THE DISTINCTION between executioner and physician has never been absolute. In 17th-century Europe, the executioner, who broke bones at the gallows, was called upon by neighbors to set bones, his expertise turned to the purpose of healing.
Today, defenders of physician-assisted suicide suggest we should encourage doctors to use their skills to kill their patients. Advocates of this change argue that just as patients have won the right to refuse treatment, to decline or discontinue respirator care, so they should be able to have their doctors prescribe barbiturates (or inject fatal compounds) to hasten death.
Almost all instances of refusing medical treatment arise in the hospital, where many eyes are on the case. A chart and record make it possible to substantiate whether the patient is terminally ill and fully competent.
A dying patient's bedside was once crowded by the family, neighbors and clergy. Now the group includes lawyers, bioethicists and risk managers. Still, the people around the bedside ensure that difficult decisions are likely to be made with ample information and forethought.
Will these characteristics carry over to assisted suicide? Not very likely. It will occur far more often in the community than in the jTC hospital, with fewer eyes on the case and no necessary record.
Moreover, it is not easy to ferret out the patient's true intentions. Given the distress, even disorientation, caused by catastrophic illness and the pain of dying, how can anyone be certain that the voice that the doctor hears is the patient's authentic voice?
Dr. Timothy Quill of the University of Rochester, who had a relatively long relationship with a patient, knowingly prescribed tranquilizers for a suicide, and wrote about it in the New England Journal of Medicine. But this incident should not be taken as the standard case. Doctors and patients are more often strangers to each other, and policy must reflect this fact.
Why should doctors assist with suicide? Proponents say doctors can relieve the family of the burden and prescribe the most comfortable way to die. The illegality of the act aside, these claims obfuscate critical issues: Is the physician's decision visible and bounded by prior review? Just how invisible Quill's act was emerged when the district attorney of Monroe County, N.Y., said no charges could be brought against him because there was no physical evidence of a crime.
Quill's defenders invoke the medical profession's historic commitment to do no harm. They assume that the covert exercise of authority will be a responsible exercise. But it seems puzzling that at the moment when the regulation of almost every aspect of a physician's decision-making, from billing practices to hospital admissions, gets the most extraordinary scrutiny, the doctor is allowed to act alone in causing death.
The answer may lie in an eagerness to maximize a patient's privacy and facilitate decision-making. But more likely it reflects a fear that the legislature will not act quickly or wisely. Actually, many states have coped effectively with termination-of-treatment questions, passing statutes on brain death, living wills and proxies to make health-care decisions. Our society has done quite well reaching consensus on bioethical issues. Our successes lie not in promoting individual discretion but setting down principles and procedures.
The better policy would be to convene a judicial hearing to review a terminally ill patient's request to die. The facts of the illness and competency of the patient assured, the hearing officer would approve the request and arrange for the barbiturates.
The judiciary might not welcome this role, but, with capital punishment in force, it would be accustomed to it.
David J. Rothman is author of "Strangers at the Bedside: A History of How Law and Bioethics Transformed Medical Decision Making."