Pain Management Rather Than Assisted Suicide: The Ethical High Ground

Abstract

Physician-assisted suicide and euthanasia (PAS/E) have been outside the bounds of acceptable behavior for physicians for hundreds of years and remain illegal in all jurisdictions except Oregon and The Netherlands. The morally, legally, and professionally acceptable alternative is excellent end-of-life care. In this article, the arguments in favor of PAS/E are discussed briefly and rebutted. The arguments against this practice are outlined and supported. Because pain (and fear of pain) at the end of life is one of the driving forces behind the recurrent debate about legalization of PAS/E, the medical profession as a whole, and pain specialists in particular, have an obligation to use all available means to relieve pain.

Case Study

Although it has been nearly 30 years, I can still remember her face. Some of her features have faded with time, but I have been unable to erase her eyes from my haunting memory. They were dark brown, and they seemed disproportionately large because of her generalized wasting. And nearly every time I saw her, they were searching, pleading, and full of fear.

Anna was only 46. She was dying of breast cancer with widespread bony metastases. The surgeon who had been overseeing her care since her diagnosis 3 years earlier asked if I would admit her to a nursing home for terminal care because he had nothing more to offer. My new rural family practice was not yet busy, so I was willing to assume her care even though I perceived this as a “dump the undesirable patient on the new guy” referral.

On admission, I continued the codeine that the surgeon had been prescribing for her at home for the past several months, even though she said it was not working. I was concerned that she might be addicted, and I needed to prove to myself that it was ineffective before resorting to the “big guns.” When she still complained of severe pain after I had increased to the maximal dose, I switched to a fixed combination oxycodone/aspirin tablet. She thought it was a little better at first, so we continued it for 3 or 4 weeks. Her pleading words and eyes finally convinced me to switch to morphine. I began at 5 mg IM QID prn and adjusted the dosage on my weekly visits. When her usage reached what the textbook of the day said was the maximum recommended dose of 60 mg/day, I said there was nothing more I could do for her pain. The very next day her husband called me and said they had talked it over and both of them wanted to know if I could give her “one big dose of morphine to get rid of all the pain forever.” I declined. It was after that when the searching and pleading in her eyes turned irreversibly to fear—a fear that continued for the remaining weeks of her life.

I am ashamed to relate this story of my inexperience and incompetence, but I do it because Anna is the only patient in my 34 years of practice who has asked me for a lethal injection. And I am certain that it was my failure that led to that desperate request.

Inadequate pain management is immoral and inexcusable. Adequate pain management is one component—perhaps the most important component—of excellent end-of-life care.

Excellent end-of-life care is whole-person care. This involves multidisciplinary efforts to assess and address the patient's physical, psychological, social, and spiritual needs. When such care is not available, the patient suffers. When such care is not available, desperate patients or their loving families may try to hasten an end to the suffering by requesting physician-assisted suicide or euthanasia (PAS/E).

PAS/E are contrary to the historic and vitally important professional ethic of caring and healing. The professional ethic of medicine is to care for the patient. Francis Peabody said in 1927, “The secret of caring for the patient is in caring for the patient”[1]. This is not a tautology but a truism. The proper response to a request for PAS/E is excellent end-of-life care—this is the ethical high ground.

But it has not always been so. In early Greek medicine, it was accepted by society, and accepted by physicians, that giving a lethal dose of hemlock to a patient when requested was indeed a part of the practice of medicine. Hippocrates, the father of Western medicine, was the first to understand and teach that the intentional hastening of death was incompatible with the role of healer. The Hippocratic ethos of both doing no harm and refusing to kill patients was revolutionary when introduced 2500 years ago. It was several centuries before this became the normative ethic of Western medicine. But once established, it has remained the dominant force defining the role and limiting the scope of practice of physicians. Even today the American Medical Association maintains an unequivocal position on this issue: “Physician assisted suicide is fundamentally incompatible with the physician's role as healer, would be difficult or impossible to control, and would pose serious societal risks. Instead of participating in assisted suicide, physicians must aggressively respond to the needs of patients at the end of life …”[2].

Over the centuries there have doubtless been infractions of the professional vow prohibiting assisted suicide. In both ancient and modern times, some physicians have on occasion secretly assisted patients with suicide or have even administered lethal medication themselves when they felt extenuating circumstances justified an exception to the societal standard and the professional rule. Until Kevorkian, it was done in secret because this rule was recognized as valid.

But that standard and that rule have been debated from time to time. The modern debate about PAS/E dates from the last half of the 19th century when the idea of using ether to intentionally and painlessly end a patient's life was raised by a nonphysician [3]. Over the ensuing years, there have been several periods of time when euthanasia was given serious public debate. But until 1984, when the Royal Dutch Medical Association took the revolutionary position that it was professionally acceptable for a physician to give a lethal injection to a patient under certain clearly defined circumstances, that debate was always silenced by returning to the professional ethic of healing and not killing.*

Arguments in Favor of PAS/E

In the current societal and professional debate about the legalization of assisted suicide, supporters offer three major arguments: a patient has a right to self-determination; it is the compassionate thing to do; and it is working in the Netherlands, so we should allow it here too. The first two arguments have remained the same for over 200 years [4].

Right to Self-determination

Proponents maintain, correctly, that a patient has a right to accept or refuse any treatment, even if that refusal leads to death. They go on to maintain, albeit incorrectly, that the patient should then have the right to request any treatment they want, even medical assistance with bringing about death. Although a patient has a negative right to be left alone, this does not translate into a positive right (an entitlement) to whatever he or she wants. If that were the case, there would be no need for laws to regulate prescription drugs; a patient could just buy whatever he or she believed was appropriate.

This principle of personal autonomy has become prominent, in fact predominant, in North American society since the social upheavals of the 1960s. It has been an important social movement with many personal and societal benefits. Many have misunderstood or misinterpreted this emphasis to the extreme of believing that personal liberty is the most important societal value and trumps all other values. However, maximizing freedom is not always a good idea because it can make some individuals vulnerable. An archaic example is the idea of dueling to protect personal honor. When it was recognized that this extreme of personal freedom was dangerous, dueling was outlawed. Modern examples include speed limits and restricted access to prescription medications. Thus, claiming a right to something based solely on maximizing personal freedom needs to be carefully scrutinized.

A physician has not only a right but an obligation to evaluate a patient's needs and authorize only those treatments that he or she believes to be in the patient's best interest. Patient autonomy is not absolute any more than is a generic right to personal freedom. When it was argued before the U.S. Supreme Court that a patient has a liberty interest in being allowed to choose the time and manner of his or her death, the justices concluded that this was not the case—there is no constitutional right to support this contention.

The right to self-determination is a very important precept of modern medical ethics, often ignored or even denied by paternalistic physicians of the past. However, it does not offer adequate justification for the legalization of assisted suicide.

Compassion

A more compelling argument is that of compassion. Physicians have been obligated for centuries to respond to the needs of their patients. And what greater need is there than for assistance with the suffering that often afflicts patients as they approach death? The issue in question, however, is how to fulfill that obligation.

Supporters of PAS/E often point out that “we shoot horses, don't we?” implying that our compassionate response to animal suffering should be extended to include human suffering. This is only tenable in a world view that concludes no moral difference between humans and animals. If you believe, as do most people in Western society, that we have a greater obligation to human beings than we do to animals and that human life is special and should be respected and protected whenever possible, then we are obligated to find a better solution to terminal suffering in humans.

Compassion, although more compelling than self-determination, is still not determinative. As Pellegrino has said, “Compassion is a virtue, not a principle. Morally weighty as it is, compassion can become maleficent unless it is constrained by principle”[5]. This truth is reinforced when we recall the etymology of the word. Compassion means “to suffer with.” Compassionate patient care involves coming alongside patients who are suffering, being with them, and doing all we can to alleviate that suffering. Killing is not compassionate. Our professional obligation to be compassionate requires more of us than the quick and easy way out of the patient's suffering. It is this professional obligation to compassion that is why excellent pain management, indeed management of all symptoms, is so important to medical professionals who provide care to patients as they approach the end of their lives [6].

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, a close reading of government data shows that the well-established requirements are not met most of the time: It is not always used as a “last resort” because 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 [7]. 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 fourth 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; regulations do not work to control the process even when it has societal sanction.

In light of these arguments offered to support the legalization of PAS/E, it is worth looking at the data from the first 3 years of experience with Oregon's law permitting physician-assisted suicide. Of the first 70 patients who died under the provisions of this law, 24% gave inadequate pain control as their reason, whereas the remaining 76% gave various autonomy-based reasons as their justification [8]. But physician autonomy still reigns in Oregon; only one in six patient requests were granted by the physicians in the first 2 years [9].

Arguments Opposed to PAS/E

In addition to the rebuttals to those arguments in favor of PAS/E, there are several specific arguments in opposition. These have been well articulated elsewhere [10–12] and will merely be summarized here in two groups. First are rule-based arguments: It goes against long-standing unwavering professional virtue and would change the very nature of the patient-doctor relationship, perhaps even detracting from efforts at palliative care. The second group is consequence-based arguments: It would be bad public policy because regulations cannot prevent abuses and expansions of the “indications” to include coerced “voluntary” PAS/E [13], surrogate nonvoluntary 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. This last concern may sound like radical doom-saying, but Derek Humphries, the founder of the Hemlock Society, recently wrote “economics, not the quest for broadened individual liberties or increased autonomy, will drive assisted suicide to the plateau of acceptable practice”[14].

The Moral High Ground

Thus, there are both deontological (rule based) and teleological (consequence based) reasons to oppose PAS/E. 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 because attempts at regulation will not protect vulnerable patients from abuses, 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 are receiving good end-of-life care rarely request that their physicians hasten death [15]. 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 and avoid overtreating the terminal disease when the patient is ready to shift goals to comfort care. With that shift, the physician must never say “There is nothing more I can do for you.” Such a statement represents an immoral abandonment of the patient, an abandonment at the most needy and vulnerable time in the patient's life. 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.” This promise includes multidimensional care that usually requires a multidisciplinary team. In addition, this promise very frequently involves consultation with specialty physicians who have expertise in the management of the troubling symptoms that have caused that patient to make this request. Because one of the more common reasons for this desperate request is inadequate pain control, primary physicians must become better at routine pain management, and they must be willing to seek and arrange consultation with a pain specialist when their efforts are inadequate.

All of the patient's physical needs must be thoroughly addressed. This means intensive symptom control. As important as pain control is, the patient's other symptoms must also be treated. Dyspnea is a terrible symptom and deserves aggressive physical, chemical, and psychological measures. Other respiratory symptoms (cough, thick secretions, hiccups) can vary in intensity from annoying to debilitating. Gastrointestinal symptoms often accompany the dying process; persistent nausea can be overwhelming; vomiting may be troublesome; constipation is almost universal in dying patients, although occasionally diarrhea may occur instead; anorexia may be worrisome to family members; cachexia and halitosis may cause friends and family members to distance themselves from a patient just at the time they need intimate support. Urinary symptoms (urgency, incontinence, hematuria, oliguria) and neurological symptoms (insomnia, agitation, delirium, seizures) and generalized physical symptoms (fatigue, fever, tetany, itching, lymphedema) also may need expert and intensive treatment.

Psychological symptoms are almost universal in dying patients and may be the dominant challenge in some. Anxiety about the future is understandable. Depression is likewise to be expected in a significant percentage of patients. Both of these manifestations of distress need treatment, whether with 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) [16].

Physicians do not often think of social issues as symptoms that need assessment and treatment. But whole-person care requires awareness of and attention to the patient's relationships. 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 is causing them unspoken distress. Byock 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”[17]. It is often appropriate to ask a person who is approaching the end of life “Are there any conversations you would like to have? Is there anyone you would like me to contact for you?”

The final dimension in whole-person care is the spiritual. Although this is important in caring for any patient who is seriously ill, it becomes imperative to be open to signs and symptoms of spiritual distress in patients who are dying. When facing death, patients often ruminate on guilt about how they have lived their lives. Others may develop uncertainty or doubts about even long-standing beliefs. They may have many questions about the meaning of life and the meaning of death. Cecily Saunders, the founder of the modern hospice movement in Britain, says that when patients ask a “why” question, she tries to turn it into a “how: question [18]. How are we going to cope with this situation? This is often helpful in redirecting concerns about meaning. In addition, spiritual counsel from a person of the same faith tradition may be of great benefit. This may involve a trusted and known clergy person or a caring and sensitive chaplain. But some patients may feel estranged from formal religion. In those cases, it may be the believing healthcare professional who can be of great assistance to the patient in spiritual distress.

It is rare indeed that one professional is able to address all these physical, psychological, social, and spiritual needs of patients who are dying. It requires a multidisciplinary team, including nurses, physicians, therapists, counselors, pastoral care workers, social workers, and lay volunteers. Such a team is usually best mobilized through a formal hospice or palliative care program but may at times be coordinated through a primary care physician's office or a community or church organization.

The Imperative for Good Pain Management

The burden and challenge of pain management at the end of life was eloquently articulated by Albert Schweitzer in 1931: “Pain is a more terrible lord of mankind than even death itself”[19]. But physicians have a reputation of doing less than a good job at this important task. The inadequacy of pain management has been the subject of editorials for at least 20 years[20]. Despite excellent resources too numerous to cite and despite practice guidelines [21] and quality improvement guidelines [22], this clinical inadequacy continues [23]. This persisting problem is not for lack of technology. Byock noted “physical pain among the terminally ill exists because doctors lack the will, not the way. Deterred by opioid phobia or ambivalence about medications, doctors, patients, and families may step back from the firm commitment that is needed for assertive pain management”[24]. The Joint Commission on Accreditation of Healthcare Organizations has recognized that there is no longer any excuse for inadequate pain management and has issued new pain management standards that affirm the patient's right to appropriate assessment and management of pain and the institution's responsibility to have policies and procedures for pain assessment and treatment, education, assurance of pain management after discharge, and performance improvement [25].

The newer technologies introduced to assist with pain management have themselves raised ethical questions, but these questions are adequately answered by an appeal to the traditional principles of medical ethics [26]. Perhaps the most commonly asked ethical question about pain management at the end of life is concern about the inadvertent, or even the intentional, suppression of respiration with the use of high doses of opioids that could lead to an earlier death. Experts in pain management have maintained that this rarely, if ever, happens because pain is a good respiratory stimulant. Even with good empiric evidence that narcotic use does not, in fact, hasten death [27], this myth continues to discourage many primary care physicians from fulfilling their obligation to relieve suffering. But let us consider the worst case scenario. What if a terminally ill patient with overwhelming pain requires rapidly increasing doses of narcotics and does actually suffer from respiratory depression.^† Is this ethically permissible or is his or her physician morally obligated to use ventilatory support to overcome this side effect? Although this question may be a product of the modern age, it was answered clearly hundreds of years ago by Thomas Aquinas (1224–1274) using his “rule of double effect.”

Rule of Double Effect

What has become known as the rule of double effect (formerly incorrectly termed “the doctrine of double effect”) is a form of reasoning that says it is morally permissible to do an act that has both a good effect and a bad effect if all of the following conditions exist: (i) the act must be inherently good or at least morally neutral, (ii) the bad effect may be anticipated but not intended, (iii) the good effect must not be achieved by means of the bad effect, and (iv) there must be a proportionately grave reason for allowing the bad effect.

Let us put to the test our paradigm case of morphine and its potential for respiratory depression. (i) Giving morphine to relieve pain is an inherently good act. (ii) The bad effect of potential respiratory depression and death may be anticipated but is not intended. (iii) The good effect of pain relief is not achieved by means of respiratory depression and death. If (ii) and (iii) were not required conditions, one could give one enormous dose of morphine with the intention of causing respiratory depression so that the patient would die, thus ending the suffering. (iv) Unrelievable pain in a dying patient is a proportionately grave reason for allowing this otherwise unjustifiable side effect. Thus, it would not be justified to give increasing doses of morphine to a patient with ureteral colic to the point of respiratory depression and death, but the imminence of death changes the moral calculus.

Terminal Sedation

Because of the continued legal and professional proscription against PAS/E, some have proposed the use of “terminal sedation,” the practice of giving sedation to a patient who is dying, expecting that he or she will die more quickly of dehydration. Some have called this “slow euthanasia”[28]. Whether this is a morally correct designation depends entirely on the intention. If the intention is clearly to hasten death, then this is euthanasia and, in my estimation, is an immoral end-run around the current legal and professional prohibitions. If, however, maximal efforts have failed to adequately relieve the suffering of an imminently dying patient, it would be ethically permissible to use this method of relief, accepting the unintended side effect of an earlier death from dehydration. This would be justifiable using the rule of double effect.

Like the use of large doses of morphine with the potential of respiratory depression, the morality of the practice of terminal sedation hinges on intention. And, of course, intention is not objectively verifiable but is subject to intellectual honesty. The difference, however, is that death from respiratory depression after increasing doses of narcotics is extremely rare. In contrast, death from dehydration in an unresponsive patient is inevitable. In addition, the need for this procedure should be quite rare given the advances in pain management along with other dimensions of palliative care.

Conclusion

PAS/E have been outside the bounds of acceptable behavior for physicians for hundreds of years. The morally, legally, and professionally acceptable alternative is excellent end-of-life care. Because pain (and fear of pain) at the end of life is one of the driving forces behind the recurrent debate about legalization of PAS/E, the medical profession as a whole, and pain specialists in particular, have an obligation to use all available means to relieve pain. That obligation includes continued research to develop new drugs and new means to accomplish this goal.

To cure, sometimes; To heal, often; To comfort, always.

15th century French proverb

References

Footnotes