ASCO--As the country awaits a Supreme Court decision on the constitutionality
of state laws forbidding physician-assisted suicide, two physicians presented
both sides of the debate at an ASCO session on end-of-life issues.
Marcia Angell, MD, executive editor of the New England Journal of
Medicine, supports physician-assisted suicide under certain circumstances
based on the concepts of patient autonomy and the physician's obligation
to act compassionately in the patient's interest.
"Even with excellent palliative care, it's simply not true that
all pain can be relieved short of rendering the patient unconscious, and
other symptoms may be even harder to treat," Dr. Angell said. Ultimately,
she said, it is the patients themselves who must decide whether their palliative
care is sufficient.
Dr. Angell believes physicians should not draw a distinction between
removing life-sustaining treatment to hasten death at a patient's request
and actively helping a patient to die by prescribing a barbiturate overdose.
She emphasized that if physician-assisted suicide were legal, no physician
would be required to perform it.
Finally, she asked, "What possible interest does society have in
requiring dying people to suffer longer? This is not a matter of life vs
death but of a faster death vs a slower, more agonizing death."
In presenting the opposing arguments, Kathleen Foley, MD, co-chief of
the 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-assisted
suicide in an environment in which physician education in palliative care
is inadequate and the lack of a national health care system allows economic
concerns to intrude on the debate.
The Reasons Patients Give
Dr. Foley's major argument against physician-assisted suicide concerns
the reasons patients give for seeking it. "Most patients are requesting
physician-assisted suicide because of profound existential issues, not
issues of pain," she said. Existential distress includes patients'
fears of being a burden, of being dependent on others, and of suffering
a loss of dignity, she said, adding that "physicians are not trained
to address these concerns."
She also cited the difficulty several major organizations, including
the New York Academy of Medicine and the Oregon Medical Association, have
had in preparing guidelines for physician-assisted suicide.
"They've come up against the fact that they can't regulate the
unregulatable," she said. She noted that several organizations have
made statements against physician-assisted suicide because they perceived
an inability to provide adequate safeguards for the public.
In response, Dr. Angell said that concerns about education in palliative
care and lack of health care access are "in and of themselves not
a reason to deny physician-assisted suicide to those very few individuals
who need and desire it. We can advocate for all of these things at the