Fred Marcus, M.D.
Modern medicine works miracles in prolonging life, even in situations
where patients and families may question the quality of that life.
Sometimes it is death instead that is prolonged, making terminally
ill patients into prisoners of technology.
Care at the end of life needs much more improvement, although
it has made tremendous progress with application of the principles
of palliative care and hospice. Much of the pain and other symptoms
can be relieved by experienced physicians and nurses, but certainly
not all, and not in every case. Suffering is also not just physical
but also psychological and spiritual, involving the quality of
life and one's sense of meaning. Only the individual can speak
to the question of when enough is enough.
Currently, physicians cannot legally offer comprehensive care
to the dying who are suffering despite the best medical expertise.
Only two options now exist.
The first is the so-called "double effect," in which enough painkiller
(usually morphine) is given to relieve suffering, and predictably
results in the patient's death. Today this is acceptable as long
as the overt intent of the physician was symptom relief and not
The second option is called "terminal sedation," in which the
patient is sedated into unconsciousness, becoming completely dependent
upon those around him until death arrives, usually brought on
by withdrawal of food and water.
These are the only approaches to terminal suffering that are
now legal. In both, the patient has no control over the process
and no ability to participate in a dignified manner in his or
her own death. A rational law, regulated and surrounded by safeguards,
would eliminate these current excuses for our inability to provide
terminally ill, suffering people with humane and compassionate
choices they can make themselves about their final days.
Carlos F. Gomez, M.D.
I have spent the last ten years of my life working with terminally
ill patients in various capacities. In addition to serving as
medical director for a hospice unit, I researched my dissertation
in the Netherlands, where I studied the euthanasia program instituted
by Dutch physicians in the 1970s. I found that attempts to "manage"
the problems of terminally ill patients through assisted suicide
or euthanasia inevitably lead to disastrous consequences. This
"modest" program is now used to justify the unilateral decision by physicians and other health care workers to intentionally
terminate the lives of handicapped newborns, or of the terminally
ill who are "lingering."
I point out the problems of the Dutch for several reasons. First,
the rationale for decriminalizing assisted death espoused by Dutch
physicians is quite similar to the reasoning that has gained wide
acceptance in the United States, i.e., physician-assisted death
enhances patients autonomy, and is an act of "mercy." Secondly,
there were broad assurances made that this sort of practice could
be well-controlled, and that it would not degenerate into indiscriminate
killing. The facts of the matter, however, argue otherwise.
Above and beyond the practical problems associated with physician-assisted
death, I do not feel that it is appropriate for physicians to
assist in killing patients. Society vests physicians with an enormous
amount of power with the understanding that we will use our knowledge
to try to heal and not kill patients. Many patients come to physicians
sick, vulnerable, and in need of care. The relationship with the
physician should be built on trust and the belief that the physician
will try to heal the patient. While I strongly believe that physicians
should assist patients in the process of dying by providing adequate
pain control and emotional support, intentionally killing patients
is unacceptable. As a hospice physician, I assure you that there
are alternative and more humane ways of caring for the terminally
ill than killing them outright.