Experts Debate Legalization of Physician-Assisted Suicide

ASCO--As the country awaits a Supreme Court decision on the constitutionalityof state laws forbidding physician-assisted suicide, two physicians presentedboth sides of the debate at an ASCO session on end-of-life issues.

Marcia Angell, MD, executive editor of the New England Journal ofMedicine, supports physician-assisted suicide under certain circumstancesbased on the concepts of patient autonomy and the physician's obligationto act compassionately in the patient's interest.

"Even with excellent palliative care, it's simply not true thatall pain can be relieved short of rendering the patient unconscious, andother symptoms may be even harder to treat," Dr. Angell said. Ultimately,she said, it is the patients themselves who must decide whether their palliativecare is sufficient.

Dr. Angell believes physicians should not draw a distinction betweenremoving life-sustaining treatment to hasten death at a patient's requestand actively helping a patient to die by prescribing a barbiturate overdose.She emphasized that if physician-assisted suicide were legal, no physicianwould be required to perform it.

Finally, she asked, "What possible interest does society have inrequiring dying people to suffer longer? This is not a matter of life vsdeath but of a faster death vs a slower, more agonizing death."

In presenting the opposing arguments, Kathleen Foley, MD, co-chief ofthe Pain and Palliative Care Service, Memorial Sloan-Kettering Cancer Center,stressed that the issue is not just one for physicians but for society,and that a national discourse on the issue is needed.

She suggested that society cannot make appropriate decisions about physician-assistedsuicide in an environment in which physician education in palliative careis inadequate and the lack of a national health care system allows economicconcerns to intrude on the debate.

The Reasons Patients Give

Dr. Foley's major argument against physician-assisted suicide concernsthe reasons patients give for seeking it. "Most patients are requestingphysician-assisted suicide because of profound existential issues, notissues of pain," she said. Existential distress includes patients'fears of being a burden, of being dependent on others, and of sufferinga loss of dignity, she said, adding that "physicians are not trainedto address these concerns."

She also cited the difficulty several major organizations, includingthe New York Academy of Medicine and the Oregon Medical Association, havehad in preparing guidelines for physician-assisted suicide.

"They've come up against the fact that they can't regulate theunregulatable," she said. She noted that several organizations havemade statements against physician-assisted suicide because they perceivedan inability to provide adequate safeguards for the public.

In response, Dr. Angell said that concerns about education in palliativecare and lack of health care access are "in and of themselves nota reason to deny physician-assisted suicide to those very few individualswho need and desire it. We can advocate for all of these things at thesame time."