Will Physician-Assisted Suicide Spread to Massachusetts?

November 04, 2012

A Massachusetts ballot proposition before voters next Tuesday pits traditional medical ethics against another creed anchored by a phrase that Hippocrates probably never uttered — patient autonomy.

The ballot proposition in question would legalize physician-assisted suicide, although supporters prefer the expressions "physician-assisted death" or "death with dignity." Regardless of the name, the proposed law would permit physicians to prescribe a lethal dose of oral narcotic to terminally ill patients who request it to end their suffering. Patients would swallow the medicine on their own, unlike the euthanasia that Dr. Jack Kevorkian illegally administered on occasion to willing patients.

If the proposition passes, and polls suggest it could, Massachusetts would become the fourth state in which physician-assisted suicide is legal. Oregon and Washington already have nearly identical laws, and the Montana Supreme Court declared in 2009 that existing state law and public policy do not bar physicians from helping terminally ill patients die.

Marcia Angell, MD, a former editor-in-chief of the New England Journal of Medicine and a leading proponent of the legislation, thinks that a victory in Massachusetts could be a tipping point in the death-with-dignity movement.

"I think Massachusetts is important," Dr. Angell, now a senior lecturer in the Division of Medical Ethics at Harvard Medical School in Boston, Massachusetts, told Medscape Medical News. "It's the first Eastern state. It's the first heavily Catholic state. If [the law] passes here, I think it will become rapidly widespread."

Dr. Angell is personally vested in the cause. Her father fatally shot himself with a pistol in 1988 to end an agonizing bout with prostate cancer. A physician-aided death, according to Dr. Angell, would have made things less horrendous for him and the rest of the family.

The ballot proposition faces staunch opposition from the Catholic Church and other religious groups, as well as the Massachusetts Medical Society (MMS), which calls physician-assisted suicide "fundamentally incompatible with the physician's role as healer." This position, which is also the official view of the American Medical Association, hearkens back to the ancient Hippocratic Oath and its pledge to refuse to "give a deadly drug to anybody if asked for it."

Nationwide, rank-and-file physicians appear to take a more sympathetic stance toward dispensing deadly drugs to relieve suffering, an issue that goes unmentioned in some modern oaths taken in medical school. Almost 46% percent of physicians surveyed by Medscape in 2010 said physician-assisted suicide should be allowed, whereas 40.7% said it should not and 13.5% said "It depends." A 2007 survey by the Louis Finkelstein Institute for Social and Religious Research along with HCD Research found that only 29% of physicians opposed legalizing the deed under all circumstances, whereas 41% favored it under a wide variety of circumstances and 30% favored it only in a few cases.

Organized medicine also is not monolithic when it comes to taking a stand on this hot button issue. The American Medical Women's Association and the American Medical Student Association have sided with aid-in-dying groups such as Compassion and Choices in support of the Massachusetts ballot proposition.

These professional attitudes mirror public opinion. In a nationwide survey conducted by Harris and BBC World News America in 2010, 58% of respondents said that "the law should allow doctors to comply with the wishes of a dying patient in severe distress who has to have his or her life ended." Various polls in Massachusetts have found similar majorities in favor of the November 6 ballot measure, although the Boston Globe has reported that the support level slipped from 68% in late September to 47% in late October, with opposition rising from 20% to 37%.

How the Law Would Work

The proposed law in Massachusetts, as well as the law in Washington, is modeled after Oregon's Death with Dignity Act, which voters approved in 1994, but which did not take effect until 1998. Similar to its forbearers, the Massachusetts Death with Dignity Act puts numerous conditions on dispensing lethal drugs in an attempt to protect patients from hasty decision-making or coercion by greedy relatives.

The patient's regular physician and a consultant must confirm that the patient has a terminal illness estimated to produce death within 6 months and that he or she is competent, acting voluntarily, and making an informed decision. As part of informed consent, the patient must be advised about alternatives such as palliative care, hospice care, and pain control. If either physician suspects the patient suffers from depression or some other psychiatric disorder, they must refer him or her to counseling. If this third professional determines that a mental disorder impairs the patient's judgment, the lethal prescription is called off.

Patients desiring a prescription of a lethal narcotic must ask for it 3 times — twice orally at least 15 days apart and once in writing. The written request must be witnessed by 2 individuals, one of whom must not be a relative or someone in line to inherit money. A physician cannot write the prescription until 15 days after the initial oral request or 48 hours after the patient signs the written request. The patient can rescind the request at any time.

The legislation would allow the patient's physician to record the underlying terminal illness as the cause of death on the death certificate. Some opponents of the ballot proposition call this fraud. Dr. Angell does not.

"The idea was not to fool anybody, but to make sure that the insurance company didn't use this as an excuse not to pay on a policy," Dr. Angell told Medscape Medical News.

The Case Against the Law

The MMS cites 4 basic reasons why it opposes the ballot proposition on physician-assisted suicide.

The society questions the very need for physician-assisted suicide. Patients already have the right to refuse life-saving treatment, such as kidney dialysis, and to receive palliative sedation for pain, according to the society.

To exercise these rights, patients should complete living wills and designate healthcare proxies, said MMS President Richard Aghababian, MD, an emergency physician. "If you make plans and indicate you want to be made comfortable at the end of life and you don't want extraordinary services, isn't that a viable solution?"

The law rests on the shaky premise that physicians can accurately predict that someone will die within 6 months. "To predict that is virtually impossible," says Dr. Aghababian. "It's an educated guess."

He points to his own health history as proof — he was diagnosed with metastatic stomach cancer almost 8 years ago. "I was told that I should get my affairs in order," said Dr. Aghababian, adding that his health was now "great."

The law lacks sufficient safeguards against abuse. Dr. Aghababian worries about lethal doses of narcotics on the loose, especially if terminally ill patients decide not to take them. "What if the drugs get into the hands of children?" he said. "Or people steal them? Or someone cajoles the patient into taking the medicine [who] might benefit from the estate left behind? No one has to necessarily witness it."

The MMS also maintains that the law's restrictions on witnesses to a patient's written request for lethal drugs do not go far enough. Even allowing a single heir to be a witness invites abuse, according to the society.

Physicians have no business helping someone commit suicide. "Above all, it's a matter of 'do no harm,' " said Dr. Aghababian, referencing the Hippocratic vow to keep patients from harm. "If physicians are trained to heal and do all they can for a patient, and then make [suicide] appear to be a viable option — that may not be the best thing. It may disrupt the doctor–patient relationship."

Dr. Angell characterizes most of the MMS objections as side issues. For example, the law does not expect physicians to guarantee that a terminal patient will die within 6 months; some may live a few months longer. "The point is, do they have a terminal illness that will bring about their death soon?" she said. "In Oregon, over 80% [of patients prescribed lethal medications] had metastatic cancer. You don't make mistakes about this."

Likewise, Dr. Angell says, the MMS argument about potential drug diversion ignores how surgery patients discharged from the hospital go home with a cache of powerful painkillers. "Nobody worries about that," she said. She noted that the state would write regulations to implement the law if passed, and these regulations would spell out enforcement mechanisms for the proper disposal of unused narcotics.

To Dr. Angell, the central issue is the role of a physician whose terminally ill patient requests a death-hastening drug. To view a physician only as a healer, she said, "is a very abstract and narrow notion of a physician's role, and a little bit removed from the specifics of the individual."

Instead, Dr. Angell makes the argument for respecting patient autonomy.

"What the physician should be doing is responding to the needs and wishes of the patient in front of him," she said. "And by definition, in these cases, the physician cannot heal. Surely physicians should be flexible enough [to say], 'Now my role is to ease suffering in accordance with the patient's wishes.' "

"It's Worked Well in Oregon," Said Physician Opponent

William "Bud" Pierce, MD, an oncologist in Salem, Oregon, was an opponent of his state's Death with Dignity Act in the 1990s. Today he qualifies as someone who has made an uneasy peace with the law.

"It's worked well in Oregon," said Dr. Pierce, now president of the Oregon Medical Association. "It has worked as its proponents envisioned it. My worries have not come to fruition."

In the first 14 years of the law's implementation, 935 patients were prescribed lethal doses of medication and 596 died as a result of ingesting the drugs, according to a report from the Oregon Department of Health. The annual number of prescription recipients and deaths has steadily risen, reaching 114 and 71, respectively, in 2011, but these numbers in a state of almost 4 million people do not suggest a runaway train to Dr. Pierce.

"It's an incredibly low number of people who seek this," he said. "It has stayed limited."

Of the 596 individuals who died, almost 98% were white; almost 70% had either attended or graduated from college; 98% were insured, mostly through private plans; and almost 90% were enrolled in hospice care. All in all, the statistics suggest an educated, well-off demographic that received progressive end-of-life care. "Oregon's palliative care is the best in the country," noted Dr. Angell.

Dr. Pierce said that he originally feared that weak, helpless people would be encouraged or coerced to pursue physician-assisted suicide by others looking to benefit financially, or else to dump a healthcare "burden." Those fears have not been borne out, he said. "There are no signs the law is being used in any nefarious way."

Rather, the picture that emerges from 14 years of data is of a small cadre of terminally ill people who, unlike pawns or victims, took charge of their death, he said. The 3 most-cited concerns they had about their final days was the loss of autonomy (90.9%), less ability to engage in enjoyable activities (88.3%), and the loss of dignity (82.7%). Roughly half said they were losing control of bodily functions. Just 22.7% mentioned inadequate pain control.

"The people who request death with dignity are not in severe physical discomfort and suffering," said Dr. Pierce. "But rather, they don't want to become pitiful and helpless before they die."

Will Physician-Assisted Suicide Become a Specialty?

Dr. Pierce said a number of his patients over the years have sought physician-assisted suicide. He cooperates — in a way.

"I won't write the prescription," he said, "but if they satisfy the requirements of the law, I will set them up with a doctor who will write the prescription. I'm their advocate, if that's what they want me to do.

"The doctors I've referred to are wonderful doctors. They care deeply about their patients. They don't promote [physician-assisted suicide]. They see what they're doing as an important component of patient autonomy."

The number of Oregon physicians who order the lethal doses of medication is tiny, noted Dr. Pierce. That observation jives with a statistic in the state report on the law's implementation from 1998 through 2011: The length of the relationship between the patient and the physician writing the prescription has been a median 12 weeks. In other words, the patient's long-standing physician probably did not write the script.

"This is something most physicians could never do," said Dr. Pierce.

Dr. Aghababian in Massachusetts has the same perspective: It is one thing, he said, for physicians to declare in a survey that they support physician-assisted suicide. "But did you ask them if they would be interested in writing the prescription?" he asked.

If Massachusetts voters legalize physician-assisted suicide next Tuesday, Dr. Angell does not want to see prescription writing referred out to a handful of specialists.

"I don't approve of that," said Dr. Angell. "I think it's abandonment. 'I'm too pure to write this prescription, so I'll find somebody else to do it.' "

She compares the controversy over physician-assisted suicide to the debate 30 years ago over withdrawing life-sustaining treatment from the terminally ill. "Nowadays, this is widely accepted. It happens every day. No doctor says, 'Well, I believe the ventilator ought to be removed, but I'm not going to write that order. I'm going to get somebody else.' "

In the next 10 to 20 years, similar reservations about writing a prescription of lethal medicine for a terminally ill patient will sound just as dated, she predicted. "We won't hear this kind of irrationality anymore."