Physician-Assisted Suicide or Palliative Care?
Capps, R. Henry, Jr., National Forum
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. …