Correspondence

Patients with Amyotrophic Lateral Sclerosis and Physician-Assisted Suicide

N Engl J Med 1999; 340:817March 11, 1999

Article

To the Editor:

In the article by Ganzini et al. (Oct. 1 issue),1 the 56 percent of people with amyotrophic lateral sclerosis (ALS) who said they would consider asking for physician-assisted suicide is not so different from the 48 percent of the general public who indicate an interest in physician-assisted suicide when asked to contemplate hypothetical scenarios of their own death.2 Although some may find it comforting to know that physician-assisted suicide could be available as a last resort, it is telling that Ganzini et al. reported only one patient who would have requested it in his or her current circumstances. Many patients express a hypothetical interest in physician-assisted suicide, but it appears that far fewer have an immediate wish to avail themselves of this option. This suggests that even for patients with terminal illnesses, it may be difficult to imagine in a realistic way what their very final days will be like.

Ganzini et al. also found that hopelessness, but not a diagnosis of depression in itself, differentiated patients who said they would consider physician-assisted suicide from those who said they would not. Hopelessness may indeed correlate more highly than depression with an interest among patients with ALS in receiving physician-assisted suicide, but it also correlates more highly with suicidal ideation generally, whether the subjects are suicidal adolescents,3 adult psychiatric patients,4 or terminally ill patients with cancer.5 Thus, it is not yet clear that physician-assisted suicide is so different from other types of suicidal behavior. What is clear is that the nature of hope, even among patients who in a medical sense are hopelessly ill, is a topic that deserves further thoughtful investigation.

Harvey Max Chochinov, M.D., Ph.D.
University of Manitoba, Winnipeg, MB R3T 2N2, Canada

Keith Wilson, Ph.D.
Rehabilitation Centre, Ottawa, ON K2A 0Z4, Canada

5 References

1. 1

   Ganzini L, Johnston WS, McFarland BH, Tolle SW, Lee MA. Attitudes of patients with amyotrophic lateral sclerosis and their care givers toward assisted suicide. N Engl J Med 1998;339:967-973
   Full Text | Web of Science | Medline

2. 2

   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 | Medline

3. 3

   Kazdin AE, French NH, Unis AS, Esveldt-Dawson K, Sherick RB. Hopelessness, depression, and suicidal intent among psychiatrically disturbed inpatient children. J Consult Clin Psychol 1983;51:504-510
   CrossRef | Web of Science | Medline

4. 4

   Beck AT, Steer RA, Kovacs M, Garrison B. Hopelessness and eventual suicide: a 10-year prospective study of patients hospitalized with suicidal ideation. Am J Psychiatry 1985;142:559-563
   Web of Science | Medline

5. 5

   Chochinov HM, Wilson KG, Enns M, Lander S. Depression, hopelessness, and suicidal ideation in the terminally ill. Psychosomatics 1998;39:366-370
   Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: We appreciate the thoughtful comments of Drs. Chochinov and Wilson. To clarify our findings, 44 percent of the subjects with ALS planned to request a prescription for a lethal drug when it became legal, despite not having any immediate plans to use the medication. Thus, the magnitude of interest Chochinov and Wilson refer to depends on how one defines “immediate wish to avail themselves of this option” — by obtaining the lethal prescription (44 percent of the subjects) or by taking it within one month (1 percent of the subjects). We agree that our data support the idea that having a lethal prescription available may be of comfort to some terminally ill patients.

Whether terminally ill persons who request physician-assisted suicide differ from members of other groups with suicidal behavior cannot be answered by studies such as ours. We are not aware of any other studies that have compared terminally ill patients who request assisted suicide with other suicidal persons. We agree that how terminally ill patients view their future may be crucial to gaining insight into why they might request, and perhaps ultimately ingest, a lethal medication and that this should be a focus of future studies on assisted suicide.

Linda Ganzini, M.D.
Veterans Affairs Medical Center

Wendy S. Johnston, M.D.
Oregon Health Sciences University, Portland, OR 97201