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PREFACE
Governor Mario M. Cuomo convened the Task Force on Life and the Law in
1984, giving it a broad mandate to recommend public policy on issues
raised by medical advances. That mandate included decisions about
life-sustaining treatment. Assisted suicide and euthanasia were not on
the agenda initially presented to the Task Force. Nor was the prospect of
legalizing the practices even remotely part of public consideration at
that time.
Recently, however, public debate about the practices has intensified.
Although no major efforts to legalize assisted suicide and euthanasia have
been launched in New York State, we chose to examine the practices and to
release this report in order to contribute to the debate unfolding in New
York and nationally.
Since the Task Force's inception, we have proposed four laws to
promote the right to decide about medical treatment, including
life sustaining measures. Three of those proposals, establishing proce-
dures for do-not-resuscitate orders in health care facilities and in
community settings, and authorizing individuals to create health care
proxies, are now law. Our fourth proposal for legislation is pending
before the New York State Legislature. It would grant family members and
others close to the patient the authority to decide about treatment,
including life-sustaining measures, for individuals who are too young or
too ill to decide for themselves and who have not left advance treatment
instructions or signed a health care proxy.
In this report, we unanimously recommend that New York laws
prohibiting assisted suicide and euthanasia should not be changed. In
essence, we propose a clear line for public policies and medical practice
between forgoing medical interventions and assistance to commit suicide or
euthanasia. Decisions to forgo treatment are an integral part of medical
practice; the use of many treatments would be inconceivable without the
ability to withhold or to stop the treatments in appropriate cases. We
have identified the wishes and interests of patients as the primary
guideposts for those decisions.
Assisted suicide and euthanasia would carry us into new terrain
American society has never sanctioned assisted suicide or mercy killing.
We believe that the practices would be profoundly dangerous for large
segments of the population, especially in light of the widespread
failure of American medicine to treat pain adequately or to diagnose
and treat depression in many cases. The risks would extend to all
individuals who are ill. They would be most severe for those whose
autonomy and well-being are already compromised by poverty, lack of access
to good medical care, or membership in a stigmatized social group. The
risks of legalizing assisted suicide and euthanasia for these individuals,
in a health care system and society that cannot effectively protect
against the impact of inadequate resources and ingrained social
disadvantage, are likely to be extraordinary.
The distinction between the refusal of medical treatment and assisted
suicide or euthanasia has not been well-articulated in the broader public
debate. In fact, the often-used rubric of the "right to die" obscures the
distinction. The media's coverage of individual cases as a way of
presenting the issues to the public also blurs the difference between a
private act and public policy; between what individuals might find
desirable or feasible in a particular case and what would actually occur
in doctors' offices, clinics, and hospitals, if assisted suicide and
euthanasia became a standard part of medical practice. Public opinion
polls, focusing on whether individuals think they might want these options
for themselves one day, also offer little insight about what it would mean
for society to make assisted suicide or direct killing practices
sanctioned and regulated by the state or supervised by the medical
profession itself.
We hope that this report will highlight certain critical distinctions
and questions for public consideration. We also hope that the report and
our recommendations will improve access to pain relief and the palliation
of symptoms, not only for those who are terminally ill or contemplating
suicide, but for all patients.
We sought the opinions and expertise of many individuals while
developing our recommendations. We extend our gratitude to all those who
generously lent their time and perspective to our discussion. Four
individuals served as consultants in our deliberations: Nessa Coyle,
R.N., Jimmie Holland, M.D., Diane Meier, M.D., and Norton Spritz, M.D. The
report does not necessarily reflect their personal views about assisted
suicide and euthanasia, but it does reflect their experience and insight
in caring for those who are severely and terminally ill. We benefitted
greatly from their expertise and their participation with us as we
explored these difficult questions. We also extend our gratitude to Chris
Hyman and Peter Millock who provided invaluable guidance throughout our
deliberations.
The Members of the Task Force on Life and the Law
***********************************************
WHEN DEATH IS SOUGHT -- ASSISTED SUICIDE AND
EUTHANASIA IN THE MEDICAL CONTEXT
EXECUTIVE SUMMARY
Over the past two decades, the right to decide about medical treatment,
including the right to refuse life-sustaining measures, has become a
fundamental tenet of American law. The Task Force has sought to make this
right a reality for the citizens of New York State, recommending legislation
on do-not-resuscitate orders, health care proxies, and, most recently,
surrogate decision making for patients without capacity. The Task Force's
legislative proposals reflect a deep respect for individual autonomy as
well as concern for the welfare of individuals nearing the end of life.
Recent proposals to legalize assisted suicide and euthanasia in some
states would transform the right to decide about medical treatment into a
far broader right to control the timing and manner of death. After lengthy
deliberations, the Task Force unanimously concluded that the dangers of
such a dramatic change in public policy would far outweigh any possible
benefits. In light of the pervasive failure of our health care system to
treat pain and diagnose and treat depression, legalizing assisted suicide
and euthanasia would be profoundly dangerous for many individuals who are ill
and vulnerable. The risks would be most severe for those who are elderly,
poor, socially disadvantaged, or without access to good medical care.
In the course of their research, many Task Force members were particularly
struck by the degree to which requests for suicide assistance by terminally
ill patients are correlated with clinical depression or unmanaged pain, both
of which can ordinarily be treated effectively with current medical
techniques. As a society, we can do far more to benefit these patients by
improving pain relief and palliative care than by changing the law to make
it easier to commit suicide or to obtain a lethal injection.
IN GENERAL
* This report, like much of the current debate, focuses solely on assisted
suicide and euthanasia by physicians, nurses, or other health care
professionals.
* In this report, "assisted suicide" refers to actions by one person to
contribute to the death of another, by providing medication or a
prescription or taking other steps. With assisted suicide, the person
who dies directly takes his or her own life. In contrast, "euthanasia"
refers to direct measures, such as a lethal injection, by one person to
end another person's life for benevolent motives. Both practices are
distinct from the withdrawal or withholding of life-sustaining treatment
in accord with accepted ethical and medical standards.
THE CLINICAL BACKGROUND
* Contrary to what many believe, the vast majority of individuals who are
terminally ill or facing severe pain or disability are not suicidal.
Moreover, terminally ill patients who do desire suicide or euthanasia
often suffer from a treatable mental disorder, most commonly
depression. When these patients receive appropriate treatment for
depression, they usually abandon the wish to commit suicide.
* Depression is distinct from the normal feelings of sadness generally
experienced by terminally ill patients. It is a myth that major
clinical depression ordinarily accompanies terminal illness.
* While thoughts about suicide ("suicidal ideation") are a significant
risk factor for suicide, many individuals experience suicidal ideation
but never commit or attempt suicide. These thoughts can be an important
and normal component of coping with terminal illness.
* Uncontrolled pain, particularly when accompanied by feelings of
hopelessness and untreated depression, is a significant contributing
factor for suicide and suicidal ideation. Medications and pain relief
techniques now make it possible to treat pain effectively for most
patients.
* Despite the fact that effective treatments are available, severely and
terminally ill patients generally do not receive adequate relief from
pain. Studies report that over 50 percent of cancer patients suffer
from unrelieved pain, even though patients wit h cancer are more likely
than other patients to receive pain treatment.
* Numerous barriers contribute to the pervasive inadequacy of pain relief
and palliative care in current clinical practice, including a lack of
professional knowledge and training, unjustified fears about physical
and psychological dependence, poor pain assessment, pharmacy practices,
and the reluctance of patients and their families to seek pain relief.
EXISTING LAW
* Under New York law, competent adults have a firmly established right to
accept or reject medical treatment, including life-sustaining measures.
Competent adults also have the right to create advance directives for
treatment decisions, such as a living will or health care proxy, to be
used in the event they lose the capacity to make medical decisions for
themselves.
* New York is one of two states in the nation that does not currently
permit the withdrawal or withholding of life-sustaining treatment from
an incapacitated adult patient who has not signed a health care proxy or
provided clear and convincing evidence of h is or her treatment wishes.
Legislation proposed by the Task Force, under consideration by the New
York State Legislature, would permit family members and others close to
the patient to decide about life-sustaining treatment in these
circumstances.
* Neither suicide nor attempted suicide is a criminal offense in any
state. Like most other states, New York prohibits assisting a suicide.
Euthanasia is barred by law in every state, including New York.
* Suicide assistance generally constitutes a form of second-degree
manslaughter under New York law. Euthanasia falls under the definition
of second-degree murder, regardless of whether the person consents to
being killed.
* The provision of pain medication is legally acceptable even if it may
hasten the patient's death, if the medication is intended to alleviate
pain or severe discomfort, not to cause death, and is provided in accord
with accepted medical standards.
* Neither the United States nor the New York State Constitution grants
individuals a "right" to suicide assistance or euthanasia. Although the
right to refuse life-sustaining treatment is constitutionally protected,
the courts have consistently distinguished the right to refuse
treatment from a right to commit suicide. In affirming the right to
forgo treatment, the courts have recognized the state's legitimate
interest in preventing suicide.
ETHICAL ISSUES
* Three general positions about assisted suicide and euthanasia have
emerged in the ethical and medical literature. First, some believe that
both practices are morally wrong and should not be performed. Others
hold that assisted suicide or euthanasia are legitimate in rare and
exceptional cases, but that professional standards and the law should
not be changed to authorize either practice. Finally, some argue that
assisted suicide, or both assisted suicide and euthanasia, should be
recognized as legally and morally acceptable options in the care of
dying or severely ill patients.
* While many individuals do not distinguish between assisted suicide and
euthanasia on ethical or policy grounds, some find assisted suicide more
acceptable than euthanasia, either intrinsically or because of
differences in the social impact and potential h arm of the two
practices.
THE TASK FORCE'S RECOMMENDATIONS: CRAFTING PUBLIC POLICY
THE ETHICS OF ASSISTED SUICIDE AND EUTHANASIA
* The members of the Task Force hold different views about the ethical
acceptability of assisted suicide and euthanasia. Despite these
differences, the Task Force members unanimously recommend that existing
law should not be changed to permit these practice s.
* Some of the Task Force members believe that assisted suicide and
euthanasia are inherently wrong, because the practices violate society's
long-standing prohibition against ending human life. These members
believe that one person should not assist another' s death or kill
another person, even for benevolent motives.
* Other Task Force members are most troubled by the prospect of
medicalizing the practices. They believe that physician-assisted
suicide and euthanasia violate values that are fundamental to the
practice of medicine and the patient-physician relationship.
* Some Task Force members do not believe that assisted suicide is
inherently unethical or incompatible with medical practice. On the
contrary, they believe that providing a quick, less prolonged death for
some patients can respect the autonomy of patients and demonstrate care
and commitment on the part of physicians or other health care
professionals. Nonetheless, these members have concluded that
legalizing assisted suicide would be unwise and dangerous public policy.
THE SOCIAL RISKS OF LEGALIZATION
* The Task Force members unanimously concluded that legalizing assisted
suicide and euthanasia would pose profound risks to many patients. For
purposes of public debate, one can describe cases of assisted suicide in
which all the recommended safeguards would be satisfied. But positing
an "ideal" or "good" case is not sufficient for public policy, if it
bears little relation to prevalent social and medical practices.
* No matter how carefully any guidelines are framed, assisted suicide and
euthanasia will be practiced through the prism of social inequality and
bias that characterizes the delivery of services in all segments of our
society, including health care. The practices will pose the greatest
risks to those who are poor, elderly, members of a minority group, or
without access to good medical care.
* The growing concern about health care costs increases the risks
presented by legalizing assisted suicide and euthanasia. This cost
consciousness will not be diminished, and may well be exacerbated, by
health care reform.
* The clinical safeguards that have been proposed to prevent abuse and
errors would not be realized in many cases. For example, most doctors
do not have a long-standing relationship with their patients or
information about the complex personal factors relevant to evaluating a
request for suicide assistance or a lethal injection. In addition,
neither treatment for pain nor the diagnosis of and treatment for
depression is widely available in clinical practice.
* In debating public policies, our society often focuses on dramatic
individual cases. With assisted suicide and euthanasia, this approach
obscures the impact of what it would mean for the state to sanction
assisted suicide or direct killing under the auspices of the medical
community.
* From the perspective of good health, many individuals may believe that
they would opt for suicide or euthanasia rather than endure a vastly
diminished quality of life. Yet, once patients are confronted with
illness, continued life often becomes more precious; given access to
appropriate relief from pain and other debilitating symptoms, many of
those who consider suicide during the course of a terminal illness
abandon their desire for a quicker death in favor of a longer life made
more tolerable with effective treatment.
* The Task Force members feel deep compassion for patients in those rare
cases when pain cannot be alleviated even with aggressive palliative
care. They also recognize that the desire for control at life's end is
widely shared and deeply felt. As a society, however, we have better
ways to give people greater control and relief from suffering than by
legalizing assisted suicide and euthanasia.
* Depression accompanied by feelings of hopelessness is the strongest
predictor of suicide for both individuals who are terminally ill and
those who are not. Most doctors, however, are not trained to diagnose
depression, especially in complex cases such as patients who are
terminally ill. Even if diagnosed, depression is often not treated. In
elderly patients as well as the terminally and chronically ill,
depression is grossly underdiagnosed and undertreated.
* The presence of unrelieved pain also increases susceptibility to
suicide. The undertreatment of pain is a widespread failure of current
medical practice, with far-reaching implications for proposals to
legalize assisted suicide and euthanasia.
* If assisted suicide and euthanasia are legalized, it will blunt our
perception of what it means for one individual to assist another to
commit suicide or to take another person's life. Over time, as the
practices are incorporated into the standard arsenal of medical
treatments, the sense of gravity about the practices would dissipate.
* The criteria and safeguards that have been proposed for assisted suicide
and euthanasia would prove elastic in clinical practice and in law.
Policies limiting suicide to the terminally ill, for example, would be
inconsistent with the notion that suicide i s a compassionate choice for
patients who are in pain or suffering. As long as the policies hinge on
notions of pain or suffering, they are uncontainable; neither pain nor
suffering can be gauged objectively, nor are they subject to the kind of
judgments needed to fashion coherent public policy. Euthanasia to cover
those who are incapable of consenting would also be a likely, if not
inevitable, extension of any policy permitting the practice for those
who can consent.
* These concerns are heightened by experience in the Netherlands, where
the practices have been legally sanctioned. Although Dutch law requires
an explicit request for euthanasia by the patient, a national study in
the Netherlands found that of approximately 3300 deaths annually
resulting from mercy killing, l,000 deaths from euthanasia occurred
without an explicit request. Moreover, in some cases, doctors have
provided assisted suicide in response to suffering caused solely by
psychiatric illness, including severe depression.
CARING FOR SEVERELY ILL PATIENTS
* Professional medical standards should recognize the provision of
effective pain relief and palliative care, including treatment for
depression or referral for treatment, as a basic obligation all
physicians owe to their patients. The legal prohibition age inst
assisted suicide and euthanasia should also guide professional standards
of conduct.
* Physicians should seek their patients' participation in decisions about
withdrawing or withholding life-sustaining treatment early enough in the
course of illness to give patients a meaningful opportunity to have
their wishes and values respected.
* Health care professionals have a duty to offer effective pain relief and
symptom palliation to patients when necessary, in accord with sound
medical judgment and the most advanced approaches available.
* New York State statutes and regulations should be modified to increase
the availability of medically necessary analgesic medications, including
opioids. This should be done in a balanced manner that acknowledges the
importance of avoiding drug diversion. Chapter 8 sets forth specific
recommendations for legal reform.
* Physicians, nurses, and patients must be aware that psychological and
physical dependence on pain medication are distinct phenomena. Contrary
to a widely shared misunderstanding, psychological dependence on pain
medication rarely occurs in terminally ill patients. While physical
dependence is more common, proper adjustment of medication can minimize
negative effects.
* The provision of appropriate pain relief rarely poses a serious risk of
respiratory depression. Moreover, the provision of pain medication is
ethically and professionally acceptable even when such treatment may
hasten the patient's death, if the medication is intended to alleviate
pain and severe discomfort, not to cause death, and is provided in
accord with accepted medical practice.
* The education of health care professionals about pain relief and
palliative care must be improved. Training in pain relief and
palliative care should be included in the curriculum of nursing schools,
medical schools, residencies, and continuing education for health care
professionals.
* Hospitals and other health care institutions should explore ways to
promote effective pain relief and palliative care, and to remove
existing barriers to such care.
* Public education is crucial to enhance pain relief practices. Like many
health care professionals, patients and families often have an
exaggerated sense of the risks of pain medication, and are reluctant to
seek treatment for pain. Nurses and physicians should create an
atmosphere that will encourage patients to seek relief of pain.
Strategies for pain relief should also maximize patients' sense of
control.
* Insurance companies and others responsible for health care financing
should promote effective pain and symptom management and address
barriers that exist for some patients.
* Health care professionals should be familiar with the characteristics of
major depression and other common psychiatric illnesses, as well as the
possibility for treatment. Major clinical depression is generally
treatable, and can be treated effectively even in the absence of
improvement in the underlying disease. Patients should also receive
appropriate treatment for less severe depression that often accompanies
terminal illness.
* Physicians should create an atmosphere within which patients feel
comfortable expressing suicidal thoughts. Discussion with a physician
or other health care professional about suicide can identify the need
for treatment and make the patient feel less isolated. This discussion
does not prompt suicide; on the contrary, talking with health care
professionals often decreases the risk of suicide.
* When a patient requests assisted suicide or euthanasia, a health care
professional should explore the significance of the request, recognize
the patient's suffering, and seek to discover the factors leading to the
request. These factors may include insufficient symptom control,
clinical depression, inadequate social support, concern about burdening
family or others, hopelessness, loss of self-esteem, or fear of
abandonment.
INTRODUCTION page 1
Respect for individual choice and self-determination has
served as a touchstone for public policies about medical decisions
over the past two decades. Designed to promote these values, legal
reform has wrought many gains, including clear recognition of a
right to refuse life-sustaining measures. Social and clinical
practices, however, have changed more slowly, often leaving patients
and those close to them without a sense of control over the course
of treatment. As a result, the public's fear of a painful death
prolonged by medical advances has not abated. This growing public
concern about control at life's end and the emphasis on individual
self-determination have brought us to a new crossroads in the realm
of medical practice and ethics. For the first time in the United
States, assisted suicide and euthanasia are issues of serious and
widespread public consideration.
Assisted suicide occurs when one person assists another to
take his or her own life, either by providing the means to commit
suicide or by taking other necessary steps. Euthanasia entails
direct measures, such as a lethal injection, by one person to end
another person's life. Euthanasia may be voluntary, performed with
the explicit consent of a competent adult, or it can be performed
without consent, in which case it is usually called "nonvoluntary"
euthanasia. Euthanasia provided over the patient's objection is
generally referred to as "involuntary" euthanasia. Both assisted
suicide and euthanasia are distinct from the withdrawal or
withholding of life-sustaining treatment.(1)
While assisted suicide and euthanasia can be offered outside
the medical context by family members or others, recent debate has
focused on these practices by physicians and other health care
professionals. Assisted suicide in the medical context is usually
provided by giving a prescription or medications to a patient
seeking to end his or her life. A lethal injection would be the
most common form of euthanasia provided by doctors.
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(1) Same use the term "euthanasia" or "passive euthanasia" to
include the wrongful or inappropriate withholding or
withdrawal of life- sustaining treatment. This report, like
much of the current debate, uses the term "euthanasia" more
narrowly, referring only to active measures, such as a lethal
injection, to end the patient's life. The Task Force
recognizes that defining the term in this way clarifies its
own intentions, but does not address the complex relationship
between action, omission and moral culpability. For a
discussion of this issue, see chapter 5, pp. 82-93.
page 2 WHEN DEATH IS SOUGHT
Several prominent cases have spurred debate about
physician-assisted suicide and euthanasia. In 1988, in an anonymous
article in the Journal of the American Medical Association, a
physician described how he had given a lethal injection to a young
woman dying of ovarian cancer.(2) The physician had no prior
relationship with the patient and had not discussed the decision
with her. Instead, he decided to provide the lethal injection based
on her mumbled words, "Let's get this over with."
On June 4, 1993, Dr. Jack Kevorkian helped Janet Adkins
commit suicide in a Volkswagen van in a Michigan park. Janet Adkins
was 54 years old and still physically active but was experiencing
the early symptoms of Alzheimer's disease. Kevorkian used a machine
he developed that delivered a fatal dose of potassium chloride when
Janet Adkins pushed a button. Nineteen other highly publicized
deaths have followed with Kevorkian's assistance. Kevorkian has had
little previous contact with the patients he assists, many of whom,
like Janet Adkins, were not terminally ill. A retired pathologist,
it is likely that he has little or no experience in diagnosing
depression or treating terminally ill patients. Although some
regard Kevorkian as a champion for human rights, he has crystallized
the doubts of many about the potential for abuse and the dangers of
physician-assisted suicide.
In contrast to Kevorkian, Dr. Timothy Quill had a
long-standing relationship with the patient whose death he assisted.
Writing about the case in the New England Journal of Medicine in
March 1991, Quill explained that he had offered all available
medical alternatives to his patient, encouraged her to accept
treatment for her condition, and spoke with her at length about her
decision before prescribing the barbiturates that would enable her
to take her own life.(3)
In February 1993, the Netherlands became the first nation to
establish policies permitting doctors to assist a suicide or to
perform voluntary euthanasia. Under Dutch law, physicians cannot be
prosecuted for either practice if they follow specified guidelines
and report their actions to the coroner in each case. Although
assisted suicide and voluntary euthanasia are both legally
sanctioned, 85 percent of these cases have been instances of
euthanasia. Policies in the Netherlands emerged from growing
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(2) "It's Over, Debbie," Journal of the American Medical
Association 259 (1988): 272. It remains unclear whether
this anonymous article described a fictitious or an actual
case.
(3) T. E. Quill, "Death and Dignity: A Case of
Individualized Decision Making," New England Journal of
Medicine 324 (1991): 691-94.
INTRODUCTION page 3
acceptance of the practice by physicians, and the long-standing
reluctance of prosecutors to enforce the law prohibiting assisted
suicide and euthanasia.
In the United States, legislative referenda to legalize the
practices have been considered in several states. In November 1991,
Washington State voted on a referendum to legalize "physician
aid-in-dying" -- defined to include both assisted suicide and
euthanasia. The referendum failed with 54 percent of the public
voting against it. If it had passed, Washington would have become
the first state in the nation to legalize these activities by
physicians or others. In November 1992, voters in California
defeated a similar referendum by the same narrow margin. These
votes will no doubt encourage attempts to legalize assisted suicide
and euthanasia in other states. At the same time, publicity about
Kevorkian and public debate about the practices have prompted other
states to strengthen or clarify their laws prohibiting assisted
suicide. Four states, including Michigan, enacted laws in 1993 to
achieve this goal.(4)
Like the referenda in Washington and California, public
opinion polls suggest that the public in the United States is
divided on the question of legalizing assisted suicide and
euthanasia. The widespread success of the book Final Exit, a how-to
on committing suicide, left no doubt, however, that some segment of
the public is deeply concerned about the dying process.(5) A best
seller for many months, the book tapped into a well-spring of
anxiety about the loss of control at life's end. The book's
popularity is a clarion call, signaling that existing social and
clinical practices do not give Americans the sense of control they
desire.
The need to make decisions about the dying process and the
failure to manage technological advances more wisely has also
profoundly influenced some segments of the medical profession. For
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(4) Under the Michigan law, the statutory prohibition on
assisted suicide will expire no later than December 31, 1994.
The law established a commission to study the issue and
recommend whether the prohibition should be continued,
modified, or abandoned.
(5) The full title of the book is Final Exit: The
Practicalities of Self-Deliverance and Assisted Suicide for
the Dying. It was written by Derek Humphrey, the founder of
the Hemlock Society. A study reported in the New England
Journal of Medicine about the book's impact concluded that,
although the overall suicide rate in New York City had not
changed following the book's publication, suicide by
asphyxiation using a plastic bag, one of the methods
recommended in the book, had increased. Of the 15
individuals reported to have used the book to commit suicide,
most were not terminally ill and six had no history of
medical illness or diagnosed illness at autopsy. P. M.
Marzuk et al., "Increase in Suicide by Asphyxiation in New
York City After the Publication of Final Exit," New England
Journal of Medicine 329 (1993): 1508-10.
page 4 WHEN DEATH IS SOUGHT
physicians, decisions to withhold or to stop treatment, calling for
their intervention in the timing and manner of death, have become
routine. While earlier generations of physicians were trained to
stave off death whenever possible and had few available means at
their disposal to do so, physicians today, especially those who are
younger, have grown accustomed to the idea that life inappropriately
prolonged can also be a defeat for them and for their patients.
The medical community, like the broader society, has therefore
reached a crossroads, with some physicians advocating legal change
that would permit them to assist their patients to commit suicide
under certain circumstances. Despite the fact that assisted suicide
is illegal in most states and euthanasia is prohibited throughout
the United States, press reports and polls suggest that some
physicians already respond to their patients' requests for help by
prescribing medication or providing a lethal injection. The
practice occurs in the private relationship between doctor and
patient, yielding little public information about the frequency or
circumstances of medically assisted suicide or euthanasia.
In New York State, no serious effort to legalize assisted
suicide or euthanasia is underway. New York's criminal law
prohibits both practices.(6) The health care proxy law, enacted in
1990 to give adults an effective way to exercise the right to decide
about treatment, including life-sustaining measures, explicitly
states that it is not designed to permit or promote assisted suicide
or euthanasia.(7) Pending legislation proposed by the Task Force,
which would allow family members and others close to the patient to
decide about treatment for incapacitated patients who have not
signed health care proxies, contains a similar statement.(8) Hence,
like the law in states across the country, New York law to date has
consistently distinguished decisions to forgo life-sustaining
treatment from assisted suicide and euthanasia.
The issue of assisted suicide has been posed most directly in
New York State by the case involving Dr. Timothy Quill. A resident
of Rochester, New York, Quill faced potential criminal and
professional sanctions following publication of his article in the
New England Journal of Medicine. A grand jury was convened in
Rochester and decided not to indict him. Likewise, the State Board
for Professional Medical Conduct considered the case and chose not
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(6) N.Y. Penal law 120.30,120.35,12,5.15(3),12,5.25(l)
(McVinney 1987). See chapter 4 for discussion of New York
law.
(7) N.Y. Public Health law, Sec. 2989(3) (McKinney 1993).
(8) New York State Assembly Bill No. 7166, Sec. 2995-q(3) (1994).
INTRODUCTION page 5
to pursue professional misconduct charges. Writing for the board, a
three member panel concluded that Quill could not have known with
certainty that his patient would use the medication he prescribed
for insomnia to kill herself. In its opinion in the Quill case, the
board recognized the important moral and social issues presented by
the case and asked the Task Force on Life and the Law to provide
guidance for policies in New York State. The Task Force agreed to
deliberate about assisted suicide and euthanasia not because of the
Quill case itself, but because the case struck a public nerve,
echoing broad public concern about the practices.
This report reflects the Task Force's exploration of medically
assisted suicide and euthanasia. It examines the clinical, legal,
and social context for the current debate about the practices.
Presented in the first half of the report, that information includes
important insight about the problem of suicide generally, the
reasons that people commit suicide, the capacity of medicine to
respond to some of those underlying reasons, and its widespread
failure to do so. Chapter Four examines in-depth the law on
assisted suicide and euthanasia and the relationship of that body of
law to prevailing medical standards. The chapter also discusses
whether there is a constitutional right to suicide assistance and
euthanasia. Chapter Five sketches the current debate about assisted
suicide and euthanasia, exploring the ethical arguments set forth by
those who advocate legalizing assisted suicide and euthanasia as
well as by those who firmly oppose any such legal change.
The second half of the report presents the Task Force's
recommendations for public policy. Those recommendations first
address whether the law should be changed to permit assisted suicide
and euthanasia. The report also describes the principles that
should animate professional medical standards. In the final
chapter, the report proposes policies to enhance the treatment
provided to dying and incurably ill patients. The debate about
assisted suicide and euthanasia has forced a reexamination of the
care provided to terminally and chronically ill individuals; it has
highlighted pervasive shortcomings in the clinical response to pain,
to suffering arising from treatable causes such as clinical
depression, and to requests for suicide assistance. The final
chapter of the report proposes specific statutory and regulatory
steps to improve access to pain relief, and provides recommendations
for clinical practice.
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(Pages 6,7,8 Intentionally left blank)
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