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The Supreme Court Addresses Physician-Assisted Suicide
Can Its Rulings Improve Palliative Care?
Ann Alpers, JD;
Bernard Lo, MD
Arch Fam Med. 1999;8:200-205.
ABSTRACT
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In June 1997, the US Supreme Court unanimously decided that competent, terminally ill patients have no general constitutional right to commit suicide or to obtain assistance in committing suicide. Thus, the broad prohibitions against any kind of suicide assistance that almost every state has enacted do not violate the constitution. While many of the rulings and the bulk of the reaction to them focused on the Supreme Court's resolution of important legal controversies regarding physician-assisted suicide, this article focuses on the resulting potential for change in physicians' opinions on palliative care. The Court's reasoning may help physicians resolve substantial ethical dilemmas regarding the provision of narcotics given in high dosages, the care of incompetent patients, and the suffering caused by symptoms other than pain. For example, the Court concluded that a physician's intent can distinguish permissible acts of aggressive pain relief from impermissible acts of hastening death. This distinction has clinical uses and can help physicians develop ethical guidelines and practice standards to improve palliative care near the end of life.
INTRODUCTION
The Supreme Court's momentous decision1-2 resolved some important legal controversies regarding physician-assisted suicide, but also raised questions about how clinicians can improve access to palliative care and how they should practice intensive palliative care. For example, the Court's opinions have created controversy about the practice of terminal sedation and the clinical applicability of the doctrine of double effect. Such questions are particularly important given the Court's suggestion that access to palliative care may be protected by the constitution.3 We suggest that how the Court treats physicians' intentions may clarify terminal sedation and keep it a viable clinical option for relief of refractory symptoms that is legal in all states. We also analyze how the Court's reasoning can help physicians resolve clinical dilemmas regarding palliative care for incompetent patients and suffering caused by symptoms other than pain.
LEGAL BACKGROUND
The Supreme Court opinions reversed 2 decisions by the US Courts of Appeals, which had found that Washington and New York violated the 14th Amendment by prohibiting physicians from prescribing lethal medication to competent, terminally ill adults who wished to hasten their deaths.4-5 These appellate decisions equated physician-assisted suicide and refusal of life-sustaining treatment and rejected the double-effect rationale for aggressive palliative care.6
The Supreme Court rejected the conclusion that terminally ill patients had a "fundamental liberty interest" in obtaining physician-assisted suicide, particularly given states' legitimate reasons for prohibiting assisted suicide. These reasons include reducing the public health risk of suicide, particularly in vulnerable groups, protecting the integrity of the medical profession, and preventing euthanasia. The Court also unanimously decided that state laws could distinguish between prohibiting physician conduct that intentionally hastens death while permitting conduct that may foreseeably hasten death but is intended for other important purposes, such as the relief of pain. The majority opinion accepted the doctrine of double effect, stating that "in some cases, painkilling drugs may hasten a patient's death, but the physician's purpose and intent is, or may be, only to ease his patient's pain."
CAN THE RULINGS IMPROVE ACCESS TO PALLIATIVE CARE?
The Supreme Court rulings have important implications for physicians and nurses who care for dying patients. These rulings must be viewed in the context of numerous clinical studies that document inadequate relief of pain near the end of life.7 The majority opinion concludes that the double-effect doctrine provides a rational and constitutional basis for states to allow narcotics given in high dosages for pain relief in terminally ill patients, while prohibiting assisted suicide. Thus, the majority opinion delineates an acceptable justification for aggressive palliative care. The concurring justices go further, suggesting that the state is obligated to permit physicians to provide adequate pain relief at the end of life, even if such care leads to unconsciousness or hastens death. These concurring opinions (which represent 5 of the 9 justices) may establish a right to pain relief that is closely allied with other personal rights such as the right to an abortion or the right to refuse medical treatment.3
Lessening Barriers to Palliative Care
The Supreme Court concluded that the double-effect rationale distinguished the use of narcotics given in high dosages from euthanasia or assisted suicide. The Court noted that "painkilling drugs may hasten a patient's death, but the physician's purpose and intent is, or may be, only to ease his patient's pain. The law has long used actors' intent or purpose to distinguish between 2 acts that may have the same result."1 The Supreme Court's acceptance of the double-effect doctrine may help relieve physicians' concerns about legal liability for providing adequate pain relief that may hasten death.8 Some physicians may worry that coroners, medical examiners, prosecutors, or licensing boards may question the use of high dosages of narcotics to relieve pain in terminally ill patients.9 While the justices did not address these barriers to pain relief, the Supreme Court's conclusion that the constitution permits states to treat pain management differently from assisted suicide may calm physicians' fears and also deter local law enforcement officers and licensing boards from excessive diligence that discourages appropriate pain management. If physicians are reassured by the Supreme Court's opinions, deficiencies in pain control at the end of life may be improved.
The concurring opinions go further than accepting the distinction between assisted suicide and palliative care. These concurrences suggest a constitutional interest in adequate pain relief for dying patients. The nature and strength of this undefined right remain unclear. Burt3 argues that the "constitutional right to palliative care" has the same legal status as the right to an abortion. He suggests that states may not unreasonably impede a terminally ill patient's access to a physician's provision of palliative care. However, we think that relief of pain is an important new dimension of the rights of medical decision making that were articulated in the Cruzan ruling.10 Cruzan assumed that competent patients have a right to refuse unwanted life-prolonging treatment. Quill and Glucksberg1-2 affirmed that right and suggested, in the concurrences, that competent patients also have a right to be free of severe suffering in terminal illness. A potential constitutional right to palliative care could add legal weight to clinicians' ethical obligation to respect the choices of informed patients near the end of life.
A right to be free of suffering, on an ethical continuum with the right to refuse treatment, would be noteworthy because it could limit physicians' power to raise conscientious objections. Physicians must respect patients' refusals of treatment, even those that conflict with their own personal values or with the mission of the health care institution.11 If the right to receive adequate pain medication has the same ethical force as the right to refuse life-sustaining treatment, we believe it should be similarly respected by physicians. Although the Supreme Court stopped short of articulating a constitutional right to be free from suffering, physicians and bioethicists regard the relief of pain as a primary moral goal of medicine.12 Some physicians may hesitate to use narcotics given in high dosages that hasten death or reject the rationale of the double effect.13-15 Despite these objections, such physicians should provide adequate pain relief to honor the terminally ill patient's right to avoid medically manageable pain. Hospitals and health care plans should also avoid limiting the pain medication available in the pharmacy, which restricts patients' access to palliative care.
Finally, the Supreme Court rulings may have important implications regarding legal barriers to palliative care. Many states have laws that restrict the amount of narcotics that can be prescribed or dispensed or sanction investigations of physicians who prescribe high dosages of narcotics to terminally ill patients. These measures may conflict with a putative constitutional right to palliative care.3 Such conflicts might be resolved through state legislation. The proposed model Pain Relief Act16 protects health care professionals from legal liability if they substantially comply with accepted guidelines for treatment of pain. Similar legislation could provide safe harbor for physicians who provide intensive palliative care to their terminally ill patients in accord with appropriate clinical guidelines.
Palliative Care for Incompetent Patients
Because the Supreme Court considered cases involving terminally ill patients who were competent, its decisions addressed competent patients. In clinical practice, however, physicians commonly encounter incompetent, terminally ill patients who experience unrelieved suffering. Indeed, patients who require high dosages of narcotics for relief of suffering may lose the capacity to make decisions about their care. If receiving palliative care becomes a legally protected right like the right to refuse treatment, then it should be available to incompetent patients as well. How might the Court's reasoning apply to the care of patients who can no longer consent to palliative care?
Incompetent patients may suffer just as much as competent patients. The physician's ethical obligation to relieve suffering is as strong in the case of incompetent, terminally ill patients as with competent, terminally ill patients. However, decisions about palliative care are more difficult if patients cannot tell physicians and nurses how much they are suffering or how much they value maintaining some level of consciousness.
In caring for terminal, incompetent patients, physicians and nurses often observe clinical findings that can reasonably be interpreted as refractory suffering. Physicians and nurses need to balance conflicting goals: to relieve suffering and not to render someone unconscious or hasten death if the patient would not have wanted it. What assumptions should be made for incompetent patients who have expressed no clear preferences about end of life care? In other clinical settings, the starting premise in difficult cases may be to err on the side of prolonging life. For example, a few states do not allow feeding tubes to be withdrawn from patients in persistent vegetative state unless a patient has given clear and convincing evidence that they would not want such treatment.10 These states assume that artificial feedings will be given to prolong life, unless there is strong evidence that the patient would not want them. We believe that the starting premise in palliative care should be to relieve suffering, even if palliation causes unconsciousness or shortens life.12 The benefit of relieving refractory suffering at the end of life outweighs the risk of further shortening an already-limited life expectancy.17 If a terminal, incompetent patient is suffering, the physician's primary ethical obligation is to relieve suffering, not to prolong life. It would be cruel to require incompetent patients to suffer avoidable pain simply because they had not previously authorized narcotics given in high dosages or sedatives.18 Physicians and nurses should increase dosages of analgesia as needed, unless there is considerable evidence that the incompetent patient would reject palliation that caused unconsciousness or hastened death or that the proxy agrees it is not in the patient's best interests to increase the dosage.
IMPLICATIONS FOR TERMINAL SEDATION
Several concurring justices encourage what sound medical practice and ethics have always required—the relief of refractory pain, even if treatment results in unconsciousness or hastened death. Justice Sandra Day O'Connor wrote favorably of "relieving pain even to the point of causing unconsciousness." Justice Stephen Breyer noted the "need for sedation which can end in coma." These justices appear to be referring to terminal sedation, although the term itself appears only in a footnote in the Quill1 majority opinion. Terminal sedation has grown particularly controversial and deserves closer analysis. Some writers argue that it cannot be meaningfully distinguished in theory from active euthanasia,19-21 which the Supreme Court held that states could continue to prohibit. Furthermore, the actual practice of terminal sedation raises difficult ethical questions. The Supreme Court's opinions, rather than confusing the topic of terminal sedation as some commentators have suggested,21 can help physicians address such issues as the intention of the physician, informed consent, and guidelines for increasing the dosage for sedation.
Terminal sedation, also known as heavy sedation at the end of life, involves sedating patients with refractory suffering to unconsciousness and withholding artificial nutrition and fluids and treatment for complications such as pneumonia.20, 22 The practice presents several potential problems with physicians' intent. First, is intent a relevant consideration in assessing a physician's actions in sedating a patient and withholding medical treatment? Second, can physicians intend only to relieve suffering if they know that terminal sedation will hasten death? Third, how does one determine intent?
The majority opinion in Quill1 noted that the intent of the patient and physician often distinguishes appropriate from inappropriate actions. "Intent or purpose is traditionally used by the law to distinguish between two acts that have the same result," wrote the Chief Justice William H. Rehnquist.1 Such traditional legal reasoning can also be used to analyze the intention of a physician who knows that death may be hastened by terminal sedation. In the formulation of the Model Penal Code, a physician would act purposely to curtail a patient's life (rather than to relieve pain or respect an informed refusal of treatment) if the physician's "conscious object [was] to cause" the patient's death. The Model Penal Code also distinguishes the mental states of "purpose" and "knowledge."23 The same physician would act "knowingly" if he or she was "aware" that the use of narcotics given in high dosages or the withholding of life-sustaining treatment would hasten death but did not necessarily hope that death would occur. By applying the purpose-knowledge distinction in Quill, the Court, in essence, agreed that physicians who act with knowledge about the effect of terminal sedation differ from physicians who act with the purpose of hastening death. This conclusion is controversial, however. Some have argued that death may be intended rather than foreseen with terminal sedation because death is inevitable.19 It has also been argued that "it is implausible to claim that death is unintended when a patient who wants to die is sedated to the point of coma and intravenous fluids and artificial fluids are withheld."20 We next analyze how understanding the role of intent in the law can help clarify terminal sedation.
How can we determine the intent of a physician who sedates a terminally ill patient and withholds nutrition, hydration, and other life-sustaining treatments? Is the physician merely respecting the decision of the patient to forgo nutrition and hydration? Or is the physician really intending to hasten the patient's death? Physicians and nurses report that they often have both intentions.24 In one study, physicians who ordered sedatives and analgesics while withholding life-sustaining interventions said they they did so to decrease pain in 88% of cases and to hasten death in 36% of cases.25
The law uses objective evidence to measure a person's subjective intent. Physicians cannot simply say that they intended to relieve pain. Their actions must also be consistent with that purpose. In the unlikely event that a physician faced criminal charges for terminal sedation, the physician's intent would be inferred from his or her words and actions in light of the surrounding circumstances.26 The jury cannot assume that a physician intended to hasten death merely because the physician knew that hastening death was a probable consequence of terminal sedation. On the other hand, physicians cannot avoid responsibility simply by saying that their purpose was to treat pain rather than to hasten death. The jury may not believe this assertion if the physician's actions make it improbable. We believe that this approach to intention should be used in ethical and legal deliberations. Physicians who expect their colleagues, patients, and the public to accept their claims that they intended only to relieve suffering must ensure that their actions are consistent with their statements.
What actions are consistent with an intent to relieve suffering but not to hasten death? Informed consent to terminal sedation is essential. In withholding life-sustaining interventions while a patient is terminally sedated, physicians claim that they are not killing the patient, but rather respecting the patient's informed refusal of interventions, such as tube feedings or antibiotics. This claim makes sense only if the physician has discussed foregoing these interventions explicitly with the patient and the patient has consented. Since death is a certain outcome of heavy sedation if fluids and nutrition are withheld, patients and surrogates should understand this explicitly. Yet anecdotal reports suggest that terminal sedation is often initiated without explicit discussion that other interventions will be withheld.13
What increases in the dosage of analgesics and sedatives are consistent with an intent to relieve pain? If patients are unconscious or otherwise unable to report pain, physicians and nurses assess whether patients are comfortable and whether the rate of infusion should be increased. Family members or health care workers, who say they cannot be certain that the patient is not suffering, sometimes ask that the morphine dosage be increased even though a patient is unconscious and appears comfortable. In other cases, caregivers cannot understand why the dying process needs to be drawn out. However, if the physician intends only to palliate suffering, there is no warrant for increasing the morphine dosage when the patient appears comfortable by sound clinical judgment.
There are generally accepted guidelines for assessing whether an unconscious surgical patient under general anesthesia is experiencing pain. We suggest similar clinical guidelines for increasing the dosage of terminal sedation. The dosage should be increased if the patient is restless or grimaces, withdraws from touch and other stimuli, has hypertension, tachycardia, or tachypnea, or has any other findings that could reasonably be interpreted as suffering. However, if the patient appears comfortable and has none of these responses or findings, it is not appropriate to increase the dosage of sedation. Increasing sedation in the latter situation would imply that the physician intended to hasten death and would cross the line from terminal sedation to active euthanasia.
We think that these guidelines answer many of the criticisms leveled at the Supreme Court's implicit acceptance of terminal sedation. Orentlicher21 believes that the Supreme Court's ruling undermines the distinction between withdrawal of life-sustaining treatment and euthanasia because he considers terminal sedation "a form of euthanasia." According to Orentlicher, "it is the physician-created state of diminished consciousness that renders the patient unable to eat, not the patient's underlying disease."21 However, the key ethical issue is whether the patient or surrogate consented to the withholding of artificial nutrition, not what caused the patient not to eat. Orentlicher also fears that terminal sedation may be misapplied or abused and that informed consent may be inadequate. Such problems clearly exist, but can be solved by careful clinical safeguards, with particular attention to informed consent.20 We acknowledge that it is difficult to prove intent and that, in any case, human actions may have multiple intentions. That intention is difficult to analyze in tough cases does not mean that it should be rejected altogether. If ethicists reject the importance of intent, they may jeopardize terminal sedation as a means to relieve refractory suffering that is legal in every state.
IMPLICATIONS FOR THE DEFINITION OF SUFFERING
Physicians are ethically obligated to relieve suffering. Suffering means many things in terminal illness. The justices generally equated "suffering" with pain when discussing terminally ill patients' interest in avoiding unnecessary suffering. Justice O'Connor refers to "great pain." Justice Breyer limited his definition of suffering to actual "physical pain." In fact, his opinion mentions "severe physical pain connected with death" as "an essential part of" that "combination of personal control . . . professional medical assistance, and the avoidance of . . . suffering" that might be called "a right to die with dignity." However, in addition to suffering from physical pain, dying patients can suffer from other physical symptoms, as well as spiritual and mental anguish caused by isolation, abandonment, or a loss of control.27 Justice John Paul Stevens' opinion sees suffering in these broader terms; he appears to support a definition of suffering that includes affronts to personal dignity and emotional trauma. For example, he argued that the interest at issue in the assisted suicide cases included "determining the character of the memories that will survive long after [the patient's] death." As such, he found constitutional support for a liberty interest that preserves a "dying patient's dignity and alleviates intolerable suffering."
Terminally ill patients commonly suffer a variety of physical symptoms other than pain, including shortness of breath and fatigue. Some suffering, such as shortness of breath, can be palliated effectively with sedatives and narcotics, provided that dosages that lead to unconsciousness or even hasten death are permitted if necessary.28 We believe the Court's acceptance of the double-effect doctrine, combined with the reasoning of the concurring justices, would distinguish physician-assisted suicide from high doses of medication for suffering such as refractory dyspnea.
Two types of suffering, however, raise ethical dilemmas that the rulings do not address. First, a few terminally ill patients have symptoms that cannot be effectively relieved, even by optimal palliative care. For example, some patients with cancer of the esophagus or head and neck cannot swallow their secretions; some patients with acquired immunodeficency syndrome suffer refractory diarrhea, and some patients with cancer experience intractable bleeding due to disseminated intravascular coagulation. Such patients can be sedated so that they are no longer conscious of their symptoms, but they will not have dignified or peaceful deaths. Furthermore, because sedation for these patients does not address pain, these situations may not be covered by the doctrine of double effect as the Supreme Court construed it.1 However, as Justice Stevens suggests, if suffering includes the "indignity of living one's final days incapacitated" or being forced to die in a way that "demeans [one's] values and poisons memories," these patients still suffer even while sedated.
A second group of terminally ill patients believes that their dignity and integrity would be undermined if they had to spend their final days unconscious to obtain relief from refractory suffering. These patients also raise ethical dilemmas. Many competent, terminally ill patients request physician-assisted suicide because they believe that their life is unacceptably undignified, not because of intractable pain.29
Some physicians believe that these 2 types of cases present strong arguments for physician-assisted suicide. Others believe that suicide assistance motivated by compassion for suffering will put physicians on a slippery slope. In the ongoing public discussion that the Supreme Court anticipated, a crucial issue will be whether it is possible to permit physician-assisted suicide in rare, compelling cases without opening the door to abuses.
SUMMARY
The Supreme Court noted that "Americans are engaged in an earnest and profound debate about the morality, legality, and practicality of physician-assisted suicide."2 The decisions in Quill and Glucksberg1-2 may help shift the focus of that debate to palliative care. The Supreme Court held that states may distinguish between physician-assisted suicide and palliative care, even if such care caused unconsciousness or hastened death. Physicians must put into practice the Court's approval of intensive palliative care. In suggesting a right to palliative care, Justice Breyer noted that the major barriers to effective palliation for the dying are institutional and professional rather than legal.2 Any right to palliative care depends on physicians and nurses to implement it in clinically appropriate ways. Physicians should assure that terminal sedation is carried out in ways that are consistent with the intent to relieving suffering. They also should identify and address palliative care issues that are not readily apparent to lay people, such as assessing suffering in sedated patients and responding to suffering in incompetent patients. The Supreme Court has removed any constitutional barrier to palliative care; the medical profession bears responsibility for making universally excellent palliative care a clinical reality.
AUTHOR INFORMATION
Accepted for publication May 28, 1998.
This study was supported in part by the Robert Wood Johnson Foundation, Princeton, NJ, and center grant MH42459 from the National Institute of Mental Health, Bethesda, Md.
We thank Meir S. Feder, JD; Stephen J. McPhee, MD; John M. Luce, MD; and Steven Z. Pantilat, MD, for their helpful comments on earlier drafts of the manuscript.
Ms Alpers is a Mayday Faculty Scholar through the American Society of Law, Medicine & Ethics, Boston, Mass.
Corresponding author: Ann Alpers, JD, Room C 126, 521 Parnassus Ave, San Francisco, CA 94143-0903 (e-mail: anna{at}medicine.ucsf.edu).
From the Program in Medical Ethics, the Center for AIDS Prevention Studies, and the Division of General Internal Medicine, University of California, San Francisco.
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