How should individual physicians proceed when opinions are so deeply divided?
Physician-Assisted Suicide: Finding a Path Forward in a Changing Legal Environment Imagine yourself with a disease that has recently be- come 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 max- imize their quantity and quality of life. Many patients would want to consider a timely transition to hospice care if no acceptable disease-directed therapies ex- isted, hoping to live as fully as possible for their remain- ing 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 poten- tially 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 un- acceptable (2). For many of these patients, the motiva- tion 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 suf- fering in the last phase of their illness, perhaps on the basis of experience. Still others might find that the pro- longed debility and dependence that might occur dur- ing 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 psychoso- cial 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 palli- ative 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. physi- cians would want access for themselves, but a smaller percentage would be willing to provide assistance to their patients (6). Positions of professional organiza- tions also vary on this subject. For example, the ACP joins the American Medical Association in opposing the practice (1), whereas the American Academy of Hos- pice 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?