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Assisted suicide and euthanasia continue to spark debate both in the community and within the profession. The clinical problems surrounding the request for these acts, the impact of such interventions on medical practice and what it means when a dying patient asks for euthanasia or assisted suicide, or when a doctor provides such assistance, remain either poorly researched or largely unexplored.

The capacity of a clinician to predict the prognosis for patients with severe and chronic illness is limited, as are the ways doctors and patients often communicate about these issues.¹ Doctors experience significant emotional distress in caring for such patients² and this may relate to inadequate training in communication skills, particularly in the care of the dying.³ In caring for a dying patient, the doctor is often ill-prepared for his or her own powerlessness over death, helplessness and uncertainty, and coping with the patient's dependency and the loss of control that illness can signify — themes that mirror some of the elements of the suffering experienced by the patient.⁴

How doctors respond to the suffering of patients and their families underpins much of the debate on euthanasia and assisted suicide. The care of the dying patient places even greater emphasis on the boundaries and frameworks that doctors need in order to provide good care.⁵ These boundaries demarcate the role of the doctor in a framework that promotes trust, a duty of care and protection from harm. "Compassion" can become a dangerous motivation alone when such frameworks and principles are lost.⁶ The emotional "disorientation" that can occur for the doctor can affect the way decisions are made, how a patient's condition is evaluated, and the doctor's perception of the benefits or risks and purpose of their interventions.⁵ Demoralisation is increasingly identified as an important clinical syndrome among patients with advanced illness, and, as discussed by Kissane,⁷ such demoralisation among doctors may affect their interactions with patients. It may diminish their capacity to effectively assess and intervene in the patient's hopelessness, depression and demoralisation, and family distress that are associated with the wish to die.⁸

The article by Haverkate and colleagues in this issue of the Journal⁹ raises a number of the problems in this field. The study reports a wide variety of emotional responses in doctors to the common interventions they use in caring for dying patients (eg, the perceived "life-shortening effects" of common treatments to alleviate pain and other symptoms). It describes the discomfort and relief reported by the clinicians involved, and concludes that their actions in deliberately hastening death may reassure the doctors of their ability to assist a dying patient and to help the patient die in the way he or she wished, even though, in some cases, the patient had not requested hastened death. Indeed, deliberate intervention to end life without request from the patient is reported to have occurred in 74 of the 558 cases (13.3%), yet this receives little critical discussion. The report does not describe the type of care patients received. This is an important issue if doctors felt euthanasia was a means of improving "the quality of dying". In addition, we know nothing of the patients' views, nor how they were expressed or interpreted. Finally, it is also noteworthy that the "discomfort" of some doctors varied according to other characteristics of the patient. That doctors experienced less discomfort in ending the life of a female patient, or a patient whom they believed was closer to death, than those who are male, younger or believed to have a better prognosis should also raise serious concerns about the processes that might underlie these decisions.

How do we respond to such findings, and what meaning do we attach to them? The conclusion reached by Haverkate et al, that by providing euthanasia a doctor is left with the satisfaction of having contributed to the quality of the dying process, is symptomatic of the depth of the problem facing medicine in the care of the dying. The provision of death comes to be viewed as one of a doctor's therapeutic tools. Death becomes a commodity within the therapeutic relationship, even a "right", and the deliberate ending of a life becomes a medical treatment.

Research such as that of Haverkate et al also raises questions about the impact of broader societal values on the doctors' actions, motivations and perceptions of their role. What social pressures come to bear on doctors' actions and beliefs about what they do, including the limitations in health resources? How readily do the behaviours and views of doctors accommodate to, reflect, or even shape these prevailing forces (such as views on acceptable care of a dying patient, and broader attitudes towards the dying and the aged)? Does the interest in, or even "comfort" in, euthanasia tell us more than we can comfortably acknowledge about doctors' (and the broader society's) views on the sick and dying?

Other questions are raised. To what extent is the issue of assisted suicide or euthanasia symptomatic of the failure to equip doctors with better skills in the care of the dying patient? The reactions of doctors tell us less about the appropriateness of euthanasia, or the needs of doctors following a death by euthanasia, than they do about how troubled and problematic the medical responses to a dying patient can be — a "symptom" of the problem modern medicine has with dying rather than the solution.¹⁰ The report by Haverkate and colleagues provokes a question that has long been asked in this field: When we talk of relief of suffering, whose suffering are we referring to?¹¹ Is it also the suffering of the doctor, pained by proximity to death and a sense of helplessness and demoralisation when feeling ill-equipped to respond to the needs of the patient and his or her family?

A pressing task is presented by the research of Haverkate and colleagues — to address the limitations of medical training; to provide better access to supervision and support for doctors and other health professionals while they are engaged in the care of seriously ill and dying patients; to develop better systems of care that identify and respond to patients' psychological and social needs alongside the skilled care of physical illness; and to improve patients' access to such care. The provision of professional support and supervision before assisted suicide or euthanasia occurs aims to better identify the needs around the dying patient, the interventions required, and aims to prevent assisted suicide. Guidelines to help doctors have been published. These include those developed by the National Health and Medical Research Council for the psychosocial care of patients with breast cancer,¹² guidelines for improving communication skills in end-of-life care,¹³ and recommended approaches to a request for euthanasia or assisted suicide.¹⁴ Acquiring such skills can improve the care by clinicians, and provide much-needed alternatives to the promotion of euthanasia or assisted suicide.

Brian J Kelly
Associate Professor, and Director
Consultation-Liaison Psychiatry, Department of Psychiatry, School of Medicine
University of Queensland, and Division of Mental Health
Princess Alexandra Hospital, Brisbane, QLD

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©MJA 2001
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