Death without dignity

When a physician-assisted suicide goes wrong, the end can be brutal. But nobody is teaching doctors how to do it right.

By Jacob Goldstein

It’s easy to forget how hard it is to kill someone. The body has an uncanny tendency to endure: The heart pumps; the lungs fill and empty; the organism persists in the face of overwhelming adversity.

Nevertheless, one would expect that a physician who was so inclined — who wanted, for example, to give a terminally ill patient a prescription for a painless and peaceful death — could readily use the modern pharmacopeia to bring a swift, sure end to life. But recent evidence suggests that attempts at physician-assisted suicide often meet with unexpected complications. What’s more, almost no one in the medical community is doing anything about it.

“If we’re going to do this, we should do it right,” says Dr. Sherwin Nuland, a surgeon at Yale Medical School.

A study published in the New England Journal of Medicine suggests that things can, and do, go wrong in physician-assisted suicide.

In 7 percent of 114 cases analyzed, patients suffered complications such as regurgitating a would-be lethal dose of drugs. In 16 percent of cases, death did not happen as expected: It took longer, or patients slipped into a protracted coma, or didn’t go into a coma, or even woke entirely after metabolizing the drugs. The study was done in the Netherlands, where physician-assisted suicide is closely monitored by the government.

No one knows how often complications occur in the United States. A threatening legal environment, widespread social controversy and an element of medical machismo that equates death with failure conspire to drive physician-assisted suicide underground. But anonymous surveys over the past decade make one thing clear: Although they often don’t discuss the matter with colleagues, it is not uncommon for U.S. doctors to help bring death to terminally ill patients.

There is no reason to believe that assisted suicide attempts run into fewer complications in this country. In fact, it seems logical to assume that the more open practice in the Netherlands would lead to a greater sharing of information and fewer complications there. The Dutch data raise a haunting question: How often do brutally sick patients who try to end their lives painlessly wind up suffering ugly, violent deaths?

In an editorial that accompanied the Dutch study, Nuland argued that organized medicine should attend to physician-assisted death “with the attention to detail that all aspects of medical practice demand. Better sooner than later.”

Within the U.S. medical establishment, however, Nuland’s is a rare voice. Even in Oregon, the only state where physician-assisted suicide is legal, doctors don’t much discuss the how-to’s or anything else about the practice.

“Many physicians are very happy to participate on an individual basis, but they remain concerned for their public reputations,” says Barbara Coombs Lee, executive director of the Oregon advocacy group Compassion in Dying. “The opponents of this practice can be brash and harsh and vitriolic, and physicians are not eager to expose themselves to that. And the universities and professional societies that sponsor continuing education have not been ready to address the clinical practice of physician-assisted dying.”

“There’s not a med school in this country that trains its students for physician-assisted suicide,” says Nuland. Medical literature offers almost no practical advice on the practice.

Doctors are apparently hungry for information. Steven Heilig, director of the Bay Area Network of Ethics Committees, an umbrella organization for the region’s hospital ethics committees, recalls a meeting at which two physicians from the Netherlands gave a presentation on the Dutch system of physician-assisted suicide: “Someone asked a clinically specific question — I think it was about dosage — and this sea of pens suddenly emerged, poised to write down everything they said.”

As a highly controversial yet widely practiced procedure undertaken haphazardly, and below the radar of medical schools and professional associations, assisted suicide invites comparison to abortion in the years before Roe vs. Wade. But the present case is unlikely to be settled by judicial fiat: The Supreme Court ruled unanimously in 1997 that physician-assisted suicide is not a right protected by the Constitution, and that states should decide the matter.

At the same time, the court also reaffirmed the legality of the “double effect” — the prescription of pain medication that may incidentally hasten a patient’s death. The key distinction is intent: If a physician’s intent is to alleviate pain, the act is defended by the Supreme Court; if the intent is to cause death, the court provides no protection.

Of course, clinical realities are seldom as clearly defined as legal ones. The theory of the double effect does not accommodate “the ambiguity of clinical intentions,” says one physician, who describes his experience of hoping simultaneously to extend his patient’s life and aid in her death.

Many opponents of physician-assisted suicide accept the propriety of the double effect. This is due in large part to growing interest in palliative care, the medical treatment of pain and suffering. In a paper published this year by the National Conference of Catholic Bishops, Dr. Carlos Gomez, director of the palliative care program at the University of Virginia, argues in support of the double effect:

“The question, ‘What is the maximum dose of morphine for a cancer patient in pain?’ has one answer: ‘The dose that will relieve the pain.’”

The furthest reach of palliative care is terminal sedation: drugging a patient into unconsciousness and keeping him that way until he dies, usually days or weeks later. Terminal sedation is practiced openly and without much controversy, and it does not seem to carry a high incidence of complication.

George Annas, professor of health law at Boston University, says the issue is not a question of “suicide or not suicide. The issue is taking care of dying patients. There’s nothing illegal, immoral or unethical about that.”

Opponents of assisted suicide generally support terminal sedation and stress the distinction between the two. “While some terminally ill patients may die under such sedation,” Gomez writes, “this is generally because they were imminently dying already.”

But many who work with the dying see acceptance of physician-assisted suicide as an eventual outgrowth of palliative care.

“People are becoming more and more aware of the dilemmas that occur at the end of life and the inadequacy of current legal options,” says Lee. “Deaths are not behind the curtain in intensive care units, they’re right at home with family members taking on the responsibilities of day-to-day care and coming to understand that people die painfully and by inches.”

Greater understanding, however, is not likely to lead to broad acceptance of assisted suicide anytime soon. In 1997 and 1998, bills to legalize physician-assisted suicide appeared in 26 states; not one was passed into law. A federal bill that would overturn Oregon’s physician-assisted suicide law recently passed the House and is moving through the Senate. For the time being, physician-assisted suicide is destined to remain illegal, underground and imprecise.