Physician-Assisted Suicide: Motives, Illness, and Demographics

Introduction and Background

In 2015, California became the fifth U.S. state to legalize physician-assisted suicide, and so-called "death-with-dignity" legislation has become one of the most hotly debated issues in recent years. Even as the debate continues, the trend is clear: more than a dozen states have already introduced death-with-dignity legislation or have committed to do so in the near future (Slew of states to consider aid-in-dying bills, 2016). While a majority of Americans continue to approve of physician-assisted suicide under certain circumstances, opponents charge that the practice places too much power in the hands of physicians who may misuse or abuse it, especially with respect to minorities or lower-income patients. Other critics charge that family members may exploit these laws to rid themselves of elderly or infirm relatives who require enormous amounts of personal care. Against this backdrop, identifying the primary motives for requesting physician-assisted suicide, determining whether patients' race and educational levels play a role in this decision, and understanding what types of terminal illnesses most frequently factor into such requests have assumed new importance and relevance.

Statement of the Problem

Physician-assisted suicide is an increasingly significant cause of death among patients with unbearable suffering and the terminally ill. In 2015, California passed the End of Life Option Act (AB 15), which allows California residents who are terminally ill or have unbearable suffering to request a prescription for medications meant to hasten death. This can occur either as physician-assisted suicide — in which the physician provides the necessary means for the patient to perform the act themselves — or as euthanasia, in which the physician performs the act on the patient. Many critics maintain that a problem exists with legalizing physician-assisted suicide because of the potential for abuse by family members of the elderly. For instance, Dore (2011) argues that "legalization of assisted suicide is a recipe for elder abuse. It devalues people with disabilities. Legalizing assisted suicide would violate official state policy preventing suicide" (p. 82). During a period in which the United States is experiencing especially rapid growth in its elderly population, these are especially salient arguments with important implications for all stakeholders.

Conversely, proponents of physician-assisted suicide maintain that it is a humane and compassionate way to help people relieve their suffering, especially in cases involving terminal conditions that will claim their lives regardless. Moreover, death-with-dignity advocates argue in support of individual autonomy, countering that everyone has a fundamental right to determine the time and manner of their own death under certain circumstances. These diametrically opposed views make additional research both timely and necessary.

Purpose and Objectives of the Study

The purpose of this study was to determine whether the factors chosen have any bearing on those who choose to end their lives with physician-assisted suicide. In support of this purpose, the objectives of the study were as follows:

1. To research scholarly articles regarding physician-assisted suicide and gather pertinent information into a comprehensive profile;
2. To research whether unbearable suffering is the dominant motive to request physician-assisted suicide;
3. To research whether the race and level of education of the patient are contributing factors when physician-assisted suicide is requested; and
4. To research whether the type of terminal illness the patient has been diagnosed with is a factor when requesting physician-assisted suicide.

Rationale of the Study

It is reasonable to posit that the overwhelming majority of Americans would prefer that no one be forced to consider suicide — with or without physician assistance — as a viable alternative, and innovations in pain management in recent years have improved the quality of life for those with terminal illnesses (Rogatz, 2011). As Rogatz emphasizes, however, "There are some patients who experience terrible suffering that can't be relieved by any of the therapeutic or palliative techniques medicine and nursing have to offer, and some of those patients desperately seek deliverance" (2011, p. 32). It is also reasonable to posit that the overwhelming majority of Americans prefer that no one be forced to experience "terrible suffering." Studies of this type can therefore provide valuable insights concerning the antecedents of physician-assisted suicide and help guide death-with-dignity policymaking efforts in the future.

Definition of Terms

Death with dignity. Although no universal definition exists, Hillyard and Dombrink (2001) generally define the death-with-dignity movement as an effort to "define and safeguard the right of patients to orchestrate their own deaths according to their own morality" (p. 8).

Euthanasia. From the Greek for "happy death," this term refers to situations in which physicians act directly to end a patient's life (Hosseini, 2012). According to Black's Law Dictionary (1990), euthanasia is "the act or practice of painlessly putting to death persons suffering from incurable and distressing diseases as an act of mercy" (p. 554).

Palliative care. The World Health Organization defines palliative care as "an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness," achieved "through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual" (cited in Lau & O'Connor, 2012, p. 56).

Physician-assisted suicide. The American Medical Association (AMA) defines physician-assisted suicide as follows: "Physician-assisted suicide occurs when a physician facilitates a patient's death by providing the necessary means and/or information to enable the patient to perform the life-ending act (e.g., the physician provides sleeping pills and information about the lethal dose, while aware that the patient may commit suicide)" (cited in Dore, 2011, p. 82).

Suicide. Black's Law Dictionary (1990) defines suicide as "self-destruction; the deliberate termination of one's own life" (p. 1434).

Limitations of the Study

The findings of this study were limited in scope by the relatively small number (n=67) of responses collected from the custom survey instrument and the inability to follow up the survey with face-to-face or telephonic interviews. In addition, there is always a potential for researcher bias when selecting peer-reviewed and scholarly sources for inclusion in a study of virtually any type (Karimov, Brengman, & Van Hove, 2011). Therefore, special effort was made to select relevant secondary resources reflecting varied perspectives on each issue of interest.

Theoretical Framework

Over the past several decades, a growing body of scholarship has been devoted to the moral and legal implications of withholding medical treatment from patients in certain circumstances, as well as physician-assisted suicide and euthanasia (Hosseini, 2012). A growing consensus has emerged from this scholarship that otherwise competent American adults have a fundamental right to make their own decisions concerning what type and amount of medical care they receive, including decisions that could cause their deaths (Hosseini, 2012).

Research Hypotheses

1. Unbearable suffering is considered a significant motive to request physician-assisted suicide (Boudreau & Somerville, 2013).
2. There is a significant difference in patients who have a higher education requesting physician-assisted suicide compared to patients who have not completed high school or college.
3. There is a significant difference in patients requesting physician-assisted suicide dependent upon the type of diagnosed terminal illness.
4. The elderly of any race or financial condition suffering from terminal illnesses who rely on family members for caregiving are more likely to seek physician-assisted suicide compared to those in tertiary or long-term care facilities.

Expected Outcomes

1. Less educated patients are more likely to seek and receive physician-assisted suicide interventions.
2. People who suffer from extremely painful terminal illnesses will be more likely to prefer physician-assisted suicide.
3. There are income-related differences in the percentages of patients seeking physician-assisted suicide.