The Articella

1. SHIFTS in ATTITUDES on EUTHANASIA in the US Medical Community


David Albert Jones on Stem Cells and the Catholic Church





in the US Medical Community







Competent Care for the Dying Instead of Physician-Assisted Suicide, Kathleen M. Foley, M.D., N Engl J Med 1997; 336:54-58 January 2, 1997  Editorial, DOI: 10.1056/NEJM199701023360109

In 1997 Kathleen M. Foley, M.D. published in the New England Journal of Medicine a detailed study of issues involved in physician-assisted suicide.  The title of her article, “Competent Care for The Dying Instead of Physician-Assisted Suicide”, reveals her conviction that appropriate palliative care, rather than euthanasia, is what dying patients truly need. Her article concludes:


In summary, there are fundamental physician-related barriers to appropriate, humane, and compassionate care for the dying. These range from attitudinal and behavioral barriers to educational and economic barriers. Physicians do not know enough about their patients, themselves, or suffering to provide assistance with dying as a medical treatment for the relief of suffering. Physicians need to explore their own perspectives on the meaning of suffering in order to develop their own approaches to the care of the dying. They need insight into how the nature of the doctor–patient relationship influences their own decision making. If legalized, physician-assisted suicide will be a substitute for rational therapeutic, psychological, and social interventions that might otherwise enhance the quality of life for patients who are dying. The medical profession needs to take the lead in developing guidelines for good care of dying patients. Identifying the factors related to physicians, patients, and the health care system that pose barriers to appropriate care at the end of life should be the first step in a national dialogue to educate health care professionals and the public on the topic of death and dying. Death is an issue that society as a whole faces, and it requires a compassionate response. But we should not confuse compassion with competence in the care of terminally ill patients.

Kathleen M. Foley, M.D.
Memorial Sloan-Kettering Cancer Center, New York, NY 10021


Julian J.Z. Prokopetz, B.A., and Lisa Soleymani Lehmann, M.D., Ph.D. N Engl J Med 2012; 367:97-99 July 12, 2012, Perspective DOI: 10.1056/NEJMp1205283

Dr. Foley's approach and conclusions contrast sharply with those of Julian J.Z. Prokopetz, B.A., and Lisa Soleymani Lehmann in a more recent article in the New England Journal of Medicine.  After praising the 1987 Oregon Death With Dignity Act (DWDA) they conclude:

    Even with allowances for conscientious objection, some physicians believe it’s inappropriate or wrong for a physician to play an active role in ending a patient’s life. We believe there is a compelling case for legalizing assisted dying, but assisted dying need not be physician-assisted.

    Under the DWDA, the patient’s physician prescribes lethal medication after confirming the prognosis and elucidating the alternatives for treatment and palliative care. In theory, however, the prescription need not come from the physician. Prognosis and treatment options are part of standard clinical discussions, so if a physician certifies that information in writing, patients could conceivably go to an independent authority to obtain the prescription. We envision the development of a central state or federal mechanism to confirm the authenticity and eligibility of patients’ requests, dispense medication, and monitor demand and use. This process would have to be transparent, with strict oversight. Such a mechanism would not only obviate physician involvement beyond usual care but would also reduce gaps in care coordination: in Oregon and Washington, patients whose doctors don’t wish to participate in assisted dying must find another provider to acquire a prescription. Physicians who strongly object to the practice could potentially refuse to provide certification or could even alter their prognosis, but these possibilities yield the same outcome as permitting conscientious objection. Patients could also provide an independent authority with their medical record as proof of their prognosis.

    Such a mechanism would make it essential for physicians to offer high-quality palliative care. The availability of assisted suicide in Oregon seems to have galvanized efforts to ensure that it is truly a last resort, and the same should hold true regardless of who writes the prescription. Usual care for terminally ill patients should include a discussion of life-preserving and palliative options so that all patients receive care consistent with their own vision of a good death.

    Momentum is building for assisted dying. With an independent dispensation mechanism, terminally ill patients who wished to exercise their autonomy in the dying process would have that option, and physicians would not be required to take actions that aren’t already part of their commitment to providing high-quality care.


11.3. Magisterial Support of Stem Cell Research: Opposition to Destruction of Embryos











THE articles cited above also offer details concerning patients' reasons for requesting Physician-Assisted Suicide. 

IN 1997 Foley noted:

Pain, AIDS, and neurodegenerative disorders are the most common conditions in patients requesting assistance in dying. There is a wide range in the age of such patients, but many are younger persons with AIDS.10 From the limited data available, the factors most commonly involved in requests for assistance are[:]

[1] concern about future loss of control,

[2] being or becoming a burden to others,

[3] or being unable to care for oneself and fear of severe pain.10

  A small number of recent studies have directly asked terminally ill patients with cancer or AIDS about their desire for death.25-27 All these studies show that the desire for death is closely associated with depression and that pain and lack of social support are contributing factors.

10. Back AL, Wallace JI, Starks HE, Pearlman RA. Physician-assisted suicide and euthanasia in Washington State: patient requests and physician responses. JAMA 1996;275:919-925

25. Brown JH, Henteleff P, Barakat S, Rowe CJ. Is it normal for terminally ill patients to desire death? Am J Psychiatry 1986;143:208-211

27. Breitbart W, Rosenfeld BD, Passik SD. Interest in physician-assisted suicide among ambulatory HIV-infected patients. Am J Psychiatry 1996;153:238-242

SIMILAR motives for requesting euthanasia are described by Prokopetz and Lehmann, with the additional mention of the desire to control the timing of death, rather than waiting for it to happen:

Advances in palliative medicine have produced effective strategies for managing and relieving pain for most terminally ill patients, including the possibility of palliative sedation. Inadequate pain control therefore ranks among the least common reasons that patients in Oregon request lethal medication. Most say that they are motivated by[:]

[1]  a loss of autonomy

[2]  and dignity

[3] and an inability to engage in activities that give their life meaning.2

Patients in the United States may already decline to receive life-sustaining treatment through advance directives, but that is a reactive stance: only when an acute condition occurs can patients decline intervention, and many patients have no life-sustaining treatments to withdraw. Some terminally ill patients wish to exercise their autonomy and control the timing of their death rather than waiting for it to happen to them.

2. Thirteenth annual report on Oregon’s Death with Dignity Act. Portland: Oregon Office of Disease Prevention and Epidemiology, 2010.

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