To the Editor:

Attorney Kathryn Tucker’s1 guidance in an issue of CHEST (July 2012) for physician aid in dying is troubling. A citation error was apparent in a reference to the Expert Consensus Statement of the Heart Rhythm Society (HRS) regarding withdrawal of cardiovascular implantable electronic devices (CIEDs).2 Tucker1 wrote, “Provision of aid in dying does not constitute assisting a suicide or euthanasia.” The HRS statement reads, “Ethically, CIED deactivation is neither physician-assisted suicide nor euthanasia.”2

CIED deactivation is not aid in dying, and the HRS statement said why: “The clinician’s intent is to discontinue the unwanted treatment and allow the patient to die naturally of the underlying disease – not to terminate the patient’s life.”2 This reaffirms a half-century of understanding in medical ethics that withdrawal of undesired care is just that and not aid in dying.

Per Tucker,1 “Principles of autonomy that underlie respecting patient rights…to request pain medication even if it advances time of death support the choice for aid in dying.” Providing medication doses that might hasten death is not equivalent to giving them because they will do so. Even autonomy has its limits.

Tucker1 again appears to misapply the HRS CIED statement, “A clinician cannot be compelled to provide treatment that conflicts with his or her personal values. In these circumstances, the clinician cannot abandon the patient but should refer the patient to a colleague who is willing to provide the service.”1 The issue was CIED removal. Refusal to aid a suicide request is not abandonment, and referral for it is morally equivalent to providing the aid in dying. Requiring it violates three federal statutes protecting conscience rights.

Tucker1 asserted, “Modern medicine can extend the dying process so long that some terminally ill patients may find the process unbearable.” The reality of aid in dying scenarios is rarely this dramatic, and exceptional cases make for bad guidelines. The claim of unbearable process refutes futile care rather than arguing for aid in dying, and futile care is preventable under existing guidelines by patients and their surrogates without violating any profession, legal, or moral precepts.

Compassion means to come alongside and suffer with, not to aid patients in self-cessation. Terminal patients have well-defined needs: Treat depression, loneliness, and pain, and death wishes abate. Palliative care and aid in dying are at odds: A clinician cannot be both patient advocate and assistant in dying. The conflict of interest is insurmountable.

References:

Tucker, KL. Aid in dying: guidance for an emerging end-of-life practice. Chest. 2012; 142: 218–224View in Article

Lampert, R, Hayes, DL, Annas, GJ…, American Heart Association, American College of Cardiology, American Geriatrics Society, American Academy of Hospice and Palliative Medicine, European Heart Rhythm Association, and Hospice and Palliative Nurses Association. HRS expert consensus statement on the management of cardiovascular implantable electronic devices (CIEDs) in patients nearing end of life or requesting withdrawal of therapy. Heart Rhythm. 2010; 7: 1008–1026

FULL ARTICLE HERE