Rethinking Medical Aid In Suicide

In a vote that is stirring unprecedented debate about issues of life and death, the only place in the United States that has legalized physician-assisted suicide is reconsidering its stand.

In the past, most Americans have said they favor patient "choice" in the matter. But Oregon's mail-in vote, which ends tomorrow, comes at a time when public opinion may be shifting.

And as the issue moves from the theoretical to the legally possible, there's no question that it is raising profound medical, religious, and ethical questions. Among these:

How should respect for the sanctity of human life be weighed against a choice involving "death with dignity?"

For those diagnosed as terminally ill, does hospice care allow for an emotional or religious experience - for family members as well as for patients - that suicide or euthanasia would eliminate?

How does all of this fit into current discussions about medical "cost containment" and universal health care?

Americans may be wavering in their support for assisted suicide because it really means allowing for another form of killing, says Courtney Campbell, a medical ethicist and philosophy professor at Oregon State University in Corvalis. "Whenever we've legalized the taking of another human life, whether it be cases of self-defense, capital punishment, or warfare, we've never been able to regulate it very effectively," she says. "We'd be setting ourselves up for that with the taking of life in medicine."

Others who track the issue disagree.

Margaret Battin, a bioethicist and professor of philosophy at the University of Utah in Salt Lake City, believes that safeguards can be built in so that individuals are not coerced into committing suicide simply to avoid medical costs that might burden their families.

Legally providing "an easy and gentle way of dying" to people who believe they have no other option can be a comfort to the family as it "says its final goodbyes and then begins the grieving process," adds Dr. Battin, who has written extensively on the subject.

And just as it is now common practice to sign "living wills" directing doctors and family members not to use extraordinary life-prolonging measures, she says, people can also sign "living won'ts" explicitly rejecting physician-assisted suicide or euthanasia.

What Oregon's law would do

Three years ago, Oregonians by a slim margin approved the "Death With Dignity" ballot measure. It allows a patient diagnosed as terminally ill to request from a physician a prescription for a lethal amount of medication to be taken orally. There is a 15-day waiting period, and a second medical opinion is required as to the patient's condition (including sound mental state). The act also specifically prohibits "lethal injection, mercy killing, or active euthanasia."

When medical and ethical questions arose about the new law (which has been tied up in court challenges), lawmakers here put another measure on this year's ballot - one that would negate the earlier vote.

Press reports here, and especially letters to the editor, have been filled with personal stories from Oregonians whose experience in dealing with the death of a loved one has led them to either support or oppose physician-assisted suicide.

Those in favor of the new ballot measure have far outspent supporters of Oregon's law in promoting their cause. These include the Roman Catholic Church, the Mormon Church, and the group Right to Life. Reformed and Orthodox Judaism, Islam, and most other Christian denominations oppose suicide and euthanasia as well.

Philosophy professor Margaret Battin says Christianity's opposition to suicide of any kind grew out of the "promise of a beatific personal afterlife." As far back as St. Augustine in the 4th century, she says, the accepted view has been that the Christian "shouldn't kill himself in order to get to the afterlife."

Still, a few religions - the Unitarian-Universalist Association and the United Church of Christ among them - have concluded that choosing to end one's life with the help of a doctor is morally acceptable.

Vote's outcome uncertain

Despite the infusion of out-of-state money to nullify the Death With Dignity law, Oregonians are exhibiting their typical independence - right up to tomorrow night's ballot deadline. According to statewide polls, more than 60 percent did not want to have to vote on the issue a second time, and they resent lawmakers' bringing it up again.

Oregon is also one of the most "unchurched" states in the nation, meaning fewer people here regularly attend religious services than elsewhere. Radio ads against the repeal are paid for by the "Don't Let 'Em Shove Their Religion Down Your Throat Committee."

Yet given the sensitivity of the subject, no one is confidently predicting an outcome. Nationwide, many Americans may be having second thoughts about physician-assisted suicide as well. Polls by the Gallup organization show the percentage of those supporting the procedure dropped from 75 percent in May 1996, to 57 percent last June.

Earlier this year, the US Supreme Court left it up to states to decide the legality of doctor-aided suicide, but it also ruled that there is no constitutional right to the practice. Chief Justice William Rehnquist warned that, if legalized, "it will prove extremely difficult to police and contain."

President Clinton, too, has expressed concern. "The risks and consequences ... are simply too great," he has said.

Rise of hospice care

Another reason more people may be questioning physician-assisted suicide is the recent increase in hospice care for patients diagnosed as terminally ill.

Such care involves close physical, social, psychological, and spiritual attention, often in conjunction with palliative (pain-reducing) drugs. In many cases, this care is provided in familiar surroundings at home - and at less cost than that of a hospital stay.

"Beyond physical and psychological comfort, spiritual comfort is an important goal of hospice care," states the National Hospice Organization, which represents 2,200 hospice programs around the country. "Patients who opt for euthanasia may miss the opportunity to transcend their suffering and find meaning in their lives for themselves and their survivors."

Supporters of "choice" on the matter agree that hospice care should be more widely available.

Ira Byock, a hospice medical director in Missoula, Mont., speaks for many on both sides of the issue when he says, "Success will not come with making assisted suicide and euthanasia legal, but rather with making them unnecessary."