The issue of assisted suicide has increasingly been raised for anyone involved in end-of-life care.  There are certain medical policies in place in my state of Massachusetts, which does not permit physician-assisted suicide on the grounds that a doctor’s mission is to heal and do no harm based on the Hippocratic Oath.  This oath is instilled in all doctors in medical school, so our role at the end of life is to minimize pain and suffering and not do anything to prolong unnecessary suffering, such as resuscitating or intubating the patient after the heart stops or the patient can no longer breath on his or her own.  

However, Massachusetts is one of over 20 states which are considering death with dignity – i.e.: assisted suicide laws, and five states – California, Oregon, Vermont, Washington, and Montana – have already made it legal.  So legally, there is growing pressure from death with dignity advocates to make assisted suicide legal – and even the terminology has been changing to make this process more acceptable – such as calling this one of the “end-of-life” options for a terminal patient.  In turn, this push to legalize this approach has triggered a national debate about whether assisted suicide, however it is called, should be legal, and what individual doctors should do when they encounter a request by a patient.  So what should doctors and patients do?  Following is a discussion about the present state of the issue and the arguments pro and con, so each person and doctor can better think about the situation and make their own decision for themselves.

 

A Little History 

The move to make assisted suicide legal has a rather tortured history.  The first drive to legalize it began as part of the eugenics movement in the early 20th century, and in Ohio, a bill was introduced in 1906 to legalize it after the mother of heiress Anna S. Hall died a painful death in cancer, but the Ohio legislature overwhelmingly rejected the bill.  Then, in the 1990s, the issue came to public attention when Dr. Jack Kevorkian, who had assisted over 40 people to commit suicide in Michigan, helped a 54-year-old woman, Janet Adkins, who had early-onset Alzheimer’s, commit suicide.  Though he was charged with murder in December 1990, the charge was dropped since Michigan had no laws outlawing suicide or doctors providing medical assistance.  But Kevorkian sought to become something of a martyr for the cause when he went beyond just assisting a suicide to actively killing a patient by giving a man a lethal injection.  He even showed himself doing so in a video aired on 60 MinutesSoon after the tape was aired, he was charged with second-degree murder, was sentenced to 10-25 years, and after serving 8 years, he was released in 2007, now a very frail and weakened man, who died in 2011.

Still the 1990s marked the beginning of the modern movement, after Oregon passed the first Death with Dignity Act in 1994 that was finally approved and put into practice in 1997.  This legislation provided the fundamental requirements for how physicians might assist in suicide legally, though no doctor had to participate in doing so. Should a physician object, he could refer the patient to another doctor willing to provide the requested assistance.  

 

pillsHowever, under this act in Oregon and the other four states where assisted suicide is a legal option, certain required guidelines have been established to protect against abuse.  As described on the Death with Dignity website (www.deathwithdignity.org), the patient has to be a mentally competent adult who has “a terminal illness with a confirmed prognosis of having 6 or fewer months to live.”  The patient has to voluntarily make the request to receive a prescription medication to “hasten their inevitable, imminent death.”  Moreover two physicians have to confirm the patient’s “residency, diagnosis, prognosis, mental competence, and voluntariness of the request.”  Moreover, there are two waiting periods, one between making the oral request, and the second between receiving and filling the prescription.  Additionally, the physician merely prescribes; the patient has to take the medication him or herself.

Though Washington passed a Death with Dignity Act in 2008 and Vermont did so in 2013, efforts in California went nowhere despite bills introduced in 1999 through 2006.  The modern controversy really began with the case of Brittany Maynard from Orange County, California.  Since she couldn’t get physician assisted suicide in California, she moved to Oregon, and her case was widely publicized.  She even recorded a video before she died, as she announced she would, on November 1, 2014.  This video was then shown in hearings in Sacramento on the End of Life Option Act, which was signed by Governor Jerry Brown in October 2015 and went into effect in June 2016.

Since then, the 21 states considering Death with Dignity (or End of Life Option) acts are primarily in the West and Northwest, such as Arizona, Colorado, Hawaii, Kansas, Michigan, Minnesota, Missouri, Nebraska, Utah, and Wisconsin, or in the New England-New York area, including Maryland, Massachusetts, New Hampshire, New Jersey, New York, Rhode Island, and the District of Columbia.  So the push is on to make this procedure legal, and as more states pass these laws, the pressure is likely to continue in other states to pass these laws.

 

What Are the Pros and Cons?

watchingAs a doctor caring for end-of-life care, I have been following these developments for end-of-life care laws and the controversy surrounding them, as the legality is considered in each state.  These laws could affect the practice of me and other doctors, since in discussing end-of-life care choices, such as whether to opt for a DNR/DNI status, which most patients chose, some patients may ask for medications to end their life, once their condition is deemed terminal with only 6 months to live.  However, I currently do not have the legal option to do this, and while some doctors might choose not to provide these medications even if they have this legal option in the future, others might make that choice. So what are the pros and cons?  

The pro argument, of course, is that this assisted suicide option gives patients with a serious illness the opportunity to have control of their own bodies and lives. It also addresses their concern about physical and psychosocial distress, by giving them the option of ending their life before their pain and suffering becomes too great.  Moreover, the supporters of assisted suicide point to the effects of the law in Oregon, which has the longest experience with such a law. For example, a study by Ganzni and his colleagues which appeared in the March 9, 2009 issue of the Archives of Internal Medicine showed that out of 56 individuals inquiring about physician-assisted death, 41 had died, but only 9 had died after receiving lethal doses of a medication prescribed by a physician.  The major reason they wanted a doctor to assist them was that they wanted to maintain control over the circumstances of their death and die at home.  They also had concerns about their loss of independence and their future pain and disability.  So the pro argument is that the patients gain this control and have the ability to take the doctor prescribed medications or not.  Another argument in favor of this choice is that if people have the right to refuse life-saving treatments, they should be free to choose to end their own lives, too.

But the con side has many strong arguments against the practice, too.  One is that if the doctor follows the patients’ wishes to hasten their death, doing so undercuts the essential role of the physician which is that of a healer who does no harm.  Another argument against the practice is that patients already have the right to refuse life-sustaining treatments, and they can end their lives in ways that do not involve physicians. Another concern is that patients could be pressured to choose the assisted suicide option by family members who stand to inherit money when the patient dies or feel the patient has become a burden, because of the astronomical costs of continued medical care and the coming expiration of insurance coverage.  Or insurance companies may push for this option because they want to save money they would otherwise have to pay out for medical care. Still another argument is that doctor’s assessment of the patient’s prognosis could be inaccurate, and a patient deemed terminal could well recover; or at least might live for many months or even years longer. Then, too, seriously ill people may suffer from undiagnosed depression or other mental illnesses that affect their ability to make an informed decision; so if their depression or mental illness was treated, they might not choose to seek out assisted suicide.

On the other hand, on the pro side, there is no evidence of coercion or abuse in studying how the law has operated in Oregon, where over 700 people have taken their lives with prescribed medication, including Brittany Maynard, as of January 2015, when an article about the debate: “Physician-Assisted Suicide: Yes or No? The Great Debate” by Emily Lea Barry appeared in Medscape, a website devoted to medical issues (www.medscape.com).

It also seems that if patients had more knowledge about and access to palliative care and hospice programs, this could reduce their desire to take lethal medications, although many patients might still want to take them.  The number of patients opting to go into a hospice or receive palliative care is certainly growing.  For instance, the number of hospice providers grew near three times from 2312 to 5800 between 1994 and 2013, while the percentage of hospitals with over 50 beds that have palliative-care programs grew from 24% to 72% in that same period, according to an article in Modern Health Care: “Assisted-Suicide Debate Focuses Attention on Palliative, Hospice Care” by Lisa Schencker in May 16, 2015.  At the same time, 93% of the terminally ill patients who chose to end their lives were in hospices before they died, showing that end-of-life patients may opt to do both – stay in a hospice or palliative care program until the pain becomes unendurable and then seek out medication from a doctor as a final solution.

 

assisted-suicideWhat do doctors think?  As of May 2016, according to an article: “Physician-Assisted Suicide Up for Debate,” by John N. Frank in Medical Economics (http://medicaleconomics.modernmedicine.com/), the American Medical Association’s official position is to oppose this suicide, and the American College of Physicians does not support legalization of physician-assisted suicide either.  The American Academy of Family Physicians doesn’t have a policy on this issue, though it follows the AMA code of ethics.  However, on the state level, in the states where the practice has been legalized, the state medical association has commonly taken a neutral stance, such as in California. And some medical groups have supported end-of-life legislation, such as the American Medical Students Association, which signed a letter of support for the California legislation, on the grounds that medical decisions belong to the patients and their care providers.

Given these conflicting points of view, what is the best approach?  I can’t really answer that question, since there are arguments by credible doctors, ethicists, and others on both sides of the fence.  Thus, I think it ultimately comes down to one’s own personal code of ethics.  It would seem that legalization is the likely wave of the future, especially since the Brittany Maynard case focused public interest on the issue, and increasingly, proposed legislation to legalize assisted suicide has gained popular support and passage in a growing number of states is likely.  In turn, the passage of this legislation could influence the position of the major medical groups that now oppose the practice to perhaps take a neutral stance.

But for now, the outcome of the move to make assisted suicide – or the end-of-life care option – as it is called in most of these bills, is unclear.  Thus, my own position is to take a neutral stance, too.  I think it is important to consider the issue; but then decide for yourself what your approach would be whether you are a patient or a physician involved in caring for a patient with a terminal condition.  


Dr. Sebastian Sepulveda has had nearly 30 years’ experience as a doctor and professor of medicine, working with patients in a community hospital and personally caring for them, many times as the sole provider of end-of-life care.  Since 2005, he has been in private practice, dealing with private outpatients and with inpatients in hospitals, especially with those who have what appears to be a terminal condition.  His book At Death’s Door and Death’s Door TV series pilot based on his work will be released in 2017.  His website is at www.atdeathsdoorbookandfilm.com