By F. Michael Gloth, III, M.D.
The nation's largest and most influential medical organizations, the American Medical Association and the American College of Physicians, as well as many smaller physicians' groups, are on record as opposing physician-assisted suicide. Yet, despite the strong and widespread opposition of the medical community, last year physicians in Oregon wrote prescriptions to help kill 38 of their patients kill themselves. The 38 deaths represent a disturbing reversal in the decline in physician-assisted suicides in Oregon seen in the prior year: from 27 in 2000 to 21 in 2001. One must ask how Oregon came to accept a practice so strongly opposed by organized medicine.
The answer is in large part due to clever media campaigns waged by advocates of physician-assisted suicide, and the willingness of these groups to distort medical facts and disseminate myths with the help of an uninformed or biased media. In today's society, image and public perception are often more persuasive than facts and logic. Advocates of physician-assisted suicide try to obscure its real nature by avoiding references to euthanasia and homicide. Suicide is not advocated, except where it is cloaked as a medical procedure with the qualifier "physician-assisted." Yet, the arguments supporting physician-assisted suicide apply equally to suicide without a physician's assistance, as well as to euthanasia and homicide. Adding the term "physician-assisted" makes it no less suicide, and no less murder — although admittedly it sounds more benign.
The confusion engendered by the lack of clear and accurate media reporting is not the only reason, of course. Many today measure the value of life in strictly utilitarian terms. Seeing diminished value in lives that are no longer robust, they conclude that physician-assisted suicide is a rational choice.
The goal of this article is to provide information on physician-assisted suicide drawn from clinical and public policy experience. Arguments on both sides of the public debate are presented, and it will be shown that as a matter of morality, medicine and public policy, physician-assisted suicide is the wrong approach to end of life care. Current public policy efforts to improve the care given to terminally ill patients will also be examined.
What is physician-assisted suicide?
Physician-assisted suicide occurs when a physician facilitates a patient's death by providing the necessary means and information to enable the patient to perform a life-ending act — for example the physician provides a potentially lethal medication and information about the lethal dose and how to administer it, aware that the patient may commit suicide. Most laws against physician-assisted suicide require evidence that the physician intervened to assist suicide. Under Maryland's law for example, physicians who provide medication to relieve pain are not prosecuted even if the dosage could increase the risk of death — unless they acted with an intent to assist a suicide. Physician-assisted suicide is distinct from active euthanasia where the physician himself directly acts to cause death — but the intent of helping to cause that death is the same.
How do states other than Oregon treat physician-assisted suicide?
Oregon stands as an anomaly. Physician-assisted suicide is a crime in forty-five states, by statute in 39 states and by common law in the remaining six. Hawaii, Nevada, Utah, and Wyoming have no controlling law on physician-assisted suicide.
In addition to Oregon, four states — Michigan, Washington, California, and Maine — have put the issue of physician-assisted suicide to a referendum. In all but Oregon, the practice was rejected by voters. In the Spring of 2002, an effort to authorize the practice in Hawaii was defeated.
Arguments favoring physician-assisted suicide
The arguments for physician-assisted suicide are generally similar to those supporting euthanasia. Most commonly it is argued that death offers the only means of attaining comfort or dignity for patients in extreme duress, such as those suffering from a terminal, painful, debilitating illness. Advocates of euthanasia and physician-assisted suicide buttress this argument with data showing that inadequate pain control is given to patients who are dying with painful conditions. The assistance of a physician is supposed to provide expertise to increase the likelihood of a successful suicide attempt and make the act "cleaner" — both literally and politically.
Arguments concerning loss of autonomy and impaired quality of life are also offered to justify physician-assisted suicide. Advocates of assisted suicide add that systemic changes to medical care, such as improved palliative care, won't benefit the individual currently dying in discomfort. They argue from the premise that immediate death is preferable to suffering with pain or "lack of dignity" in the last days, weeks or months of life.
Another argument in favor of assisted suicide is the prevention of "botched" suicide. Most terminally ill patients who wish to commit suicide want it accomplished by medical means, nonviolently — suicide by self-administered drugs is not always easy to accomplish. Failed attempts can cause greater trauma for the patient and caregivers than the natural course of the disease itself. In such circumstances, patients may beg caregivers to complete their failed attempt to die. This scenario is meant to bolster the argument for physician-assisted suicide, on the theory that such assistance prevents a greater harm than it causes.
Reasons to oppose physician-assisted suicide
Catholic teaching condemns physician-assisted suicide because it, like murder, involves taking an innocent human life:
Suicide is always as morally objectionable as murder. The Church's tradition has always rejected it as a gravely evil choice: To concur with the intention of another person to commit suicide and to help in carrying it out through so-called "assisted suicide" means to cooperate in, and at times to be the actual perpetrator of, an injustice which can never be excused, even if it is requested. In a remarkably relevant passage Saint Augustine writes that "it is never licit to kill another: even if he should wish it, indeed if he request it because, hanging between life and death, he begs for help in freeing the soul struggling against the bonds of the body and longing to be released; nor is it licit even when a sick person is no longer able to live (The Gospel of Life, no. 66).
Policy makers and the public are not always receptive to appeals to Catholic moral teaching. Fortunately, well-established principles of medicine and bioethics provide sound and abundant grounds for opposing physician-assisted suicide.
In fact, the chief argument — that assisted suicide is needed to avoid the excruciating pain and suffering that may accompany a terminal illness — is based on a fallacy. Advances in pain management now make it possible to control pain effectively in dying patients; only rarely is it necessary to induce sleep to relieve pain or distress in the final stage of dying. But it is true that many physicians don't provide adequate pain relief. It is also true that changes in health care are required to better train and prepare physicians for pain control, and to better understand and provide end of life care. However, health care providers who specialize in pain relief and those involved with hospice are much more knowledgeable than the average physician about providing comfort and dignity at the end of life. In 2002 the American Geriatrics Society released guidelines emphasizing the availability of treatment for pain in older adults.
Although untreated pain is an argument that sways many in the general public to support physician-assisted suicide, it is not among the top reasons why patients request it, as Lois Snyder, Esq., Director of the Center for Ethics and Professionalism for the American College of Physicians, has noted:
The more compelling arguments for physician-assisted suicide — about avoiding great pain and suffering — do not seem to be motivating requests for physician-assisted suicide in Oregon. Based on current evidence, people seeking physician-assisted suicide there are more often concerned about loss of autonomy and control. We question whether it is medicine's role to give patients control over the timing and manner of death.
This finding is supported by a report from the Oregon Health Division's Fifth Annual Report on Oregon's Death with Dignity Act, indicating that the dominant reasons for requesting physician-assisted suicide were loss of autonomy (84%), decreasing ability to participate in activities that make life enjoyable (84%), and losing control of bodily functions (47%).
Federal Law
The federal government has also tried to address this issue. The Pain Relief Promotion Act passed the House of Representatives in 2000, but was not brought to a vote in the Senate. The bill promoted pain management and palliative care through the education and training of health care providers. It also banned dispensing federally-controlled drugs with the intent to assist in a patient's suicide. It provided a safe haven for physicians who dispense pain control medications in accordance with the federal Controlled Substance Act.
Paradoxically, some physicians and even some health-related organizations opposed the legislation, despite its specific language protecting providers who prescribe medications for pain relief. The strategy for convincing legislators that a bill promoting pain relief would actually do the opposite and impede pain relief is laid out in some detail in a book entitled Handbook of Pain Relief in Older Adults, to be released by Humana Press later this year. Advocates of physician-assisted suicide and euthanasia knew that support for their agenda was thin, both in the medical community and in the general public. Seniors, a rapidly growing political force, are particularly leery of measures that may appear to be incremental steps toward arbitrarily limiting life. There is, of course, overwhelming support for providing pain relief for those who are suffering. Therefore opposition to the legislation, could not be based on opposition to pain control or support for assisted suicide, instead, doubts had to be raised about the effectiveness of the bill in advancing pain control.
Opponents therefore broadcast their "fears" that physicians would misunderstand the bill, that this would have a "chilling effect" on physicians prescribing medication for pain, and, thus, that pain relief efforts would be impeded. Ultimately the strategy was effective and even persuaded some well-recognized experts in palliative care to oppose the Pain Relief Promotion Act.
When a bill bans physician-assisted suicide but affirms and protects physicians using controlled drugs for pain management, does that have a chilling effect on patient care? Experience with state legislation shows the opposite is true. Maryland, for example, banned physician-assisted suicide in 1999. Now that the law has been in effect for a few years it is clear that such legislation has not had a "chilling effect" on pharmaceutical prescribing. To the contrary, Drug Enforcement Administration records from 1992-2000 show that in Maryland, as in every state that passed a similar law in that time period, there has been an increase in the per capita use of opioids, like morphine, used for pain control (see figure 1). When physicians attending lectures I've given on pain management throughout the country learn about these protections for prescribers, they react with a mixture of relief and elation that such legislation exists.
Opponents of a ban on physician-assisted suicide continue to raise the issue of its supposed "chilling effect" on pain management, but they carefully avoid reference to the accumulating evidence against this argument in state after state. Their other arguments — for example, that physicians fear government intervention and oversight, or that assisted suicide is a "states' rights" issue — are specious. The real agenda of many groups organized against bans on physician-assisted suicide is to promote legalized euthanasia. They fear that banning assisted suicide will hurt their cause, whereas allowing it will be an incremental step toward their goal of permitting active euthanasia.
The Federal Courts
In 1997, the U.S. Supreme Court ruled that state laws that criminalize physician-assisted suicide are not unconstitutional. That ruling did not make physician-assisted suicide a crime. It simply declared that criminalizing physician-assisted suicide is a matter that each state may decide for itself.
But the court will likely consider the issue again. In November 2001, U. S. Attorney General John Ashcroft issued a directive entitled "Dispensing of Controlled Substances to Assist Suicide" (the "Ashcroft Directive"). The directive concludes that assisted suicide is not "a legitimate medical purpose" for drugs controlled by the federal government under the Controlled Substances Act. Under the directive, doctors who use these drugs to assist suicide are subject to having their federal narcotics prescribing licenses suspended or revoked.
Opponents of the directive have again raised the unfounded fear of a "chilling effect" on pain relief. They claim the directive will undo years of work spent in overcoming apprehension about addiction and securing adequate pain relief for patients. In April 2002, U.S. District Judge Robert Jones permanently restrained the Ashcroft Directive, stating that the U.S. Attorney General had "overstepped the authority of the federal Controlled Substances Act when he declared that physician-assisted suicide was not a 'legitimate medical purpose.'" The Attorney General has appealed Judge Jones' decision and the case is pending before the 9th Circuit Court of Appeals as of this writing.
The role of physicians
The nation's largest medical specialty organization and second-largest physician group, the American College of Physicians, has officially announced its opposition to physician-assisted suicide as a matter of principle. It has also expressed concerns about effectively regulating the practice and protecting vulnerable populations, as well as the potential for abuse. The College continues to be concerned about research showing that physicians and other clinicians are often not well trained in end of life care. If physician-assisted suicide were to be accepted as standard practice, the College believes it would undermine the physician-patient relationship as well as improvements in end of life care.
The nation's largest medical group, the American Medical Association (AMA), has taken a similar stance, stating that allowing physicians to participate in assisted suicide would cause more harm than good. The AMA maintains that physician-assisted suicide is fundamentally incompatible with the physician's role as healer, would be difficult or impossible to control, and would pose serious societal risks. The American Medical Association's 156-year-old Code of Medical Ethics prohibits physician-assisted suicide in the same strong language it uses to prohibit physician involvement in euthanasia.
Legalizing physician-assisted suicide would bring subtle and not-so-subtle pressure to bear on terminally ill patients who fear their illness is physically, emotionally, or financially burdensome to families or caretakers. The legal option to commit suicide with a physician's help would be perceived as an obligation by many terminally ill patients concerned about being a burden to loved ones — patients who might not otherwise have considered suicide at all.
Instead of participating in assisted suicide, physicians should respond aggressively to the needs of patients at the end of life. The American Medical Association affirms that patients should not be abandoned simply because a cure may be impossible, as now happens too often. Multidisciplinary interventions should be sought, including specialty consultation, hospice care, spiritual support, family counseling and other assistance. Patients near the end of life deserve to receive emotional support, comfort care, adequate pain control, respect for patient autonomy, and good communication.
For physicians, the issue transcends state legislation. Doctors must not be forced to participate in physician-assisted suicide, abortion, capital punishment or other practices that run counter to professional ethics or personal beliefs. And physician-assisted suicide raises other medical dilemmas as well. My own research and many other studies demonstrate that accurate diagnosis and prognosis cannot always be assured. For some patients who died from physician-assisted suicide, subsequent autopsies revealed that they did not have a terminal illness! The impact such an error has on survivors (not to mention the patient) can only be imagined.
Distinguishing between actively ending a life and allowing the natural progression of events is an integral part of discussions of physician-assisted suicide. Honoring a person's wishes regarding burdensome interventions, such as cardiopulmonary resuscitation (CPR) or ventilatory support neither hastens death nor prolongs life. In such situations, the public often has a misconception of the impact of some medical interventions. Our inability to extend life or even to predict our ability to do so is far different from the impression one might get from watching prime-time television. Oftentimes medical interventions may actually cause more suffering and even unintentionally hasten death. Reviews of the evidence on the use of feeding tubes and CPR in frail older adults have made this abundantly clear. What is important in providing care at the end of life is that physicians maintain the patient-physician relationship no matter what course the patient finally chooses, short of participating in suicide. Withdrawing or withholding treatments, e.g. respirators, CPR, and even hydration or nutrition at the request of a terminally ill patient or the patient's surrogate can be consistent with professional principles and are supported by the American Medical Association's Code of Medical Ethics.
There is, of course, a final reason to advocate for physician-assisted suicide. It is cheaper to kill a person than to provide care. Yet a physician's first obligation is to "Do No Harm." Until that is replaced with "Save more money," it will be difficult to support physician-assisted suicide.
Dr. Gloth is Associate Professor of Medicine at Johns Hopkins University School of Medicine and president of Victory Springs Senior Health Associates, Inc. He is the former President of the Hospice Network of Maryland and is Board Certified in Hospice and Palliative Medicine. Dr. Gloth currently serves as the Associate Medical Director for Carroll Hospice in Maryland.