Physician-assisted suicide (PAS) is the provision of medication for the purpose of bringing about death. Throughout history, physicians have secretly practiced PAS and euthanasia, in which doctors directly administer lethal drugs. In the United States, ethical and legal debates over PAS sprung into prominence in 1990 when Jack Kevorkian brought the topic to the public’s attention. Kevorkian, nicknamed Dr. Death, advocated its legalization and, until his death, had conducted over 130 assisted suicides (1). In June 1997, the U.S. Supreme Court ruled that individuals do not have a constitutional right to PAS. But the court did not prohibit the practice either. Rather, it allowed the states to decide for themselves. As of early 2013, Oregon, Washington, and Montana are the only three states that have legalized PAS, having done so in 1997, 2008, and 2009, respectively (2). Whether the option of PAS is a constitutional right, an act of compassion, or a violation of the traditional principles underlying medicine, the concerns surrounding PAS continue to carry implications for patients near the end of life.
Reasons for Requesting PAS
Investigators have conducted studies on patient rationale for requesting assisted suicide. Results indicate that uncontrollable pain is not the most important factor among patients interested in PAS. Instead, patients more frequently cite depression, hopelessness, and psychological distress as reasons for PAS (3). Other motivations include loss of autonomy, dignity, and fatigue at the end of life, which may result from an inability to participate in once-enjoyable activities (4,5). A 2005 investigation of the Oregon health care system demonstrated that patients requesting assisted suicide are more likely to be younger, unmarried, and have a higher degree of education. Patients with a college education are almost eight times more likely to use PAS than those without a high school education. The most frequent conditions suffered by PAS-seeking individuals include amyotrophic lateral sclerosis, HIV/AIDS, and malignant cancer (4). In particular, cancer patients made 31 of the first 43 requests for assisted suicide (3).
Arguments Supporting PAS Legalization
Supporters of PAS argue that physicians have a responsibility to relieve suffering and to respect patient autonomy. Forms of suffering not only include physical and psychological issues but also interpersonal and existential matters; for example, a patient may consider himself a burden to his family and incapable of enjoying life. Despite available counseling and technology, medical interventions may not alleviate patient suffering. In such cases, supporters indicate that having the option of assisted suicide is an act of compassion that respects patient autonomy (5). Proponents argue that it is wrong to leave patients in a state of unbearable pain, and that uncertainty over whether the physician will honor the patient’s desires may cause a rift in the patient-physician relationship (6). Pointing out the fact that patients have the legal right to refuse treatment, which may hasten death, proponents also claim that individuals should have the right to request medical interventions that can directly result in death (7). Some patients nearing the end of life may simply prefer assisted suicide to heavy sedation or withdrawal from life support. Furthermore, the decision to undergo PAS, contrary to the decision to end life-sustaining treatment, is always an active one made by the patient him or herself (6). Lastly, supporters point out that the choice between life and death is a personal matter that should not be regulated by the government (5).
Arguments Against PAS Legalization
Opponents of PAS argue that the practice undermines the Hippocratic principles that have governed medicine for thousands of years. Dating back to the fifth century B.C., the Hippocratic Oath states that one “will neither give a deadly drug to anybody who asked for it, nor […] make a suggestion to this effect” (8). Not granting a patient’s choice to undergo assisted suicide does not directly imply that the physician has acted without compassion and abandoned the individual. The term “compassion,” which means to suffer with, indicates that the physician is obligated to remain with the patient throughout the struggle. Opponents argue that in cases of physical or psychological suffering, the physician should take whatever measures possible to end the pain. However, when dealing with interpersonal or spiritual problems that extend beyond medicinal treatment, health professionals should recruit the necessary individuals to provide the patient comfort and peace; these may include the clergy, family, or friends. Such practices, critics claim, outline the quintessential role of the physician in a patient-physician relationship. Legalizing PAS would effectively compromise the patient-physician relationship and demoralize the physician’s role as a healer (5). Furthermore, the legalization of PAS may hinder progress that has been made in palliative care (7).
Opponents also claim that legalizing PAS will widen possibilities for misuse and abuse. For instance, if PAS becomes socially and legally acceptable, the practice could be further extended to include patients with non-terminal illnesses and to those without the capacity to make autonomous decisions. In addition, society may begin viewing the disabled, the elderly, and the sick, among others, as appropriate candidates for PAS. As a result, these vulnerable subgroups may be discriminated against and be coerced into opting for assisted suicide (5).
Map of the United States highlighting states that have legalized physician-assisted suicide.
Criticism of the Current Regulations on PAS
There are a number of guidelines surrounding PAS. For example, Oregon law requires the patient to make two oral requests and one written request. In particular, there must be a 15-day waiting period between oral requests and a two-day lapse between making the written request and receiving medication (2). Oregon law also requires physicians to offer palliative care as an alternative option (9). Aside from these procedural steps, there are several other regulations that are subject to personal opinion. For example, patients must be diagnosed with less than six months to live and be cleared of impaired judgment (2). Whether or not an individual meets these criteria depends upon the health professionals making the assessments. It is difficult to accurately determine how long a patient has left to live and to understand an individual’s motivations and state of mind concerning assisted suicide (5).
Despite the legal requirements listed above, critics claim that these safeguards can be easily circumvented. For example, though physicians must present palliative care as another option, they may be uninformed about methods of relieving patient suffering, thereby hindering their ability to offer credible and practical solutions (9). Meanwhile, the law does not require physicians to direct patients to palliative care specialists. In Oregon, physicians referred only 13 percent of the first 142 patients requesting PAS to palliative care consultants. The current situation effectively encourages physicians to offer the option of palliative care for the purpose of meeting legal requirements, rather than for the purpose of relieving patient distress (9).
Critics also pointed out issues with the current legal statutes surrounding psychiatric problems. In particular, Oregon law requires physicians to refer patients to a psychiatrist or psychologist only when the physician believes that an individual suffers from impaired judgment. However, previous studies suggest that physicians are not adequately equipped to diagnose patients with depression or impaired judgment (9). Such a diagnosis would require health professionals to examine the patient’s previous experiences with death and to be aware of suicide-associated risk factors, including alcoholism and past episodes of depression. Though the Oregon University Center for Ethics recommends that all PAS cases undergo psychiatric evaluation, physicians have referred patients to psychiatrists at a low and decreasing rate. By 2006, only four percent of PAS cases in Oregon underwent proper evaluation. In addition to determining whether a patient is capable of making an informed decision, such evaluation may provide mental relief and take away the individual’s desire to die. Critics point out that having a professional capable of understanding and relieving a patient’s desperation is necessary for the individual to make an informed decision about PAS (9).
Another criticism of the legal system is the lack of safeguards against coercion. Though Oregon law requires patients to have the capacity to voluntarily request assisted suicide, the possibility of coercion still remains, especially among older individuals who are more dependent on their family members. Consider the case of Kate Cheney, an 85-year-old widow diagnosed with terminal stomach cancer. Due to fear of experiencing unbearable pain and of losing bodily control, she looked into the option of PAS and proceeded with the necessary evaluations with the assistance of her daughter Erika. She ultimately received the lethal drugs upon being deemed competent, despite the fact that one psychologist had noted memory defects and possible coercion by her daughter. Cheney decided to take the medication shortly after being placed into a nursing home by her family. Cases like this highlight the coercion that may result from caretaker and financial burdens, among other considerations (9).
Conclusion
Debates concerning assisted suicide continue today. Is PAS ethically and legally justified? Should the principles underlying hospice care be altered to accommodate PAS? Whatever position one takes, it is safe to say that it is critical to improve palliative care and the regulations surrounding health care. To protect patient rights and enable individuals to make informed decisions, the health care system must provide better access to specialists equipped with the necessary tools and understanding and to prevent safeguards surrounding PAS from being circumvented.
Contact Danny Wong at
Danny.Wong.14@dartmouth.edu
References
1. H. Chua-Eoan, The Life and Deaths of Jack Kevorkian (2011). Available at http://www.time.com/time/nation/article/0,8599,2075644,00.html (03 January 2013).
2. V. Lachman, MEDSURG Nursing 19, 121-125 (2010).
3. E. J. Emanuel, J. Am. Med. Assoc. Intern. Med. 162, 142-152 (2002).
4. K. Darr, J. Health Law 40, 29-63 (2007).
5. L. Snyder, J. D., D. P. Sulmasy, Ann. Int. Med. 135, 209-216 (2001).
6. M. Angell, New Engl. J. Med. 336, 50-53 (1997).
7. R. D. Orr, Is Physician-Assisted Suicide Ever Justified? (2006). Available at http://www.the-hospitalist.org/details/article/255671/Is_Physician-Assisted_Suicide_Ever_Justified_.html (03 January 2013).
8. P. Tyson, The Hippocratic Oath Today (2001). Available at http://www.pbs.org/wgbh/nova/body/hippocratic-oath-today.html (03 January 2013).
9. H. Hendin, K. Foley, Mich. Law Rev. 106, 1613-1639 (2008).