在關於醫師協助安樂死的爭論中，最重要的問題是：病人為何不想活了？一份在八月四日The Lancet雜誌的新觀點，提出了些讓人訝異的答案。生物倫理學家，James V. Lavery, PhD,同時也任教於多倫多大學，擺脫以往關於政客、倫理學者和醫師的觀點，直接與病人接觸，提出了新的看法：「病人們以非人的角度看待他們自己，「我只是一堆馬鈴薯而已」「我曾經輝煌一時，不過現在只是個沒用的玩偶」」。他說：「事實上當他們發覺喪失自我，是自身本質上的一項改變時，他們就會將安樂死或自殺行為作為減輕喪失自我的方法。」
Different Look at Physician-Assisted Suicide
Loss of Self Makes Life Seem Not Worth Living for Some Patients
By Daniel J. DeNoon
WebMD Medical News
Reviewed by Aman Shah, MD
Aug. 10, 2001 -- Lost in the bitter battle over physician-assisted suicide is the most important question: Why do some ill people want to die? A new look at the issue in the Aug. 4 issue of The Lancet yields some surprising answers.
Bioethicist James V. Lavery, PhD, and co-workers at the University of Toronto took a new tack by moving the debate away from politicians, ethicists, and doctors and talking to the patients themselves.
"People often referred to themselves in nonhuman terms -- 'I'm just a sack of potatoes;' 'I used to be somebody, but now I'm no better than a doll,'" Lavery tells WebMD. "What people were really getting at is that they were seeing a loss of self, a change in their fundamental nature or essence. They saw euthanasia or assisted suicide as a way of lessening this loss of self."
"Our theory is that it is exactly in those circumstances -- and only in those circumstances -- that people desire euthanasia," he says.
Lavery personally held open-ended discussions with 32 people with HIV or AIDS. Some were near death; others simply believed that they eventually would die a terrible death. Even though it is illegal in Canada, 20 of them already had decided to seek physician-assisted suicide or euthanasia. Three patients had decided not to do so, and the remaining nine were undecided.
They told Lavery about their hopes and fears. They told him how they felt about dying. They told him why they did or didn't want to die.
Two themes emerged from these stories. One was a sense of disintegration, resulting from the morbidity of the disease, and the other was loss of community -- the steady loss of the ability to maintain close personal relationships. Combined, these two factors led to a perceived loss of self.
"When we were listening to people's stories, they used the same concepts -- for example, dignity," Lavery says. "They used 'loss of dignity' to refer to losing friends, to being discriminated against, to refer to when they couldn't control their own bodily functions anymore. One guy said, 'Once you have lost your loved ones or have been turned out, you don't have anything anymore.'"
This loss of community appears to be a core feature of loss of self. The finding doesn't settle the debate over whether physician-assisted suicide is right or wrong. But it may do something far more useful: It can point to ways that end-of-life care can be improved.
Robert A. Pearlman, MD, MPH, a professor of medicine at the University of Washington and director of the Northwest Ethics Center for Veterans Health Care in Seattle, co-authored an accompanying editorial.
Pearlman says end-of-life care needs to address the issues of loss of self and loss of community. He argues that healthcare research should look for ways to help people deal with the isolation or loss of meaning that comes from the loss of community that patients described to Lavery. Pearlman also endorses Lavery's approach of listening to patients instead of asking their doctors.
"Patients can be our teachers, as opposed to assuming we understand their experiences," he tells WebMD. "There is the need for healthcare providers and families to hear about patient experiences so they can better address them and do a better job in promoting quality of life and quality of dying."
Lavery points to two patients. One, a man at death's door, was a community activist who remained involved from his hospital bed. He strongly believed that physician-assisted suicide should be legal, but he did not want it for himself. Another man was far less ill, but he was rejected by his family when he told them he was gay and was rejected by his lover when he told him he had HIV. This man wanted very much to die.
"Caregivers must be attentive not only to the physical side of illness but also to the meaning of what dignity really is," Lavery says. "Dignity has to do with integrity of the self. You cannot expect that people will lie isolated in a bed and not experience profound changes in how they perceive themselves. As a response to terminal illness, we should ensure highest quality not only of technical care for symptoms, but for community. We should provide a role for patients and keep this role for them until they die."