Physician-Assisted Suicide and Euthanasia

Dear Editors: Re: Boudreau JD. Physician-assisted suicide and euthanasia: can you even imagine teaching medical students how to end their patients' lives? Perm J 2011 Fall;15(4):79–84. Considering that physician-assisted suicide and euthanasia is a sensitive and controversial topic, the reductionism and the lack of objectivity of the question asked and of its discussion are intriguing. It is clear that the author and advisers wished no answer but their own. It is not usual for scholars to be reluctant to confront their views with others. Surprising it is, that of those with the most experience in the field, none were consulted, namely from the Netherlands, Belgium, and the State of Oregon. Their comments would have broadened the horizon for the readership and rectified some lexical vagaries. It is generally understood that kill and murder are acts perpetrated on nonconsenting victims. Thus, the absolute moral value of “not to kill” does not apply to requested euthanasia, and “self-murder” is an oxymoron. The experts from overseas would have insisted that euthanasia cannot be reduced to the “teaching of an act intended to hasten death”; and that what can very well be role-modeled is a humanism paving the way toward the “presence and accompaniment,” hailed by Dr Boudreau, which is the essence of the Belgian Integral Palliative Care: high-quality palliative care, open to the “act” of advancing death, when suffering cannot be relieved and proves intolerable to the desolate dying patient, who requests it.1 From the Netherlands likewise, one would appreciate how the “euthanasia talk,” over weeks and months, can be taught, along with excellent palliation and end-of-life care. In this humanistic, reassuring process, nine out of ten formal requests sublimate into a natural death.2 Only one in ten will want the request honored, as recommended by Eric Cassell, MD: “Assisting a patient in dying is not an easy way out. When terminally ill patients request assistance in dying because of their suffering, and their request meets commonly endorsed safeguards, their request should be honored.”3 In that perspective, bright and sensitive medical students, learn to develop a rich “autonomie-en-lien” (bonds in autonomy), an obbligato tandem between patient and physician, wherein both remain free, yet tied by the bonds of humanity (Marc Desmets, MD; personal communication; 2012).a The morality of an act resting on its justification and its benevolence—as per philosopher Tom Beauchamp, MD4—is in the realm of the physician; benevolence, as the answer to suffering, affirmed solely by the patient. “Only the patients know how awful their own suffering is,” wrote Cassell.3 In the above context, to entertain nightmares of “Modules of euthanasia,” taught by certified “euthanatricians” teaching evidence-based medicine, which may well be irrelevant when “The One and Only Mrs Jones” will face death,5 all belong to fiction. Curricula, textbooks, research, hence journals, on end-of-life and palliative care abound and have been on the rise, more so where regulated physician-assisted dying has been enacted. Palliative care, including medically assisted dying are already taught in the Netherlands and in Belgium by qualified medical educators. “Palliative care education fits very well with the aims and agenda of general medical education, helping to correct the imbalance between knowledge, skills and attitudes.”6 In 2007, the Flemish Palliative Care Federation stated: “No dual track in end-of-life care by which palliative care practice and teaching on the one hand and euthanasia on the other would develop in separation” … “Each patient's choice must be respected.”1 What is needed then is a continued expansion of those activities by mentors respectful of patients' autonomy and for whom the faculty's agenda is aligned with, and subordinated to, the patient's own. Paternalism is no longer a virtue but an oppressive tyranny (vide infra). “The first duty of the physician is no longer to save life at all costs, but to respect his patient's choices,” affirmed the Hon Baudouin.7 Dr Cicely Saunders reminded all that: “Whatever our own beliefs, we should never impose them on another person, least of all on any individual who is dependent upon us.”8 Should a ludicrous specialty of “euthanatrists” ever be considered necessary, one for “terminalists” or “sedationists” is then urgently needed to administer terminal sedation, for both euthanasia and terminal sedation end in death. The insinuated inadequacies regarding “death talk,” diagnosing depression, and pain management are still being raised. To be noted, even in reputed palliative care units, terminal sedation can last more than 10 days (in 10% of cases) and even more than 20 days (in 3.4% of cases).9 The longer it lasts, the more knowledge, skills and humanism are necessary to cope with the wide spectrum of physical, psychosocial and spiritual problems that develop, for both staff and families. Not rarely, experienced palliativists at times do poorly in such situations, as heard personally in workshops on “prolonged terminal sedations.”

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