Euthanasia: No Substitute for Rational Pain Interventions

MIAMI, Fla--Public support of physician-assisted suicide and euthanasiastems from multiple medical, social, and economic factors, KathleenFoley, MD, said at the annual meeting of the American Pain Society.(See table for a list of some of these factors.)

However, advocacy groups that support legalization of euthanasiafor terminal patients who request it may be ignoring the possibilitythat the physical and psychological factors contributing to thepatient's wish to die can be identified and treated or palliated.

Dr. Foley pointed out that much of the physician-assisted suicide/euthanasiadebate has focused on cancer patients and patients with AIDS.Studies have shown that these patients have a high prevalenceof physical and psychological symptoms, as well as existentialdistress, she said.

In this regard, Dr. Foley cited the work of Cecily Saunders, apioneer in palliative care, who described a model of sufferingas "total pain," which includes physical, psychological,emotional, existential, and social factors.

She emphasized that factors that contribute to existential distressare not being fully appreciated in this debate. Common existentialissues for patients with advanced cancer include hopelessness,futility, meaninglessness, disappointment, remorse, death anxiety,and disruption of personal identity.

Suicide-Pain Link

Several vulnerability factors have been documented that may contributeto suicide in patients with cancer or AIDS. Uncontrolled painis recognized as a contributing factor, and persistent pain interfereswith the patient's ability to receive support from family andothers, Dr. Foley said.

The literature also suggests that cancer patients with pain areespecially vulnerable to suicide due to the increased likelihoodof the presence of multiple risk factors, such as depression,delirium, loss of control, and hopelessness.

Dr. Foley cited research done by William Breitbart, MD, and hiscolleagues at Memorial Sloan-Kettering Cancer Center in which33% of cancer patients were diagnosed with major depression, 20%with delirium, and 50% with an adjustment disorder, with anxiousand depressed features at the time of evaluation. Dr. Breitbartfound that suicide ideation without intent to act occurred in17% of 185 cancer patients with pain. The suicidal ideation wasmore closely correlated with mood disturbance and degree of depressionthan with pain.

Dr. Foley emphasized her concern that if physician-assisted suicideand euthanasia were legalized, they might then be substitutedfor rational therapeutic, psychological, and social support interventionsthat might enhance patients' quality of life as they die.

The Public Debate

The current public debate in this country is strongly biased infavor of patient autonomy and, thus, in favor of physician-assistedsuicide and euthanasia, Dr. Foley said. She highlighted severalevents that have dominated the public debate on these issues:

1. Dr. Kevorkian's participation in both physician-assisted suicideand euthanasia for patients with medical illness.

2. Surveys that have attempted to poll the public perspectiveon this topic.

3. Books, newspaper articles, and television programs that haveportrayed advanced cancer patients choosing various modes of assistedsuicide or euthanasia.

4. The publication of Derek Humphrey's book Final Exit,a bestseller on the New York Times book list.

5. The experience in the Netherlands, where euthanasia has beenpermitted, although not legalized.

6. The referendums in the states of Washington and Californiato legalize euthanasia and the passage of such legislation inOregon (currently blocked from being put into effect by a FederalDistrict Court order).

The professional debate on the subject has been accelerated bythe publication of books and articles in prominent medical journals,she said, citing the article "It's Over, Debbie" inJAMA and the book by Dr. Timothy Quill (Death With Dignity).

At the Bedside

When patients request physician assisted suicide or euthanasia,the professional response, Dr. Foley said, should be to intervenewith assessment and treatment of the patient's suffering, includingtherapeutic approaches that may provide improved pain and symptomcontrol, and reduction in psychological distress.

She emphasized that dying is a societal as well as a medical issue,and cited a recent recommendation by the World Health OrganizationCancer Pain and Palliative Care Unit that governments should notconsider legalizing physician-assisted suicide and euthanasiauntil they have ensured that all of their citizens will have accessto adequate pain treatment and palliative care.

Defing the Terms of The Euthanasia Debate

Voluntary active euthanasia--When a physician intentionallyadministers a treatment (usually medication) to cause the patient'sdeath, with the patient's full, informed consent.

Involuntary active euthanasia--When a physician intentionallyadministers a treatment (usually medication) to cause the patient'sdeath, without the patient's full consent. The patient may beeither incompetent or may never have asked for the intervention.

Physician-assisted suicide--When the physician providesa causative agent, usually a medication, to a patient, with theintent that the patient will use the drug to commit suicide.

Assisted suicide--The provision of assistance, eg, medication,carbon monoxide tanks, or various other physical or medicinalapproaches, with the intent that the patient will use these agentsto commit suicide.

Factors That Have Led to Increased Public Support of Physician-AssistedSuicide

Advancements in high-tech medical support systems for patientswith respiratory and cardiac failure

Changes in the trajectory of dying in terminal patients, withmany patients with cancer and AIDS alive for months and yearsafter diagnosis of an incurable illness

The increasing elderly population

The greater emphasis on patient autonomy

A concerted policy shift from societal to individual rights

The highly debated limitations in health-care resources, particularlyfor patients with chronic incurable illnesses

From a presentation by Kathleen Foley, MD.