The Right to Die

By Ken Gewertz

Gazette Staff

In 1989, Sidney Wanzer visited his brother at his home in North Carolina for a goodbye visit. He brought with him a bottle of sleeping pills.

Wanzer's brother was suffering from advanced lung cancer and was in terrible pain and discomfort. He had asked Wanzer, a physician, to bring him something that would allow him to end his life.

As it turned out, the patient never took advantage of the opportunity Wanzer had provided. Instead, he died naturally a week later. During his visit, Wanzer had spoken with his brother's doctor and persuaded him to increase the patient's pain medicine, which helped make his last days more comfortable. But Wanzer does not regret his decision to provide his brother with the option of taking his life.

"During that week, he had the means to end his life in his bedside drawer. He didn't use them, but the fact that they were there was highly comforting."

To most physicians, trained to do battle with the conditions that threaten human life, death is the enemy. Giving in to death is considered defeat.

Wanzer, director of Law School Health Services, shares this perspective. But he believes that under some circumstances death can be a friend, and giving in to it, even hastening it, can be part of the physician's proper role.

Wanzer has been involved in the debate over physician-assisted suicide ever since 1992, when he took part in a symposium sponsored by the Massachusetts Bar Association that focused on the legal aspects of this controversial issue.

"The panel was made up mostly of doctors and lawyers, and somehow we just clicked," Wanzer said. "After the symposium ended we decided to keep the conversation going."

The group met once a month for the next two-and-a-half years, attracting several new members, including James Vorenberg, Roscoe Pound Professor of Law. Finally, they drew up a piece of model legislation to authorize and regulate physician-assisted suicide. That legislation and an article explaining the thinking behind it appeared in the winter 1996 issue of the Harvard Journal on Legislation.

Democratic state representative Douglas Petersen of Marblehead has agreed to introduce the model legislation later this year for consideration during the state legislature's 1997 session.

"We sweated blood over every phrase in that statute," Wanzer said. "Sometimes it took us two hours just to write one sentence."

But before the writing could even begin, the group had to make a basic choice -- to what extent should the legislation spell out guidelines and requirements? Should it be a statement of principles of a dozen lines or so, leaving specific interpretations up to the physician, or should it be highly detailed, and therefore more intrusive?

"We opted for the more detailed and intrusive approach because we felt that was the best way to safeguard the patient against abuse and to safeguard the physician against liability for following the patient's wishes," Wanzer said.

One consequence of this decision was a provision that requires the patient to be examined by a mental health professional to determine whether the wish to die might be the product of an emotional condition that could be treated by other means.

Said Vorenberg: "I've felt for a long time that anyone has a right to be released from life if life has become a trap, but it would be a tragedy if a transitory depression or some condition that's been blown out of proportion influenced someone to take their life."

For similar reasons, the statute requires that the patient's diagnosis be confirmed by a second physician before a decision to choose suicide can be approved.

A second important decision was who should be eligible for assisted suicide? Most of those who have grappled with the subject have argued that only the terminally ill (generally defined as patients with a maximum of six months to live) should be allowed to choose death. But Wanzer's group decided to expand this category.

"We decided that people who were not terminally ill but who were suffering from unbearable and intractable illness should have the option of assisted suicide. Such an illness might involve extreme pain, but it might also be a condition that was simply debilitating, like Lou Gehrig's disease."

But what of the "slippery slope" argument, that legalizing assisted suicide opens the way to enforced euthanasia for the useless and unfit? Wanzer believes these fears to be exaggerated.

"I don't think that's a big problem, although many do," he said. "This is only aimed at people who want it. No one is pushed into it, neither physician nor patient. It's simply one option for a person who is in a highly defined situation and who finds life unbearable."

To many who oppose physician-assisted suicide, the idea of a medical doctor helping a patient die is inimical to medicine's central concern, the preservation of life. But Wanzer does not see it this way.

"I would look at physician-assisted suicide as part of the spectrum of treatment that should be available to the patient. At one end is the aggressive, full-steam-ahead approach where the restoration of health seems likely. As full recovery begins to seem less possible, treatment becomes less and less aggressive until we're applying comfort measures only. Finally, at the other end of the spectrum is assisted suicide."

Wanzer believes that while medicine generally does an excellent job of treating illness aggressively, its treatment of those with little or no chance of recovery is less exemplary.

"Patients should have the meticulous attention of their physician at the end. Many doctors tend to pull back if a patient can't be brought back to a state of good health. They see it as a failure."

Wanzer believes that to make sure dying patients receive adequate care, caregivers must agree on the point at which the restoration of health is no longer possible.

"Goal definition is terribly important," he said. "If all the caregivers are in agreement, they can help the patient to die peacefully because it's easier to make all the decisions that come up in the course of treatment -- whether to treat pneumonia with antibiotics, whether to remove feeding tubes, how much pain medicine to use."

In this goal-setting process, the physician must also pay strict attention to the patient's wishes and act accordingly. Wanzer points out that patients have an absolute right to decline treatment, a principle that has been clearly substantiated by the courts.

And since there is no legal or ethical difference between stopping treatment and never having started it in the first place, a patient who wishes to hasten death by stopping treatment has a perfect right to do so.

If the approach of death is seen for what it is and treated appropriately, then most patients will be able to spend their last days in comfort, and assisted suicide will not be necessary, Wanzer said.

"The majority of people who are dying should be able to be treated in such a way that their last days are bearable. The need for assisted suicide or any premature ending of life should be very rare. In the lifetime career of a physician, it should occur in only a handful of instances."