Clinical Advances in Hematology & Oncology
December 2014, Volume 12, Issue 12
Assisted Suicide for Patients With Terminal Illness
“I don’t want to achieve immortality through my work . . . I want to achieve it through not dying.”
“I hope I die before I get old.”
—The Who, “My Generation”
“. . . or before I get too sick.”
On November 1, 2014, Brittany Maynard—who had reignited the right-to-die debate several weeks earlier by announcing she would end her own life—took a fatal dose of a barbiturate. This young woman had fatal, inoperable brain cancer. Radiation would have been barely palliative, and her natural demise would have been accompanied by pain and a loss of cognition. In order to carry out her carefully thought-out decision to take her own life, she had to move with her family from California to Oregon, which is one of the few US states that allows assisted suicide. Before she died, she wrote letters and spent time with her friends and family, even visiting the Grand Canyon for the first time. When she felt it was time, she died with her family at her bedside.
There is an important distinction between euthanasia and assisted suicide. In euthanasia, the lethal substance is administered by another person. This practice is illegal throughout the United States. In assisted suicide, the person self-administers the lethal substance. Death With Dignity laws allow a mentally competent adult with an illness leading to death within 6 months to request and receive a prescription medication to hasten death. At all times, the decision remains with the patient as to whether and when to take the medication. Patients sometimes die before taking the medication, or change their mind about taking it. Whether patients choose to use their prescription or not, many feel comforted to have it available if needed.
Assisted suicide is legal in Switzerland, Germany, Albania, Colombia, and Japan; voluntary euthanasia in the setting of hopeless and unbearable pain and suffering is legal in a number of other countries, including Belgium, Luxembourg, and the Netherlands. Quebec became the first Canadian province to pass right-to-die legislation. Hundreds of individuals have made use of the law, which some consider a success and others deem a failure.
Opponents of euthanasia and physician-assisted suicide contend that doctors have a moral responsibility to keep their patients alive, as reflected by the Hippocratic Oath. They argue there may be a “slippery slope” from euthanasia to murder. They also contend that legalizing euthanasia distracts from the need to find better ways to relieve pain and suffering, and will unfairly target the poor and disabled and create incentives for insurance companies to support the premature termination of lives to save money. Proponents say that these concerns should not override the right to autonomy.
I recently saw a review of surgeon Atul Gawande’s Being Mortal in the New York Times Sunday Book Review. The review was by Sheri Fink, the author of one of the books I read with my book club, Five Days at Memorial. I downloaded the book, and once I started reading it I was unable to stop. It is a marvelous discussion of the end of life and how to approach discussion of it with family, friends, and patients. It should clearly be required reading for all entering our profession, including doctors, nurses, social workers, and support staff. Not known for being overly touchy-feely myself, I found it revelatory. Life is more than safety and longevity; it is identity and autonomy, dreams and relationships. I gained a better understanding of what we can and cannot do for those nearing the end of life, and the importance of viewing life not only from the perspective of medical science but from that of the patient who has fears, wishes, and expectations. We can do so much more for our patients by promoting appropriate support and discouraging inappropriate intervention. Terminal patients who enter hospice care actually live longer than those who do not, and with a better quality of life.
But in my opinion, there comes a point when the suffering just ain’t worth it. As Kenny Rogers sang in “The Gambler”: “You got to know when to hold ’em, know when to fold ’em . . .”
Until next month . . .
Bruce D. Cheson, MD