Physician-Assisted Dying: Compassion or a Slippery Slope?

Roxanne Nelson

August 13, 2015

Physician-assisted suicide and euthanasia are highly controversial issues, but these practices have become legal, to varying degrees, in several countries and in several states in America. Although laws and safeguards are in place in all jurisdictions, there is concern that these practices are a "slippery slope" to abuse and misuse.

This argument is often invoked by bioethicists, and it "connotes the notion that a particular course of action will lead inevitably to undesirable and unintended consequences," Barron H. Lerner, MD, PhD, and Arthur L. Caplan, PhD, both from the division of medical ethics at Langone Medical Center, New York University, in New York City, write in a commentary published in the August 10 issue of JAMA Internal Medicine.

The commentary accompanies two reports, one from the Netherlands and one from Belgium, the first countries to legalize these practices.

"Although neither article mentions the term slippery slope, both studies report 'worrisome' findings that seem to validate concerns about where these practices might lead," write Drs Lerner and Caplan. "These findings, and other recent data regarding the speeding of patients' deaths, make this a key moment to revisit efforts in the legalization of assisted dying in the United States and elsewhere, and, specifically, the role of the medical profession."

Trends in Legalization

In 2002, the Netherlands became the first country in the world to legalize euthanasia and physician-assisted suicide. Belgium followed soon afterward, and then Luxembourg, in 2009, passed a law on palliative care, advance directive and assistance in dying, and assisted suicide.

Earlier this year, Canada joined the list when its Supreme Court struck down a ban on physician-assisted suicide, according to a report published on the BBC News website.

Switzerland permits assisted suicide under some circumstances. Other countries, such as Finland and Germany, do not have specific laws banning it. Debates on the issue are ongoing in other nations, such as the United Kingdom, where proposed legislation would permit a physician to prescribe a lethal drug to a terminally ill patient.

In the United States, patients are allowed to refuse food, water, medication, and treatments, and thus end their lives. Five states currently allow assisted suicide. Oregon was first, in 1997, followed by Washington State about a decade later; since then Vermont, Montana, and most recently, New Mexico have passed similar laws.

Altogether, 25 states and the District of Columbia have considered legislation related to physician-assisted dying this year, according to a report from the Death With Dignity National Center in Portland, Oregon.

Dutch Findings: Physical Reasons Trump Psych Reasons

In their report from the Netherlands, Marianne C. Snijdewind, MA, from the VU University Medical Center in Amsterdam, and colleagues focus on the reasons individuals request euthanasia or assisted suicide.

The researchers examined requests that were made to the End-of-Life Clinic, which was founded in 2012 by Right to Die NL. Throughout the country, mobile teams, consisting of a physician and a nurse, offer services to patients whose own doctors refuse to grant their requests for euthanasia or assisted suicide.

The team examined 645 requests made to this clinic in the first year of its existence — March 2012 to March 2013 — and grouped the patients requesting euthanasia or assisted suicide into one of five categories:

  • patients considered to have a somatic condition had cancer, cardiovascular disease, neurologic (physical), pulmonary, rheumatoid, other physical discomfort, or a combination thereof

  • patients considered to have a psychological condition had only a psychiatric or psychological condition

  • patients considered to have a somatic and psychological condition had both a psychiatric or psychological condition and a somatic condition

  • patients considered to have cognitive decline had a neurologic (cognitive) condition

  • patients considered to be tired of living had only that condition.

Of the 645 requests, 25.1% were granted, 46.5% were refused, 9.1% were withdrawn, and 19.2% of the patients died before the request could be assessed.

Of the 162 requests that were granted, the euthanasia or physician-assisted suicide was performed in the clinic in 56.8% of the cases and by the regular physician in 14.2%. In 29.0% of the cases, the regular physician agreed to perform euthanasia or physician-assisted suicide in the near future.

Patients with cancer are those most likely to request and receive euthanasia in the Netherlands, the researchers report. The proportion of requests by cancer patients granted in the clinic was much lower than the proportion granted in the overall population of cancer patients (23% vs 79%).

This is not surprising, Snijdewind an colleagues point out, because physicians are generally willing to grant a request for patients with advanced cancer, so only a small group of patients seek out services at the End-of-Life Clinic.

Overall, fewer requests for euthanasia and physician-assisted suicide were granted in the clinic than in the Netherlands as a whole (25% vs 32% - 45%). This could be because the clinic received more of the less common cases, the researchers report. In addition, there were more requests from people older than 80 years in the clinic than in the Netherlands as a whole (53.7% vs 24.5%).

In the Netherlands, euthanasia and physician-assisted suicide are permitted for patients with early dementia or psychiatric disease, patients with psychological suffering, and patients who have no serious illness but are just tired of living. However, a recent survey demonstrated that most Dutch physicians would not grant requests for those reasons. Only 7% of the physicians had actually helped a patient die who did not have cancer or another severe physical illness.

The survey responses are similar to the findings in the current study. "The patients with the highest number of granted requests were those suffering from somatic medical conditions, and of these patients, 33% of the requests were granted," Snijdewind commented in a podcast posted on the JAMA Internal Medicine website.

Of the 162 patients granted a request, 89.4% not only had a somatic condition, they often reported physical decline or loss of strength.

Requests were least likely to be granted for patients with a psychological condition. Of the 121 patients with a psychological condition requesting euthanasia and physician-assisted suicide, only 5.0% were granted, she explained. And of the 40 requests from patients who were tired of living, only 27.5% were granted.

"Being married or living together and having children increased the likelihood of a request being granted," said Snijdewind. "This suggests that the involvement of relatives influences the decision, and they can be a good source of information."

"I think this suggests that granting euthanasia or physician-assisted suicide to people who are suffering from psychological problems in the absence of a serious physical illness can be tricky for the team at the clinic," she added, "just as it is for physicians in Dutch society in general."

A Layer of Scrutiny

In the podcast, Dr Lerner reiterated concerns about the slippery slope, and noted that he feels "the concerns are real when you put in programs where you speed up the dying process in some way."

"Most of us are comfortable [with euthanasia] with physical suffering where there is no chance that the person will get better," he said. "It gets much harder in the realm of psychology. For a physician, when someone is suffering psychologically, the last thing you want to happen is for them to die. You want to do everything possible to help them and relieve suffering."

"When you see terms like psychological suffering and tired of living, it really raises red flags," he added.

When you see terms like psychological suffering and tired of living, it really raises red flags.

This is a very important study, Dr Lerner said, because it helps put an additional layer of scrutiny on these clinics, which are controversial to begin with. "You also want to make sure that people who have the possibility of getting better are not using this process to immediately end their lives, when there is a possibility of recovery," he explained.

Responding to the concern about the slippery slope, Snijdewind emphasized that "it needs to be clearly stated that the End-of-Life Clinic has to operate under the same laws as any other physician in the Netherlands, and the same regulations apply."

"So I don't really know if we need to worry about the End-of-Life Clinic," she added.

Clinics like these can support physicians and help them deal with these cases. "But at the same time, we can also wonder what the long-term effects will be," she said. "Physicians may be less willing to perform assisted dying because it is a really intense process, and since there is an option for referral, they may be less willing to perform it themselves."

Belgium Finds That Requests Are Increasing

In the report from Belgium, Sigrid Dierickx, MSc, from Vrije Universiteit Brussel and Ghent University in Belgium, and colleagues describe an increase in the prevalence of euthanasia in Flanders, the Dutch-speaking region of Belgium, from 1.9% of all deaths in 2007 to 4.6% in 2013.

The prevalence of euthanasia increased in all patient groups and in all healthcare settings. In particular, there were significant increases in the number of requests from 2007 to 2013 (3.4% to 5.9%; P < .001) and the proportion of requests granted (55.4% to 76.7%; P < .001).

The most pronounced increases in the frequency of requests from 2007 to 2013 were in people 80 years or older (2.0% to 4.6%; P < .001), people with a college or university education (4.5% to 12.9%; P = .008), and people with cardiovascular disease (0.8% to 3.0%; P < .001).

The largest increases in the rates of requests granted from 2007 to 2013 were in women (45.7% to 76.4%; P < .001), people 80 years or older (38.1% to 75.4%; P < .001), people who had less education (35.1% to 69.5%; P < .001), and people who died in nursing homes (22.9% to 68.2%; P < .001).

The most common reasons for granting a euthanasia request were patient request (88.3%; 95% confidence interval [CI], 82.5% - 92.4%), physical and/or mental suffering (87.1%; 95% CI, 81.7% - 91.1%), and the lack of prospect for improvement (77.7%; 95% CI, 71.6% - 82.8%).

The most common reasons for not granting a request were that the patient died before the decision could be made (58.5%; 95% CI, 44.8% - 71.0%), the patient revoked the request (17.9%; 95% CI, 9.9% - 30.2%), and the legal criteria were not met (19.6%; 95% CI, 10.8% - 33.0%).

These increases reflect continuing attitudinal and cultural shifts.

The percentage of cases in which the physician reported denying the request for reasons "external" to the patient (restrictive institutional policy, personal objections, or fear of legal consequences) declined from 23.4% in 2007 to 2.0% in 2013 (P = .003).

"These increases reflect continuing attitudinal and cultural shifts," Dierickx and her colleagues explain. "Values of autonomy and self-determination have become more prominent, and acceptance of euthanasia continues to increase in the population at large."

Acceptance of euthanasia continues to increase in the population at large.

"In our opinion, physicians, as part of the overall society, share this overarching perspective, which may in part explain their greater willingness to grant euthanasia requests," they add.

Worrisome Trends

In their commentary, Drs Lerner and Caplan point out that in Belgium, physical suffering without prospect of improvement was the most common reason given for granting euthanasia but, as in the Netherlands, "there are worrisome trends."

"Applicants were allowed to list tiredness of life in their requests in 2013 (but not in 2007), and the fastest-growing populations receiving euthanasia include those potentially vulnerable to discrimination and stigma, such as women, people older than 80 years, those with less educational attainment, and nursing home residents," they write.

Although both studies were well done, there are gaps, the editorialists note. For example, both lack any descriptions of specific cases, which makes it difficult to know exactly what the physical and psychological suffering of the individuals in question actually looked like.

"Similarly, we do not know what those who identified themselves as lonely or tired of living were experiencing," they note. "Had they and their physicians exhausted all options that might have restored some of their happiness? Could and should public policy do more for them?"

The euthanasia practices is these two countries are unlikely to become a reality in the United States, but the rapidly aging population demanding this type of service "should give us pause," Drs Lerner and Caplan emphasize.

"There are numerous groups that are potentially vulnerable to abuses waiting at the end of the slippery slope — the elderly, the disabled, the poor, minorities, and people with psychiatric impairments," they conclude. "When a society does poorly in the alleviation of suffering, it should be careful not to slide into trouble. Instead, it should fix its real problems."

American Experience

It is doubtful that euthanasia will ever get a foothold in the United States, but these data are still relevant, Dr Lerner explained. There has been a lot of interest in assisted dying, and many states are looking at legislation, he pointed out. In addition, there appears to be a shift in attitude in the general population. A recent Gallup poll reported that 68% of Americans believe physicians should be legally allowed to help terminally ill patients to commit suicide, which is up 10 percentage points from 2014.

There is also some evidence that American doctors are becoming less opposed to assisted suicide. In a Medscape survey of more than 21,000 doctors (17,000 American and 4000 European physicians) conducted in 2014, 54% stated that they would "support the patient's decision to end their life," provided that "there is no shred of doubt that the disease is incurable and terminal."

This is an increase from 2010, when 46% of physicians surveyed felt that it should be allowed.

"There are safeguards, and there hasn't been a huge jump in these requests in the United States," said Dr Lerner. "But in these studies, terms like being tired of life and psychological suffering are always the sort of things we need to keep an eye on. We want to help people and we want to end suffering when it's appropriate, but we don't want to replace efforts to alleviate suffering with pills and injections."

In 2013, researchers from the Seattle Cancer Care Alliance, after the implementation of its Death With Dignity program, reported that over almost 3 years, 114 patients had enquired about the program, and 40 patients (35%) actually received a prescription for a lethal dose of secobarbital. Even then, only 24 patients (60%) ended up taking the medication. Qualitatively, patients and families were grateful to receive the lethal prescription, whether it was used or not, they pointed out.

"I would say the lesson learned from the Seattle experience is that our mission hasn't changed," lead author Elizabeth Trice Loggers, MD, PhD, medical director of palliative care at Seattle Cancer Care Alliance, told Medscape Medical News at the time the study was published. "Our primary goal and responsibility is to cure cancer. But when cure isn't possible, Death With Dignity can be offered as one small part of the broader array of high-quality end-of life options, which include palliative care and hospice.

The Dutch study was supported by the End-of-Life Clinic. The Belgian study was supported by a grant from the Agency for Innovation by Science and Technology. Ms Snijdewind reported receiving financial support from the End-of-Life Clinic for the submitted work. Dr Lerner and Dr Caplan have disclosed no relevant financial relationships.

JAMA Intern Med. Published online August 10, 2015. Commentary, Dutch study, Belgian study


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