetary benefit.

In his new book "The Culture of Death: the Assault on Medical Ethics in America" (dedicated to Ralph Nader) Wesley J. Smith devotes many pages to Futile Care Theory and its implications .He says that the serious implications of rationing were "revealed in 1994 by Robert M. Vearch, who wrote apocalyptically, 'the era of health care rationing is upon us!' He urged rationing via global budgeting in which an administrator of a state health plan, a hospital, a specific hospital department, or a health maintenance organization would be given a fixed pile of money. The amount would not be enough for every physician to do everything for every patient. How would this money be allocated? By "the community," guided by "religious and philosophical traditions" - in other words by Bioethicists. The first casualty would be the Hippocratic Ethic, which he (Robert M. Veatch) urges we discard because it "specifies in its most crucial central principle that the individual physician should benefit the patient according to the physician's ability and judgment." Would you trust a physician with your very life? Think about this very carefully in the light of Futile Care Theory.

Do older folks have a duty to die because of the financial and emotional burdens of caring for the elderly, disabled, and chronically ill? The premier advocate for the "duty to die" is an East Tennessee University philosophy professor, John Hardwig. Hardwig takes the "deconstruction of the Hippocratic tradition to a new level, asserting that it is sometimes the moral thing to do for a physician to sacrifice the interests of his or her patients to those of non-patients—specifically to those of the other members of the family." In my humble opinion John Hardwig is a loose canon, a very dangerous individual who refuses to see that the problem is all about money, and that we do not live in an altruistic country.

One doctor wrote on a listserv "The reason I do not have a living will or any other document is that I believe the wind has shifted in the wrong direction. I believe there is more of a chance that that paper will hurt me (end my life prematurely) then help me. Of course I am fortunate enough to have loving people at my side. HMO's and others use that paper as a budget balancer." How many of us are as fortunate as that doctor? What are the larger societal issues involved when money and health care allocation collide?