2 Surveys Find Doctors Back Physician-Assisted Suicide

Doctors are increasingly in favor of helping terminally ill patients end their lives, but they have profound misgivings about being able to do the job right, according to the two most rigorous surveys yet to address that vexing end-of-life dilemma.

More than 2,700 physicians who treat terminal patients were surveyed in Oregon, where voters narrowly passed the nation’s first Death With Dignity Act in 1994. It was struck down by a court challenge that is being appealed.

The survey results showed that 60% supported legalizing physician-assisted suicide, the highest level of support among physicians documented thus far.

However, even among those in favor of the practice, 51% said they did not know which drugs to prescribe to ensure that a patient would die comfortably and avoid becoming an “incomplete suicide,” as the researchers put it.

Many physicians doubted they could fulfill key provisions of the landmark Oregon act. More than 50% said they weren’t confident of predicting that a patient had no more than six months to live, and 28% said they couldn’t always rule out that a patient’s request to die reflected clinical depression, which is often treatable.

“No one has ever looked so starkly at the practical concerns and applications” of physician-assisted dying, said a coauthor of the study, Dr. Susan Tolle of the Oregon Health Sciences University. “It’s clear that these concerns can no longer be ignored.”

In the other survey of 1,119 physicians in Michigan, where Dr. Jack Kevorkian has gained notoriety by assisting in 27 suicides, researchers found that 56% favored legalizing the practice under some conditions, while 37% preferred explicitly banning it.

Moreover, supporters expressed preference for a law that heavily regulated the practice, possibly requiring outside experts in pain management and psychiatry to rule out all possible medical treatments for a patient before allowing a primary physician to assist in a suicide.

What the survey shows, said coauthor Jerald Bachman of the University of Michigan, is that “if there is going to be a movement in the direction of legalization [of physician-assisted suicide], it should be narrow and constrained and bend over backward in regard to safeguards.” For this reason, he added, “A lot of physicians who would like to avoid a total ban and see some legalization are very unhappy with Kevorkian as a model,” he added.

Both surveys, which appear in today’s New England Journal of Medicine, are expected to advance public debate on the issue by emphasizing that it is one thing to back an idea morally, quite another to put it into practice. “This should take the discussion to a much deeper level,” Tolle said.

The Oregon survey, which consisted of an extensive questionnaire returned by 70% of state-licensed physicians who care for the gravely ill, delved extensively into physicians’ qualms.

“I was impressed by the findings,” said George Annas, a Boston University law professor who has studied the issue. “Even the people who are in favor of this have a lot of practical concerns. They don’t teach things in medical school such as which drugs are most effective at killing someone.”

A major concern was that gravely ill people might request suicide assistance largely because they can’t afford medical care or don’t want to burden their families. More than 80% of the Oregon respondents said that finances might motivate some patient or hospital decisions, raising the specter of physicians helping poor and uninsured people kill themselves to cut costs while continuing to care for those who can afford it.

That is also a major concern within the ethics community, Annas said. “Probably the worst context for this discussion is in the midst of a crisis about the cost of health care. Because physician-assisted suicide is very cheap. Even if you were for it you might hesitate to enact it at this time in history.”

Supporters of death-with-dignity measures say that physician-assisted suicides remain ethically defensible when a person afflicted by a terminal illness has only months to live, is mentally competent and has no hope of spontaneous recovery or medical treatment other than pain relief.

The Oregon survey reveals shortcomings in the state’s Death With Dignity Act, Tolle pointed out. For instance, 32% of respondents said they should be able to reveal a patient’s suicide wish to other health care providers.

But that revelation might not only violate confidentiality rules, it might compromise other doctors and nurses. “They might be unknowingly entrapped in a suicide they object to,” she said, adding that the the act doesn’t address such confidentiality questions.

The American Medical Assn., the nation’s largest physician group, is against physician-assisted suicide and euthanasia. The procedures “pose a serious risk of abuse that is virtually uncontrollable,” the association says. “Such practices are ethically prohibited, they are fundamentally inconsistent with the physician’s role as healer, and they could contribute to erosion of the physician/patient relationship.”

Despite such professional strictures and the lack of laws allowing physician-assisted suicide, the practice does occur. Among the Oregon physicians surveyed, 187, or 7%, said they had written a prescription for a lethal dose of drugs to a patient who had requested suicide assistance. And most of those physicians, the Oregon researchers write, said their patients “had taken the medication.”