By Ronald W. Pies, MD and Annette Hanson, MD (Originally published on July 7, 2018)
Editor’s note: The presented analysis in this submitted column reflects the views of the authors, not necessarily those of MD Mag. Health care professionals and researchers interested in responding to this piece or similarly contributing to MD Mag can contact the editorial staff here.
In an age of “alternative facts”, it’s hard to sort out myth from reality when it comes to so-called ‘medical-aid-in-dying’ (MAID)—also called physician assisted suicide (PAS). By whatever label we attach to it, this practice involves a physician’s prescribing a lethal drug for a patient with a putatively terminal illness who is requesting this “service.” Some form of MAID/PAS is now legal in 5 states and the District of Columbia.
People of good conscience, including many physicians, are sharply divided on the ethics of MAID/PAS. Unfortunately, much of the support for this practice is founded on several myths and misconceptions regarding existing MAID laws and practices. Here are 12 of the most common.
1. Everyone has a “right to die”, including a right to take one’s own life, acting alone or with assistance.
In contrast to “liberties”, rights entail the cooperation or assistance of others.1 Mentally competent people may be at liberty to end their own lives (i.e., will not be prosecuted), but there is no recognized right to suicide that involves the cooperation of others. In Washington v. Glucksberg [521 U.S. 702 (1997)], the US Supreme Court (USSC) denied that there is a constitutionally-protected “right to commit suicide” or a right to PAS. To rule otherwise, the majority held, would force them to “reverse centuries of legal doctrine and practice, and strike down the considered policy choice of almost every state.”
That said, the USSC has held that all competent persons have the right to refuse unwanted or “heroic” measures that merely prolong the dying process.2 Similarly, in Vacco v. Quill [521 U.S. 793(1997)], the USSC held that there is a legal difference between withdrawal of care and provision of a lethal intervention; i.e., everyone has a right to refuse medical care, but no one has a “right” to receive a lethal means of ending one’s life.
2. People who request “medical aid in dying” usually do so because they are experiencing severe, intractable pain and suffering.
Most requests for medical-aid-in-dying are not made by patients experiencing “untreatable pain or suffering”, as data from Oregon have shown; rather, the most common reasons for requesting medical aid in dying were loss of autonomy (97.2%), inability to engage in enjoyable activities (88.9%), and loss of dignity (75.0%).3
Many patients who request assisted suicide are clinically depressed and could be successfully treated, once properly diagnosed.
3. In states such as Oregon and Washington, where PAS is legal, there are adequate safeguards in place to ensure proper application of the PAS law.
In Oregon, reporting to the state is done solely by the physician prescribing the lethal drugs, who has a vested interest in minimizing problems. Moreover, if a physician was negligent in making the initial diagnosis or prognosis, there is no way to track this, since, by law, all death certificates will state that the person died of the putative underlying disease. At the same time, the physician is rarely present at the time the patient ingests the lethal drug, so the possibility of abuse—e.g., by coercive family members—cannot be adequately assessed.
The Oregon department of human services has said it has no authority to investigate individual death-with-dignity cases,4 and Oregon has acknowledged that its law does not adequately protect all people with mental illness from receiving lethal prescriptions.5 Thus, it is nearly impossible to determine cases in which, for example, terminally ill patients were pressured to end their lives by family members. A study in the Michigan Law Review (2008) found that “seemingly reasonable safeguards for the care and protection of terminally ill patients written into the Oregon law are being circumvented…[and that]…the Oregon Public Health Division (OPHD), which is charged with monitoring the law…does not collect the information it would need to effectively monitor the law…OPHD…acts as the defender of the law rather than as the protector of the welfare of terminally ill patients.”6
Kenneth R. Stevens, Jr., MD, and William I. Toffler, MD, both of the Oregon Health & Science University, point to other actual or potential abuses in PAS-permissive states, including "physician shopping" to get around safeguards; nurse-assisted suicide without orders from a physician; and economic pressures to use PAS, such as Oregon Medicaid patients being denied cancer treatment but offered coverage for assisted suicide.7 Furthermore, an investigative piece by the Des Moines Register revealed that mandatory reporting requirements were not followed by hundreds of doctors in states where MAID/PAS is legal.8
4. In the US, only people with terminal or incurable illnesses are eligible for PAS.
Most PAS legislation applies to an adult with a terminal illness or condition predicted to have less than 6 months to live. In Oregon and Washington State, nearly identical criteria are interpreted to mean less than 6 months to live—specifically, without treatment. Thus, a healthy 20-year-old with insulin-dependent diabetes could be deemed “terminal” for the purpose of Oregon’s “Death with Dignity Act.”
So, too, patients refusing appropriate treatment may be deemed “terminal” under current interpretation of the Oregon law. Thus, a patient with anorexia nervosa who refused treatment could be eligible for PAS under Oregon law, even though she could recover with intensive therapy. As Swedish investigator Fabian Stahle observes, “This is in fact an alteration of the traditional meaning of the concept of ‘incurable.’”9
5. “Slippery slope” arguments against PAS are overblown. In European countries that allow PAS, there is no evidence that patients are being euthanized improperly.
People with non-terminal illnesses have been legally euthanized at their own request in several countries for nearly 15 years. This has included certain eligible patients who have only psychiatric disorders. In 2002, Belgium, the Netherlands, and Luxembourg removed any distinctions between terminal and non-terminal conditions—and between physical suffering and mental suffering—for legally permitted PAS. Between 2008 and 2014, more than 200 psychiatric patients were euthanized by their own request in the Netherlands (1% of all euthanasia in that country). Among them, 52% had a diagnosis of personality disorder, 56% refused 1 or more offered treatments, and 20% had never even had an inpatient stay (1 indication of previous treatment intensity). When asked the primary reason for seeking PAS/euthanasia, 66% cited “social isolation and loneliness.”
Despite the legal requirement for agreement between outside consultants, for 24% of psychiatric patients euthanized, at least 1 outside consultant disagreed.10-12
The US has not been immune to the slippery slope, either. For example, in Oregon, a psychiatrist opened a fee-for-service death clinic, where for $5,000, “terminally ill patients who are eligible to take advantage of…Oregon's suicide law can book a death that might look a lot like a wedding package.” 13
6. The method of “assisted dying” now used in Oregon and other PAS-states assures the patient of a quick, peaceful death, without serious complications.
A peaceful death is by no means guaranteed using current methods of PAS, as a recent piece by Lo pointed out: 14 “Physicians who support PAD need to consider how to address the potential for adverse outcomes, including longer time to death than expected (up to 24 hours or more), awakening from unconsciousness, nausea, vomiting, and gasping.”
Data collected between 1998-2015 showed that the time between ingestion of lethal drugs and death ranged from 1 minute to more than 4 days. During this same period (1998-2015), 27 cases (out of 994) involved difficulty ingesting or regurgitating the drugs, and there were 6 known instances in which patients regained consciousness after ingesting the drugs. However, it is difficult to know the actual rate of drug-induced complications, since in the majority (54%) of cases between1998-2015, no health care professional was present to attend and observe the patient’s death.15
7. “Death with Dignity” all comes down to the patient’s autonomy, and the right of patients to end life on their terms.
In the first place, under current legislation permitting so-called medical aid in dying, the patient is completely dependent on the judgment, authorization, and prescriptive power of the physician—hardly a state of autonomy.1 Moreover, autonomy is only 1 of the 4 ‘cornerstones’ of medical ethics; the others are beneficence, non-malfeasance and justice. As Desai and Grossberg observe in their textbook on long-term care:
“The preeminence of autonomy as an ethical principle in the United States can sometimes lead health care providers to disregard other moral considerations and common sense when making clinical decisions…we strongly feel that the role of the medical profession is to understand but not to support such wishes [for physician-assisted death]. Every person’s life is valuable, irrespective of one’s physical and mental state, even when that person has ceased to deem life valuable.”16
8. Doctors who conscientiously oppose PAS are perfectly free to refuse participation in it.
In theory, the California guidelines state that "A healthcare provider who refuses to participate in activities under the act on the basis of conscience, morality or ethics cannot be subject to censure, discipline … or other penalty by a healthcare provider, professional association or organization," the guidelines say.17 However, prior to its PAS law being declared unconstitutional, physicians in California could be compelled to participate in PAS, under certain circumstances.
California's health department regulation requires a state facility to provide PAS. If the request is denied, the patient has a right to a judicial hearing on the matter. If the court determines the patient is qualified, the attending physician must write a prescription for lethal drugs.18 Moreover, there is evidence that physicians are sometimes pressured or intimidated by patients to assist in suicide.7
9. Terminally ill people who request MAID are not suicidal and don’t commit suicide. They are dying, and simply want “hastening” of an inevitable death. In contrast, genuinely suicidal people are not dying of a terminal condition, yet they want to die.
This argument plays fast and loose with language, logic, and law. In fact, it turns ordinary language on its head, thereby eliminating suicide by linguistic fiat. As the American Nursing Association states, “suicide is the act of taking one's own life,”19 regardless of the act’s context. There may indeed be different psychological profiles that distinguish suicide in the context of terminal illness from suicide in other contexts, but that does not overturn the ordinary language meaning of suicide. Thus, when a terminally ill patient (or any other person) knowingly and intentionally ingests a lethal drug, that act is, incontrovertibly, suicide.
Most suicides occur in the context of serious psychiatric illness. Yet patients who express suicidal ideation in the context of a condition such as major depression rarely want to die; rather, as numerous suicide prevention websites note, “Most suicidal people do not want to die. They are experiencing severe emotional pain, and are desperate for the pain to go away.” 20
10. People requesting PAS are carefully screened by mental health professionals to rule out depression.
Most PAS statutes modeled after the Oregon Death with Dignity statute do not require examination by a mental health professional, except when the participating physician is concerned and decides to do so. Specifically, “The patient is referred to a psychologist or psychiatrist if concern exists that the patient has a psychiatric disorder including depression that may impair judgment.”21
A study of the Oregon law concluded that “Although most terminally ill Oregonians who receive aid in dying do not have depressive disorders, the current practice of the Death with Dignity Act may fail to protect some patients whose choices are influenced by depression from receiving a prescription for a lethal drug.”21
In Oregon, 204 patients were prescribed lethal drugs in 2016 under the “Death with Dignity” statute, yet only 5 patients were referred for psychiatric or psychological evaluation.22
11. Doctors who participate in PAS are almost always comfortable doing so and rarely regret their decision.
Many doctors who have participated in euthanasia and/or PAS are adversely affected— emotionally and psychologically—by their experiences. In a structured, in-depth telephone interview survey of 38 US oncologists who reported participating in euthanasia or PAS, nearly a quarter of the physicians regretted their actions. Another 16% reported that the emotional burden of performing euthanasia or PAS adversely affected their medical practice.23 For example, one physician felt so “burned out” that he moved from the city in which he was practicing to a small town. Similarly, reactions among European doctors suggest that PAS and euthanasia often provoke strong negative feelings.24
12. For terminally ill patients, the only means of achieving “death with dignity” is by taking a lethal drug prescribed by one’s doctor.
Only a small minority of persons with a terminal disease seek a physician’s prescription for a lethal drug. It is not clear why self-poisoning confers more dignity to one’s death than more traditional and much more common ways of dying. Many people who are dying choose to “bear with” their pain. Some seek hospice care and—in cases of severe, intractable pain—merit palliative sedation.25
Some choose voluntary stopping of eating and drinking (VSED), which, according to one study involving hospice nurses, results in a more satisfactory death than seen with PAS. In fact, “as compared with patients who died by physician-assisted suicide, those who stopped eating and drinking were rated by hospice nurses as suffering less and being more at peace in the last two weeks of life.”26
A form of VSED called ‘sallekhana’ has been practiced in the Jain religion for centuries and is regarded as an ethical and dignified means of achieving a “natural” death.27
The case for physician-assisted suicide legislation rests on a number of misconceptions, as regards the adequacy, safety, and application of existing PAS statutes. The best available evidence suggests that current practices under PAS statutes are not adequately monitored and do not adequately protect vulnerable populations, such as patients with clinical depression. The American College of Physicians,28the American Medical Association, the World Medical Association and the American Nurses Association have all registered opposition to physician-assisted suicide.
It is critical that physicians inform themselves as regards the actual nature and function—or dysfunction—of medical aid in dying legislation. The first step is to recognize and challenge the many myths that surround these well-intended but misguided laws.
The authors wish to recognize the important contributions of Dr. Mark Komrad and Mr. Alex Schadenberg to the discussion of physician-assisted suicide.
Ronald W. Pies, MD is Professor Emeritus of Psychiatry and Lecturer on Bioethics at SUNY Upstate Medical University, Syracuse, NY; and Clinical Professor of Psychiatry, Tufts U. School of Medicine, Boston.
Annette Hanson, MD, is Director of the Forensic Psychiatry Fellowship Program, and Clinical Assistant Professor, Department of Psychiatry, University of Maryland School of Medicine.
- Szasz T: Fatal Freedom. Syracuse University Press, 1995.
- Loggers ET, Starks H, Shannon-Dudley M et al. Implementing a Death with Dignity program at a comprehensive cancer center. N Engl J Med. 2013 Apr 11;368(15):1417-24.https://www.nejm.org/doi/full/10.1056/NEJMsa1213398
- Oregon board investigates failed assisted suicide. Jun 20, 2005 http://www.drugtopics.com/community-pharmacy/oregon-board-investigates-failed-assisted-suicide
- The Oregon Death With Dignity Act: A Guidebook for Healthcare Providers, page 43. Accessed at: http://www.ohsu.edu/xd/education/continuing-education/center-for-ethics/ethics-outreach/upload/Oregon-Death-with-Dignity-Act-Guidebook.pdf
- Hendin H, Foley K. Physician-Assisted Suicide in Oregon: A Medical Perspective, Mich. L. Rev. 106; 1613 (2008). Available at: https://repository.law.umich.edu/mlr/vol106/iss8/7
- Stevens KR, Toffler WI. Euthanasia and physician-assisted suicide. JAMA, 2016;316(15): 1599 https://jamanetwork.com/journals/jama/article-abstract/2569774
- Suicide with a helping hand worries Iowans on both sides of 'right to die'. Desmoine Register, 2016 Nov 25 https://www.desmoinesregister.com/story/news/investigations/2016/11/25/too-weak-kill-herself-assistance-legal/92407392/
- Stahle F. Oregon Health Authority Reveals Hidden Problems with the Oregon Assisted Suicide Model. https://www.masscitizensforlife.org/oregon-health-authority-reveals-hidden-problems-with-the-oregon-assisted-suicide-model
- Kim SYH, De Vries RG, Peteet JR. Euthanasia and Assisted Suicide of Patients With Psychiatric Disorders in the Netherlands 2011 to 2014. JAMA Psychiatry. 2016;73(4):362-368 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5530592/
- Komrad MS. APA Position on Medical Euthanasia. Psychiatric Times. Feb. 25,c 2017. http://www.psychiatrictimes.com/suicide/apa-position-medical-euthanasia
- Lo B. Beyond Legalization — Dilemmas Physicians Confront Regarding Aid in Dying.” N Engl J Med. 2018; 378(22):2060-2062 https://www.nejm.org/doi/10.1056/NEJMp1802218?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dwww.ncbi.nlm.nih.gov
- Desai AK, Grossberg GT. Psychiatric Consultation in Long-Term Care, Johns Hopkins University Press, 2010, p. 262.
- McGreevy P. Guidelines issued for California's assisted suicide law http://www.latimes.com/politics/la-pol-sac-guidelines-california-assisted-suicide-law-20160120-story.html
- California Code of Regulations. § 4601. Petitions to the Superior Court and Access to the End of Life Option Act. http://www.dsh.ca.gov/Publications/docs/Regulations/2016_10_31_End_of_Life_ISOR.pdf
- American Nurses Association. Position Statement. Euthanasia, Assisted Suicide, and Aid in Dying. April 24, 2013 https://www.nursingworld.org/~4af287/globalassets/docs/ana/ethics/euthanasia-assisted-suicideaid-in-dying_ps042513.pdf
- Ganzini L, Goy ER, Dobscha SK. Prevalence of depression and anxiety in patients requesting physicians’ aid in dying: cross sectional survey BMJ 2008; 337:a1682 https://www.bmj.com/content/337/bmj.a1682
- Emanuel EJ, Daniels ER, Fairclough DL, Clarridge BR. The Practice of Euthanasia and Physician-Assisted Suicide in the United States. Adherence to Proposed Safeguards and Effects on Physicians. JAMA. 1998;280(6):507–513. doi:10.1001/jama.280.6.507 https://jamanetwork.com/journals/jama/article-abstract/187854
- Stevens KR Jr. Emotional and psychological effects of physician-assisted suicide and euthanasia on participating physicians. Issues Law Med. 2006 Spring; 21(3):187-200.https://www.ncbi.nlm.nih.gov/pubmed/16676767
- Statement on Palliative Sedation. Approved by the AAHPM Board of Directors on December 5, 2014 http://aahpm.org/positions/palliative-sedation
- Ganzini L, Goy ER, Miller LL et al. Nurses' experiences with hospice patients who refuse food and fluids to hasten death. N Engl J Med. 2003 Jul 24;349(4):359-65.https://www.nejm.org/doi/full/10.1056/NEJMsa035086
- Tukol JTK. Sallekhana. https://www.jainworld.com/education/seniors/senles15.htm
- Sulmasy LS, Mueller PS. Ethics and the Legalization of Physician-Assisted Suicide: An American College of Physicians Position Paper. Ann Intern Med. 2017;167(8):576-578. http://annals.org/aim/fullarticle/2654458/ethics-legalization-physician-assisted-suicide-american-college-physicians-position-paper