The Role of Physicians in Caring for Aged and Dying Patients
I will prescribe regimen for the good of my patients according to my ability and judgment and never do harm to anyone. To please no one will I prescribe a deadly drug, nor give advice which may cause his death.... But I will preserve the purity of my life and my art.
- Excerpt from Hippocratic Oath
Physicians face many personal and ethical challenges in providing care for dying and aged patients. The development of new life-sustaining technology and an aging American population have produced a changing health care environment in relation to end-of-life choices. Once, physicians offered few life-sustaining medical treatments and limited comfort care. Death was sometimes cruel and painful. Today, life-prolonging and proposed life-ending treatments pose a challenge to the ethical assessment of proper end-of-life medical care. In times to come, the assessment of a dying patient may include two distinct methods and philosophies of providing for a less painful and less cruel death - physician-assisted suicide and palliative care. Proponents of the "right to die" have energized support for physician-assisted suicide, often overlooking significant technological advances in palliative care.
The World Health Organization defines palliative care as comprehensive medical care for patients whose disease has no other curative treatments ("Cancer Pain Relief and Palliative Care." Report of a WHO Expert Committee. World Health Organization Technical Report Series. 1990, p. 11). The same organization identifies components of palliative care as including symptom relief, pain relief, psychosocial therapy, and pastoral care (11). While palliative-care measures emphasize the quality of life of the individual and family, physician-assisted suicide addresses the eminent death of the patient by providing the mechanism for patients to end their life at a chosen time. The physician may or may not be present when the suicidal act occurs. Although debates have raged concerning the moral and ethical dilemmas posed by physician-assisted suicide, no acceptable resolution has arisen.
Physicians and society must be actively involved in shaping future medical standards of care for dying and aged patients, while employing a rigorous standard of ethics and morality. I believe that palliative care offers a more ethical therapy for a dying patient than physician-assisted suicide by enhancing patient autonomy, reducing suffering in the final days of life, and preserving the therapeutic role of the physician. The effective administration of palliative care should become the foundation for providing a more dignified and moral end-of-life therapy.
Physicians have a moral and professional duty to respect and encourage patient autonomy and self-determination. The application of this responsibility, however, sometimes becomes more challenging as a patient ages and sickens. Terminally ill patients may suffer cognitive, emotional, and psychological deficits that can undermine their capacity to exercise their autonomy. The approach a physician assumes with a dying patient should reflect this reality. Physicians must be especially scrupulous in considering the possibility of competency deficiencies in suicidal terminal patients.
Proponents of physician-assisted suicide might argue that a reasoned plea for help by suicide is competent based upon the patient's present or future quality of life. Proponents contend that a patient with autonomous desires, including suicide, should have those desires honored regardless of other ethical standards. The patient is reasoned to have a new understanding of death that allows competent decisionmaking in seeking a physician's guidance with suicide. Death is implied to be the only quality-of-life improvement option.
However, I believe that a patient's competence to make an autonomous decision always must be questioned if the patient wishes to commit suicide. Suicide is not a true expression of autonomy, because the nature of the suicidal act is both violent and hurtful (J. Callahan, "The Ethics of Assisted Suicide." Health and Social Work. 19 : 239). Patients with terminal illnesses certainly face terrible situations, but suicide is at best a questionably competent response. Three major criteria apply to the evaluation of the competency of any patient. The patient should "communicate and understand relevant information," "reason and deliberate about alternative treatments," and "possess goals and values by which to assess alternatives" (D.W. Brock, "Informed Consent." Health Care Ethics. Ed. D. VanDeVeer and T. Regan. Philadelphia: Temple University Press, 1987. p. 113). A suicidal person may or may not fail the first two criteria of competence, but every suicidal person fails the third criterion.
The psychology of suicide prevents suicidal patients from properly appraising their goals and values. Most suicidal patients who succeed at killing themselves do so accidentally. Greater than 90 percent of suicidal patients (whether terminally iii or healthy) exhibit symptoms of depression or are suffering a psychiatric illness (Callahan, p. 241). Upon presentation to a physician, a suicidal patient who suffered from a psychiatric disorder or who was not terminally ill would immediately be hospitalized. The traditional standard of care for suicidal or psychiatric patients has included heroic measures such as hospitalization, regardless of their wishes. Suicidal patients who are not terminally ill are deemed incompetent to make the health care decisions based upon the third criteria of competency, despite apparent rationality. A terminally iii or dying patient should not be judged by a less rigorous standard of competency than a healthy individual. And certainly terminal illnesses do not provide a mystical understanding of death or suicide.
Proponents of physician-assisted suicide would argue that the only peaceful means of death is by suicide, when one can determine the time and means of death. Proponents argue that a physician-assisted suicide is painless and simple. However, assisting a patient may be the easiest means of terminal health care, but it certainly is not the most ethical. Suicide by nature is neither painless nor simple, but very taxing spiritually and physically. Often patients who are committing suicide gasp for breath, struggle for continued life, or call for help. In the book Final Exit, Derek Humphrey of the National Hemlock Society provides guidelines for suicidal acts. The National Hemlock Society recommends suffocation in addition to lethal medication for the commission of suicide. In addition, the physician (or suicide helper) must suppress the patient's attempts to remove the asphyxiate by physically restraining the arms and legs. (D.M. Gianelli, "Inside a Hemlock Society 'How to Do It' Session." American Medical News. 39 : 25). Is this a peaceful death or a violent murder? While the methodology of assisted suicide would certainly be refined in a health care environment where physician-assisted suicide was accepted, the euphemistic refinement in the methodology would not change the violence of suicide or patients' last struggles for their lives. Suicide in any form is not a natural death.
The therapeutic role of the physician certainly is challenged by the dying patient. A physician's responsibility is to aid in the healing of patients, and death is seldom a desired outcome of a healing treatment. Traditionally, the therapeutic role of physicians has held to the philosophy of doing no harm. If a physician seeks to do no harm to his patients, how can the therapeutic role justify a physician's assistance in suicide? The technology to kill someone has been present for many years, but physician-assisted suicide is a modern issue. Why would helping to kill a patient seem more therapeutic today than thirty years ago?
Proponents of the "right to die" movement have argued that physicians should extend their therapeutic spectrum to include helping patients die. Proponents argue that the act of killing is far less harmful than the act of prolonging life by futile treatment. But when faced with a suicidal individual, a physician, like any other citizen, would be accountable for providing a lethal weapon such as a gun to the individual. Patients who seek medication to end their lives pose a similar dilemma, only asking for a different type of lethal weapon. Is the physician any less accountable? Life's value dictates that one person should not facilely be allowed to participate in deciding the fate of another. Ending life in the face of viable palliative alternatives is clearly harmful. Physicians must do no harm to preserve the public's trust and their own therapeutic role.
One of the greatest fears of a dying patient is not death, but the pain associated with the final days of life. Physician attitudes toward dying patients must include compassion for physical and psychological pain. Technology has provided physicians with many new choices in controlling the pain and symptoms of patients. Most proponents and opponents of physician-assisted suicide consider pain relief a key issue in providing meaningful care to dying patients.
Unfortunately, physicians' training has lagged behind the new technologies and pain medicines. Physicians have traditionally been fearful of using adequate pain control out of fear of the addictive or other harmful properties of pain medications. Terminally ill patients are in special situations; clearly, pain control is far more important for them than a nebulous avoidance of potentially harmful properties of pain medication. The attitudes of physicians toward pain relief in the final days of a patient's life may significantly alter a patient's perspective on the possibility of physician-assisted suicide.
Palliative care provides a means to care for dying patients and their families. This philosophy of care provides for both psychological and physical pains. Palliative-care physicians are diligent in using proper medications such as opioids at indicated levels to maintain the patient's comfort. The physician must also address psychological and spiritual issues. A dying patient has many unique concerns and feelings. Dying patients face the psychological reconciliation of very painful losses, even painful enough to wish the hastening of death (S.D. Block and J.A. Billings. "Patient Requests for Euthanasia and Assisted Suicide in Terminal Illness: The Role of the Psychiatrist." Psychosomatics. 36 : 448). The physician must bear in mind and understand each of these losses. The transition from life to death does not have to be violent but can be peaceful.
Physician training also has neglected training physicians to deal with spiritual issues such as the realization of hope. Dying or aged patients who have a deteriorating quality of life and have lost all hope of improvement are more likely to request physician-assisted suicide (J.R. Peteet, "Treating Patients Who Request Assisted Suicide: A Closer Look at the Physician's Role." Archives of Family Medicine. 3 : 724). Physicians should be better trained to evaluate the needs of patients and counsel patients in understanding their disease, establishing adequate support systems, and reestablishing realistic hope (Peteet, p. 724). Physician-assisted suicide has garnered support in part because medical training is failing to prepare physicians for compassionate end-of-life care. The attitudes of future physicians must be redirected to caring compassionately for dying patients.
Palliative care offers an alternative to killing the patient that preserves the therapeutic role. The therapeutic role of providing a smooth, comfortable transition to death is more healing than aiding patients in ending their lives. The moral duty of physicians mandates the protection of life while respecting the feelings of the patient. Caring for a dying patient is demanding. Some technological medical treatments have extended the natural course of life and death. Especially as society becomes more elderly, the use of technology must not be abused either to hasten death or prolong life futilely. Instead, physicians have a moral responsibility to provide necessary care to aid patients in a painless progression to natural death.
The role of the physician in caring for the families of dying patients is also significant. Family members often have difficulty coping with the impending loss of their loved ones. The therapeutic role of the physician in caring for family members certainly is not addressed by physician-assisted suicide. Families must cope not only with the loss of their loved ones but also with the manner of death. The stigma of suicide often deepens grief, while the emotional support provided by a physician during palliative care may enable families in easing their grief and accepting the death. In a palliative-care setting, physicians can aid dying patients with the transition to death while assisting family members with the changes in life without special loved ones.
Physicians' attitudes toward dying patients will shape the type of care a patient receives. Although the movement in society to encourage physician-assisted suicide probably will continue, physicians must play an active role in preserving patient autonomy, reducing pain, and fulfilling their professional mandates in the therapeutic role. These important components of caring for dying patients and their families can be fulfilled most clearly by effective palliative care. The physician's therapeutic role with a dying patient must be cherished, lest physicians and society forget the most fundamental tenets of medicine - to do no harm and to comfort ill and aged patients.
R. Henry Capps, Jr., is a medical student at East Carolina University School of Medicine, studying for a career as a family physician. He was a summa cure laude graduate of Campbell University, where he was the recipient of a Phi Kappa Phi Fellowship in 1995.…