Dying With Dignity
Original article was published by World Health Forum (WHO) 1998, Vol. 19, No. 4: 429-430. The readers are encouraged to read the Round Table Discussion.
Every one of us will be confronted by our own death and that of the people we care about, yet it is difficult to name any other fact of life that is so fiercely resisted. In our culture denial of death is pervasive. In the past, death at home surrounded by relatives was perhaps easier to accept as a natural event. Now that more people die in hospitals, set apart from the living, death seems all the more mysterious, frightening and remote from our existence.
Hospice care has accomplished a great deal in preventing the lonely and painful deaths that many people fear, and we physicians caring for people dying from cancer or AIDS find it difficult to discern a need for physician-assisted suicide. It is deceptive and demeaning to suggest that all such requests are the result of inadequate professional care, psychopathology, or the spiritual weakness of patients. Nevertheless, surveys show a growing acceptance of physician-assisted suicide by the medical community, even though it is a power many doctors do not want to have.
Despite laws against it, it is generally accepted that assisted suicide is practiced, particularly by physicians treating AIDS patients. Without this possibility, patients may attempt to end their lives early on and without assistance because they are afraid of losing control and of becoming unable to act as their illness progresses. Especially if they are distressed enough to end their lives in a violent way, their families bear that scar for ever. A planned, assisted suicide, it is argued, allows for reconciliation and saying goodbye: there is a peacefulness that does not occur otherwise. The movement to legalize physician - assisted suicide does not say that people ought to die in this way, but that they should have the option to do so if they wish.
In this view of the situation, the question of who administers the final medication to a terminally ill person may be less important than that of who determines whether that life should end. Guidelines on eligibility for assisted suicide would guard against abuses; their development should include such verifiable terms as "terminally ill", "mentally competent", and "adult". As long as the practice is covert there is no hope of establishing such guidelines. Meanwhile, the American Medical Association, which considers physician - assisted suicide "fundamentally incompatible with the physician's role as healers", plans to launch a programme to educate doctors and patients on the best end-of-life care.
In July 1997 the US Supreme Court unanimously ruled that terminally ill patients do not have a constitutional right to physician-assisted suicide, but did not bar states from legalizing the practice. I see this decision as one step in a very long process: the debate about the legality and practicality of physician-assisted suicide should continue in our democratic society, and state legislature may be a better forum that federal courts for dealing with the thorny issue.
Assisted suicide is currently illegal in 44 US states and the District of Columbia, and the law is unclear in five other states. In Oregon, physician-assisted suicide was legalized in 1994 but has not been put into effect; 18 states have been considering initiatives for or against the matter in recent months, but no legislative support for assisted suicide has been forthcoming.
Dr. Rita Luthra
Director, Women's Health & Education Center
Readers may be interested in WHO's Round Table discussion on terminal care:
Abiven M. Dying with dignity.
World Health Forum, 1991, 12: 375-381;discussion 382-399.
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