Tempers flare as the controversy over assisted suicide heats up
Data allow debate to take center stage
Although seven months have passed since Oregon voters decided to legalize assisted suicide, the debate over the issue is far from over in both the public's and providers' eyes. Both proponents and opponents of assisted suicide have based their arguments on what was an unchartered territory in health care. No data existed on physician's views regarding assisted suicide until recently. (For more on finding common ground in the debate, see story, p. 64.)
The results of a national survey among physicians published in the April 23, 1998, New England Journal of Medicine has sparked renewed debate on both sides of the issue. And for hospital ethics committees seeking an answer to the problem, the search might mean a long wait.
Adding to the dilemma of assisted suicide is the pressure from the public to change the law. "Public opinion polls show that two-thirds of the people are in favor of legalizing assisted suicide, but the polls are often taken from the voting block, and those people generally tend to be among the well vs. the terminally ill," says Diane Meier, MD. Meier is director of the palliative care program at Mount Sinai Medical Center and associate professor of the department of geriatrics and internal medicine at City University of New York, located in New York City.
"Ethics committees, like everyone else involved in health care, will struggle with the issue of assisted suicide. There is no easy answer," says Larry I. Palmer, JD, professor of law at Cornell University in Ithaca, NY. "The ethics committee might be appropriate in addressing the issue, but it's likely that the committee won't resolve it also.
"I see the committee serving as a forum for helping physicians engage in the discussion about assisted suicide with their patients. And public visibility regarding the issue is making patients discuss this with their physician, and the patient does have that right."
First national attempt
Historically, several studies have been published regarding physician-assisted suicide and euthanasia in the United States, but there were no national data on physician attitudes. So in 1996, researchers mailed more than 3,100 questionnaires to a stratified sample of physicians in 10 specialties where physicians are most likely to receive requests from patients for assistance with suicide or euthanasia.1
More than one-fifth of the respondents said they would be willing to assist in a patient's suicide if it were legal. The survey was conducted before the Oregon vote to legalize physician-assisted suicide.
Researchers achieved a 61% response rate and found the following results:
· 11% of respondents said that under current legal constraints, there were circumstances in which they would be willing to hasten a patient's death by prescribing medication.
· 7% said they would provide a lethal injection.
· 36% said they would prescribe medication if it were legal.
· 24% said they would provide a lethal injection if it were legal.
· 18% of the physicians (since entering practice) reported having received a request from a patient for assistance with suicide.
· 11% had received a request for a lethal injection.
· 3% reported writing at least one prescription to be used to hasten death.
· 5% reported they had administered at least one lethal injection.
Not a frequent request
The most important finding from the research is that patients are not requesting assistance with suicide very often, says Meier, lead author of the study. "Our survey looked at a physician's life time practice, which spans three and four decades. And the reports of requests ranged from one to two over that time, which is a very infrequent amount."
The biggest obstacles stopping physicians from helping patients with suicide are laws prohibiting the practice, according to the survey results. "I think that physicians would be willing to assist in a patient's suicide if the laws were to change, but not as high as the [survey] results indicate," says Palmer.
"When you're talking about whether or not a physician would assist in abstract examples, he or she is all for it, but the answer might change if they are asked by their spouse or friend to assist in suicide. At that point the issue becomes much more difficult," Palmer explains.
And while some proponents of assisted suicide argue that public opinion is warming to the idea of legalization, the actuality of it happening is slim, he says. "We shouldn't assume that because voters in Oregon approved it, it will become a model piece of legislation for other states," he explains.
"I do think more states will follow Oregon's lead, but I think most will wait to see what happens there this year," says Jan Hare, PhD, associate professor in the College of Human Development at the University of Wisconsin - Stout. And the states more likely to pass any legislation legalizing assisted suicide are ones where policies are set based on grassroots ballot measures, she says.
Palmer agrees, but points out that the ballot measure procedure is not available in many states. "And don't forget that legalization efforts failed in California and Washington, which also pass legislation from grassroots ballot measures," he says.
The final solution might be settled on a federal level rather than a state-by-state effort, he says. "I think it will come down to Congress debating over whether certain prescriptions are medically necessary. If a prescription is not considered necessary, it can't be filled using federal funds, so that might be one technicality where the issue gets grounded."
Perhaps more disturbing than the willingness of physicians to assist in suicide is the public's opinion on the topic, Hare says. "We just finished the data analysis on a Wisconsin project on public opinion regarding physician-assisted suicide. Our most interesting findings concern the factors which influence an individual's thinking."
The data, which will be published at a later date, indicate the public does not believe it will be kept comfortable when dying, Hare says. Similarly, physicians involved in the national survey said they had a difficult time distinguishing between giving pain medicine to relieve suffering and administering a lethal injection, which suggests further education of health care providers is needed. (For more information on education regarding pain management, see story, p. 65.)
Patients also worry that technology they don't want will be imposed on them anyway. "These beliefs, I fear, are what really drive the enormous support for assisted suicide," Hare explains. (For more on patients' reasons for requesting suicide, see box, p. 62.)
Whether hospitals or hospices will bear the brunt of the requests for assisted suicide in Oregon has yet to be determined. The key issue for ethics committees, however, is allowing physicians and patients discuss the issue, say Hare and Palmer.
"By definition, physician-assisted suicide means that the patient will take the last step toward ending his or her life, most likely via administration of an oral medication," Hare explains.
"I think it's also a matter of creating a consensus between the facility, the physician, and the patient. And since the Supreme Court left the issue to the legislatures of each state to struggle with, there's no easy answer," Palmer adds.
"The public's fears about a painful death are justified, and this debate points out the need to make those fears unjustified," Meier says.
Reference
1. Meier D, Emmons C, Wallenstein S, et al. A national survey of physician-assisted suicide and euthanasia in the United States. NEJM 1998; 338:1,193-1,201.
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