Most NEJM Readers Oppose Physician-Assisted Suicide

September 11, 2013

Roughly 2 in 3 readers of the New England Journal of Medicine (NEJM) oppose physician-assisted suicide, according to survey results published online today in the journal.

That level of opposition to physicians prescribing a lethal dose of narcotic to a terminally ill patient who requests it held true for 2356 readers in 74 countries (64.6%) as well as a subset of 1712 US readers from 49 states (67.3%).

Readers were responding to a case vignette of a 72-year-old Oregon man who was receiving palliative care for metastatic pancreatic cancer and considering physician-assisted suicide, which is legal in his state. The case, along with pro and con arguments on the controversial practice, was published in the April 11, 2013, edition of the NEJM. Readers were asked to vote online whether physician-assisted suicide should be permitted.

Most of the readers casting votes appeared to be physicians, based on some 200 comments posted online regarding the case vignette.

James Colbert, MD, the lead author of the article summarizing the survey results, and his coauthors, write that online voting "is prone to bias and is not likely to be scientifically valid."

Sharing that opinion is Marcia Angell, MD, a former editor of the NEJM and a proponent of physician-assisted suicide.

"[The survey] doesn't tell me much," said Dr. Angell, a senior lecturer on medical ethics at Harvard Medical School, in Boston. "These are the people who chose to respond. They're not all practicing physicians."

Scientific validity notwithstanding, the survey results mirror the position of many medical societies, including the American Medical Association, which considers physician-assisted suicide incompatible with the profession's mission of healing and the oath to "do no harm." One medical society that has taken a stand for physician-assisted suicide is the American Medical Women's Association.

Recent initiatives to legalize the practice in Vermont, Maine, and Massachusetts have all met resistance from state medical societies, but had mixed results in the polls. In November 2012, Massachusetts voters rejected a ballot proposition legalizing physician-assisted suicide. In May, a similar measure failed in the Maine legislature but passed in the Vermont legislature, making Vermont the third state besides Oregon and Washington to explicitly allow physician-assisted suicide.

In addition, the practice is technically legal in Montana because the state supreme court has declared that nothing in state law or public policy prohibits physicians from helping terminally ill patients end their lives.

Does Patient Autonomy Trump Other Concerns?

The comments posted online about the case of the dying Oregon patient took familiar positions in the debate on physician-assisted suicide. Many of its supporters appealed to the principle of patient autonomy — that is, honoring the patient's wishes. "The real argument is not about physician-assisted suicide, but who, or what, has ultimate control or ownership of your own body," stated a reader identifying himself as an obstetrician-gynecologist in Freeport, Florida. Other supporters said physicians have a duty to relieve suffering as well as heal.

Many opponents reiterated the argument that giving a terminally ill patient a lethal dose of medicine violated their Hippocratic duty to do no harm and warned that permitting physician-assisted suicide could create a slippery slope toward euthanasia. Some opponents also questioned letting patient autonomy trump other concerns.

"I'm struck that my aboriginal patients never ask about euthanasia," wrote a reader identifying herself as a Canadian internist in a remote area of the country. "I am realizing that our focus on individual autonomy is a culture-specific one, and occurs at the expense of other values such as connection to other people, valuing of the full human experience, and the ability to receive our life's trajectory without always controlling it.

"To raise my hand to kill…never for me, and never (I hope) for my profession."

Looking at the debate on physician-assisted suicide in the pages of the NEJM, sponsored by the Massachusetts Medical Society, Dr. Angell noted that "doctors often — and certainly the leadership of organized medicine — tend to think that this issue is about them."

"The discussion is always self-referential and self-reverential," Dr. Angell told Medscape Medical News. "But it's really an issue about patients."

Dr. Angell remains a staunch proponent of patient autonomy as the controlling principle in physician-assisted suicide.

"This isn't a matter of choosing death over life," Dr. Angell said. "By definition, the patient is dying, and dying soon. The only issue is the manner of death. The suffering of the terminally ill patient, and the patient's choice to end his life — that is paramount. I can't think of any other value that could compete."

The authors have disclosed no relevant financial relationships.

N Engl J Med. Published online September 12, 2013. Full article

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