Whose Right to Die?

America should think again before pressing ahead with the legalization of physician-assisted suicide and voluntary euthanasia

Myth No. 3: It is terminally ill patients with uncontrollable pain who are most likely to be interested in physician-assisted suicide or euthanasia. "In the case of a terminally ill adult who ends his life in the final stages of an incurable and painful degenerative disease, in order to avoid debilitating pain and a humiliating death, the decision to commit suicide is not senseless, and death does not come too early" (Ninth Circuit Court of Appeals).

The empirical studies of physician-assisted suicide and euthanasia in the Netherlands (where the practices have long been accepted), the United States, and elsewhere indicate that pain plays a minor role in motivating requests for the procedures. A 1996 update of the comprehensive and rigorous 1991 Remmelink Report on euthanasia practices in the Netherlands revealed that in only 32 percent of all cases did pain play any role in requests for euthanasia; indeed, pain was the sole reason for requesting euthanasia in no cases. A study of patients in nursing homes in the Netherlands revealed that pain was among the reasons for requesting physician-assisted suicide or euthanasia in only 29 percent of cases and was the main reason in only 11 percent. A study of physicians in Washington State who admitted to having received requests for physician-assisted suicide or euthanasia revealed that severe pain played a role in only about a third of the requests. A study of HIV-infected patients in New York found that interest in physician-assisted suicide was not associated with patients' experiencing pain or with pain-related limitations on function. My own recent study of cancer patients, conducted in Boston, reveals that those with pain are more likely than others to oppose physician-assisted suicide and euthanasia. These patients are also more likely to say that they would ask to change doctors if their attending physician indicated that he or she had performed physician-assisted suicide or euthanasia. No study has ever shown that pain plays a major role in motivating patient requests for physician-assisted suicide or euthanasia.

What does motivate requests? According to studies, depression and general psychological distress. The Remmelink Report found that among Dutch patients the leading reason for requesting euthanasia was a perceived loss of dignity. The study of Washington State physicians found that the leading factors driving requests were fear of a loss of control or of dignity, of being a burden, and of being dependent. Among the New York HIV-infected patients the leading factors were depression, hopelessness, and having few—and poor-quality -- social supports. In my own study, patients who were depressed were most likely to discuss euthanasia seriously, to hoard drugs for suicide, and to have read Final Exit, the Hemlock Society suicide manual.

These studies highlight an important conflict between people's actual attitudes and likely medical practice. Many Americans say they would support physician-assisted suicide or euthanasia for patients in pain; they oppose the practices for patients who worry about being a burden, about life's being meaningless, about hopelessness. But patients with depression and psychological distress are most likely to request death; patients in pain are less likely to request it.

Myth No. 4: The experience with euthanasia in the Netherlands shows that permitting physician-assisted suicide and euthanasia will not eventually get out of hand. "There is no reason to believe that legalizing assisted suicide will lead to the horrific consequences its opponents suggest" (Ninth Circuit Court of Appeals).

The slippery slope feared by opponents and supporters alike is the route from physician-assisted suicide or euthanasia for terminally ill but competent adults to euthanasia for patients who cannot give consent: the unconscious, the demented, the mentally ill, and children. Because the Netherlands is the one developed democracy that has experience with sanctioned euthanasia, advocates and adversaries alike invoke it to defend their points of view. What does the Dutch experience actually show?

Contemporary Dutch policy regarding voluntary euthanasia had its origins in 1973, with the case of a physician, Geertruida Postma, who injected a deaf, partially paralyzed seventy-eight-year-old woman with morphine, ending her life. The patient happened to be Postma's mother. Postma was convicted of murder but given a suspended sentence of one week in jail and one year on probation, a sentence that effectively exonerated her. A subsequent case in 1981 resulted in an agreement between Dutch prosecutors and the Royal Dutch Medical Society, under the terms of which physicians who participated in physician-assisted suicide or euthanasia would not be prosecuted for murder if they adhered to certain guidelines. The main guidelines, parts of which have been incorporated into proposals for outright legalization in other countries, are that 1) the patient must make an informed, free, and explicit request for physician-assisted suicide or euthanasia, and the request must be repeated over time; 2) the patient must be experiencing unbearable suffering—physical or psychological—that cannot be relieved by any intervention except physician-assisted suicide or euthanasia; 3) the attending physician must have a consultation with a second, independent physician to confirm that the case is appropriate for physician-assisted suicide or euthanasia; and 4) the physician must report the facts of the case to the coroner, as part of a notification procedure developed to permit investigation and to ensure that the guidelines have been followed.

It is important to recognize that despite a widespread perception to the contrary, euthanasia has not been legalized under the Dutch penal code—it remains a crime, albeit one that will not be prosecuted if performed in accordance with the guidelines. Several recent efforts in the Netherlands to overtly legalize physician-assisted suicide and euthanasia have been defeated, primarily because of opposition from Dutch religious authorities. The Dutch rules differ from what U.S. proposals (such as those embodied in a 1994 Oregon measure on physician-assisted suicide, still in the courts) would require in the following respects: they do not stipulate that a patient must be terminally ill, and they do not require that a patient be experiencing physical pain or suffering—a patient can be experiencing psychological suffering only.

Not until 1990, a decade after the Dutch rules were promulgated, was the comprehensive and reliable empirical study done of physician-assisted suicide and euthanasia in the Netherlands which resulted in the Remmelink Report. The recent update of this report reveals that of about 9,700 requests for physician-assisted suicide or euthanasia made each year in the Netherlands, about 3,600 are acceded to, accounting for 2.7 percent of all deaths in the Netherlands (2.3 percent from euthanasia, 0.4 percent from physician-assisted suicide). Nearly 80 percent of patients who undergo physician-assisted suicide or euthanasia have cancer, with just four percent having neurological conditions such as Lou Gehrig's disease or multiple sclerosis. The report revealed that 53 percent of the Dutch physicians interviewed had participated in physician-assisted suicide or euthanasia at some point in their career; 29 percent had participated within the previous two years. Only 12 percent of the Dutch doctors categorically refused to participate in physician-assisted suicide or euthanasia, most likely for religious reasons.

Presented by

Ezekiel J. Emanuel is an oncologist, a bioethicist, and a vice provost of the University of Pennsylvania. He is the author or editor of 10 books, including Brothers Emanuel and Reinventing American Health Care.

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