What do I do now?

Commentary 1

Both the moral and professional anguish that the medical student felt in response to the patient's request are vital sentiments which must be retained within the medical community. As the laws on doctor assisted suicide become increasingly liberalised, it is important that doctors (and future doctors) do not become so callous that they would dismiss such a request outright or, in the other extreme, so accustomed to agreeing to such pleas that it simply becomes routine. Instead, society needs doctors who can express care and respect as well as displaying compassion and dignity for the dying, even when these two come into conflict, as in the above example.

The patient's request also reveals the student's own sense of inadequacy because of a lack of preparation for such a discussion, as well as a fear which pushes in the direction of moral paralysis such that the student responds “on auto pilot.” Such lessons in personal and professional vulnerability are one of the many valuable ways in which the dying can teach the living.

In the circumstances, what alternatives might have been open to the student? He or she could have just dismissed the request saying, “There, there, you're not ready to die yet,” but that kind of condescension would have betrayed the trust, care, and honesty which were at the heart of their relationship. Evidence also suggests that a large majority of patient requests for assistance in dying decline when their pain is alleviated. Alternatively, the student might have inquired more about why the patient wanted to die and have used the conversation to investigate her wishes further. However, this would fall outside the role, skills, and responsibility of the medical student. There are other healthcare professionals who are better placed to explore the patient's request in a caring, compassionate manner.

Had this event taken place in Oregon in the United States it is possible that the patient's request might have ultimately led to the use of the Oregon Death with Dignity Act (ODDA). This permits licensed doctors to prescribe a lethal dose of medication to a patient who is terminally ill, with the intent to end the patient's life in a “humane and dignified manner.” I use “possible” and “might” advisedly here, because the ODDA requires the patient to initiate the request for lethal medication to their attending physician; the request cannot be conveyed by a student or a family member. Moreover, the doctor who prescribes the medication must also be licensed to practise, a certification the student currently lacks.

Perhaps the patient would have chosen this option had it been available to her. Her doctor would not be required to participate in this process, but would also be immune from any legal liability or professional disciplinary action. However, no legal safeguards can answer the profound question of moral conscience and professional integrity faced by the student: “Did I do the right thing?”

Commentary 2

This case provides an excellent but sad illustration of the complex issues involved in helping sick people to die. While the reaction here is that of a student, it is also the reaction of many experienced doctors in that it is emotional, irrational, and hasty. In most cases, Dutch medical students are able to approach their teachers and share similar euthanasia experiences in a climate of open discussion. Students are scared by these questions as they should be. Responding professionally to these challenges means that the patient's disturbing question must be dealt with in the calm, caring manner expected of a doctor and there needs to be a clear understanding of the boundaries of medical student responsibility.

Helping a patient to die should never be a student's responsibility, but students do have a responsibility to respond appropriately to such a request. They must be open minded in acknowledging the patient's distress and should pass on the information as soon as possible to the doctor in charge. The doctor should then interview the patient, exploring all the facts and taking sufficient time to show that the request has been taken seriously. Being taken seriously and being provided with a possible means for decreasing their suffering may be enough to comfort the patient.

This approach may be shared by Dutch and non-Dutch doctors alike, but the next step in the Netherlands concerns the doctor's duty to determine whether or not to take the request seriously and to determine whether or not the patient fulfils certain criteria. The doctor starts with an in depth assessment of the patient's circumstances, covering such issues as: “Is the request to die voluntary?” “Is it repeated and well considered?” “Is the patient's suffering unbearable and irreversible?” If the answer to all of these is yes and the patient has a serious condition with no hope of recovery, then the procedure to end their life may be started. The doctor must ask a colleague to confirm that all the legal conditions have been complied with. This acts as both a support for the doctor as well as a double check to prevent acts of doctor assisted death without due care. If the decision is made to end the patient's life the act takes place in a calm atmosphere, usually in the patient's home, with effective medication. The doctor must then submit a report to the local coroner who sets off the legal evaluation process, sending the report to a regional euthanasia evaluation committee, which will decide on the medical, ethical, and legal acceptability of the act.

Questions like these are scary for students and should be shared and discussed. If not, this fear will still be with them when they become doctors.