When is euthanasia an ethical option?

Dr. Jack Kevorkian, the infamous suicide doctor from the 1990s, passed away last week at the age of 83. While his methods and criteria were at times questionable–seeking out publicity and media attention for his credo and often working out of his old beat-up Volkswagen van–he crucially brought the topic of euthanasia to national attention. The ethical debate over this procedure will continue to grow in importance as the health of the baby boomer generation begins to deteriorate, and, unfortunately, it must be discussed as a viable option in the course of treatment.

Largely instigated by Dr. Kevorkian’s efforts, the Oregon Death with Dignity Act was passed in 1997, long before health care reform and the dispute over so-called “death lists.” Thus far, the Death with Dignity Act has helped 525 individuals end their own lives, and similar laws have been passed and upheld in Washington state and Montana. There are stringent criteria in the laws determining who is eligible, and in Oregon, this includes whether the patient suffers from a mental illness. On the surface, this seems like a necessary, sensible, and humane criteria for the law. However, upon closer inspection it raises problems with feasibility, for who suffering from a terminal illness who wants to end their lives is not depressed? The Beck Depression Inventory (BDI) is a widely used and respected neuropsychological questionnaire used to assess depressive symptoms. While it is by no means as comprehensive as the DSM-IV diagnostics, it does provide a relatively sufficient snapshot of an individual’s current mood and state of mind. Going by these questions, though, it seems doubtful whether anyone in a position to take advantage of Oregon’s Act would qualify. The BDI asks questions about recent weight loss, insomnia, sexual interest, thoughts of suicide, and general mood and interest in life. Surely someone who is terminally ill and considering ending their lives would not be as interested in sex, food, and the day-to-day goings on around them. Assisted suicide is not merely another option for those who are contemplating it, it is a last resort.

Along these same lines, another contentious patient group to consider in this debate are those diagnosed with Alzheimer’s disease or dementia. Anyone who has a family member suffering from these disorders knows how debilitating, humiliating, and dehumanizing they are. It is difficult to imagine that individuals in the late stages of Alzheimer’s take much satisfaction or joy from their lives, and, represented both anecdotally and artistically, there are numerous cases of patients ending their lives while they still maintain some semblance of control. However, these patients are also widely deemed ineligible to provide informed consent for medical procedures and are thereby explicitly excluded from the above laws. This creates another problem in which those individuals who may be most likely to elect for this assistance are not eligible to obtain it.

I realize that this is an incredibly sensitive and controversial topic, but it does need to be discussed as both the future of our medical system and the health of our parents and grandparents deteriorates. No one wants to think that they will need to consider this decision for themselves or their family members, yet this issue must be addressed as the demand for health care increases and the supply dwindles.

Apart from the logistical question of treatment availability, the much larger issue at stake is the humaneness and ethics of this approach. Every patient suffering from a debilitating terminal illness should have the right to determine their own course of treatment, including end-of-care plans. Do not resuscitate (DNR) orders are commonplace in hospitals and hospice care, yet the active version of these orders is much more difficult to carry out. And when the patient no longer has full mental or emotional capacity this decision becomes all the more tenuous and ethically and emotionally demanding. Yet watching a loved one’s mind and body deteriorate is torturous for all parties involved. Explicit end-of-life plans should be detailed by every individual as they age and discussed with family members in the case of an emergency.

Currently, Belgium, Colombia, Luxembourg, The Netherlands, and Switzerland all allow physician-assisted suicide in some form, and there is a growing underground tourism industry to these countries for this specific reason. Perhaps as the demand for this type of treatment increases policies adequately addressing it will follow.

(Thanks to Steve Smith for the idea for this post.)

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