Euthanasia and Assisted Suicide - Requests To Die And Physician Compliance

As various states enacted right-to-die legislation, researchers sought to determine physicians' attitudes

TABLE 6.7
End-of-life practices in the Netherlands in 1990, 1995, and 2001

	1990	1995	2001
Interview studies
Number of requests for euthanasia or assisted suicide later in disease	25,100	34,500	34,700
Number of explicit requests for euthanasia or assisted suicide at a particular time	8,900	9,700	9,700
End-of-life practices
Euthanasia	1.9%	2.3%	2.2%
Physician-assisted suicide	0.3%	0.4%	0.1%
Ending of life without patient's explicit request	..*	0.7%	0.6%
Death-certificate studies
Euthanasia	1.7%	2.4%	2.6%
Physician-assisted suicide	0.2%	0.2%	0.2%
Ending of life without patient's explicit request	0.8%	0.7%	0.7%
Alleviation of symptoms with possible life-shortening effect	18.8%	19.1%	20.1%
Non-treatment decision	17.9%	20.2%	20.2%
Total	39.4%	42.6%	43.8%
*Frequency not assessed in this study.
SOURCE: Bregje D. Onwuteaka-Phillipsen, et al., "Table 1. End-of-life Practices in the Netherlands in 1990, 1995, and 2001," in "Euthanasia and Other End-of-Life Decisions in the Netherlands in 1990, 1995, and 2001," The Lancet, vol. 362, no. 9381, August 2, 2003. Reproduced with permission from Elsevier.

toward assisting in patient death. Ezekiel J. Emanuel reviewed the data compiled in various reports 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). As shown in Table 6.4, Emanuel found substantial support among medical students for the legalization of either euthanasia or physician-assisted suicide (PAS) among American physicians. Many physicians expressed support for euthanasia and PAS. A majority of both Oregon medical students (52 percent) and non-Oregon medical students (60 percent), when asked if they would be willing to perform PAS if it was legal, stated that they would. However, when practicing oncologists (oncology is the specialty devoted to care of cancer patients) were asked if they would administer or prescribe drugs to end the life of a patient with metastatic cancer at the patient's request, the percents were much lower. Emanuel also noted some interesting conclusions in his report: most of the public support for these interventions was only for patients in excruciating pain, yet patients most likely to request the interventions are those who are depressed and feel hopeless. (See Table 6.5.) Emanuel also noted that 1 percent or less of all dying Americans receive euthanasia or PAS.

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 percent) came from patients alone or in conjunction with their families. Only 46 requests (11 percent) came from the family alone. (See Table 3.1 in Chapter 3.) Of the requests, 52 percent were for a lethal prescription, 25 percent for a lethal injection, and 23 percent for either a prescription or an injection.

Meier and her colleagues found that the patients requesting euthanasia or PAS were predominantly male (61 percent), 46 to 75 years old (56 percent), and of white European descent (89 percent). Almost half (47 percent) were college graduates and had a primary diagnosis of cancer. A large number were experiencing severe pain (38 percent) or severe discomfort other than pain (42 percent). Many were described by their physicians as dependent (53 percent), bedridden (42 percent), and expected to live less than 1 month (28 percent). (See Table 3.1 in Chapter 3.) Physicians were most likely to honor requests for a lethal prescription or a lethal injection if the patient was in severe pain or in severe discomfort other than pain, but less likely to honor the request if the patient was depressed at that time. (See Table 3.2 in Chapter 3.)

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 percent of the physicians);
• Loss of dignity (53 percent);
• Fear of uncontrollable symptoms (52 percent);
• Actual pain (50 percent);
• Loss of meaning in life (47 percent);
• Being a burden (34 percent);
• Dependency (30 percent).

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.

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), Dr. 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. Dr. 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 Dr. 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 percent of the requests, there was not a single case in which pain was the only reason for requesting assistance to die.

The findings of Dr. Emanuel's study are remarkably similar to those reported by Meier and her colleagues from the national physician survey discussed in the previous section. Dr. 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.