The University Record, March 18, 1998

Decisions on one's own death should rest with self, family, physician

Sherwin Nuland, author of the best-seller How We Die, lectured at the Medical Center last week. Photo by Rebecca A. Doyle

By Jane R. Elgass

Physician-assisted suicide is a difficult and uncomfortable topic that demands an active dialogue, Sherwin Nuland told a standing-room-only audience in University Hospital's Ford Amphitheatre last week.

Nuland, a surgeon and medical historian who is the best-selling author of How We Die: Reflections on Life's Final Chapter and other books, also said that decisions about physician-assisted suicide belong with patients, their families and their doctors, not in the courts or state legislatures. Society, however, has to give permission for making these decisions.

In fact, he noted, the concept of a comfortable death has for many years been understood to be a prerogative of physicians. "Nobody's talking, but it's being done."

A quick look at history shows that Greek physicians did not subscribe to their own Hippocratic Oath, which states "I will give no deadly medicines to anyone if asked, nor suggest and such counsel." Suicide was rampant in that period, a way of getting out of problems, and physicians were the ones who had the poison to give to patients.

"The whole world for some turns on these [Hippocratic Oath] words," Nuland said. "How valid is it now? Are we, should we be bound by strictures that physicians at the time didn't observe?"

Following the fall of Rome there was a long period "when the notion of helping someone die was not extant," Nuland explained. Then, in 1516, Thomas More in Utopia talked about the concept of helping people who are suffering, indicating that it was a function of a civil society to see that there is no suffering at the end of life.

The term "euthanasia" first appeared in a medical dictionary in 1718, defined as a "good death."

The appearance of ether, nitrous oxide and morphine in the late 1700s and early 1800s prompted "a complete turnabout in the attitude toward pain," Nuland said. Prior to that, pain was considered a necessary evil.

The first indication that a physician might have some role in a patient's death came in 1826 in Germany when Karl Marx noted that a physician should provide physical, moral and spiritual comfort. The availability of morphine created an environment in which the relief of pain could be considered, Nuland said.

Debates about euthanasia began after the Civil War with the New England Journal of Medicine suggesting the compromise of "passive euthanasia" in 1884: physicians should not do things to prolong life, but should provide sufficient narcotics to make the patient comfortable. At the same time, physicians were beginning to appear at the bedside.

The mid-1940s marked a major turning point. With advances in medicine, "symptoms became the signal to work harder to keep the patient alive, and the suffering of patients increased markedly," Nuland stated.

The question today, he said, is whether it is sufficient to provide passive euthanasia in the historical sense or in the modern sense, killing the patient at his or her or the family's request.

Nuland noted that for every assisted-suicide that makes news there's a "triumphant story about an unassisted death in the hands of nature."

We cannot expect "objectivity on this issue," Nuland said, "because it deals with the most irrational currents that run in the human mind." While increasing numbers of people are creating advance directives, survival is a powerful basic instinct that can take over at the final moment. This is true for the patient and the family and, to some extent, for the physician, he explained. "It is a primitive, often chaotic response, an attempt to inject rationality into a fear-filled process."

Nuland said that much of the demand for access to physician-assisted suicide could be eliminated with better palliative care.

Patients with cancer, AIDS and neurological diseases are those most likely to ask for physician-assisted suicide, Nuland noted. Two of the most common reasons are pain and believing themselves to be a burden on their families. Better social services are needed by these patients and better "comfort care" should be offered by physicians to relieve pain.

The physicians and physicians-to-be in the audience were urged to "face the turmoil rather than pretend to intellectual objectivity. Pay attention to the discomforts of dying people. Reassure them that when the time comes, their suffering will be relieved."

We are at the beginning of a revolution in comfort care, the surgeon-historian said. There is a heightened awareness of what is available and of the responsibilities of the physician, but the profession needs time to sort this out.

Nuland said a 1997 survey showed that only five of 126 medical schools had a course on death and dying and 70 percent of the physicians polled said they had inadequate information on pain control.

"A continuing public discussion is critical," Nuland said. "There never will be consensus, but continuing public debate will reveal fact and fancy and maybe tolerance for other's beliefs."

Nuland added legislation of physician-assisted suicide is "worse than senseless." We must put our trust in the relationships among doctors, patients and families rather than advocacy groups or the courts, he said.

Nuland advocates a decision reached by the doctor, the patient and the family, "ratified by a member of society." The decision should include consultation by a physician in the same specialty as the patient's physician and one with expertise in pain management and palliative care. A psychiatric evaluation would be useful if the patient is suffering from depression, and Nuland would insist on a spiritual consultation to discover the patient's values.

"The ultimate court," he said, "are the sages in the community. We must ask them to sit in judgment. They must allow euthanasia by a willing physician, but the final judgment must remain in the hands of the patient, family and doctors."

The Hippocratic Oath also states " . . . abstain from whatever is deleterious and mischievous." "To my mind," Nuland said, "allowing a patient in pain to suffer is deleterious and mischievous."

Nuland's visit to campus was part of the Year of Humanities and Arts/Arts of Citizenship "Talking Bridges" series and was cosponsored by the Medical School and the Historical Center for Health Sciences.