Law & Medicine

Physician-assisted suicide


 

Question: Which is the single best statement?

A. In 1994, Oregon became the first U.S. state to legalize physician-assisted suicide (PAS).

B. To date, PAS is legal in three other states: Washington, Montana, and Vermont.

C. The U.S. Supreme Court has held there is no constitutional right to PAS.

D. All are correct.

E. Only 1 and 2 are correct.

Answer: D. "Measure 16," as it was famously known at the time, was Oregon’s initiative that garnered a majority vote in 1994 and allowed the state to become the first in the United States to legalize physician-assisted suicide (PAS).1

Since that time, Washington2 and most recently Vermont,3 have joined Oregon in legalizing PAS, while the state Supreme Court of Montana has held there is no public interest reason against the use of PAS in that state.4

What does the U.S. Supreme Court have to say about PAS?

In 1990, it unambiguously endorsed a patient’s right to forgo medical treatment, including artificial hydration and nutrition.5 However, it was in the 1997 landmark case of Vacco v. Quill6 that the court carefully distinguished between assisting suicide and withdrawing life-sustaining treatment, emphasizing issues of causation and intent.

On causation, the court reasoned that when a patient refuses life-sustaining treatment, he dies from an underlying fatal disease. But if a patient ingests a lethal medication, he is killed by that medication. As to intent, a physician who honors a patient’s refusal of treatment purposefully intends only to respect his patient’s wishes and to cease doing futile or degrading things.

On the other hand, a doctor who assists a suicide "must, necessarily and indubitably, intend primarily that the patient be made dead." In its companion case Washington v. Glucksberg7, the Supreme Court held that the asserted "right" to assistance in committing suicide is not a fundamental liberty interest protected by the Due Process Clause.

In the vast majority of jurisdictions, assisting or causing one to commit suicide, including physician-assisted suicide, remains a crime, for example, manslaughter under Hawaii law Section 707-702, and a felony in California under Section 10.401.

However, some advocates of PAS have construed the absence of a specific statute outlawing PAS, or the existence of liberal living-will statutes or other state law, as tacit condoning of PAS. They assert that the term PAS is a misnomer, as the act is one of assisting a dying patient, not causing a suicide. Such interpretations, however, can be expected to face state challenges.8

The relevant state statutes where PAS is legal provide similar provisions and safeguards. Only competent individuals who are terminally ill (death expected within 6 months) can make a request for a lethal dose of medication to carry out the suicidal act. The request to the doctor is first made verbally, then in writing, and a second opinion must be obtained to confirm the patient’s intent, understanding, and free choice. There is also a waiting period.

Even in states where PAS is legal, only a minority of physicians are participants. For example, 61 physicians in Oregon wrote a total of 115 prescriptions in 2012; there were 77 known Death With Dignity Act deaths in Oregon that year.9

The main arguments for legalizing PAS include patient autonomy, dignity, and relief from intolerable pain and suffering. Opponents, fearing the slide down the slippery slope, assert that no patient needs to suffer, because highly effective palliative care is readily available. Besides, allowing physicians to facilitate the death of their patients threatens the integrity of the medical profession.

Like most professional organizations, the American Medical Association is strongly opposed to PAS. Its Code of Medical Ethics states: "Allowing physicians to engage in assisted suicide would cause more harm than good. Physician-assisted suicide is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks. ... Instead of participating in assisted suicide, physicians must aggressively respond to the needs of patients at the end of life."10

Emotions can run high over the PAS issue, as evident in the hysteria that spilled over a provision in the health care reform bill during the Affordable Car Act debate. Section 1233 of "Advance Care Planning Consultation (ACPC)" in the bill would have reimbursed providers for voluntarily discussing with Medicare patients designated end-of-life topics such as advance directives, surrogacy, life-sustaining treatment, and palliative care, including hospice. However, nothing in Section 1233 suggested cost containment was a motive, nor did the bill express any preference for a treatment to be implemented or forgone.

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