The Dutch example: Other supporters of PAS/E offer a more pragmatic defense of their position, suggesting that the Dutch have proven that regulated euthanasia can work; however, it is not always used as a “last resort.” In nearly 20% of cases available palliative measures were declined by the patient; 60% of cases were not reported truthfully; 50% of cases did not have the required consultation; and—most worrisome of all—25% of patients who were given a lethal injection did not request euthanasia.5
Conversely, only about one-third of patient requests for euthanasia are carried out by Dutch physicians. Thus, two-thirds of patients who request euthanasia are denied it, and one-quarter of patients who are euthanized did not request it, suggesting that it is not patient autonomy that drives the Dutch euthanasia program, but physician autonomy. We must conclude that the Dutch experiment with regulated euthanasia has failed.
Arguments Opposing Physician-Assisted Suicide/Euthanasia
In addition to these rebuttals to those arguments in favor of PAS/E, there are several specific arguments in opposition. These have been well articulated elsewhere.6-8 They will merely be summarized here in two groups:
- Rule-based arguments: PAS/E goes against longstanding professional virtue and would change the nature of the patient-doctor relationship, perhaps even detracting from efforts at palliative care; and
- Consequence-based arguments: PAS/E would be bad public policy because regulations cannot prevent abuses and expansions of the “indications” to include coerced “voluntary” PAS/E, surrogate non-voluntary PAS/E for those who have lost decision-making capacity, requests from patients who are suffering (but not terminally ill), and even discriminatory involuntary euthanasia as a cost-control measure.9
The Moral High Ground
If we accept that PAS/E are contrary to physician virtue and moral tradition, and further that legalization of such activities would be bad public policy, what then is the alternative? The alternative is excellent end-of-life care. This requires a commitment to compassion, a willingness to “suffer with” the patient. Good palliative/hospice care has the goal of helping the patient to live each day as well as possible. Patients who receive good end-of-life care rarely request that their physicians hasten death.10
If a terminally ill patient does make such a request, the physician must elicit the reason by saying, “I’m sorry you are suffering. How can I help to make it better?” In addition, the physician should give the patient as much control as possible over treatment options when the patient is ready to shift goals to comfort care. The physician must never say, “There is nothing more I can do for you.” Such a statement represents an immoral abandonment of the patient. Instead the physician should say, “There is nothing more we can do to stop or slow the disease process, but there is a lot more we can do for you.”
All of the patient’s physical needs must be thoroughly addressed. This means intensive symptom control of pain and dyspnea, the two most feared symptoms at the end of life, as well as the multitude of other symptoms experienced by patients as they approach death.
Psychological symptoms are almost universal in dying patients. Anxiety about the future is understandable. Depression is likewise to be expected in a significant percentage of patients. Both need treatment, whether that be drugs, counseling, or someone to sit with the patient. Ramsay has said that people who are dying need only two things, comfort (symptom control) and company (human presence).11
Social issues also need assessment and treatment. Many dying people are lonely. Friends often stop visiting because they are uncomfortable and do not know what to say. Even family members may distance themselves physically and emotionally from a patient who is approaching death. Patients may have “unfinished business” that causes them unspoken distress. Byock has observed that a person who is dying often needs to say one or more of the following five things: “Will you forgive me?” “I forgive you,” “Thank you,” “I love you,” and “Goodbye.”12