Physician-Assisted Suicide: Family Issues
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The role of families in ethical discussions about physician-assisted suicide is addressed from the viewpoint of medical ethics and the perspective of a family physician. The possibility that an individual possesses and exercises autonomy only within the context of social relationships is discussed, and the family dimensions of assisted suicide are presented.
Key Words: physician-assisted, suicide, family, ethics
Howard Brody, M.D., Ph.D., is Director, Center for Ethics and Humanities in the Life Sciences and Professor of Family Practice and Philosophy, Michigan State University, Lansing, Michigan 48824. Electronic Mail may be sent via Internet to 2992HOW@MSU.EDU.
The publicity surrounding the activities of Dr. Jack Kevorkian since 1990 has brought physician-assisted suicide to the forefront as a medical-ethical issue in Michigan. Proponents of assisted suicide generally address the individual patient's right to be free of suffering and to exercise control over the circumstances of dying. Opponents commonly focus upon religious arguments against suicide and mercy killing; the "slippery slope" of feared societal consequences; and violations of physician integrity should physicians become involved in deliberately causing death. As the debate is thus framed, it is easy to assume that the family has no role, or merely a peripheral one.
In this paper I will address the various ways in which the family emerges as a focus of concern, upon a deeper or broader understanding of the issues raised by physician-assisted suicide. I will address these issues principally from the viewpoint of medical ethics, and secondarily from the perspective of a family physician; I make no pretense of being a family psychologist or family therapist.
While I will show below that the family has hardly been absent from ethical discussions about physician-assisted suicide, the lack of clear focus upon the family dimensions of the topic may signal a more basic problem with medical ethics as it has emerged over the past quarter century in the U.S. James Lindemann Nelson (1992), among others, has criticized today's medical ethics for lacking a cogent conception of the role of the family. To put the matter in the simplest possible terms, much of modern medical ethics has been based upon the principle of respect for individual autonomy. This has led to the assumption that the family enters in either as a mere extension of individual autonomy (as when, for instance, a patient who was brought up as a Jehovah's Witness freely chooses to forego a blood transfusion), or else as a threat to autonomy (as when, for instance, a reluctant Jehovah's Witness refuses a transfusion, and the medical caregivers suspect that he would have accepted it but for undue pressure from family members). The possibility that an individual possesses and exercises autonomy only within the context of a set of social relationships, among which the family is pivotal, seems not to be appreciated sufficiently in many ethical analyses. A careful study of the family dimensions of physician-assisted suicide may help in a small way to correct this blind spot.
By "physician-assisted suicide" I mean a situation in which a patient kills him-or herself, using means which have been supplied by the physician, with the physician being aware that the patient intended to use those means for the purposes of suicide. Such cases generally arise with patients who suffer from terminal or irreversible, degenerative illnesses; although of course the presence of such an illness is not necessary for the definition to apply.
The publicity surrounding Dr. Jack Kevorkian has led to an atypical public image of physician-assisted suicide. The patient's death is caused by an apparatus which the patient could not obtain or manipulate on his own; and the physician must be present at the time of death to set up the apparatus, even though the final action which "throws the switch" is the patient's and not the physician's. While few reliable data exist on the prevalence of any assisted suicide practices in the U.S., it seems much more likely that the "usual" case of physician-assisted suicide involves the physician giving the patient a lethal supply of pills, which the patient may (or may not) later elect to swallow as the disease progresses (Quill, 1991).
The Family and the Decision to Request Suicide
A patient seldom comes to a physician to request assistance with suicide unless the decision has first been discussed within the family, or unless the family setting has in some way influenced the decision. Advocates of legalizing physician-assisted suicide tend to view the family relationship among the potential safeguards which assure that a right to suicide assistance will not be abused. Presumably the family will help to assure that the patient's choice is truly voluntary and that the patient has appropriately sought out other care options before concluding that death through suicide is the only effective way to avoid further suffering. While admittedly some families are abusive or neglectful, proponents assume that other safeguards, such as mandatory mental health evaluations, will successfully identify these exceptional cases.
By contrast, opponents of physician-assisted suicide tend to assume that the family's influence will make it highly likely that the patient's choice of death cannot truly be said to be "rational." Since caring for a person with a terminal or incurable disease is extremely taxing, the family will almost inevitably come to harbor wishes that the patient's death will occur sooner rather than later so that their ordeal may end. Even if these wishes are consciously suppressed or denied, they may subtly influence the communication between the family members and the patient. The end result may well be that the patient will come to feel that his life is no longer worthwhile, and that he would be performing an act of generosity toward his family were he to speed up the process of his dying. Opponents further suggest that patients who are suffering sufficiently so as to be logical candidates for assisted suicide are precisely those patients who are psychologically vulnerable to such subtle messages.
The views of both advocates and opponents toward the role of the family tends to mirror their views of the role of the personal physician. To some, having a personal physician of long standing is an extremely useful safeguard for the patient to the extent that one set of proposed criteria for physician-assisted suicide would make this relationship with the assisting physician an absolute requirement (Quill, Cassel & Meier, 1992). Such a physician might best realize when a patient is acting fully in character, or when other factors, such as depression or psychosocial conflicts, may be driving a decision. On the other hand, the tightly bonded personal physician might also have unconscious feelings of anger toward the patient who may have become very demanding; of frustration at the inability to cure or control the disease; and of fatigue after trying to be available and helpful during a long and depressing illness (Miles, 1994). Intimate relationships are two-edged swords, whether with the physician or with one's family.
The law tends to take a particularly jaundiced view of the implications of close family ties. It is commonplace, in proposals for regulating physician-assisted suicide, to specify that witnesses to a request for suicide should not be related to the patient, presumably to prevent a family member from falsely certifying that an incompetent patient has requested death in order to gain an inheritance (e.g., Michigan Commission, 1994).
Impact Upon the Family
In a typical case of suicide, the surviving family members experience anger and prolonged, abnormal grieving; dealing with the suicide of a relative is generally much more difficult than dealing with the loss of that relative through natural death. Because the phenomenon of physician-assisted suicide, to the extent that it occurs today in the U.S., is an underground event generally inaccessible to scientific scrutiny, we have no reliable data on the impact of that particular sort of suicide upon the family.
If, however, one reviews what the media has revealed about the families of patients who were assisted in death by Dr. Kevorkian, this atypical sampling suggests that there is a much greater degree of respect and acceptance for the patient's decision than would be the case in the more usual sort of suicide. Specifically, the family is unlikely to interpret the suicide as an angry or rejecting action directed at themselves. Perhaps this is because a suicide in the face of terminal suffering is far more "understandable" than a suicide triggered by depression or other mental illness; or perhaps it is in part because the physician's participation makes the act somehow more acceptable socially. At any rate, family members have later been among Dr. Kevorkian's strongest supporters and defenders.
The way that families appear to respond to physician-assisted suicide may have an influence upon the decision to seek this particular means of death. Two observations have been offered by opponents of physician-assisted suicide that are pertinent to this question. First, some critics noted, after the first set of deaths engineered by Dr. Kevorkian, that all of his patients so far had been women; and they took this as evidence that the choice to commit suicide could not be a fully "rational" or "voluntary" choice, but instead reflected the malign influence of a powerful, zealous male physician upon a vulnerable female patient. Second, other critics have suggested that no patient who requests suicide assistance from a physician "really" wants to die—because there are so many effective ways of killing oneself that do not require a physician's involvement. Seeking the physician's assistance must therefore be a disguised "cry for help" and a sign that the patient at some level desires to be talked out of suicide.
In response to these criticisms, one may note that women appear to be statistically more likely than men to choose a method of suicide which is less messy and disturbing for those who come upon the death scene: For instance, more women swallow poison whereas more men use firearms. This could mean, among other things, that women are more concerned, even when contemplating suicide, about sparing the feelings of their loved ones. If that were the case, and if women felt that physician-assisted suicide would be easier for family members to handle emotionally, then it would not be surprising if a disproportionate number of women sought such assistance. Using similar reasoning, the patient who seeks a physician's help rather than leaping from a tall building or using a handgun may be making a disguised plea for help but may also want the reassurance that he will truly end up dead rather than merely maimed and brain-damaged; and he may also want to die in a way that does not leave an imprint of emotional devastation upon the family or upon whoever first finds the body. If I am correct in suggesting that physician-assisted suicide might have a more benign impact upon family members than suicide in other circumstances, then under some circumstances a preference for this type of suicide may be a sign of rational decision making, not of the reverse.
These observations about the impact of suicide upon the family raise a more general question about physician-assisted suicide, and especially about the factual assumptions upon which some of the ethical argument has been based. Some psychologists and psychiatrists approach physician-assisted suicide as merely a subset of cases of suicide generally, and then assume that one can apply the scientific knowledge that exists about suicide to this set of cases. For instance, based on the well-documented observation that the vast majority of people who commit suicide are mentally ill, these experts allege that patients seeking suicide assistance from a physician must also be mentally ill; and if the physician reports no signs of mental illness in such a patient, it must be because the physician is an incompetent diagnostician, and not because the patient is rational (Conwell, & Caine, 1991).
If, on the other hand, we can confirm the hypothesis that physician-assisted suicide in cases of suffering from severe, incurable disease causes a very different reaction among surviving family members than do other cases of suicide, then this finding may be indirect evidence that people with severe medical illness who seek a physician's assistance in suicide represent a separate class or population of patients from those who call suicide hot lines or show up in emergency rooms after typical suicide attempts. And that fact in turn would mean that psychological data gathered among the latter population of patients might be inapplicable, at least in part, to the former group. It might turn out that patients who commit suicide (or seek it) with a physician's assistance in the face of suffering caused by incurable illness represent one extreme end of a spectrum of patients with incurable medical problems, rather than one extreme end of the spectrum of all suicidal patients. Whether or not this is so is ultimately an empirical matter to be settled by careful research, even though it is hard to see how in today's legal climate such research could be conducted. (Legalization of physician-assisted suicide in Oregon, if court challenges to the 1994 referendum are overcome, may provide the first opportunity in the U.S. for accurate studies.)
Formal Role of the Family
The concerns expressed above about the family's influence upon a patient's decision to seek physician-assisted suicide relate to the informal role of the family in the decision process. There is also dispute about what, if any, formal role the family ought to have in the process, assuming for purposes of argument that physician-assisted suicide is to be openly allowed with appropriate safeguards.
Some have proposed that close family members must concur with a patient's request for suicide assistance. This proposal seems like a helpful safeguard to prevent the suicide of patients who act precipitously, or who are acting out of character in a way that may signal an as-yet-undiagnosed mental illness. Others might argue that it is simply unseemly or offensive for the legal system to allow a patient to die with a physician's assistance, when close family members oppose this plan and perhaps have not even been notified by the patient that this plan is in process. And still others might argue that family members have legitimate interests of their own and deserve protection in any legal decision process.
However, proponents of physician-assisted suicide as a matter of patients' rights would not agree to giving any family members veto power over a patient's voluntary and informed choice. After all, the issues are whether the patient has chosen freely and whether the patient is truly suffering; and the family members, especially if they have their own emotional problems or dysfunctions to deal with, may be singularly unhelpful in determining either how free was the patient's choice, or how badly the patient is suffering. Their objections to the suicide may reflect their own emotional turmoil much more than any helpful facts about the patient's status. Moreover, if one grants some family members this veto power, precisely how far should it be extended within the family circle? Should an estranged brother or niece who has not seen the patient for 20 years be allowed to derail an otherwise justifiable process?
One compromise position favors requiring that immediate family members be informed without giving them power to control the final decision. If some sort of counseling process should precede any assistance with suicide, then it would seem appropriate to question very carefully any patient who has close family members whom he has not informed about his desire to die, or who has avoided discussing the matter with his family. In particular family situations there may turn out to be very good reasons for this reluctance; but the reasons ought to be made clear before the counselor could approve the patient's decision process as optimally rational and informed.
Some members of the Michigan Commission on Death and Dying drafted a model statute for the regulation of physician-assisted suicide; the statute calls for encouraging but not requiring family notification and allowing the patient to have the final decision in instances where family members might object (Michigan Commission, 1994). The Oregon referendum passed narrowly by the voters of that state in November 1994 has no requirement for family notification or consent.
Availability of Support Services
Both proponents and opponents of physician-assisted suicide agree that when a patient asks this aid from a physician, the first response should be neither ready acquiescence nor moralistic condemnation, but rather a careful search for the sources of suffering which might be ameliorated by some means short of death. Quill (1993) has suggested a useful typology of reasons why patients might ask for suicide assistance. In the typical case, he claims, a better alternative to assisted suicide will be found upon careful inquiry.
Only in the very unusual case will no other means of relieving suffering be available and acceptable to the patient. One of Quill's categories is requesting to die because of the emotional impact of family turmoil or dysfunction, in which case family counseling and not suicide assistance is obviously indicated.
A discussion of this sort, however, tends to make certain assumptions that are natural to middle class patients with adequate health insurance, but which hardly reflects the reality of a large number of persons in the U.S. today. Some proponents of physician-assisted suicide assume a well-functioning and supportive family and a personal physician who has known the patient for a long time. Upon a request for suicide, the physician can readily call upon skilled mental health professionals to assess the patient's competence. If need be, the psychiatric services requested could be highly specialized, as for example when screening elderly, seriously ill patients for masked depression, which could require an experienced geropsychiatrist (Conwell & Caine, 1991). Finally, if problems are identified that can be ameliorated by other means, the relevant professionals are supposedly available. If better pain control is needed, then skilled hospice teams are presumed to be an option; if family dysfunction is identified, then family therapists could be called in; and so forth.
A thoughtful report by a New York state ethics panel (New York Task Force, 1994) unanimously opposes the legalization of assisted suicide, because all of these assumptions are demonstrably untrue for a large number of especially vulnerable patients. They may lack finances or health insurance and so may be dependent upon community mental health clinics with long waiting lists for any psychological counseling and assessment. They may live alone and so be ineligible for home-care hospice services. They may receive almost all of their medical care from emergency rooms or charity clinics and have no personal physician. The New York Task Force suggests, in effect, that a society which would wish to provide the option of legal physician-assisted suicide would first have to eliminate numerous inequities in the provision of medical and mental health services; otherwise the risks that vulnerable patients would be driven to requesting suicide for problems which, under better circumstances, could easily be ameliorated is simply too great. A spokesperson for a community clinic in an inner-city Latino neighborhood stated in a public television program on euthanasia that it is ironic that the only "right to health care" that anyone has come offering his patients lately is a right to be killed and not a right to receive needed services.
Underlying the ethical and legal debates over physician-assisted suicide are a number of issues that focus upon the family. Some positions on assisted suicide rely upon assumptions regarding the psychodynamics of the request for suicide assistance, which can be properly evaluated only with more research in the future. In the meantime, a patient requesting assistance with suicide from a physician should receive a sympathetic but searching evaluation to try to identify other ways to relieve suffering; and providers skilled in family assessment can be valuable contributors to that process.
Conwell, Y, & Caine, E.D. (1991). Rational suicide and the right to die: reality and myth. New England Journal of Medicine, 325,1100-1103.
Michigan Commission on Death and Dying (June 1994). Final Report of the Michigan Commission on Death and Dying. Lansing, MI:
Miles, S.E. (1994). Physicians and their patients' suicides. Journal of the American Medical Association, 271,1786-1788.
Nelson, J.L. (1992). Taking families seriously. Hastings Center Report, 22, 6-12.
New York Task Force on Life and the Law (1994). When Death is Sought: Assisted Suicide and Euthanasia in the Medical Context. New York, NY:
Quill, T.E. (1991). Death and dignity: A case of individualized decision making. New England Journal of Medicine, 324,691-694.
Quill, T.E. (1993). Doctor, I want to die. Will you help me? Journal of the American Medical Association, 270,870-873.
Quill, T.E., Cassel, C.K., & Meier, D.E. (1992). Care of the hopelessly ill: Proposed criteria for physician-assisted suicide. New England Journal of Medicine, 327,1380-1384.