Statutory proposals for physician-assisted suicide (PAS) have often
included provisions for a waiting period and a consultation for mental disability.
This is important because sick and dying people are often responding to pain
or psychological anguish, or searching for meaning and control.1 Subtle
impairments of cognition and attention can compromise the decision-making
ability of even seemingly competent persons.2 These
factors can distort patients' perceptions of their own interests and affect
the decisions they make. Many such requests turn out to be transient and ameliorated
by symptom improvement or psychological adjustment with time.1
Research has demonstrated that almost all patients can be made physically
comfortable with methods that are readily at hand.3,4 The
few who cannot be awake and reasonably comfortable can have ongoing sedation
through to death, as authorized by existing law.5,6 Thus,
policymakers might reasonably question relying on the decisions of very sick
people who may misperceive the symptoms they will have to bear or whose suffering
could be ameliorated by better access to effective palliative care.
Another problem is that many patients with progressive, eventually fatal
illness find that they cannot count on reliable care with only reasonable
burdens on loved ones. Persons might well prefer suicide to overwhelming pain,
demeaning nursing home conditions, or family bankruptcy. Patients weigh the
impact of their survival and death on their loved ones,7 and
financial and emotional pressures can shape decision making.8 In
our society there are pervasive disparities in health care access and utilization,9 with those who are physically frail, poor, socially
isolated, uninsured, illiterate, or non–English speaking are likely
to need a helpful care system and simultaneously least likely to be able to
find help. For example, minorities, people with Medicaid, or those living
in lower income areas are less likely to use hospice services.10,11 Serious
illness has become the most common cause of personal bankruptcy, with studies
showing that nearly half of US bankruptcy filings result from the financial
burden of severe illness or injury.12
Descriptions of the practice of PAS and euthanasia where these practices
are legal do not provide definitive information on the implications of legalizing
PAS for disadvantaged persons. On the one hand, in 1998, nearly one third
of Oregon residents who made requests for lethal medication under Oregon's
law authorizing PAS gave the reasons of fear of "being a burden," financial
pressures, and the lack of social support.13 However,
patients requesting PAS in Oregon have been similar to the general population
in being 97% white and 98% insured for hospice,14 and
Oregonians who received lethal prescriptions were relatively affluent and
insured.15 In 1 study in the Netherlands,
where PAS is also legal, education and income did not correlate with the utilization
of PAS.16 Most states, however, are characterized
by much greater social inequalities and cultural diversity. Both the Netherlands
and Oregon have authorized PAS for only a few years, and the practice remains
under close scrutiny. Certainly, many persons in the United States cannot
count on living out the end of life with comfort, companionship, and financial
Finally, empowering physicians to assist in suicide might seriously
undermine patients' trust in the medical profession. Physicians play an inescapable
role in presenting and shaping health care decisions. Patients and families
find it essential to rely on physicians when fear, lack of information, unfamiliarity,
and other factors limit their independence and authority. By empowering physicians
to help the patient to take his or her own life, legalizing PAS threatens
to make patients and families suspicious at a time when they would like to
rely on a trusting relationship with their physician.
Author Affiliations: Dr Lorenz is a VA HSR
& D Career Development Awardee.
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