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No one knows how often complications occur in the United States. A threatening legal environment, widespread social controversy and an element of medical machismo that equates death with failure conspire to drive physician-assisted suicide underground. But anonymous surveys over the past decade make one thing clear: Although they often don't discuss the matter with colleagues, it is not uncommon for U.

There is no reason to believe that assisted suicide attempts run into fewer complications in this country. In fact, it seems logical to assume that the more open practice in the Netherlands would lead to a greater sharing of information and fewer complications there. The Dutch data raise a haunting question: How often do brutally sick patients who try to end their lives painlessly wind up suffering ugly, violent deaths? In an editorial that accompanied the Dutch study, Nuland argued that organized medicine should attend to physician-assisted death "with the attention to detail that all aspects of medical practice demand.

Better sooner than later.

Within the U. Even in Oregon, the only state where physician-assisted suicide is legal, doctors don't much discuss the how-to's or anything else about the practice. And the universities and professional societies that sponsor continuing education have not been ready to address the clinical practice of physician-assisted dying. Medical literature offers almost no practical advice on the practice.

Doctors are apparently hungry for information.

Death without Dignity

Steven Heilig, director of the Bay Area Network of Ethics Committees, an umbrella organization for the region's hospital ethics committees, recalls a meeting at which two physicians from the Netherlands gave a presentation on the Dutch system of physician-assisted suicide: "Someone asked a clinically specific question -- I think it was about dosage -- and this sea of pens suddenly emerged, poised to write down everything they said.

As a highly controversial yet widely practiced procedure undertaken haphazardly, and below the radar of medical schools and professional associations, assisted suicide invites comparison to abortion in the years before Roe vs. But the present case is unlikely to be settled by judicial fiat: The Supreme Court ruled unanimously in that physician-assisted suicide is not a right protected by the Constitution, and that states should decide the matter. At the same time, the court also reaffirmed the legality of the "double effect" -- the prescription of pain medication that may incidentally hasten a patient's death.

The key distinction is intent: If a physician's intent is to alleviate pain, the act is defended by the Supreme Court; if the intent is to cause death, the court provides no protection. Of course, clinical realities are seldom as clearly defined as legal ones. The theory of the double effect does not accommodate "the ambiguity of clinical intentions," says one physician, who describes his experience of hoping simultaneously to extend his patient's life and aid in her death.

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Many opponents of physician-assisted suicide accept the propriety of the double effect. This is due in large part to growing interest in palliative care, the medical treatment of pain and suffering. Carlos Gomez, director of the palliative care program at the University of Virginia, argues in support of the double effect:.

The furthest reach of palliative care is terminal sedation: drugging a patient into unconsciousness and keeping him that way until he dies, usually days or weeks later. Terminal sedation is practiced openly and without much controversy, and it does not seem to carry a high incidence of complication.

George Annas, professor of health law at Boston University, says the issue is not a question of "suicide or not suicide. The issue is taking care of dying patients. Acute myelofibrosis was the final diagnosis. In a period of mere months, his bone marrow had turned to useless fiber. This is very rare, we were told, at the specialty Philadelphia teaching hospital where I finally brought him, desperate for answers.

How long does he have? Maybe six months. The pain, though, no one could understand. It racked him, left him screaming and shaking. Yet it did. They treated his pain as best they could, but it was never enough.

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It is difficult to describe retrospectively the stages of disbelief, rage, and acceptance he went through. Before he came back from the hospital for what would be his final time, my husband and I cleared the house of his entire gun collection. We feared my father would do something desperate.

Throughout his life he would say that if he ever had a serious illness, he would just take his hunting rifle and end it. It seemed so wrong. Society says suicide — giving up — is wrong, and guns are violence. So, my husband and I acted. But now I understand this man was terrified that he had run out of options, that I had taken away what he saw as his only alternative.

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I started to understand. But I need to help you in a way that is legal. But that was a pipe dream. The closest state was Vermont, at least an eight-hour drive with a man screaming in constant severe pain, and a requirement first to establish residency. My mother, perhaps because she was there and living with the consequences of his disease, or perhaps because the stigma of suicide ran strong in our small Pennsylvania community, focused on preventing his desired death.

The Human Impact of Technological Dying, 1st Edition

In the end, he died in hospice care in a hospital on Thanksgiving day, in a morphine-induced haze from which he would occasionally awaken and scream. Home care was not an option; no hospice provider offered IV opiate medication in our rural area of Pennsylvania. It was his worst nightmare come true, a diapered hell. Yet there was no option. I had taken away the only other real option for someone as incapacitated as he, to die by his own hand with a gun in his beloved woods. Yet why, in his home state, did society dictate that my dad had but two choices, equally inhumane and unacceptable: violent suicide or an agonizing death?