New England Journal of Medicine Article
I came across an article in the New England Journal of Medicine offering the scenario of a 72-year old man in the end stages of pancreatic cancer who asks his doctor about assisted dying. The question to the forum is: should it be permitted or not. They provided a professional pro and con opinion then opened it to comments.
Below are quotes from among over 200 comments from physicians, medical students and people like you and me from around the world who endeavor to keep up with the conversation on this issue. Please refer to the article for full details. I did not correct spelling or grammar. I grouped them here by U.S. states, other countries, and a group of unknown origin, after selecting those I found most interesting on both sides of the debate. I actually found a pretty even split among all the comments on the site, but my sample didn’t end up reflecting that same distribution. I color-coded the first word of each comment I posted to give a quick overview (PRO / CON). My comment is at the end.
Physician from Arizona: I was trained to heal and even though I understand the fact that a patient would like to end his/her life with “dignity,” I don’t think I could bring myself together and help them do it.
Physician from California: We have to remember that everybody is the master of his/her own body and choosing the option of dignified death should be the right of the patient and not the physician, lawyer or society at large.
Physician from California: Once the request for hastening dying is balanced against the depression that is intrinsic to the dying process, then the autonomy of the terminally ill cancer sufferer is at the top of the priority chain of ethical principles.
Medical student from California: It is high time that we have an alternative to our inevitable end. We must be entrusted to find a collaborative approach to death as we do with birth. Birth is joyous and assisted. We celebrate it. We welcome it. Death should have its rituals as well. It should be free of fear. It is a very personal choice and a difficult one. It should be honored.
Physician from California: Life is sacred and we must obey the natural law not to kill.
Physician from California: Physicians not only have a right to assist patients with suicide they have a moral duty to do so. The concept is complex and necessary restrictive guidelines need to be in place.
Elder law attorney from Washington, DC: It is the height of unethical behavior for a doctor or relative to substitute his or her opinion of what is best for a dying person’s well being for the patient’s. Using the “art of healing” as a reason to deny a dying person his or her wish is a paternalistic, self-referential shield that fails to engage the patient in his or her life decisions. Patients are not passive recipients of the wisdom of doctors.
Physician from Florida: Today, why are we not lord and masters of our own bodies? Do we belong to the state, or some religious organization? If we do not own and are therefore not able to control our own bodies, who does? Why, legally, does the state have the right to tell us what we can do with our own body, our most precious possession?
Physician from Florida: He is neither suffering nor is he in an unresponsive state (the two specific situations that he did not wish to be in). If by ‘prognosis’ you mean that he understands that there is no cure for his disease, then that realization, by itself, almost certainly does not qualify for life terminating drugs.
Widower from Hawaii: (After declining treatment for pancreatic cancer) With daily visits by an oncologist and surrounded by all 16 family members, aged 3 months to 86, my wife, mentally alert, phoned thanks and good-byes to relatives and close friends around the world. There was no bitterness, no hesitation, never a moment unattended, awake or asleep. She breathed her last in my arms on day 8 and I regard it as our ultimate expression of mutual love in a long life filled with love.
Professor (emerit.) of Surgery from Illinois: Once such a request for help comes from their patients to end their suffering, doctors cannot shy away by cynically claiming, “the last thing” is your problem-not mine. We are in this problem-together!
Physician from Illinois: I am a retired internist. The past 5 years I have had the privilege of being a volunteer at our local hospice. Hospice/palliative care is now able to provide caring and supportive care to the majority of our patients. There is, however, a small minority for whom assisted suicide would be the kindest choice.
Patient from Louisiana: If I experience a complication or progression of my illness that results in a terminal situation, I have made it clear I do not want extraordinary measures made to treat or resuscitate me. If I am suffering and in the terminal phase, I should have the option of physician-assisted suicide or some legal method of obtaining the necessary drugs to end my life. To deny patients this option is an unethical and cruel abuse of our humanity.
Surgeon from Maine: I have argued for assisted euthanasia for many years, including presenting a case at a meeting of the MMS, when they were discussing the issue many years ago, as a delegate from Plymouth, MA.
Physician from Massachusetts: The doctor should not be involved in providing the means. Why not ask the priest or the lawyer to help provide the means?
Physician from U.S.: 78-year old retired general/oncologic surgeon, currently in good health but well aware that a terminal illness like pancreatic cancer could arise at any time. I am the master of my own destiny, I should have the right to choose and would hope that my personal physician could assist me in my choice. I am disappointed that Massachusetts voted not to allow “Death with Dignity.” I have always felt that the concept of holding out “hope” for terminally ill patients is not only unrealistic but often cruel in not recognizing the reality of ultimate death.
Nurse from Massachusetts: …nurses are the ones who spend more time with them, have an explicit framework to specifically assess and diagnose spiritual distress, changes in role and family processes, and other critical aspects of quality of life, and are far more often present for individual and family at death. Similar polls of nurses are over whelmingly in favor of death with dignity initiatives. It is unfortunate that this debate is so often framed in terms of what physicians want to do. Far better that we all should do what patients ask of us; patient autonomy has always had primacy in nursing practice.
Physician from Michigan: Some physicians feel a heroic obligation to save a life against all odds, to the point not only of futility but absurdity, and in doing so they feel a rewarding sense of accomplishment. They force their beliefs against the wishes of the victim (pardon me, the patient).
Physician from Minnesota: Physicians are highly trained medical professionals who promote and restore human health by diagnosing and treating disease. When disease-associated pain is present, they alleviate it. Taking a patient’s life only creates pathology it doesn’t treat any disease. It is oxymoronic to see physician-assisted suicide as providing any form of health care. Indeed outside of the privileged doctor-patient relationship such behavior would simply be recognized as homicide.
Physician from Minnesota: No PAS should not be legalized. I don’t care what kind of consent process or how many behavioural science consultations or screenings you do. We are undoubtedly starting down a slippery slope, especially as we enter into an era of increased regulation and financial constraint.
Physician from New Jersey: As it is my desire to pass gently into the good night when my time is come, if I can assist a fellow human to leave this world gently and by choice when their time is nigh, then I believe it is the moral choice.
Physician from Ohio: When my terminally ill wife with colon cancer indicated she did not want to keep going, her message was conveyed to her hospice caretakers who ensured she would be comfortable. As a physician I personally did not feel comfortable managing a medical situation for which I was not prepared for.
Physician from Oklahoma: Is there a day in the future when people will be asked about their acts or not? In other words, is there “Allah” (God) or not? If you believe in Allah and that there is day of judgment where you will be asked about every single act, word you spoke or listened to, look… then you need to have good answer to why you helped someone kill himself.
Elderly woman from Oregon: I do not think we are puppets of some idea of a supreme being, we rather seem designed to learn and apply knowledge to our individual circumstances, and at near age 86, I hope to choose to end my earth time in dignity with euthanasia under specific circumstances and have outlined those in my directive.
Physician from Oregon: The greatest benefit of the law in Oregon has been its effect in enabling communication. This issue is not simple. The Oregon law does not give Oregonians the “right to die.” But it does give Oregon clinicians and family members the right to assist in their deaths, under carefully prescribed circumstances.
Physician from Pennsylvania: Individual vs Societal Rights. I have never understood how a society that prides itself on self-reliance, individual courage, free will, and the rights of the individual, feels justified in removing these rights from individuals at the end of their lives.
Physician from Pennsylvania: I respect the views, some very eloquently stated, of those selecting option 1. My vote is for option 2.
Physician from Tennessee: Why can’t we accept and recognize that patients have the right to decide when to end their lives with their pain controlled, their dignity preserved and with our support? Why do we abandon our patients and their families in such a difficult times? Properly screened patients (and families) should be allowed to make this decision with the support of a physician who can guide them through the process and relieve them from guilt and remorse.
Physician from Utah: If society deems carefully planned and supervised suicide as an option, why does it have to be PHYSICIAN-assisted? Anyone could be trained to perform this function – certainly it is not part of a physician’s training.
Physician from Albania: He always asked me whether I can do something else to make his misery go away. I never quite understood what he meant by that until I got a call from the medical examiner. They asked me whether I knew Mr. X and was he one of my patients. I said yes. They told me police had to break into his apartment that day. They found him dead on the floor. He had killed himself using a kitchen knife. He should have had a better option and I should have been a better physician.
Physician from Belgium: With good palliative and terminal care most of these cases can be handled without the need for euthanasia or assisted suicide. We have to introduce the ‘ars moriendi,’ the ‘art’ of dying, facing existential and spiritual problems.
Physician from Brazil: We are doctors not murders. I myself am a religious doctor and I know that lives belong to God. We are living a life that does not belong to us. We are here to proceed the evolution of our Espirits and so are our patients. We do not have the authorization to end someone’s life.
Physician from Brazil: I believe that our society must allow the final expression of free will once the individual is faced with the alternative of avoiding suffering and loss of all his dignity so let the choice for an “ending” according to his moral values be a real one.
Physician from Canada: They would prefer that the patient suffer rather than risk upsetting some abstract and totally subjective set of values. They would hold us all hostage for the sake of their morality. The hypocrisy and sanctimony of their argument is an infinitely greater risk to our freedom than any abstract notion they would force upon us.
Physician from Canada: Listening to a request for death but never carrying it out can be the height of hypocrisy. And individual autonomy is what this question is all about not your book learned ideas of other values and ethics for the collective.
Physician from Canada: This is a personal matter for the individual facing death and has nothing to do with a proper debate on the modern process of death. It is high time to drop the moral blackmail and use of loaded terms such as ‘therapeutic homicide’.
Physician from Canada: Religious dogma of “only God is giving life and only God can take away life” should not be the rational, the actual basis of laws.
Physician from Canada: people with advanced ALS or multiple sclerosis who cannot move more than their eyes often will chose to be disconnected from life support. Some of them would like to have the option of a well performed general anesthesia that would allow them to die comfortably before they reach this advanced stage. Why deny people this option is beyond understanding.
Physician from Canada: We have all watched people suffer and silently wished for the end. Many of us have provided opioids at doses needed for pain control, but that could cause respiratory depression. But we know very well that there is a clear difference between that, and deliberately bringing the end sooner. To raise my hand to kill… never for me, and never (I hope) for my profession.
Physician from Canada: We do not chose to be born. Life happens. I understand that suffering is difficult, distressing and terrible for both the patient and the family. But let’s face it, it’s part of life. NO ONE goes through life without suffering at some point. It is part of being human. Not accepting it seems to be annihilating the core fact of our humanity.
Woman from Canada: A person who dies meets his maker, or so believe most Americans. Our maker has something to say about willfully taking a human life. I do not belong to myself, being created by a higher power, and do not have any inalienable right to determine my death.
Physician from China: Physicians should not be the one to make decision to end a life. But morality is a basic human right and an individual choice. Patients with end stage disease should have the right to die with dignity.
Physician from Dominican Republic: A doctor is a healer not a killer. Death is not part of life because life ends when we died. Living is to watch the sun every morning and the moon every night. A doctor saves the life and the souls of his patients everyday no matter how difficult it is sometimes…
Physician from Egypt: Timing of death is related only to our God. I think we cannot go for helping patients to get suicide, the image of doctor is only to help patients to get better as to improve pain control, relieve symptoms. Practically speaking in this situation of advanced pancreatic cancer, we give strong narcotic with laxatives and usually the survival is very limited to a few weeks maximim.
80-year old man from France: The debate about end of life conditions is nowadays very hot in our country. I strongly believe that the respect of patient’s wishes will not deserve palliative cares, but on the contrary facilitate their development. As wrote Seneque in one of his letter to Lucilius : “the best death is the one I wish”.
Physician from Greece: A colleague once confided softly: “If I am ever in that state, please kill me mercifully.” Recently, Richard Lehman of the BMJ made a bitterly humorous request to be given a strong i.v. anaesthetic and a massive dose of potassium chloride, in case of a massive stroke. Do we as physicians dream of the right to a dignified death for ourselves, but refuse to consider it for our patients? Our ethics have not changed, but medicine has come to a point where we are prolonging wretched conditions of debilitation, humiliation, pain and misery.
Physician from Greece: What constitutes bad medicine, and also fuels the euthanasia argument, is the overaggressive management of advanced cancer with multiple toxic therapies that add only misery to the patient’s last few days/weeks/months. Providing death on request only erodes the status of the medical profession, and is beyond the jurisdiction of medicine.”
Physician from India: A right to die a dignified death by a patient who has fully intact faculties is not an issue to be brushed aside.
Physician from India: I believe life is a gift of God. We have no right to terminate it. We should continuously struggle to minimise the sufferings of our patients and not to indulge in practice of physician-assisted suicide.
Physician from India: The role of the Physician should be just saving life. The patient then has a choice whether to go to the Physician or not and next to the person who could assist him with ending his life (someone whose only training is this and not currently practising any other kind of curative medicine).
Physician from India: I have worked in oncology units and have experienced the pain and sufferings those terminally ill patients undergo. We can have euthanasia with proper regulations in place. We cannot provide any better life to them by any means, so why deny their peaceful termination of their own hopeless journey!
Physician from India: Death is inevitable and is not to be feared and dreaded. We are not in the normal course of life given the luxury of choice as to when and how we die. If given a choice between needless pain and suffering to both the patient and family; the obvious choice is assisted suicide.
Physician from India: I agree with the general principle of physician-assisted suicide. I think doctors who work hard to save a patients life, who have spent time with the patient and have the trust of the patient are in the best position to bear the moral responsibility of taking a patient’s life.
Physician from Italy: Please remember that the Nazi euthanasia program was the foundation of the destruction of the European Jews.
Physician from Italy: The only person who has the right to decide when and how to die is the patient. Religions have nothing to do with it. Our job as physicians does not end when the patient cannot be cured. We must take care of him/her to the end, and that entails also, if the patient so desires, assisting suicide.
Physician from Italy: The choice to kill oneself is the paradigm of a personal choice. As such, it should not involve other persons either relatives or kin. For the same reason physician-assisted suicide should not be done in patients like that described in this case vignette.
Physician from Lebanon: We doctors are born to help those who want to live and not to euthanize those who want to die, that is the dignity of our profession.
Physician from The Netherlands: Discussing the possibility should be legally and professionally obligatory to be one of the “treatment options” right from the first diagnosis! And as such part of palliative care.
Physician from The Netherlands: Banning euthanasia and physician assisted suicide doesn’t mean it never happens. It just means you don’t know how often it happens.
Physician from Pakistan: I understand and accept both points of view. As an oncologist I have spent many a nights fretting and being upset about unnecessary suffering and not being able to make them as comfortable as they should be, but at the same time I do not think I have the courage to knowingly help patients for euthanasia.
Physician from Pakistan: Help patients relieve their sufferings. Dr assisted suicide should be permitted
Student from Peru: When a patient is in the terminal stage in any disease and you as his physician can not give him quality of life then why you have to make him suffer? “Primum non nocere” always… and in this case making him suffer is harming him in spirit.
Physician from Portugal: Medicine is about “healing.” Decisions about suicide at will are not and should never be medicine. If considered a “right” and allowed by society, please create a “legal executioner or hangman” for the job.
Physician from Portugal: The issue of assisted suicide is not a purely medical issue: it involves legal, anthropological, spiritual and ethical issues, which largely exceeds the medical problem. The balance between the safeguarding of life, and mercy and compassion for the suffering often creates gray areas of difficult decision.
Physician from Russian Federation: There is a risk of an abuse of authority if the physician is a maniac or physicians are associated with criminals. Ethical and moral aspects of this issue are very complicated and open to questions.
Physician from Saudi Arabia: Patients with major depressive disorder with suicidal thought and intention are considered in critical state and urgent action is needed to protect them and prevent them from suicidal attempts — so why would we facilitate death in a patient with terminal illness?
Physician from South Africa: Where it is legally authorized, the physician may help those who are in despair to end their lives, if any medical intervention has become futile.
Physician from Spain: Thou shall not kill. Sometimes being a doctor is very difficult. Of course we have to better help the patients when dying and to alleviate them is an essential part of our professional caring. But I strongly feel that to allow killing is a terrible mistake.
Woman from UK: You can privately, quietly, ensure the right dose of the right medication is given with no questions asked. Before you respond from your positions of power and control, please consider what it is like for ordinary people.
Student from UK: Indeed the very idea of a killing doctor almost presents as an oxymoron, however with the training and in-depth understanding that all doctors must possess it seems to me that a doctor is the only humane and realistic choice of assistant to suicide.
Physician: When you kill someone you forever remove the virtue of hope, which is so inherent in the work of a physician. When all our drugs and all our armenmentaria are gone, we can always give hope as long as there is life.
Physician: We are doing this everyday through Hospice. We just don’t call it assisted suicide. Terminally ill patients should have the right to choose their end. And helping a patient walk through death’s door with everyone’s consent should be a privilege not denied to their physicians.
Patient: My husband and I have plans to take our lives when we become unable to care for ourselves, mentally or physically. We don’t want to burden our children with our care and believe that the money we would spend on hiring caregivers would be better served paying for our grand children’s education. We are living too long now and the cost/benefit ratio is too low to sustain.
Physician: I favor physician-assisted suicide. It is the ultimate compassionate act in the doctor-patient relationship. To deny it would be to abandon the patient.
Physician: I would hope, that under such or other similar circumstances, I would be given the choice to end the misery. I do not think that anyone else should be able to enforce his/her convictions of prolonging my ordeal for me.
Physician: My father died free of pain (from a recurrent cancer) with the help of a generous dose of morphine from his primary care physician. My mother and I were grateful that he could say goodbye in peace.
Medical student: …listen to what they are saying, analyze if it’s logical. Every case is different. As a doctor, my first duty is to listen to my patient, only he knows his pain and mental anguish. Mr Wallace … fears that such a day would come and wants to opt out of experiencing that condition. I completely understand his fear and respect his wishes. I am okay with assisting him as per his wishes. And I won’t be a murderer if I do so, not in my eyes at least.
Physician: I believe if a person has a terminal illness that causes him/her to suffer, to live an uncomfortable life, the person that is stable should have a decision of life or death … as long as the procedure is assisted by a doctor.
PhD: A person, no matter the age, who is terminally ill should have the right to Death With Dignity and this includes euthanasia
Physician: After practicing as a critical care physician for over 30 years, I am still puzzled as to why is it wrong to assist those who wish to die while in our care? If changes in the practice of medicine now give us the additional responsibility to walk with those on their way to end, we should respectfully perform that task. Not everything we do in medicine is to our liking or edifying. Assisting in a peaceful death may be one of those unpleasant tasks we need to accept reluctantly. I think that is a service to the society.
Physician: Few of us are prepared to swear with a straight face to Apollo, Asclepius, Hygieia, and Panacea, and the ancient oath not only proscribes assisted suicide but also abortion. Likewise some commenters have hearkened to a simplistic version of Judeo-Christian morality and vitalist belief that mere human beings should never weigh in on quality of life or take actions that hasten death. Bottom line is that we must learn more and engage in a more substantive debate of this subject.
Following is my comment– Someone here wrote: We do not choose to be born. Is that a scientific fact?
What if we DO chose to be born… into this body at this time in history on this planet in this country in this community to these parents, into this dysfunctional society, but instead of dying at the end this body’s ability to function we are transformed into our true essence and return home filled with new adventures to tell our loved ones about and lessons learned for the growth of our eternal souls? Then part of healing involves facilitating the soul to exit the body in as peaceful a way as possible by practicing the art of conscious dying, which does not preclude assisted-dying or euthanasia.
This is my understanding of the process after having died and come back to tell about it, and spending the last 40 years studying about it. Actually, we do chose to be born, it’s a great honor and privilege, and when it’s over, it’s great to be going home again. Talk about a paradigm shift!! Hello! The earth is not flat. The planets revolve around the sun. Time to wake up