Assisted Suicide Is the Wrong Prescription
Physician-assisted suicide (PAS) now stands at a tipping point in the United States. This practice involves a physician prescribing a non-FDA approved lethal overdose of drugs to a person believed to have a terminal illness. For 30 years, pro-assisted suicide organizations have been lobbying for legalization of assisted suicide throughout the U.S. In 1997, Oregon became the first state to pass PAS legislation. In April of this year, Hawai’i became the sixth. Nearly 20 percent of the U.S. population now lives in a jurisdiction where PAS is legal.
Another critical event took place in June 2018. The American Medical Association’s ethics council, which spent the past 2 years reviewing PAS, concluded that the AMA should reaffirm its longstanding opposition to the practice. The current AMA position states that assisted suicide “is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks.” However, the AMA’s governing body narrowly rejected the ethics council report and referred the issue back for further study.
As a physician in practice for nearly 20 years, these events leave me saddened and discouraged. I have studied this issue carefully over the past 3 years, since PAS legislation was first introduced in my home state of Maryland. What I have concluded is that PAS is shockingly dangerous public policy that physicians and the public should reject. Here are 5 reasons:
1. PAS is unethical for doctors and nurses and is not medical care. The Oath of Hippocrates, from over 2400 years ago, states that “neither will I administer a deadly drug to anybody when asked to do so, nor will I suggest such a course.” In modern times, most major medical organizations, including the AMA, the American College of Physicians, the American Nurses Association, the National Hospice and Palliative Care Organization, and the World Medical Association, have agreed and issued statements opposing PAS. PAS has no basis in medical science or tradition, no peer-reviewed guidelines or standards of care. No one would consider giving patients cyanide tablets or carbon monoxide to be medical care. Neither is misusing dangerous controlled drugs as poisons.
2. The supposed “safeguards” in PAS laws are an illusion. They include no requirement for psychiatric evaluation or for witnesses to the consumption of the lethal overdose, no medical examiner inquests, no independent safety monitoring board, and no mandatory routine audits of records and documentation. There is no requirement that the prescribing physician has a meaningful long-term patient-physician relationship with the patient seeking assisted suicide and physicians are immunized from ordinary negligence. Additionally, all medical records and documents connected to the provision of assisted suicide are protected from legal discovery or subpoena, ensuring that no investigation is ever likely to take place.
3. Abuses of PAS laws are already occurring in the U.S. Despite the extraordinary legal protections given to PAS practitioners and the lack of meaningful oversight, cases in the U.S. have been documented where PAS drugs have been given to patients with severe depression and dementia, and at the urging of relatives rather than a patient’s independent request. We know that patients in Oregon have been given PAS drugs and lived for years afterwards, when the law requires a six month prognosis. In addition, there are reports that health insurance companies have denied patients investigational therapies while offering to pay for PAS drugs. Documents from the Oregon PAS program also show that patients may take as long as four days to die after ingesting PAS drugs. For 80 percent of patients, it is unknown if complications occurred (because of lack of medical witnesses). Doctors experimenting with novel PAS drug cocktails in Washington State caused some patients to “scream in pain” before dying.
4. PAS is unnecessary. Patients may already decline any and all medical care that they do not want, and can encode their wishes in advance directives, to be overseen by designated and empowered health-care proxies. Palliative care, hospice care, and pain management programs have made enormous stride in the past decades, and almost all pain and distress at the very end of life can be treated with medications. Moreover, the great majority of patients do not seek PAS because of pain (less than 25 percent in Oregon). Rather, loss of autonomy and fear of being a burden on others are the dominant reasons.
5. The vast majority of doctors in the U.S. will not practice PAS. In Oregon, all suicide prescriptions are written by only 2–3 percent of the state’s doctors, and the average duration of the doctor-patient relationship is only three months, indicating that patients’ personal physicians are rarely providing these prescriptions. In Washington DC, nearly one year after legalization of PAS, only two out of 11,000 licensed physicians (0.02 percent) have registered to participate. These facts indicate that the vast majority of U.S. physicians recognize that PAS is wrong and that physicians who practice PAS may not be trusted by patients with their lives and their health.
Assisted suicide is dangerous and unnecessary, and will permanently damage the integrity of and public trust in the health professions and the health-care system. What is more, there has never been a time in human history when assisted suicide and euthanasia have been less needed. Palliative care, hospice care, and pain management programs are what physicians and legislatures should be promoting — not assisted suicide.
Dr. Joseph E. Marine is a member of the American Medical Association and an associate professor of medicine at Johns Hopkins University.