Physician-assisted suicide

Physician-assisted suicide is the provision of medication by a doctor for a patient to take in order to end their own life. In the book, it is a boundary concept: the possibility of a chosen death is defended as a response to suffering and loss of control, while critics distinguish it from allowing an illness to take its course and warn that a choice made for someone else is not the same choice at all.

Definition and Ethical Distinctions

The practice depends on a patient’s own decision to take the medication. That distinguishes it both from withdrawing life-sustaining treatment, which permits the underlying condition to progress, and from active euthanasia, in which another person causes death. The distinction becomes especially consequential when a patient cannot communicate or has not expressed a wish to die. The book notes that involuntary active euthanasia was not legal at the time of the review of the LifeCare deaths, and frames action without a patient’s expressed wishes as a violation of the patient’s authority over medical care. It also raises the danger of a doctor or other decision-maker imposing a judgment about what quality of life another person should accept.

Legalization in Europe

The account traces a gradual change in European law. In 1973, a Dutch court ruled that euthanasia and physician-assisted suicide were not punishable under certain circumstances, imposing a suspended sentence. The practices were decriminalized in the Netherlands during the 1980s and formally legalized by parliament in 2001. Similar laws followed in Belgium in 2002 and Luxembourg in 2009. In neither the Dutch nor Belgian system did a terminal diagnosis have to be a condition of approval.

The book describes safeguards in the Netherlands: a person was supposed to make repeated requests and suffer unbearably, with no prospect of improvement, as certified by two doctors. But a study found that the rules were not always followed and that a small number of people were killed each year without making an explicit request; prosecutions in such cases were rare. The gap between stated safeguards and actual practice turns legalization into a question not only of individual choice, but also of how reliably a system can preserve that choice.

Belgium’s arrangements make the process more concrete. One pharmacy chain sold home-euthanasia kits for about €45, intended for doctors treating specific patients who had signed a request at least a month earlier and discussed it with two independent doctors. The kits included midazolam, the sedative drug also found in the Memorial investigation, sodium thiopental, and a paralytic agent that stops breathing. The described clinical framework depended on advance, patient-specific authorization; the presence of a drug in a different setting does not by itself establish that such authorization existed.

The American Debate

Advocates argued that access to a painless death at a time of one’s choosing could ease the terror, loss of control, and suffering associated with grave progressive illnesses, including metastatic cancer. They also questioned why a person dependent on life support could choose death by refusing treatment while someone seeking medical help to end life could not make a comparable choice.

Opponents drew the line at intention: removing life support lets nature take its course, they argued, whereas assisting suicide is intended to shorten life and is ethically akin to active euthanasia. They warned that acceptance could make terminally ill or disabled people feel devalued or abandoned, and could diminish the possibility of family reconnection, spiritual insight, or personal growth near the end of life. Physician-assisted suicide became legal in Oregon in the 1990s and later in Washington and Vermont; Montana’s state supreme court held that it was not legally forbidden there. At the time covered by the book, most American doctors continued to reject the practice as unethical.

As an alternative response to suffering, hospitals and doctors increasingly offered palliative and hospice care. These programs combined medical treatment, counseling, and support to relieve symptoms and maintain comfort rather than pursue a cure. Hospice, which developed in Britain and took root in the United States in the 1970s, was understood as a philosophy of care for dying patients and their families. Patients had to agree to forgo treatments intended to extend life, and Medicare began covering hospice care in 1982.

The Memorial Case and the Question of Intent

The distinction between comfort care and an intention to hasten death bears directly on the book’s account of Memorial Medical Center. Susan Mulderick told investigators that her discussions about medication concerned comfort, not speeding the dying process. She described Ativan as an example of a drug that could relax patients. Yet records seized from the pharmacy showed that Anna Pou and other doctors had already prescribed Ativan and other ordinary comfort medications during the disaster. The disagreement was therefore not simply about whether medication could ease distress, but about what was proposed, for what purpose, and with whose authorization.

The investigation also demonstrates why drug evidence and conclusions about intent must be kept distinct. Bodies recovered after more than a week in the heat could not provide ordinary blood samples, and investigators were told that decomposition might affect drug concentrations. Tissue testing nevertheless detected morphine in nine of eighteen cases and midazolam in about five or six others. When experts later reviewed results from forty-one Memorial and LifeCare bodies, twenty-three tested positive for morphine, midazolam, or both. They cautioned that postmortem concentrations were difficult to interpret and examined each patient’s clinical history, prescriptions, and recorded condition. Drug detection could inform questions about exposure and cause of death, but did not alone settle whether a patient had requested assistance in dying or whether a caregiver intended to cause death.

That evidentiary and ethical distinction gives the concept its particular force in the narrative. A legal practice premised on a patient’s advance, voluntary request cannot be treated as equivalent to medication administered amid a disaster merely because the same drug appears in both settings. The book keeps the central questions separate: what medication was present, what effect it may have had, what a caregiver intended, and whether the patient had chosen it.