Legalization Of Physician-assisted Suicide Research Articles

Whose life is it, anyway? The federal government vs. the state of Oregon on the legality of physician-assisted suicide

Whose life is it, anyway? The federal government vs. the state of Oregon on the legality of physician-assisted suicide

The Past and Future of Palliative Care

The Past and Future of Palliative Care Kathleen M. Foley A national dialogue is now in full flower on how to advance palliative care and expand hospice services in the United States. Driving this discussion are concerns about an aging population, the changing trajectory of illness, advancements in high-tech life support systems, limitations in health care resources, and issues surrounding patient autonomy and the right to a dignified death. The public concern has been magnified by media attention to the legal, ethical, and moral issues surrounding end of life care—withholding and withdrawing care, Kevorkian's advocacy for assisted death, Oregon's legalization of physician-assisted suicide, and health care professionals' support for futility decision-making. In the last fifteen years, the convergence of the hospice and palliative care movements reflects a growing response by a wide range of stakeholders to improve the quality of living for patients and families with serious chronic illness. Hospice care in the United States began as a grassroots movement to improve the quality of dying for patients at home. It has evolved into a fully funded entitlement program providing care to more than 50 percent of Americans who die of cancer and to approximately 20 to 30 percent of those who die from other chronic diseases. Health care professionals have fostered the more recent palliative care movement, which aims to improve the care of the seriously ill and dying in the hospitals and nursing homes where more than 55 percent of Americans die. The two initiatives share a common philosophy and goal—to improve the quality of life for patients with serious, chronic illness, and for their families as well. A tipping point in the history of these movements and in public and professional discussions about end of life care came with the publication of the SUPPORT study, which validated widespread concerns among the public and health care professionals about the barriers and challenges to providing humane, compassionate care. This pivotal two-phase study of almost 10,000 patients in five major American hospitals revealed serious limitations in the care of patients with life-threatening illness. Patient and family communication with health care professionals about care at the end of life was poor, the cost of care depleted some family's life savings, and half of patients experienced moderate to severe pain in the last three days of life. Interventions to address communication and pain management were not successful. This study, coupled with surveys of public attitudes and beliefs and focus group discussions, led to a growing consensus that significant barriers—organizational, institutional, educational, and economic—had to be overcome before end of life care could be improved. Three reports from the Institute of Medicine frame the problem and provide solutions by offering evidence-based recommendations to address the field's most challenging issues: the lack of professional education and knowledge on end of life care, and the need to develop and expand hospice and palliative care services to hospitals and nursing homes, where the majority of Americans die. These reports represented the first time the IOM had specifically addressed care of the dying. [End Page S42] The Hospice Movement The United States has had a rich tradition in providing hospice care for the terminally ill at home. Initially an advocacy movement, hospice responded to the public's concern about the overmedicalization and institutionalization of care of the dying. In 1975, the first free-standing hospice opened in Connecticut, modeled after the innovative program of Dame Cicely Saunders at St. Christopher's Hospice in London, the 1967 birthplace of the modern-day hospice movement. The movement resonated with a growing number of charismatic nurses, physicians, and volunteers who started community hospice programs to care for the dying at home. Initially, this grassroots effort, with its community-based, home-centered care programs, operated outside the traditional hospital-based health care system, as a parallel initiative for those with terminal illness. By 1982, it had sufficient political and social force to successfully lobby Congress for the passage of the Medicare Hospice Benefit, whose reimbursement formula focused on home-based care and has defined hospice care in the United States. The Medicare Hospice Benefit is an...

Physician-Assisted Suicide and Criminal Prosecution: Are Physicians at Risk?

The legalization of physician-assisted suicide (PAS) remains a hotly debated issue throughout the United States, and continues to capture the attention of government officials at both the state and federal levels. While the practice is currently legal in Oregon, some federal lawmakers and officials from the U.S. Department of Justice have attempted to outlaw that state's practice through legislation (e.g., the Pain Relief Promotion Act of 1999), or through a strained interpretation of the federal Controlled Substances Act. And while several citizen groups throughout the United States have attempted but failed to legalize PAS through popular initiative, several state lawmakers have succeeded in specifically outlawing the practice. Yet even though physician-assisted suicide (PAS) remains unlawful in every state except Oregon, there is ample evidence that American physicians throughout the United States have participated in PAS by providing their terminally ill patients with lethal prescriptions.

Under Siege: The Global Fate of Euthanasia and Assisted-Suicide Legislation

Over the last 40 years public views concerning voluntary life-ending behaviours have changed. The notion of medical doctors being involved in the death of patients who explicitly request it was widely rejected until the 1960s, but now, at least in general opinion polls, it is quite widely accepted. For instance, in Australia, in 1962, only 42% agreed to the sanctioning, in principle, of physicians ending the life of a terminally ill patient further to the patientʼs request. This percentage rose to 78% in the 1990s. Similarly, in Canada, the percentage favouring, in principle, a certain level of legalisation of physician-assisted suicide went up from 45% in 1968 to 78% in 1990. In the Netherlands, in 1966, only 40% of the population agreed to the premise that euthanasia could, in certain situations, be acceptable; this rose to over 50% by 1970, and has been consistently over 70% since 1990.

Honoring treatment preferences near the end of life: the oregon physician orders for life-sustaining treatment (POLST) program.

When people speak of end-of-life care in Oregon, the first thing that comes to mind for many is the legalization of physician-assisted suicide in 1997.1 The Oregon Death with Dignity Act allows the attending physician of a terminally ill patient, under certain circumstances, to prescribe a lethal dose of medication that the patient then self-administers. The law has been used infrequently with a total of 129 people dying under the Act in the first five years of implementation. This translates to less than one in one thousand deaths in Oregon each year.2 Over the past decade, health care providers in Oregon have been working quietly in other areas to improve the care of the dying. While much work is still needed, Oregon has also had some notable successes. One of these areas relates to the ability of health care providers to systematically document and communicate a patient’s preferences to have or refuse life-sustaining treatments when the person is unable to speak for himself or herself.

“Unintended consequences”: Can legalizing physician-assisted suicide actually result in improved palliative care practices?

In this issue of Palliative & Supportive Care, we are pleased to present recent work from Dr. E.R. Goy et al. (“Oregon hospice nurses and social workers' assessment of physician progress in palliative care over the past 5 years”) regarding their observations of the impact of the legalization of physician-assisted suicide in the state of Oregon. In 1977, Oregon enacted the Death with Dignity Act, which legalized physician-assisted suicide for terminally ill patients. In the past 5 years, a relatively small number of terminally ill patients in Oregon have requested assisted suicide and, after evaluation, were provided with physician assistance (Ganzini et al., 2002).

From the USA

Reading this position paper reminded me of George Bernard Shaw’s quip about England and America: two countries separated by the same language.’ While I easily appreciate most of the argument, some parts seem quite foreign,’ while major elements are lacking that I would expect in a review on euthanasia and physician-assisted suicide from North America. I wish the intended audience was defined. The absence of references to articles and monographs that have accompanied the heated public and professional debates on these issues in the USA suggests strict reliance on a European viewpoint. The section on `Medicalized killing’ was most anomalous. Here, the paper only refers to withholding and withdrawing `futile treatment.’ The concept of futility, while popular in the recent past, has largely been abandoned as a useful construct. More importantly, we recognize the right of patients to refuse any treatment, regardless of whether it can be construed as futile. Withholding or withdrawing a potentially life-sustaining treatment at the wish of the patient is carefully distinguished from euthanasia or assisted suicide. Likewise, sedation for intractable dist ress in the dying patient’ / a much more precise term than terminal sedation’ and less prone to misunderstanding / is generally (but not universally) accepted here as distinct from euthanasia or assisted suicide. However, no discussion of acceptable medical procedures that might hasten or cause death should omit the important and often unappreciated rule of double effect. The document does elsewhere resort to distinguishing between intended and unintended effects of treatment, a difference that, I would argue, is often hazy but is essential in applying the principal of double effect. A great deal of palliative care that might be viewed as hastening death is commonly justified by this rule, while overt terminal sedation’ is a rather rare practice. Some commentators also recognize `voluntarily stopping eating and drinking’ as an acceptable method for allowing dying patients to hasten death. Importantly, such methods that hasten death are only ethically acceptable in patients near death; broader application of euthanasia, suicide, and related approaches to self-determined’ death are rarely endorsed. The definitions of euthanasia and physician-assisted suicide also look foreign insofar as they seem to imply that only physicians can carry out euthanasia and that euthanasia and assisted suicide are solely accomplished with drugs. Other persons may carry out or assist in these acts, and other methods may be used. I do not believe the combination of barbiturates and neuromuscular blockers are `usually’ chosen for euthanasia in this country. The debate in the USA has been extremely heated, and many writers readily vilify the Dutch and advocates of legalization as somehow inhumane and ignorant of palliative care, while dismissing so much of the data that helps frame the issues in more objective terms. The document at hand seems to fall into some of these traps. For instance, it refers to legalized euthanasia or physician-assisted suicide `under certain circumstances’ without describing, for instance, the careful safeguards built into the Oregon Death with D ignity Act. I find the statement that palliative care . . . seeks to strengthen and restore autonomy, and not to destroy it’ biased and inflammatory, while the listing of only potential ills from legalized euthanasia (paragraph 4.7) suggests a one-sided view. I would have liked to see some reference to the increasing data indicating that physician-assisted suicide and euthanasia are not regularly sought because of intractable physical suffering or even depression, but rather because of concerns about control, independence, and quality of life. Likewise, the legalization of physician-assisted suicide in Oregon has led to very few uses of this optionand does not seem to have produced many of the `potential’ bad outcomes listed under paragraph 4.7. Dismissing the best data we have / from the Netherlands and now from Oregon / as having significant methodological weaknesses’ reads more like a convenient dodge than a dispassionate appraisal of the literature. The appeal to living wills and advance directives as an antidote to patients’ fears of prolonged and unbearable distress may represent wishful thinking, since the bulk of evidence indicates that these instruments are rarely prepared by patients and are then often not available to key clinicians when the documents might be useful, and finally are not respected when patient instructions conflict with what the physician believes is right. The key conclusion of the article seems to come in paragraph 4.5. `The provision of euthanasia and physician-assisted suicide should not be part of the responsibility of pallia tive care.’ The Task Force should first acknowledge that the major, challenging policy issue / Palliative Medicine 2003; 17: 104 /105

Attitudes of osteopathic physicians toward physician-assisted suicide.

The use of physician-assisted suicide (PAS) in the care of terminally ill patients is controversial. While there are published surveys assessing the attitudes and views of physicians in certain specialties, both nationally and in targeted geographic areas, no such data are available specifically pertaining to osteopathic physicians, who deliver 9% of the primary care in the United States. This article describes a study whose purpose was to identify the views and perspectives of osteopathic physicians on PAS through a national survey. Questionnaires were forwarded to all board-certified internists who are members of the American College of Osteopathic Internists and all surgeons and a random sample of family physicians who are members of the American Osteopathic Association. Physicians were surveyed with initial and follow-up mailings. The 49-item questionnaire was a modified version of the Physician Survey, Center for Ethics in Health Care: Oregon Health Sciences University. Of the 2910 questionnaires that were mailed, 1028 were returned in a usable form, for a 35% response rate. Respondents were predominantly (81%) male and from all parts of the country. Most (58%) would not be willing to prescribe a medication for a competent, terminally ill patient to use with the primary intention of ending his or her own life, and most (55%) would oppose the legalization of PAS. Thirty-three percent of osteopathic physicians admit to receiving requests by terminally ill patients for PAS. Most (53%) osteopathic physicians indicate that the osteopathic principle of holistic care has influenced their decision-making on this issue, and a significant minority (44%) responded that the osteopathic oath influenced their view on PAS. Religion and the degree of prayer frequency were important predictors of the decisions to support or oppose PAS. When compared to other physician surveys, this survey of osteopathic physicians demonstrates some similarities in response but also significant differences. These data suggest that osteopathic education and training may result in a perspective on PAS that reflects the distinctiveness of the osteopathic profession.

Cultural Bias and Liberal Neutrality

Liberals often view religion chiefly as "a problem" for democratic discourse in modern pluralistic societies and propose an allegedly neutral solution in the form of philosophical distinctions between "the right" and "the good" or populist invocations of a "right to choose." Drawing on cultural theory and ethnographic research among activists in the Oregon debates over the legalization of physician-assisted suicide, I demonstrate that liberal "neutrality" harbors its own cultural bias, flattens the complexity of public debates, and undermines liberalism's own commitments to equality. I conclude that the praiseworthy liberal goal of impartiality in policy decisions would best be met not by the inaccessible norm of neutrality but by a norm of inclusivity, which intentionally solicits multiple cultural perspectives.

The ethics of PAS: Morally relevant relationships between personal assistance services and physician-assisted suicide

Batavia AI. The ethics of PAS: morally relevant relationships between personal assistance services and physician-assisted suicide. Arch Phys Med Rehabil 2001;82 Suppl 2:S25-31. Although personal assistance services would appear to have no direct connection to the national debate over legalization of physician-assisted suicide, arguments relating to personal assistance have been raised in the debate. Independent living opponents of a right to assisted suicide contend that people with disabilities who do not have access to the basic personal assistance services they need are inherently oppressed, and a society that provides a right to assisted suicide is essentially an accomplice in coercing such individuals to end their lives. Independent living proponents of the right argue that people with disabilities should have control over the assistance they need to achieve all their goals, and access to desired assistance in seeking death may allow some to decide to forgo or postpone what would otherwise be a desperate act. Both sides would agree that personal assistance services are extremely important to people with disabilities, and that universal access to such services will eliminate a major area of contention in the right-to-die debate in the United States. © 2001 by the American Congress of Rehabilitation Medicine

The ethics of PAS: Morally relevant relationships between personal assistance services and physician-assisted suicide

Batavia AI. The ethics of PAS: morally relevant relationships between personal assistance services and physician-assisted suicide. Arch Phys Med Rehabil 2001;82 Suppl 2:S25-31. Although personal assistance services would appear to have no direct connection to the national debate over legalization of physician-assisted suicide, arguments relating to personal assistance have been raised in the debate. Independent living opponents of a right to assisted suicide contend that people with disabilities who do not have access to the basic personal assistance services they need are inherently oppressed, and a society that provides a right to assisted suicide is essentially an accomplice in coercing such individuals to end their lives. Independent living proponents of the right argue that people with disabilities should have control over the assistance they need to achieve all their goals, and access to desired assistance in seeking death may allow some to decide to forgo or postpone what would otherwise be a desperate act. Both sides would agree that personal assistance services are extremely important to people with disabilities, and that universal access to such services will eliminate a major area of contention in the right-to-die debate in the United States. © 2001 by the American Congress of Rehabilitation Medicine

Medical ethics in a multicultural society.

Contemporary research and teaching in medical ethics is unduly influenced by the imagery of stability, order and uniformity. Many commentators presume the existence of a placid social order and pay little regard to differences in understandings of birth, illness, suffering, death and the nature of healing. Moral philosophers such as John Rawls and Norman Daniels, for example, argue that with the existence of an ‘overlapping consensus,’ morality is in a state of ‘side reflective equilibrium’1. Tom Beauchamp and James Childress, two of the earliest proponents of the ‘principlist’ approach to bioethics, take this view2, as do advocates of case-based moral reasoning (casuistry) such as Albert Jonsen and Stephen Toulmin3. Notwithstanding methodological differences in the manner these philosophers address practical ethical issues in medicine and healthcare, all of them presume the existence of a stable, settled moral order. ‘Society’ is discussed in monolithic terms, and both principlists and casuists pay remarkably little attention to the role of religion and culture or ethnicity in shaping understandings of such topics as abortion, physician-assisted suicide, prenatal genetic testing, stem-cell research or the withdrawal of treatment in end-of-life care. Relying upon philosphical approaches that presume the existence of shared principles and moral paradigms, contemporary ethicists commonly neglect to address important differences in the moral understandings of particular religious communities and ethnic groups4. The notion of ‘common morality’ tends to obfuscate the complex realities of providing medical care in multicultural, multifaith societies5. In pluralistic settings, different interpretive communities can exist, with distinctive understandings of what constitutes moral conduct, forms of evidence and reasoned arguments6. In short, commentators on the ethics of medicine and healthcare greatly over-simplify their task by presuming widespread social support for norms and practices that are in reality subject to vigorous dispute. Let us consider the position of a physician or nurse in London, New York, Sydney or Toronto, where patients come from diverse cultural and religious backgrounds. Some patients wish to receive detailed information about their diagnosis, prognosis, and treatment options. Other patients follow a different cultural script, expecting family members to make important health-related decisions and shield them from ‘bad news’. Some patients, fearful that they will become captive to sophisticated medical technologies, prepare advance directives refusing various possible medical interventions. Others, perhaps because of deep religious belief, want ‘everything done’, and insist on cardiopulmonary resuscitation even in circumstances deemed medically futile by healthcare providers. Some families seek to practise their religious traditions by asking physicians to circumcise their male children—an act that other groups see as child abuse and a violation of human rights. Members of some right-to-die organizations insist that compassionate healthcare providers and legislators would permit physician-assisted suicide, whereas members of many Jewish, Muslim and Christian religious communities declare that legalization of physician-assisted suicide would seriously devalue human life. To contribute usefully to contemporary debates, ethicists need to better address the multiethnic, multifaith character of contemporary social settings7. They need to recognize the existence of a plurality of ‘communities of interpretation’ and ‘local moral worlds’8.

Ethical and legal issues in palliative care

This article reviews the ethical principles underlying palliative care, stressing the importance of respecting patient's rights to withdraw or withhold life-sustaining treatment, including artificial hydration and nutrition. There is no ethical or constitutional right to receive physician-assisted suicide or voluntary active euthanasia. This article discusses current ethical controversies in palliative care, including futility, medication dosage and double-effect, terminal sedation, legalization of physician-assisted suicide and euthanasia, and patient refusal of hydration and nutrition. Relevant legal issues are discussed in tandem with the ethical issues.

Bioethics, Assisted Suicide, and the "Right to Die"

Physician-assisted suicide is much talked about. But confusion remains as to what precisely it is, and debate continues about its ethical implications. Is physician-assisted suicide distinguishable from refusal of treatment? Is there a "right to die?" Does assisted suicide necessarily have to mean physician-assisted suicide? What is the relationship of physician-assisted suicide to end-of-life care? How should physicians deal with a request for assisted suicide? These issues are explored in this paper, along with a review of the ethical arguments for and against physician-assisted suicide. The paper concludes that society should encourage individuals not to see assisted suicide as their best option. A better policy than widespread legalization of physician-assisted suicide is to provide the necessary social support, health care including mental health care, hospice care, and compassion to those who feel they face an undignified life, or an undignified painful death. This paper is based on a presentation made at the AACP 2000 Annual Meeting, October 14, 2000.

Physicians' Voices on Physician-Assisted Suicide: Looking Beyond the Numbers

Most empirical research examining physician views on physician-assisted suicide (PAS) has used quantitative methods to characterize positions and identify predictors of individual attitudes. This approach has generated limited information about the nature and depth of sentiments among physicians most impassioned about PAS. This study reports qualitative data provided by 909 physicians as part of a larger survey (N = 2,805) regarding attitudes toward and experiences with PAS and palliative care. Emergent themes illustrate important clinical, social, and ethical considerations in this area. The data illustrate the diverse and ardent responses that PAS evokes among certain physicians. The role of physicians' personal values is central to discussions about legalization of PAS. Polarized views such as those expressed by physicians in this study are not likely to be reconciled, thereby constraining the development of public policy regarding PAS.

Correlates of physicians' endorsement of the legalization of physician-assisted suicide.

Correlates of physicians' endorsement of the legalization of physician-assisted suicide.

Experience with Physician-Assisted Suicide and Euthanasia

The legalization of physician-assisted suicide remains an important ethical and public policy issue. Advocates and opponents have made predictions

The Nazi! accusation and current US proposals.

In contemporary ethical discourse generally, and in discussions concerning the legalization of physician-assisted suicide (PAS) and voluntary active euthanasia (VAE) specifically, recourse is sometimes had to the Nazi! accusation. Some disputants charge that such practices are or will become equivalent to the Nazi 'euthanasia' program in which over 73,000 handicapped children and adults were killed without consent. This paper reflects on the circumstances that lead to the use of this charge and offers reasons for putting the Nazi! charge aside in contemporary discussions of PAS and VAE. A number of the philosophical presuppositions common to both the Nazi 'euthanasia' program and the currently proposed practices of PAS and VAE are examined. Noting that racist ideology and violent coercion characterized the Nazi program, the paper concludes with a cautionary consideration of the current circumstances that would specify PAS and VAE in the US.

The legalization of physician-assisted suicide.

With the enactment of an Oregon statute permitting physician-assisted suicide,1,2 the recognition of a constitutional right to assisted suicide by two U.S. courts of appeals,3,4 discussed elsewhere in this issue of the Journal, 5 and the acquittals of Dr. Jack Kevorkian,6,7 there appears to be a dramatic shift in right-to-die law. Although the law previously distinguished between the withdrawal of life-sustaining treatment and assisted suicide, these recent events suggest that the distinction is being abandoned and that the law is undergoing a profound change.I will argue here that this interpretation is mistaken. Instead of a shift in . . .

Attitudes of Michigan physicians and the public toward legalizing physician-assisted suicide and voluntary euthanasia.

There has been a continuing public debate about assisted suicide and the proper role, if any, of physicians in this practice. Legislative bans and various forms of legalization have been proposed. We mailed questionnaires to three stratified random samples of Michigan physicians in specialties likely to involve the care of terminally ill patients: 500 in the spring of 1994, 500 in the summer of 1994, and 600 in the spring of 1995. Similar questionnaires were mailed to stratified random samples of Michigan adults: 449 in the spring of 1994 and 899 in the summer of 1994. Several different questionnaire forms were used, all of which included questions about whether physician-assisted suicide should be banned in Michigan or legalized under certain conditions. Usable questionnaires were returned by 1119 of 1518 physicians eligible for the study (74 percent), and 998 of 1307 eligible adults in the sample of the general public (76 percent). Asked to choose between legalization of physician-assisted suicide and an explicit ban, 56 percent of physicians and 66 percent of the public support legalization, 37 percent of physicians and 26 percent of the public preferred a ban, and 8 percent of each group were uncertain. When the physicians were given a wider range of choices, 40 percent preferred legalization, 37 percent preferred "no law" (i.e., no government regulation), 17 percent favored prohibition, and 5 percent were uncertain. If physician-assisted suicide were legal, 35 percent of physicians said they might participate if requested--22 percent would participate in either assisted suicide or voluntary euthanasia, and 13 percent would participate only in assisted suicide. Support for physician-assisted suicide was lowest among the strongly religious. Most Michigan physicians prefer either the legalization of physician-assisted suicide or no law at all; fewer than one fifth prefer a complete ban on the practice. Given a choice between legalization and a ban, two thirds of the Michigan public prefer legalization and one quarter prefer a ban.