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Summer 2008 | Vol 11 No 4

The last word

Rational suicide and the older adult

A humane experiment gone adrift

By Dr. Isaac Sakinofsky

By choosing the metaphor of ending life after finishing a good meal, Ruth von Fuchs would beguile us into believing that requesting physician-assisted suicide (PAS) is a serene, natural process, like ordering an after-dinner coffee. As a suicide student for half a century, I know suicide is never so tranquil and measured a process; rather, it stems from deep despair, anguish and perhaps also chagrin, over a personal predicament that embodies severe mental or physical suffering or incapacitation. Although ageing brings susceptibility to debilitating or terminal physical illness, an intolerable predicament can arise at any age and it would be discriminatory to focus on the elderly when discussing PAS (which von Fuchs broaches, but does not term as such).

PAS involves taking one’s own life with the help of a doctor who plays no direct role other than supplying the lethal agents. It is legally practised in the Netherlands and Oregon. In Oregon it is applicable to competent adults with terminal illness if the diagnosis and prognosis are confirmed by two physicians and judgement is unimpaired by psychiatric disorder. It is noteworthy that Oregon does not require an applicant to be suffering, whereas unbearable suffering is a precondition in the Netherlands. Every case must be carried out in consultation, performed with due care and reported to the authorities.

Peggy Battin, a Utah philosophy professor, recently examined data from these two localities to determine whether certain vulnerable groups were being targeted. There was no evidence of increased risk for the elderly, women, minors, the uninsured, undereducated, poor, physically disabled, chronically ill, psychiatrically ill or racial and ethnic minorities. In only one vulnerable group, HIV/AIDS, was the proportion excessive.

The case with HIV/AIDS illustrates the fear element driving many applicants to seek PAS or euthanasia (where the doctor personally administers the lethal agents). In Amsterdam, of 131 gay men with AIDS who died before 1995, 22 per cent died by euthanasia or PAS. The advent of clinically effective drug cocktails may since have significantly reduced such requests. This example also serves as a backdrop for the arguments of Herbert Hendin, a respected US psychiatrist strongly opposed to PAS and euthanasia. Hendin quotes the case of a young professional he calls Tim, who first saw him after being diagnosed with myelocytic leukemia, a disease with a 25 per cent chance of survival. Tim was understandably fearful and preoccupied with suicide and wanted the doctor to support his decision. “Once Tim and I could talk about the possibility or likelihood of his dying – what separation from his family and the destruction of his body meant to him – his desperation subsided. He accepted medical treatment, complained relatively little about the unpleasant side-effects and used the remaining months of his life to become closer to his wife and parents. Two days before he died he talked of what he would have missed without the opportunity for a loving parting.”

Hendin is concerned that what began as a humane experiment has gone adrift, and is now not humane at all because patients are not getting proper treatment. Instead of alleviating the patient’s terror behind the PAS request, physicians are merely confirming the patient’s decision-making competence and have become their patient’s willing executioners. Virtually every guideline set up by the Dutch, says Hendin, has been corrupted with time. About 1,000 cases a year are life-ending acts without explicit requests or consent from the patients. Of the total annual mortality of 136,000 in 2005, 0.1 per cent were by PAS, but 1.7 per cent by voluntary active euthanasia and 0.4 per cent by involuntary active euthanasia. Frequently, cases are neither documented nor reported, and no colleague consults in the decision-making or examines the patient.

Hendin’s worst fears that legally sanctioning PAS would lead to a “slippery slope” have been realized in the Netherlands, where the practice now encompasses the chronically ill or psychologically distressed without physical illness. More patients die from voluntary and non-voluntary euthanasia than PAS. He quotes such egregious cases as that of a man given a choice by his wife between euthanasia and admission to a chronic facility. He chose euthanasia, and the doctor, although aware of the coercion, obliged. One Dutch study reported that more requests for euthanasia come from families than from patients themselves.

A major factor in the Netherlands has been neglect of palliative and hospice care. In the Netherlands, Hendin argues, Dutch physicians turn to euthanasia when they feel helpless and do not know what else to do. The Dutch government now acknowledges the country’s deficiencies in palliative care and is creating centres for such care. There is also a grassroots movement by palliative care physicians to educate all Dutch physicians in the care of terminally ill patients.

The right to die movement followed a change in societal values, which were based on the sanctity and value of life. With the shift towards autonomy came the protection of people’s rights to self-determination. Such rights should certainly be supported to the extent that they do not impinge upon others’ rights and are exercised responsibly. It is all too easy to cast oneself into the character of God and override the tentative but true wishes of others, as Ann Wickett, wife of Derek Humphry, founder of the Hemlock Society, alleges that he did (she called him “a killer”), and as some Dutch physicians appear to have done. In the matter of PAS we should tread very carefully.

Dr. Isaac Sakinofsky is head of the High Risk Consultation Clinic at the Centre for Addiction and Mental Health in Toronto.

Editorials do not necessarily reflect the views of CAMH.