Correspondence

Legalized Physician-Assisted Suicide in Oregon

N Engl J Med 1999; 341:212-213July 15, 1999

Article

To the Editor:

It is premature to draw any definitive conclusions about the experience with legalized physician-assisted suicide in Oregon as reported by Chin et al. (Feb. 18 issue),1 because the surveillance by state investigators relied on physicians' reports of care at the end of life. Patients or their families were not interviewed. These reports constitute physicians' perceptions of patients' experiences; they are not firsthand accounts. Although the finding that patients were not worried about pain control or the financial impact of their illnesses may reflect the relative ease of access to health care and the high rate of use of morphine in Oregon, these observations may also reflect the physicians' perceived competence in managing pain2 and their financial standing.

However, fears of loss of autonomy and bodily control and of disability (only 21 percent of the case patients, as compared with 84 percent of the control patients, were completely disabled at the time of death) may be fears on the part of both patients and physicians.3 To better advise patients in these most profound decisions at the end of life, we must learn to confront our own fear of loss of bodily control and recognize that physical disability is not the same as the loss of spiritual, emotional, intellectual, or environmental autonomy. To reduce the desire for physician-assisted suicide, we must try to alleviate disability and loss of autonomy, as well as the stigma attached to these conditions.

These limitations suggest the need for a prospective study of the Oregon initiative that gives greater weight to the patient's voice. By assessing physicians' perceptions and the perspectives of consenting patients and their families, we can better distinguish the attitudes of patients who choose physician-assisted suicide from those of doctors who are willing to provide this assistance. Although such a study will prove ethically and methodologically challenging, we must go beyond physicians' recollections of patients' fears in order to create a thoughtful and compassionate climate in which end-of-life decisions are made.

Joseph J. Fins, M.D.
Elizabeth A. Bancroft, M.D.
New York Presbyterian Hospital–Cornell Campus, New York, NY 10021

3 References

1
Chin AE, Hedberg K, Higginson GK, Fleming DW. Legalized physician-assisted suicide in Oregon -- the first year's experience. N Engl J Med 1999;340:577-583
Full Text | Web of Science | Medline

2
Cherny NI, Catane R. Professional negligence in the management of cancer pain: a case for urgent reforms. Cancer 1995;76:2181-2185
CrossRef | Web of Science | Medline

3
Patterson DR, Miller-Perrin C, McCormick TR, Hudson LD. When life support is questioned early in the care of patients with cervical-level quadriplegia. N Engl J Med 1993;328:506-509
Full Text | Web of Science | Medline

To the Editor:

Chin et al. report that many patients were unable to obtain the lethal prescription from the first physician approached, ultimately obtaining the desired prescription from a second or third physician with whom they were less likely to be acquainted. On another aspect of data gathering, since the disclosure of physician-assisted suicide in Oregon is voluntary, the authors could not know how many other patients received assistance with suicide from physicians who failed to report it. Perhaps there should be reporting by pharmacists as well as by physicians.

Chin et al. report that the patients who chose physician-assisted suicide were more socially isolated (they were divorced or had never married) than the controls. This finding suggests that the psychological profile and living situation of patients who choose physician-assisted suicide differ from the norm and are themselves subjects of appropriate concern. Facing dying and death is difficult for anybody, but it must be especially difficult for those who lack the support of family members and other intimates. Fear of loss of autonomy and fear of loss of control of bodily functions were strong motivating factors for the patients who chose physician-assisted suicide, perhaps a predictable response for persons who lack emotional attachments to and a comfortable dependency on caring others. Is it reasonable to assume that many of these patients may have been depressed? Unfortunately, there were psychological or psychiatric consultations for only 4 of the 15 patients who died after ingesting lethal medication, and the report does not indicate the consultants' level of expertise or the time they spent on the consultation.

Unfortunately, the protection of confidentiality for patient and physician has meant that physician-assisted suicide in Oregon remains secretive. This limits the procurement of data, thus crippling the state's and the public's monitoring of this procedure.

Miles J. Edwards, M.D.
William E. Connor, M.D.
Oregon Health Sciences University, Portland, OR 97201-3098

Author/Editor Response

The authors reply:

To the Editor: We certainly agree with Drs. Edwards and Connor and Drs. Fins and Bancroft that a single study cannot address all the questions raised about legalized physician-assisted suicide. The primary source of information for our study was the reporting system created by Oregon's Death with Dignity Act.1 Thus, we relied on information from physicians who wrote prescriptions and completed death certificates. We carefully considered how much additional intrusion into the lives of patients and their families was acceptable during an emotional and important decision-making time. Given the highly charged public debate over physician-assisted suicide in Oregon in 1998 and the intense scrutiny by the media, we were especially concerned about the consequences of an inadvertent breach of confidentiality that might result from a more invasive approach, one that involved interviews with other health care providers or family members. We believed that our decision — to conduct additional in-depth interviews with the physicians who wrote prescriptions for lethal medications — best balanced the need for immediate information and evaluation with the need to respect the privacy and confidentiality of those involved.

Drs. Edwards and Connor state that disclosure of legalized physician-assisted suicide in Oregon is voluntary; this is not true. The Oregon Death with Dignity Act1 and the accompanying Oregon Administrative Rules2 require that physicians report the writing of all prescriptions for lethal medications to the Oregon Health Division. Physicians who provide prescriptions for the purpose of physician-assisted suicide without subsequently reporting that they have done so are not protected from criminal prosecution by the law and, by definition, are participating in an illegal medical procedure.

Drs. Edwards and Connor correctly note that being divorced or never having married was statistically associated with choosing physician-assisted suicide. We urge caution in interpreting this result as meaning that the persons who chose physician-assisted suicide were more socially isolated than those who did not choose it. That marital status is an indicator of social isolation and a determinant of physician-assisted suicide is only one of several possible explanations, and it should be viewed as speculative.

Finally, we are perplexed by the statement of Drs. Edwards and Connor that because of the protection of patients' and physicians' confidentiality, physician-assisted suicide remains secretive and that this has crippled monitoring efforts. As with any reportable condition, patients' confidentiality is paramount and is a fundamental tenet of ethical public health practice. The Oregon Health Division is committed to providing the public with information on the impact of legalized physician-assisted suicide while guaranteeing the confidentiality of the patients and physicians involved, as explicitly required by the Oregon Death with Dignity Act.1 Any perceived lapses in this commitment, especially in the current atmosphere of intense public scrutiny, would render our reporting system ineffective.

Arthur Eugene Chin, M.D.
Katrina Hedberg, M.D., M.P.H.
David W. Fleming, M.D.
Oregon Health Division, Portland, OR 97232

2 References