Euthanasia and Assisted Suicide - The Right To Life

The National Right to Life Committee (NRLC) opposes euthanasia of any kind, including the belief that people who do not have a good quality of life should have the right to choose to die. In "What's Wrong with Making Assisted Suicide Legal?" (NRLC, 1998), David N. O'Steen, executive director of NRLC, and Burke J. Balch, director of the NRLC medical ethics department, propose that people who are feeling suicidal should be helped with their problems, not helped to die.

O'Steen and Balch believe that the assumption that suicidal people are competent and are simply exercising their right to make a rational decision to die is false. They contend that suicidal people are usually depressed or mentally ill, and their attempts to end their lives do not necessarily stem from specific wishes to die. On the contrary, O'Steen and Balch feel these attempts are cries for help that should be answered.

They point to a number of studies showing that most terminally ill patients are suicidal not because they are sick but because they are depressed. Their solution is to treat the depression, not end it by euthanasia. In the case of the severely disabled who might be contemplating suicide, O'Steen and Balch report that most people with disabilities feel that it is the conduct of the able-bodied majority toward them, rather than their own physical or mental impairment, which makes their lives even more difficult. People with disabilities face many obstacles that are the result of social problems such as denial of access, FIGURE 6.3
Assisted Suicide Funding Restriction Act of 1997 discrimination in employment, and attitudes of aversion or pity instead of respect. The authors feel that true respect for the rights of people with disabilities would prompt actions to remove those obstacles, rather than "helping" them to commit suicide.

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). (See Figure 6.3 for the statement President Clinton made on signing the bill.) The law bans federal funding

TABLE 6.4
Attitudes toward euthanasia and physician-assisted suicide (PAS) among physicians¹, 2002

					Support for			Willing to perform
Study	Publication date	Type of survey	Response rate	Types of physicians surveyed	euthanasia	PAS	Support legalization of either euthanasia or PAS	euthanasia	PAS
Heilig19	1989	Mail	38.8	676 San Francisco, Calif, physicians	702	NA	NA	452	NA
Washington State Medical Association20	1991	Mail	55	1105 Washington State physicians	27.83	39.63	49.13	29.73
Overmyer21	1991	Mail	24.9	498 Physicians subscribing to Physician's Management	29.94		NA	NA	NA
American Society of Internal Medicine (ASIM)22	1992	Unstated	40	402 ASIM members	NA	NA	28.95	NA	NA
Caralis and Hammond23	1992	Mail	66	360 Medical students, house staff, and physicians at University of Miami, Miami, Fla	<56	NA	NA	NA	NA
Fried et al24	1993	Mail	65	265 Rhode Island physicians	1.27	8.67	35	28	NA
Shapiro et al25	1994	Mail	33	740 Wisconsin internists, family practitioners, and geriatricians	17.48	NA	NA	27.8	NA
Cohen et al26	1994	Mail	69	938 Washington State physicians	429	509	53	33	40
Doukas et al27	1995	Mail	61.6	154 Michigan oncologists	NA	NA	20.8	8	14
Duberstein et al28	1995	Mail	61.3	114 Monroe County, New York, physicians	NA	5110	3110	NA	NA
Bachman et al29	1996	Mail	74	1119 Michigan physicians	5911		5611	3511
Lee et al30	1996	Mail	70	2761 Oregon physicians	NA	6612	6012	NA	4612
Emanuel et al31	1996	Telephone	73	355 US oncologists	22.513	45.513	43.1	NA	NA
Dickinson et al32	1996	Mail	54	587 South Carolina physicians	559	589	52	29	33
Ganzini et al33	1996	Mail	77	321 Oregon psychiatrists	NA	6914	56	NA	NA
Siaw and Tan34	1996	Mail	34.1	1028 Hawaii physicians, resident	58.415	60.015	NA	27.6	28.8
				physicians, and medical students	9.815	15.615
Portenoy et al35	1997	Mail	33	200 New York City physicians involved in cancer care	NA	36.7	NA	NA	NA
Slome et al36	1997	Mail	60	118 San Francisco AIDS physicians	NA	4816	NA	NA	NA
Abramson et al37	1998	Mail	35	133 Florida oncologists	42	NA	NA	NA	NA
			32	210 Florida nononcologist physicians	65	NA	NA	NA	NA
Meier et al38	1998	Mail	61	1902 US physicians	NA	NA	NA	2417	3617
			71	275 US oncologists	NA	NA	NA	2717	4417
Carver et al39	1999	Mail	65	370 US neurologists	NA	NA	5018	2918	4418
			77	114 US amyotrophic lateral sclerosis specialists	NA	NA	4818	2518	4718
			65	161 US neuro-oncologists	NA	NA	4918	2818	4118
Mangus et al40	1999	Mail	58	227 Oregon medical students	NA	NA	6412	NA	5212
			33	113 Non-Oregon medical students	NA	NA	6612	NA	6012
Willems et al41	2000	Telephone	80	152 Oregon oncologists, internists, and family practitioners	2413	5313	NA	NA	NA
American Society of Clinical Oncology42	2000	Mail	41.73	3299 US oncologists	6.513	22.513	NA	2.013	15.613
1Data are given as percentages unless otherwise indicated. NA indicates not available. In many surveys, the precise wording of the question was not specified.
2The questions stated: "Do you feel that patients should have the option of requesting active euthanasia when faced with incurable terminal illness?" and "If the Humane and Dignified Death Act is passed by California voters, would you participate in carrying out a patient's request for active voluntary euthanasia?"
3The questions stated: "Suppose you had a patient who was terminally ill, mentally competent, and who requested in writing from you aid-in-dying. Should a physician have the legal right to give that patient a lethal injection to knowingly hasten death?" or "Would you give a prescription for a lethal dose of medication to be self-administered by the patient?" "Would you be willing to be personally involved in aiding a patient's death?"
4The question stated: "There are circumstances in which a physician would be justified in deliberately causing a patient's death."
5The question asked how respondents would vote on Washington State Initiative 119 to legalize euthanasia.
6The question asked about support for administering intravenous medication to cause cardiac arrest to a 29-year-old patient with acquired immunodeficiency syndrome (AIDS) with bowel obstructions who requests "medication to induce cardiopulmonary arrest."

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.

TABLE 6.4
Attitudes toward euthanasia and physician-assisted suicide (PAS) among physicians¹, 2002

7The questions stated that there was an "80-year-old man, who had terminal metastatic lung cancer," competent and not depressed, whose "pain was under satisfactory control, but he cannot bear being so debilitated that he can no longer do any of the things that made his life meaningful. He is asking for you to prescribe enough sleeping pills so that if he took them all, he would kill himself." Similarly, "the patient is in the hospital, too weak to swallow a lot of pills, and wishes to end his life. He is asking for a lethal injection."

8The question asked whether physicians would agree to perform euthanasia for a 24-year-old burn victim who had to undergo daily painful treatments, repeatedly stated a desire for death, and requests euthanasia. Respondents were also asked whether they would be willing to perform euthanasia if it were legalized.

9The proportion of physicians who disagree with the statement that euthanasia or PAS "is never ethically justified."

10The yes or no questions stated: "Suicide may be an acceptable alternative for a patient with painful, debilitating terminal illness," and "I support legislation to legalize physician-assisted suicide under certain circumstances."

11The questions and choice of answers stated: "Suppose that the Michigan legislature were deciding between just 2 choices: (1) enacting a law banning all physician-assisted suicide or (2) enacting Plan A for physician-assisted suicide [which would legalize PAS]." "I support some forms of PAS, but only if the patient takes the final action." "I support the physician taking the final action." "I might be willing to participate in some forms of PAS."

12The yes or no questions stated: PAS "would be ethical in some cases" and "should be legal in some cases." "I might be willing in some cases to write a prescription for a lethal dose of medication requested by a terminally ill patient, if PAS were legal."

13The question stated: "A patient develops metastatic cancer, which invades the bones and causes excruciating pain. Current levels of morphine, nerve blocks, and other treatments are failing to control the pain completely. Would it be all right for the doctor, upon request from the patient, to administer intravenous drugs, such as potassium chloride intentionally to end the patient's life or to prescribe drugs so the patient could end his or her own life by overdose?"

14The questions stated whether, at least under some circumstances, physicians should be permitted to "write a prescription for medication whose sole purpose would be to allow [a competent terminally ill patient] to end his or her life?" and whether they supported implementation of Oregon Measure 16 to legalize PAS.

15The larger proportion are those physicians who approve of euthanasia or PAS in "some circumstances (unstipulated)," whereas the smaller proportion are those physicians who think it would be acceptable to perform euthanasia or PAS on a "terminally ill competent patient with lung cancer" who requests these interventions.

16The question stated whether physicians would prescribe a dose of lethal medication for a competent AIDS patient to commit suicide at a future date.

17The proportion of physicians who would be willing under some circumstances to perform euthanasia or prescribe a medication for PAS if they were legal.

18The question stated whether PAS should be made explicitly legal by statute for terminally ill patients. The question about willingness to perform euthanasia or PAS asked, "Are there any clinical circumstances under which you would participate in [euthanasia or PAS] if legalized?"

19Heilig S. The SFMS euthanasia survey: results and analysis. SF Med. 1989;61:24-26, 34.

20Washington State Medical Association. Initiative 1991 WSMA Membership Survey. Seattle: Washington State Medical Association; March 1991.

21Overmyer M. National survey: physicians' views on the right to die. Physician's Manag. 1991;31: 40-60.

22Crosby C. Internists grapple with how they should respond to requests for aid in dying. Internist. 1992;33:10.

23Caralis PV, Hammond JS. Attitudes of medical students, housestaff, and faculty physicians toward euthanasia and termination of life-sustaining treatment. Crit Care Med. 1992;20:683-690.

24Fried TR, Stein MD, O'Sullivan PS, Brock DW, Novack DH. Limits of patient autonomy: physician attitudes and practices regarding life-sustaining treatments and euthanasia. Arch Intern Med. 1993;153:722-728.

25Shapiro RS, Derse AR, Gottlieb M, Schiedermayer D, Olson M. Willingness to perform euthanasia: a survey of physician attitudes. Arch Intern Med. 1994;154:575-584.

26Cohen JS, Fihn SD, Boyko E, Jonsen AR, Wood RW. Attitudes toward assisted suicide and euthanasia among physicians in Washington State. N Engl J Med. 1994;331:89-94.

27Doukas DJ, Waterhouse D, Gorenflo DW, Seid J. Attitudes and behaviors on physician-assisted death: a study of Michigan oncologists. J Clin Oncol. 1995;13:1055-1061.

28Duberstein PR, Conwell Y, Cox C, Podgorski CA, Glazer RS, Caine ED. Attitudes toward self-determined death: a survey of primary care physicians. J Am Geriatr Soc. 1995;43:395-400.

29Bachman JG, Alcser KH, Doukas DJ, Lichtenstein RL, Corning AD, Brody H. Attitudes of Michigan physicians and the public toward legalizing physician-assisted suicide and voluntary euthanasia. N Engl J Med. 1996;334:303-309.

30Lee MA, Nelson HD, Tilden VP, et al. Legalizing assisted suicide: views of physicians in Oregon. N Engl J Med. 1996;334:310-315.

31Emanuel EJ, Fairclough DL, Daniels ER, Clarridge BR. Euthanasia and physician-assisted suicide: attitudes and experiences of oncology patients, oncologists, and the public. Lancet. 1996; 347:1805-1810.

32Dickinson GE, Lancaster CJ, Sumner ED, Cohen JS. Attitudes toward assisted suicide and euthanasia among physicians in South Carolina. J S C Med Assoc. 1996;92:395-399.

33Ganzini L, Fenn DS, Lee MA, Heintz RT, Bloom JD. Attitudes of Oregon psychiatrists toward physician-assisted suicide. Am J Psychiatry. 1996;153:1469–1475.

34Siaw LK, Tan SY. How Hawaii's doctors feel about physician-assisted suicide and euthanasia: an overview. Hawaii Med J. 1996;12:296-298.

35Portenoy RK, Coyle N, Kash KM, et al. Determinants of the willingness to endorse assisted suicide: a survey of physicians, nurses, and social workers. Psychosomatics. 1997;38:277-287.

36Slome LR, Mitchell TF, Charlebois E, Benevedes JM, Abrams DI. Physician-assisted suicide and patients with human immunodeficiency virus disease. N Engl J Med. 1997;336:417-421.

37Abramson N, Stokes J, Weinreb NJ, Clark WS. Euthanasia and doctor-assisted suicide: responses by oncologists and non-oncologists. South Med J. 1998;91:637-642.

38Meier DE, Emmons CA, Wallenstein S, Quill T, Morrison RS, Cassel CK. A national survey of physician-assisted suicide and euthanasia in the United States. N Engl J Med. 1998;338:1193-1201.

39Carver AC, Vickrey BG, Bernat JL, Keran C, Ringel SP, Foley KM. End-of-life care: a survey of US neurologists' attitudes, behavior, and knowledge. Neurology. 1999;53:284-293.

40Mangus RS, Dipiero A, Hawkins CE. Medical students' attitudes toward physician-assisted suicide. JAMA. 1999;282:2080-2081.

41Willems DL, Daniels ER, van der Wal G, van der Maas PJ, Emanuel EJ. Attitudes and practices concerning the end of life: a comparison between physicians from the United States and from the Netherlands. Arch Intern Med. 2000;160:63-68.

42Emanuel EJ, Fairclough D, Clarridge BC, et al. Attitudes and practices of U.S. oncologists regarding euthanasia and physician-assisted suicide. Ann Intern Med. 2000;133:527-532.

SOURCE: Ezekiel J. Emanuel, "Table 3. Attitudes toward Euthanasia and Physician-Assisted Suicide (PAS) among American Physicians," in "Euthanasia and Physician-Assisted Suicide: A Review of the Empirical Data from the United States," Archives of Internal Medicine, vol. 162, no. 2, January 28, 2002