Feb. 23, 2000 (Boston) -- Few inflammatory issues in medicine burn as intensely as the questions of physician-assisted suicide and euthanasia. But in a series of articles in the Feb. 24 issue of The New England Journal of Medicine, researchers from Oregon, where physician-assisted suicide is legal, and from the Netherlands, where the practice is not legal but is accepted, attempt to balance the heat of debate with the dispassionate light of evidence.
"There is concern that with the legalization of assisted suicide, women, poor persons, and those who are members of ethnic or racial minority groups may request assistance with suicide because of inadequate social support or lack of access to health care," write Linda Ganzini, MD, and her colleagues in Oregon. However, "after two years of legally assisted suicide, we found little evidence that vulnerable groups have been given prescriptions for lethal medication in lieu of palliative care." Palliative care is care intended only to ease the severity of symptoms without curing the condition.
Physician-assisted suicide, by itself a hot button issue in medical ethics circles, is when a patient actively puts an end to his or her own life with the help of a physician. This help usually comes in the form of a prescription for a potentially fatal medication. Physician-assisted suicide therefore differs from euthanasia, which is when a person other than the patient intentionally puts the patient to death. Euthanasia is sometimes called "mercy killing" because patients put to death in this manner typically have an incurable or extremely painful disease.
Physicians in Oregon granted only one in six patient requests for a lethal prescription, and only one in 10 of such requests actually resulted in suicide. In all, 15% of eligible patients changed their minds about suicide, some because they found sufficient relief through pain control medications or other measures.
"As a researcher, at every point I've tried to have people who are both very opposed and very supportive of assisted suicide look at the survey and the results. Both sides were very relieved that physicians seemed to be operating in a responsible and very prudent manner," says Ganzini, director of geriatric psychiatry at the Portland VA Medical Center and associate professor of psychiatry at Oregon Health Sciences University, in an interview with WebMD. "Both sides were relieved that patients were getting palliative interventions and that it was working sometimes. So I think there is common ground there, and I think everybody should give a sigh of relief about that."
In a separate study, researchers from the Oregon Health Division in Portland report that terminally ill patients who opted for and carried out suicide with the help of their doctors in 1999 accounted for only 27 of the nearly 30,000 deaths reported in the state last year. Amy D. Sullivan, MD, MPH, and colleagues say that patients appeared to have many complex and often overlapping reasons for deciding to ask for help with ending their lives. According to family members, dying patients most frequently cited physical suffering, fears of loss of control over their lives, and concerns about loss of bodily functions as reasons for seeking help.
But Johanna H. Groenenwoud, MD, and colleagues from the Netherlands -- where both physician-assisted suicide and euthanasia are allowed under strictly controlled circumstances -- report that plans for a peaceful assisted suicide can sometimes go awry, and physicians may have to step in to ensure that patients do not suffer.
In a study of more than 100 cases of intended assisted suicide and more than 500 cases of euthanasia, complications included a longer than expected time to death and failure to induce coma. In 7% of suicides, patients awakened from their comas. This happened in 16% of euthanasia cases.
Technical complications included difficulty in finding a vein for lethal injection of medication, trouble swallowing pills or vomiting them up once they had been swallowed, or loss of consciousness before the drug could be administered. In 18% of cases where the physician's intent was to help the patient with suicide, the doctor felt it necessary to intervene by administering a lethal drug, either because of problems with completion or because the patient was unable to take medication.
The studies pick a tentative and delicate path through the minefield that lies between the camps of right-to-die extremists such as Jack Kevorkian on one flank and right-to-life zealots on the other, says Sherwin B. Nuland, MD, clinical professor of surgery at Yale University School of Medicine. Nuland wrote an editorial accompanying the studies.
"Opponents of physician-assisted suicide will look at these complications as evidence to support their viewpoint, and they are justified in doing so. But those who believe that in certain, carefully controlled situations, providing assistance with suicide is an ethical responsibility should see the findings in an entirely different light," Nuland writes.
He says that physicians must decide for themselves if, when, and how they should help dying patients find relief from unrelenting suffering, and that those who choose to take concrete steps must do everything in their power to ensure as peaceful and untroubled a death as possible.
"You have to remember that there will probably be a relatively small proportion of physicians whose conscience allows them to participate in [physician-assisted suicide and euthanasia]," Nuland tells WebMD. "But I think for those people there should be training, and I think the natural trainers are anesthesiologists and clinical pharmacologists." He emphasizes that training in physician-assisted suicide should be readily available but totally voluntary, and it should not be part of the standard medical school curriculum.
A medical ethicist who was not involved in the studies but supports protection of private decisions between dying patients and their doctors tells WebMD that our society is not ready to publicly support either physician-assisted suicide or euthanasia.
"Doctors have a legal, moral, and ethical obligation to keep their patients out of pain, and if that involves giving them lethal prescriptions and risking that [patients] take them to kill themselves, that's perfectly fine. Even the U.S. Supreme Court says that's fine," says George J. Annas, JD, MPH, an Edward R. Utley professor, chairman of the health law department at Boston University School of Public Health, and a professor in the Boston University schools of Medicine and Law. "If you've got to kill your patient to keep them out of pain -- as long as you don't intend to kill them but intend to keep them out of pain -- that's the practice of medicine."
- In the state of Oregon, where physician-assisted suicide is legal, only one in six requests for lethal prescriptions are granted, while only one in 10 such requests actually results in suicide.
- Although some had feared that those who lack social support or access to health care, including women, poor people, and minorities, would be more likely to seek physician-assisted suicide, new research shows that this is not the case.
- In another study, researchers noted complications, such as a longer than expected time to death or failure to induce coma. In 7% of assisted suicides and 16% of euthanasia cases, patients woke up from their comas.