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Am Fam Physician. 1998;57(3):427-433

to the editor: I wish to discuss the editorial by Drs. Brody and Vandekieft,1 which pleads that physicians approach a patient's request for assisted suicide from a morally neutral stance in order to discuss it thoroughly, and reach an agreement that strengthens the physician-patient relationship. To support this opinion, the authors cite “Quill's paradox,” which says that most patients given a means for suicide will not use it, but instead will find the option of personal deliverance merely a comforting idea. I wish to question several of the authors' assumptions.

First, some have pointed out that rational suicide is a cultural phenomenon, most popular in the well-educated affluent Caucasian community.2,3 For the most part, however, requests for suicide and suicide attempts are not unencumbered and rational, but are due to psychiatric depression.4

Second, Quill is quite well-known as a major promoter of assisted suicide;5 his “law” is most undoubtedly based on anecdotal experience. However, Hendin, a psychiatrist and the executive director of the American Suicide Foundation, warns that “a doctor who suggests euthanasia as an option to a patient ... or relatives who respond too readily to a patient's mention of euthanasia send a powerful message that they believe that the patient should not continue to live. In such cases, we are not dealing with autonomy or the patient's right to die, but with ... their right to influence the ending of a life that has become a burden, or that they think is not worth living ... ”6

Indeed, a poll of dying patients confirms that assisted suicide is rarely wished for, except in those patients where clinical depression is present.7 As for strengthening the physician-patient relationship, it should be noted that in the same poll, a small but significant percentage of patients said they would actually change physicians if they knew their physician were in favor of euthanasia.7

Third, the authors' insistence that physicians who hold a moral position condemn a patient's actions is ridiculous. Most physicians encourage their patients to discuss their fears, hopes and darkest impulses. It is our duty to listen, to understand and to advise our patients of their options, including that option which we feel is best.

I suspect that what the authors are actually proposing is something a bit different: that assisted suicide should be considered a purely private issue, in the same way that Roe vs. Wade has made abortion an absolutely private matter in which physicians, family members, religious leaders and legislatures have no right to interfere with a woman's private choice. This would, of course, effectively silence any public debate over or opposition to euthanasia. However, the editorial takes this further than Roe vs. Wade, which does not assume physician neutrality, but views the physician involved as a moral agent who brings his medical and psychiatric knowledge to a woman's decision.

As physicians, we cannot and should not ignore the societal aspects of euthanasia, especially since the law would position us as enforcers of such a public policy. When medical societies have been morally neutral on this subject, the public interprets this silence as support for such a policy. Approval of any suicide is a dangerous public policy, for it encourages more suicides among the depressed, and in the case of physician-assisted suicide, leads to the idea that some lives are not worth living and are better off dead.

An example of how easily a discussion concerning assisted suicide for the competent can turn into approval of unwanted active euthanasia for the handicapped can be seen in the editorial; although it is intended as discussion of requested rational suicide, it begins with an anecdote in which active euthanasia is requested not by a patient but by a relative of a disabled person because the caretaker feels the patient is a burden. If good and honorable men such as the authors have accidentally become confused at the difference between such requests and a patient's presumably rational desire for suicide, how much will this confusion spread in a community where not all are such good and honorable men?

in reply: Dr. O'Connor has offered a number of thoughtful comments on physician-assisted suicide. Rather than reply point by point, we would rather view her letter as helpful warning of ways in which our original editorial is open to misunderstanding. These misunderstandings highlight the need for open, deliberative dialogue on this complex and controversial topic.

Our central point was that assisted suicide is a “hot button” topic for many if not most family physicians, and the immediate emotional reaction to a patient's raising this issue might work against the optimal therapeutic process. Fortunately, we argued, the supportive and compassionate approach to the patient will differ little, regardless of whether the physician is morally in support of or opposed to physician-assisted suicide. The first task in either case is to determine what has caused the patient to seek such a “solution” and then to explore alternative ways of dealing with the suffering.

We assumed in framing our recommendations that the physician would have a strong moral stance on the subject of suicide assistance, and so we had no intention of calling for “moral neutrality.” Moral neutrality and a compassionate, inquiring, nonjudgmental attitude toward the patient are two very different things. In calling assisted suicide a “very personal” issue, we meant to address its emotional impact on the physician, rather than to suggest that it should be seen as a purely private transaction for purposes of public policy.

We applaud Dr. O'Connor for her own compassion and capability, which allow her “to listen, to understand and to advise” even if the patient requests an option she finds morally repugnant. As she admits in another context, not all physicians are equally capable and farsighted, else we would have had no reason to write the editorial. But we are aware of anecdotal reports in which reactions from physicians and health care providers were much less compassionate. We have, for instance, heard of hospice programs which will work to disenroll a patient once the patient has shown an interest in requesting physician-assisted suicide. Family physicians will, we hope, aspire to do better.

Finally, Dr. O'Connor notes that one of the case vignettes we used to begin the editorial involved an ambiguous request for assistance, where the intended “victim” of the “suicide” might have been a relative rather than the one making the request. We did not, and assumed that the reader would not, confuse such a statement with a request from a supposedly competent patient himself. Instead we included that vignette to illustrate the various ways that the issue of physician-assisted suicide might insert itself into the daily work of the family physician, pressing every “hot button” in the process.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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