Responding to requests for physician-assisted death
- Timothy E Quill, MD
Timothy E Quill, MD
- Professor of Medicine, Psychiatry and Medical Humanities
- University of Rochester School of Medicine
- Margaret P Battin, MFA, PhD
Margaret P Battin, MFA, PhD
- Distinguished Professor, Department of Philosophy and Division of Medical Ethics and Humanities
- University of Utah
Euthanasia and physician-assisted death burst into the United States public arena in 1988 with the publication of "It's over, Debbie" . This article stirred an emotional debate, with many people criticizing what they saw as nonvoluntary euthanasia involving a lethal injection delivered by a physician who did not know the patient and who had only ambiguous evidence of her wishes ("Let's get this over with") [2,3]. The case later turned out to be a fabrication. A later (true) case report describing a patient with a terminal illness who made an intensely personal decision for aid in dying, involving a self-administered drug prescribed only after extensive discussion with her own physician, was received with less criticism and more balanced discussion; it was eventually considered by a grand jury, which recommended against indicting her physician . These two cases, in a sense, set the stage for the current disputes in the United States over physician-assisted dying. Less volatile discussion, as well as practice, had already begun elsewhere, especially in the Netherlands. In recent years, much of the developed world—those countries with long-life expectancies, highly developed healthcare systems, and mortality characterized primarily by diseases with long downhill courses (cancer, heart and other organ system failure, and dementia)—have seen the emergence of end-of-life debates and increasing pressures for legalization of assisted dying.
Many physicians, particularly those in the fields of oncology and palliative care, will be faced with a request for assistance in dying sometime in their professional lifetimes. No matter where clinicians stand ethically and morally on the permissibility of this practice and regardless of whether these practices are legally permitted or prohibited in a given jurisdiction, clinicians have to carefully consider and decide how they will respond to these requests. This topic focuses on the clinical aspects of evaluating and responding to such requests, emphasizing the importance of full evaluation, including the adequacy of palliative care and the availability of alternative treatments to alleviate suffering, and practical approaches that respect the values of the patient, the family, and the clinician as well as the particular legal constraints under which they reside. An extensive discussion of the ethical and legal issues surrounding euthanasia and assisted suicide is provided elsewhere. (See "Euthanasia and physician-assisted death".)
THE DEBATE OVER TERMINOLOGY
In this rapidly changing legal context, controversy abounds as to whether to label the practice addressed here with the negatively-valenced term "physician-assisted suicide" (typically used by opponents), the more neutral term "physician-assisted dying," or the more positively-valenced term "physician aid in dying" (typically favored by proponents) [5-8]. We prefer the relatively neutral term physician-assisted dying (PAD) as synonymous (in content, although not in emotional valence) with both physician-assisted suicide and aid in dying.
The term "euthanasia" also varies in its negative or positive connotations in different regions. In the Netherlands, "euthanasia" is understood in terms of its Greek roots: eu ("good") and thanatos ("death"), which means "good death," something that the patient chooses in preference to the "bad death" that might otherwise occur. In contrast, the term "euthanasia" is avoided in Germany, where the term is often associated with Nazi extermination policies, suggesting politically motivated death that is against the victim's wishes or interests (in this case, involuntary euthanasia). The Canadian Society of Palliative Care Physicians is endorsing the terms “patient administered physician hastened death” and “physician administered physician hastened death” respectively to ensure there is no misunderstanding, and clearly distinguish these practices from “palliative care”. In US jurisdictions where the practice is legally permitted, it is generally called "aid in dying" or referred to as "death with dignity", the title of the original Oregon statute. These and other terms relevant to this discussion are outlined in the table (table 1).
In the interest of neutrality and relative simplicity, the remainder of this topic will use the descriptive term "physician-assisted dying" (PAD) instead of "physician-assisted suicide," "aid in dying," or "patient administered physician hastened death." It will use "voluntary-active euthanasia" (VAE) rather than "physician-administered physician hastened death" because of its common usage in the literature and because there is no internationally recognized neutral term available.
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- THE DEBATE OVER TERMINOLOGY
- Terms to use with patients
- DEFINING AND DESCRIBING PRACTICES
- Physician-assisted dying
- Voluntary active euthanasia
- Potential alternatives to PAD and VAE
- CURRENT LEGAL STATUS
- WHO ASKS ABOUT ASSISTANCE IN DYING?
- RESPONDING TO INQUIRIES ABOUT FUTURE PAD OR VAE
- Addressing the patient's concerns
- Defining physician limitations
- Responding to a request in advance of need
- HANDLING A CURRENT URGENT REQUEST
- Understanding the family's concerns
- Assessing the patient's capacity
- Ensuring the adequacy of current palliative care in addressing the patient's suffering
- Consultation services for physicians
- PERSONAL AND PROFESSIONAL CHALLENGES FOR THE CLINICIAN
- Defining limitations