MSJAMA. Legal status of physician-assisted suicide.

WHILE PHYSICIANS GENERALLY UNDERSTAND THE DISTINCtions among euthanasia, physician-assisted suicide (PAS), and the withdrawal of life support, the public tends to confuse these terms, potentially leading to misunderstandings between physicians and patients. The withdrawal of life support when it has been deemed futile has been widely upheld as legal by US courts. The uncertain legal status of euthanasia and physician-assisted suicide will be determined partly by the attitudes of the public about the end of life. Although surveys have found that more than 90% of the public would endorse withdrawal of life support in the case of terminal illness, there is much less support for active euthanasia and PAS. In fact, many surveys show about one third support of PAS under most circumstances, one third support depending on the circumstances, and one third opposition under most circumstances. In general, these data suggest that the public is evenly divided among viewpoints despite disagreement over what those very viewpoints encompass. Some of this confusion may be due to the complex interplay between the legal system and society’s interpretation of legal and ethical behavior. A century of endof-life jurisprudence in the United States provides the fundamental framework for understanding the differences among end-of-life options and provides an ethical framework for debates over assisted death. In 1914, the New York Supreme Court firmly established the legal principle of patient autonomy following a case in which a surgeon removed a tumor with the patient under anesthesia and without the patient’s consent. Autonomy refers to a patient’s right to self-determination, now considered a central bioethical principle. Justice Benjamin Cardozo wrote in his decision: “It is trespass. Every human being of adult years and sound mind has a right to determine what shall be done with his own body; and a surgeon who performs an operation without his patient’s consent commits an assault.” Subsequent decisions have upheld the idea of patient autonomy, including the landmark end-oflife cases of the end of the 20th century, in re Quinlan and Cruzan v Director. The Quinlan case, in particular, firmly established the right to refuse treatment as a critical component of patient autonomy. Karen Ann Quinlan was a 21-year-old who entered a persistent vegetative state after an alleged alcohol and tranquilizer overdose in 1975. The New Jersey Supreme Court decided to uphold her father’s wish to disconnect Quinlan’s ventilator, establishing the right to withdraw life-sustaining therapy from consenting adults in certain circumstances. This case, along with Cruzan, not only allowed a patient to refuse lifesustaining treatment, but also allowed a surrogate to make that decision. This principle has been refined to include the right to refuse artificial nutrition and hydration, and the establishment of “best interests” standards, allowing a surrogate to substitute judgment in the best interests of an incapacitated patient when the wishes of the patient are unknown. The essence of these cases is summarized in the Natanson v Kline court decision: “Anglo-American law starts with the premise of thorough-going self-determination. It follows that each man is considered to be master of his own body, and he may, if he be of sound mind, expressly prohibit the performance of lifesaving surgery, or other medical treatment. A doctor might well believe that an operation or form of treatment is desirable or necessary, but the law does not permit him to substitute his own judgment for that of the patient by any form of artifice or deception.” The principles instituted by this legal history have led to increasing public awareness of end-of-life issues and the development and popularization of advance directives such as living wills and do-not-resuscitate orders. The gradual extension of legal rights in the end-of-life arena has led to the current debate over PAS. On one side of the debate, proponents of PAS seek to show that there is no moral difference between withholding lifesaving treatment and providing a patient the means to end life. On the other side, opponents argue that the artificial hastening of death is unlike allowing the unhindered progression of a terminal illness. However, the courts have generally held that an individual’s right to self-determination, including choices about death, outweighs a societal interest in the sanctity of life. Indeed, PAS opponents and the US Supreme Court have already recognized the administration of escalating doses of pain relievers in order to alleviate discomfort as ethically and professionally acceptable, even when administered to achieve “terminal sedation,” where the patient is likely to die because of the dosage of medication. Physicians are generally protected in these cases under the established principle of “double effect,” wherein one act produces two inseparable effects: one good (relieving pain) and one bad (opiate sedation to the point of death). Theologians and legal scholars alike have upheld such acts as morally good despite the consequences of the “bad” effect. Similarly, in its amicus brief in Compassion in Dying v State of Washington, the American Medical Association stated that “It is ethically acceptable for a physician to gradually increase the appropriate medication for a patient, realizing that the medication may depress respiration and cause death.” The principle of double effect leads to a nuanced difference between active and passive euthanasia, making legal resolution of the PAS debate difficult. Whereas one might legally construe a hospital’s insistence on continuing life support as assault and the unvarying avoidance of terminal sedation as unethically inadequate pain relief, the withholding of a lethal prescription does not similarly trespass against a patient’s rights.