Physician-Assisted Dying: The Case for Palliative Care and Patient Choice (review)

Physician-assisted dying was brought to public attention by the actions of Dr. Jack Kevorkian (now imprisoned), who took it upon himself to assist people who wanted—for a variety of reasons—to die. Later examination of his "cases" revealed that only 35% would have been diagnosed as terminally ill by end-of-life care specialists. The idea of physician-assisted death polarized both the general public and the medical profession, and the opportunity for reasoned discourse was temporarily lost. This book, edited by two early proponents of the practice, provides the necessary reasoned discourse for physicians, legislators, disability activists, and anyone who is involved in palliative and end-of-life care situations. The authors of the various chapters address the subject from the perspectives of ethical principles; clinical, philosophical, and religious issues; actual practice and creating a legislatively favorable climate; and the political and legal issues that impede implementation. The editors conclude with the goals and standards of physician-assisted death, descriptively titling their chapter "Excellent Palliative Care as the Standard, Physician-Assisted Dying as a Last Resort," which is the underlying theme of most of the book. This book is a complement to The Case Against Assisted Suicide: For the Right to End-of-Life Care (Foley and Hendin 2002).

How we use words influences how people think. Some words have such strong associations with religious, political, and societal issues that using them becomes inflammatory. I have long felt, as do the editors, that suicide is not an appropriate word to be used for decisions about end-of-life dying. Instead, they have used the term "physician-assisted dying," which more accurately reflects the process and timing of what is occurring. In my own classes and training of health professionals, I have always made the distinction between people who choose to die but don't have to, and people who are at the end of life facing choices about their dying. The first is suicide, which our society stigmatizes; the second is physician-assisted dying. This book does not justify suicide. Rather, it places the role of the physician in the context of end-of-life care as it respects patient and family values. It does not advocate that all physicians must provide the service, but that physicians be responsive to competent autonomous requests by terminally ill patients to find suitable ways to address the problem to the patient's satisfaction.

As health care professionals, we know that we can get what we want at the time of our dying because we have the knowledge and means to make it happen. The issue for most health care professionals is how hard this is to do for others, not for ourselves. There is an excellent chapter—"Assisted Death in the Netherlands: Physicians at the Bedside When Help Is Requested" (Kimsma and van Leeuwen), based on 16 years of collecting data—that investigates the experiences of physicians who practice legally permitted physician-assisted dying. An excerpt clearly describes the ambivalence surrounding the process:

Euthanasia is a process filled with emotions, which arise with the initial request for assisted death and evolve as the physician's relationship with the patient and family change over time. The act itself is approached with the utmost apprehension. Physicians' emotional reactions of anxiety, resistance, and uncertainty are balanced by rational convictions not to abandon one's patient. . . . These emotions are and should remain integral to the process of assistance in dying because they forestall development of routine reactions and attitudes of callousness.

One of best features of this collection is that it is able to definitively comment on Oregon's three years of experience with legalized physician-assisted dying and the Netherland's 16 years of permitting voluntary active euthanasia. In both places, better and more frequent use of palliative care measures is an outcome of legalized assisted dying. In Oregon, physicians have increased their...