The aim should be the alleviation of suffering, not the administration of medications that provide a ‘quick fix’ to complicated medical and social situations.
—Baron Lerner, MD, PhD (see page 113)
Good palliative care and hospice services do limit the expansion of physician-assisted suicide.
—Linda Ganzini, MD, MPH
In 1997, after surviving a storm of high-court legal challenges, Oregon’s Death With Dignity Act went into effect, making Oregon the first American state to legalize physician-assisted suicide. The Supreme Court ruled that there was no right to assisted suicide in the Constitution but implied that states have the right to decide whether to permit or prohibit the practice.
To date, five states have legalized physician-assisted suicide: Oregon, Vermont, Washington, California, and Montana (via court ruling). California was the most recent state to join in legalizing physician-assisted suicide, with the End of Life Option Act passing through the California Assembly and State Senate in September and Governor Jerry Brown signing the bill into law in early October. (The California law will not take effect until 2016.) A proposed bill in New York also seeks to legalize physician-assisted death.
The vast majority of those requesting physician-assisted suicide are advanced cancer patients with a life expectancy of less than 6 months. Physician-assisted suicide has been legal in Oregon for nearly 2 decades, but has largely remained under the nation’s public radar. Then, in 2014, came the highly publicized case of Brittany Maynard, a young woman diagnosed with aggressive glioblastoma. Following two resections, her oncologist told her that she would likely die of the tumor within 6 months.
Ms. Maynard’s quality of life was rapidly deteriorating, but instead of receiving palliative radiation, the 29-year-old opted to relocate to Oregon and enter the legal process of having a physician prescribe life-ending drugs. As she was going through the strict legal process associated with Oregon’s physician-assisted suicide law, Ms. Maynard became a prominent advocate for the Compassion and Choices campaign that works to legalize Death With Dignity in all states. According to her family, Ms. Maynard died peacefully on November 1, 2014, in the company of her loved ones after taking the prescribed lethal dose of medication.
A Battle of Ethics
During the contentious run-up to the passage of Oregon’s Death With Dignity Act, the medical establishment was divided by the ethical conflict posed by physician participation in patient suicide. The American Medical Association (AMA) adopted a policy opposing doctor-aided death in 1993 and has since reaffirmed that position numerous times. In a press release, an AMA spokesperson commented, “Physician-assisted suicide is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks.”
In a spirited public debate in 1997, internationally recognized pain and palliative care expert Kathleen M. Foley, MD, of Memorial Sloan Kettering Cancer Center, argued against legalizing physician-assisted suicide with then Editor-in-Chief of The New England Journal of Medicine, Marcia Angell, MD, who—under certain clinical circumstances—supported the use of physician-assisted suicide.
At the time, Dr. Foley’s major argument against physician-assisted suicide concerned the reasons patients give for seeking it. According to Dr. Foley, most patients who request physician-assisted suicide do so because of profound existential issues, not issues of pain. Existential distress includes patients’ fears of being a burden, of being dependent on others, and of suffering a loss of dignity—clinical challenges that physicians are not trained to address.
On the other hand, Dr. Angell’s support of physician-assisted suicide was strengthened by the death of her father, who committed suicide while suffering terribly during the late stages of prostate cancer. “Long before my father’s death, I believed that physician-assisted suicide ought to be permissible under some circumstances, but his death strengthened my conviction that it is simply a part of good medical care—something to be done reluctantly and sadly, as a last resort, but done nonetheless,” said Dr. Angell in a public statement.
In a 2012 article in The New York Review of Books,1 Dr. Angell reaffirmed her belief in physician-assisted suicide under limited circumstances. She deftly connected the historical dots that have led us to this ongoing debate over physician-assisted suicide, beginning with the case of Karen Ann Quinlan.
In 1976, Ms. Quinlan, a young woman whose brain was irreversibly damaged by an alcohol-and-diazepam overdose, was kept alive in a vegetative state for months. Her family decided to disconnect the ventilator, resulting in a strident court battle, culminating in a landmark decision that allowed the family to stop life-sustaining treatments.
In effect, the court allowed intervention to end life in a hopeless medical case. Dr. Angell argued that, similar to disconnecting a ventilator, proper and compassionate use of physician-assisted suicide is a medical intervention to end suffering in the imminently dying, which should be allowed by law.
‘Slippery Slope’ Argument
Opponents of physician-assisted suicide use the “slippery slope” theory, in which a first step leads to a chain of related steps culminating in a significant and unwanted effect. The Netherlands and Belgium are often cited in the slippery slope argument. Physician-assisted suicide and euthanasia (ie, active physician participation) was legalized in both the Netherlands and Belgium in 2002. Although quite different from the United States in terms of demographics and sociopolitical structure, the data from these two nations are important in the overall discussion of physician-assisted suicide.
In 2012, 3% of total yearly deaths in the Netherlands were the result of physician-assisted suicide or euthanasia; 7% of those patients were euthanized without their explicit consent. Moreover, since 2006, the number of euthanasia procedures has increased each successive year by about 15%.
Data from Belgium are even more disconcerting. According to a study published this year in The New England Journal of Medicine,2 Belgian doctors deliberately “hasten the death” of patients “without an explicit request” at a rate constituting 1.7% of all deaths in the country. There were 61,621 deaths in Belgium during 2013 for which there are comprehensive data, which means, according to the study authors, that doctors are now euthanizing more than 1,000 patients a year without their having requested it.
In an interview with The ASCO Post, Baron Lerner, MD, PhD, Professor of Medicine at New York University Langone Medical Center, addressed the Belgium experience:
The trend seems to be due to the related ideas of patients’ rights and a ‘humanistic’ (as opposed to a religious) approach to death and dying. The earlier doctor-driven emphasis on prolonging life at all costs and relieving suffering is being replaced, in some circles, by the acceptance of the patient’s ability to determine when they have lived long enough. To some degree, these are radical concepts, even in the case of patients with terminal cancer. To apply them to people with psychological suffering is a huge—and worrisome—leap from what most of us were taught in medical school.
The American palliative care community contends that when high-quality palliative care is implemented, suicidal ideation becomes far less frequent. Asked about his thoughts on that, Dr. Lerner replied, “Yes, there are exciting emerging data suggesting that high-quality palliative care can help to relieve both physical and emotional suffering of patients with cancer and other diseases.”
He added, “It is a challenge to get physicians to use these services and to get them paid for, but these goals should be a huge priority. The aim should be the alleviation of suffering, not the administration of medications that provide a ‘quick fix’ to complicated medical and social situations.”
The Oregon Experience
According to a report from the Oregon Public Health Division,3 from 1998 through 2014, a total of 1,327 people have had lethal prescriptions written and 859 patients have died from ingesting medications prescribed under the Death With Dignity Act. Since the legalization of physician-assisted suicide in Oregon, there has been a slow, incremental increase in its use.
According to a survey of Oregon hospice nurses,4 the most important reasons for requesting assistance with suicide among patients who received prescriptions for lethal medications were a desire to control the circumstances of death, a desire to die at home, the belief that continuing to live was pointless, and being ready to die.
The ASCO Post asked one of the authors of the survey, Linda Ganzini, MD, MPH, Professor of Psychiatry and Medicine Senior Scholar at Oregon Health & Science University, whether the gradually increased use of physician-assisted suicide in Oregon is a worrisome trend. She said:
First off, we have very accessible and comprehensive palliative care services in Oregon, which tends to divert the requests for physician-assisted suicide. Moreover, Oregon has very strict control over the process that limits the expansion of its use. Also, our studies show that many people who initially express the desire for physician-assisted suicide, once they enter hospice, ultimately change their minds. So good palliative care and hospice services do limit the expansion of physician-assisted suicide.
In Oregon, there are no data validating a concern among some experts that physician-assisted suicide will somehow inordinately affect poor and underserved populations. Indeed, more than 97% of the patients who died from ingesting a lethal dose of medication were white. More than 98% had health insurance; 90% were enrolled in hospice, and more than 72% had college degrees.
The European data out of Belgium and the Netherlands are relevant, to a degree, in the important debate over physician-assisted suicide in the United States. If anything, the data appear to bolster the slippery slope argument.
Along with the five U.S. states that have legalized physician-assisted suicide, 25 state legislatures and the District of Columbia have considered legislation related to physician-assisted dying during 2015. And a 2014 Gallup poll found that 7 of 10 Americans believe physicians should be allowed to “legally end a patient’s life by some painless means.”5
Physicians will continue to disagree about the wisdom of prescribing lethal doses of medication to terminally ill people who want to hasten their own deaths. Nonetheless, the states that currently have legal physician-assisted suicide and the potential for similar legal changes in other states provide the medical profession with an opportunity to evaluate what more can be done to continue to improve care at the end of life—including the use of physician-assisted suicide. ■
Disclosure: Drs. Lerner and Ganzini reported no potential conflicts of interest.
1. Angell M: May doctors help you to die? New York Rev Books, October 11, 2012.
2. Chambaere K1, Vander Stichele R, Mortier F, et al: Recent trends in euthanasia and other end-of-life practices in Belgium. N Engl J Med 372:1179-1181, 2015.
3. Oregon Public Health Division: Oregon’s Death With Dignity Act—2014. Available at https://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Documents/year17.pdf. Accessed October 20, 2015.
4. Ganzini L, Harvath TA, Jackson A, et al: Experiences of Oregon nurses and social workers with hospice patients who requested assistance with suicide. N Engl J Med 347:582-588, 2002.
5. McCarthy J: Seven in 10 Americans back euthanasia. Available at http://www.gallup.com/poll/171704/seven-americans-back-euthanasia.aspx. Accessed October 20, 2015.