Opinions: Viewpoints

Is it appropriate for a doctor to help someone to die?

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 death.

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.

Fred Marcus, M.D., President of the Board of Directors of the Death With Dignity Education Center, is a practicing medical oncologist at the Sequoia Medical Group in Redwood City and former two-term Chairman of the Department of Medicine at Sequoia Hospital in Redwood City. He is a former member of the academic faculty of UCSF. As an oncologist, he has sought to educate others on medical aspects of end-of-life decisions. Carlos F. Gomez, M.D., is currently an Assistant Professor of Medicine at the University of Virginia School of Medicine. He is also a hospice physician, and medical director of the Center for Hospice and Palliative Care at the University of Virginia. In addition to his medical training, he also has a background in medical ethics, and holds a doctorate in public policy studies from the University of Chicago.
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