Rx For Death

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Surveys of doctors themselves show how many are unaware of their patients' options or unwilling to respect them. Many health-care workers knew little about new laws that allowed them to withhold or withdraw machines like respirators and kidney machines or even feeding tubes. Many rejected the idea that once a treatment is started, it can still be dropped, even though the law upholds a patient's right to do so. Though the courts have recognized the right of patients to refuse food and water, 42% of health-care workers rejected that option.

Even when patients go to the trouble of expressing their wishes, the doctor's values may prevail. One study found that in 25 of 71 cases, when patients were moved from nursing homes to hospitals, their living wills never made it onto their hospital charts. "It's easy to say the patient doesn't really understand because he's never been in this situation before and therefore doesn't know what the treatment is all about," says Dr. David Orentlicher, a professor of medicine at Northwestern University. "It's also easy to say to a relative that the patient never really anticipated in his living will this specific situation."

And if the doctor's values don't prevail over the patient's, the families' often will. Given the anguish at the deathbed, it is not surprising that patients and relatives may argue over treatment decisions -- or that doctors often side with the family. "The law is designed to give preference to living wills over the wishes of relatives," says Robert Risley, a Los Angeles attorney who drafted the state's initiative to legalize doctor- assisted suicide. "But as a practical matter it throws the health-care provider into a dilemma if there is a conflict."

The fear of litigation haunts every aspect of treatment. Says Curtis Harris, a specialist in endocrinology and president of the 22,000-member American Academy of Medical Ethics: "I have seen patients that were clearly within the last hours of life and no one could do anything and a white knight son comes in from out of town and says, 'If you don't do everything you can to save her, I'm going to sue your socks off.' " Dr. John Ely, a professor at the University of Iowa College of Medicine says there has never been a successful suit against a physician who gave treatment in accordance with family wishes and against the patient's wishes. "That's because the patients aren't there," he says. "They are either incompetent or they have already died."

Suicide, the unpunishable crime, has always posed a challenge to societies that want to deter it. Under English common law, suicide was a felony punishable by burying the body by a public highway with a stake driven through the heart, to keep the spirit from wandering. It is no longer a crime in the U.S., but assisting in one is illegal in more than 20 states. No one knows how often doctors write the prescription and whisper the recipe for a deadly overdose; but one informal survey of internists last year found that one in five say they have helped cause the death of a patient. Poll after poll shows that as many as half of Americans favor doctors doing so.

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