Assisted suicide compared with refusal of treatment: a valid distinction? University of Pennsylvania Center for Bioethics Assisted Suicide Consensus Panel.

In recent years, assisted suicide for dying persons has become a prominent issue of public and professional debate. Although in June 1997 the Supreme Court affirmed the constitutionality of laws prohibiting assisted suicide, Oregon recently implemented a law passed by referendum that permits physician-assisted suicide. To clearly address contested ethical and public policy issues, we must understand the nature of assisted suicide and the ways in which it is similar to or different from other end-of-life medical practices. Physician-assisted suicide is one of a spectrum of end-of-life issues in the medical context. Such issues range from withholding or withdrawing life-sustaining treatment to prescribing high doses of pain-relieving medication that may hasten death to performing voluntary euthanasia by administering a lethal injection in response to a patient's request (1-3). In physician-assisted suicide, a physician provides but does not directly administer medical means with which a patient can perform a life-taking act. The relevant differences among these related end-of-life practices tend to be obscured by such vague and potentially misleading terms as passive euthanasia, double-effect euthanasia, and aid in dying. For ethical and policy analysis, it is important to clarify these differences. However, because moral complexity and ideological conflict make clarity difficult to achieve, confusion often surrounds end-of-life decisions (4). Is physician-assisted suicidekilling oneself by ingesting prescribed lethal medicationfundamentally distinct from refusal of life-sustaining treatment, to which every patient has a legal and moral right? After examining competing conceptual, clinical, and ethical considerations, we argue in favor of maintaining a distinction between these practices. Three cases help focus our discussion. Illustrative Cases Timothy Quill's narrative about his patient Diane has been recognized as a paradigm of physician-assisted suicide (5). Shortly after receiving a diagnosis of leukemia and refusing aggressive treatment, Diane requested a prescription of barbiturates that could be used to end her life if she determined that her suffering had become unbearable; her physician provided the prescription. Diane was enrolled in a hospice program, and after several months, facing increasingly distressing pain, fatigue, and deterioration, she ended her life by ingesting the barbiturates. BB, a 37-year-old woman, had a devastating stroke and developed the locked-in syndrome (6). She became quadriplegic and unable to speak but retained higher mental functions and perception of pain. In a rehabilitation facility, BB was weaned from a ventilator and learned to communicate through a specially designed computer system. Finding her quality of life intolerable, she repeatedly communicated a wish to die. Psychiatric consultation determined that she had decision-making capacity. The medical staff reluctantly agreed to withdraw artificial nutrition and hydration and provide only comfort care. David Eddy (7) wrote about his mother, who at 84 years of age became bedridden and incontinent. Her eyesight deteriorated, and she was confined to a nursing home after a series of acute medical problems. She was not dying but decided to seek death because she had irreversibly lost her capacity for independent living and her quality of life had deteriorated. She considered but rejected the idea of clandestine assisted suicide by ingesting lethal medication. After surviving a bout of pneumonia despite refusing antibiotics, she chose to stop eating and drinking. Her physician agreed to help keep her comfortable while she awaited death, which arrived several days later. Are the deaths of BB and David Eddy's mother so similar to Diane's that we should reject as morally arbitrary the line between refusal of treatment and assisted suicide? Do morally significant differences between these and other comparable cases support maintaining that line? Reasons for Drawing the Line Legal and ethical commentators often explain the distinction between withdrawal of life-sustaining treatment and assisted suicide by citing a difference of causation (8-10). Stopping life support is said to allow the patient to die by letting nature take its course. Death is caused not by withdrawal of treatment but by the underlying disease. In assisted suicide, ingestion of lethal medication prescribed by a physician causes death. However, withdrawal of life-sustaining treatment occurs in different contexts. For imminently dying patients whose lives are temporarily being prolonged by life support, it is reasonable to assume that death is caused by the disease, not by withdrawal of treatment. In these cases, regardless of treatment, death will soon occur; therefore, continued treatment serves more to prolong dying than to preserve life. Is the situation different in cases in which long-term survival is contingent on life-sustaining treatment? BB was not terminally ill; however, patients like BB, who are chronically dependent on life-sustaining treatment, can live for years. When such patients decide to stop this treatment, the cause of death arguably includes both the underlying disease or injury and the withdrawal of life-sustaining care. Some have argued in favor of recognizing that withdrawal of life support causes death by presenting the following scenario (11). Consider a ventilator-dependent patient who was not seeking death, and suppose that a person plotting the death of that patient maliciously withdrew him or her from the ventilator. The perpetrator would be charged with murder and could not successfully argue that the underlying disease, not the action of pulling the plug, caused the patient's death. The same treatment-terminating act causes both this hypothetical death, which is engineered by a malicious perpetrator, and the deaths of competent patients who refuse continued life-sustaining treatment. It is important to note, however, that causation in fact is not the same as causation in the law. Although a clinician's withdrawal of life-sustaining treatment may in fact contribute causally to the deaths of patients who refuse such treatment, it does not follow that the clinician is morally or legally culpable for wrongful killing. Similar considerations must be made regarding the cause of a death that follows a patient's voluntary decision to refuse food and water. Patients who are imminently dying of a progressive disease, such as cancer, become cachectic and often lose their appetites and urge to drink as part of the natural course of the disease (12). If such patients stop eating and drinking, it is reasonable to attribute their deaths to the underlying disease. However, David Eddy's mother was not terminally ill. She died of dehydration after her resolute decision to stop eating and drinking. A second commonly cited rationale for drawing the line points to a difference in physicians' intentions (8, 10). In the case of assisted suicide, it is claimed that by supplying the means of terminating life, the physician intends to assist in causing death. In contrast, physicians who withdraw life-sustaining treatment in response to patients' requests are considered to have fundamentally different intentions: They intend to respect patients' rights, relieve suffering, and stop treatment that is seen as futile. Clinicians who do not specifically intend to help a patient terminate his or her life do not assist in suicide. The intentions involved in end-of-life decisions are complex and may be ambiguous (13). In many cases, clinicians who withdraw treatment do not intend to bring about death. In addition, death does not always necessarily result when a life-sustaining treatment is stopped. In some cases, however, the physician intends to help the patient escape an irreversibly intolerable condition by withdrawing life-sustaining care. Does this intent make the action similar to assisting in suicide by prescribing lethal medication? Both patient and physician may see treatment withdrawal that results in death as a way to make the best of a bad situation. However, when prescribing lethal medication at the request of a dying patient, the physician may or may not intend that the patient use it to end life. The intent in some cases may be to provide the patient with the security of a self-administered means of ending life in response to intolerable suffering; this security may help the patient endure. However, regardless of the nuances of intent, a physician who complies with a patient's request for a prescription of lethal medication is responsible for assisting in suicide if the patient takes the medication to end his or her life. Given this complexity, the potential for ambiguity, and the difficulty of specifying clinicians' intentions, appeal to intention offers no basis for a clear moral distinction between withdrawing life-sustaining treatment and physician-assisted suicide. Reasons for Rejecting the Line The major criticism of maintaining a sharp distinction between assisted suicide and withdrawal of life-sustaining treatment or refusal of food and water is that such a distinction is arbitrary (14). This was a key premise in the Second Circuit Court opinion later reversed by the Supreme Court, which declared that New York State's law prohibiting assisted suicide violated the equal protection clause of the Constitution's 14th Amendment. The opinion stated: Withdrawal of life support requires physicians or those acting at their direction physically to remove equipment and, often, to administer palliative drugs which may themselves contribute to death. The ending of life by these means is nothing more nor less than assisted suicide (15). According to this argument, cases like those of Diane, BB, and David Eddy's mother should be viewed as essentially similar. Neither BB nor Mrs. Eddy was terminally ill. Their decisions to stop life-sustaining treatment o