Physician Aid-in-Dying

Physician Aid-in-Dying: Case 2

A middle-aged woman diagnosed with acute myelogenous leukemia has refused chemotherapy for her condition. She is educated, articulate and quite aware that she will certainly die without treatment. She is upset by her diagnosis, but is not depressed. Her close family wishes she would accept treatment because they do not want her to die, but even so, they honor her refusal. She understands that her death will likely be painful and may be prolonged and requests a supply of barbiturates that she might use to take her life when the appropriate time comes.

Physician Aid-in-Dying: Case 1

A recently divorced fifty-five-year-old man with severe rheumatoid arthritis comes in for a routine visit complaining of insomnia. He requests a specific barbiturate, Seconal®, as a sleep aid, asking for a month's supply. On further questioning, he states that he wakes up every morning at four, tired but unable to go back to sleep. He admits that he rarely leaves his house during the day, stating that he has no interest in the activities he used to find enjoyable.

What is an appropriate course of action?

CASE STUDIES

A recently divorced fifty-five-year-old man with severe rheumatoid arthritis comes in for a routine visit complaining of insomnia. He requests a specific barbiturate, Seconal®, as a sleep aid, asking for a month's supply. On further questioning, he states that he wakes up every morning at four, tired but unable to go back to sleep. He admits that he rarely leaves his house during the day, stating that he has no interest in the activities he used to find enjoyable.

What is an appropriate course of action?

Case Discussion

The request for a specific quantity of a specific barbiturate suggests that this patient is contemplating suicide. This concern should be addressed explicitly with the patient. His sleep pattern (early morning awakening) and lack of interest in previously enjoyable pastimes (anhedonia) suggest major depression. This should be fully evaluated and treated. In addition, pain management and long term care options should be fully revisited in a patient with complaints such as his.

Even if the patient were fully competent, most proponents of PAD would object to aiding his suicide as he is not terminally ill. This said, rheumatoid arthritis can be a painful and debilitating chronic condition and it is unclear whether there is any relevant ethical or legal distinction between such a patient and one who is terminally ill.

A middle-aged woman diagnosed with acute myelogenous leukemia has refused chemotherapy for her condition. She is educated, articulate and quite aware that she will certainly die without treatment. She is upset by her diagnosis, but is not depressed. Her close family wishes she would accept treatment because they do not want her to die, but even so, they honor her refusal. She understands that her death will likely be painful and may be prolonged and requests a supply of barbiturates that she might use to take her life when the appropriate time comes.

What is an appropriate course of action?
 

Case Discussion

This is the story of "Diane," related by Dr. Timothy Quill (citation above). It represents the sort of case that advocates cite when making the argument for PAD. Suicide appears rational, the condition undeniably terminal. Dr. Quill provided the prescription and the patient ultimately used it. Others have argued that appropriate palliative care would have been sufficient to provide for a peaceful death and that the focus on PAD actually points to the failure of physicians to use palliative measures effectively. Ultimately, the choice of action in such a case depends on the strength and soundness of the particular physician-patient relationship and the values of the individuals involved.