0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
msJAMA |

Moral and Practical Challenges of Physician-Assisted Suicide FREE

Karl Lorenz, MD, MSHS; Joanne Lynn, MD, MA, MS
JAMA. 2003;289(17):2282. doi:10.1001/jama.289.17.2282.
Text Size: A A A
Published online

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 resources.3,17

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.

References
Emanuel EJ, Fairclough DL, Emanuel LL. Attitudes and desires related to euthanasia and physician-assisted suicide among terminally ill patients and their caregivers.  JAMA.2000;284:2460-2468.
Drought TS, Koenig BA. "Choice" in end-of-life decision making: Researching fact or fiction?  Gerontologist.2002;42:114-128.
Field MJ, Cassel CK. Approaching Death: Improving Care at the End of Life. Washington, DC: National Academy Press; 1997.
Zech DF, Grond S, Lynch J, Hertel D, Lehmann KA. Validation of World Health Organization guidelines for cancer pain relief.  Pain.1995;63:65-76.
Quill TE, Cassel C. Professional organizations' position statements on physician-assisted suicide.  Ann Intern Med.2003;138:208-211.
Quill TE, Byock IR. Responding to intractable terminal suffering.  Ann Intern Med.2000;132:408-414.
Steinhauser KE, Christakis NA, Clipp EC, McNeilly M, McIntyre L, Tulsky JA. Factors considered important at the end of life by patients, family, physicians, and other care providers.  JAMA.2000;284:2476-2482.
Covinsky KE, Landefeld CS, Teno J.  et al.  Is economic hardship on the families of the seriously ill associated with patient and surrogate care preferences?  Arch Intern Med.1996;156:1737-1741.
Robert Wood Johnson Foundation.  Access reports. Available at: http://www.accessproject.org/publications.htm. Accessed March 24, 2003.
Virnig BA, Kind S, McBean M, Fisher E. Geographic variation in hospice use prior to death.  J Am Geriatr Soc.2000;48:1117-1125.
Iwashyna TJ, Chang VW, Zhang JX, Christakis NA. The lack of effect of market structure on hospice use.  Health Serv Res.2002;37:1531-1551.
Crenshaw A. Study cites medical bills for many bankruptcies.  Washington Post.April 25, 2000, section E, p 1.
Ganzini L, Nelson HD, Schmidt TA, Kraemer DF, Delorit MA, Lee MA. Physicians' experiences with the Oregon Death With Dignity Act.  N Engl J Med.2000;342:557-563.
Chin AE, Hedberg K, Higginson GK, Fleming DW. Legalized physician-assisted suicide in Oregon—the first year's experience.  N Engl J Med.1999;340:577-583.
Sullivan AD, Hedberg K, Fleming DW. Legalized physician-assisted suicide in Oregon—the second year.  N Engl J Med.2000;342:598-604.
Veldink JH, Wokke JH, van der Wal G, Vianney de Jong JM, van den Berg LH. Euthanasia and physician-assisted suicide among patients with amyotrophic lateral sclerosis in the Netherlands.  N Engl J Med.2002;346:1638-1644.
Foley K, Gelband H. Improving Palliative Care for Cancer: Summary and RecommendationsWashingon, DC: National Cancer Policy Board; 2001.

Author Affiliations: Dr Lorenz is a VA HSR & D Career Development Awardee.

Figures

Tables

References

Emanuel EJ, Fairclough DL, Emanuel LL. Attitudes and desires related to euthanasia and physician-assisted suicide among terminally ill patients and their caregivers.  JAMA.2000;284:2460-2468.
Drought TS, Koenig BA. "Choice" in end-of-life decision making: Researching fact or fiction?  Gerontologist.2002;42:114-128.
Field MJ, Cassel CK. Approaching Death: Improving Care at the End of Life. Washington, DC: National Academy Press; 1997.
Zech DF, Grond S, Lynch J, Hertel D, Lehmann KA. Validation of World Health Organization guidelines for cancer pain relief.  Pain.1995;63:65-76.
Quill TE, Cassel C. Professional organizations' position statements on physician-assisted suicide.  Ann Intern Med.2003;138:208-211.
Quill TE, Byock IR. Responding to intractable terminal suffering.  Ann Intern Med.2000;132:408-414.
Steinhauser KE, Christakis NA, Clipp EC, McNeilly M, McIntyre L, Tulsky JA. Factors considered important at the end of life by patients, family, physicians, and other care providers.  JAMA.2000;284:2476-2482.
Covinsky KE, Landefeld CS, Teno J.  et al.  Is economic hardship on the families of the seriously ill associated with patient and surrogate care preferences?  Arch Intern Med.1996;156:1737-1741.
Robert Wood Johnson Foundation.  Access reports. Available at: http://www.accessproject.org/publications.htm. Accessed March 24, 2003.
Virnig BA, Kind S, McBean M, Fisher E. Geographic variation in hospice use prior to death.  J Am Geriatr Soc.2000;48:1117-1125.
Iwashyna TJ, Chang VW, Zhang JX, Christakis NA. The lack of effect of market structure on hospice use.  Health Serv Res.2002;37:1531-1551.
Crenshaw A. Study cites medical bills for many bankruptcies.  Washington Post.April 25, 2000, section E, p 1.
Ganzini L, Nelson HD, Schmidt TA, Kraemer DF, Delorit MA, Lee MA. Physicians' experiences with the Oregon Death With Dignity Act.  N Engl J Med.2000;342:557-563.
Chin AE, Hedberg K, Higginson GK, Fleming DW. Legalized physician-assisted suicide in Oregon—the first year's experience.  N Engl J Med.1999;340:577-583.
Sullivan AD, Hedberg K, Fleming DW. Legalized physician-assisted suicide in Oregon—the second year.  N Engl J Med.2000;342:598-604.
Veldink JH, Wokke JH, van der Wal G, Vianney de Jong JM, van den Berg LH. Euthanasia and physician-assisted suicide among patients with amyotrophic lateral sclerosis in the Netherlands.  N Engl J Med.2002;346:1638-1644.
Foley K, Gelband H. Improving Palliative Care for Cancer: Summary and RecommendationsWashingon, DC: National Cancer Policy Board; 2001.
CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.