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Physician Assisted Suicide: Is Legal Always Right?

Death is never timely, only inevitable. Although it is one of life's essential features, Americans usually exhaust every effort and pay any price to stay beyond its reach. For some afflicted souls, however, life can be so unbearable that they dream of a quick, effective, and merciful exit. Now, for certain competent, yet terminally ill individuals who find the emotional and physical cost of life too dear, their doctors may be able to furnish such a means to their end. This spring, in a span of less than one month, federal appeals courts in New York and California ruled that two state bans on assisted suicide were unconstitutional.

Ban on Assisted Suicide Unconstitutional

In one suit, brought by three physicians and initially, three terminally ill patients who had sought their assistance to commit suicide, the Second Circuit Court of Appeals, with jurisdiction over several eastern states, held that willing physicians may prescribe drugs for self-administration by mentally competent patients who seek to end their lives during the final stages of terminal illness. The state penal code, however, provided that a person who intentionally aids another to commit suicide is guilty of a felony.

All three patients had compelling arguments for suicide. One of the patients, a 76-year-old retired physical education instructor, described a large cancerous tumor wrapped around the right carotid artery in her neck which was collapsing her esophagus and invading her voice box. She could barely swallow, drank liquids in small amounts, and absorbed nourishment through a feeding tube.

A 48-year-old publishing executive suffering from AIDS explained the several AIDS-related conditions he suffered, including two parasitic infections, blindness in one eye, severe fevers, exhaustion, lesions on the brain, and extreme pain. He endured daily injections of medication, while another drug was administered through a tube connected to an artery in his chest.

A 28-year-old former fashion editor under treatment for AIDS had also suffered parasitic infection, AIDS-related pneumonia, cancerous skin lesions, fevers, nausea, and "wasting," and underwent routine intravenous feedings and medical treatments with significant adverse side effects.

All three patients asked that they be able to have suitable drugs available for the purpose of hastening their deaths humanely when they could no longer endure the pain.

According to one of the plaintiff-physicians, the law permits patients dependent on life-sustaining treatments to ask their physician to discontinue them, while dying patients who live independently of artificial interventions, yet suffer agonizing pain, enjoy no similar options under current legal restrictions. As a result, the doctor claimed that it is "unfair, discriminatory, and inhumane to deprive some dying patients of such vital choices."

The appellate court agreed. The state had not treated equally all competent persons in the final stages of fatal illness who wish to hasten their deaths, and the court held the state criminal laws violative of the equal protection clause of the United States Constitution to the extent they prevented physicians from prescribing drugs for those patients to self-administer. The court reasoned that the ending of life either by withdrawing treatment or administering prescription drugs "is nothing more nor less than assisted suicide" and could find no compelling state interest to require "the prolongation of a life that is all but ended."

Terminally Ill May Hasten Death

In a similar case decided only a few weeks earlier by an 8 to 3 majority, the United States Court of Appeals for the Ninth Circuit, with jurisdiction over nine western states and Guam, declared that a Washington state statute prohibiting assisted suicide violated the constitutional due process rights of mentally competent, terminally ill adults who wish to seek a physician's assistance in actively hastening their deaths. The court found no meaningful legal distinction between an act of omission (such as withholding nutrition and hydration) and an act of commission (such as providing a prescription for a lethal dose of a drug). Citing the importance of removing government from an intensely personal decision, the appellate court stated that the state's interest in forcing patients to remain alive is less compelling when they are "no longer able to pursue liberty or happiness and do not wish to pursue life." The three judges in the minority were concerned with the potential for abuse, including coercion of he disabled and the elderly.

While the two decisions turned on different constitutional grounds, both courts found no distinction between withholding or withdrawing treatment, and providing patients with the means to commit suicide. Neither court mandated that states enact guidelines to implement the practice, but the Second Circuit indicated that the states could establish rules and procedures to assure that all choices are free from coercion. In 1994, however, the New York State Task Force on Life and the Law had recommended that the state not legalize physician-assisted suicide since it would not be possible to establish adequate safeguards to protect vulnerable populations from abuse. The Ninth Circuit Court also indicated that states could adopt guidelines, but suggested they could raise constitutional concerns if too restrictive.

The Washington State Medical Association as well as the New York Medical Society maintain official positions which oppose physician-assisted suicide. Both cases are expected to be appealed to the United States Supreme Court. If the Supreme Court declines to review the appellate decisions, or in the event it votes to uphold either of them, the practice of physician-assisted suicide will become legal. The highest state courts in both California and Michigan have previously reported contrary decisions which found no constitutional right to assistance in suicide. Legislation is currently pending in eight states which would permit physician-assisted suicide under certain circumstances.

AMA Policy in Opposition

The argument most often made to support the concept of physician-assisted suicide is that patients at the end of life who suffer from terminal conditions often endure agonizing and intolerable pain. According to a poll published in the March 27, 1996 issue of the Journal of the American Medical Association, however, patients who requested aid in dying pointed to a fear of being a burden on others more often than pain. In fact, a new study published in the February 1996 American Journal of Medicine indicates that for many critically and terminally ill patients, life at any cost is preferable to death. Forty-two percent reported that they were willing to stay on respirators indefinitely, and the majority said they would want their doctors to try to revive them if their hearts stopped.

The American Medical Association (AMA) contends that physician-assisted suicide is fundamentally incompatible with the physician's role as healer and caregiver and recently reaffirmed its strong opposition to the practice. The organization's official policy states that requests for such assistance actually represent a signal to the physician that the patient's needs have not been met and further evaluation is necessary to identify the elements contributing to the patient's suffering.

Recently, in Washington, D.C., a House subcommittee sponsored the nation's first congressional hearing on assisted suicide. Apparently disturbed by the recent court decisions, Representative Charles T. Canady (R. Fla.) said he called the hearing to initiate public debate. Fifteen witnesses testified, including AMA President Lonnie R. Bristow, M.D., who said that the movement to legalize assisted suicide reflects society's failure to address properly the complex issues raised at the end of life. Herbert Hendin, M.D., executive director of the American Suicide Foundation, testified that the experience in the Netherlands (where the courts have issued guidelines for the practice and laws against it are rarely enforced) illustrate how a practice initially intended as an unfortunate necessity in exceptional cases can become, through social sanction, almost a routine way of dealing with serious illness. In fact, approximately half of the deaths in Holland actively caused by physicians in 1990 occurred without the consent of the patient.

Although the Rhode Island Medical Society had consistently opposed any participation by a physician in the suicide or euthanasia of a patient, the state society recently voted to take a neutral stance on the issue. Only two other state societies, Michigan and Oregon, have also voted to break with the AMA to adopt a neutral stance on the practice.

Legal v. Moral Debate

This issue has deeply divided the medical community as well as religious organizations, courts across the country, and ethical authorities. The debate it has generated, however, may actually telegraph society's failure -- not just official medicine's -- to address the needs of patients as they near the end of their life. If patients could anticipate, with assurance, adequate financial and emotional support, as well as effective management of pain and comfort for their physical needs, death might not loom as the only treatment modality of choice.

First, "do no harm" is medicine's most fundamental ethical tenet. The goal of all medical treatment and care has always been to relieve pain and suffering and to preserve life -- not to end it. At the turn of a page, a court can suddenly decide that conduct once considered criminal is now perfectly "legitimate."

Although assuredly well-intentioned, the recent federal appeals courts' decisions exemplify the maxim that hard cases make bad law. Only plaintiffs who suffer the most terrible illnesses and pain have the standing to bring these suits. Who wouldn't be moved to consider granting them eternal rest and relief? But, the agony of certain patients in exceptional cases should not obscure the value of medical ethics or fundamental values at the end of life. While a court can make physician-assisted suicide legal, it cannot make it right. No matter how restrictive, all the rules and regulations capable of being conceived and promulgated may fail to protect the weaker members of society.

Long-Term Societal Ramifications

These troubling decisions may be less a victory for individual human rights than a step toward a society-wide "disease and defect" physical cleansing. Both courts found no difference between withdrawing treatment or furnishing patients with the means to kill themselves. But intentionally causing a patient's death by helping him or her inject lethal drugs is not a logical extension of other ethically and legally sound actions such as the right to die a natural death. Will the next court also fail to draw a bright distinction between physician-assisted suicide and active euthanasia?

Proponents of assisted suicide may be influenced by the cost containment efforts which are a major focus in the delivery of health care in the United States today. They must be wary of the next "logical" step -- the imposition of a "best interest" or "substituted judgment" standard for terminally ill patients, for example, those in persistent vegetative states who cannot express their constitutional rights to have their physicians cooperate in their deaths.

The Second Circuit Court stated that the discontinuance of artificial life-sustaining processes or the refusal to accept them in the first place hastens a patient's death "by means that are not natural in any sense." Rather, the alternative is true. Artificial processes serve as temporary interference, and their absence allows the dying process to continue on its course.

Some lines need to be drawn so sharply they will never be crossed. Physician-assisted suicide may be one of them. These decisions could send the message to patients in similar circumstances that the courts believe their lives are not worth living, that there is a societal willingness to dispose of dying human beings in the final days of life, and that it is the duty of the sick and the elderly to die.

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