The positive virtues of physician-assisted suicide: physician-assisted suicide is among the most hotly debated bioethical issues of our time.

Every reasonable person prefers that no patient ever contemplate suicide--with or without assistance--and recent improvements in pain management

have begun to reduce the number of patients seeking such assistance. However, there are some patients who experience terrible suffering that can't be relieved by any of the therapeutic or palliative techniques medicine and nursing have to offer, and some of those patients desperately seek deliverance.

Physician-assisted suicide isn't about physicians becoming killers. It's about patients whose suffering we can't relieve and about not turning away from them when they ask for help. Will there be physicians who feel they can't do this? Of course, and they shouldn't be obliged to. But if other physicians consider it merciful to help such patients by merely writing a prescription, it is unreasonable to place them in jeopardy of criminal prosecution, loss of license, or other penalty for doing so.

Many arguments are put forward for maintaining the prohibition against physician-assisted suicide, but I believe they are outweighed by two fundamental principles that support ending the prohibition: patient autonomy--the right to control one's own body--and the physician's duty to relieve suffering.

Society recognizes the competent patient's right to autonomy--to decide what will or won't be done to his or her body. There is almost universal agreement that a competent adult has the right to self-determination, including the right to have life-sustaining treatment withheld or withdrawn. Suicide, once illegal throughout the United States, is no longer illegal in any part of the country. Yet assisting a person to take her or his own life is prohibited in every state but Oregon. If patients seek such help, it is cruel to leave them to fend for themselves, weighing options that are both traumatic and uncertain, when humane assistance could be made available.

The physician's obligations are many but, when cure is impossible and palliation has failed to achieve its objectives, there is always a residual obligation to relieve suffering. Ultimately, if the physician has exhausted all reasonable palliative measures, it is the patient--and only the patient--who can judge whether death is harmful or a good to be sought. Marcia Angell, former executive editor of the New England Journal of Medicine, has put it this way:

   The highest ethical imperative of doctors should be to provide care in
   whatever way best serves patients' interests, in accord with each patient's
   wishes, not with a theoretical commitment to preserve life no matter what
   the cost in suffering.... The greatest harm we can do is to consign a
   desperate patient to unbearable suffering--or force the patient to seek out
   a stranger like Dr. Kevorkian.

Let's examine the key arguments made against physician-assisted suicide. First, much weight is placed on the Hippocratic injunction to do no harm. It has been asserted that sanctioning physician-assisted suicide "would give doctors a license to kill," and physicians who accede to such requests have been branded by some as murderers. This is both illogical and inflammatory. Withdrawal of life-sustaining treatment--for example, disconnecting a ventilator at a patient's request--is accepted by society, yet this requires a more definitive act by a physician than prescribing a medication that a patient has requested and is free to take or not, as he or she sees fit. Why should the latter be perceived as doing harm when the former is not? Rather than characterizing this as "killing," we should see it as bringing the dying process to a merciful end. The physician who complies with a plea for final release from a patient facing death under unbearable conditions is doing good, not harm, and her or his actions are entirely consonant with the Hippocratic tradition.

Second, it is argued that requests for assisted suicide come largely from patients who haven't received adequate pain control or who are clinically depressed and haven't been properly diagnosed or treated. There is no question that proper management of such conditions would significantly reduce the number of patients who consider suicide; any sanctioning of assistance should be contingent upon prior management of pain and depression.

However, treatable pain is not the only reason, or even the most common reason, why patients seek to end their lives. Severe body wasting, intractable vomiting, urinary and bowel incontinence, immobility, and total dependence are recognized as more important than pain in the desire for hastened death. There is a growing awareness that loss of dignity and of those attributes that we associate particularly with being human are the factors that most commonly reduce patients to a state of unrelieved misery and desperation.

Third, it is argued that permitting physician-assisted suicide would undermine the sense of trust that patients have in their doctors. This is curious reasoning; patients are not lying in bed wondering if their physicians are going to kill them--and permitting assisted suicide shouldn't create such fears, since the act of administering a fatal dose would be solely within the control of the patient. Rather than undermining a patient's trust, I would expect the legalization of physician-assisted suicide to enhance that trust. I have spoken with a great many people who feel that they would like to be able to trust their physicians to provide such help in the event of unrelieved suffering--and making that possible would give such patients a greater sense of security. Furthermore, some patients have taken their own lives at a relatively early stage of terminal illness precisely because they feared that progressively increasing disability, without anyone to assist them, would rob them of this option at a later time when they were truly desperate. A patient contemplating suicide would be much less likely to take such a step if he or she were confident of receiving assistance in the future if so desired.

Fourth, it is argued that patients don't need assistance to commit suicide; they can manage it all by themselves. This seems both callous and unrealistic. Are patients to shoot themselves, jump from a window, starve themselves to death, or rig a pipe to the car exhaust? All of these methods have been used by patients in the final stages of desperation, but it is a hideous experience for both patient and survivors. Even patients who can't contemplate such traumatic acts and instead manage to hoard a supply of lethal drugs may be too weak to complete the process without help and therefore face a high risk of failure, with dreadful consequences for themselves and their families.

Fifth, it is argued that requests for assisted suicide are not frequent enough to warrant changing the law. Interestingly, some physicians say they have rarely, if ever, received such requests, while others say they have often received requests. This is a curious discrepancy, but I think it can be explained: the patient who seeks help with suicide will cautiously test a physician's receptivity to the idea and simply won't approach a physician who is unreceptive. Thus, there are two subsets of physicians in this situation: those who are open to the idea of assisted suicide and those who aren't. Patients are likely to seek help from the former but not from the latter.

A study carried out a few years ago by the University of Washington School of Medicine queried 828 physicians (a 25 percent sample of primary care physicians and all physicians in selected medical subspecialties) with a response rate of 57 percent. Of these respondents, 12 percent reported receiving one or more explicit requests for assisted suicide, and one-fourth of the patients requesting such assistance received prescriptions.

A survey of physicians in San Francisco treating AIDS patients brought responses from half, and 53 percent of those respondents reported helping patients take their own lives by prescribing lethal doses of narcotics. Clearly, requests for assisted suicide can't be dismissed as rare occurrences.

Sixth, it is argued that sanctioning assisted suicide would fail to address the needs of patients who are incompetent. This is obviously true, since proposals for legalization specify that assistance be given only to a patient who is competent and who requests it. However, in essence, this argument says that, because we can't establish a procedure that will deal with every patient, we won't make assisted suicide available to any patient. What logic! Imagine the outcry if that logic were applied to a procedure such as organ transplantation, which has benefited so many people in this country.

Seventh, it is argued that once we open the door to physician-assisted suicide we will find ourselves on a slippery slope leading to coercion and involuntary euthanasia of vulnerable patients. Why so? We have learned to grapple with many slippery slopes in medicine--such as Do Not Resuscitate (DNR) orders and the withdrawal of life support. We don't deal with those slippery slopes by prohibition but, rather, by adopting reasonable ground rules and setting appropriate limits.

The slippery slope argument discounts the real harm of failing to respond to the pleas of real people and considers only the potential harm that might be done to others at some future time and place. As in the case of other slippery slopes, theoretical future harm can be mitigated by establishing appropriate criteria that would have to be met before a patient could receive assistance. Such criteria have been outlined frequently. Stated briefly, they include:

1. The patient must have an incurable condition causing severe, unrelenting suffering.

2. The patient must understand his or her condition and prognosis, which must be verified by an independent second opinion.

3. All reasonable palliative measures must have been presented to and considered by the patient.

4. The patient must clearly and repeatedly request assistance in dying.

5. A psychiatric consultation must be held to establish if the patient is suffering from a treatable depression.

6. The prescribing physician, absent a close preexisting relationship (which would be ideal), must get to know the patient well enough to understand the reasons for her or his request.

7. No physician should be expected to violate his or her own basic values. A physician who is unwilling to assist the patient should facilitate transfer to another physician who would be prepared to do so.

8. All of the foregoing must be clearly documented.

Application of the above criteria would substantially reduce the risk of abuse but couldn't guarantee that abuse would never occur. We must recognize, however, that abuses occur today--in part because we tolerate covert action that is subject to no safeguards at all. A more open process would, in the words of philosopher and ethicist Margaret Battin, prod us to develop much stronger protections for the kinds of choices about death we already make in what are often quite casual, cavalier ways."

It seems improbable that assisted suicide would pose a special danger to the elderly, infirm, and disabled. To paraphrase John Maynard Keynes, in the long run we are all elderly, infirm, or disabled and, since society well knows this, serious attention would surely be given to adequate protections against abuse. It isn't my intention to dispose glibly of the fear that society would view vulnerable patients as a liability and would manipulate them to end their lives prematurely. Of course, this concern must be respected, but the risk can be minimized by applying the criteria listed above. Furthermore, this argument assumes that termination of life is invariably an evil against which we must protect vulnerable patients who are poor or otherwise lacking in societal support. But, by definition, we are speaking of patients who desperately wish final release from unrelieved suffering, and poor and vulnerable patients are least able to secure aid in dying if they want it. The well-to-do patient may, with some effort and some good luck, find a physician who is willing to provide covert help; the poor and disenfranchised rarely have access to such assistance in today's world.

Eighth, it is argued that the Netherlands experience proves that societal tolerance of physician-assisted suicide leads to serious abuse. Aside from the fact that the data are subject to varying interpretation depending upon which analysis one believes, the situation in the Netherlands holds few lessons for us, because for many years that country followed the ambiguous practice of technically prohibiting but tacitly permitting assisted suicide and euthanasia.

The climate in the United States is different; our regulatory mechanisms would be different--much stricter, of course--and we should expect different outcomes. The experience of Oregon--the only one of our fifty states to permit physician-assisted suicide--is instructive. During the first three years that Oregon's law has been in effect, seventy terminally ill patients took advantage of the opportunity to self-administer medication to end protracted dying. Despite dire warnings, there was no precipitous rush by Oregonians to embrace assisted suicide. The poor and the uninsured weren't victimized; almost all of these seventy patients had health insurance, most were on hospice care, and most were people with at least some college education. There were no untoward complications. The Oregon experience is far more relevant for the United States than the Dutch experience, and it vindicates those who, despite extremely vocal opposition, advocated for the legislation.

Ninth, it has been argued that a society that doesn't assure all its citizens the right to basic health care and protect them against catastrophic health costs has no business considering physician-assisted suicide. I find this an astonishing argument. It says to every patient who seeks ultimate relief from severe suffering that his or her case won't be considered until all of us are assured basic health care and financial protection. These are certainly proper goals for any decent society, but they won't be attained in the United States until it becomes a more generous and responsible nation --and that day seems to be far off. Patients seeking deliverance from unrelieved suffering shouldn't be held hostage pending hoped-for future developments that are not even visible on the distant horizon.

Finally, it is argued that the status quo is acceptable--that a patient who is determined to end his or her life can find a sympathetic physician who will provide the necessary prescription and that physicians are virtually never prosecuted for such acts. There are at least four reasons to reject the status quo. First, it forces patients and physicians to undertake a clandestine conspiracy to violate the law, thus compromising the integrity of patient, physician, and family. Second, such secret compacts, by their very nature, are subject to faulty implementation with a high risk of failure and consequent tragedy for both patient and family. Third, the assumption that a determined patient can find a sympathetic physician applies, at best, to middle- and upper-income persons who have ongoing relationships with their physicians; the poor, as I've already noted, rarely have such an opportunity. Fourth, covert action places a physician in danger of criminal prosecution or loss of license and, although such penalties are assumed to be unlikely, that risk certainly inhibits some physicians from doing what they believe is proper to help their patients.

I believe that removing the prohibition against physician assistance, rather than opening the flood gates to ill-advised suicides, is likely to reduce the incentive for suicide: patients who fear great suffering in the final stages of illness would have the assurance that help would be available if needed and they would be more inclined to test their own abilities to withstand the trials that lie ahead.

Life is the most precious gift of all, and no sane person wants to part with it, but there are some circumstances where life has lost its value. A competent person who has thoughtfully considered his or her own situation and finds that unrelieved suffering outweighs the value of continued life shouldn't have to starve to death or find other drastic and violent solutions when more merciful means exist. Those physicians who wish to fulfill what they perceive to be their humane responsibilities to their patients shouldn't be forced by legislative prohibition into covert actions.

There is no risk-free solution to these very sensitive problems. However, I believe that reasonable protections can be put in place that will minimize the risk of abuse and that the humanitarian benefits of legalizing physician-assisted suicide outweigh that risk. All physicians are bound by the injunction to do no harm, but we must recognize that harm may result not only from the commission of a wrongful act but also from the omission of an act of mercy. While not every physician will feel comfortable offering help in these tragic situations, many believe it is right to do so and our society should not criminalize such humanitarian acts.

Peter Rogatz, M.D., M.P.H., is a founding board member of Compassion in Dying of New York, a member of the Ethics Committee of Hospice Care Network (Long Island and Queens), and a member of the Committee on Bioethical Issues of the Medical Society of the State of New York. He previously served as professor of community and preventive medicine at the State University of New York at Stony Brook from 1970 to 1991.