Physician assisted suicide and the Supreme Court: putting the constitutional claim to rest

Like the debate about many controversial questions of ethics and medical care in America, public debate about physician assisted suicide became focused on questions of constitutional law. On June 26, 1997, the United States Supreme Court unanimously rejected any constitutional right of terminally ill patients to physician assisted suicide. An analysis of the Court's reasoning reveals that its decisions resolved only a narrow constitutional question that affects relatively few people--mentally competent, terminally ill patients who wish to hasten their imminent deaths by having a physician prescribe medication that they intend to use to commit suicide. Although suicide is not a crime, states remain free to prohibit assisted suicide. One consequence of the Court's decisions may be renewed debate on state laws. A more productive result would be to address the broader public health concerns that gave rise to support for physician assisted suicide--inadequate care for the terminally ill and prevention of suicide.     

Physician-assisted suicide: reflections on Oregon's first case

The authors analyze Oregon's first reported assisted suicide of Mrs. A as a real life application of the Oregon Death with Dignity Act. They critique the effectiveness of the Act's safeguards as illustrated by the case of Mrs. A. They point out that the Act does not require that physicians be adequately trained in palliative care in order to participate in assisted suicide. Most physicians do not have such training. Without it, they are not able to effectively present alternatives to patients requesting assisted suicide. Most physicians also lack the expertise to assess patients' decision-making capacity. Nor does the Act ensure that physicians will be in a position to assess coercion of patients' decisions. The Act requires physicians to report only minimal information about their cases, and there are no enforcement provisions to see that even this is done. Under the Act, a good faith standard rather than the more usual negligence standard immunizes physicians from civil or criminal liability even when they act negligently. The authors demonstrate that the Act protects physicians more than patients, and encourages secrecy. The authors conclude that secrecy will need to be replaced by openness to permit the kind of examination the practice of assisted suicide warrants.     

Physician-assisted suicide and the Supreme Court: the Washington and Vacco verdicts

In June 1997, the Supreme Court decided that statutes proscribing physicians from providing lethal medication for use by competent, terminally ill patients do not violate the Due Process or Equal Protection Clauses of the Constitution. The Court returned the question of physician-assisted suicide to the states, but did not foreclose future review of state laws that may be too restrictive of care at the end of life. The conceptual distinctions between assisted suicide, refusal of life-sustaining treatment, and administration of pain medication to terminally ill patients were endorsed as important guideposts for future analyses.     

Community health promotion nursing practice

As social workers, we are educated about the values of client self-determination as well as the affirmation of uniqueness in how the client experiences life and death. In terms of choices at the end of life, assisted suicide has begun to come out of the closet, so to speak, and as a result, the National Association of Social Worker's adopted a policy in 1993 which addresses this end of life option. Oregon passed Ballot Measure 16 in November of 1994 which allows for a terminally ill person to request drugs to end life. As the legalities of assisted suicide are decided by judges and courts, some terminally ill people will think about and decide to take their own lives rather than wait for the disease process to come to its own ending. There are very few practice guidelines available to social workers who work with the suicidal terminally ill. A traditional mental health model for evaluation of lethality cannot be imposed onto this population. A three-part model for assessment and evaluation of a suicidal request from a terminally ill person is proposed in this article.     

The role of the psychologist in determining competence for assisted suicide/euthanasia in the terminally ill.

This paper discusses the history of assisted suicide/euthanasia and public attitudes in Canada; discusses depression in the terminally ill and the potential role of the psychologist in the assisted suicide/ euthanasia process; and specifically addresses the importance of determining competence in terminally ill patients. One area in which the services of psychologists have not been used to their fullest potential is in the care of the terminally ill, particularly in helping them make end-of-life decisions. It is very important that individuals making end-of-life decisions be assessed for mental disorders in order to ensure they are able to make competent decisions. If assisted suicide and euthanasia were to become legalized, psychologists should be involved in the assessment process in order to determine competency. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

What happens now? Oregon and physician-assisted suicide

With assisted suicide now legally sanctioned, health care professionals in Oregon face the challenge of implementing Oregon's Death with Dignity Act. Physicians, hospice professionals, pharmacists, and other caregivers may find their relationships with patients, families, and fellow professionals changing in unanticipated ways as all learn what it means to make aid in dying openly and compassionately available to patients at the end of life.     

Oregon's first year: The medicalization of control.

The results of Oregon's first year with physician-assisted suicide raise two questions. First, how will it be possible to evaluate what is actually going on in Oregon if there is no public access to the records and if physicians are shielded by patient confidentiality rules? The second question is whether the public understood that many, not most, of those who want physician-assisted suicide want it not to relieve suffering as ordinarily understood but to maintain control over their dying, something that may not correlate at all with suffering from illness and disease. This commentary reviews the existing evidence from the Netherlands and suggests that abuse of the vulnerable will likely occur in Oregon over time. It also reviews the insufficiency of the data emerging from Oregon. Finally, it addresses the various issues raised by the other commentators to the main article. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychiatry and physician-assisted suicide

The psychiatric literature on physician-assisted suicide is scant and almost universally opposed to legalization. This opposition stems from the traditional perspective of suicide as a symptom of mental illness and the tendency of psychiatrists to extend their view of suicide in the medically well to the terminally ill. This article examines the basis for and validity of this opposition and makes recommendations about the role of the psychiatrist in physician-assisted suicide.     

Therapeutic death: A look at Oregon's law.

Oregon voters approved the first American statute authorizing physician-assisted suicide, the Oregon Death With Dignity Act, in 1994. The authors of this article identify some positive and negative psychological effects of laws such as Oregon's on patients. Generally, they conclude, on the basis of psychological theory and the available data, that laws such as Oregon's benefit patients psychologically. Undoubtedly, however, there exist important possible antitherapeutic effects on patients, and the authors hope that discussion of both therapeutic and antitherapeutic consequences will stimulate future research by social scientists in this area. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Factors to consider before participating in a hastened death: Issues for medical professionals.

An emerging problem that health professionals face in working with terminally ill patients is how to respond to the concerns and conflicts that emerge near the end of life. Most important are those that challenge the traditional healing, caring, and therapeutic roles. Among these, perhaps none has drawn as much attention as the issue of physician-assisted dying—particularly what has been termed assisted suicide. Although the ethics of assisted dying have been actively debated by ethicists for decades, the topic is now being discussed with increasing frequency in medical, psychiatric, psychological, and legal journals. Interest has been driven by the interrelationship of changing public opinion, demographics, and the nature of the dying process; admissions of assistance by numerous physicians; and several statewide attempts at legal change, culminating in a successful voters' initiative in Oregon. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Terminal illness and hastened death requests: The important role of the mental health professional.

Do terminally ill individuals have the right to decide the timing of their death and to have assistance in a hastened death? This article is based on an American Psychological Association briefing paper prepared for the media regarding the June 1997 Supreme Court decision on physician-assisted suicide. The Court's decision clarified the role medical doctors can play in caring for the terminally ill, but the role of mental health professionals is still evolving. It is clear, however, that on the basis of behavioral research and clinical experience, a mental health assessment by a qualified mental health professional is imperative for any ill person requesting a hastened death. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Potential for non-shivering thermogenesis in perfused chicken (Gallus domesticus) muscle

The state of Oregon decided to cover all potentially eligible Medicaid citizens to 100% of poverty. Previously, Oregon had covered persons up to 67% of poverty. In order to keep overall program costs in check. Oregon decided to limit the number of services that its Medicaid program would cover. Oregon's normative choice was to contain program costs by covering all eligible persons up to 100% of poverty, while at the same time uniformly limiting access to certain services for everyone in the overall group of eligible persons. The state developed a prioritization list of medical services and priced the components on the list. The amount of money ultimately available for the Medicaid program was a political decision informed by data about the cost of different services and influenced by the priorities set through an independent process of priority-setting. Physicians were asked to determine what works medically, how well it works, and what benefits accrue to patients. Recognizing that physician perspectives on efficacy might vary from patients' perspectives on valuation of benefits, Oregon's planners developed a method for valuing medical outcomes that stemmed from particular medical interventions. This blend of medical fact and value to patients allowed for comparing valuations by introducing cost considerations. Condition-treatment (CT) pairs linked a medical condition with one or more courses of treatment. The goal was to determine the likely incremental medical benefit from a given treatment. In addition, Oregon developed a Quality-of-Well-Being scale to determine the net patient benefit from medical intervention and used a telephone survey to value that net benefit. A cost-benefit ratio was derived, and a prioritization of CT pairs was developed. The article analyzes and evaluates Oregon's use of cost-benefit calculations in the allocation of Medicaid funds, noting that Oregon itself backed away from many of the implications of its cost-benefit analysis and that the Americans with Disabilities Act has constrained use of quality-of-life judgments in Medicaid resource allocation decision-making.     

The effect of sotalol hydrochloride therapy on atrial signal-averaged ECG in patients with paroxysmal atrial fibrillation

BACKGROUND: There has been a continuing public debate about assisted suicide and the proper role, if any, of physicians in this practice. Legislative bans and various forms of legalization have been proposed. METHODS: We mailed questionnaires to three stratified random samples of Michigan physicians in specialties likely to involve the care of terminally ill patients: 500 in the spring of 1994, 500 in the summer of 1994, and 600 in the spring of 1995. Similar questionnaires were mailed to stratified random samples of Michigan adults: 449 in the spring of 1994 and 899 in the summer of 1994. Several different questionnaire forms were used, all of which included questions about whether physician-assisted suicide should be banned in Michigan or legalized under certain conditions. RESULTS: Usable questionnaires were returned by 1119 of 1518 physicians eligible for the study (74 percent), and 998 of 1307 eligible adults in the sample of the general public (76 percent). Asked to choose between legalization of physician-assisted suicide and an explicit ban, 56 percent of physicians and 66 percent of the public support legalization, 37 percent of physicians and 26 percent of the public preferred a ban, and 8 percent of each group were uncertain. When the physicians were given a wider range of choices, 40 percent preferred legalization, 37 percent preferred "no law" (i.e., no government regulation), 17 percent favored prohibition, and 5 percent were uncertain. If physician-assisted suicide were legal, 35 percent of physicians said they might participate if requested--22 percent would participate in either assisted suicide or voluntary euthanasia, and 13 percent would participate only in assisted suicide. Support for physician-assisted suicide was lowest among the strongly religious. CONCLUSIONS: Most Michigan physicians prefer either the legalization of physician-assisted suicide or no law at all; fewer than one fifth prefer a complete ban on the practice. Given a choice between legalization and a ban, two thirds of the Michigan public prefer legalization and one quarter prefer a ban.     

Psychologists, psychiatrists, and physician-assisted suicide: The relationship between underlying beliefs and professional behavior.

Would you, as a practicing professional, conduct evaluations of patients desiring physician-assisted suicide (PAS)? Would you assist directly? The authors surveyed psychologists and psychiatrists licensed in New Mexico in order to understand the ethical reasoning mental health practitioners use making judgements about PAS and to discern what criteria they use in responding to patients desiring aid in dying. Fundamental agreement on the validity of various justifications for or against PAS suggests open-mindedness and empathy. Yet, practitioners report a tendency to act in accordance with their own belief systems rather than the patient's, raising questions about objectivity. How do you compare to these professionals? (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Misconceived sources of opposition to physician-assisted suicide.

This article addresses 2 prominent sources of opposition to physician-assisted suicide (PAS): first, the fear of abuse and, second, common moral distinctions drawn between PAS and other forms of end-of-life decisions and care. Each is grounded in a false assumption that PAS is radically different from other forms of widely accepted end-of-life decisions and care. The experience to date in Oregon gives some reassurance that the practice there permitting PAS has not been significantly abused. Moreover, the author argues that abuse, understood as decisions not in accord with what the patient wants, or would have wanted, is greatest when someone, other than the patient is the decision maker. On this ground, PAS should be less subject to abuse than other surrogate decisions about life support. Moreover, Oregon's law, like virtually all proposals to legalize PAS, contains numerous safeguards that are not present in decisions about life support generally. Second, it is argued that some prominent conceptualizations of accepted end-of-life decisions and care thought to distinguish them morally from PAS fail on closer analysis to do so. (PsycINFO Database Record (c) 2010 APA, all rights reserved)