Several months ago, the U.K. courts ordered Ken Starmer, Director of Public Prosecutions, to delineate the conditions under which his office would be likely or unlikely to prosecute people who helped friends or relatives kill themselves. This list of conditions is intended to provide information so that those who wish to assist another commit suicide can make an informed decision. Yet Section 2(1) of the Suicide Act of 1961 provides: “A person who aids, abets, counsels or procures the suicide of another, or an attempt by another to commit suicide, shall be liable on conviction on indictment to imprisonment for a term not exceeding fourteen years.”1 Mr. Starmer clearly stated that the taking of another person’s life remains a murder. However, his goal in publishing this new guideline is to make it easier to escape liability for assisted suicide. So why complicate matters with these new guidelines instead of just making assisted-suicide legal now?
Many studies indicate that a small, but definite proportion of U.S. physicians have performed physician-assisted suicide (PAS), even though it is illegal.2 The only national survey conducted found that, among a representative sample of 1,902 U.S. physicians with a high likelihood of caring for dying patients, 18.3 percent reported having received a request from a patient for medication to use with the primary intention of ending the patient’s life. Of those physicians, 16 percent (or 42 physicians) had actually written the prescription and 59 percent of those patients (or 25 patients) used the prescriptions to end their lives.3 At first glance, I believed that those patients were lucky to find a physician who was willing to help them determine the time, place, and method of their death. As a resident, I have witnessed how we torture patients with lines, tubes, and isolation at the end of life. I even found myself hoping that I would ultimately undergo a peaceful, painless death in my sleep.
But were those patients really that lucky? Those patients could have been suffering from untreated depression, poorly controlled symptoms, or lack of social support. Oregon was the first state to legalize PAS by passing the Death with Dignity Act in 1997. A subsequent study in 2000 in Oregon examined the characteristics and circumstances of patients who requested and ultimately decided to use PAS to end their lives. The study found that 46% of patients who received one or more palliative interventions changed their minds about assisted suicide, as compared to 15% of patients who received no intervention. Interventions included pain/symptom control, referral to hospice, treatment of depression, general reassurance, social work consult, palliative care consult, or an alternative means of hastening death.4 According to this study, an extra 30 percent of the patients continued living because of interventions that physicians assume are already in place before a physician assists a patient with suicide. In fact, the Death with Dignity Act tried to protect such patients by including a provision that required a referral to a psychiatrist or psychologist for counseling if a psychiatric disorder was suspected in a patient requesting PAS. However, from 1998 to 2006, only 12.6% of patients who received prescriptions for lethal medications were referred for psychiatric evaluations. In 2007, none of the 85 patients who received prescriptions received such referrals.5 Even with legal safeguards, notwithstanding the difficulty of enforcing such laws, one wonders how many physicians are not abiding by those standards and thus erroneously or prematurely facilitating patient suicide.
PAS is also complicated by its effects on physicians. A study found that, although a majority of oncologists who have participated in PAS illegally had a positive experience, 25 percent regretted performing euthanasia or PAS, and 15 percent suffered emotional distress unrelated to fear of prosecution.1 The specific etiology of that regret is not reported, but it is probable that it stems from physicians’ hindsight that they had mistakenly assisted a patient suicide without properly exhausting all other palliative interventions. Another likely explanation is that physicians realized that they were misguided by their own self-imposed values. These perceptions are haunting and could never be validated or invalidated. Although twenty-five percent is a minority, these reports suggest that physicians need adequate training and emotional support in dealing with PAS to minimize possible errors or even perceptions of them. Feelings of regret, failure, guilt, trauma, and incompetence are all familiar emotions to us, as physicians, but they usually result from a horrible disease or an unintentional medical error. I’m not sure we’re ready to handle the emotions concomitant with committing an intentional one.
The medical community is not ready for PAS to be legalized right now. Physicians have only minimal training in how to technically and emotionally handle PAS situations. Furthermore, even after 10 years of legalizing PAS in Oregon with specific provisions meant to protect patients, these safeguards alone are inadequate, and some patients may have still been victims of assisted suicide. However, keeping PAS illegal is an impediment to providing adequate safeguards, research-based guidelines, and emotional support for both the patients and physicians that will continue to partake in PAS despite its illegality. It is merely ignoring the needs of our patients and placing both patients and physicians at risk for quietly mishandling PAS situations. Perhaps the U.K. is on to something—keep PAS illegal to minimize harm until there is adequate training/support for physicians and effective methods of enforcing the guidelines necessary to protect patients. The legalization of PAS is forthcoming, the prior step is to work with the public and establish proper training and guidelines to ensure that PAS will have a safe place in our society. With the new guidelines that Mr. Starmer just publicly announced, it seems that the UK is on the right track.
Dr. Eng is a 2nd year resident in internal medicine at NYU Medical Center.
2 Emanuel E. Euthanasia and physician-assisted suicide, a review of the empirical data from the United States. Arch Intern Med. 2002;162:142-152.
3 Meier D.E., Emmons C., Wallenstein S., Quill T. et al. A national survey of physician-assisted suicide and euthanasia in the United States. N Engl J Med. 1998;338:1193-201.
4 Ganzini L., Nelson H.D., Schmidt T.A., Kraemer D.F., Delorit M.A., Lee M.A. Physician’s experiences with the Oregon Death with Dignity Act. N Engl J Med. 2000;342:557-563.
5 Steinbrook R. Physician-assisted death – from Oregon to Washington state. N Engl J Med. 2008;359(24):2513-2515.