Physician-assisted suicide: ten questions.

Bicoastal decisions of federal circuit courts have upheld the practice of physician-assisted suicide (PAS). Thus the United States has now entered the broader international debate over managing the end of life. Holland has accepted both euthanasia and physician-assisted suicide for several years. Last year one of the territories of Australia provided the same options. Referenda on these topics were held in California and Washington State, where they were turned back by the voters, and in Oregon, where a measure to permit PAS is now under appeal. And for several years Jack Kevorkian has been carrying on his own brand of guerrilla warfare and theater in Michigan for the cause of physician-assisted suicide. But now two federal circuit courts have succeeded in doing what Kevorkian has been unable to do: upholding the practice of physicians aiding the dying by giving patients the means by which to kill themselves.

These rulings, which will in all likelihood be appealed and will probably not be implemented for quite a while--if at all--focus debate on issues that have been simmering for decades. I would like to ask some questions concerning the practice of PAS, questions that I hope will bring out the seriousness and complexity of the issues involved.

First, why so fast? The PAS debate is already falling into the traditional American practice of acting first and thinking later, or never. What PAS needs more than anything is debate. The positive effects of such debate can be shown by recalling the very intense national and international debates that surrounded the Karen Ann Quinlan and Nancy Cruzan cases. Both involved ethical and legal elements in the removal of therapies deemed nonbeneficial by the families, a ventilator in the Quinlan case and nutrition and hydration in the Cruzan case.

The prolonged public debate served to clarify the issues and helped establish a national consensus which supported the removal of therapies that prolonged life but provided few other benefits. While the process was long and extremely painful for the patients' families, the nation benefited because there was no fast resolution.

Second, why do experts dominate the debate? In some ways the issue is being managed by individuals and interest groups committed to one side or the other. Obviously they should be in the debate but they aren't the only interested parties, and their interests are not necessarily the critical ones. Only a genuine national, popular debate can benefit the resolution of this issue. The national discussion over Quinlan and Cruzan were entered into by citizens from all walks of life. Bringing in the viewpoints of the people most likely to be affected by the outcome of the debate will ensure that a wide spectrum of issues are expressed and evaluated.

Third, can we get the debate out of the courts? We know that Roe decriminalized abortion and that the practice of abortion has drastically changed, but the issue itself was not resolved by Roe. I suspect the same will be true here. Regardless of how the Supreme Court might decide--and eventually this issue of PAS will come before it--the decision will still have to be received and implemented. To the extent that such an important decision is made in the absence of a national debate, it will serve only as the source of further division.

Fourth, can we avoid comparing this issue to abortion? While there are obvious conceptual and principled issues relating to the sanctity of life and the right to life, there are also critical differences. In PAS we are clearly talking about adults. We are also talking about individuals who are supposed to be making this decision for themselves and will perform this action by themselves. There is no question about the personhood of an individual interested in PAS, there is no issue of another having a right over this individual, and there is no issue of another's life being ended by the patient's decision to end his or her own life. Thus, some of the key issues surrounding abortion are absent. Conflating the debates would serve no good, other than scoring ideological points which would only further obfuscate the issue.

Fifth, why are we focusing on PAS instead of first reviewing how the care of the dying is being managed currently? Or, to ask the question differently, is there something going on with the care of the dying that is prompting this debate? I would answer yes. Unfortunately, even though we have had an extensive debate over extraordinary means and the forgoing of nonbeneficial therapy, medical practice seems to be to continue life-prolonging interventions as long and widely as possible. A recent study revealed that do-not-resuscitate orders are written only many weeks after patients request them, and that individuals are kept in intensive-care units longer than their conditions warrant. Even following the second phase of this study, in which physicians and other health-care workers were explicitly informed about responding to patients' wishes, practice barely changed. My general sense is that interventions are being continued much longer than is medically or ethically warranted. Thus the PAS movement may be a cry for help, or may be saying that if physicians won't stop useless therapy, then patients will literally have to take matters into their own hands. Maybe the first step is to ensure that useless therapies are terminated, not patients.

Sixth, why does the alleged right to kill oneself imply that a physician can be, or ought to be obligated to provide assistance? The mythology of rugged individualism and the widely celebrated autonomy of the patient which drive this debate suddenly are nowhere to be found. The argument is that individuals do not have access to the effective means to take their own lives, or that under certain conditions they are unable to do so. Both claims are probably true, but we need to examine carefully why the claim that I may have some kind of a right to kill myself confers some sort of an obligation on another to assist me. Suicide, I take it, may be a liberty right, which means that as long as no one stops me from doing what I want, my right is secured. No one, however, is mandated ethically or legally to assist me in achieving this alleged right. So why should suicide be the exception?

Seventh, do we want to change the role of the doctor from healer to someone who assists in killing? While this may sound like an attempt to stack the deck, it is nonetheless a real issue. Legalizing PAS will dramatically change the role of the physician (see Leon R. Kass, "Why Doctors Must Not Kill," Commonweal, August 9,1991). Recognition of such a shift has not yet been a significant part of the debate. Note has been made of late of the deleterious effect of the changing economics of health care on the relationship between patient and physician. Those who are worried about the diminished time a physician is allotted to spend with a patient, or the decreased therapeutic options a physician may have to offer a patient, ought to be concerned about a more fundamental change that would allow the physician to offer the patient an agent that would end all treatment prematurely.

Eighth, concern for the terminally ill who are suffering is a driving force in the movement to legalize PAS, but might economics also play a role? It is cheaper to help someone commit suicide than to maintain that person in an intensive-care unit--or anywhere else in the hospital. So we need to keep an eye on the economics of health care and the growing use of cost-effectiveness criteria to determine appropriate treatment options.

Ninth, will options become obligations, especially if they are a lot cheaper? This is a difficult question because essentially only time will tell. Nonetheless, options have a funny way of becoming established as standard medical practice. Any diagnostic test might serve as an example. While many of these have a critical role in medicine, often they are mandated by the doctor so that he or she can say, during a malpractice trial, that the treatment included every test possible and left no possibility unexamined. Thus the institutionalization of defensive medicine and the removal of choice from both patient and physician.

Tenth, do people think that the nature of PAS will be changed by suggesting that this is a medical therapy? The role of the physician is to cure within the limits of both his or her capacity and that of modern medicine. The function of a therapy is to cure the patient or at least ameliorate the symptoms. The function of medicine has not been to provide assistance so a patient can kill him- or herself. The role of the physician has been healing, not helping someone to commit suicide. In PAS, the nature of medicine and therapy is being given a radically new role. By having a physician assist in suicide we are trying to legitimatize it by medicalizing the event. But suicide is neither a medical procedure nor a medical therapy.

While PAS appeals in a genuine sense to the relief of the suffering of the terminally ill and the dying, it would profoundly change the nature of medicine and the role of the dying. No matter how poignant are the cases presented to us, we would be well-advised to think this one through very carefully. This is not a private decision; it is a profoundly social one.

Thomas A. Shannon is a member of the department of humanities and arts at Worcester Polytechnic Institute, Worcester, Massachusetts.