Who Has Final Say?

The Supreme Court may have been unanimous in ruling on Thursday that terminally ill patients have no right to medical help in committing suicide, but the decision does little to resolve the myriad, murky, practical concerns that many Americans have about exactly how they will die.

The question of doctor-assisted suicide now returns to state governments, which the court ruled have the right to outlaw the practice. And, as ever, the issue ultimately remains to be negotiated in the private realm occupied by dying patients, their families and doctors and nurses.

Both sides in the debate over assisted suicide say the practice is likely to continue underground in the way doctors say it has been done quietly for years. Critics hope the court ruling will discourage it; some proponents hope it will inspire more doctors and patients who resort to the practice to speak out in the hope of convincing the public that it should be made legal.

There are likely to be renewed efforts in some states to legalize assisted suicide, though several previous attempts have failed to overcome the qualms of the public or the courts. Some may eventually succeed, perhaps even encouraging patients to cross state lines to die, just as pregnant women once crossed state lines for legal abortions.

In his ruling, Chief Justice William Rehnquist seemed to encourage states to explore different approaches, noting that the decision “permits this debate to continue, as it should in a democratic society.”

By drawing attention to the issue of assisted suicide, and concluding that there is no right to a doctor’s help, the ruling is also expected to focus new attention on what some say is the alternative - efforts by the medical profession to humanize and improve care at the end of life.

One question doctors and ethicists say will have to be worked out involves the use of heavy sedation: Under what circumstances, if any, should doctors be allowed to sedate a suffering and dying patient to a point of unconsciousness, and then allow the patient to expire?

“The Supreme Court, when it refused to recognize a right to assistance in dying, flung open the door to what will become a long, prolonged, heated societal debate about the morality of assisted suicide,” said Arthur Caplan, the director of the Center for Bioethics at the University of Pennsylvania. “I see this not as the end of anything, but as the beginning of what is going to take years to work through.”

The argument over assisted suicide - whether it is murderous or humane - has confounded consensus for years. It has gained strength with the rise of life-sustaining technologies that have not only kept many people alive, but have also prolonged, and make more agonizing, the process of death for many.

Though polls suggest that a majority of Americans support the notion of assisted suicide, doctors and ethicists have been bitterly divided. And while most states have laws prohibiting assisted suicide, voters in Oregon are scheduled to vote this November on whether to become the first state to make it legal.

Surveys of doctors suggest that many have been asked by patients for help in dying, and that a significant percentage have agreed. The Supreme Court had been asked to decide whether state laws banning the practice in New York and Washington were unconstitutional.

“I think it will be business as usual with regard to the underground practice,” Dr. Timothy Quill, the lead plaintiff in the New York case, said on Thursday, predicting how the ruling might affect doctors. “The vourt didn’t suggest that the laws should be more vigorously enforced.”

Daniel Callahan, a co-founder of the Hastings Center, which does research on medical ethics, said: “I suspect there is a fair amount of physician-assisted suicide already going on illegally. Prosecutors don’t go after it. I think that will continue to be the case, because it is hard to find out what’s going on.”

The effect of the ruling on efforts to legalize assisted suicide at the state level remains to be seen. While proponents believe the justices simply tossed the matter back to the states, others said the court’s unanimous view that there is no right would tend to reinforce legal bans.

“It entrenches the existing laws against assisted suicide,” said Robert Sedler, a professor of constitutional law at Wayne State University in Detroit who has argued in favor of legalizing assisted suicide before the State Supreme Court in Michigan, which became a focal point for the debate after Dr. Jack Kevorkian began helping terminally ill patients die. “The proponents of assisted suicide will have a heavy burden getting legislatures to repeal them.”

Yale Kamisar, a professor of constitutional and criminal law at the University of Michigan, said that within the next 10 years he would expect the practice to be legalized in a handful of states like Oregon, Florida and California. If that happens, he and others said they would anticipate that some patients would travel out of state to die. “It will happen, but I don’t think it will be a major thing, like getting divorced in Las Vegas,” Kamisar said.

If terminally ill patients have been willing to fly cross-country for the services of Kevorkian, ethicists said, others would probably do so for assistance that was legal.

But the ruling will also probably focus attention on alternatives to assisted suicide - efforts to improve the training of health-care professionals, members of the clergy and the general public on such issues as how painkillers can be used and depression treated in terminally ill patients.

Many states, including New York, have already begun reconsidering regulations that have restricted the use of narcotics to reduce pain. Doctors are beginning to receive more training in palliative medicine and in how to communicate more effectively with terminally ill patients.

“My hope is that this discussion and the higher level of consciousness about what constitutes high-quality, end-of-life care will actually reduce the underground practice of assisted suicide,” said Dr. Diane Meier, director of the palliative care initiative at the Mount Sinai School of Medicine.

But Dr. Howard Grossman, an internist in Manhattan who was a plaintiff in the New York case before the Supreme Court, called such arguments “part of the disinformation campaign that the opponents of assisted suicide have created.”