Murder: an urban legion?

“So, I told the doctor at the nursing home that I loved my father more than anything. Dad was my friend and the most wonderful man I had ever known.  I wanted everything for him. But, I said, Dad was sick, weak, confused and he never wanted to live like that.  The next morning he was dead.  That was OK by me.”

Recently, I participated in a panel discussion about hospice, palliative care, living wills, end-of-life quality and, especially, pending legislation to legalize physician-assisted suicide in New Jersey.  There were many arguments, for and against physician Aid in Dying.  “There should be a right to die.”  “We do not have a right to die, life is too precious.”  We must have choice.  We have too much choice. Suicide is needed to relieve suffering.  Suicide will increase suffering by ignoring comfort and wasting life.  It will destroy the physician-patient relationship.  It will make the physician-patient relationship more honest, stronger.

I had heard these thoughts before.  Then, a new idea entered the debate. In the words of a woman perched in the second row, “Well, it should be legal, because doctors do it all the time.”

“Do you mean that patient’s are deliberately killed by their physicians?”

“Absolutely,” was the answer, confirmed by the nods of a nearly unanimous audience

An older gentleman clarified;  “It’s like wink-wink and then it’s done.”

I was flabbergasted. Giving a treatment or medication in order to deliberately cause death is not only unethical, a calamitous violation of the Hippocratic Oath, it is 100% illegal in all 50 States and the District of Columbia. Whether, it is a relative, a pharmacist, a nurse or a doctor who carries out such an act, whatever the reason, we have a special term for that act.  We call it First Degree Murder.

Nonetheless, for many mercy killing is part of urban legion and is, wink-wink, acceptable.  Almost all the attendees the other night, and one of the speakers, who notably holds a PhD in Sociology, believe that it happens all the time and at some level is necessary.  Are they correct?  Are back room medical murders really a ubiquitous dark secret?  Perhaps, we fail to understand the difference between intent and result.

Professional caregivers, especially at the end-of-life, often take advantage of the centuries old concept of “double-effect.”  This canon says that if I give a terminal patient a drug, such as morphine, with the specific goal of providing comfort and if while I am making that patient comfortable it has the side-effect of causing sedation, slowing of breathing and even hastening death, that is ethically acceptable.  It is about intent.  My intent is to relieve suffering and preserve the quality of life. My goal is not to end life.

Physicians, palliative care experts and hospice workers know that when life is frail and there is great pain, shortness of breath or suffering, it can be very difficult to give just the “perfect” amount of medicine so as to provide comfort, but not accelerate the patient’s demise.  If we want to be absolutely “safe,” that is not risk life-ending side effects, we will have to let patients suffer.  This would be reprehensible.  There is a “risk” to provide comfort and compassionate people put quality first.

I suspect that most of the time what is seen as intentionally causing death is rather intentionally providing comfort with the possibility of death. The complex situation at the end-of-life caused by fear, anger, fatigue, deforming disease, treatment, other illness, complication and aggressive comfort measures, makes it very difficult for the lay person to sort out what is cause and what is result.  A caregiver’s inadequate explanation such as, “the time has come to make her comfortable,” or, “we cannot let his suffering continue so I will hang the morphine drip,” may be very confusing.

Euthanasia has been debated since Socrates, but continues to be illegal in most of the world.  In 30 years experience at death’s bedside I have only seen one event that approached intentional comfort killing and that physician faced disciplinary action. Nonetheless, as was clear from our conversation the other night, many people believe bedroom murders are a common event.  I hope not, but beyond whispered stories, it is hard to be sure.

While there are many sound arguments for physician-assisted suicide, the legion of medical murder does not belong in that discussion.  Any “Doctor” who would carry out such an act is not a humanitarian to be respected, protected and followed.  Their evil is not the start of a slippery slope; they have fallen off the mountain.  The possibility of such deeds poisons the medical profession and all of us.




  • Josh
    What's the difference between physician-assisted suicide and euthanasia, ethically speaking? I don't see one, but you seem to come down harder against those who would employ euthanasia rather than PAS.
  • Euthanasia is not assisted dying which is a conscious and informed request to end an individual's suffering (by the individual his or herself) from an undeniable terminal and often painful disease. Love and compassion and responsibility to those we love and also professionally care for must surely include the timely support at the end of light and life. I am thrilled and so grateful that Archbishop Desmond Tutu and the former Archbishop of Canterbury Lord Carey have spoken out in support of changing the law here in the UK. Next week we have a Bill being read in The House of Lords I will be willing it through so that no one else in the UK has to go to Switzerland to end there suffering.
  • Elle
    What you have described as "intent to ease suffering", knowing it may hasten death, is what lazy lay people call "mercy killing". I say this having experienced it 3 times with people close to me. Lay people don't understand the distinction between easing suffering & hastening death - I suspect that the distinction matters more to doctors than to us. Generally speaking, we (lay people) are happy to see suffering eased, no matter the result. I've generally thought of it as hastening the end, and as long as there is no suffering, that's fine. I'm sorry you have been upset by our laziness. In fact, we are grateful to medical people for the easing.
  • Liz
    You said, " I suspect that most of the time what is seen as intentionally causing death is rather intentionally providing comfort with the possibility of death." That is a way of whitewashing a probable outcome and removing one's self from the probable outcome of a act; a way to insulate yourself the consequences of your actions by focusing on relieving suffering rather than acknowledging that you are likely going to cause the patient's death. I'd imagine this is something many have to do. Heck I had trouble dealing with deciding to end my cat's life and that was "just" a well loved cat, not a human. I am not sure how I would cope with a situation where giving an adequate dose of some drug to relieve suffering would likely also kill the person. I'd probably have to resort to some kind of mental gymnastics to deal with the fundamental underlying issue - do we justify and/or judge what we are doing by the process or the outcome? This is the classic ethics debate - justifying the means because the ends is acceptable even when the means are not or justifying a poor ends because we used acceptable means… You have come down on the side of the "means". My dad had polio and post polio syndrome with 1/3 of his lung power. Leaving out all the details that led up to this, he decided his quality of life sucked, was getting worse and he did not want to live the rest of his life the way he was (in a ventilator unit of a nursing home stuck in bed - he had already been there 3 months as they were trying to get rid of the antibiotic resistant hospital induced pneumonia that he got while hospitalized for something else). Had the breathing tube pulled (was not breathing for him per say but assisted him to make it easier) and was given the usual, has full lung function, morphine dose (we had to give permission for that which I didn't exactly give - rather I said he was his body and his life and while I didn't want him to die it was his choice - he had though about this for years about what he would do when he got to that point in his life). Any idiot knew what would happen next with only having 1/3 of his lung power - the stated intent in giving him the morphine was to relieve suffering KNOWING it would hasten his death. Wink wink we all knew what the outcome would be from that. It is still illegal to do that in that state. It was clear that the MD had done this before at the request of patients. I do not think that doctor fell off the mountain. My father would have found another way to die and at least this way it was "better" if one can put that kind of label on it rather than taking another route (he also belonged to the Hemlock society). His death was a far less painful one than the one my aunt had where it took her 3 months to starve herself to death when she had stage 4 ovarian cancer that was no longer responding to treatment and she decided no more clinical trials hoping for something that was unlikely to happen. All that being said, doing something like this without an EXPLICIT request from the patient and a waiting period (which that facility required which also speaks to the fact that this was not an uncommon request that they complied with - legal or not) so that they could change their mind if this was an impulsive request (and they required counseling as well) would be, in my opinion, unethical because it is not the doctor's right to make the decision, that is the patient's right. But it has to be out in the open with safeguards. No wink wink.
  • meyati
    No -wink-wink in New Mexico. Doctor assisted suicide is perfectly legal here, in this very Catholic state. Doctors and patients filed a class action lawsuit against the state. All judges ruled that the government does not have the right to interfere in a patient-doctor relationship. Now finding a doctor that would assist might well be a different story, but it's legal.
  • maggiebea
    I don't know today, but in the mid-20th Century doctors quite commonly decided to let 'defective' infants die. That is, knowing that life might be prolonged with one or other specific intervention, the doc would withhold it, often without telling the parents. One young mother of my acquaintance had to argue with the doctor before he would try to save her child ... whose 'defect' was not, in fact, necessarily life-threatening. I realize that from a legal standpoint 'failure to save' may not be the equivalent of 'action to kill' but from a moral standpoint it sure looked like an intention for death to come soon. Some of these infants were also not fed or hydrated.
  • jerseyRN4726
    In my experience as a hospice nurse, referrals too often come so late that the patient dies soon after admission. The family blames the morphine and/or hospice for the death when in fact the patient hadn't been pain-managed until hospice got involved... the patient died of his/her disease, not medication. With the patient dying inevitably, the choice is to die comfortably (right interventions for symptom control; meds on board) or die in discomfort (no/wrong interventions, no meds, wrong meds or not enough meds).
  • jerseyRN4726
    p.s. that docs kill patients on the Q.T. (a.k.a. "down low") is an urban legend. (or maybe a suburban legend.)
    • D Someya Reed
      @jerseyRN4726: So how do you explain the following quote from the “Highlight” section of the article titled, Physician Assisted Death, by Timothy Quill, MD and Jane Greenlaw, RN, JD as shown on the website? “Empirical studies in the United States show an underground practice of physician-assisted death that is not actively prosecuted as long as it is not openly discussed.” “Empirical” refers to actual observation, not beliefs. Will you say that the authors are making it up for their own purposes or gain? Perhaps to sell books? If you Google “Physician Assisted Death” with or without the Hastings Center you will find the entire article should you wish to read it. I would recommend that you do. This is but one such article by those in the medical industry. There are many others which concur with this one. What evidence do you have to the contrary to back up your statement?
  • Have been wanting to say this for so long: I associate all this blame with the Reagan era fear of drugs. I remember a tv interview in the 80s - seriously ill college girl in UK becomes honor student with heroin to keep the pain at bay. Since no objectors to dangerous dose seem to be receiving one, I wish they would be quiet about what they've never suffered.
  • Jo
    I've wondered about the morphine. My mom was on hospice and was given morphine. She passed away not long after. As a CNA I sat with an elderly woman who was in the process of dying..liver cancer or kidney cancer, I can't recall. She was very restless and in pain. The family had put a mattress on the floor because she kept trying to get out of the bed. It was hard to see her suffering. The hospice nurse finally gave approval for the family to give her a shot of morphine, which her grandson did. She died not long after. She is the only person I have ever been with at the moment they died. She finally looked so peaceful and she was no longer in pain. I just realized that the person I saw laying there was just a body..her spirit was gone. Very good article Dr. Salwitz!

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