Last week’s piece on Physician Assisted Suicide (PAS) by Dr. Juliana Eng addresses in simple and clear terms an issue that, at times, occupies the front pages of our newspapers or becomes the center of heated public debate or the theme of elaborated ethical argumentations. For long periods, however, the request of some of our patients to be helped in putting an end to their suffering, be it physical or existential or both, goes on silently in the professional lives of many of us.
As Ethics Editor of Clinical Correlation, I would very much like to see Dr. Eng’s piece stir a debate in our community as members of New York University regarding PAS and its many medical, moral, psychological and social implications. In my opinion, to be useful, this debate should not be adversarial or focused on dogmatic reasoning. Rather, it should be a forum where each one of us feels at ease to express his or her views as a practicing physician who may have encountered patients requesting PAS, but also as a person who may have been personally touched by the extreme suffering of a relative or friend.
I was first asked by a patient to help her dying during my internship in 1983. She was a 60 year old immigrant lady, who had worked as a janitor for her entire life. She was always alone, having no family left anywhere in the world or friends who could be near her. She had metastatic lung cancer and was in extreme physical and existential suffering. Even after analgesia was increased to an optimal level, her existential suffering persisted. She died, in no more physical pain, two weeks later. It was not up to me to respond to her request (I was only an intern and EAS was not legally allowed), yet this patient had given me the privilege to share in her desire to put an end to her longstanding pain. I owed it to her and to myself to make a decision about where I stood. Though our patients’ suffering may be unbearable for them and also for us, when we are unable to alleviate it, I have become convinced that “reverence for life” is at the core of being a physician. (1) In 1992, Dr. Edmund Pellegrino argued cogently that doctors must not kill, and I refer interested readers to his original article for an insightful review of the ethical and social arguments against EAS. (2) Some colleagues may agree with this view, while others may rather see helping a patient die as an act of piety, when the suffering truly cannot be alleviated and when there has been a special longstanding connection between the patient and her doctor. (3) Yet, most importantly, we all need to understand the sources of suffering of our patients and to find effective ways to address their unmet needs .
A survey of 988 terminally ill patients and 893 primary care-givers in the US from 5 outpatients setting (4 urban, 1 rural) between March 1996 and July 1997, reported that when presented with hypothetical scenarios, 60.2% of 988 patients supported EAS and 10.6% seriously considered EAS. At two to six month follow-up interviews, however, 50% had changed their mind. According to their caregivers, of 256 decedents among the initial patient group, 14% had asked about EAS, 2.5% had hoarded drugs, yet only one (0.4%) actually died of EAS. From this study, it appeared that factors associated with being less likely to consider EAS were feeling appreciated, being aged 65 or older and being African-American. By contrast, factors associated with being more likely to consider EAS were the presence of depressive symptoms, unmet care giving needs and pain. (4)
From these and other data, it appears likely that untreated depression is strongly associated with requests for EAS, but other pressures, related to prior social stigmatization or other factors, may contribute to increase patients’ desire to die. (5,6) Psychosocial distress, lack of social support, spiritual distress, and poor quality of life are main factors in patients’ requests for hastened death. Existential suffering, characterized by fear of being a burden to others, loss of control over the circumstances of death, perceived loss of dignity and lack of meaning to life, seems to heavily contribute to patients’ “weariness of life.” (7,8) Race, culture, gender and age have been shown to affect attitudes toward end-of-life matters and EAS of both patients and physicians. (9) A 2002 study showed that individuals’ psychosocial traits and beliefs can be more predictive of cancer patients’ attitudes toward PAS than disease severity or symptomatic distress – an issue that deserves further investigation. (10)
Further research is needed to explore the interaction of physical health, functional status, social isolation, depressive symptoms and uncontrolled pain in terminally ill patients, in order to enable all physicians to recognize and address the unmet needs of those patients asking their doctor’s help to end their lives, before considering such requests. Communicating with patients and their families, understanding their existential issues at the end of life, and preserving and promoting the dignity of terminally ill patients are essential for responding to their requests for EAS. (7,8) Finally, as Dr. Eng correctly stresses, emotional support should be provided for those physicians who find themselves involved in their patients’ requests for PAS, regardless of their final choice to provide or deny assistance to their patients who wish to die.
“Whether or not one has been a believer, there is a spiritual challenge in dying.” (11) The challenge is equal, if not greater, in regard to helping another fellow human being end his or her life. PAS is not merely a matter of laws and regulations: it is first a spiritual challenge for the patient and the physician.
1. Schweitzer A. Reverence for life. New York: Harper and Row, 1966.
2. Pellegrino ED. Doctors must not kill. J Clin Ethics 1992; 3:95 -102
3. Quill TE . Doctor, I want to die. Will you help me? JAMA 1993; 270: 870-873.
4. Emanuel EJ, Fairclough DL, Emanuel LL. Attitudes and desires related to euthanasia and physician-assisted suicide among terminally ill patients and their caregivers. JAMA 2000; 284:2460-8
5. Breitbart W, Rosenfeld BD, Passik SD. Interest in physician-assisted suicide among ambulatory HIV-infected patients. Am J Psychiatry. 1996;153:238-242.
6. Emanuel EJ. Depression, euthanasia, and improving end-of-life care. J Clin Oncol 2005; 23:6456-8.
7. Gallagher R. Can’t we get this over with? An approach to assessing the patient who requests hastened death. Can Fam Physician 2009: 55: 260-261.
8. Chochinov HM. Dignity and the essence of medicine: the A, B, C, and D of dignity conserving care. BMJ 2007;335:184–17.
9. Mebane EW, Oman RF, Kroonen LT, Goldstein MK.The influence of physician race, age, and gender on physician attitudes toward advance care directives and preferences for end-of-life decision-making. J Am Geriatr Soc. 1999 ; 47:579-91.
10. Suarez-Almazor ME, Newman C, Hanson J, Bruera E. Attitudes of terminally ill cancer patients about euthanasia and assisted suicide: predominance of psychosocial determinants and beliefs over symptom distress and subsequent survival. J Clin Oncol 2002;20:2134–41.
11. Pellegrino ED. Ethical issues in palliative care. In “Handbook of psychiatry in palliative care.” Oxford University Press 2000