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Physician-Assisted Dying
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JAMA
January 19, 2016
A Turning Point?
In 2014, Brittany Maynard, who was dying of brain cancer, took a deliberative decision supported by her family to move from California to Oregon to utilize the Oregon Death with Dignity Act. Highly visible, deeply personal decisions by Maynard and others have influenced social and political discourse around physician-assisted dying (PAD). Although PAD broadly encompasses physician-assisted suicide (PAS) (medicines prescribed specifically for the purpose of being taken by patients to end their lives) and euthanasia (lethal medicines administered by physicians at the patient’s request), states currently only authorize the former.
CONSTITUTIONALITY AND STATES’ RIGHTS
As long ago as 1997, the Supreme Court invited state experimentation regarding a “profound debate about the morality, legality, and practicality” of PAD.1 Although the Supreme Court found no constitutional “right to die” it granted states wide scope to legislate. The Court ruled that the federal government could not prohibit physicians from prescribing controlled drugs to assist patient deaths if authorized under state law.2 This ruling led to numerous states enacting law governing end-of-life care (Table).
Opening the Floodgate
To narrow the group of patients eligible for PAD, all state statutes limit the practice to terminally ill adults. Although a diagnosis of terminal illness is complex and uncertain, current legislation requires agreement by 2 independent physicians that the individual has a condition that will likely result in death within 6 months. Research also suggests that PAD laws do not significantly increase rates of patients who request assistance in dying, even after PAD is legally available over long periods of time.6,7 Many patients who request physician help in dying, moreover, do not use the prescribed medications immediately, or ever.
Since the Death with Dignity Act was enacted in 1997, only 65% of the 1327 patients who have received a lethal prescription have died from ingesting that prescription medicine.6 All state statutes empower patients to change their minds at any time. These laws have narrow definitions of consent and capacity, and specifically authorize patients to retract their consent.
Disproportionate Access for the Poor
Most patients who request PAD are well educated, insured, and in hospice care, rather than being poor and in public hospitals.6 It is unknown whether the Affordable Care Act might increase patient preferences for hospice and other palliative care services over PAD. Universal health coverage that includes high-quality end-of-life care would be the most effective way of ensuring that the poor and vulnerable are not drawn to PAD for financial reasons.
Abuse of PAD
All existing laws require safeguards against abuse. In addition to the requirement of 2 physicians certifying that death is imminent, state laws require a mandatory assessment by mental health professionals if either physician suspects the patient may lack full mental capacity, which includes depression. Following capacity assessments, all states require a waiting period, after which patients must restate their request orally and in writing. Two individuals must witness patient requests in all states, with at least 1 witness having no personal interest (a relative, beneficiary, or attending physician).
To increase safeguards, states could consider introducing multidisciplinary panels to support patients through the entire process, including verifying consent and capacity, ensuring appropriate psychosocial counseling, and discussing all palliative and end-of-life options.
TURNING POINT IN SOCIAL AND ETHICAL THOUGHT
For the first time, a 2015 poll found that more than half of physicians surveyed favored medical assistance in dying. Although the American Medical Association opposes PAD, the California Medical Association shifted its position to “neutral” following the passage this year of the End of Life Option Act.
Just before Maynard took the final step in her life’s journey, she wrote, “Goodbye to all my dear friends and family that I love. Today is the day I have chosen to pass away with dignity in the face of my terminal illness, this terrible brain cancer that has taken so much from me … but would have taken so much more.”8 Her final words reflect that PAD is a deeply personal choice. The question is whether more states will authorize the practice and, if so, what safeguards will be put in place to ensure the practice is not misused and remains consistent with prevailing social and ethical thought.