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Doctors are apparently hungry for information. Steven Heilig, director of the Bay Area Network of Ethics Committees, an umbrella organization for the region's hospital ethics committees, recalls a meeting at which two physicians from the Netherlands gave a presentation on the Dutch system of physician-assisted suicide: "Someone asked a clinically specific question -- I think it was about dosage -- and this sea of pens suddenly emerged, poised to write down everything they said."

As a highly controversial yet widely practiced procedure undertaken haphazardly, and below the radar of medical schools and professional associations, assisted suicide invites comparison to abortion in the years before Roe vs. Wade. But the present case is unlikely to be settled by judicial fiat: The Supreme Court ruled unanimously in 1997 that physician-assisted suicide is not a right protected by the Constitution, and that states should decide the matter.

At the same time, the court also reaffirmed the legality of the "double effect" -- the prescription of pain medication that may incidentally hasten a patient's death. The key distinction is intent: If a physician's intent is to alleviate pain, the act is defended by the Supreme Court; if the intent is to cause death, the court provides no protection.

Of course, clinical realities are seldom as clearly defined as legal ones. The theory of the double effect does not accommodate "the ambiguity of clinical intentions," says one physician, who describes his experience of hoping simultaneously to extend his patient's life and aid in her death.

Many opponents of physician-assisted suicide accept the propriety of the double effect. This is due in large part to growing interest in palliative care, the medical treatment of pain and suffering. In a paper published this year by the National Conference of Catholic Bishops, Dr. Carlos Gomez, director of the palliative care program at the University of Virginia, argues in support of the double effect:

"The question, 'What is the maximum dose of morphine for a cancer patient in pain?' has one answer: 'The dose that will relieve the pain.'"

The furthest reach of palliative care is terminal sedation: drugging a patient into unconsciousness and keeping him that way until he dies, usually days or weeks later. Terminal sedation is practiced openly and without much controversy, and it does not seem to carry a high incidence of complication.

George Annas, professor of health law at Boston University, says the issue is not a question of "suicide or not suicide. The issue is taking care of dying patients. There's nothing illegal, immoral or unethical about that."

Opponents of assisted suicide generally support terminal sedation and stress the distinction between the two. "While some terminally ill patients may die under such sedation," Gomez writes, "this is generally because they were imminently dying already."

But many who work with the dying see acceptance of physician-assisted suicide as an eventual outgrowth of palliative care.

"People are becoming more and more aware of the dilemmas that occur at the end of life and the inadequacy of current legal options," says Lee. "Deaths are not behind the curtain in intensive care units, they're right at home with family members taking on the responsibilities of day-to-day care and coming to understand that people die painfully and by inches."

Greater understanding, however, is not likely to lead to broad acceptance of assisted suicide anytime soon. In 1997 and 1998, bills to legalize physician-assisted suicide appeared in 26 states; not one was passed into law. A federal bill that would overturn Oregon's physician-assisted suicide law recently passed the House and is moving through the Senate. For the time being, physician-assisted suicide is destined to remain illegal, underground and imprecise.
salon.com | April 19, 2000

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