The Morality of Dying
With the Supreme Court poised to decide whether doctors have a constitutional right to help sick people kill themselves, the spotlight once again falls on Dr. Timothy Quill. An internal medicine specialist at the University of Rochester in New York, he is the lead plaintiff in one of the cases that the court is expected to consider early next year--a case challenging the state’s law against physician-assisted suicide.
Quill first surfaced as an advocate of the right to die in 1991. That was when the New England Journal of Medicine published his account of helping a woman with terminal leukemia end her life by swallowing an overdose of barbiturates he prescribed. Because the story flouted the central medical ethic of saving life at all costs, it sparked deep debate and wide publicity.
This month, Quill defends physician-assisted suicide in a new book, “A Midwife Through the Dying Process” (The Johns Hopkins University Press, $24.95). It is built around case studies of nine patients he cared for at the end of their lives. The book’s guiding metaphor was furnished by a woman with fatal stomach cancer, who died after Quill withdrew her feeding tube and upped her morphine levels. During the ordeal, she lamented in a letter to Quill that no other doctor seemed willing to “midwife me through the dying process if that’s what it came to.”
Quill’s approach is generally applauded as far more careful than that of Dr. Jack Kevorkian, who has abetted dozens of suicides in Michigan with what many medical experts regard as unseemly haste. But for all Quill’s thoughtfulness, he argues in “Midwife” for even more freedom to hasten death than do other advocates. While many ethicists insist that patients be diagnosed as terminally ill before a doctor is allowed to aid their suicides, Quill is against that restriction. And he sees no real moral difference between facilitating a suicide, where the patient takes the final self-destructive step, and euthanasia, where the doctor does so, presumably at the patient’s request.
He addressed such questions in a recent interview with Times Medical Writer Terence Monmaney, excerpted here.
The Times: You mention in the new book that dying can be part of a “healing” process. What do you mean by that?
Quill: It’s a way of achieving completion to your life, closure, the opportunity to say what hasn’t been said or put things together. . . . It doesn’t happen to everybody, but some people get much clearer about who they are and what’s important to them than at any other time in their lives.
Q: Surveys have suggested that while a slight majority of physicians are comfortable with the idea of physician-assisted suicide, many are not really sure how to go about it. They’re very concerned about ruling out clinical depression and about which drugs to give and at what doses. What needs to be done?
A: In these cases where [doctors] are struggling--and they should struggle, I really don’t want to make this process too easy--if you have an open system, and there is a question of depression, we would get a consultation by an expert . . . maybe a psychiatrist. Same thing if uncontrolled pain was the issue. Before you’d ever want somebody to act, you’d want to get your best pain people to get a look at the situation and say, “Is there some other way we can do this?” And then also in an open system, you could decide, well, if we are going to do this, what does the data say about the ways [of hastening death] that work and how can we ensure that it works? You’d hate to have people then go through a process, decide that this is really the only option for this particular person that makes sense, and then not have it work.
Q: What researchers refer to as an “incomplete suicide.”
A: Right.
Q: You argue that stopping life support and assisting in a suicide are morally similar. Many medical ethicists would disagree. Would you expand on that?
A: From an individual patient’s point of view, there’s often not a lot of difference. If I’m in a very bad situation, and I see my suffering as overwhelming and I’m ready to die, I am currently lucky if I’m on life support because you as my doctor can help me [die]. It can be seen as OK by society. But if I’m in that same state or a worse state and I don’t have a life support to stop, [assisted suicide] is not allowed. . . . Having been through the discussion process with a number of patients, I think it’s very similar from a psychological point of view. And the process that we go through to stop life supports, which is a very serious, sober process, is probably a good model for this kind of decision. Get our best minds together, make sure [the patient’s decision] is not colored by depression and so forth, and only do it as a last resort.
Q: Traditionally, the distinction has been that withdrawing life support is taking somebody out of a situation that, in effect, medicine put them in. In contrast, assisting a suicide is taking a proactive step to bring about the end of somebody’s life.
A: These distinctions . . . don’t hold up to the scrutiny of many people’s experience. Some of the same risks hold for both kinds of acts that could be influenced by social forces that don’t have a lot to do with the patient. Also, most of the patients we care for who end up in this kind of situation are at the end of a long road, and we have helped to bring them there using technology and medical intervention.
Q: Also, you say the difference between euthanasia and physician-assisted suicide is not “morally distinct.” Many people would be deeply concerned about that, given the fear that euthanasia might be enacted without full informed consent.
A: The difference is, who is the final actor? Physician-assisted suicide has the added safeguard of the patient finally having to act or not act for his or herself. And I think that’s an important safeguard. But in euthanasia, it has to be beyond the shadow of a doubt that . . . the doctor is acting as the agent of a person who cannot in some way act on his or her own. So I think that in many ways they’re morally equivalent even though I think there are important practical differences.
Q: In discussing the kinds of laws that might be enacted if physician-assisted suicide were to pass legal muster, some experts suggest that it should be limited to people who are terminally ill. You question this notion.
A: I struggle with this area. And I think [for now] we really need to limit it to the terminally ill. I do think you can determine with quite a degree of certainty when someone is imminently dying, their suffering is extreme, they’re not going to get better. And no matter what the Supreme Court says, you need to figure out a way to respond to that group of patients.
But then you say, what about those who aren’t imminently dying? . . . That’s a much more problematic group, it’s a much larger group. I think the hurdles and the safeguards would be much harder for that group. Longer waiting periods [between a request and the final action to end life] make sense, more mandatory consultations make sense, because [the patients] have a much longer prognosis. Whereas a mandatory waiting period of, for example, two weeks when somebody is imminently dying just isn’t fair. They’re likely to be dead anyway in two weeks, so that doesn’t make sense.
Q: In your book you refer to an “afterlife” and use the word “soul.” Do you believe there is a soul? And what is it? Do you believe in an afterlife?
A: I certainly believe there is a soulful aspect of life, I believe there is a spiritual life. I believe there are forces that are much bigger than we are that are operative in life. And in some sense, that there is an afterlife, although I don’t think about it in any conventional terms, in terms of a concrete place that we go to, that kind of thing. I believe pretty strongly that there is a spiritual life, that there is something common to all religions that is trying to capture a common spiritual experience.
