Pros and Cons of Physician-Assisted Suicide

October 5, 2017

Pros and Cons of Physician-Assisted Suicide

  1. Abigail Zuger, MD

The American College of Physicians again declines to endorse the practice but provides articulate commentary both in support and in opposition.

  1. Abigail Zuger, MD

Twenty years ago, Oregon became the first state in the U.S. to legalize physician-assisted suicide (PAS). Thirty other states have debated and rejected similar legislation, whereas 5 states and the District of Columbia have legalized PAS or enabled it by judicial ruling. This ongoing national conversation has prompted the American College of Physicians (ACP) to reconsider its 2001 position paper against the practice — and once again, the organization has declined to endorse it. In a position paper supplemented by several independent commentaries, reasons to support and to disagree with the ACP decision were reviewed.

Writing on behalf of the ACP, Sulmasy and Mueller note that proponents of PAS consider it to be a logical extension of physicians' obligations to respect patient autonomy, to relieve suffering, and to support their patients during moments of crisis. PAS opponents counter by citing intrinsic professional obligations to avoid doing harm, as well as longstanding specific injunctions against colluding in suicide. Opponents point out that patient autonomy is not an absolute right, and they worry that societal acceptance of PAS might start “a slow slide down a slippery slope” toward acceptance of involuntary euthanasia; this is the concern that prompts many advocacy groups for disabled people to firmly oppose PAS.

Sulmasy and Mueller review the confusing ethical landscape of end-of-life care, including physicians' duties to honor patients' decisions to stop or forego lifesaving treatments and to medicate pain even if pain medication might shorten life. However, the authors emphasize that terminal illness brings many kinds of suffering: not only physical pain and clinical depression that should be addressed medically, but also spiritual and existential suffering that seldom can be addressed medically and that perhaps should not be seen as projects for physicians to undertake.

“Is it reasonable to ask medicine to relieve all human suffering?” these authors ask. “Is a medicalized death a good death?” They conclude that medicalizing death even further, with a doctor providing a terminal prescription, “does not address the needs of dying patients and their families. What is needed is care that emphasizes caring in the last phase of life.” To this end, they include in their discussion a 12-step plan for physicians to use when caring for dying patients.

Writing in disagreement with the ACP, Quill and colleagues first note that they support this 12-step plan. They add, however, that if the process proves unsuccessful, “all legally available last-resort options should be explored.” They urge physicians who cannot personally support a patient's wish for help with suicide to help the patient find a doctor who can. “We are concerned that concluding a guideline by stating ‘physicians should not do this' is a problematic public health response,” these authors write. “Even if one personally disagrees with the behavior, studying it might tell us much about the state of end-of-life care and how it can be improved.”

Writing in support of the ACP's decision, Kussmaul notes that the “slippery slope” objection to PAS might be dismissed as alarmist but is not easily refuted. He cites statistics from the Netherlands (where PAS has long been legal) indicating that, in 2015, “hundreds of persons were put to death without their express consent or because of psychiatric illness, dementia, or just ‘old age.'” Kussmaul cites the moral standard that underlies many people's opposition to suicide, specifying that “human life has intrinsic worth and dignity and that its value extends beyond the individual to the community,” and stating that he believes it is a value that persists even if the individual temporarily or permanently stops believing in it himself or herself.

Finally, Hedberg and New of Oregon's Health Authority provide statistics on the state's PAS activity. From 1998 through June 2017, 1857 Oregon residents (about 0.2% of all decedents) received “death with dignity” prescriptions, and 1186 (64%) ingested the drugs; 1179 died from the medications, and 7 regained consciousness. Six of these seven have since died of their underlying illnesses. The most common underlying diseases in these patients were cancer (77%) and amyotrophic lateral sclerosis (8%). Reasons cited for suicide usually were loss of autonomy (91%) and inability to enjoy usual activities (90%), whereas pain and financial concerns were mentioned by only 26% and 4% of patients, respectively. Patients who requested help with suicide were younger and far more likely to be college-educated than other Oregon patients with similar illnesses. Only 374 physicians (0.6% of the state's total) participated in the program, and most of those who did (62%) wrote only one prescription.

Many physicians feel strongly one way or the other about physician-assisted suicide, and most others probably aren't sure what they feel. Regardless of their thoughts on this topic, all physicians and medical students should read the articles in this series. The data and the issues are presented with clarity, passion, and a balanced concern for the welfare of patients and their doctors.

Dr. Paul Mueller is an Associate Editor for NEJM Journal Watch General Medicine and an author of the ACP position paper. He had no role in selecting or summarizing this paper for NEJM Journal Watch.

Editor Disclosures at Time of Publication

  • Disclosures for Abigail Zuger, MD at time of publication Editorial boards Clinical Infectious Diseases; Open Forum Infectious Diseases

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