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Neurology Today:
doi: 10.1097/01.NT.0000407801.63464.30
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Viewpoint: Can Physicians Really Provide Death with Dignity?

Masdeu, Joseph C. MD, PHD

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I read with interest the Viewpoint by Dr. Lynne Taylor supporting assisted suicide (“Can We Really Prepare for Enabling ‘Death with Dignity’?” July 7). As this piece was written by someone I know first-hand to be an excellent and caring neurologist, I wondered whether I could consider as an ethical option to use medication with the main purpose of shortening my patients' lives. After careful consideration, I concluded I could not. For stressed terminal patients the ethical option is palliative care.

DR. JOSEPH C. MASDEU...
DR. JOSEPH C. MASDEU...
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Palliative care is neither assisted suicide nor euthanasia. In palliative care analgesics are used with the primary purpose of alleviating pain or suffering, even if as a side effect their use shortens the patient's life. But the goal is not to shorten the patient's life, which continues to be precious to the physician. Foregoing therapies that may prolong someone's agony uselessly is not assisted suicide either, but has been found to be sound practice and a wise use of resources.

If assisted suicide is a legitimate option, one would wonder why, as Dr. Taylor pointed out, all the physicians at the palliative care service at the University of Washington, are “opting out” of it? And why, when in 1997 the Supreme Court considered (and rejected) a constitutional right to assisted suicide, all the medical societies, including the AAN, contributed amicus curiae briefs against assisted suicide? In these and other documents I found many reasons that make assisted suicide unadvisable.

For one, instances where medical motivations are used to justify assisted suicide can be better addressed by means other than shortening purposely the patient's life. As pointed out by the Neurology Today editorial, patients in the throes of death seldom request assisted suicide. More often patients are moved by concerns about future loss of control, loss of dignity, or pain. These concerns can be met by reassuring the patient of a continuing commitment to attentive comfort care, by appropriate analgesia and treatment of depression and, often, by assisting the patient to confront an underlying and unspoken fear of death.

A full approach to palliative care addresses spiritual and existential feelings as well as personal and social burdens, using a team approach that draws on social workers and pastors as well as physicians and nurses. Clinicians with experience assisting dying patients to confront such concerns report that the desire for death passes, and that patients say they have found unexpected meaning in their lives that makes their final days worth living. Actually, but not paradoxically, palliative care is neglected in the few countries with laws allowing assisted suicide: terminating life is perceived as more expedient.

Admitting the practice of assisted suicide opens the door to the practice of involuntary euthanasia. Even when patients “consent” to assisted suicide, they may do so under feelings of guilt about being a burden to their families or society. Criteria for assisted suicide like those from Oregon presume the ability on the part of the physician to make the necessary assessments on an objective basis. However, case studies from the United States and the Netherlands demonstrate that a physician's willingness to assist in suicide is itself a powerful influence on the decision of a patient with suicidal tendencies, and that such physicians are not capable of making an objective assessment of the impact their attitude has had upon the patient.

Once the societal taboo against physician-assisted killing is lifted, there is a natural tendency for physicians to expand the “benefits” of euthanasia to incompetent patients in a frightening way.

The Netherlands provides an example of how a judicial decision allowing assisted suicide (1984) was followed in due time by a law allowing euthanasia for patients with diminished capacity (2002). Even when the judicial rules required the consent of the competent patient, numerous reports described cases of involuntary euthanasia. The frequency of involuntary euthanasia was estimated at 0.7 percent of total deaths in 1995. Interpretation of the law by many of the physicians practicing assisted suicide was very lax, admitting involuntary euthanasia.

A further step in this road is well documented in a horrifying but enlightening paper that should be read by any physician considering the practice of assisted suicide. After extensive research on the medical culture of the Germany of the 1930s, then the medical Mecca of the world, Leo Alexander concluded in a leading New England Journal of Medicine article about the atrocities of Nazi physicians in 1949: “Whatever proportion these crimes finally assumed, it became evident to all who investigated them that they started from very small beginnings. The beginnings at first were merely a subtle shift in emphasis in the basic attitude of the physicians. It started with the acceptance of the attitude, basic to the euthanasia movement, that there is such a thing as life not worthy to be lived.”

As a physician, I have witnessed the death of some of my patients. They died with dignity, helped by compassionate care and analgesics when needed. Had they killed themselves, would their deaths have been any more dignified?

Dr. Masdeu has practiced clinical neurology for more than 30 years, 21 of them as departmental chairperson. Currently he is a senior physician at the NIH, but the views expressed in this work are his own and do not represent an official position of the NIH.

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REFERENCES:

• Taylor LP. Viewpoint: Can we really prepare for enabling ‘death with dignity’? Taylor LP. Neurology Today 2011; http://bit.ly/o46KP6

• Bernat JL. Ethical and legal issues in palliative care. Neurol Clin 2001;19:969–87.

• Coleson RE. The Glucksberg & Quill amicus curiae briefs. Issues Law Med 1997;13:1–99.

• Vincent Humbert's letter to Chirac. BBC News, 2003 Sept. 26. http://bbc.in/ppEDYF

• Cohen-Almagor R. Non-voluntary and involuntary euthanasia in the Netherlands: Dutch perspectives. Issues Law Med 2003;18:239–57.

• Alexander L. Medical science under dictatorship. N Engl J Med 1949; 249:39–47.

©2011 American Academy of Neurology

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