Correspondence

Physician-Assisted Death

N Engl J Med 2002; 347:1041-1043September 26, 2002

Article

To the Editor:

According to Ganzini and Block (May 23 issue),1 “experts assert that with excellent palliative care, most requests for hastened death would not be made.” They consider rates of physician-assisted death of 10 to 20 percent, as reported for patients with cancer and amyotrophic lateral sclerosis (ALS) in the Netherlands, unacceptably high. Expert opinions offer no proof or strong evidence in this regard. The rate may also depend, for example, on “moral questions surrounding life, suffering, and death.”2 Population polls in the Netherlands have repeatedly shown that a majority is in favor of physician-assisted death in well-defined circumstances, including those in which there is no hope for the future, unbearable suffering, and repeated and consistent requests for such assistance. For many Dutch people, this mode of death is not taboo and there is no moral objection to it. The best that patients with ALS may hope for in the terminal stage of their disease is to go on living for a limited period under a blanket of morphine. Is it so surprising that 17 percent of Dutch patients with ALS are not looking forward to this prospect and that they prefer an almost certainly gentle and quick death?

Ganzini and Block indicate that excellent palliative care is available for, at most, 50 percent of patients in the United States who die at home. What happens to patients with ALS who are not fortunate enough to receive excellent care in the terminal stage of their disease and who ask for a hastened death? Is it acceptable that the law forbids physicians to help them?

Frans G.I. Jennekens, M.D.
Louis Kater, M.D.
University Medical Centre, 3508 GA Utrecht, the Netherlands
fajenn@xs4all.nl

2 References

1
Ganzini L, Block S. Physician-assisted death -- a last resort? N Engl J Med 2002;346:1663-1665
Full Text | Web of Science | Medline

2
Groenewoud JH. Review of: Physician-Assisted Suicide: What Are the Issues? N Engl J Med 2002;346:1836-1836
Full Text

To the Editor:

The report by Veldink et al.1 and the accompanying editorial by Ganzini and Block mention that loss of autonomy and control contributes to the high frequency of requests for physician-assisted death in patients with ALS. If patients know that assistance in dying is available, it may relieve their anxiety and restore their sense of control. After the legalization of physician-assisted suicide in Oregon, more than a third of the persons who received a lethal prescription did not ingest the medication.2,3

I worked with an anxious patient with ALS who feared loss of control. She threatened to jump out the window so that “it would be over,” but when assured that her primary clinicians would provide terminal sedation when she wanted it, her anxiety melted, her threats ceased, and she later died peacefully in her sleep without any death-hastening interventions. Terminal sedation, which is legal throughout the United States, has in common with physician-assisted suicide the hastening of death and the relief of suffering. In terminal sedation, however, hastened death is regarded as an unwanted but unavoidable side effect, rather than an intended outcome.4

Cavin P. Leeman, M.D.
State University of New York Downstate Medical Center, Brooklyn, NY 11203
cpl@cpleeman.net

4 References

1
Veldink JH, Wokke JHJ, van der Wal G, Vianney de Jong JMB, van den Berg LH. Euthanasia and physician-assisted suicide among patients with amyotrophic lateral sclerosis in the Netherlands. N Engl J Med 2002;346:1638-1644
Full Text | Web of Science | Medline

2
Hedberg K, Hopkins D, Southwick K. Legalized physician-assisted suicide in Oregon, 2001. N Engl J Med 2002;346:450-452
Full Text | Web of Science | Medline

3
Sullivan AD, Hedberg K, Hopkins D. Legalized physician-assisted suicide in Oregon, 1998-2000. N Engl J Med 2001;344:605-607
Full Text | Web of Science | Medline

4
Gauthier CC. Active voluntary euthanasia, terminal sedation, and assisted suicide. J Clin Ethics 2001;12:43-50
Web of Science | Medline

To the Editor:

The data presented by Veldink et al. add to a growing body of evidence that suggests that despite our best efforts at cure and palliation, there will continue to be patients for whom suicide is preferable to continued suffering. Although the focus of our attention and resources should be on improving treatment, the rights and needs of patients who wish to commit suicide but who require assistance in doing so cannot be overlooked. The erroneous assumption that this assistance must be provided by the treating physician hopelessly complicates the ethical dilemma of assisted suicide with legitimate concern about potential conflicts of interest or inappropriate selective application. This complication can be circumvented by limiting the activities of physicians to the provision of treatment, palliation, and prognostic information to patients with incurable diseases. Patients who still seek assistance with suicide should be able to turn to licensed nonphysicians who can provide such assistance in a carefully prescribed and scrutinized way. If society's consensus is that assisted suicide is acceptable, it need not and should not be physicians who provide it.

Paul Druck, M.D.
Department of Veterans Affairs Medical Center, Minneapolis, MN 55417

Author/Editor Response

The authors reply:

To the Editor: Leeman addresses the important issues of reasons why patients request physician-assisted death. Few researchers have asked patients why they want physician-assisted suicide or euthanasia.1 Anxiety and pain correlate with an interest in physician-assisted death but clearly do not fully explain this interest. We agree that the knowledge that assistance in dying is available may be reassuring to patients and may restore part of their autonomy. Many patients who request assistance in dying or who receive lethal prescriptions do not die with a physician's assistance.2,3 Nevertheless, it cannot be inferred that the availability of assistance in dying leads to increased feelings of control. As Leeman notes, such an inference is based on anecdotal evidence and not on the results of carefully designed studies.

Leeman's second point relates to the option of terminal sedation in terminally ill patients. We do not know of any study on terminal sedation in patients with ALS; in contrast, there have been many such studies in patients with cancer. In the latter patients it is unlikely that deep sedation hastens death, unless hydration and nutrition are also foregone. There are essential differences between patients with cancer and patients with ALS, including the fact that terminally ill patients with ALS have respiratory insufficiency. As a consequence, the use of benzodiazepines for terminal sedation in patients with ALS will have the added effect of hastening death in a manner analogous to the use of opiates. Although terminal sedation can be an adequate palliative treatment for terminally ill patients, we do not see the need for it among patients who are terminally ill with ALS.

Druck sees the practice of physician-assisted suicide as immoral and contrary to a physician's oath, and he therefore proposes that licensed nonphysicians carry out this practice. However, we think that it should be physicians who provide assistance with dying, for several reasons. Physicians are medically and technically qualified to perform this task, given the possible complications.4 End-of-life decisions, including those involving terminal sedation, euthanasia, and physician-assisted suicide, can be seen as last options in programs of palliative care. Discussing these issues with patients and their relatives and making a final decision require the knowledge, experience, and compassion of a physician and should be part of the physician–patient relationship. Of course, there is a conflict of duties, but this conflict is not resolved by bringing in a nonmedical person.

Jan H. Veldink, M.D.
Leonard H. van den Berg, M.D., Ph.D.
University Medical Center Utrecht, 3508 GA Utrecht, the Netherlands
l.h.vandenberg@neuro.azu.nl

Gerrit van der Wal, M.D., Ph.D.
Vrije Universiteit Medical Center, 1081 BT Amsterdam, the Netherlands

4 References

1
Ganzini L, Johnston WS, McFarland BH, Tolle SE, 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
Ganzini L, Nelson HD, Schmidt TA, Kraemer DF, Delorit MA, Lee MA. Physicians' experiences with the Oregon Death with Dignity Act. N Engl J Med 2000;342:557-563[Erratum, N Engl J Med 2000;342:1538.]
Full Text | Web of Science | Medline

3
Haverkate I, Onwuteaka-Philipsen BD, van Der Heide A, Kostense PJ, van Der Wal G, van Der Maas PJ. Refused and granted requests for euthanasia and assisted suicide in the Netherlands: interview study with structured questionnaire. BMJ 2000;321:865-866
CrossRef | Web of Science | Medline

4
Groenewoud JH, van der Heide A, Onwuteaka-Philipsen BD, Willems DL, van der Maas PJ, van der Wal G. Clinical problems with the performance of euthanasia and physician-assisted suicide in the Netherlands. N Engl J Med 2000;342:551-556
Full Text | Web of Science | Medline

Author/Editor Response

The editorialists reply:

To the Editor: We contend that the rate of physician-assisted death in the Netherlands is unacceptably high. Nevertheless, we agree with Jennekens and Kater that this contention does not have strong empirical support. We remain troubled by the absence of evidence that Dutch patients receive adequate palliative care as an alternative to euthanasia. We hope that our Dutch colleagues proceed with studies to address these concerns.

In the United States, one's fortune is an important determinant of access to excellent palliative care. A system in which patients may choose euthanasia primarily because they cannot get basic treatment for their symptoms is unacceptable. If a patient requests euthanasia and the physician anticipates that treatment of his or her symptoms could result in a change of preference, the physician's obligation is to use all available means to help in palliation.

Some patients take comfort in knowing about the option of refusing life-sustaining treatment, including food and fluids. A discussion of terminal sedation may be valuable for patients who fear that their physical suffering at the end of life will go untreated. In our clinical experience with patients who persistently request assisted suicide, these alternatives may not be accepted by those who have a strong desire to control the timing and manner of their death or those who find the idea that they will be dependent on others before death intolerable.

Not all health care professionals agree that existential suffering warrants acts that hasten death, although these acts may be legal. Not all physicians are comfortable in caring for a patient whose request for terminal sedation represents a deliberate attempt to hasten death.1

(The views expressed are those of the authors and do not necessarily represent those of the Department of Veterans Affairs.)

Linda Ganzini, M.D.
Portland Veterans Affairs Medical Center, Portland, OR 97239
ganzinil@ohsu.edu

Susan Block, M.D.
Dana–Farber Cancer Institute, Boston, MA 02115

1 References

1
Jansen LA, Sulmasy DP. Sedation, alimentation, hydration, and equivocation: careful conversation about care at the end of life. Ann Intern Med 2002;136:845-849
Web of Science | Medline

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