Editors' Note

Editors' Note: In the article “High hypothetical interest in physician-assisted death in multiple sclerosis,” the opinions of persons with multiple sclerosis (MS) regarding physician-assisted death (PAD) were assessed. Investigators surveyed participants in the North American Research Committee on Multiple Sclerosis Registry regarding PAD. For each of 5 hypothetical situations, respondents indicated whether they definitely would, probably would, probably would not, or definitely would not consider PAD. More than one-third of surveyed patients with MS said they would definitely or probably consider PAD in each of the 5 hypothetical situations and two-thirds would consider requesting PAD for unbearable pain. On multivariable analysis, religiosity, social support, depression, pain, disability, sex, and race were associated with considering PAD in some or all of the situations presented. The authors concluded that depending upon the situation, a large proportion of persons with MS would consider PAD and that the association of depression with considering PAD emphasizes the importance of diagnosing and treating depression. An accompanying editorial, “Physician-assisted death in chronic neurologic diseases,” by Bernat and McQuillen, stated that physicians should not suggest to their patients that dying is a better solution than continued life and that for patients who muse about PAD, physicians should have a low threshold for referring them to palliative medicine to achieve optimal symptom palliation including the identification and treatment of depression. Commenting on the study, Dr. Masdeu discusses Leo Alexander's report on medical records left behind by the Nazi regime. Alexander concluded that atrocious crimes committed were, at first, merely a subtle shift in emphasis in the basic attitude of the physicians and that those started with the acceptance that there is such a thing as life not worthy to be lived. Commenting on the editorial, Dr. Bier reminds the readers that among legislative criteria granting the right to practice PAD, there are 4 requirements: requests must be voluntary, persistent, well-thought, and well-informed. Furthermore, he corrects that the law in Belgium allows only active euthanasia and not PAD (the editorial stated that in the Netherlands and Belgium, “voluntary active euthanasia now far surpasses PAD in frequency”). Finally, Dr. Sethi highlights the other side of the argument, explaining that a fundamental belief underlying the right to die (RTD) is that one's body and one's life are one's own to dispose of as one sees fit. He adds that a form of PAD by withholding extraordinary life support measures (such as intubation and mechanical ventilation of terminally ill patients) is already routinely practiced in critical care units across the world and that different religions have different perspectives when it comes to the RTD. Marrie et al., authors of the original study, explain that the issue of PAD in chronic illness is complex and that whether the individual physician supports or opposes PAD, it is clear that people with MS are thinking about this issue and want to talk about it. They also add that perspectives may differ based on religious beliefs, cultural practices, and other factors. Also in response, Drs. Bernat and McQuillen clarify that, from a legal standpoint, the right to die is a slogan since no American court found a constitutionally protected right to die. However, terminally ill patients may voluntarily choose to stop eating and drinking without it being considered suicide. From an ethical perspective, it remains controversial whether death with dignity would be best achieved by legalizing PAD or by enhancing the quality and availability of palliative care.—Chafic Karam, MD, and Robert C. Griggs, MD