Physician-Assisted Suicide (PAS)

Why would anyone consider Physician-Assisted Suicide (PAS)? It’s a scenario that’s seen all too often—a chronically ill woman is suffering in severe excruciating pain daily and feels like she’s become a burden to her family, a lonely man is suffering with a life-limiting illness and has no family to offer any care or support to him. These individuals have lost their independence and feel like they have no quality of life left to live. Great strides have been made to improve end-of-life care through palliative care and hospice programs, but sometimes that’s just not enough.
In America, the care that is offered to the elderly and the chronically ill is less than ideal. Statistics show that an estimated 40-70% of patients die in pain and another 50-60% die feeling shortness of breath. Ninety percent of the nursing homes where patients go to receive 24-hour nursing care are seriously understaffed. Patients who are home and have care provided by family often feel like they are a burden on their caregivers. The cost of hiring in-home caregivers support is not covered by Medicare or state and federal Medicaid systems. Caregivers often suffer from physical, emotional, financial, psychological and social strain. A person may feel as if they have lost all control of their life when they suffer from chronic and life-limiting illnesses. The body isn’t doing what it should and there is no way to stop it.
Therefore, a person my feel like they can regain some control through Physician-Assisted Suicide (PAS). If they can’t control the illness, they can at least control the way they die. Suffering has always been a part of human existence. Since the beginning of medicine there have been requests made to end this suffering by means of physician-assisted suicide.

Physician-assisted suicide is when a patient voluntarily choses to terminate their own life by the administration of a legal substance with the assistance of a physician either directly or indirectly. The patient is provided a medical means and/or knowledge to commit suicide by a physician. The life-ending act is performed by the patient and not the physician. Recent studies show that approximately 57% of physicians practicing today have received a request for physician-assisted suicide in some form or another.
There are many alternatives to PAS that exist. Unrelieved physical suffering may have been greater in the past, but now modern medicine has more knowledge and skills to relieve suffering than ever before. If all patients had access to careful assessment and optimal symptom control and supportive care, palliative care specialists believe that most patients with life-threatening illnesses suffering could be sufficiently reduced to eliminate their desire for a quick death. When the patient’s desire prevails, there are other available avenues to relieve the suffering and avoid prolonging life against their wishes. The driving force behind patients seeking physician-assisted suicide is quality of life.
In October 1997, physician-assisted suicide became legal in the state of Oregon. By the end of the year 2000, approximately 70 people had utilized the physician-assisted suicide law to end their lives. One hundred percent of these cases reported that individuals were not able to take care for themselves and make their own decisions and loss of autonomy. Eighty-six percent of these cases reported that individuals were suffering from loss of dignity and the ability to participate in enjoyable activities.
Currently, physician-assisted suicide is legal in Oregon, Washington, Vermont and Montana. Oregon was the first to pass the Death with Dignity Act in 1997. The requirements for attending/prescribing or consulting with a physician to write a prescription are listed in the following table. Washington followed suit passing the Death with Dignity Act in 2008, and Montana passed the Rights of Terminally III Act in 2009.
Table 1.
Safeguards and Guidelines in the Oregon Act
1. Requires the patient give a fully informed, voluntary decision. 2. Applies only to the last 6 months of the patient’s life. 3. Makes it mandatory that a second opinion by a qualified physician be given that the patient has fewer than 6 months to live. 4. Requires two oral requests by the patient.
5. Requires a written request by the patient.
6. Allows cancellation of the request at any time.
7. Makes it mandatory that a 15-day waiting period occurs after the first
oral request. 8. Makes it mandatory that 48-hours (2 days) elapse after the patient makes a written request to receive the medication. 9. Punishes anyone who uses coercion on a patient to use the Act. 10. Provides for psychological counseling if either of the patient’s physicians thinks the patient needs counseling. 11. Recommends the patient inform his/her next of kin.
12. Excludes nonresidents of Oregon from taking part.
13. Mandates participating physicians are licensed in Oregon. 14. Mandates Health Division Review.
15. Does not authorize mercy killing or active euthanasia.
Source: Compassion & Choices of Oregon, 2009b.
Physician-assisted suicide is illegal in Canada. In the Netherlands, it is legal under certain circumstances, and the right to choose physician-assisted suicide remains highly favored. Physician-assisted suicide is also illegal in the United Kingdom. They currently focus on palliative care. Under strictly defined regulations, physician-assisted suicide is legal in the following countries: Australia, Columbia, and Japan. The legalization of physician-assisted suicide remains controversial.
The topic periodically comes up for intense attention. Organized medicine agrees on two principles: 1. Physicians have an obligation to relieve pain and suffering and to promote the dignity of dying patients in their care. 2. The principle of patient bodily integrity requires that physicians must respect patients’ competent decisions to forgo life-sustaining treatment. There are four main points argued against the acceptance and legalization of physician-assisted suicide along with their counter argument. Improved Access to Hospice and Palliative Care
With quality end-of-life care being made available through hospice and palliative care programs, there is no reason for anyone to seek physician-assisted suicide. In the United States, there are over 4,500 hospice agencies. Millions of people don’t have access to the hospice agencies because of the restrictions on funding and the inflexibility of the Medicare Hospice Benefit requiring patients to have a life expectancy of six months or less. Counter argument: Rare cases of persistent and untreatable suffering will still exist even with improved access to quality end-of-life care. Hospice and palliative care aren’t always sufficient to treat severe suffering. Limits on Patient Autonomy
Physician-assisted suicide requires the assistance of another person. In the opinion of Bouvia vs. Superior Court, “the right to dies is an integral part of our right to control our own destinies so long as the rights of others are not affected,” was determined. Our society threatens physician-assisted suicide by worsening the value of human life. The sanctity of life is the responsibility of society to preserve it. Counter argument: Physicians who are requested to help to end a patients’ life have the right to decline on the basis of conscientious objection. The “Slippery Slope” to Social Depravity
There is concern to the opposition to physician-assisted suicide being allowed with euthanasia not too far behind. Without the consent of individuals in physical handicap, the elderly, the demented, the individuals with mental illness, and the homeless, there is a slippery slope toward euthanasia without the consent of the individuals is deemed “useless” by society. Counter argument: The “slippery slope” would not be allowed to happen within our highly cultured societies. Violation of the Hippocratic Oath
The Hippocratic Oath states that a physician’s obligation is primum non nocere, “first, do no harm.” The direct contrast to that is physician-assisted suicide, where killing a patient is deliberately regarded as harm. Counter argument: According to an individual patient’s needs, the Hippocratic Oath should not be interpreted. Alternatives to Physician-Assisted Suicide
Those opposing to physician-assisted suicide argue that there are legal and morally ethical alternatives to assisted death. Patients have the right to refuse any further medical treatments that may prolong the death, including the medications. Counter argument: Life-sustaining measures to live and still suffer are not relied on by some patients. Withholding life-sustaining treatments would only prolong suffering for these patients. Another argument is that patients can, and often do, decide to stop eating and drinking to speed up their death. Within one to three weeks afterwards, the death will usually occur, and it would be reported as a “good death.”
Counter argument: One to three weeks of intense suffering is too much for any one person to have to put up with. This debate has yet to see any final resolution. Physician-assisted suicide may become more of a reality in our society because of the undercurrent of public support. The United States Supreme Court handed down two cases central to physician-assisted suicide in 1997: Vacco vs. Quill and Gregoire vs. Glucksberg. In both case, it was determined that there was no constitutional right on the grounds of equal protection or personal liberty to the physician-assisted suicide. Both constitutional history and the Western Civilization trends were argued by the court and generally worked against reading the Constitution that way.
The court was sensitive in its decision to the prospect of unintended and unwanted consequences that might follow the recognition of a Constitutional right to physician-assisted suicide. However, it was never said that physician-assisted suicide would ever be legitimate. It was concluded that the states of the Union could decide the matter for themselves. Requests for physician-assisted suicide should be taken very seriously. Responses to these requests should be compassionate and immediate. There are six steps that should physicians should take when responding to requests for physician-assisted suicides: Step 1: Clarify the Request
Step 2: Determine the Root Causes
Step 3: Affirm Your Commitment to Care for the Patient
Step 4: Address the Root Causes of the Request
Step 5: Educate the Patient About Legal Alternatives for Comfort and Control Step 6: Seek Counseling from Trusted Colleagues and Advisors
Step 1: Clarify the Request
The physician should talk to the patient about what suffering means to them. Determine if their point of view can be defined. Listen carefully to their request paying specific attention to the nature of the request. Calmly ask questions to extract the specifics of their request and why they’re requesting such help. Ask directed and detailed questions to learn whether the patient is imagining an unlikely or preventable future. Listen to the patient’s answers with sympathy but not as if you’re endorsing their request to their perception of what they consider to be a worthless life. The physician must be fully aware of his or her own biases in order to effectively respond to the patient’s needs. If the idea of suicide is offensive to the physician, the patient may feel his or her disapprobation and worry about abandonment.
Step 2: Determine the Root Causes
The physician needs to assess the patient’s underlying causes for requesting physician-assisted suicide. The patient’s request may be a failure of the physician in addressing the needs of the patient. The attributes of suffering should be focused on: physical, psychological, social, spiritual, and practical concerns. The physician should evaluate to see if the patient is having some type of clinical depression or common fear about their future outlook. The patient may be worrying about suffering with pain or other symptoms, loss of control or independence, a sense of abandonment, loneliness, indignity, a loss of their self-image, or being a burden to someone.
Step 3: Affirm Your Commitment to Care for the Patient
The fear of abandonment is often felt in patients as they face the end-of-life. They want to be assured that someone will be with them at this time in their life. The physician should listen to and acknowledge the feelings and fears that the patient may express. They should commit to helping the patient find answers to their concerns. The physician should commit to the patient as well as the patient’s family and anyone who is close to the patient that they will continue to be the patient’s physician until their life has ended.
Step 4: Address the Root Causes of the Request
A patient’s request for a quick death is caused by some type of suffering on their behalf. They physician should discuss with the patient their health care preferences and goals. Alternative approaches or services should be discussed at this time with the patient. The physician should be able to determine if supportive counseling is needed for the patient.
Step 5: Educate the Patient about Legal Alternatives for Control and Comfort
Patients often have misconceptions about the benefits of requesting physician-assisted suicide. They may not be aware of the emotional effort that goes into planning for physician-assisted suicide. They also may not be aware of the emotional strain on family and friends. The physician should discuss the legal alternatives to physician-assisted suicide.
The legal alternatives include refusal of treatment, withdrawal of treatment, declining oral intake, and end-of-life sedation. The patient should be made aware that they have a right to decline or consent to any treatment or hospitalization, but that their declining of treatment will not affect their ability to receive high quality end-of-life care. The patient should also be made aware that they have the right to stop any treatment at any time including the stopping of any fluids or nutrition.
Patients suffering with unbearable and unmanageable pain may be approaching their last days or hours of life, and the only option available to them is end-of-life sedation. Before the end-of-life sedation should be considered for a patient, the attending physician and members of the health care team should know that all available therapies were tried. This option has to be agreed upon with the patient and their families with the patient have the final say so if they are capable of making the decision for themselves.
Step 6: Consult with Colleagues
Physician-assisted suicide requests are the most challenging situations that physicians have to face in their practice of medicine. The physicians often hesitate to involve others in these situations for reasons about personal issues being raised, convictions about the inappropriateness of talking about death and concerns about the legal implications of the situation. The personal, ethical and legal ramifications for physician-assisted suicides should be supported by a trusted colleague or advisor of the physician. The trusted colleague could be a mentor, peer, religious advisor, or ethics consultants.
Support may also come from nurses, social workers, chaplains, or other members involved in the care of the patient. Physician-assisted suicide requests should be a sign to the physician that a patient’s needs are not being met and that further evaluation is needed to identify the elements contributing to the patient’s suffering. Unfortunately, there is no easy answer to the question of physician-assisted suicide. Patients have the right to withhold and withdraw life-sustaining procedures. Patients also have the right to receive powerful medication for pain relief and sedation. Physicians who oppose physician-assisted suicide do not always have to prescribe lethal medication.