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Euthanasia: An Unbiased Decision?
SPECIAL ARTICLE
Euthanasia:
An Unbiased Decision?
Shimon M. Glick, MD, Beer-Sheva,
Israel
I
n the field of medical research, and particularly in the area of clinical trials, the absolute need for unbiased observations has been fully appreciated only in the last few decades. It took many years before it was recognized that subtle bias could invalidate even the best designed clinical trials and must be scrupulously avoided to prevent the investigator from reaching erroneous conclusions. Today, even seemingly trivial deviations from random sampling and proper matching of study and control groups will not be forgiven by editors or decision makers who want to base their decisions on scientific evidence untainted by conflict of interest. Similarly, it took a series of unfortunate revelations of misconduct before institutions and journals began to examine more carefully their practices, with an eye to eliminating conflicts of interest on the part of researchers and authors. I contend that with respect to the subject of euthanasia there is currently an overly rapid movement in the direction of a drastic, and perhaps a dangerous, change in the traditional ethics of Western medicine. There is insufficient acknowledgement of the conflicts of interests on the part of the proponents of this societal change, and insufficient evidence to justify such a change.
BIAS IN THE CARE OF THE TERMINALLY ILL We, as physicians, and our colleagues in other health professions, all have our own biases and emotional needs that we are obligated to identify and confront. Who among us, when faced with a chronically ill, terminal patient, has not sensed an almost audible sigh of relief when on morning report the resident reports that the patient hnally died? But the relief, in no small measure, results from an unburdening of the staff and not just from the termination of the patient’s suffering. Unquestionably, American medicine has for decades been guilty of often thoughtless over-treatment
Am J Med. 1997; 102:294-296. From the Jakobovits Center for Jewish Medical Ethics, Center for Medical Education, Ben-Gurion University Faculty of Health Sciences, and Soroka Medical Center, Beer-Sheva, Israel. Requests for reprints should be addressed to Shimon M. Glick, MD, Ben. Gurien University of the Negev, P.O.B. 653, Beer-Sheva 84105, Israel. Manuscript submitted May 8, 1996 and accepted in revised form October 30, 1996.
294
01997 by Excerpta All rights reserved.
Medica,
Inc.
of patients, imposing upon them each technological advance merely because it was available. In an era of cost-plus reimbursement and fee-for-service, the physician and the hospital were not entirely free of protreatment bias. The appropriate backlash against such overzealous ignoring of patients’ desires and welfare may now be going to the other extreme. One should be no less sensitive to bias that results in premature withdrawal of indicated therapy. There is a fascinating, insightful responsum in Jewish halakhic tradition, which is, as is generally known, very much life-oriented. A 19th century rabbinical scholar, Rabbi Hayim Palache,’ in Izmir, Turkey, was consulted by a devout layman about his wife who had been incurably ill for many years, who had been suffering terribly, and was now begging for an end to her life. Active euthanasia, of course, was not even considered by this observant Jew, but he did ask whether the Jewish tradition permitted prayer for his wife’s death; this might be classified perhaps as a legitimate and merciful act of compassion. The rabbi responded with thoughtful sensitivity in his lengthy discussion, concluding that it is indeed permissible under these grave circumstances to pray for the sufferer’s demise. But he restricted the prayers to individuals who are not directly involved in the care of the patient. Their prayer was sanctioned because their sole concern was the welfare of the patient. Family members, and others involved in any way in the care of the patient, were disqualihed from indulging in such prayer because their prayer might be tainted with a degree of self-interest. This is a remarkably perceptive observation and one in line with a long tradition in the Jewish legal system of disqualification of judges and witnesses for the slightest suggestion of even subtle, unconscious bias.
MANAGED CARE AND THE TERMINALLY ILL In addition to the endogenous bias of the health professionals, we should also confront honestly the increasing pressures from outside sources. In the climate of “managed care,“2 and “bottom line” concerns in the healthcare field, the economic and social pressures are inexorable in the direction once described by Woody Allen as “death is a great way to save money.” Who of us is immune to these pressures from hospital administrators and public officials to the extent that he or she can honestly feel completely free of conflict of interest and bias? oQo2-9343/97/$17.00
PII SOOO2-9343(97)00016-8
EUTHANASIA/GLICK
In a climate of economic constraints and rising health care costs, the “right to die” can easily be converted into the “duty to die.” Euthanasia activists, public officials, ethicists, family members, and the media, by their emphasis on the right to die have added an unfortunate, and almost intolerable, burden to suffering vulnerable patients, who may begin to feel guilty that they have not yet requested euthanasia and have chosen to continue their life. One almost has the deja vu feeling of a revival of death as a duty to the state as was the case in ancient Rome. Recent proposals by prominent ethicists3-5 and public officials have contributed to this climate. Sulmasy’ recently described an imaginary conversation between a futuristic director of a managed care HMO and an elderly prospective member, in which it was clear to the applicant what the preference of the HMO would be in the case of long-drawnout illnesses requiring large expenditures. But this futuristic scenario has already arrived. In a recent workshop at the annual meeting of the American College of Physicians on how to talk with a patient about a DNR order,7 the tone of the “model” discussion seemed not much less one-sided, and was more in line with Sulmasy’s HMO director rather than with an unbiased physician, who first listened carefully to ascertain the patient’s wishes and needs. Hendins recently analyzed the communication processesin two widely publicized casesof active euthanasia and physician-assistedsuicide, presented by their proponents as model cases.He concluded that it was perhaps as much the physicians’ and families’ needs and biases that were being treated as those of the patients. If such is the case with the model casesthat are held up as ideal examples, what may one expect when the practice of physician-assisted suicide or active euthanasia becomes widespread?
violation of autonomy than selling oneself into slavery. As Daniel Callahan’o states: “It is a fundamental moral wrong for one person to give his life and fate to another, whatever the good consequences, and no less a wrong for another person to have that total final power.” If there is such a unanimous revulsion toward slavery, from which there may be a chance of escape, how much more so should there be for death, from which there is no return? A second point to be considered when patient autonomy is used to justify active euthanasia is whether a decision for suicide really can be a truly autonomous one in the present climate. We no longer readily accept the participation of prisoners in human experimentation because of the concern that their consent may not be autonomous. Can a vulnerable, sick, suffering person be truly capable of an autonomous decision in an environment where the media, the medical community, the bioethicists, the caregivers, and the family overtly and covertly convey the messagethat the time has come to die? An honest researcher would question seriously a consent from such an experimental subject, even were the risks minimal. In the case of euthanasia, one is not dealing with a minor risk, but with an irreversible taking of human life-on the basis of what kind of autonomy? In this context, John Stuart Mill suggested that one may restrain an unwitting man from crossing an unsafe bridge because he does not desire, after all, to fall into the water. The person’s ignorance of the danger makes his choice less than fully autonomous. One might logically extend the permissibility to prevent suicide to cases in which because of anxiety, suffering, and lack of information patients might have been pressured into an unwise decision, and into one where they certainly cannot judge the consequences fully. No one has, after all, come back from the dead. Furthermore, in an unbiased analysis AUTONOMY UNLIMITED? of the considerations of autonomy, it should be eviIn the United States, and much of the West, the prin- dent that suicide or euthanasia is not merely an issue ciple of autonomy is one of the overriding considera- of individual autonomy. Individual acts do not occur tions cited in support of euthanasia and physician-as in a social vacuum; they do influence others. Even if sisted suicide. In the modern climate of individualism one accepts an individualistic view of moralityand self-realization, such a principle is indeed attrac- that all is permitted if no harm is done to anothertive, especially in the face of severe suffering and ob- it is simplistic to consider only direct physical harm. trusive life-sustaining technology. Yet there are several A private act can indeed wreak havoc on a family caveats that should be borne in mind if we are to in- and a community, and as such it is incumbent on voke autonomy in an unbiased manner. society to protect its members. Rarely mentioned is the position of John Stuart Recently, an elderly Israeli couple residing on a kibMill, the spiritual father of autonomy. In his classic butz commited suicide while still reasonably healthy book On Li&@,’ he specifically excluded from the becausethey did not wish to fall ill and become a burfreedoms conferred by autonomy the right to sell den to their family and community. While this was aponeself into slavery, because it is self-defeating to parently a voluntary, seemingly fully autonomous, act use one’s freedom for the purpose of losing one’s taken under no pressure, it had serious impact on its freedom. While Mill himself did not rule out suicide, community. Other older people in the kibbutz suddenly a good case can be made that suicide is a greater felt uncomfortable that they, too, might be looked March
1997
The American
Journal
of Medicine@
Volume
102
295
EUTHANASlA/GLICK
upon by their community as burdens. This feeling developed although much of Israeli society still frowns upon suicide. But the favorable publicity given to such suicides by the media and the mounting economic pressures are likely to have deleterious effects on the elderly and the disabled.
ing the death process, and in 60% of these there was no discussion with the patient. And most of the cases are still not reported to the authorities.” There have been a number of cases each year in which nonterminal patients have been killed or assistedto commit suicide that have gone unpunished.‘g~20 The observation that, in a homogeneous, highly educated, civilized, and disciplined country like the Netherlands, IN WHOSE INTEREST? one has difficulty even over a relatively short time in One of the foundations of the physician-patient re- adhering fully to criteria for which there was a virtulationship is the trust of the patient in the physician as ally unmimous consensus is most disturbing, and an unbiased advocate of the patient’s best interests. raises the possibility of great difficulties in maintainPatients, vulnerable and helpless to extricate theming safeguards against abuse. selves from the situation, turn to the physician. In spite An unbiased conclusion seems warranted. One of some recent erosion of this trust, much of this es- should be very cautious before disregarding the censential relationship, at least on a one-to-one basis, still turies-old professional ethic, or as Miles21 has reremains. The patient accepts as axiomatic that the phy- cently referred to it, the “profession’s gyrocompass,” sician will exhaust every possibility to cure, to relieve, without much better evidence to support such a and to help the patient cope with all the vicissitudes drastic step. Even if our ethics might permit such a of the struggle until death conquers. Among the factors step, our science should not. in the patient’s trust is the knowledge that the physician’s armamentarium does not include any easy op- ACKNOWLEDGMENTS tions beyond curing and caring and that the physician I thank Drs. Jochanan Ben-Bassat, Velvel Greene, Yerucham Leavitt, and Reuven has only the patient’s interests at heart. The inclusion Sobel for their helpful comments and criticisms. of killing in the physician’s armamentarium, in an era REFERENCES of economic and social pressures, may convert the 1. Palache H. Hikekei Lev. Vol 1, responsum 50, Salonika 1840. Israel: Book subtle societal message that the patient’s life is no Export Enterprises Ltd; reprinted 1978. longer worth the struggle into suspicion and mistrust 2. Council on Ethical and Judicial Affairs, American Medical Association. Ethical issues in managed care. JAMA. 1995;273:330-335. of the physician-patient interaction. In the words of a 3. Callahan D. Setting Limits-Medical Goals in an Aging Society. New York: British television program several years ago, the pa- Simon & Schuster; 1987. tient may ask quite reasonably: “Doctor, are you doing 4. Daniels N. Am I My Parent’s Keeper? An Essay on Justice Between the Young and the Old. New York: Oxford University Press; 1988. this for me, or am I doing this for you?’ In an era of evidence-based medicine, an unbiased 5. Battin MP. Age rationing and the just distribution of health care: is there a duty to die? In: The least Worst Death. New York: Oxford University Press; scientist should demand better data than are pres- 1994:69-98. ently available that active euthanasia and physician- 6. Sulmasy DP. Managed care and managed death. Arch Intern Med. assisted suicide are indeed beneficial for patients, for 1995;155:133-136. the profession, and for society. The case reports and 7. Finding the right words to talk about DNR. ACP Reporter. July-August descriptions of individual patient experiences, such 1995:ll. 8. Hendin H. Selling death and dignity. Hastings Center Report. 1995;25:19-23. as that of Quill’sI dramatic and moving story of Diane 9. Mill JS. On Liberty. Cambridge: Hackett; 1978. and several other recent publications on the sub- 10. Callahan D. When self-determination runs amok. Hastings Center Report. ject,12,13are largely narratives, albeit impressive ones, 1992;22:52-55. and are an inadequate data base for policy making. 11. Quill TE. Death and dignity: a case of individualized decision making. NEJM. Data from 25 years experience with tens of thousands 1991;324:691-694. 12. Sharelson L. A Chosen Death. New York: Simon & Shuster; 1995. of cases of euthanasia in the Netherlands present dis- 13. Jamison S. Final Acts of Love. New York: GP Putnam & Sons; 1995. turbing testimony to the dangers of the present trend. 14. Gomez CF. Regulating Death: Euthanasia and the Case of the Netherlands. While it is easy to discredit opponents of the Dutch New York: Free Press/Macmillan; 1991. practice’4,‘5 as biased conservatives, the data from the 15. Fenigson R. Euthanasia in the Netherlands. Issues Law Med. 1990;6:229-245. supporters of euthanasia are no less troubling. The 16. Van der Maas PJ, van Delden JJM, Pijnenborg L. Medical Decisions Concerning the End of Life. Amsterdam: Elsevier; 1992. explicit criteria., so carefully promoted initially, of 17. Van Delden, Je JM, Pijnenborg L, van der Maas PJ. The Remmelink study purely voluntary, patient-initiated, consultant-ap- two years later. Hastings Center Report. 1993;23:24-27. proved, and fully documented euthanasia have fre- 18. Mullens A. The Dutch experience with euthanasia: lessons for Canada. quently been disregarded. According to the most re- CMAJ. 1995;152:1845-1852. liable official government statistic~‘~~‘~about 1,000 19. Ogilvie AD, Potts SG. Assisted suicide for depression: the slippery slope in action? BMJ. 1994;309:492-493. cases of nonvoluntary euthanasia of adults and chil- 20. Dutch prosecutors gettough on euthanasia. BMJ. 1994;308:1119-1120. dren occur annually. In about 8,000 cases, symptom 21. Miles SH. Physician-assisted suicide and the profession’s gyrocompass. supression therapy is given with the purpose of speed- Hastings Center Report. 1995;25:17-19. 296
March
1997
The American
Journal
of Medicine@
Volume
102
Euthanasia:
An Unbiased Decision?
Shimon M. Glick, MD, Beer-Sheva,
Israel
I
n the field of medical research, and particularly in the area of clinical trials, the absolute need for unbiased observations has been fully appreciated only in the last few decades. It took many years before it was recognized that subtle bias could invalidate even the best designed clinical trials and must be scrupulously avoided to prevent the investigator from reaching erroneous conclusions. Today, even seemingly trivial deviations from random sampling and proper matching of study and control groups will not be forgiven by editors or decision makers who want to base their decisions on scientific evidence untainted by conflict of interest. Similarly, it took a series of unfortunate revelations of misconduct before institutions and journals began to examine more carefully their practices, with an eye to eliminating conflicts of interest on the part of researchers and authors. I contend that with respect to the subject of euthanasia there is currently an overly rapid movement in the direction of a drastic, and perhaps a dangerous, change in the traditional ethics of Western medicine. There is insufficient acknowledgement of the conflicts of interests on the part of the proponents of this societal change, and insufficient evidence to justify such a change.
BIAS IN THE CARE OF THE TERMINALLY ILL We, as physicians, and our colleagues in other health professions, all have our own biases and emotional needs that we are obligated to identify and confront. Who among us, when faced with a chronically ill, terminal patient, has not sensed an almost audible sigh of relief when on morning report the resident reports that the patient hnally died? But the relief, in no small measure, results from an unburdening of the staff and not just from the termination of the patient’s suffering. Unquestionably, American medicine has for decades been guilty of often thoughtless over-treatment
Am J Med. 1997; 102:294-296. From the Jakobovits Center for Jewish Medical Ethics, Center for Medical Education, Ben-Gurion University Faculty of Health Sciences, and Soroka Medical Center, Beer-Sheva, Israel. Requests for reprints should be addressed to Shimon M. Glick, MD, Ben. Gurien University of the Negev, P.O.B. 653, Beer-Sheva 84105, Israel. Manuscript submitted May 8, 1996 and accepted in revised form October 30, 1996.
294
01997 by Excerpta All rights reserved.
Medica,
Inc.
of patients, imposing upon them each technological advance merely because it was available. In an era of cost-plus reimbursement and fee-for-service, the physician and the hospital were not entirely free of protreatment bias. The appropriate backlash against such overzealous ignoring of patients’ desires and welfare may now be going to the other extreme. One should be no less sensitive to bias that results in premature withdrawal of indicated therapy. There is a fascinating, insightful responsum in Jewish halakhic tradition, which is, as is generally known, very much life-oriented. A 19th century rabbinical scholar, Rabbi Hayim Palache,’ in Izmir, Turkey, was consulted by a devout layman about his wife who had been incurably ill for many years, who had been suffering terribly, and was now begging for an end to her life. Active euthanasia, of course, was not even considered by this observant Jew, but he did ask whether the Jewish tradition permitted prayer for his wife’s death; this might be classified perhaps as a legitimate and merciful act of compassion. The rabbi responded with thoughtful sensitivity in his lengthy discussion, concluding that it is indeed permissible under these grave circumstances to pray for the sufferer’s demise. But he restricted the prayers to individuals who are not directly involved in the care of the patient. Their prayer was sanctioned because their sole concern was the welfare of the patient. Family members, and others involved in any way in the care of the patient, were disqualihed from indulging in such prayer because their prayer might be tainted with a degree of self-interest. This is a remarkably perceptive observation and one in line with a long tradition in the Jewish legal system of disqualification of judges and witnesses for the slightest suggestion of even subtle, unconscious bias.
MANAGED CARE AND THE TERMINALLY ILL In addition to the endogenous bias of the health professionals, we should also confront honestly the increasing pressures from outside sources. In the climate of “managed care,“2 and “bottom line” concerns in the healthcare field, the economic and social pressures are inexorable in the direction once described by Woody Allen as “death is a great way to save money.” Who of us is immune to these pressures from hospital administrators and public officials to the extent that he or she can honestly feel completely free of conflict of interest and bias? oQo2-9343/97/$17.00
PII SOOO2-9343(97)00016-8
EUTHANASIA/GLICK
In a climate of economic constraints and rising health care costs, the “right to die” can easily be converted into the “duty to die.” Euthanasia activists, public officials, ethicists, family members, and the media, by their emphasis on the right to die have added an unfortunate, and almost intolerable, burden to suffering vulnerable patients, who may begin to feel guilty that they have not yet requested euthanasia and have chosen to continue their life. One almost has the deja vu feeling of a revival of death as a duty to the state as was the case in ancient Rome. Recent proposals by prominent ethicists3-5 and public officials have contributed to this climate. Sulmasy’ recently described an imaginary conversation between a futuristic director of a managed care HMO and an elderly prospective member, in which it was clear to the applicant what the preference of the HMO would be in the case of long-drawnout illnesses requiring large expenditures. But this futuristic scenario has already arrived. In a recent workshop at the annual meeting of the American College of Physicians on how to talk with a patient about a DNR order,7 the tone of the “model” discussion seemed not much less one-sided, and was more in line with Sulmasy’s HMO director rather than with an unbiased physician, who first listened carefully to ascertain the patient’s wishes and needs. Hendins recently analyzed the communication processesin two widely publicized casesof active euthanasia and physician-assistedsuicide, presented by their proponents as model cases.He concluded that it was perhaps as much the physicians’ and families’ needs and biases that were being treated as those of the patients. If such is the case with the model casesthat are held up as ideal examples, what may one expect when the practice of physician-assisted suicide or active euthanasia becomes widespread?
violation of autonomy than selling oneself into slavery. As Daniel Callahan’o states: “It is a fundamental moral wrong for one person to give his life and fate to another, whatever the good consequences, and no less a wrong for another person to have that total final power.” If there is such a unanimous revulsion toward slavery, from which there may be a chance of escape, how much more so should there be for death, from which there is no return? A second point to be considered when patient autonomy is used to justify active euthanasia is whether a decision for suicide really can be a truly autonomous one in the present climate. We no longer readily accept the participation of prisoners in human experimentation because of the concern that their consent may not be autonomous. Can a vulnerable, sick, suffering person be truly capable of an autonomous decision in an environment where the media, the medical community, the bioethicists, the caregivers, and the family overtly and covertly convey the messagethat the time has come to die? An honest researcher would question seriously a consent from such an experimental subject, even were the risks minimal. In the case of euthanasia, one is not dealing with a minor risk, but with an irreversible taking of human life-on the basis of what kind of autonomy? In this context, John Stuart Mill suggested that one may restrain an unwitting man from crossing an unsafe bridge because he does not desire, after all, to fall into the water. The person’s ignorance of the danger makes his choice less than fully autonomous. One might logically extend the permissibility to prevent suicide to cases in which because of anxiety, suffering, and lack of information patients might have been pressured into an unwise decision, and into one where they certainly cannot judge the consequences fully. No one has, after all, come back from the dead. Furthermore, in an unbiased analysis AUTONOMY UNLIMITED? of the considerations of autonomy, it should be eviIn the United States, and much of the West, the prin- dent that suicide or euthanasia is not merely an issue ciple of autonomy is one of the overriding considera- of individual autonomy. Individual acts do not occur tions cited in support of euthanasia and physician-as in a social vacuum; they do influence others. Even if sisted suicide. In the modern climate of individualism one accepts an individualistic view of moralityand self-realization, such a principle is indeed attrac- that all is permitted if no harm is done to anothertive, especially in the face of severe suffering and ob- it is simplistic to consider only direct physical harm. trusive life-sustaining technology. Yet there are several A private act can indeed wreak havoc on a family caveats that should be borne in mind if we are to in- and a community, and as such it is incumbent on voke autonomy in an unbiased manner. society to protect its members. Rarely mentioned is the position of John Stuart Recently, an elderly Israeli couple residing on a kibMill, the spiritual father of autonomy. In his classic butz commited suicide while still reasonably healthy book On Li&@,’ he specifically excluded from the becausethey did not wish to fall ill and become a burfreedoms conferred by autonomy the right to sell den to their family and community. While this was aponeself into slavery, because it is self-defeating to parently a voluntary, seemingly fully autonomous, act use one’s freedom for the purpose of losing one’s taken under no pressure, it had serious impact on its freedom. While Mill himself did not rule out suicide, community. Other older people in the kibbutz suddenly a good case can be made that suicide is a greater felt uncomfortable that they, too, might be looked March
1997
The American
Journal
of Medicine@
Volume
102
295
EUTHANASlA/GLICK
upon by their community as burdens. This feeling developed although much of Israeli society still frowns upon suicide. But the favorable publicity given to such suicides by the media and the mounting economic pressures are likely to have deleterious effects on the elderly and the disabled.
ing the death process, and in 60% of these there was no discussion with the patient. And most of the cases are still not reported to the authorities.” There have been a number of cases each year in which nonterminal patients have been killed or assistedto commit suicide that have gone unpunished.‘g~20 The observation that, in a homogeneous, highly educated, civilized, and disciplined country like the Netherlands, IN WHOSE INTEREST? one has difficulty even over a relatively short time in One of the foundations of the physician-patient re- adhering fully to criteria for which there was a virtulationship is the trust of the patient in the physician as ally unmimous consensus is most disturbing, and an unbiased advocate of the patient’s best interests. raises the possibility of great difficulties in maintainPatients, vulnerable and helpless to extricate theming safeguards against abuse. selves from the situation, turn to the physician. In spite An unbiased conclusion seems warranted. One of some recent erosion of this trust, much of this es- should be very cautious before disregarding the censential relationship, at least on a one-to-one basis, still turies-old professional ethic, or as Miles21 has reremains. The patient accepts as axiomatic that the phy- cently referred to it, the “profession’s gyrocompass,” sician will exhaust every possibility to cure, to relieve, without much better evidence to support such a and to help the patient cope with all the vicissitudes drastic step. Even if our ethics might permit such a of the struggle until death conquers. Among the factors step, our science should not. in the patient’s trust is the knowledge that the physician’s armamentarium does not include any easy op- ACKNOWLEDGMENTS tions beyond curing and caring and that the physician I thank Drs. Jochanan Ben-Bassat, Velvel Greene, Yerucham Leavitt, and Reuven has only the patient’s interests at heart. The inclusion Sobel for their helpful comments and criticisms. of killing in the physician’s armamentarium, in an era REFERENCES of economic and social pressures, may convert the 1. Palache H. Hikekei Lev. Vol 1, responsum 50, Salonika 1840. Israel: Book subtle societal message that the patient’s life is no Export Enterprises Ltd; reprinted 1978. longer worth the struggle into suspicion and mistrust 2. Council on Ethical and Judicial Affairs, American Medical Association. Ethical issues in managed care. JAMA. 1995;273:330-335. of the physician-patient interaction. In the words of a 3. Callahan D. Setting Limits-Medical Goals in an Aging Society. New York: British television program several years ago, the pa- Simon & Schuster; 1987. tient may ask quite reasonably: “Doctor, are you doing 4. Daniels N. Am I My Parent’s Keeper? An Essay on Justice Between the Young and the Old. New York: Oxford University Press; 1988. this for me, or am I doing this for you?’ In an era of evidence-based medicine, an unbiased 5. Battin MP. Age rationing and the just distribution of health care: is there a duty to die? In: The least Worst Death. New York: Oxford University Press; scientist should demand better data than are pres- 1994:69-98. ently available that active euthanasia and physician- 6. Sulmasy DP. Managed care and managed death. Arch Intern Med. assisted suicide are indeed beneficial for patients, for 1995;155:133-136. the profession, and for society. The case reports and 7. Finding the right words to talk about DNR. ACP Reporter. July-August descriptions of individual patient experiences, such 1995:ll. 8. Hendin H. Selling death and dignity. Hastings Center Report. 1995;25:19-23. as that of Quill’sI dramatic and moving story of Diane 9. Mill JS. On Liberty. Cambridge: Hackett; 1978. and several other recent publications on the sub- 10. Callahan D. When self-determination runs amok. Hastings Center Report. ject,12,13are largely narratives, albeit impressive ones, 1992;22:52-55. and are an inadequate data base for policy making. 11. Quill TE. Death and dignity: a case of individualized decision making. NEJM. Data from 25 years experience with tens of thousands 1991;324:691-694. 12. Sharelson L. A Chosen Death. New York: Simon & Shuster; 1995. of cases of euthanasia in the Netherlands present dis- 13. Jamison S. Final Acts of Love. New York: GP Putnam & Sons; 1995. turbing testimony to the dangers of the present trend. 14. Gomez CF. Regulating Death: Euthanasia and the Case of the Netherlands. While it is easy to discredit opponents of the Dutch New York: Free Press/Macmillan; 1991. practice’4,‘5 as biased conservatives, the data from the 15. Fenigson R. Euthanasia in the Netherlands. Issues Law Med. 1990;6:229-245. supporters of euthanasia are no less troubling. The 16. Van der Maas PJ, van Delden JJM, Pijnenborg L. Medical Decisions Concerning the End of Life. Amsterdam: Elsevier; 1992. explicit criteria., so carefully promoted initially, of 17. Van Delden, Je JM, Pijnenborg L, van der Maas PJ. The Remmelink study purely voluntary, patient-initiated, consultant-ap- two years later. Hastings Center Report. 1993;23:24-27. proved, and fully documented euthanasia have fre- 18. Mullens A. The Dutch experience with euthanasia: lessons for Canada. quently been disregarded. According to the most re- CMAJ. 1995;152:1845-1852. liable official government statistic~‘~~‘~about 1,000 19. Ogilvie AD, Potts SG. Assisted suicide for depression: the slippery slope in action? BMJ. 1994;309:492-493. cases of nonvoluntary euthanasia of adults and chil- 20. Dutch prosecutors gettough on euthanasia. BMJ. 1994;308:1119-1120. dren occur annually. In about 8,000 cases, symptom 21. Miles SH. Physician-assisted suicide and the profession’s gyrocompass. supression therapy is given with the purpose of speed- Hastings Center Report. 1995;25:17-19. 296
March
1997
The American
Journal
of Medicine@
Volume
102