Sherwin B. Nuland wrote a book about it: "How we Die". He has little patience with the idea of dignified or easeful deaths, and his accounts, while never gratuitous, spare you little. Here is the kind of detailed analysis of death normally found only in medical journals. He makes the point that death these days is a 'hidden secret', packaged, cleansed and removed from sight. He presents death 'in its biological and clinical reality'. Some of its harshest words are for Derek Humphry, founder of the Hemlock Society, and for his 'ill-advised cookbook', Final Exit. There is a chapter about suicide/euthanasia.
This is frigtening to the core.....
Physician-Assisted Suicide and Euthanasia in Practice
Sherwin B. Nuland, M.D.
Many readers of the
Journal who closely follow the national debate over euthanasia and assisted suicide may find themselves wondering why there has been so little discussion of the actual clinical outcomes of attempts to help patients end lives of intractable anguish. No matter how useful the guidance of tradition, the tenets of religion, the codes of ethicists and professional societies, or even the laws of the state, the critical ingredient of examined experience is all but missing from the debate. In this issue of the
Journal, Groenewoud and colleagues describe the Dutch experience with clinical problems in euthanasia and assisted suicide.
1 Their report helps fill the huge gap in our knowledge. But it is only a beginning — and necessarily an imprecise one at that.
Surveys of physicians' experiences are prone to inaccuracy. Moreover, in this particular group, the possibility of error in the form of underreporting was compounded by the fact that approximately 10 percent of the potential respondents refused to take part in the study. Why? When outcomes are being carefully overseen by government and professional authorities, it seems likely that the physicians whose patients experienced the worst complications would be most reluctant to answer questions about untoward events.
But even with the data reported by willing participants, the incidence of complications was noteworthy in cases in which physicians provided assistance with suicide or performed euthanasia. This is information that will come as a shock to the many members of the public — including legislators and even some physicians — who have never considered that the procedures involved in physician-assisted suicide and euthanasia might sometimes add to the suffering they are meant to alleviate and might also preclude the tranquil death being sought. Not only are patients hurt by such untoward events as those described by Groenewoud and colleagues, but so are the family members who witness or hear of them.
In view of what the Dutch authors describe, it is of interest that neither the report on the first year of experience with legalized physician-assisted suicide in Oregon
2 nor the two other reports on the subject in this issue of the
Journal (the report by Sullivan et al. on the second year of experience in Oregon
3 and that by Ganzini et al. on physicians' experiences
4) note any complications. In one of the few American reports on the subject, Emanuel and colleagues
5 state that 15 percent of attempts at physician-assisted suicide were unsuccessful, as determined by telephone interviews with the participating oncologists. The investigators did not inquire about complications. According to another American report,
6 none of 204 attempts at physician-assisted suicide in the state of Washington failed. In this study as well, no questions were asked about complications.
The Dutch report therefore introduces a new element into the calculus of our national debate, one that should have made its appearance long ago: patients who wish to receive help in dying face a small but nevertheless worrisome possibility that some untoward event will prevent the smooth accomplishment of their wish. Not surprisingly, Groenewoud et al. report that complications were more likely with physician-assisted suicide than with euthanasia. Moreover, in 21 of 114 cases in which the original intention was to provide assistance with suicide, the attending physician found it necessary to intervene by administering a lethal drug, usually because things were not going as they should have.
Opponents of physician-assisted suicide will look at these complications as evidence to support their viewpoint, and they are justified in doing so. But those who believe that in certain, carefully controlled situations, providing assistance with suicide is an ethical responsibility should see the findings in an entirely different light. Doctors are unprepared to end life. If this is a burden to be taken on and if the medical profession accepts it as falling within the realm of individual conscience, then thorough training in techniques must be made available. Until only a few years ago, most of us were dreadfully inadequate at providing palliative care for our patients, because little attention was paid to such matters in our daily work. The situation is greatly improved today, but only because of public demand. We are now hearing, if not a clear demand, a strong sentiment in favor of medical assistance in dying. It is only a matter of time before organized medicine recognizes the pragmatic necessity to support physicians who feel they have a moral obligation to provide such assistance. They should do so with the attention to detail that all aspects of medical practice demand. Better sooner than later.
There is no certain way to explain the relative absence of complications reported in the sparse American literature on physician-assisted suicide. But I doubt that such findings will hold up in the long term. Perhaps larger numbers of cases will change them, and increasing acceptance on the part of physicians may result in a greater willingness to report untoward events. Is it really possible that debilitated, terminally ill people, in physical and mental anguish, will unfailingly succeed in attempts to end their lives without medical help? Can
any experienced witness to dying believe such a thing?
The Dutch findings seem more credible. In evaluating them, we should not neglect one obvious lesson. The report by Groenewoud et al. provides ample reason why the Royal Dutch Medical Association has been wise in its recommendation that a physician be in attendance when lethal measures are instituted. If the prevention and relief of suffering are the aims of medical interventions — and not only the preservation or prolongation of life — it seems imperative to rethink our profession's reluctance to participate in euthanasia or even be present during an assisted suicide without legal guarantees of protection.
Many opponents of these practices point to the Hippocratic Oath and its prohibition on hastening death. But those who turn to the oath in an effort to shape or legitimize their ethical viewpoints must realize that the statement has been embraced over approximately the past 200 years far more as a symbol of professional cohesion than for its content.
7 Its pithy sentences cannot be used as all-encompassing maxims to avoid the personal responsibility inherent in the practice of medicine. Ultimately, a physician's conduct at the bedside is a matter of individual conscience. The wisdom of past years and moments enters into the deliberation, but decision making in the present bears a burden that is unique to the particular transaction between the doctor and the individual patient who has come for help. To seek refuge in ancient aphorisms is to turn away from the unique needs of each of our patients who have entrusted themselves to our care.
Physicians who believe that it is a person's right to choose death when suffering cannot otherwise be relieved must turn to their consciences in deciding whether to provide help in such a situation. Once the decision to intervene has been made, the goal should be to ensure that death is as merciful and serene as possible.
