Assisted Suicide: Finding Common Ground

Physician-assisted suicide used to be a question for academics to debate. No more. Oregon has legalized the practice, and the data from the law's first year of implementation are in (1). Efforts are under way to legalize physician-assisted suicide in other states. Thirty-seven states currently prohibit assisted suicide—including physician-assisted suicide—by statute, and 8 states prohibit it under the common law or a homicide statute (2).

Will many other states quickly follow Oregon's lead? Probably not. In 1997 and 1998, bills on assisted suicide were introduced in 26 states. All were defeated. Voters in Michigan and Washington State rejected state ballot initiatives that would have legalized physician-assisted suicide. Many states, including Virginia, Michigan, South Carolina, Iowa, and Rhode Island, approved new bans on assisted suicide. However, Oregon has changed the landscape of the law and, arguably, the practice of medicine.

The U.S. Supreme Court has said that there is no constitutional right to physician-assisted suicide (3, 4). States are free to ban it. However, they are also free to permit it, and Oregon has chosen to do so in certain circumstances (5). The inadequate state of end-of-life care continues to keep legalization on the front burner. By finding Jack Kevorkian guilty of murder, a Michigan jury rejected his plea that they allow him to blur the line between assisted suicide and euthanasia. However, there is still much public support for his cause, and well-organized efforts to legalize physician-assisted suicide continue. Consideration of the so-called Pain Relief Promotion Act of 1999 and other bills in Congress has kept physician-assisted suicide on the national policy and legislative agenda. There has never been a more crucial time for physicians to attend closely to the debate.

In 1997, the University of Pennsylvania's Center for Bioethics convened a national panel of experts on the subject of assisted suicide. The panel membership was multidisciplinary, with representatives from medicine, nursing, psychology, hospice, patient advocacy, law, philosophy, the clergy, and bioethics. It was deliberately composed of persons who had diverse viewpoints on assisted suicide—both proponents and critics. Our goal was not to argue the pros or cons of assisted suicide. Instead, starting from the assumption that physician-assisted suicide would become legal—as it did in Oregon a few months after we started meeting—and that some persons would want to take advantage of it, the panel sought to find common ground in examining ways in which to guide its practice. We also sought to determine safeguards that would keep physician-assisted suicide voluntary, regulated, and, most important, an option of last resort.

The University of Pennsylvania's project, Finding Common Ground, established the Assisted Suicide Consensus Panel to debate several questions: What is assisted suicide? Is physician-assisted suicide different from refusal of treatment? What are the alternatives to it? How useful are currently available guidelines for physician-assisted suicide? Does assisted suicide necessarily mean physician-assisted suicide? Can assisted suicide be effectively and meaningfully regulated? How should physicians respond to requests for assistance in dying? The five papers presented in this issue are the results of the panel's deliberations and consensus process. Panel members did not agree on everything; given our differing points of view, that would not have been expected. However, as we sought to put rhetoric and politics aside, we did find much common ground.

This brings us back to Oregon and the pressing nature of these issues. In Oregon, terminally ill, mentally capable adult residents can get a prescription for a lethal dose of medicine from a physician if they make numerous oral and written requests within certain time periods and follow specific procedures. Physicians who assist such patients must comply with a long list of requirements.

What has been the result? According to a recent article in The New England Journal of Medicine, during the first year of implementation, 23 persons (18 of whom had cancer) received prescriptions for lethal medications in connection with the Oregon law. Of these 23 persons, 15 died after taking the medication. Another 6 died of their underlying illnesses, but it is not clear whether this number includes deaths that occurred as a result of “double effect.” Two persons were alive as of 1 January 1999 (1).

Of the 15 persons who died as a result of physician-assisted suicide, all were white and 8 were male; their median age was 69 years. Four patients had had psychiatric consultations in accord with the law's procedures. Persons who were divorced or had never married were more likely to choose physician-assisted suicide. In a study that examined reasons why death was sought, it was found that decisions to seek physician-assisted suicide were associated with concerns about loss of autonomy and control, not pain or fear of pain (1).

Proponents and opponents of physician-assisted suicide will view the initial Oregon experience differently. Proponents will say that the law is working, that the floodgates have not, in fact, been opened and that no abuses have occurred. Opponents will suspect underreporting, as has been seen in the Netherlands. They may also point to the fact that what were supposed to be the most compelling reasons for supporting the practice, pain and suffering, were not identified as motivations for seeking physician-assisted suicide.

Data often inform debate about difficult ethical and moral questions but do not settle them. How would you react to a patient's request for physician-assisted suicide? The papers in this issue should contribute to advancing the policy dialogue and be of assistance to physicians who grapple with these issues in practice, not just on paper.

• Copyright ©2004 by the American College of Physicians