Correspondence
Physician-Assisted Suicide
N Engl J Med 1996; 335:518-520August 15, 1996
- Article
To the Editor:
The February 1 issue contained reports on attitudes toward physician-assisted suicide and voluntary euthanasia. Bachman et al.1 found that “most Michigan physicians prefer either the legalization of physician-assisted suicide or no law at all; fewer than one fifth prefer a complete ban on the practice.” Lee et al.2 found that “Oregon physicians have a more favorable attitude toward legalized physician-assisted suicide, are more willing to participate, and are currently participating in greater numbers than other surveyed groups of physicians in the United States.”
. . . Popular opinion does not necessarily represent either a moral standard or a legislative mandate. In polls on issues such as abortion, universal access to health care, and capital punishment, the majority opinion has occasionally been at odds with the ethically preferable position. It is critical that information from surveys on these contentious issues not be misused in the way a drunk might misuse a lamppost — by using it for support rather than for illumination.
2 ReferencesArthur Kavanaugh, M.D.
Veterans Affairs Medical Center, Dallas, TX 752161
Bachman JG ,Alcser KH ,Doukas DJ ,Lichtenstein RL ,Corning AD ,Brody H . Attitudes of Michigan physicians and the public toward legalizing physician-assisted suicide and voluntary euthanasia. N Engl J Med 1996;334:303-309
Full Text | Web of Science | Medline2
Lee MA ,Nelson HD ,Tilden VP ,Ganzini L ,Schmidt TA ,Tolle SW . Legalizing assisted suicide -- views of physicians in Oregon. N Engl J Med 1996;334:310-315
Full Text | Web of Science | Medline
To the Editor:
Studies should be viewed critically when they attempt to estimate, using hypothetical scenarios, the percentage of physicians who would actually take part in euthanasia or physician-assisted suicide. Asking physicians “If assisted suicide were legal, would you do it?” permits a level of abstraction that does not exist in the real world. It may also lead to an underestimation of the number of physicians who would in fact participate. In Michigan and Washington, where there have been active debates but no successful legislation, 35 percent and 40 percent of physicians, respectively, have reported that they would be willing to assist in a suicide if it was legal to do so.1,2 In Oregon, where the legislative vote to legalize assisted suicide has undoubtedly prompted physicians to consider the issue even more deeply, the percentage of willing physicians is somewhat higher, at 46 percent.3 In the Netherlands, meanwhile, where both euthanasia and assisted suicide have been decriminalized for several years, fully 88 percent of physicians are willing to perform these acts.4 As of 1991, 54 percent had already done so.4
In jurisdictions where assisted suicide has received legislative recognition, relatively more physicians express a willingness to perform it; where it is currently practiced, the rate of actual participation is very high. This suggests that legalization leads gradually, but perhaps inevitably, to more widespread participation than before-the-fact surveys can predict. Once euthanasia and assisted suicide have been condoned legally, accepted professionally, and practiced openly, how many physicians will really turn away a terminally ill patient who meets all the required guidelines and requests a physician-hastened death? Physicians may comply with these requests much more commonly than the available surveys indicate. It is likely that legalization would result in the (possibly reluctant) participation of large numbers of physicians who, in the present climate of prohibition, cannot imagine themselves performing euthanasia or assisted suicide.5
5 ReferencesKeith G. Wilson, Ph.D.
The Rehabilitation Centre, Ottawa, ON K1H 8M2, CanadaHarvey Max Chochinov, M.D.
University of Manitoba, Winnipeg, MB R2E 3N4, Canada1
Bachman JG ,Alcser KH ,Doukas DJ ,Lichtenstein RL ,Corning AD ,Brody H . Attitudes of Michigan physicians and the public toward legalizing physician-assisted suicide and voluntary euthanasia. N Engl J Med 1996;334:303-309
Full Text | Web of Science | Medline2
Cohen JS ,Fihn SD ,Boyko EJ ,Jonsen AR ,Wood RW . Attitudes toward assisted suicide and euthanasia among physicians in Washington State. N Engl J Med 1994;331:89-94
Full Text | Web of Science | Medline3
Lee MA ,Nelson HD ,Tilden VP ,Ganzini L ,Schmidt TA ,Tolle SW . Legalizing assisted suicide -- views of physicians in Oregon. N Engl J Med 1996;334:310-315
Full Text | Web of Science | Medline4
van der Maas PJ ,van Delden JJM ,Pijnenborg L ,Looman CWN . Euthanasia and other medical decisions concerning the end of life. Lancet 1991;338:669-674
CrossRef | Web of Science | Medline5
Chochinov HM ,Wilson KG . The euthanasia debate: attitudes, practices and psychiatric considerations. Can J Psychiatry 1995;40:593-602
Web of Science | Medline
To the Editor:
Many Oregon physicians surveyed by Lee et al. expressed concern that people who are not terminally ill would seek to end their lives for reasons other than “unbearable suffering.” The reasons included “financial pressure” and “being a burden.” The Council on Scientific Affairs of the American Medical Association has expressed similar concern.1
We share this concern. Such pressures on patients may relate, at least in part, to our present health care system, in which families of sick and dying patients bear real financial burdens. In addition, the shift toward managed care is creating ethical dilemmas for doctors and health care alliances alike. Doing less or withholding treatment can certainly decrease costs and increase profits for providers and their systems. These savings can be important, particularly when they concern patients at the end of life.
One measure that would be more cost effective than doing nothing is actively terminating a patient's life. At least one health care policy analyst has seriously proposed just such a cost-saving strategy.2 Under his plan, financial incentives would be offered to the families of terminally ill patients willing to undergo active euthanasia.
In Oregon, such concepts are not simply theoretical musings. Well over half of all citizens are now enrolled in some form of managed care. Many programs consider cost effectiveness a key factor in determining what services are covered. The Oregon Health Plan, our well-publicized, statewide Medicaid program, even ranks services on the basis of this and related factors. In terms of cost effectiveness alone, few procedures would be ranked higher than assisted suicide.
2 ReferencesWilliam L. Toffler, M.D.
Miles J. Edwards, M.D.
Oregon Health Sciences University, Portland, OR 97201-30981
Council on Scientific Affairs, American Medical Association
CrossRef | Web of Science2
Fung KK . Dying for money. Am J Econ Sociol 1993;52:275-288
CrossRef | Web of Science | Medline
To the Editor:
Because the doctor–patient relationship is fragile but emotionally loaded, when Oregon physicians express a willingness to end life, they send a subtle, yet powerful, message to their patients and society. Among other things, they imply that they sometimes consider some people's lives no longer worth living. This message may itself damage the vital trust between doctors and patients. It undermines the physician's ability to provide a valuing relationship. . . . The willingness of Oregon doctors to take up the mantle of death, as well as of life, is a frightening specter.
N. Gregory Hamilton, M.D.
720 S.W. Washington, Suite 670, Portland, OR 97205Pamela J. Edwards, M.D.
Stephen T. Robinson, M.D.
Oregon Health Sciences University, Portland, OR 97201-3098Author/Editor Response
The authors reply:
To the Editor: Kavanaugh points out that polls do not provide a legislative mandate. We agree. The purpose of our research has been to inform the debate on physician-assisted suicide, not decide it. Indeed, we stated that “complex issues should not be decided by opinion polls, . . . but neither should medical ethicists or political decision makers ignore the strongly held views of . . . physicians and their potential patients.”
Kavanaugh argues that in matters such as abortion, universal access to health care, and capital punishment, majority opinion can be “at odds with the ethically preferable position.” But whose ethically preferable position? Ethicists have differed on these topics and on others, such as the subject of requests to withdraw life support; moreover, views are not the same in 1996 as they were in 1956 or 1906.
Wilson and Chochinov think that estimates based on hypothetical scenarios should be viewed critically, and we agree. We have tried to be cautious in interpreting data based on hypothetical questions, and we urge others to do so as well. Nevertheless, fashioning public policy requires exploring alternative views of the future, even though they are hypothetical.
Wilson and Chochinov suggest that some physicians might participate reluctantly if physician-assisted suicide were legalized. Again, we agree. Although proposals for such legalization generally make explicit a physician's right to refuse, some may still feel obligated to respect a patient's autonomy and honor requests for assisted suicide, even if their own judgment or preferences run otherwise. As in other end-of-life decisions involving a disagreement with a patient's requests or demands, the physician would have to weigh the competing values and decide whether to comply, refer the patient to another physician, or do neither. Recent findings point to another, more fundamental problem, however: medical personnel too often fail to communicate effectively with dying patients about pain management and other options that are already legally available.1 We agree with Lo that physicians need to reaffirm their “traditional responsibility for relieving pain, responding to patients' concerns, helping them make difficult decisions, and respecting their informed choices.” 2
We concur with Toffler and Edwards that managed care, financial burdens, or both can have coercive effects on patients. But the lack of universal health care coverage, coupled with the growing emphasis on profit in managed care, raises many ethical problems.3,4 We think it is better to tackle these problems directly and not confound them with the issues of physician-assisted suicide and euthanasia.
4 ReferencesJerald G. Bachman, Ph.D.
Kirsten H. Alcser, Ph.D.
David J. Doukas, M.D.
Richard L. Lichtenstein, Ph.D.
University of Michigan, Ann Arbor, MI 48106-12481
The SUPPORT Principal Investigators
CrossRef | Web of Science2
Lo B . Improving care near the end of life: why is it so hard? JAMA 1995;274:1634-1636
CrossRef | Web of Science | Medline3
Council on Ethical and Judicial Affairs, American Medical Association
CrossRef | Web of Science4
Kassirer JP . Managed care and the morality of the marketplace. N Engl J Med 1995;333:50-52
Full Text | Web of Science | Medline
Author/Editor Response
We surveyed Oregon physicians about physician-assisted suicide because after the passage of the Oregon Death with Dignity Act, legalization was not an abstract concept for them. We reasoned that from their unique vantage point, Oregon physicians could contribute a practical perspective to a debate that had heretofore been strictly philosophical. The resulting information should not be confused with ethical guidelines or appropriate policy, as Kavanaugh points out. We believe, however, that it adds a needed dimension to the debate; that is, it presents the real problems to be overcome if physician-assisted suicide is accepted as a matter of policy. Will our data be “misused in the way a drunk might misuse a lamppost. . .”? We hope not. The work of research is to illuminate what is, not what should be, and as researchers we rest our case on “what is” in Oregon.
Wilson and Chochinov predict that the willingness of physicians to participate in assisted suicide is increased in places where it is legalized. Hypothetical scenarios may either overestimate or underestimate actual behavior. Removing the legal barrier in Oregon forced physicians to grapple with their personal views about such participation. That alone may explain the fact that the willingness we found is greater than has been found in other surveys in the United States. It is important to remember, however, that 31 percent of the respondents were morally opposed to legalization and participation, regardless of the social and legal context.
We agree with Toffler and Edwards, who share the concern of a large majority of our respondents that financial pressures or the fear of being a burden will motivate some requests for assisted suicide. We agree that these issues are real, not only in Oregon, but also throughout the United States. In countries where physician-assisted suicide is allowed, universal health coverage may reduce the financial incentive.
Hamilton et al. contend that physicians' willingness to end life sends a message that may damage trust between doctors and patients. Apparently, this view is not shared by a majority of the voters in Oregon. The assumption should be subject to empirical validation.
Melinda A. Lee, M.D.
Heidi D. Nelson, M.D.
Virginia P. Tilden, R.N., D.N.Sc.
Oregon Health Sciences University, Portland, OR 97201-3098
