Physician-Assisted Suicide: Finding a Path Forward in a Changing Legal Environment

Imagine yourself with a disease that has recently become terminal. What kinds of treatments and options would be most important to you? Almost everyone would want to be sure their physicians had considered, if not tried, all potentially effective disease-directed therapy and best possible palliative treatments to maximize their quantity and quality of life. Many patients would want to consider a timely transition to hospice care if no acceptable disease-directed therapies existed, hoping to live as fully as possible for their remaining time, and then to die peacefully. On these points we are completely in sync with the American College of Physicians (ACP) position paper (1). We also know that most patients would want to know that they could refuse burdensome treatments that may keep them alive but with a low quality of life. (In fact, most patients die having forgone some potentially life-sustaining treatment.) A substantial minority of terminally ill patients also would want some assurances about their ability to access or potentially activate a physician-assisted suicide if their suffering becomes unacceptable (2). For many of these patients, the motivation is to maintain control over the manner and timing of their own death (many have been making a series of very challenging decisions throughout their illness and see no reason not to stay in charge of the last phase). Others fear the potential of unacceptable physical suffering in the last phase of their illness, perhaps on the basis of experience. Still others might find that the prolonged debility and dependence that might occur during the dying process are unacceptable (3). Knowledge about what last-resort options are available (4), as well as which options one's own doctor can support, would be reassuring to these patients. It would free their emotional energy for other psychosocial and spiritual matters potentially critical to this last phase of life, and most patients ultimately will not need a medically assisted death if they receive excellent end-of-life care. However, even with the best possible palliative and hospice care, a small percentage of patients eventually will want direct assistance with dying now. Carefully exploring the why now for such requests and redoubling efforts to palliate suffering are the next steps, followed by an exploration of legally available options for responding (2). The legal landscape for patients who want to end their life now is rapidly changing in North America and western Europe (5). Both physician-assisted suicide and voluntary active euthanasia have been legal in the Netherlands, Belgium, and Luxembourg for many years, and both recently were legalized in Canada. Physician-assisted suicide is now legal in 6 states and the District of Columbia (affecting one sixth of the U.S. population), whereas it remains either explicitly illegal or legally uncertain in the remaining states. Most of the U.S. population favors legalization of physician-assisted death, although support decreases slightly when the word suicide is used in questionnaires (5). The medical profession's views are decidedly mixed on the subject of legal access. Most U.S. physicians would want access for themselves, but a smaller percentage would be willing to provide assistance to their patients (6). Positions of professional organizations also vary on this subject. For example, the ACP joins the American Medical Association in opposing the practice (1), whereas the American Academy of Hospice and Palliative Medicine has a neutral position, and the American Medical Student Association and the American Medical Women's Association are in favor of legalization. How should individual physicians proceed when opinions are so deeply divided? We clearly support the steps outlined in the ACP position statement with regard to responding to patient requests for assisted suicide (1). However, if requests persist and the unacceptable suffering continues, we believe all legally available last-resort options should be explored (Table 1). Clinicians should determine in advance which options they can and cannot personally support (4). They should extend themselves, if possible, to respond to their patients' needs and requests without violating their fundamental personal values, regardless of the status of the law. If a patient desires a legally permitted option that the physician cannot support and common ground cannot be found, the patient should be given the opportunity to change physicians in a timely way so that access is allowed. Table 1. Last-Resort Options Given the rapidly changing legal environment with regard to physician-assisted suicide and voluntary active euthanasia, we are concerned that concluding a guideline by stating physicians should not do this is a problematic public health response. Even if one personally disagrees with the behavior, studying it might tell us much about the state of end-of-life care and how it can be improved. The Remmelink studies from the Netherlands (5) and Oregon Health Department data (7) provide examples of collecting meaningful information in an attempt to understand and improve practice. The scale and diversity of a state like California and a country like Canada warrant similar studies. Table 2 gives examples of areas that should be examined as these large-scale implementation efforts are under way. Table 2. Representative Study Questions to Understand the Effect of Legalization of Physician-Assisted Suicide In addition, we worry that the ACP's rigid opposition will prevent physicians who will practice physician-assisted suicide from sharing ideas about better policies and procedures. Given the diversity of opinions and the legality of the procedure for so many people, this response seems like a missed opportunity to educate clinicians and learn about best practices. We should continue to debate the ethical and moral implications of permitting or prohibiting potentially life-ending medical practices. We need to support an environment that both redoubles our efforts to provide palliative and hospice care to all seriously ill patients and enhances our imperative to listen and respond to those who still feel they may need an escape from the last stages of this process. We currently have an opportunity to learn about this process on a larger scale with a more diverse population than ever before. Let's make sure our processes and safeguards are as robust and responsive as possible, and let's learn as much as we can so that these new laws help us serve our patients and families in the best way possible.