The adolescent patient's decision to die

Those who are treating a severely ill patient who decides to die are faced with an agonizing dilemma. The problem is magnified when life can be sustained for a significant period if the patient accepts dependence on a drug, a procedure, or a machine. A patient may, however, refuse further transfusions, another course of a cytotoxic drug, further cancer surgery or radiation, an organ transplant, renal dialysis or an artificial organ on pacemaker. New techniques to prolong life make this problem increasingly common in situations where death is not imminent, but the quality of life is greatly impaired. In pediatrics the problem of a patient's decision to die is complicated even more by special developmental, ethical, legal, and family considerations. There has been little discussion in the medical literature of these issues, but recently there has been editorial recognition of the need for further debate on the issues of euthanasia and the child's right to die.1-3 The basic question to be faced is should a physician always oppose a patient's request to end his life and, if not, under what conditions should he respect or even support a patient in his decision to die? These are situations of conflict between our commitment to relieve suffering and our commitment to prolong life. Sometimes it is evident to everyone that death is imminent, the suffering severe, and that efforts to prolong life will only prolong suffering, while at other times it is clear that the wish to die is irrationally out of proportion to the suffering. There is also, however, a very difficult middle ground.