Assisted suicide and the case of Dr. Quill and Diane.

Dr. Timothy Quill provoked a great deal of debate when The New England Journal of Medicine published his description of a woman named Diane, a patient whom Quill helped to commit suicide.(1) Among the responses published in a later issue of the journal was the comment of a physician who stated that "it is the role of a physician to prevent suicide attempts wherever there is a possibility that they may occur."(2) The moral principle seems clear. Physicians should never help patients commit suicide. That physician, and many others, view the prohibition of physician-assisted suicide as a moral absolute. Such actions are always wrong. Indeed, the terminology surrounding suicide implies such a moral determination. People "commit" suicide, just as they commit other types of sins. It is wrong to commit a sin. But we err when we view difficult moral dilemmas such as physician-assisted suicide as yes/no, pro/anti, or right/wrong issues. This type of dichotomous approach to moral reasoning strips away the complex ethical concerns that physicians face when dealing with terminally ill patients. Such dichotomous thinking also tends to separate people into opposite camps whose views are quite similar, for it deemphasizes those values that they share. Such a dichotomous approach to moral reasoning, relying on strong principles or fast rules, contrasts with a method of moral reasoning described by Jonsen and Toulmin in their book The Abuse of Casuistry.(3) Casuistry is a method of reasoning that focuses on the complexity of particular cases as they arise in such disparate disciplines as law, medicine, and ethics. In casuistry, one compares the case at hand both to paradigmatic cases and to previous cases one has studied or been involved with. The skilled casuist expertly teases out the relevant similarities and dissimilarities between this new case and the others. Where relevantly similar, the new case should generate the same conclusion that the previous cases did (the conclusion being a verdict in law, a diagnosis or treatment plan in medicine, and a moral judgment in ethics). Where dissimilar, one must make judgments about how to factor these dissimilarities into one's final decision. By applying casuistic methods to the case of Diane, I hope to reveal the complexity of the moral decisions Quill faced. In this article, I will compare Quill's actions to those taken by physicians in other well-known cases, such as the anonymous physician in the "It's Over, Debbie" case and the suicide specialist, Dr. Jack Kevorkian. In addition, I will explore the alternative actions available to Quill. Only by dwelling on these practical matters, as defined by the particular situation facing Quill, can we begin to judge the moral implications of his actions. The Facts of the Case Any good judge, physician, or ethicist must begin with the facts of the case at hand. When we meet Diane, Quill tells us that he has known her for more than eight years and has helped her battle both alcohol abuse and depression. However, Quill and Diane discover that they now face a problem greater than any they have faced together before: Diane has leukemia. After several long discussions with Quill, Diane decides that a 25% chance of long-term survival is not good enough for her to undergo the agonies of chemotherapy and bone marrow transplant. She chooses to accept certain death rather than suffer these additional agonies. Quill brings an impressive background to the case, having training or experience in internal medicine, psychiatry, and hospice care. His background is ideally suited to taking care of terminally ill patients. Quill now faces a difficult situation that, in this day of patient rights and informed consent, is becoming increasingly common. He wants to help Diane conquer her illness, but he knows he must respect her right to refuse. Thus, he pushes for her to consider treatment but ultimately bows to her consistent desire to forgo treatment. …