Assisted suicide and Euthanasia: the illusion and faade

Dorothy Guellec


are the long-standing ethics of our health care system suddenly so threatened?

Maybe it is all about money, or is it? HMO’s already induce physicians to keep

costs low, using a combination of financial rewards or punishments, which create

in my opinion an implicit conflict of interest between doctors and some

patients. After the Supreme Court decision in 1997 states took it upon

themselves to change the terrain re: legalizing physician-assisted suicide. Is

it merely coincidence that the first state to approve a program of explicit

health care rationing is also the first state to approve physician-assisted

suicide? Maybe it is courage and not coincidence, but at the same time, it is

interesting to find the first operational assisted suicide law so plainly

juxtaposed against “the first openly acknowledged system of health care

rationing.” I was talking about Oregon. The physician assisted suicide ballot

initiative in Maine was not approved.    


study soon to be published in JAMA (Journal of the American Medical Association)

indicates that interest in euthanasia and PAS (physician assisted suicide) among

dying patients is more often related to psychological distress than physical

symptoms. This study was done with private funding from the Commonwealth Fund

and the Nathan Cummings Foundation. According to the study about one in ten

terminally ill patients said they seriously considered using physician-assisted

suicide or euthanasia to end their own lives, and “just a fraction of these

attempted to act on their thoughts.” The findings point out that despite the

highly charged public debate surrounding PAS and euthanasia, the majority of

dying patients would not consider this option for themselves. As I pointed out

in a previous Commentary many people change their minds and this was confirmed

in the Commonwealth/Cummings study. The research is the first major assessment

of terminally ill patients’ attitudes about assisted suicide and euthanasia.

The authors of this study caution physicians who receive requests for euthanasia

or PAS to think first about depression and “other psychological stressors.”


I began to investigate Oregon’s first year and the claim that “no abuses

were reported” my spontaneous reaction was “Wow! No kidding?” Wouldn’t

common sense dictate the greatest care by proponents to put their best foot

forward, to pick as PAS candidates those who would most easily pass public

inspection? Would any physician be foolish enough to step forward and confess

violating the law? Since there is no statutory requirement that abuses be

reported by doctors or lay people, nor strong incentives to do so, why should we

expect to hear about them?


debate about guidelines continues without resolution. In the Netherlands where

euthanasia and physician assisted suicide were decriminalized guidelines were

established but very little can be learned from the Dutch experience. The force

and legality of their guidelines are questionable. Many physicians do not follow

the guidelines and high rates of noncompliance have been reported. This would be

different I’m sure were the practice completely legal. Perhaps the harshest

indictment of efforts to construct guidelines comes from Callahan and White who

dismiss all efforts at constructing guidelines as “an elaborate regulatory façade

concealing a poverty of potential for actual enforcement.” The main reason for

thinking that the slope around physician-assisted suicide might be too slippery

even for the most carefully crafted guidelines, is that the presumptions behind

the guidelines are inherently slippery in ways that no amount of regulatory

precision can fix. Doctor patient relationships are private and sacred and

cannot be monitored, and what cannot be moderated cannot be regulated. Callahan

and White are very exacting in their long (83) pages Univ. of Richmond Law

article “the Legalization of Physician Assisted Suicide: Creating a Regulatory

Potemkin Village.” The title implies that a façade would be erected with the

regulations and guidelines, but behind the façade or illusion of regulation

there would be nothing at all.


PAS (physician assisted suicide) is not, as many like to put it, simply a

logical extension of the physician’s duty to relieve pain and suffering, an

old obligation in a new garment. Maybe PAS appeals to those who must be in

control. It may turn out that catering to this compulsion for control represents

far greater abuse than a failure to adhere to the law. A study in the New

England Journal of Medicine (February 24, 2000) about physicians’ experiences

with the Oregon Death with Dignity Act pointed out that 46% “of the patients

for whom substantive interventions were made, changed their minds about assisted

suicide.” The conclusion and data suggest that in Oregon physicians grant

about 1 in 6 requests for a prescription for a lethal medication and that 1 in

10 actually culminate in suicide. Substantive palliative interventions (pain

relieving) lead some – but not all – patients to change their minds.


and the media have focused primarily on the importance of personal autonomy in

the context of the “right to die”, little attention has been paid to

concurrent efforts to disregard autonomy when a dying or disabled person wants

care that bioethicists, moral philosophers, doctors, and above all managed-care

health insurance executives deem “futile’. Futile Care Theory goes something

like this. When a patient reaches a certain “predefined stage of illness, or

injury, any further treatment other than comfort care shall be deemed

“futile” and shall therefore be withheld, regardless of the desires of the

patient or family.” The personal values and morals of the patient are no

longer relevant. End of story, and often, end of life. Physicians must place the

patients’ interests above the cost considerations of third party payers or

their own monetary benefit.


his new book “The Culture of Death: the Assault on Medical Ethics in

America” (dedicated to Ralph Nader) Wesley J. Smith devotes many pages to

Futile Care Theory and its implications .He says that the serious implications

of rationing were “revealed in 1994 by Robert M. Vearch, who wrote

apocalyptically, ‘the era of health care rationing is upon us!’ He urged

rationing via global budgeting in which an administrator of a state health plan,

a hospital, a specific hospital department, or a health maintenance organization

would be given a fixed pile of money. The amount would not be enough for every

physician to do everything for every patient. How would this money be allocated?

By “the community,” guided by “religious and philosophical traditions”

– in other words by Bioethicists. The first casualty would be the Hippocratic

Ethic, which he (Robert M. Veatch) urges we discard because it “specifies in

its most crucial central principle that the individual physician should benefit

the patient according to the physician’s ability and judgment.” Would you

trust a physician with your very life? Think about this very carefully in the

light of Futile Care Theory.


older folks have a duty to die because of the financial and emotional burdens of

caring for the elderly, disabled, and chronically ill? The premier advocate for

the “duty to die” is an East Tennessee University philosophy professor, John

Hardwig. Hardwig takes the “deconstruction of the Hippocratic tradition to a

new level, asserting that it is sometimes the moral thing to do for a physician

to sacrifice the interests of his or her patients to those of

non-patients—specifically to those of the other members of the family.” In

my humble opinion John Hardwig is a loose canon, a very dangerous individual who

refuses to see that the problem is all about money, and that we do not live in

an altruistic country.


doctor wrote on a listserv “The reason I do not have a living will or any

other document is that I believe the wind has shifted in the wrong direction. I

believe there is more of a chance that that paper will hurt me (end my life

prematurely) then help me. Of course I am fortunate enough to have loving people

at my side. HMO’s and others use that paper as a budget balancer.” How many

of us are as fortunate as that doctor? What are the larger societal issues

involved when money and health care allocation collide?



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