Correspondence
Physician-Assisted Suicide and Euthanasia in the United States
N Engl J Med 1998; 339:775-776September 10, 1998
- Article
To the Editor:
The article by Meier et al. (April 23 issue)1 on physician-assisted suicide and euthanasia in the United States contains somewhat misleading information about the Oregon law on assisted suicide. The authors say that the majority of patients to whom physicians gave prescriptions to assist them in suicide would have met the criteria of the Oregon law's regulatory safeguards for this practice. They list such criteria as the patient's age and prognosis, the presence of a repeated request, the physician's belief that the request reflected the patient's wishes, consultation with another physician, and the presence of a group of clinical symptoms such as severe discomfort, pain, dependence on others, and being bedridden.
The Oregon law, unlike Dutch law, does not regard suffering as a requirement for assisted suicide and refers to no clinical symptoms. That the patient must be over 18 years of age and have a terminal illness with a prognosis of less than six months' survival are statutory requirements of the law, not safeguards. A repeated request is such a safeguard, but only half the patients receiving prescriptions in the survey by Meier et al. met that requirement. Obtaining a second opinion is another safeguard, but fewer than 1 percent of physicians who assisted in suicide obtained such an opinion.
Euthanasia is prohibited by the Oregon law, so none of the 4.7 percent of physicians who gave lethal injections were in compliance with the law. In all cases of assisted suicide or euthanasia, physicians said that they “believed that the request reflected the patient's wishes.” This safeguard presumably refers to the stipulation in the Oregon law that the patient's decision be voluntary and uncoerced. The survey did not determine, however, what efforts the physician made to find out whether this was so. Simple belief is not enough.
Belying such belief, and perhaps most disturbing in the survey, is the fact that, in 79 percent of cases, physicians who gave lethal injections to patients had received no direct request from the patients to do so. Meier has written elsewhere that the likelihood that such practices would increase with legalization2 and the fact that these practices cannot be regulated have led her to cease to favor legalization of assisted suicide or euthanasia.3
3 ReferencesHerbert Hendin, M.D.
American Foundation for Suicide Prevention, New York, NY 100051
Meier DE ,Emmons C-A ,Wallenstein S ,Quill T ,Morrison RS ,Cassel CK . A national survey of physician-assisted suicide and euthanasia in the United States. N Engl J Med 1998;338:1193-1201
Full Text | Web of Science | Medline2
Hendin H. Seduced by death: doctors, patients, and assisted suicide. New York: W.W. Norton, 1998.
3
Meier D. A change of heart on assisted suicide. New York Times. April 24, 1998.
To the Editor:
According to the survey by Meier et al., 97 percent of those who received prescriptions for a lethal dose of medication were men. This rate contrasts with that of the group who received a lethal injection, of which only 57 percent were men. For lethal injection, the request was more likely to be somewhat indirect or made by a family member, and the doctor–patient relationship was, in some cases, of very short duration. Although statistical probabilities are not reported, the differences based on sex are likely to be statistically significant and, at least for feminists, clinically significant; they should give us pause as we debate legalizing assisted suicide. How do the authors interpret these findings?
Susan Dorr Goold, M.D.
University of Michigan, Ann Arbor, MI 48109-0376Author/Editor Response
The authors reply:
To the Editor: Contrary to Hendin's assertion, nowhere in our article did we claim that Oregon's Death with Dignity Act1 requires evidence of suffering by a patient as a safeguard. We did list (as a footnote to Table 4) that the law requires that a patient be an adult with a terminal illness and a life expectancy of less than six months, that the request be made by the patient, and that the request be voluntary. Our data suggest that the majority of patients who received a prescription for a lethal dose of medication met these requirements. Our national survey was conducted before the passage of the Oregon legislation; at that time, physician-assisted suicide was illegal in all 50 states. The fact that procedural safeguards (such as getting a second opinion) were not followed is not surprising. Since lethal injections are not permitted under the Oregon law, it is not appropriate to assess the conformity of the use of lethal injection with the legislation.
We do not know the reasons for the disparity between men and women in the proportions of patients receiving prescriptions for a lethal dose of medication (a weighted 97 percent were men). The survey contained data on only 36 patients who received such a prescription for whom sex was reported. The raw (unweighted) numbers show that two thirds (24 patients) were men. The weighted proportions are considerably more lopsided because the seven prescriptions written by general internists or family practitioners (groups of physicians whose responses were weighted more heavily to reflect their preponderance in the population of U.S. physicians) were all written for men. Given the low prevalence of such prescriptions in our study, it is uncertain whether the sex differences found were in fact true differences or whether they were an artifact of the statistical weighting necessary to analyze the survey. The raw data suggest that both assistance with suicide from a physician and euthanasia are more commonly requested and received by men, with men making up 60 to 66 percent of the patients described. Most,2-4 but not all,5 previous surveys have found a similar sex distribution. Possible explanations for this disparity are that women are less inclined to seek to hasten their own deaths, that they are uncomfortable asking their physicians (most of whom are men) for help, or some other factor or combination of factors.
5 ReferencesDiane E. Meier, M.D.
R. Sean Morrison, M.D.
Sylvan Wallenstein, Ph.D.
Mount Sinai School of Medicine, New York, NY 100291
Oregon Death with Dignity Act, Or. Laws ch. 3 (initiative measure no. 16), 1995.
2
Back AL ,Wallace JI ,Starks HE ,Pearlman RA . Physician-assisted suicide and euthanasia in Washington state: patient requests and physician responses. JAMA 1996;275:919-925
CrossRef | Web of Science | Medline3
Pijnenborg L ,van der Maas PJ ,van Delden JJM ,Looman CWN . Life-terminating acts without explicit request of patient. Lancet 1993;341:1196-1199
CrossRef | Web of Science | Medline4
van der Wal G ,van der Maas PJ ,Bosma JM , et al. Evaluation of the notification procedure for physician-assisted death in the Netherlands. N Engl J Med 1996;335:1706-1711
Full Text | Web of Science | Medline5
van der Maas PJ ,van der Wal G ,Haverkate I , et al. Euthanasia, physician-assisted suicide, and other medical practices involving the end of life in the Netherlands, 1990-1995. N Engl J Med 1996;335:1699-1705
Full Text | Web of Science | Medline
