A Good Death?

This was the case that the right-to-die movement had been waiting for. In March, a Rochester, New York, physician reported that he had helped a patient with leukemia kill herself by taking an overdose of barbiturates. Dr. Timothy E. Quill's disclosure in The New England Journal of Medicine broke a long-standing taboo against public discussion of what appears to be a fairly common medical practice.

But the response to Quill's article was markedly different from the reaction to the use of Dr. Jack Kevorkian's suicide machine last summer by Janet Adkins, an Oregon woman with Alzheimer's disease. It also contrasted sharply with the controversy raised by "It's Over, Debbie," an anonymous account of active euthanasia that appeared in The Journal of the American Medical Association in 1988.

While those cases provoked much criticism, especially among physicians, Quill's report elicited mostly favorable comments, even from medical ethicists. And while advocates of the right to die saw the impact of the earlier controversies as mixed, they praised Quill unequivocally for helping to advance their cause. "We were pleased to see this man have the courage to say this," Derek Humphry, founder of the Hemlock Society, told the Los Angeles Times. "This case is the archetypal best sort of case."

Humphry may be right from a public relations standpoint. But the differences that distinguish Quill's actions in the public mind are not as important as they night appear. Indeed, focusing on them distracts attention from important questions about the law's approach to suicide and euthanasia.

One red herring is the nature of the doctor/patient relationship. "The difference in the cases is like night and day," George Annas, a Boston University medical ethicist, told the New York Times. He noted that Quill had known his patient, a 45-year-old woman dubbed "Diane," for many years. By contrast, Kevorkian had been in touch with Janet Adkins for only a few weeks prior to her suicide and had first met her the weekend before. And the author of "It's Over, Debbie" was a resident physician on call; his only contact with the patient, who was dying of ovarian cancer, occurred the night he killed her.

Annas also stressed the remoteness of Quill's involvement in his patient's death. After Diane repeatedly told him that she wanted to commit suicide, Quill advised her to seek information from the Hemlock Society. A week later, she called him and asked for sleeping pills. He supplied them, carefully informing her of the soporific and lethal dosages. In the case of Janet Adkins, Kevorkian hooked her up to his suicide apparatus and stood by as she pressed a button to administer a fatal dose of potassium chloride. The physician who treated "Debbie," on the other hand, directly injected her with an overdose of morphine.

These differences matter under the law. While attorneys advised Quill that he probably would not face criminal charges, Kevorkian escaped prosecution only because of a quirk of Michigan law; Debbie's doctor, if he or she could be identified, might well be charged with homicide. Yet the essence of the act was the same in each case, given one crucial condition: the patient's consent.

Pace Annas, a lengthy or close relationship does not guarantee consent; indeed, doctors who know their patients well might be more inclined to make decisions on their behalf. Conversely, a brief, businesslike relationship does not preclude informed consent. The accounts of Janet Adkins's friends and relatives, together with the messages she left and the papers she signed, make it clear that her decision to commit suicide was a thoughtful one.

"It's Over, Debbie" leaves some doubt on this score, since the patient's instructions, as reported, were ambiguous. But if her request had been clear and documented, there would be no reason for legally distinguishing between her case and the other two. Furthermore, although all three cases involved a terminally ill patient, assisted by a doctor, this similarity is not relevant to the question of consent. It's easy for most people to understand why someone faced with the prospect of dying painfully from cancer or of slowly losing her mind to Alzheimer's disease might want to commit suicide. In any case, polls find most Americans believe physicians should be allowed to assist such patients.

But if the law is to respect fundamental rights, it must not inquire into the why and how of suicide. Just as the right to property entails the right to give it away or destroy it, the right to live entails the right to die. The decision of whether to commit or assist a suicide should remain with the individual.

Few people who support a right of suicide would apply it to children, the severely mentally retarded, or someone in the advanced stages of Alzheimer's. But this sort of exception can be carried too far: Suicidal intent in itself should not prove legal incompetence, even when the reason seems irrational or when the person, if stopped, would live to regret the impulse. Mistakes, even fatal ones, are a price of liberty.

Still, defining the limits of the law does not end the moral debate. As Quill put it: "People have a right to commit suicide, but my participation is something I am very conservative about." Accepting another's right to kill himself does not mean that you agree to assist him, or even that you approve. You might still wonder what reasons (if any) are adequate and what role (if any) physicians should play. These are questions that should be thrashed out by doctors, philosophers, and religious leaders. But not by legislators.