In March 1989, the New England Journal of Medicine published an article in which 12 doctors called for "a second look" at physicians' responsibility toward hopelessly ill patients. The authors made news by stating, "It is not immoral for a physician to assist in the rational suicide of a terminally ill patient."
Since then, there have been a lot more headlines about physician-assisted suicide. Earlier this year, Dr. Timothy Quill, a physician in Rochester, N.Y., wrote about his experience in helping a terminally ill leukemia patient to commit suicide by prescribing enough barbiturates to end her life peacefully.
His account drew the attention of legal authorities, but a grand jury declined to indict him.
Dr. Quill has been called heroic by many people, including many medical professionals. But there are plenty of physicians who view any participation in assisted suicides as an act that does serious damage to the physician-patient relationship.
The same charge has been raised in relation to "Final Exit," the best-selling book on assisted suicide. But the sustained sales of this book provide concrete evidence that there is widespread fear of the way many Americans now die slowly, painfully and at great cost in both human and financial terms.
Dr. Ronald Cranford is a neurologist in Minneapolis who has become known for his interest in controversial cases in which life-prolonging medical treatment was withdrawn from patients in a persistent vegetative state. He sees the book's popularity as a statement to the medical community that "we're doing a miserable job" when it comes to physician-patient relationships.
Dr. Cranford sees the contortions doctors go through even to remove medical treatment that is simply prolonging the dying process as a worrisome sign that doctors lack the moral courage to do what is best for patients. "We're more concerned with legal liability than with moral responsibility," he says.
He contrasts the American approach to dying with that of the Netherlands, where there is a strong tradition of long-lasting, trusting relationships between doctors and patients. Among the Dutch there is widespread acceptance of the notion that a compassionate doctor would help a terminally ill patient to die peacefully when it is clear that death is imminent.
Dr. Cranford suggests that in the American debate over assisted suicide, the two sides are often talking past each other. Lay people are saying, "I don't want a lot of suffering." They're not necessarily saying, "I want to commit suicide." On the other hand, Dr. Cranford says, physicians are thinking, "My God, I don't want to kill!"
Meanwhile, other countries look curiously at the American debate. The Dutch view with alarm the American trend toward allowing third parties to decide the fate of comatose or incompetent patients. They see that as far more dangerous ethically than a physician's assistance in bringing life to a less painful close.
Moreover, many European doctors are critical of the split in the American approach toward helping a patient to die. As the two articles in the New England Journal of Medicine suggest, the American medical community shows a growing acceptance of physician-assisted suicide (providing the means for a patient to commit suicide, but not actually administering the fatal dose). But there is still widespread criticism in this country of Dutch-style active euthanasia.
That's simply splitting hairs, the Europeans say.
They ask: If physicians are going to help their patients to die in a responsible way, shouldn't they be there to make sure it's done right?
Send your comments and questions about death and dying to Sara Engram, Mortal Matters, The Evening Sun, P.O. Box 1377, Baltimore, Md. 21278.