TABLE 6.6 Percentage of high school students who felt sad or hopeless, who seriously considered attempting suicide, and who made a suicide plan, by sex and selected U.S. sites, 2003
| TABLE 6.6 | |||||||||
|---|---|---|---|---|---|---|---|---|---|
| Percentage of high school students who felt sad or hopeless, who seriously considered attempting suicide, and who made a suicide plan, by sex and selected U.S. sites, 2003 | |||||||||
| Site | Felt sad or hopelessa,b | Seriously considered attempting suicideb | Made a suicide planb | ||||||
| Female | Male | Total | Female | Male | Total | Female | Male | Total | |
| Percent | Percent | Percent | Percent | Percent | Percent | Percent | Percent | Percent | |
| State surveys | |||||||||
| Alabama | 31.3 | 23.1 | 27.1 | 17.2 | 11.6 | 14.4 | 15.1 | 8.7 | 11.9 |
| Alaska | 30.1 | 20.8 | 25.2 | 21.1 | 12.7 | 16.7 | 16.6 | 8.6 | 12.5 |
| Arizona | 39.3 | 21.1 | 30.4 | 23.0 | 11.8 | 17.6 | 15.4 | 9.5 | 12.6 |
| Delaware | 33.7 | 21.0 | 27.4 | 20.0 | 11.0 | 15.6 | 14.0 | 9.2 | 11.7 |
| Florida | 37.6 | 22.7 | 30.1 | 20.4 | 11.3 | 15.8 | 14.8 | 10.3 | 12.6 |
| Georgia | 35.0 | 22.1 | 28.5 | 19.8 | 13.1 | 16.4 | 14.5 | 11.4 | 13.0 |
| Idaho | 35.9 | 21.9 | 28.7 | 22.4 | 13.4 | 17.8 | 17.4 | 12.4 | 14.9 |
| Indiana | 30.3 | 21.0 | 25.5 | 18.9 | 13.3 | 16.0 | 14.0 | 11.2 | 12.6 |
| Kentucky | 36.7 | 23.6 | 30.1 | 21.0 | 14.3 | 17.6 | 14.8 | 13.8 | 14.5 |
| Maine | 31.3 | 18.2 | 24.7 | 21.5 | 12.4 | 17.1 | 17.9 | 11.8 | 15.0 |
| Massachusetts | 35.0 | 21.1 | 28.0 | 20.0 | 12.7 | 16.3 | 15.0 | 10.0 | 12.5 |
| Michigan | 36.5 | 24.1 | 30.2 | 21.8 | 14.1 | 18.1 | 15.9 | 12.3 | 14.2 |
| Mississippi | 35.0 | 21.7 | 28.7 | 16.1 | 10.4 | 13.5 | 13.3 | 9.3 | 11.6 |
| Missouri | 32.1 | 20.2 | 26.0 | 21.5 | 12.2 | 16.8 | 15.9 | 9.9 | 12.9 |
| Montana | 33.1 | 20.2 | 26.4 | 24.2 | 13.8 | 18.9 | 18.0 | 11.7 | 14.8 |
| Nebraska | 31.6 | 19.2 | 25.3 | 24.0 | 12.2 | 17.9 | 20.1 | 14.5 | 17.2 |
| Nevada | 36.4 | 23.7 | 29.9 | 24.2 | 12.2 | 18.1 | 17.6 | 12.7 | 15.1 |
| New Hampshire | 34.2 | 21.6 | 28.0 | 22.5 | 12.9 | 17.8 | 16.9 | 9.6 | 13.3 |
| New York | 34.3 | 21.3 | 27.8 | 19.6 | 9.3 | 14.4 | 14.0 | 7.8 | 10.9 |
| North Carolina | 38.4 | 22.7 | 30.6 | 23.0 | 13.2 | 18.1 | c | c | c |
| North Dakota | 27.3 | 14.8 | 20.8 | 17.6 | 9.8 | 13.6 | 13.7 | 9.1 | 11.3 |
| Ohio | 37.4 | 23.9 | 30.6 | 21.3 | 15.2 | 18.2 | 16.5 | 11.8 | 14.1 |
| Oklahoma | 32.3 | 22.1 | 27.1 | 17.1 | 13.7 | 15.4 | 14.5 | 11.8 | 13.3 |
| Rhode Island | 29.4 | 19.4 | 24.3 | 16.5 | 11.9 | 14.1 | 13.2 | 9.3 | 11.2 |
| South Dakota | 31.4 | 18.1 | 24.6 | 21.8 | 15.9 | 18.8 | 18.0 | 12.1 | 15.0 |
| Tennessee | 37.4 | 19.6 | 28.3 | 21.6 | 13.6 | 17.5 | 17.7 | 10.6 | 14.1 |
| Texasd | 40.9 | 22.7 | 31.7 | 22.2 | 12.6 | 17.3 | 15.7 | 11.2 | 13.4 |
| Utah | 31.9 | 21.6 | 26.6 | 18.0 | 14.2 | 16.1 | 14.0 | 10.8 | 12.4 |
| Vermont | 29.4 | 18.4 | 23.8 | c | c | c | 16.7 | 10.6 | 13.6 |
| West Virginia | 41.7 | 22.6 | 31.9 | 24.0 | 12.1 | 17.8 | 19.4 | 10.5 | 14.8 |
| Wisconsin | 33.5 | 17.6 | 25.3 | 25.6 | 13.8 | 19.6 | c | c | c |
| Wyoming | 36.9 | 23.5 | 30.2 | 24.8 | 17.5 | 21.0 | 17.5 | 14.1 | 15.8 |
| Median | 34.2 | 21.4 | 27.9 | 21.5 | 12.7 | 17.3 | 15.8 | 10.7 | 13.3 |
| Range | 27.3-41.7 | 14.8-24.1 | 20.8-31.9 | 16.1-25.6 | 9.3-17.5 | 13.5-21.0 | 13.2-20.1 | 7.8-14.5 | 10.9-17.2 |
| Local surveyse | |||||||||
| Boston PS, MA | 36.7 | 21.4 | 29.1 | 17.2 | 8.3 | 12.9 | 15.7 | 7.7 | 11.9 |
| Broward County PS, FL | 38.8 | 23.0 | 30.9 | 18.9 | 10.0 | 14.5 | 13.3 | 8.6 | 11.1 |
| Chicago PS, IL | 35.6 | 26.0 | 31.1 | 15.7 | 11.0 | 13.5 | 13.0 | 9.3 | 11.2 |
| Dallas ISD, TX | 40.1 | 20.2 | 30.4 | 22.1 | 8.2 | 15.3 | 17.1 | 6.2 | 11.7 |
| DeKalb County PS, GA | 34.7 | 22.2 | 28.5 | 18.7 | 8.5 | 13.7 | 12.9 | 8.4 | 10.7 |
| Detroit PS, MI | 37.5 | 24.8 | 31.4 | 17.7 | 11.0 | 14.6 | 13.1 | 9.5 | 11.4 |
| District of Columbia PS | 36.4 | 25.6 | 31.1 | 18.5 | 9.6 | 14.2 | 15.9 | 10.8 | 13.5 |
| Los Angeles USD, CA | 44.2 | 25.1 | 34.6 | 22.9 | 9.2 | 16.0 | 18.9 | 10.4 | 14.6 |
| Memphis PS, TN | 34.7 | 20.3 | 27.4 | 15.0 | 10.1 | 12.5 | 12.3 | 9.4 | 10.9 |
| Miami-Dade County PS, FL | 37.9 | 23.3 | 30.5 | 17.2 | 8.8 | 12.9 | 13.7 | 8.0 | 10.8 |
| Milwaukee PS, WI | 39.0 | 23.2 | 31.1 | 20.3 | 13.0 | 16.7 | c | c | c |
| New Orleans PS, LA | 32.6 | 18.8 | 25.9 | 12.4 | 10.6 | 11.5 | 9.5 | 7.6 | 8.6 |
| New York City PS, NY | 39.3 | 24.9 | 32.2 | 17.8 | 9.3 | 13.6 | 13.5 | 7.9 | 10.7 |
privacy is not explicitly mentioned in the Constitution, the Supreme Court has interpreted several amendments as encompassing this right. In Roe v. Wade (410 US 113, 1973) the High Court ruled that the Fourteenth Amendment protects the right to privacy against state action, specifically a woman's right to abortion. In the landmark Karen Ann Quinlan case, the Court held that the right to privacy included the right to refuse unwanted medical treatment and, as a consequence, the right to die.
The Acceptability of Euthanasia and Physician-Assisted Suicide
In "When Is Physician Assisted Suicide or Euthanasia Acceptable?" (Journal of Medical Ethics, vol. 29, no. 6, December, 2003), S. Frileux and colleagues examined the opinion of the general public on euthanasia and physician-assisted suicide (PAS). Frileux and colleagues define these terms as follows: "In physician-assisted suicide, the physician provides the patient with the means to end his or her own life. In euthanasia, the
TABLE 6.6 Percentage of high school students who felt sad or hopeless, who seriously considered attempting suicide, and who made a suicide plan, by sex and selected U.S. sites, 2003 [CONTINUED]
| TABLE 6.6 | |||||||||
|---|---|---|---|---|---|---|---|---|---|
| Percentage of high school students who felt sad or hopeless, who seriously considered attempting suicide, and who made a suicide plan, by sex and selected U.S. sites, 2003 [CONTINUED] | |||||||||
| Site | Felt sad or hopelessa,b | Seriously considered attempting suicideb | Made a suicide planb | ||||||
| Female | Male | Total | Female | Male | Total | Female | Male | Total | |
| Percent | Percent | Percent | Percent | Percent | Percent | Percent | Percent | Percent | |
| aFelt so sad or hopeless almost every day for ≥2 weeks in a row that they stopped doing some usual activities. | |||||||||
| bDuring the 12 months preceding the survey. | |||||||||
| cNot available. | |||||||||
| dSurvey did not include students from one of the state's large school districts. | |||||||||
| ePS=public school, SD=school district, ISD=independent school district, USD=unified school district. | |||||||||
| SOURCE: Jo Anne Grunbaum, et al., "Table 17. Percentage of High School Students Who Felt Sad or Hopeless, Who Seriously Considered Attempting Suicide, and Who Made a Suicide Plan, by Sex—Selected U.S. Sites, Youth Risk Behavior Survey, 2003," in "Youth Risk Behavior Surveillance—United States, 2003," Morbidity and Mortality Weekly Report, vol. 53, no. SS-2, May 21, 2004, http://www.cdc.gov/mmwr/PDF/SS/SS5302.pdf (accessed November 9, 2005) | |||||||||
| Orange County PS, FL | 37.0 | 18.6 | 27.8 | 20.2 | 10.3 | 15.3 | 15.0 | 10.1 | 12.6 |
| Palm Beach County SD, FL | 39.9 | 24.9 | 32.5 | 22.2 | 13.1 | 17.7 | 15.4 | 9.7 | 12.7 |
| Philadelphia SD, PA | 38.9 | 28.5 | 33.9 | 18.7 | 9.1 | 14.0 | 15.6 | 9.2 | 12.4 |
| San Bernardino USD, CA | 38.9 | 24.7 | 31.9 | 20.1 | 12.6 | 16.6 | 16.4 | 13.4 | 15.0 |
| San Diego USD, CA | 40.7 | 22.0 | 31.1 | 24.6 | 14.4 | 19.4 | 21.7 | 11.8 | 16.7 |
| Median | 38.3 | 23.2 | 31.1 | 18.7 | 10.0 | 14.3 | 15.0 | 9.3 | 11.7 |
| Range | 32.6-44.2 | 18.6-28.5 | 25.9-34.6 | 12.4-24.6 | 8.2-14.4 | 11.5-19.4 | 9.5-21.7 | 6.2-13.4 | 8.6-16.7 |
FIGURE 6.2 Annual suicide rates among persons aged 10-14 years, by year and method, 1992–2001
L. C. Kaldjian and colleagues conducted a study to determine the attitudes of internists (doctors specializing in internal medicine) towards PAS and other end-of-life
TABLE 6.7 Number of suicide deaths and suicide death rates, 2002
| TABLE 6.7 | ||
|---|---|---|
| Number of suicide deaths and suicide death rates, 2002 | ||
| Mechanism of suicide | Number of deaths | Rate of death (per 100,000 population) |
| SOURCE: Adapted from "Table 18. Number of Deaths, Death Rates, and Age-Adjusted Death Rates for Injury Deaths by Mechanism and Intent of Death: United States, 2002," in "Deaths: Final Data for 2002," National Vital Statistics Reports, vol. 53, no. 5, October 12, 2004, http://www.cdc.gov/nchs/data/nvsr/nvsr53/nvsr53_05acc.pdf (accessed March 3, 2006) | ||
| All mechanisms | 31,655 | 11.0 |
| Firearm | 17,108 | 5.9 |
| Suffocation | 6,462 | 2.2 |
| Poisoning | 5,486 | 1.9 |
| Fall | 740 | 0.3 |
| Cut/pierce | 566 | 0.2 |
| Drowning | 368 | 0.1 |
| Other specified, classifiable | 315 | 0.1 |
| Other specified, not elsewhere classified | 200 | 0.1 |
| Fire/flame | 150 | 0.1 |
| Unspecified | 145 | 0.1 |
| All transport | 112 | 0.0 |
| Motor vehicle traffic | 112 | 0.0 |
care issues ("Internists' Attitudes toward Terminal Sedation in End of Life Care," Journal of Medical Ethics, vol. 30, no. 5, October 2004). Most physicians in the study (96%) agreed that it is appropriate to increase pain-reducing medication when needed in end-of-life care. More than three-quarters (78%) also agreed that if a terminally ill patient has pain that cannot be managed well, terminal sedation (TS) is appropriate. (TS means alleviating the pain and discomfort of dying people by sedating them or by providing medication that alleviates their painful or uncomfortable symptoms but that has complete sedation as a side effect. These patients are not usually given nutrition or fluids. TS is controversial because some feel it is tantamount to euthanasia, only slower, while still being perfectly legal.) One-third (33%) agreed that PAS is acceptable in some circumstances.
The results of the Kaldjian study also revealed that those who reported more experience with terminally ill patients were relatively more likely to support TS but not PAS than those who reported less or no experience with terminally ill patients. Those most likely to support both TS and PAS were those with no experience with terminally ill patients. In addition, the data showed that those who did not attend religious services or attended less than monthly were most likely to support both TS and PAS, while those who attended weekly were least likely to support both. No matter the number of terminal patients physicians cared for in the preceding year or the frequency with which they attended religious services, a large proportion supported TS but not PAS.
Assisted Suicide Funding Restriction Act of 1997
In April 1997 President Bill Clinton signed into law the Assisted Suicide Funding Restriction Act of 1997 (PL 105-12). The law bans federal funding of "active means of causing death, such as by lethal injection or the provision of a lethal oral drug overdose." It does not, however, prohibit the use of federal funds for actions some consider to be passive euthanasia—withholding or withdrawing medical treatment or artificial nutrition and hydration, which may eventually lead to death. Neither does it prohibit "the use of items, goods, benefits, or services" to relieve pain or discomfort, even if they hasten death, so long as they are not intended to do so.
Patients Requesting Assisted Suicide and Euthanasia
Diane E. Meier et al studied various characteristics of patients requesting and receiving euthanasia and PAS and reported the results in "Characteristics of Patients Requesting and Receiving Physician-Assisted Death" (Archives of Internal Medicine, vol. 163, no. 13, July 14, 2003). The 1,902 physicians who responded to the researchers' survey reported 415 recent requests for aid in dying. Of these requests, 361 (89%) came from patients alone or in conjunction with their families. Only forty-six requests (11%) came from the family alone. Of the requests, 52% were for a lethal prescription, 25% for a lethal injection, and 23% for either a prescription or an injection.
Meier and her colleagues found that the patients requesting euthanasia or PAS were predominantly male (61%), forty-six to seventy-five years old (56%), and of white European descent (89%). Almost half (47%) were college graduates and had a primary diagnosis of cancer. A large number were experiencing severe pain (38%) or severe discomfort other than pain (42%). Many were described by their physicians as dependent (53%), bedridden (42%), and expected to live less than one month (28%).
Marijke C. Jansen-van der Weide, Bregje D. Onwuteaka-Philipsen, and Gerrit van der Wal published a study in 2005 that revealed characteristics of patients in the Netherlands who explicitly requested euthanasia or physician-assisted suicide from April 2000 to December 2002. As in the Meier study, more than half the patients requesting euthanasia and assisted suicide (EAS) were male (54%). Most of the patients were diagnosed with cancer (90%), a greater percentage than in the Meier study. Although only 9% were diagnosed with depression, 92% were "feeling bad."
Reasons for Assisted Suicide Requests
In an earlier study, "A National Survey of Physician Assisted Suicide and Euthanasia in the United States" (New England Journal of Medicine, vol. 338, no. 17, April 23, 1998), Meier and her colleagues surveyed physicians across medical specialties and throughout the country "to assess the prevalence of requests for assistance with suicide or euthanasia and of compliance with such requests." The physicians were asked to describe the reasons patients were requesting assistance to die. The patients' reasons, as perceived by the physicians, were:
- Discomfort other than pain (reported by 79% of the physicians)
- Loss of dignity (53%)
- Fear of uncontrollable symptoms (52%)
- Actual pain (50%)
- Loss of meaning in life (47%)
- Being a burden (34%)
- Dependency (30%)
Interestingly, the patients' primary concerns were not physical (pain and suffering), but were more likely to be focused on loss of control, being a burden or dependent on others, and loss of dignity.
Results of the Jansen-van der Weide, Onwuteaka-Philipsen, and van der Wal study revealed some of the same reasons patients requested assistance in dying. The three most often cited reasons for requesting euthanasia or PAS were pointless suffering (75%), deterioration or loss of dignity (69%), and weakness or tiredness (60%). Depression was the reason most likely to have influenced a patient to request assistance in dying, while not wanting to burden his or her family was the second most influential factor.
PAIN NOT THE MAJOR REASON FOR REQUESTS TO DIE
Ezekiel Emanuel, an associate professor at Harvard Medical School and a member of the National Bioethics Advisory Commission, suggests that, contrary to popular belief, pain is not the major motivation behind a patient's request to die. In "Whose Right to Die?" (Atlantic Monthly, March 1997), Emanuel reported that empirical studies support this fact. Washington State physicians who received requests to assist in death or to perform euthanasia indicated that severe pain played a role in patient decisions in only about one-third of the requests. Emanuel's own study of cancer patients in Boston revealed that patients in pain were more likely to oppose euthanasia and physician-assisted suicide.
According to Emanuel, studies in the Netherlands—where assisted suicide and euthanasia have been practiced for many years—provide more evidence that pain is a minor factor in requests to end one's life. (The Netherlands, Belgium, and the state of Oregon in the United States are the only places in the world where physician-assisted suicide is legal.) A 1996 update of the Dutch government's landmark Remmelink Report illustrated that, while pain played some role in 32% of the requests, there was not a single case in which pain was the only reason for requesting assistance to die.
The findings of Emanuel's study are remarkably similar to those revealed by the Meier and Jansen-van der Weide studies. Emanuel found that the major reasons for assisted suicide and euthanasia requests ranged from depression to hopelessness to fear of loss of dignity and being a burden. His Boston study also showed that depressed patients were more likely to discuss euthanasia, to stockpile drugs for future suicide, and to have read the suicide manual Final Exit by the Hemlock Society.
Nurses and Patient Requests for Assisted Suicide
According to a national survey, one in five nurses who worked in adult critical care units have hastened a patient's death. In this survey, "The Role of Critical Care Nurses in Euthanasia and Assisted Suicide" (New England Journal of Medicine, vol. 334, no. 21, May 23, 1996), David A. Asch, M.D., defined euthanasia and assisted suicide as circumstances in which a person performs an act with the specific intent of causing or hastening a patient's death. In this category Dr. Asch included intentional overdose of narcotics or other substances, or providing explicit advice to patients about how to commit suicide. Withholding and withdrawing life-sustaining treatment, such as removing a mechanical ventilator, were not included.
A total of 852 nurses responded to the survey. Sixteen percent (129 nurses) reported that they had participated in active euthanasia and assisted suicide at least once in their careers. Sixty-five percent of those nurses who participated at least once in active euthanasia or assisted suicide had done so three or fewer times, while 5% reported doing so more than twenty times.
Based on the responses, Dr. Asch estimated that at least 7% (fifty-eight nurses) had engaged in euthanasia or assisted suicide at least once without a request from either the patient or a surrogate. Eight percent (sixty-two nurses) indicated having done so at least once without a request from the attending physician. These sixty-two nurses further indicated some instances in which they practiced euthanasia or assisted suicide following an attending physician's explicit request, or with the physician's advance knowledge.
Reasons given by the nurses for practicing euthanasia or assisted suicide included concern about the overuse of life-sustaining technology; a sense of responsibility for the patient's welfare; a desire to relieve suffering; and a desire to overcome the perceived unresponsiveness of physicians toward that suffering.
Some experts questioned the accuracy of the survey's results and considered the survey questions ambiguous. Others claimed that the interpretation of euthanasia and assisted suicide was questionable in cases in which the dispensing of pain-relieving medicine resulted in death. Many nurses expressed concern that publicizing the results of the study would undermine the patients' and families' trust in nurses who work in intensive care units.
Individually and as members of professional associations, nurses continue to grapple with questions about end-of-life care and patient requests for assisted suicide. To assist all nurses in providing competent and compassionate care for the dying, the Oncology Nursing Society (ONS) published a position paper and practice guidelines, "The Nurse's Responsibility to the Patient Requesting Assisted Suicide," in January 2001. (Oncology nurses care for terminally ill patients more often than nurses in other clinical settings.)
The ONS guidelines encourage nurses to engage in frank discussions with patients requesting assisted suicide, while actively seeking to identify and address patients' previously unmet needs. Although ONS guidelines definitively prohibit nurse involvement in assisted suicide, the professional society also cautions nurses to "resist the inclination to abandon terminally ill patients who request assisted suicide." The guidelines advise, "In state(s) where assisted suicide is legal, the nurse may choose to continue to provide care or may withdraw from the situation after transferring responsibility for care to a nursing colleague."
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