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While the U.S. Supreme Court debates the legal, ethical and moral issues of physician- assisted suicides, two Duke University Medical Center physicians are concerned that patients who request such assistance may lack the information or the mental stability they need to make a decision.

Dr. Harold Koenig, a geriatric psychiatrist and associate professor, has found that most patients who ask to die are clinically depressed, and their feelings often change if treated. But Koenig says most doctors don't recognize such depression. He is available for interviews at (919) 681-6633.

Dr. James Tulsky, co-director of medical ethics at Duke, says many doctors don't know how to talk to their acutely ill patients about their feelings and thoughts on death, and patients are suffering needlessly because of it. He's teaching physicians how to communicate with dying patients, making Duke one of only five medical centers in the country to offer such courses. He is available for interviews at (919) 286-6963.

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Dr. Harold Koenig In his own clinical practice as well as in several studies he has conducted, Koenig has found that patients who are properly treated for their depression will usually change their minds about wanting to die. But Koenig says few attending physicians are trained to diagnose depression and often mistake its symptoms for those that accompany the patient's physical illness.

"Eighty to 90 percent of the time, primary care doctors don't recognize clinical depression," he said. "My concern is that doctors will comply with the patient's request because they don't understand the underlying reasons behind the patient's desire to die." Reasons for wanting to die often stem from fear of prolonged pain and suffering, feelings of desertion or anger at family members, and feelings of anxiety, despair and hopelessness arising from depression.

Koenig believes the law should require an independent psychiatrist to meet with patients over a period of time to assess their mental and emotional state. Patients who are depressed should receive treatment even if they are terminal and say they don't want treatment, he said, because you may be depriving them of important family interactions that aren't possible in a state of depression.

"I think it is ethical and moral to impose that treatment on the patient because their desire to die may stem from a treatable illness that is affecting their judgment," Koenig said. "You'll never know if they would have changed their minds if you didn't give them the chance to be treated."

Koenig further points out that feelings of sadness and grief that accompany a terminal or chronic illness are not the same as depression, and that being depressed is not a normal state for terminal patients.

While advocates of assisted dying say the decision is an intensely personal one, Koenig counters that suicide affects far more than the person who is committing the act. "On average, about six people are deeply affected by the act. When a person commits suicide, he or she is acting as a role model to society and to their own families."

In two studies of how families view assisted suicide, Koenig found that the desire to live is strong even among very old, sick patients. One study showed that 99 percent of chronically ill or terminal patients who are not depressed do not have thoughts of wanting to die. Those who had such thoughts were almost always suffering from clinical depression, Koenig said.

In another study, Koenig found that 39 percent of frail, elderly patients favored the notion of assisted suicide for terminal patients, whereas nearly 60 percent of their younger relatives favored the measure. Such results are important if assisted suicide becomes legal, because relatives may be called on to make decisions on behalf of patients who become unable to decide for themselves.

Koenig is also very concerned about pressure from the health care industry. He says there will be tremendous pressures as the baby boomers age to find expedient solutions to the problems of caring for older people, and legalizing assisted suicide can pave the way to an easy and cost-effective solution for many people.

"I think there will be a lot of financial pressure particularly induced by the health maintenance organizations who are paying physicians' salaries, to at least make this an option available to a lot of people," he said. "Given the tremendous costs of health care and the increase in Medicare costs that have totaled over $100 billion in the past 10 years, everyone is looking for some way to cut the cost of health care."

Dr. James Tulsky, a medical ethicist at Duke and assistant professor of medicine, said the decisions patients make about their care often don't reflect their true wishes. That's usually because patients don't understand the medical jargon they hear from doctors on advanced directives and life-sustaining treatments.

Tulsky, also a researcher at the Durham VA Medical Center, says patients cannot be expected to make a rational decision on end-of-life care if they don't understand their options . Nor can doctors advise patients without knowing what the patient's values and desires in life really are.

"My concern is that patients are not encouraged to make decisions that are consonant with their values and real goals for care," said Tulsky. "Physicians tend to talk about treatments and how we can extend life. I believe we need to be learning about our patients' values in order to help them plan their deaths to be in accordance with how they have lived their lives."

Funded by The Project on Death in America, Tulsky's charge has been to improve the care of dying patients in America by promoting change in health care institutions. His answer to that challenge has been to create a curriculum to teach medical students, residents and faculty some specific behaviors to help them elicit the values, goals and preferences of patients facing death. The program is one of only five among the nation's 126 medical schools that teaches physicians these skills.

"The real focus is to get caregivers to stop talking about medicine and start talking about how the patient feels about dying -- what is dying doing to his or her life," he said. "We want them to empathize with the patient's feelings, not to squelch them."

That includes teaching doctors to assess emotional and spiritual suffering, not just pain and physical discomfort. For example, does the patient care more about quality of life or length of life? Does the patient want to live to participate in a specific family event, such as the birth of a grandchild?

"I think assisted suicide has become such an issue because we haven't adequately addressed issues that underlie the suffering that comes when people reach the terminal stages of illness," Tulsky said. "The real problem is that too many people in this country die in pain, with life-sustaining interventions in place that they don't understand or necessarily want. And they die without a health care provider who really knows what they want or how to give them good palliative care."