Physician-assisted suicide occurs when a physician prescribes lethal drugs to a patient so that the patient can self-administer the drugs to bring about his own death. According to a 2015 Gallup Poll, 58% of Americans support physician-assisted suicide (PAS). That is up from 51% in 2013. Among adults between the ages of 18 and 34 years the numbers are even higher at 81%. There are now four states where PAS is legal: California, Oregon, Vermont and Washington. Montana does not have regulatory framework for PAS; however, built into Montana’s “Rights of the Terminally Ill Act” of 2009, are protections or immunities for physicians and/or advanced practice nurses in regard to withholding or withdrawing treatment.
As a healthcare provider, I find these trends disturbing.
In November of this year, voters in Colorado, where I live, will be voting on Proposition 106 (referred to as Prop 106), Colorado’s “End-of-Life Options Act.” Supporters have raised approximately $5 million; opponents $1.8 million. It is vital that healthcare providers, and the public in general, be educated on the gravity of this decision and the devastating impact it will have on societies’ most vulnerable if it passes (e.g. the disabled, elderly and depressed). I’d like to present a discussion on issues surrounding PAS in general and more specifically Prop 106.
PAS violates the trust between patient and provider as well as the Hippocratic Oath.
Physician-assisted suicide brings into question the physician’s integrity and commitment to do no harm and to act in the patient’s best interest. There are also concerns for perverted incentives as PAS makes it easier for abuse within a broken healthcare environment; as insurance companies stealthily replace genuine compassion and supportive care services, such as palliative care, with cost-cutting. We have seen this in Oregon and California. As Ryan Anderson, PhD, from The Heritage Foundation states, “Physician-assisted suicide offers a cheap, quick fix in a world of increasingly scarce health care resources.” For healthcare providers, this could lead to unexpected mandates overriding how they care for their patients or their patients’ best interest. An often cited quote of theologian Richard Neuhaus states, “What is permitted will eventually become obligatory.”
PAS places the most vulnerable at risk (the depressed, disabled, elderly, children).
Historically, we have seen safeguards erode once PAS is in place. The Netherlands is a prime example for us to examine. Several decades ago, in the 70s and 80s, PAS advocates in the Netherlands justified PAS by stating it would be limited to a number of terminally ill patients experiencing unbearable suffering. Up until 2001, only adults had access to PAS (though it was still technically a crime), but in 2001, it was made legal, and the laws even allowed children 12-16 years old to have access to PAS with parental consent. As of 2002, PAS is no longer limited to those with a terminal illness, but also includes psychological suffering. In individuals over the age of 70, PAS is permitted if they are “tired of living.”
In 2005, the Groningen Protocol was initiated which allows newborns and infants to be euthanized when it is determined that they have “no hope of a good quality of life.” As history has shown in the Netherlands, PAS opens the door for euthanasia, regardless of age, with little justification. It also begs the question – who defines what good quality of life means to another individual?
J. Pereira, MBChB, MSc, from the Univeristy of Ottawa, Division of Palliative Care, laid out the historical evidence of how laws that were to prevent abuse have been largely ignored without consequences; cautioning about the “illusion of safeguards and controls.”
PAS may specifically target people suffering with depression and veterans.
A Study that appeared in the Journal of the American Medical Association (JAMA) in 2000 identified depression as the primary factor motivating individuals to consider PAS. Oregon’s Department of Health noted a decline in formal psychiatric evaluations and expressed a concern that undiagnosed depression might contribute to decisions for PAS. Those suffering from depression are, without a doubt, vulnerable.
This should be a concern for voters in Colorado as Colorado’s suicide rate is one of the highest in the country, indicating we are not doing enough to deal with this problem. Suicide among veterans with PTSD is also on the rise. New Hampshire Representative Al Baldasaro expressed deep concern that such “end of life choices” as PAS would increase the suicide rate among veterans. In a speech addressing efforts to help veterans with PTSD and assisted suicide, Representative Baldasaro asked:
What message are you sending to the community out there and all the good work every one of us has done to protect people from killing themselves? Now we want to make it easy?
PAS ignores palliative care.
Given its’ effectiveness, palliative care should receive more resources and emphasis. Palliative care specialists have expertise in the diseases, treatments, and most importantly, symptom management (e.g. pain, shortness of breath, nausea/vomiting, constipation, depression, etc). In a 2014 report, the Institutes of Medicine summarized key findings and recommendations for improving quality of life near the end of life. Palliative care was highlighted:
Palliative care is associated with a higher quality of life, including better understanding and communication, access to home care, emotional and spiritual support, well-being and dignity, care at time of death, and lighter symptom burden. Some evidence suggests that, on average, palliative care and hospice patients may live longer than similarly ill patients who do not receive such care… Although professional guidelines and expert advice increasingly encourage oncologists, cardiologists, and other disease-oriented specialists to counsel patients about palliative care, wide-spread adoption of timely referral to palliative care appears slow.
Specific problems with Colorado’s Prop 106:
- Prop 106 does not require psychiatric/mental health evaluation. In Oregon, less than 5.5% of PAS patients were referred for psychiatric evaluation. Prop 106 states that a patient can be determined mentally capable by two physicians without any requirements for expertise in mental health. Studies done in the 1990s revealed that patients who were experiencing depression were 4-5 times more likely to seriously pursue information about PAS. One study showed pain was the only motivator in a mere 3% of PAS cases and one of several motivators in 46%. Pain was not cited as a factor at all in 51% of the patients in this report.
- Another concern with Prop 106 is that it allows for any two doctors to determine when a patient is terminal with only six months to live, regardless of the physician’s area of expertise or experience with the patient’s particular illness. There has been much attention in the media about medication errors, and we know that diagnosing a terminal illness is rife with opportunity for error. Patients may not even be terminal or dying. In one study, 1 of 5 patients were discharged alive from hospice. A terminal diagnosis of less than six months is not a guaranteed outcome. In fact, diseases such as myeloma or advanced breast cancer, once considered terminal, are now essentially chronic diseases as newer treatments are more effective in prolonging overall survival and quality of life. Physicians who do not specialize in oncology may not be familiar or up to date with newer, more effective treatments that offer improved patient outcomes and, as a result, label patients as terminal, depriving them of state-of-the-art care.
- Proposition 106 carries with it many other ethical concerns. For example, no witnesses are required when the drugs are “self-administered.” Witnesses are required when the request for lethal drugs is made; however, there are no required qualifications for these witnesses. There are no safeguards to ensure the patient is not coerced, something that could easily occur if the witness had alternative motives such as an inheritance.
- Prop 106 does not require the presence of a physician at the time the drugs are administered. There have been cases where there were complications, such as vomiting up the drugs, patients only taking a portion, delay in death/prolonged dying, induced coma rather than death. What happens when such complications occur? Who will provide the care in these situations? Physician-assisted suicide is not always smooth and peaceful. Who will help the patient if they change their minds after taking the drugs – while the patient struggles, gasping, fighting against the drugs’ effect?
- Another concern is that information surrounding PAS will not be readily obtained. It will be impossible to obtain accurate stats on PAS. All records are required to be private, and death certificates will only document the patient’s underlying illness as the cause of death, rather than PAS.
- In Colorado, we have already seen the explosion of “doc-in-a-box” or “cottage industry” with the state’s approval of medicinal marijuana, as well as an increase in “marijuana tourism.” An inadvertent consequence of Prop 106 is the potential for physicians to gain financial incentives or financial motivation for opening clinics for the purpose of providing PAS. On top of that, Colorado could see an increase in “suicide tourism.”
In a video entitled “Do No Harm,” Dr. William Bolthouse, from Denver, explains that with PAS,
Once you dig into it, there seems to be an insidious dark side that I think needs to be talked about…this law will give the government immense power to decide who lives and who dies…all of these laws are based on the false assumption that your doctor can predict how long you are going to live.
All individuals have a right to life and dignity. America is quickly becoming a culture of death. Compassion is on “life-support.” Proponents of PAS play with semantics. They twist the meaning of “death with dignity” to avoid the less acceptable terms of euthanasia or death by assisted suicide.
We need to advocate for human dignity, for the right to life, and to ensure everyone has the opportunity to receive compassionate mental health care and/or palliative or hospice care when needed at the end of life. We need to stand in the gap on behalf of the vulnerable.
Classifying a subgroup of people as legally eligible to be killed violates our nation’s commitment to equality before the law—showing profound disrespect for and callousness to those who will be judged to have lives no longer ‘worth living,’ not least the frail elderly, the demented, and the disabled. No natural right to PAS exists, and arguments for such a right are incoherent: A legal system that allows assisted suicide abandons the natural right to life of all its citizens. ~ Ryan Anderson, PhD