Physician assisted death in vulnerable populations

Hyperbole and misplaced emphasis are unhelpful in ethical debate,
particularly for contentious issues such as physician-assisted death
(PAD). The assertion by Quill (1) that the Battin analysis (2) 'dispels
many of the concerns' of the impact of PAD on vulnerable groups is an
exaggeration of the security of the findings, given the nature and type of
data provided. The data in the study is limited in both quantity and
quality, and the time scale for Oregon - 9 years - is short. By focussing
only on the over 85's as the "elderly" group misses out on older people
from 65 to 84 who are not only more likely to have more frailty than other
age groups, but who are also over-represented in the PAD ratios in both
countries. It is also somewhat lacking in perspective to dismiss the
euthanasia of 3% of those with Alzheimer's disease and advance directives
as effectively unimportant in the debate, a point which fuels further
concern over the inherent prejudices against disability implicit in
advance directives (3).

Of more concern is the narrow definition of vulnerability, and indeed the
recognition that vulnerability not only carries corresponding
responsibility but also that vulnerability applies to the majority of the
population at any one time (4). Perhaps the most illuminating metaphor for
our universal extrinsic vulnerability is captured in Sontag's Illness as
Metaphor, wherein she talks of the social and philosophical context so
colouring the context of healthcare that it is "impossible to take up
residence unprejudiced by the lurid metaphors with which it has been
landscaped". It is in this context that the leniency of the courts, and
the lack of sanction from the medical profession, for involuntary
euthanasia of a patient with Alzheimer's disease in the Netherlands raise
serious concerns (5). The societal and professional damage and concerns
arising from PAD require a broader and less polemical discussion, and may
be also be aided by the insights of doctors involved with other forms of
physician-assisted death should also be considered (6).

1) Quill TE. Physician assisted death in vulnerable populations. BMJ
2007;335:625-6.

2) Battin MP, van der Heide A, Ganzini L, van der Wal G, Onwuteaka-
Philipsen BD. Legal physician-assisted dying in Oregon and the
Netherlands: evidence concerning the impact on patients in "vulnerable"
groups. J Med Ethics 2007;33:591-7.

3) O'Neill D. Present, rather than, advance directives.
Lancet. 2001;358:1921-2

4) Vladeck BC. How useful is 'vulnerable' as a concept?
Health Aff (Millwood). 2007;26:1231-4.

5) Sheldon T. Dutch GP found guilty of murder faces no penalty. BMJ
2001;322:509.

6) Gawande A. When law and ethics collide--why physicians participate in
executions. N Engl J Med. 2006;354:1221-9.

Competing interests:
None declared