Increase in debates, state bans don’t change central fact: It’s coming
Increase in debates, state bans don’t change central fact: It’s coming
Polls show public wants assisted suicide option
Our holding permits this debate to continue, as it should in a democratic society. — U.S. Supreme Court
With the flourish of a pen when writing the majority opinion in June 1997, the U.S. Supreme Court set the stage for what has been — and continues to be — a tumultuous journey in reaching an agreeable solution to assisted suicide in this nation.
It’s been almost two years since the U.S. Supreme Court declined to find the laws against assisted suicide unconstitutional. The court’s refusal cleared the way for Oregon to enact its Death with Dignity Act, first approved by voters in 1994 but blocked from implementation through court challenges. In keeping with the wishes of the Supreme Court justices, states are continuing the debate, and there’s no indication that the controversy is waning. For instance:
• At least 37 states have explicitly criminalized the act of assisted suicide through legislation, with several states debating the issue in current legislative sessions, including California, Hawaii, and Maryland.
• Last November, voters in Michigan rejected by a 3-1 margin a ballot measure to legalize assisted suicide. Organi zers on both sides say the battle is not over.
• In December 1998, two terminally ill Alaskans challenged that state’s ban on assisted suicide, saying they wanted control over end-of-life decisions and the option of hastening death. The case, known as Sampson and Doe v. State of Alaska, is being sponsored by the Portland, OR-based Compassion in Dying Federation.
• In February, the Oregon Health Division, also in Portland, published in the New England Journal of Medicine its highly anticipated report on the results of the law’s first year.1 Contrary to the predictions of critics, patients choosing assisted suicide were neither poor nor in extreme pain.
"Our findings revealed that finances and fear of pain did not appear to be critical considerations in the choice of physician-assisted suicide," notes Katrina Hedberg, MD, medical epidemiologist at the Oregon Health Division and author of the report. (For additional information on characteristics of those patients who chose assisted suicide, see related article, p. 51. For compliance forms required by the Death with Dignity Act, see insert.)
• A class-action federal lawsuit filed in Detroit in March could dramatically alter the legal landscape. The lawsuit seeks to establish a federally protected constitutional right to be free from "unbearable and irremediable" suffering due to a medical condition. In effect, this right would allow for assistance with death and protect physicians and other providers from prosecution.
• Finally, the fourth trial — and first conviction — of Jack Kevorkian, the retired patholo gist turned right-to-die crusader, occurred in late March 1999. While critics and supporters disagree over the ethical and moral issues of Kevorkian’s actions, both agree the conviction does not end the debate. As the baby-boomer generation ages, the issue will become even more prominent and may lead to more uncertainty.
In fact, the only certainty emerging from the assisted suicide debate so far is the fact that many predictions about the effects of legalization have proved false. A growing acceptance of assisted suicide and increased awareness about better pain management could mean you’ll face the issue of assisted suicide sooner than you think. It might take several years, but the U.S. Supreme Court no doubt will rule on a case where the issue of personal liberty is at stake — and the Court always rules in favor of personal liberty, predicts Peter A. Rasmussen, MD, an oncologist in Salem, OR.
Here’s why the tide is changing in the assisted suicide debate:
1. Public opinion is changing.
While a majority of physicians and providers disagree with a patient’s right to request assistance with suicide, public opinion on the matter favors legalization of assisted suicide. A Cable News Network poll conducted last summer, for example, found 79% of respondents in favor of Oregon’s law, compared with 15% who opposed the law.
"The call for assisted suicide hasn’t come from the medical community or medical ethicists. Patients are driving this," says Rasmussen, who has had two patients request assisted suicide since the law was enacted. A majority of physicians in Oregon support the right of the patient to assisted suicide but don’t want to participate, he adds.2
Getting the hospital’s ethics committee to start dialogue on the subject was a little more difficult, however. "I work in a public hospital, so if a patient requests assisted suicide, that’s OK, but it’s not talked about among staff," he explains. "It was difficult for us to reach a consensus on a policy. The only way to ensure that staff didn’t feel like they were getting into an uncomfortable position was to let them know that a patient mentioned suicide, but some of the nursing staff threatened to quit. It’s definitely an evolving process."
Public opinion on Kevorkian seems equally divided. An ABC News poll conducted among a random national sample of 518 adults following the conviction showed 55% disagreeing with the jury’s verdict to convict and 39% agreeing. Additionally, an ABC News poll conducted last summer showed 52% of Americans supporting assisted suicide in general and 44% opposing it.
A survey conducted in July 1998 by GLS Research in San Francisco found that Americans support assisted suicide by a 3-1 margin: 69% in favor, 23% opposed. The survey was conducted for the Compassion in Dying Federation. (For more results, see story, p. 52.)
2. Palliative care is improving.
Because of discussions about assisted suicide, patients become more knowledgeable regarding palliative care during end-of-life care, says Barbara Coombs Lee, FNP, JD, executive director of Compassion in Dying Federation and co-author of Oregon’s Death with Dignity Act. "I believe the phenomenon of improved care in Oregon results from an increased awareness of state-of-the-art palliative care on the part of physicians, and an empowered, educated patient group." (For more suggestions on improving palliative care, see story, p. 53.)
"Patients in Oregon are aware suffering is not a necessary part of the dying process, and physicians respond to the expectation that symptoms will be alleviated," says Coombs Lee.
Patients should never consider assisted suicide because they fear untreated pain, she asserts. In fact, when patients first mention assisted suicide, physicians and providers should review and optimize the treatment of pain, she says.
Patients in Oregon are benefiting from a continuum approach to end-of-life care, she says. "We’re second in the country in utilization of morphine. Of those 15 people who chose assisted suicide, 74% were in hospice. That’s an incredible penetration rate. The national penetration rate is 17%."
Regardless of how patients arrive at the decision to employ assisted suicide, it’s important to ensure that physicians and patients are comfortable with the decision, she adds. "We discuss the ethics of the situation, and we offer alternatives. But if it looks like the last resort is to assist the patient in their death, then we all can do it without risk."
References
1. Chin A, Hedberg K, Higginson G, et al. Legalized physician-assisted suicide in Oregon — The first year’s experience. NEJM 1999; 340:577-583.
2. Lee MA, Nelson HD, Tilden VP, et al. Legalizing assisted suicide — Views of physicians in Oregon. NEJM 1996; 334:310-315.
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