The Debate Over Physician-Assisted Suicide Continues

Patients who choose to request a physician's assistance in ending their lives usually do so because they want to exercise control over the end of their lives, they do not wish to be a burden or dependent on others for their care, they see their futures as assuredly worse than their current lives, or they are struggling to find a meaning in their continued existence.

These are among the findings of Linda Ganzini, M.D., M.P.H., and her colleagues, who have studied the views and experiences of patients and caregivers in Oregon since the state legalized physician-assisted suicide in 1997 with the Death with Dignity Act.

"We have surveyed physicians, social workers, hospice nurses and other health care professionals who have cared for these people," Ganzini told Psychiatric Times. She added that most of the professionals "have agreed that depression is not an important reason, which is not what I expected to see."

Oregon is the only state in which patients can legally receive prescriptions for life-ending medications. If the federal government has its way, however, physicians writing such prescriptions could face loss of prescribing privileges under the Controlled Substances Act.

U.S. Attorney General John Ashcroft issued a directive in 2001 declaring that assisted suicide is not a "legitimate medical purpose." A federal court has enjoined the government from enforcing its directive and, at press time, the 9th Circuit Court of Appeals is considering whether or not to uphold the injunction. In all likelihood, the issue will wind up being appealed to the U.S. Supreme Court by whichever side loses in the Court of Appeals.

In a statement issued by the U.S. Department of Justice, Assistant Attorney General Robert D. McCallum Jr. argued, "Pain management, in contrast to assisted suicide, has long been recognized as a legitimate medical purpose justifying physicians' dispensing of controlled substances. There are important medical, ethical, and legal distinctions between intentionally causing a patient's death and providing sufficient dosages of pain medications to eliminate or alleviate pain."

In addition, the statement pointed out, Ashcroft's directive "promotes the ability of physicians to use federally controlled substances to manage pain. Physicians should feel confident that they may prescribe federally controlled drugs to relieve pain, even if their prescriptions may have the unintended effect of hastening the patient's death, without fear that their prescriptions will be subject to greater questioning, investigation, or monitoring."

Ashcroft's position echoes the American Medical Association's Code of Medical Ethics, which states, "Physician-assisted suicide is fundamentally incompatible with the physician's role as a healer, would be difficult or impossible to control, and would pose serious societal risks."

In his order blocking the Department of Justice directive, U.S. District Judge Robert Jones said in a press release that the department was attempting to "stifle an ongoing, earnest and profound debate in the various states concerning physician-assisted suicide." While the debate is ongoing, no other state has followed Oregon's lead. Voters in California, Michigan, Maine and Washington state have rejected assisted-suicide ballot measures, and the Maine legislature defeated a bill that would have implemented an Oregon-style plan. Forty states explicitly forbid physician-assisted suicide; six states prohibit it through common law. Only three states other than Oregon--North Carolina, Utah and Wyoming--do not have laws prohibiting physician-assisted suicide.

Vermont's legislature considered measures in 2003 on both sides of the issue, as well as one that attempted to strike a middle ground. Two bills (S 112, S 181) would have allowed physician-assisted suicide, one would have prohibited it (H 275), and two others would have created a commission on palliative care (H 318, H 419). All failed to reach the floor, but their introduction led to a series of physician forums around the state under the auspices of the Vermont Medical Society. The issue is expected to be reviewed at the society's annual meeting.

Within psychiatry, there are two broad schools of thought regarding the issue, according to Ronald Baron, M.D., chair of the committee on suicidology of the American Academy of Psychiatry and the Law. "When I was with the American College of Forensic Psychiatry, we had the attorney for [Jack] Kevorkian [M.D.] as a speaker. When we put it to a vote after the presentation, the younger psychiatrists were against assisted suicide, while the older psychiatrists who had elderly patients were for it."

(Kevorkian, a Michigan physician, was sentenced to 10 to 25 years in prison in 1999 for giving a patient a lethal injection. He reportedly assisted at least 130 patients with ending their lives between 1990 and 1998--Ed.)

"What I see as a clinician is different from what people who are younger are seeing," Baron explained. "As you get older, and have various kinds of diseases, and your relatives and friends die, you sometimes have a problem finding a motivation to live. A lot of them are relieved to have a fatal illness or some way that will terminate their lives. But there is another group of psychiatrists who say, 'Treat the depression. Many patients will cheer up and have a better life.' Suicide prevention is really the treatment of depression."

Among psychiatrists in Oregon, Ganzini, who is professor of psychiatry at Oregon Health and Sciences University, found that 54% supported physician-assisted suicide when she surveyed them five years ago. Nearly 75% of the state's psychologists supported the law, while between20% and 33% of all health careprofessionals were opposed to it.

"The highest level of support was among hospice social workers and psychologists," Ganzini reported. "The lowest level--48%--was among hospice nurses. The biggest reason for opposing it is that suicide is not morally acceptable; that it's not an appropriate role for a health care provider and that it is not morally acceptable for people to choose to hasten their death. The strongest relationship for these people was how important religion is in one's life."

Among physicians who had prescribed end-of-life medications, Ganzini said, most of them felt they had acted appropriately, but many were surprised by how emotionally difficult the whole experience was. Some have participated more than once, but most had only received one or two requests.

Receiving physician assistance in ending one's life in Oregon is not as easy as opponents of the state's law might assume. To qualify for the program, a patient must be an Oregon resident, at least 18 years of age, and terminally ill with a prognosis of death within six months or less. In addition, the attending physician must be licensed in Oregon, and must be willing to participate.

"Participation is voluntary for the physician as well as the patient," Darcy Niemeyer from the Oregon Department of Human Services, Health Services, told PT. "Some physicians have employment relationships that prevent them from participating. Some employers--for example, the U.S. Department of Veterans Affairs or hospitals operated by the Catholic Church--will not permit their physicians to participate."

After a patient requests an end-of-life prescription, the request must be repeated at least 15 days later. That request must be followed by a written request that is signed by two witnesses, one of whom may not be related to the patient. A consulting physician is then called to confirm the diagnosis and prognosis and to determine whether or not the patient is able to make and communicate health care decisions for themselves. If the patient is mentally impaired, a psychological examination is ordered.

Before the attending physician may write the end-of-life prescription, the patient must be informed of alternatives, including hospice care and palliative treatments. If the patient persists in requesting the prescription, the physician must wait another 48 hours before writing it and may request that next-of-kin be notified. Finally, the pharmacist who receives the prescription has the right to refuse to fill it.

"For every 10 people who make an explicit request, only one dies by assisted suicide," Ganzini said. "There is a great deal of winnowing at the point of the request. Physicians make interventions that help patients change their minds, the most important being a referral to hospice. What [this] suggests is that, among patients who request suicide, a substantial portion will change their minds with improved palliative care.

"But palliative care cannot give patients the control they want. It's tough to leave this world totally in the driver's seat. Not wanting people to take care of you is particularly frightening for people who want assisted suicide."

Nor is improved hospice care always an alternative. Oregon has one of the highest rates of deaths in hospice of any state, but some patients are not satisfied with that choice. "It turns out that 85% of people who die by assisted suicide in Oregon are in a hospice and have been there for a median of seven weeks," Ganzini said. "It may be that there are ways we can interact with patients before they get into the hospice that will change their attitudes."

From 1997 to 2002, 129 patients died as a result of taking end-of-life prescription medications, accounting for less than one in every 1,000 deaths in Oregon. According to the Oregon Department of Human Services, 58 patients received lethal prescriptions, but only 36 died as a result of using them in 2002. Another 16 died of their illnesses, and six remained alive at the end of the year.

From 1998 to 2002, the participating patients' mean age was 69; 97% percent were white, 55% were male, and 38% had a bachelor's degree or higher. Forty-seven percent were married, 22% were widowed and 25% were divorced. Two patients were between the ages of 25 and 34, and three were between 35 and 44.

"The patients who ended their lives this way were in general very assertive, independent, determined, persuasive people who put a great deal of effort into determining how they were going to die," said Ganzini. "The ambivalent are left behind, because they don't have energy to fight."

Cancer was the most common disease, affecting 79% of the patients who requested physician-assisted suicide. Other illnesses included amyotrophic lateral sclerosis (8%) and chronic obstructive pulmonary disease (6%).

Medical specialties of physicians writing prescriptions included oncology (45%), internal medicine (29%) and family medicine (24%). Five percent of physicians writing prescriptions noted "other" as their specialty.

Whether or not patients in Oregon will continue to be able to request physician-assisted suicide, they will continue to choose to end their lives, Baron stated. "No matter what we doctors think, people will take the matter into their own hands. That's an extra-legal determination that people make. If somebody wants to die, all they have to do is refuse to eat or drink. In two or three weeks, more or less, they'll be dead. You can't maintain them forever with just an IV.

"Sometimes, as a physician, you have to curb your therapeutic ambition. If you prolong a life of misery, the patient doesn't thank you. If there's good hope that a quality life can be achieved, that's different, and people do make mistakes about that." (Please see p37 for one opinion on this issue--Ed.)