Who Makes the Call?

by Hamza Sheikh

I want to click the off switch.
And if I can no longer choose
I want someone who loves me
there, not a doctor with forty
patients and his morality to keep
me sort of, kind of alive or sort
of undead. Why are we more
rational and kinder to our pets
than with ourselves or our parents?
Death is not the worst thing;
denying it can be.
Marge Piercy

Death is not the greatest of evils; it is worse to want to die, and not be able to.

I will give no deadly medicine to any one if asked, nor suggest any such counsel.
The Hippocratic Oath

 He will live badly who does not know how to die well.

“If I go through with it I die, if I don’t go through with it, my choice is essentially to suffer and to inflict suffering on my family and then die. Possibly in a way that is more stressful and painful than this way.1 With Beethoven’s 9th playing in the background, Craig Ewert, who suffered from motor neuron disease or amytrophic lateral sclerosis (ALS), ended his life in Switzerland in 2006 by drinking a lethal dose of barbiturates, prescribed by his physician. His death, a case of “physician-assisted suicide”, was first of its kind to be broadcast worldwide in the documentary film The Suicide Tourist, shown in 2007 on PBS Frontline. Ewert’s televised death sparked worldwide debate over the morality of physician-assisted suicide. While some celebrated his death to mark an end to his suffering and pain, others were outraged by the act. The organization “Care Not Kill” argued that proper palliative care, along with support of loved ones, would have lessened his suffering and added value to his life. Ewert, however, departed from the world with a death that he longed for. The central ethical argument about his death revolves around the question of whether to respect individual autonomy over the manner and timing of death. Advocates of physician-assisted suicide raise slogans such as “My Life, My Death, My Choice”.  John Humphrys, author of The Welcome Visitor: Living Well, Dying Well, poses a question to the reader, “Why should we feel guilt at the end of suffering? Why should death not be a welcome visitor?”2

Physician-assisted suicide is the act of a physician helping a patient end his or her life in a way that relieves suffering and pain. This practice is currently legal in the U.S. states of Oregon and Washington, as well as Belgium, the Netherlands and Switzerland. Unlike voluntary euthanasia, in physician-assisted suicide, the doctor does not inject a lethal dose of a medication into the patient but rather provides a prescription for such a medication, which the patient may or may not decide to use. Under the Oregon Death with Dignity Act, for example, before the physician prescribes lethal medication, however, the patient must meet a specific set of guidelines.  He or she must make an initial oral request, a written request, and a second oral request for physician-assisted suicide during a fifteen-day waiting period. The attending physician must determine that the patient has a terminal illness, is mentally capable, and has made the request voluntarily. The patient must receive information from the physician about both diagnosis and prognosis, the potential risks and probable results of taking the medication, and alternatives such as hospice care and pain control. The patient must also consult a second physician to confirm the diagnosis and to affirm that he or she is mentally capable and is making an informed and voluntary decision. If either doctor suspects that the patient is suffering from impaired judgment, a referral for counseling must be made. Some may view these guidelines as overly restrictive or unreasonable, while others may see them as a necessary and just set of precautions.  Ewert’s death resulted in heated debates among public policy makers, religious groups, government officials, health care professionals, activist groups and individuals. The controversy around physician-assisted suicide still continues and there is as yet no general consensus over the issue.

In October 1997, Oregon became the first state in the U.S. to legalize physician-assisted suicide. The Oregon Death with Dignity Act permits a state resident who is terminally ill (expected to die within six months), at least eighteen years of age, and capable of making and communicating health-care decisions to “obtain a prescription for medication to end his or her life in a humane and dignified manner.”3 The Catholic Church and other faith-based pro-life groups condemned the Oregon act by stating that no human has the right to play God and if physician-assisted suicide is legal, then we will have set foot on a very slippery slope that could lead to support for various forms of euthanasia. Opponents of physician-assisted suicide contend that some elders who feel that they no longer enjoy the quality of life they once had and are a burden to their caretakers will feel pressured into seeking this kind of help. In addition, some older people who live alone often describe feeling isolated; these feelings of isolation and depression may lead some to seek to end their own lives with physician assistance. Given their sense of isolation and difficulties with medical treatment and long term care, it is not surprising, opponents contend, that some people who become seriously ill and dependent on others might decide that they would be better off dead.

However, Candace Cummins Gauthier, author of “Moral Responsibility and Respect for Autonomy,” responds to the fear of the “slippery slope” by arguing that the law provides critical safeguards4. The only individuals who legally qualify for physician assistance with suicide are those terminal patients who are capable of making health-care decisions, are fully informed, and have made repeated requests. Allowing terminally ill patients to obtain prescriptions to end their lives at a time and in a manner of their own choosing seems no different from allowing patients to decide when and how they will die by refusing life-sustaining medical technology. Under the legalized systems that now exist, as long as two physicians are involved, making sure that the patient is fully informed, is not suffering from impaired judgment, and is not being coerced or pressured in any way, it is unlikely that allowing physician-assisted suicide will victimize vulnerable patients.

Voicing similar arguments, Rae Langton, a professor of philosophy at the Massachusetts Institute of Technology, supports physician-assisted suicideAccording to Professor Langton, the idea of the slippery slope is not unique to the issue of physician-assisted suicide; it arises in every ethical argument. “There isn’t always a clear line between permissibility and non permissibility. ‘Slippery slope’ is not enough proof to reject physician- assisted suicide,” Langton states5. She claims that the ethical problem of slippery slope can be solved if there is proper screening of patients. This would involve a collaboration of social workers and medical staff, who involve themselves in the patient’s life and try to understand what the patient really wants and why. She believes, however, that if the idea of physician-assisted suicide goes against a doctor’s conscience, he or she should not lend such assistance to a terminal patient.

On the other side, prolife activists believe that the validity of a terminally ill patient’s decision is often questionable since the person may be suffering from mental confusion and depression as a result of significant pain and therefore is not capable of competent, genuine and voluntary consent. In response, advocates of physician-assisted suicide contend that a solution to this problem is an advanced declaration that will allow an individual to make a decision before actually having suffered the illness. But can one really be certain if he or she would be better off dead without having experienced the illness?

The principle of beneficence requires that physicians do no harm to their patients. One might interpret this principle as prohibiting physician-assisted suicide. However, one could also argue that, in the case of physician-assisted suicide, death is not harmful to the terminal patient who is suffering and asking for release. New York Times health columnist Jane E. Brody, quoting Dr. Timothy Quill of the University of Rochester School of Medicine, writes that “knowing last-resort options are available ‘is very important to those who fear being trapped in a life filled with suffering without the prospect of a timely escape.’” 6 Justified by beneficence, providing this kind of help promotes the patient’s good by offering the security of knowing that when the physical and emotional effects of an illness become unbearable, the patient has a way to end his life with dignity. Physicians willing to do this are also preventing the harm of future suffering that will serve no good purpose, since the patient has an incurable illness.

Also, statistics from Oregon indicate that physician-assisted suicide is not used very often. Annual reports indicate that 292 patients died after ingesting the prescribed drugs in the nine years after the law went into effect (1998-2006). In 2010, 96 patients with terminal illness received prescriptions for lethal medication, though only 59 patients died from taking the medication.7 This may indicate that simply knowing they can end their suffering, if it becomes unbearable, provides a much needed sense of security and control for terminally ill patients.

Those who oppose physician-assisted suicide also argue that there have been many cases in which individuals have been misdiagnosed with terminal illness. In 2007, in the UK, H. (a mental patient) was told she had terminal breast cancer. Her doctors informed her that she had only a few weeks to live. H. was moved to a palliative care hospital, where two months later, a CT scan revealed that her condition had been misdiagnosed. Since her mental health treatment had been discontinued, she had become even more psychiatrically ill during hospice care. The case was settled after the hospital agreed to pay H. £25,000 for malpractice8. A single misdiagnosis can dramatically change a person’s life, resulting in needless suffering of both the patient and relatives.

You matter because you are you. You matter to the last moment of your life, and we will do all we can, not only to help you die peacefully, but also to live until you die.

Dame Cicely Saunders, founder of Hospice

Dr. Ira Byock, author of “Why Both Sides Are Wrong,” presents a counterargument that terminally ill patients may opt for assisted suicide because of critical deficiencies and weaknesses in today’s medical practice9. He explains that inadequate medical education and deficiencies in long-term care are two instructive examples. Medical school curricula remain underdeveloped in topics such as communication, pain assessment and management, ethics of decision-making and guidance for individuals facing life’s end. People living with advanced illness are often understandably worried about the future, what will become of them and their families, and may even question whether life is still worth living. These are not psychiatric conditions, merely difficult, normal aspects of human life. Physicians should be able to respond therapeutically to those concerns, and the basic counseling skills required to do so must be taught and tested as core medical school curricula.

In addition, prolife activists argue that dying patients need a better quality of the end of their lives, not an early death because society has few places for them. Assisted living facilities are in short supply and too expensive for many people. Likewise, nursing homes can easily bankrupt a couple, leaving a surviving spouse with few assets. A dying man who feels that he is a financial drain on his family may come to experience himself and his life as a burden to others. Assisted suicide would “provide a bolthole for lazy doctors.” “It is the need to go the extra mile in relieving intractable symptoms that has lead to some of the most significant breakthroughs in palliative medicine,” says Byock.

Prolife activists feel that simply listening can be therapeutic for the terminal patient. When a person is nearing death, he/she might feel lonely and would want somebody to be there with them, to hold their hand and just listen to their stories and not tell them what to do. According to Langton, a “good death,” however, does not always occur in hospitals. She feels that hospice care is a good alternative for many patients, but the practice should be improved. Hospice care should not only involve pain treatment, but also set an example for a healthy lifestyle. This can involve everyday activities such as gardening and music therapy.

However, some advocates of physician-assisted suicide believe that hospice care does not always act in the best interest of the patient. Painkillers provided to patients may temporarily relieve pain but in the longer run, the effects of these drugs can be disastrous.  The strongest painkillers, opioids such as morphine, are capable of killing a patient if administered at higher doses. Advocates of physician-assisted suicide also claim that terminally ill people, who express the need for assisted suicide, and are not allowed their choice, are a drain on medical funds. The funds spent on keeping these patients alive “forcibly” could instead be used to treat patients who really need medical care and show a willingness to live. In the words of Victorian poet Arthur Hugh Clough, “Thou shalt not kill; but need’st not strive officiously to keep alive.”10

When I presented Professor Langton with the debate over the lethality of painkillers used in hospice care, she held a mug in one hand and a pencil in the other. She extended her arms and asked me to view the mug as a level of morphine that simply numbed pain, whereas the pencil was a level that could potentially kill the patient. “ Everything between the mug and the pencil can be viewed as bringing the patient a step closer to death.  Maybe a day earlier, does it really matter? Morphine has the capability of lowering pain by orders of magnitude. It is a good drug and pain seems to soak up the side effects of the drug. Patient feels good.” The point Professor Langton makes here is that pain relief can bring on death in a way that is not so deliberate.

On the other hand, according to Nina Pickerrel, a deacon at the Grace Cathedral Church, San Francisco, “No human, be it priest, doctor or family member, has the right to play God.” Her main argument is that people have been known to change their minds when they are approaching death and sometimes it’s too late. “You see when a person is 50, they may have a different opinion and when they are 80 or 90, it’s a completely different story.” 11 I presented Pickerrel with the scenario of a terminally ill patient in unbearable pain, who has only a certain number of days to live, and asked her whether she would reconsider her opinion on physician-assisted suicide. Pickerrel pondered and then responded, “The unspoken truth is morphine. You gradually increase it until the body gives itself away to the drug. Hospice care should be provided.” Pickerrel agreed that though morphine is capable of killing a person, however the primary intention of the drug is not to end a life but to alleviate the person’s suffering.

Langton finds the concept of “playing God” odd. “Imagine there is a terminally ill patient who has suffered a heart attack, and there is still a chance to save him. The physician, however, decides not to and lets the patient die. Would that be considered playing God? What is really the difference between letting someone die and assisting death?” Langton feels it would be ideal if government policies were neutral, not biased toward a particular religion. She feels that there should be separation of religion and state, but acknowledges that this is not possible in non-secular countries.

However, assisted suicide can lead to ethical complications, as intentions of the family or loved one lending support may be questionable. George De Lury, a New York City resident, made headlines after being sentenced to six months jail time for helping his wife Myrna Lebov die in July 1995; he then wrote a book about the experience and became a nationally known advocate for assisted suicide. In his book, But What if She Wants to Die?, De Lury recounted the loneliness of the 25 years he spent caring for his wife and the pain of watching her decline; he grappled openly with whether he made the right decision. The wife’s family vowed to sue De Lury. In their view, assisting his spouse’s suicide was not an act of compassion but one of personal gratification for Delury. According to the relatives, the 52 year old woman was still capable of finding pleasure in life despite all her troubles. If she was depressed, they charged, it was because she kept hearing from her husband what a burden she had become to him. De Lury admits showing her this passage from his diary: ”I have fallen prey to the tyranny of a victim. You are sucking the life out of me like a vampire.” 12

On June 5, 2007, George De Lury, 74, ended his own life after penning a scathing suicide note to politicians, sending copies to friends and reporters detailing his medical problems and the powerlessness he felt over his life. In that letter, De Lury wrote: “I have chosen to step out of life because I have been scared to death by the medical profession’s ‘ethics,’ by the dogmatic rigidity of religious conservatives, and by the unthinking sentimentality of the public’s denial of death.” 13

Susan Dunshee, president of the board of Compassion In Dying in Seattle, which advocates legalized assisted suicide, believes that if the practice of assisting terminally ill people to end their lives was open and regulated, then there would be clarity in cases such as these. “To determine whether truly there is a compassionate act or an element of abuse. If there had been a clear protocol that he could follow, it’s likely that he would not have to go to jail.”14

The enumeration in the Constitution of certain rights shall not be construed to deny or disparage others retained by the people.

9th Amendment, United States Constitution

The late Dr. Jack Kevorkian, a famous advocate of physician-assisted suicide, helped nearly 130 patients to end their lives. When asked whether he would end his life if he was terminally ill and in pain, he responded, “If I was in pain and there was no cure, of course! I am doing this for me. See it’s my natural right. That’s in the constitution, in the 9th Amendment, which is ignored. I have a natural right to do whatever I want with my body. Anything! As long as it doesn’t effect anybody else or any other property and I have self permission.” 15 Dr. Kevorkian raises an important issue of right to die as a Constitutional right in a democracy.

Dr. Robert Young, a research associate at the La Trobe University in Australia, believes that a patient’s welfare interests and respect for their self-determination should guide medical care, not a commitment to preserving life at all costs. 16 Many doctors in The Netherlands and, to judge from available survey evidence, in other Western countries as well, see the practice of physician-assisted suicide as not only compatible with their professional commitments, but also with their conception of the best medical care for the dying. Young advocates that doctors should not be prohibited by law from lending their professional assistance to those competent, terminally ill persons for whom no cure is possible and who wish for an easy death.

Any good expert on ethics knows that there are seldom absolute rights and wrongs. This does not mean, however, that the debate over physician-assisted suicide should hang in the air. Government policies should be enacted that regulate physician-assisted suicide. If a law is passed to legalize physician-assisted suicide, then strict measures should be taken to make sure a patient has been correctly diagnosed with a terminal illness, that he or she meets the criteria as set by laws such as the Oregon Death With Dignity Act and has been made aware of alternatives such as hospice care. The debate cannot possibly be settled unless the government takes a completely neutral stance on the issue, i.e., religion is separated from state.

Medical schools should update their curricula so that their courses emphasize topics such as communication, pain assessment and management, ethics of decision-making, and guidance for people facing life’s end. Health care reforms should encourage the further development of hospice care and nursing home facilities. The facilities should be subsidized for patients who have limited funds and cannot support themselves. The environments of hospitals, hospice care and nursing homes should be improved to make them more welcoming for the patients. Medical treatment should not only focus on physical healing, but mental health, too. Family members, doctors and social workers should all work collaboratively to understand and address a patient’s needs. Advanced declaration forms should be filled out and signed in the presence of medical counselors and be made available only to those who are of a sound age and mentally capable of making decisions. All life forms should be valued and protected, but if physical and emotional effects of a terminal illness become unbearable, the patient should have a way to end his life with dignity. 

Works Cited

1. “Craig Ewert – Assisted Suicide in Switzerland”. Fox News. Video 2008. Web. 15 June 2011. <http://www.youtube.com/watch?v=LWy6pKVendQ> 

Also see Zaritsky, John. The Suicide Tourist. Film. CTV Television Network, 2007.  Web. 15 June 2011.

2. Humphrys, John, and Sarah Jarvis. The Welcome Visitor: Living Well, Dying Well. London: Hodder and Stoughton, 2009.

3.  Ballot Measure 16 (1994)The Oregon Death With Dignity Act.2009. Web. 15 June 2011. <http://www.tivcme.com/ethics2009/appendixd.htm&gt;

4. Gauthier, Candace Cummins, “Moral Responsibility and Respect for Autonomy” in Maglin, Nan Bauer, and Donna Marie Perry, eds. Final Acts: Death, Dying, and the Choices We Make. New Brunswick, N.J.: Rutgers University Press, 2010.

5. Personal Interview, Prof. Rae Langton, Massachusetts Institute of Technology, May 2011.

6.  Introduction, Maglin, Nan Bauer, and Donna Marie Perry, eds. Final Acts: Death, Dying, and the Choices We Make. New Brunswick, N.J.: Rutgers University Press, 2010, p.9.

7. Oregon’s Death With Dignity Act-2010. Web. 15 June 2011. <http://public.health.oregon.gov/ProviderPartnerResources/Evaluation Research/DeathwithDignityAct/Documents/year13.pdf>

8. Linder Myers Solicitors. “Case Report: Misdiagnosis of Terminal Illness for Mental Patient: H v. Pennine Acute Hospitals NHS Trust” Web. 15 June 2011. <http://www.lindermyers.co.uk/case-report-misdiagnosis-of-terminal-illness-for-mental-patient_1038.html&gt;

9. Byock, Ira, “Why Both Sides Are Wrong”, in Maglin, Nan Bauer, and Donna Marie Perry, eds. Final Acts: Death, Dying, and the Choices We Make. New Brunswick, N.J.: Rutgers University Press, 2010.

10. Andrews, Robert (ed.) Famous Lines: A Columbia Dictionary of Familiar Quotations. New York: Columbia University Press, 1996.

11. Personal Interview, Nina Pickerrel, May 2011.

12. Herszenhorn, David M. “Writer Jailed for Assisting Wife’s Suicide Reveals That He Suffocated Her”. The New York Times.  June 19, 1997. Web. 15 June 2011.

13. Birnbacher, Dieter and Edgar Dahl. Giving Death a Helping Hand: Physician-Assisted Suicide and Public Policy, An International Perspective.Springer. 2008.

14. Pierre-Pierre, Garry. “Man Sent to Six Months in Wife’s Suicide”, The New York Times, 5/18/1996. Web 15 June 2011. <http://www.nytimes.com/1996/05/18/nyregion/man-sentenced-to-6-months-in-wife-s-suicide.html&gt;

15. “Kevorkian on Physician-Assisted Suicide”. Anderson Cooper 360°.  CNN, 2010. Video. Web 15 June  2011. <http://ac360.blogs.cnn.com/2010/04/15/video-dr-kevorkian-on-physician-assisted-suicide/&gt;

16. Young, Robert. “Voluntary Euthanasia.”Stanford Encyclopedia of Philosophy. 1996. Web. 15 June 2011. <http://plato.stanford.edu/entries/euthanasia-voluntary/>.

Works Consulted

Cassidy, J. “Care Not Killing.” British Medical Journal. (International edition). London: Jan 1, 2011. Vol. 342, Iss. 7787; p. 29.  Web. 15 June 2011. <http://proquest.umi.com.libproxy.mit.edu/pqdweb?did=2248794901&sid=1&Fmt=2&clientId=5482&RQT=309&VName=PQD>

Cavan, Seamus and Shean Dolan. Euthanasia: The Debate Over the Right to Die. 1st ed. New York: Rosen Publishing Group, 2000. 1-12.

“Doctor-Shopping for Assisted Suicide?” America 203.13 (2010): 8. Web. 15 June 2011. <http://www.americamagazine.org/content/signs.cfm?signID=557&gt;

Dyer, C. “’Locked-in’ Patient Asks for Ruling on Mercy Killing.” British Medical Journal 341.7765 (2010): 168. <http://www.ncbi.nlm.nih.gov/pubmed/20647279&gt;

Hall, Allan. “‘I screamed, but there was nothing to hear’: Man trapped in 23-year ‘coma’ reveals horror of being unable to tell doctors he was conscious.” DailyMail Online. 3/11/2009 Web. 15 June 2011. <http://www.dailymail.co.uk/news/worldnews/article-1230092/Rom-Houben-Patient-trapped-23-year-coma-conscious-along.html>.

Manning, Michael. “Introduction.” Euthanasia and Physician-Assisted Suicide:Killing Or Caring? 1st ed. New Jersey, USA: Paulist Press, 1998. 1-6.

Munson, Ronald. Intervention and Reflection: Basic Issues in Medical Ethics. 8th ed. Belmont, CA: Thomson Wadsworth, 2008.

Stafford, N. “German Court Ruling Gives Support to Right to Die Campaign.” British Medical Journal 341.7762 (2010): 15.  Web. 15 June 2011. <http://www.ncbi.nlm.nih.gov/pubmed/20587576&gt;

Warnock, Mary, and Elisabeth Macdonald. Easeful Death: Is There a Case for Assisted Dying? New York: Oxford University Press, 2008.

Hamza Sheikh is a member of the class of 2013. He is majoring in Chemistry and aspires to be a doctor one day. He grew up in Pakistan and moved to the United States 3 years ago. Hamza enjoys listening to music, travelling, playing sports, learning about different cultures and languages. He calls himself a romantic and wants to learn the phrase ‘I Love You’ in every language possible. He loves animals and wants to be a part time veterinarian.

He got the inspiration to write this essay after he learnt about his friend’s relative’s illness, who is suffering from a motor neuron disease and has been in a vegetative state for almost 2 years. Hamza wants to improve the quality of assisted living facilities and believes that death is a societal problem, which should not be ignored. He had the opportunity to talk to some really interesting people while doing research and learned a lot in the process.

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