A Debate on Physician-Assisted Suicide

Editor's note: As part of the ongoing discussion at many levels of our society about physician-assisted suicide, a debate was held at the October 1997 Institute on Psychiatric Services in Washington, D.C. Dr. Hartmann argued in favor of physician-assisted suicide, and Dr. Meyerson argued in opposition. Alan A. Stone, M.D., was the moderator. This article presents the opening statements of the two debaters, slightly edited and updated to reflect subsequent developments.

Dr. Hartmann: This debate is a small part of a large continuing American and international debate on physician-assisted suicide. I will argue that physician-assisted suicide should be legal, and Dr. Meyerson will argue that it should not.

The state of Oregon now has a law called the Death With Dignity Act. It narrowly passed by referendum in 1994 with 51 percent of the vote and was then put on hold by legal challenges until October 14, 1997, when the U.S. Supreme Court removed the final legal obstacle to its becoming law. Energetic opponents attempted to repeal the law in a referendum in November 1997, but it was upheld by a vote of about three to two.

Under the Oregon law, a mentally competent adult suffering from a terminal illness likely to result in death within six months may choose to receive a lethal dose of medication, after consulting with two doctors and waiting 15 days.

I favor that law and others like it.

Good values clash with good values in the area of physician-assisted suicide. People often hold on to some of these values with firm feeling and long-standing conviction—feeling and conviction not always fully reasoned or reasonable, and certainly not always stemming from advanced education and training.

Part of our possible usefulness today in considering this area, as both citizens and psychiatrists or mental health colleagues, is not just to look at specific and legitimate psychiatric areas of special interest in physician-assisted suicide, such as, "Is the wish to die always a symptom of mental illness?" Part of our potential usefulness is also at what is probably a more general and preliminary level: to acknowledge and identify some psychological obstacles to discussion and to help clear some ground so that these emotion-laden areas can be open for reasonable discussion, as opposed to mere intellectual decoration on the surface of deeply held positions.

Laws simply criminalizing physician-assisted suicide do not help clear such ground. Rather, the reverse. They do affect practice, powerfully if always imperfectly, but they also foster passionate premature closure rather than reasonable discussion, acknowledgment of complexity, learning, and evolution of varieties of decent, balanced, and caring solutions.

Let me cite an issue that, at least temporarily, displaced physician-assisted suicide as a topic of medical-ethical debate in 1997: cloning. A member of the medical-ethical panel immediately set up to deal with what to do about cloning said of the panel's discussions, "Logic was air-tight, but it did not change anyone's mind.… Logical arguments [were] only rationalizations for gut feelings or religious viewpoints" (1).

So let us be a bit modest about the power of this debate. In physician-assisted suicide, there are many obstacles to real discussion, including people's general reluctance to get anywhere near making any exceptions to "thou shalt not kill." However, one large obstacle to discussion of physician-assisted suicide is that people have deep wishes not to be in conflict, to have one simple, clear guiding philosophy or value or commandment or model that will settle difficult dilemmas for us. We wish for the security and beauty of simplicity. We human beings—including physicians and Supreme Court judges—are, on the whole, uncomfortable with what is not perfectly resolved and with the idea that some conflicts are not wholly resolvable—that some of our own powerful values necessarily and inevitably clash with other of our own powerful values.

Moreover, we are often uncomfortable even with acknowledging that this discomfort or conflict exists, so we tend to deny that there are major philosophical as well as emotional conflicts, and to deny that we often wish away conflicts by leaning unreasonably on authority and what seem to be familiar or simplifying solutions. At a level that I think is always in conflict with our most adult selves, we all still sometimes have wishes to have good parents. Much of the strength and irrational appeal of authoritative guides or governments, and of many or most religions, have their roots in this psychological area.

"Thou shalt not kill," for instance, is an extraordinarily powerful, appealing, and all-but-universal ethical guideline. Yet most of us do not often, or comfortably, examine too closely its edges, where most human beings allow some exceptions. (The exceptions are in line with scholarly opinion that considers "thou shalt not murder" a more accurate translation of the Biblical Hebrew.)

Another deep and powerful ethical guideline, also all but universal, and also deeply relevant to physician-assisted suicide and of comparable weight to "thou shalt not kill," is the Golden Rule, in either its positive or its more careful negative form: "Do not do unto others what you would not have them do unto you," and that may, in relatively rare cases, clash with "thou shalt not kill."

History, or tradition, is another guide that seems absolute and overriding to many people, but tradition is often more complex than its pure adherents admit, while change, slower or faster, is not only traditional, but also essential for civilization.

More specific to physicians, including, of course, psychiatrists, is the Hippocratic oath, which—although it has had various forms over the centuries, and various translations—is often used as if it were a clear, simple, single clinical guideline. It is not a clear, simple guideline. A serious discussion of its problems and clashes with practice, with other ethical guidelines, and with regulations, economic pressures, and laws would be timely and useful—far more so than is currently admitted by those who have not read the Hippocratic oath or who only vaguely remember it, or those who want it to be above dispute. Some people wish it to be above dispute perhaps partly because to doubt or correct or edit any part of it might throw it all into question, and it is felt to be overall a good and sound document, protective of patients and of medicine as a good profession. (That said, let me remind you that in one recent translation, the Hippocratic oath says, "I will give no deadly medicine to anyone if asked.")

Allied to, although not explicitly a part of, most versions of the Hippocratic oath is the excellent and powerful and perhaps most fundamental commandment to physicians, "Above all, do no harm." Yet again, that is a fine, but imperfect, commandment for some difficult situations in real life. We do, of course, use medicines that do harm if they also do what we consider more good than harm.

Although apparently wonderfully clear, "Above all, do no harm" does require judgment and is open to different interpretations. Some would say that to help speed the death of a terminally ill, severely suffering, mentally competent patient who asks for help in dying is to do harm; others—many laypeople and many physicians—would say that to withhold help in speeding a patient's end would be to do not only harm but more harm.

Another source of deep values and commandments for many Americans, and, of course, for our laws, is the U.S. Constitution and Bill of Rights. But there, too, in not a few important areas, are found difficulties of interpretation, disagreements, and even significant changes of interpretation over time. That was clearly the case in the recent history of an emotional area related to physician-assisted suicide—abortion—and it is also true in physician-assisted suicide, where rulings in two cases decided in one direction on constitutional grounds by two appellate courts (the second and ninth circuits in New York and the State of Washington, respectively) were overruled in 1997 by the U.S. Supreme Court.

So one of my major points is to warn us against total reliance on any simple, single statement or institution, and to suggest that where serious basic value conflicts exist, laws that in effect would silence and foreclose one-half of the values and of the discussion and the hard work of developing variety and experimentation with careful balanced, relatively good solutions—such laws are less wise than laws that allow more liberty and careful variety and debate.

Recent polls show that in the past half century the American public has moved from a large minority who approve of physician-assisted suicide in some circumstances to about two-thirds or three-quarters (1996 polls) who now think that physician-assisted suicide should be legal in some circumstances (2). Polls suggest that currently only about one-half of American physicians favor physician-assisted suicide in some circumstances (3). No one knows what percentage of American psychiatrists favor it, although in Oregon a poll suggests that half to two-thirds of Oregon psychiatrists favor physician-assisted suicide in some circumstances (4).

A great many judicious people think something that wisely ought to be rare but possible ought to be legal rather than illegal. Many of us clearly do not think that "thou shalt not kill" ends the argument, or that "above all, do no harm" ends the argument, or that the Supreme Court ended the argument. Probably hugely more of us do not think that a position of the American Medical Association, or the American Psychiatric Association's joining in an amicus brief with AMA, ends the argument.

There are dozens of good areas for discussion and argument in physician-assisted suicide, and dozens of good people who have recently argued them. I'll pick a few to comment on, while also giving a bit of a whirlwind tour of some of the many recent issues and players and law cases and arguments.

• A U.S. Supreme Court case, Casey v. Planned Parenthood, allowed people to make their own decisions about intimate matters.

• A U.S. Supreme Court case, the Cruzan case, allowed the removal of life supports.

• A Ninth Circuit Court of Appeals case, Washington v. Glucksberg, argued for a constitutional liberty right to physician-assisted suicide largely based on due process.

• A Second Circuit Court of Appeals case, Vacco v. Quill, in New York, argued for physician-assisted suicide largely using the equal-protection clause.

• A U.S. Supreme Court decision in June 1997 overturned Washington v. Glucksberg and Vacco v. Quill and did not find a constitutional right to physician-assisted suicide but allowed state legislatures to deal with it.

• Comments by justices other than Rehnquist in the 1997 Supreme Court case gave some support to physician-assisted suicide. For instance, Breyer considered a "right to die with dignity."

• Countless other comments about the ruling also supported physician-assisted suicide, including those by Harvard law professor Lawrence Tribe, the New York Times, and many other newspapers, journalists, and essayists, as well as several amicus briefs. I particularly commend the so-called "philosophers' brief," which bases much of the case for physician-assisted suicide on autonomy.

• Real-life experiments with physician-assisted suicide have provided valuable experience, including those of many physicians over the centuries, some of which have been reported, but many not; those of provocative physicians such as Dr. Kevorkian; and calmer and wider experiments, such as those in Holland, Oregon, and Australia.

• Another move is the current AMA position accepting the Supreme Court's decision in the Cruzan case and insisting that the right line to draw is more or less between so-called passive pulling the plug (the AMA accepts this) and so-called active prescribing pills for a competent patient requesting them (the AMA rejects this) (5). The 1997 Supreme Court decision (overturning Washington v. Glucksberg and Vacco v. Quill) largely accepted that line.

• The APA has no official position on physician-assisted suicide, but in 1996 its board of trustees, after a brief debate (that, oddly, hardly touched on any issues of content), voted to join the AMA amicus brief.

• Other prominent psychiatrists have furthered the debate. For instance, Dr. Herbert Hendin, a suicidologist, went to Holland and wrote a book saying that the Dutch experience shows physician-assisted suicide to be unworkable (6). Various Dutch psychiatrists have commented that they do not think Hendin's book is accurate or fair. Other American psychiatrists have added their comments, including as Alan Stone, Keith Brody, L. Jolyon West, and David Spiegel.

• Medical ethicists have also entered the debate—for example, two energetic opponents of physician-assisted suicide, Linda Emanuel and Ezekiel Emanuel. Ezekiel Emanuel has frequently noted that depression is the problem and that depression is treatable. (Not necessarily, and not always. The wish for a good death is often far from a depressed wish, and, separately, depression is not always treatable.) Linda Emanuel (7) helps AMA develop its positions, favors better palliative care, and does admit that physician-assisted suicide is "justifiable in rare cases."

• The issues involved in suicide itself, not just physician-assisted suicide, must be considered. Suicide has in this century been legalized in many jurisdictions; physician-assisted suicide has not. However, many religions still flatly oppose all suicide. Yet, if suicide is legal, the legal and moral position of physician-assisted suicide is on different and narrower ground. (Laws against physician-assisted suicide seem to me to be used, often covertly, to buttress religious disapproval of suicide itself by making suicide as painful and difficult as possible, by refusing any help for dignified suicide to all those who ask for it.

• The issues of euthanasia versus physician-assisted suicide are often blurred, especially by opponents of physician-assisted suicide. It is possible to clarify the difference between assisting death against a patient's will and assisting a patient to take some control of the time and way of death.

• The issue of euthanasia versus physician-assisted suicide leads to questions of so-called slippery slopes, a catchy image used and abused to blur physician-assisted suicide terribly with giving the state power to kill, which is not at all what physician-assisted suicide is. Watch out for the slippery-slope metaphor. In physician-assisted suicide, it is usually a dishonest slope sitting queasily on a conceptual swamp.

• Another serious question is whether good regulation of physician-assisted suicide would be possible, both to separate it more clearly from euthanasia and greatly to increase the likelihood of carefulness and minimal abuse and unfairness.

• Palliative care is useful and in need of great improvement, but it is not a solution. It is expensive and likely to remain grossly inadequate in the U.S., and even where it is good and available, it does not fully solve the question of physician-assisted suicide.

• The issue of fairness also arises. What would be the effect of more or less legal physician-assisted suicide on fairness—for example, on the poor and vulnerable versus the rich and powerful? This issue presents a mixed picture, but legal physician-assisted suicide would be potentially fairer than the present system.

• The relationship of abortion and the abortion debate to physician-assisted suicide should be considered in its emotional, ethical, legal, and political dimensions. One large difference is the presence of adult choice—the presence in physician-assisted suicide of a competent adult patient.

• The question of dying well matters. Physician-assisted suicide is probably more urgent now and more popular now because modern medicine has made dying worse—often both longer and worse.

• AIDS is a major example of doctors often contributing to making dying worse.

• There are many disadvantages to criminalizing physician-assisted suicide, including huge potential risk and damage to individual doctors, to other persons, and to honesty, openness, trust, and respect in doctor-patient relationships and medical care.

Doctors in general have all the above concerns and some more specific medical ones. For instance, cancer specialists, AIDS specialists, and many others have specific front-line problems about how to be compassionate; how to cure when they can, but when they cannot cure, how to help as much as they can and harm as little as they can; how to help against pain; how to help preserve the patient's dignity and autonomy; and how to do what the patient wishes. Physicians who are morally opposed to physician-assisted suicide should not have to take part in it. (No one that I know of is proposing that they do so).

However, physicians currently are also under such pressure from managed care and have suffered such losses of professional autonomy—and damage to the doctor-patient relationship—that neither good palliative care nor good physician-assisted suicide is likely to be widely and carefully available. That our current American model of medical care, which is dominated by business and profit and managed care, might see good palliative care as particularly expensive, and physician-assisted suicide as relatively cheap is, I think, a reason not to make physician-assisted suicide illegal but to reform our system of financing health care.

And what about psychiatrists? We have all of the concerns I have described and some additional psychiatric concerns about physician-assisted suicide. For instance, is depression the whole problem? No. Is depression always curable? No. Can a psychiatrist tell a reasonable wish to die from depression? Often yes. If physician-assisted suicide is legal, how does it affect the treatment of other depressed or suicidal patients? (This is a serious but workable clinical area, demanding honesty and toughness about our own educated, limited, but relevant judgment and clinical caution about what is clear psychosis or treatable depression; what is a shade of gray and debatable, thus requiring great caution; and what is a competent and reasonable wish to die sooner rather than later.)

Does deciding that a patient asking for physician-assisted suicide is not depressed mean that the physician is taking a direct part in killing? Or, as proponents of physician-assisted suicide would say, is it letting patients have more control over their own time and way of death—that is, not being a direct gatekeeper of death but a direct gatekeeper to more choice? Psychiatrists also face burnout with physician-assisted suicide, and significant transference and countertransference issues.

In conclusion of this first part of the debate, what do we want for ourselves and for our society? What is ideal? Can we design it, in a complex world where good values clash with other good values? Given major arguments for the decency and dignity of physician-assisted suicide, and major public approval, let us carefully allow it to exist in various forms with various regulations in different states and countries, and encourage variety and careful experiment and respectful debate. If physician-assisted suicide were illegal in all relatively advanced societies, that would discourage attempts to think through, discuss, and try out careful ethical guidelines for something that is fairly rare, but is—now and historically, nationally and internationally—present in the practice of many good physicians and the wishes of many good people.

I do not think more and more life is always better.

I do not think pulling the plug versus prescribing pills is a morally strong boundary to draw.

I value life, autonomy, dignity, medical compassion, liberty, and choices.

I would not like the choice for physician-assisted suicide to have to be everywhere covert and illegal, or available only to the educated and the rich.

I would myself like to have a lethal dose of sleeping pills and a good physician and some choice available to me if and when I have a painful terminal disease. I think most people would. What do you want?

I think physician-assisted suicide should be legal.

Dr. Meyerson: The debate on physician-assisted suicide tends to focus on the patient's needs for relief from pain and suffering. By physician-assisted suicide, one refers to the physician's following the wishes of a patient by actively and intentionally aiding and abetting the death of that patient. Physician-assisted suicide is distinguished from euthanasia, which includes cases in which the patient may be assisted by the physician to die but not necessarily with the full knowledge of the patient, as in the case of an unconscious, terminally ill person.

The majority of physicians and laypersons believe that there should be a patient's right to die, at least under limited circumstances. This simple fact is presented, in the context of a democratic society, as a reason for legalization of physician-assisted suicide. However, even if one accepts the premise of that argument, and we should not, two essential questions remain. Should the humane and logical extension of relief of suffering be to require legalization of terminating the life of a suffering person when that requires an affirmative act on the part of someone else? If assisted suicide is legalized, should the assisting person be a physician?

That the act should be legalized if performed by someone can be argued, but not convincingly, and the counterarguments are at least as compelling. The argument against physicians' being the agents or even the angels of death is compelling when the art and science of medicine and particularly psychiatry are taken into account. I will address each of the arguments for the affirmative.

Before I get into the formal part of the negative case, I would like to share my personal reasons for believing that there should be no legalization, or other formal acceptance, of physicians' ending or terminating the life of a patient—killing someone.

Why did most of us go into medicine? Perhaps that is an unanswerable question, but it is one that each of us has struggled with in some fashion. For myself, and, I suspect, for many others, the answer lies in a combination of personal experience of physicians and the public image of medicine as portrayed in biography and art, mainly fiction and films. My experience involved Sidney Rosenfeld, M.D., who doctored my family from before my birth until his death about ten years ago. Sidney was a committed family doctor treating my cousin's idiopathic thrombocytopenia purpura, my father's thyroid and prostate conditions, my mother's various ills including depression and osteoporosis, and my own childhood and adolescent ailments. My earliest exposure to medicine was in Sidney's office, where he would show how fluoroscopy worked, how to listen through a stethoscope, and other magic of medicine. His goals were to share his love of medicine and to distract me from the needle he was going to stick in my little tush.

When my mother became unremittingly depressed in her sixties in response to growing deafness and inherited, sex-linked tendencies toward depression, which she shared with her mother and her two sisters, Sidney first tried counseling and then insisted she see a psychiatrist. As she grew older, my mother developed osteoporosis, and her multiple spinal fractures made her six inches shorter at her death at 82 than when she was in her 50s. As the back pain and her narcissistic injuries became intractable, she would talk of suicide and on several occasions asked my father and Sidney to help her commit suicide. On one occasion, she asked me as well. In each case she received the same answer, in essence: "We love you, we don't want to lose you, let us help you." The help was better pain management, psychiatric treatment, and distraction of every kind.

Until her death my mother was not openly grateful to us for refusing. She always longed for an end, but she knew she mattered to her family and to her physician, whom she had known for 70 years. My mother was fully able bodied despite her ailments and could have killed herself at any time. Perhaps our refusal to stop loving her and valuing her life, and Sidney's persistent offers of hope, new drugs, new consultants, plain support, and patience, also tilted the balance toward life.

Along with Sidney's wonderful example, literature and movies were an intermittent reinforcer of my belief in the life-giving and life-valuing core of the medical profession. Semmelweis, Koch, Fleming, and, beyond all others, Pasteur as portrayed by Paul Muni and as described in two biographies were the heroic figures around which my imago of physicianhood was formed. Dedicated men, alas only men, committed to saving life and to prevention, diagnosis, and treatment of disease and suffering.

I remember the raging debate in the great film about Pasteur with Paul Muni. Should inoculations be given to patients even to save their lives? Could one risk the side effects of the unproven sera even in cases of extreme illness? This debate in modern guise still rages among institutional review boards all over the country. It is a worthy one, with both sides maintaining the essence of physicianhood.

I do not believe that those who advocate physician-assisted suicide maintain the essence of physicianhood that characterizes our ideals. Even the withdrawal of life support appears to follow the logic and passion of the physician's credo that I know— "Prolong life, relieve suffering"—in that these patients appear to have no viability and thus the relief of suffering is paramount. Even when a physician gives incremental pain medication to patients who might use it to kill themselves a few hours or days prematurely, if one's motivation is the relief of suffering and not to help the patient die, then one remains a physician. But to actively and intentionally kill a sentient patient, whatever the motivation, is an act outside of the profession. One might find a way to justify it as a human being but not as a physician.

The 50 international doctors who are willing to risk injection with an attenuated, live AIDS virus are the living embodiment of the highest ideals of the medical profession, the essence of its best identity. Killing patients is not. Dr. Kevorkian will not take his place beside Koch, Pasteur, Lister, and the others in any medical pantheon I care to believe in. One doesn't have to condemn Kevorkian's actions to think they are not inherently medical.

Now for the less personal and formal presentation of the negative position in this debate. Mercy is often the basis for the pro argument, which asserts that the relief of pain and suffering justifies the act of assisted suicide. However, such a decision can often be and perhaps always is misguided when the assessment is made by people other than the patient. It is analogous to the difference between how people with a disability value their lives and how people without a disability value the lives of the disabled.

Palliative care in the U.S. is notoriously underused. Ideally, it can manage almost all pain adequately. In the few cases of unmanageable suffering, anaesthetic coma can be induced until death or new palliative or curative treatments can be developed. A study by Van der Maas and colleagues (8) indicated that in only 3 percent of cases is pain alone the motivation for requests for physician-assisted suicide; pain in conjunction with other factors still represents less than half of requests. The majority are not pain related. The relief of suffering should not be achieved by ending the suffering life. One could argue that the end of life in an anaesthetic coma is not appealing, but it does provide mercy without violating the moral and ethical boundaries of society and physicianhood.

Proponents also hold that some mercy killing is justified as they believe that acts of omission such as the withdrawal of life-sustaining equipment are equated with acts of commission (physician-assisted suicide). Are acts of omission morally and ethically distinct from actively causing death? Triage medicine involves the potential choice of omission of care for one who is sure to expire in favor of providing care for another whose chances of survival are greater. When a physician or family member chooses to withdraw life-sustaining care, the motive may be to reduce suffering. In a physician-assisted death or suicide, the motive is to kill a patient whose sentient life is still a reality, and the positive act to end it is the goal. The distinction between physician and executioner is a far cry from that of physician and triage officer.

Advising a family and patient on withdrawal of equipment or that, to be fully effective, a pain medication may reach levels that will cause death is also morally and ethically distinct from purposely killing a patient. Emanuel (9) suggests that in circumstances in which palliative care can eliminate physical pain, misery is reduced to the point where one cannot choose physician-assisted death over medication-induced coma, which point does not justify mercy killing.

The right to die with dignity is raised as a reason for physician-assisted death. Dignity is a subjective and culture-driven notion. Its use as a justification for mercy killing requires one to accept the sense of dignity of an elderly Eskimo or Native American, for example, which involves allowing self-imposed isolation, starvation, freezing, and exposure to animals of prey, while also accepting another person's request for an overdose to relieve his impaired sense of dignity. If the person in the first instance is exemplary of dignity and autonomy, how can society set itself up to decide or relegate to the physician the right to distinguish which person, in which situation, and from which culture should be assisted to die by the doctor? Psychiatrists should be most aware of the vulnerability of these value-laden motivations to be irrational and ego-syntonic. Are physicians to simply follow a patient's values and idiosyncratic notions of dignity and override our ethical positions of "do no harm," "preserve life," and, yes, "relieve suffering"?

I, says Grandma or Grandpapa, am no longer beautiful, wise, a leader, able to provide materially for my family, or continent. All of these situations are reasonable causes of a loss of a sense of dignity for some people. But a reason for dying at the hands of a physician requires a degree of certainty that the patient isn't treatably depressed. Were physician-assisted suicide a professionally acceptable and legal practice, then a patient suffering a loss of beauty or any other reason for loss of dignity could doctor-shop until he or she found the right narcissistic physician to empathize with the sense of loss of dignity and kill out of a kind of empathic mercy.

Autonomy, self-determination, and the right to privacy are also raised as arguments for the affirmative position. Autonomy does not require that even freely given requests for physician-assisted death be followed. All autonomy rights are limited by the rights of others not to be interfered with or injured. If a patient is to be allowed the right to die or be killed, under some restricted circumstances, does that equate with being able to prescribe the physician's role in that killing? Arguably, attorneys in their role in adversary systems might find it closer to their ethical and psychological essence to kill a patient than a physician would or should.

The right to privacy is proffered as a basis for asserting that physician-assisted death should be a decision involving only the physician and the patient. Emanuel (9) argues that the public importance of this matter, its private nature not withstanding, seems to be a point of consensus. The argument for physicians' assisting death privately as part of the physician-patient relationship ignores the family's interest, the societal interest, and, unfortunately, the issues imposed by managed care with enforced rationing. The cartoon of the physician informing the patient, "Your HMO will not pay for your treatment but does cover physician-assisted death. Come back in the morning and I'll kill you" may be bizarre humor, but it points to a real danger affecting all of us. Should any active killing of one individual by another be allowed in a purely private setting? How dangerous, how cowardly, how grandiose.

Proponents of physician-assisted suicide also assert that professions should serve society's needs. Should the medical profession therefore actively assist a patient's death? This argument essentially ignores the long traditions of medical ethics by asserting that ethics should be suspended in favor of legal decisions or the will of the voters. As Emanuel (9) believes, societal values can be defined and applied to support or oppose physician-assisted death based on the tradition that an appropriate professional position may be determined by assessment of overall benefit to patients or society. However, this approach largely ignores traditional ethics and the insights that psychiatry and psychoanalysis bring to bear.

The profession of medicine lost much of society's generally positive transference when from the 1950s on we became tainted by the pollution of the Hippocratic tradition with the venality inherent in some physicians' exploitation of Medicaid and Medicare, private hospitals and clinics laden with conflicts of interest, machinery medicine, and so forth. If we lost the public's respect for those apparent changes, imagine the distortion of our benign imago if we assume the official role of killer, even under the best-intentioned rationale.

Consider the following possible scenario. Dr. H, the internist, says to Mrs. C, "You've not responded to chemotherapy. Further treatment seems hopeless. You may live for several years but more likely one or two. In that time the tumor, already causing weakness, will cause headaches and disability. You are already financially dependent on your family. As time goes on, the cost of nursing care will be added, or you will have to move to a costlier hospice or nursing home. I want you to know that if you wish to end your life, your pain, the indignity of loss of function, and the burden to your loved ones, I will assist you in a painless death."

Has Dr. H added to Mrs. C's sense of comfort, or has he eroded what little hope she had? By the power of his position and suggestive language, has he reframed the patient's sense of a loving connection to her family into one of clinging, resented dependence? Has he tipped his professional identity from healer, soother, prolonger of life, and potential savior (granted, lost in this case) into one immutably tainted with fearful, judgmental rejection of the patient's basic value? If you are not sure of the answers, that should prevent your accepting the physician as the instrument of death.

Legal trends are said to support physician-assisted suicide. It is odd that the only instances when it has been argued in law that citizens have a right to physicians' assistance is for abortion or physician-assisted suicide. Although courts often fail to convict physicians of physician-assisted suicide, including Kevorkian, the trend in both public opinion and new legislation is to bar physician-assisted suicide or to fail to adopt it as law. The Supreme Court has decided that the Constitution doesn't include physician-assisted suicide as a protected liberty. The only state to pass a law on physician-assisted suicide is Oregon; when it revisited its plebiscite last year, the voters reaffirmed their belief in its utility by a small majority.

Fifty bills for physician-assisted suicide have been introduced in the states, and only Oregon's passed. A 1996 Washington Post poll indicated that while a small majority of Americans favor some form of physician-assisted suicide, blacks, the elderly, and those earning under $15,000 were against legalization (10). Seventy percent of blacks opposed it, and 20 percent were in favor. Among the elderly, these figures were 58 and 35 percent, and among those earning under $15,000, they were 54 and 37 percent. The Academy of Medicine has recognized poverty, minority status, and age as the three most significant correlates of mortality and disability in America (11). It appears that those most likely to be shuffled off this mortal coil would least appreciate our assistance along the way.

Whatever the majority wishes, should physicians seek to join soldiers at war, persons defending their lives, police, and executioners as the instruments of societally approved killing? Certainly, the movement toward legalization and my parody of the fictional Dr. H embody worthwhile values, including a desire to maintain patients' autonomy and alleviate their suffering. However, the opposing values of "do no harm" and the preservation of life should be compelling for physicians when the good values can be accomplished, as they can, by means other than the physician's becoming the agent of death.

Those holding the affirmative position argue that legalization permits restraints and prevents us from sliding down the notorious slippery slope. They argue that physicians already engage in physician-assisted death and that legalization such as in Holland would bring it into the open and provide a barrier against errors of judgment or malpractice. Opponents argue that the slippery slope to widespread misuse would be oiled by legalization.

Concern about the slippery slope is real, but there are no empirical studies to determine which mechanism is more effective in reducing unjustifiable killing. Again, it is evident that a society that allows and even legally encourages physicians to kill patients will have a different group psychology or ethos than one that doesn't. Respect for life is a general good, and for physicians it should not be eroded, even by "merciful" impulses.

The Dutch experience is cited as a basis for U.S. physicians to carry out physician-assisted suicide. Dr. Hartmann argues that Holland should be a model for the U.S. and assumes that Holland and the United States are sufficiently similar for us to adopt their position. However, Holland has universal health coverage, widespread availability of hospice care, and a legal distinction between illegal and punishable acts; we do not. Compared with the U.S., Holland has no state-based legal system, a culture of pragmatism mixed with Calvinism, less cultural and ethnic diversity, and far less violence.

In addition, the Dutch approach to physician-assisted suicide is fraught with major problems. First, the law includes psychiatric illness as well as medical illness; however, one criterion of the law is that the patient's decision be "well considered," and significant controversy has arisen about whether decisions by seriously psychiatrically ill persons can meet this standard. Second, another legal criterion is "incurability," which may be impossible to determine in many cases, perhaps most of all in psychiatry, where new and more effective drugs are rapidly becoming available.

Third, many Dutch psychiatrists refuse to participate in physician-assisted suicide, feeling that the boundary violations inherent in participation taint their ability to form a therapeutic alliance (12). These psychiatrists also believe that countertransference toward chronically ill patients can intrude. Fourth, 60 percent of Dutch physicians don't report cases of physician-assisted suicide (13), which is perhaps related to the Dutch courts. Despite legalization, courts have levied civil and criminal penalties in several cases in which family members or prosecutors filed actions and physicians were deemed incorrect or negligent in agreeing to participate in the patient's death.

In conclusion, I can think of no better way to end the argument for the negative case than by quoting the AMA guidelines (5), supported by APA: "Life should be cherished despite disabilities and handicaps except when the prolongation would be inhumane and unconscionable. Under these circumstances, withholding or removing life-supporting means is ethical provided that the normal care given an individual who is ill is not discontinued." They go on, "For humane reasons, with informed consent, a physician may do what is medically necessary to alleviate severe pain and cease or omit treatment to permit a terminally ill patient to die when death is imminent. However, the physician should not intentionally cause death."

In short, we don't require doctors to kill. Anyone can do it. We need to use the power of medicine to improve the care of the terminally ill. Legalization of physician-assisted suicide does not represent an argument for adoption of the practice as ethically sound.

Dr. Hartmann is a past-president of the American Psychiatric Association and is on the faculty of Harvard Medical School. Send correspondence to him at 147 Brattle Street, Cambridge, Massachusetts 02138. Dr. Meyerson is professor and vice-chair in the department of psychiatry at the University of Medicine and Dentistry of New Jersey-New Jersey Medical School, 215 South Orange Avenue, Newark, New Jersey 07103 (e-mail, [email protected]).