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.

Literature Review: History and Legal Landscape of Physician-Assisted Suicide

Background and Overview

The so-called "right to die" movement is certainly not a new phenomenon. Rather, it represents an ongoing debate over the precise role of physicians in helping people end their suffering — a debate dating to the turn of the 20th century (Hillyard & Dombrink, 2001). Fenigsen and Fenigsen (2012) report that "historically, the American ['right-to-die'] movement has always promoted active euthanasia, lethal injections administered by physicians, with (or, sometimes, without) consent of the patient" (p. 304). Notable examples include the American Euthanasia Society's sponsorship of a bill in New York State in 1938 that would have legalized voluntary active euthanasia, and several initiatives to legalize some form of physician-assisted suicide between the 1940s and 1950s, including those by W. G. Lennox, Dr. Foster Kennedy, Rev. Joseph Fletcher, Dr. Abraham Wolbarst, and the Hemlock Society (Fenigsen & Fenigsen, 2012).

More recently, this debate has become more formalized and intensive by virtue of fundamental changes in American society concerning individual rights across a broad spectrum of issues. Hillyard and Dombrink report that "historically speaking, the right-to-die movement resonates with other rights-oriented movements of the 1960s and the 1970s" (2001, p. 8). Since that time, the right-to-die movement has been alternatively supported by these "rights" movements in the 1970s and subsequently challenged by more conservative politicians during the 1980s (Hillyard & Dombrink, 2001).

While advocates of death-with-dignity have not achieved their full goal of legalizing the practice nationwide, their vocal demands have served as a catalyst for more intensive scrutiny of physician-assisted suicide. As Hillyard and Dombrink conclude, "Ultimately, the death with dignity movement has succeeded in tapping into the discourse from each of these social movements and their attendant arenas of debate to frame its grievances, press its claims, and seek support for the movement" (2001, pp. 8–9).

This debate became even more heated during the early 1990s following the highly publicized efforts of Dr. Jack Kevorkian, who performed the first physician-assisted suicide in the United States (Fins, 1999). Fins (1999) reports that "this story could be said to have begun in June 1990, when we read that the retired pathologist had helped a 54-year-old woman with a presumptive diagnosis of Alzheimer's disease to end her life" (p. 81). Following a final tennis game and writing an explanatory message to her family, the patient, Janet Adkins, entered Dr. Kevorkian's infamous Volkswagen microbus, where she was connected to his so-called "suicide machine" and received a lethal injection of a combination of medications (Fins, 1999). According to Wolfson (1998), "[Adkins] was in many ways typical of the victims that would follow: female, not terminally ill, and killed not long after her first meeting with Kevorkian" (p. 51).

Following Adkins's death, Dr. Kevorkian was tried and convicted of second-degree murder when he assisted another patient, Thomas Youk, with his suicide (Fins, 1999). Kevorkian received a 10-to-25-year sentence on April 13, 1999, following three acquittals and a mistrial, of which he served 8 years before being paroled — with the stipulation that he abstain from providing life-ending assistance to anyone or from promoting the act (Fins, 1999). While one physician noted that "it could be argued that we have made remarkable progress since Kevorkian's first assisted suicide" (Fins, 1999, p. 81), Fins qualifies this assertion by pointing out that Kevorkian was not solely responsible for this progress. Nevertheless, his actions and the media attention they attracted served as a springboard for more thoughtful debate among state and national policymakers (Fins, 1999).

Beyond the high-profile efforts of Dr. Kevorkian, another major factor in the intensified 1990s debate was the 1995 publication of the comprehensive "Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment" (SUPPORT), sponsored by the Robert Wood Johnson Foundation (Fins, 1999). According to Bauer-Maglin and Perry (2010), "The $28 million study is considered definitive because it surveyed 9,105 seriously ill patients in detail, including following about half of the group until death" (p. 181). The SUPPORT study considered a wide range of factors, including the expenditure of life savings on hospital care for terminally ill patients, the pain experiences of dying patients, and the amount of time spent on artificial life support systems (Bauer-Maglin & Perry, 2010).

The SUPPORT study found that unacceptably high percentages of terminally ill patients were not receiving adequate pain management and that their preferences for end-of-life care were either unsolicited or ignored (Fins, 1999). Increased media coverage following the study's publication included reports that terminally ill patients were often unaware of advance directives, that doctors were failing to provide adequate pain management for dying patients, and that even when patients had stipulated advance directives, their physicians were unaware of them (Fins, 1999). As a result, Fins (1999) reports that "SUPPORT's conclusions helped to further a desire for the legalization of physician-assisted suicide that had begun in earnest with Timothy Quill's 1991 New England Journal of Medicine account of how he helped his patient 'Diane' end her life" (p. 82).

The publication of Quill's study, together with the publicity surrounding Dr. Kevorkian's conviction, resulted in calls from medical ethicists and leading physicians to develop formal regulatory guidelines (Fins, 1999). While many analysts interpreted the SUPPORT findings as clear evidence of deficiencies in medical care, others viewed them as legitimate rationale in support of legalizing physician-assisted suicide. As Fins (1999) puts it, "After all, if things were this bad in American hospitals, then patients must be given an ability to control the timing and manner of their deaths" (p. 82). It became increasingly clear that some type of legislation was needed to help terminally ill patients avoid unnecessary suffering.

Legal History and Court Decisions

At the state level, efforts to legislate regulatory guidelines for physician-assisted suicide were spurred by New York Governor Mario Cuomo's Task Force on Life and the Law, which investigated the pros and cons and concluded that legalizing the practice was not in the public's best interests (Fins, 1999). State laws prohibiting physician-assisted suicide were increasingly challenged in federal courts, with an early precedential case (Compassion in Dying v. Washington, 1994) rejecting Washington State's law against physician-assisted suicide and holding that "if women had the right to make important intimate choices about questions such as abortion, then dying patients — invoking a comparable liberty interest — had a similar right to determine how they died" (cited in Fins, 1999, p. 82).

Conversely, a federal district court in a New York state case (Quill v. Koppel, 1994) upheld the state's laws against physician-assisted suicide, finding them constitutional (Fins, 1999). These conflicting decisions were subsequently appealed to the Circuit Courts of Appeal. The Ninth Circuit Court initially overturned its lower court's decision, thereby reinstating Washington State's prohibition against physician-assisted suicide. The full Ninth Circuit then heard the case en banc and held in an eight-to-three decision that there was a fundamental constitutional right to physician-assisted suicide (Fins, 1999). Writing for the majority, Judge Stephen Reinhardt cited the equal protection clause of the 14th Amendment and emphasized that "a competent, terminally ill adult, having lived nearly the full measure of his life, has a strong liberty interest in choosing a dignified and humane death rather than being reduced to a state of helplessness, diapered, sedated, incompetent" (cited in Fins, 1999, p. 82).

Likewise, the Second Circuit Court of Appeals in New York reversed the district court and ruled that the state's laws against physician-assisted suicide were unconstitutional, also citing the equal protection clause of the 14th Amendment. The judges argued that if terminally ill patients had the right to have life-sustaining therapies withdrawn in order to die, then patients who were not sustained by such measures were denied an equal opportunity under the law to end their lives (Fins, 1999). The U.S. Supreme Court agreed to hear both Circuit Court decisions to resolve these issues at the national level. In January 1997, the Supreme Court held that U.S. citizens did not have a constitutional right to physician-assisted suicide in Vacco v. Quill (1997) (Fins, 1999).

Concurrent with the Supreme Court's decision, several states were considering physician-assisted suicide legislation, and Oregon became the first state to legalize the practice in November 1997 (Fins, 1999). Pursuant to Oregon's Death with Dignity Act, physicians were authorized to prescribe lethal dosages of medications in cases where terminally ill patients made repeated and voluntary requests for life-ending assistance (Fins, 1999). Since that time, several other states have joined Oregon in legalizing some form of physician-assisted suicide.

Physician-Assisted Suicide vs. Euthanasia

Proponents of physician-assisted suicide frequently attempt to differentiate the practice from active euthanasia; however, both practices share many of the same objections (Dixon, 1998). As Dixon emphasizes, "Both can lead to abuse, both implicate the physician in the death of a patient, and both violate whatever objections there are to killing. Their moral similarity derives from the similar roles of the physician" (1998, p. 25). The Hippocratic Oath administered to all physicians counsels them to "abstain from doing harm." According to one physician, "The classical version of the Hippocratic Oath in medicine has various requirements for physicians. Among those, the physician is required to state that: 'I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to that effect'" (cited in Hosseini, 2012, p. 203). On its face, this proscription would appear to obviate the arguments in support of physician-assisted suicide, but the issue reaches far deeper than this classical version indicates. Indeed, even the ancient Greeks were divided on whether some people should be allowed to die of their own volition and whether they should be permitted to receive assistance in doing so (Hosseini, 2012).

Today, the debate over the legalization of physician-assisted suicide typically excludes euthanasia as defined above, but the two practices are sufficiently similar in their objectives to warrant consideration together. In this regard, Gorsuch (2006) advises that:

Though an analytical distinction exists between assisted suicide and euthanasia, there is a great deal they share in common, and those who support legalizing one tend to support legalizing the other for the same or similar reasons — whether it be out of a sense that fairness requires killing those who wish to die but who cannot kill themselves, a desire to promote individual autonomy whether it is expressed in terms of a desire to kill oneself or have another do so, or a sense that the actions serve a similar social utility in allowing patients to avoid needless suffering. (p. 6)

Nevertheless, many proponents of physician-assisted suicide in the United States have attempted to develop a distinction between the two practices through legislation that legalizes the former but not the latter. This reluctance may be a lingering legacy of Dr. Kevorkian's notoriety, but the fact remains that even Oregon's law specifically legalizes physician-assisted suicide and not euthanasia (Gorsuch, 2006). As Gorsuch ponders, "Is there really any meaningful moral distinction that can be drawn between assisted suicide and euthanasia? If not, what is at work here?" (2006, p. 6).

What is at work is the notion that even people who should be allowed to take their own lives — with physician assistance — should remain in final control of the circumstances of their death without the active involvement of anyone else. In both physician-assisted suicide and euthanasia situations, however, there is a conscious decision on the part of the individual to seek life-ending treatment and a conscious decision on the part of the treating physician to provide it, making the legal distinction between the two practices less meaningful (Gorsuch, 2006). In the Netherlands, both practices are legal, based on the rationale that "they are considered to be identical because intentionally and effectively they both involve actively assisting death" (cited in Gorsuch, 2006, p. 6).

Moreover, many physicians concur that there is little or no real difference between physician-assisted suicide and euthanasia beyond the strictly mechanical act of actively helping someone consume already-prescribed lethal medications. As Dr. John Keown queries, "What, for example, is the supposed difference between a doctor handing a lethal pill to a patient; placing the pill on the patient's tongue; and dropping it down the patient's throat?" (cited in Gorsuch, 2006, p. 6). Consequently, even seemingly progressive states that have enacted laws allowing physician-assisted suicide are effectively excluding some patients who would otherwise be able to avail themselves of these laws if they were physically able to do so. As Gorsuch points out, "Thinking that physician-assisted suicide is the entire answer...is a fantasy. There will always be patients who cannot drink, or are semiconscious, or prefer that a physician perform this act" (2006, p. 6).

It is noteworthy that other countries that have legalized physician-assisted suicide have not drawn any legal distinctions between the practice and euthanasia. Gorsuch adds that "the distinction between the practices is made almost exclusively in American debate — the Dutch and most others who have contemplated legalization see little reason to distinguish between the practices" (p. 6). The rationale for maintaining this distinction in the United States is likely attributable, at least in part, to the efforts of proponents of physician-assisted suicide to challenge existing laws that prohibit the practice. This assertion is supported by the fact that the Euthanasia Society of America and other similar advocacy groups only came into existence during the late 1970s and 1980s, as legal challenges to physician-assisted suicide were becoming more commonplace (Gorsuch, 2006).