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The Morality of Dying

A doctor challenging New York's law against physician-assisted suicide sees no moral difference between facilitating a death and euthanasia.


With the Supreme Court poised to decide whether doctors have a constitutional right to help sick people kill themselves, the spotlight once again falls on Dr. Timothy Quill. An internal medicine specialist at the University of Rochester in New York, he is the lead plaintiff in one of the cases that the court is expected to consider early next year--a case challenging the state's law against physician-assisted suicide.

Quill first surfaced as an advocate of the right to die in 1991. That was when the New England Journal of Medicine published his account of helping a woman with terminal leukemia end her life by swallowing an overdose of barbiturates he prescribed. Because the story flouted the central medical ethic of saving life at all costs, it sparked deep debate and wide publicity.

This month, Quill defends physician-assisted suicide in a new book, "A Midwife Through the Dying Process" (The Johns Hopkins University Press, $24.95). It is built around case studies of nine patients he cared for at the end of their lives. The book's guiding metaphor was furnished by a woman with fatal stomach cancer, who died after Quill withdrew her feeding tube and upped her morphine levels. During the ordeal, she lamented in a letter to Quill that no other doctor seemed willing to "midwife me through the dying process if that's what it came to."

Quill's approach is generally applauded as far more careful than that of Dr. Jack Kevorkian, who has abetted dozens of suicides in Michigan with what many medical experts regard as unseemly haste. But for all Quill's thoughtfulness, he argues in "Midwife" for even more freedom to hasten death than do other advocates. While many ethicists insist that patients be diagnosed as terminally ill before a doctor is allowed to aid their suicides, Quill is against that restriction. And he sees no real moral difference between facilitating a suicide, where the patient takes the final self-destructive step, and euthanasia, where the doctor does so, presumably at the patient's request.

He addressed such questions in a recent interview with Times Medical Writer Terence Monmaney, excerpted here.

The Times: You mention in the new book that dying can be part of a "healing" process. What do you mean by that?

Quill: It's a way of achieving completion to your life, closure, the opportunity to say what hasn't been said or put things together. . . . It doesn't happen to everybody, but some people get much clearer about who they are and what's important to them than at any other time in their lives.

Q: Surveys have suggested that while a slight majority of physicians are comfortable with the idea of physician-assisted suicide, many are not really sure how to go about it. They're very concerned about ruling out clinical depression and about which drugs to give and at what doses. What needs to be done?

A: In these cases where [doctors] are struggling--and they should struggle, I really don't want to make this process too easy--if you have an open system, and there is a question of depression, we would get a consultation by an expert . . . maybe a psychiatrist. Same thing if uncontrolled pain was the issue. Before you'd ever want somebody to act, you'd want to get your best pain people to get a look at the situation and say, "Is there some other way we can do this?" And then also in an open system, you could decide, well, if we are going to do this, what does the data say about the ways [of hastening death] that work and how can we ensure that it works? You'd hate to have people then go through a process, decide that this is really the only option for this particular person that makes sense, and then not have it work.

Q: What researchers refer to as an "incomplete suicide."

A: Right.

Q: You argue that stopping life support and assisting in a suicide are morally similar. Many medical ethicists would disagree. Would you expand on that?

A: From an individual patient's point of view, there's often not a lot of difference. If I'm in a very bad situation, and I see my suffering as overwhelming and I'm ready to die, I am currently lucky if I'm on life support because you as my doctor can help me [die]. It can be seen as OK by society. But if I'm in that same state or a worse state and I don't have a life support to stop, [assisted suicide] is not allowed. . . . Having been through the discussion process with a number of patients, I think it's very similar from a psychological point of view. And the process that we go through to stop life supports, which is a very serious, sober process, is probably a good model for this kind of decision. Get our best minds together, make sure [the patient's decision] is not colored by depression and so forth, and only do it as a last resort.

Q: Traditionally, the distinction has been that withdrawing life support is taking somebody out of a situation that, in effect, medicine put them in. In contrast, assisting a suicide is taking a proactive step to bring about the end of somebody's life.

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