Last month, voters in Washington State voted 58% to 42% to allow physician-assisted death (PAD) for terminally ill patients, making it the second state after Oregon to allow such a practice. In a recent New England Journal of Medicine article covering this development, Dr. Robert Steinbrook notes that Washington’s “Death and Dignity Act…permits…[adult] state residents…with an illness expected to lead to death within 6 months to request and receive a prescription for a lethal dose of a medication that they may self-administer in order to end their life.”

The law, which will take effect on March 4, 2009, is based closely on the Oregon PAD law, which has been in effect since October 1997. Steinbrook points out that Oregon’s legalization of PAD has had some interesting effects—or rather, non-effects—on the number of patients who have exercised their “right to die.” Between 1998 and 2007, “physicians wrote a total of 541 prescriptions for lethal doses of medications…and 341 people died as a result of taking the medications. Thirteen patients who had received prescriptions were alive at the end of 2007, and the rest of [the 541 people] who received prescriptions ultimately died of their underlying disease.”

These are not huge numbers: 341 people over nine years comes out to about 38 terminally ill people per year seeking to end their lives. In other words, PAD has not turned out to be a slippery slope toward mass suicide. In fact, most Oregonians who sought PAD between ’98 and ’07 belonged to a relatively predictable demographic: they were old (median age of 69), suffering from terminal cancer (81.5%), and were enrolled in hospice programs (86%).

This last point is particularly interesting. Steinbrook suggests that a shift toward hospice care within the medical community may be associated with an increase in PAD because hospice care tends to “address many of the key reasons why patients request assistance in dying — such as loss of autonomy, dignity, and the ability to care for themselves in a home environment.” Certainly a growth in hospice care doesn’t necessarily mean that more patients will seek out PAD. But given what we’ve seen in Oregon—and hospice care’s focus on making patients comfortable with the fact that they are dying—a growth in hospice care could very well put more people in a position to do just that.

And hospice care is growing: According to the AARP, the number of Medicare certified hospices increased from 31 in 1984 to 3,078 in 2007. In 2005, approximately 1.2 million people received hospices services, of which at least 80 percent were persons aged 65 or older. With hospice care on the rise—and the aging of the Baby Boomers growing the ranks of patients most likely to use these services—the Centers for Medicare and Medicaid project that national spending on hospice care will increase at an annual rate of 9 percent through 2015.

This raises the question: How would America respond if PAD, or at least the option of PAD, did in fact become more common?

To put it simply, things could get ugly. Today Americans are split on the issue of physician-assisted death. A 2007 Associated Press survey of 1,000 adults found that 48% thought it should be legal for doctors to give terminally ill patients fatal drugs; 44% thought the practice should be illegal.

In fact, the split over PAD is even more charged than the numbers above suggest. Support and opposition breaks down along religious, political, racial, gender and geographic lines. A 2004 CBS poll found that two-thirds of white evangelical Christians and those who attend religious services weekly or almost every week most strongly oppose physician-assisted death. “Additionally, six in ten Republicans, conservatives and African Americans oppose physician-assisted suicide” and “majorities of women, those aged 65 or older and Southerners also oppose allowing doctors to assist patients who are terminally ill to take their own lives.”

By contrast, “liberals, Northeasterners and those who attend religious services only a few times a year or never are the most likely to support physician-assisted suicide: about six in ten of people in these groups think it should be allowed. Supporters of physician-assisted suicide also include majorities of men, Democrats, those in the western region, those who have at least a college degree, and those whose household incomes are $50,000 or higher.” 


In other words, controversy around PAD would align with a lot of pre-existing political fault lines, which means we face a charged debate. Worse still, the issue is equally political for doctors. A March 2005 HCD Research poll of 1,00 physicians found that “a majority of self-identified conservatives (72%) thought that assisted suicide is unethical, while a majority of liberals (81%) said it was ethical to assist a patient who has opted for suicide. Among conservatives, a majority (66%) opposes legalization of physician-assisted death; among liberals, 64% broadly support it.”

With trends pointing to a health care environment in which PAD is—if not more common—at least not as taboo as it once was, we may be facing a serious political battle at some point down the road.  Indeed, opponents of PAD have never minced words. The American Medical Association, for example, has long taken a strong stance against physician-assisted death because the organization views the practice as being "fundamentally inconsistent with the physician's role as healer.” Back in 1996, the AMA pushed for the Supreme Court “to make a declaration on the misguided and unethical practice of physician-assisted suicide” and strike down Oregon’s law (the High Court eventually upheld the state’s legalization of physician-assisted death).  


Despite its high-profile opposition to the practice, however, the AMA is in the minority when it comes to PAD. The aforementioned 2005 HCD poll found that 57% of doctors “believe that it is ethical to assist an individual who has made a rational choice to die due to unbearable suffering, while 39% believe it is unethical.” A later 2005 HCD poll found that “62 percent of physicians…[say] that ‘physicians should be given the right to dispense prescriptions to patients to end their life.’”


Still, the AMA’s objection to PAD is unlikely to waver, even in the face of a professional consensus. The organization simply doesn’t think that a doctor should ever facilitate death, whatever the situation.

There are, of course, other, more practical objections to PAD. One concern is that if physician-assisted death is readily available it will be too easy for patients who are suffering temporary pain, are depressed, or otherwise miserable—to end their lives unnecessarily. Imagine someone asking to die while they’re very depressed. Wouldn’t it wrong to help them without first exposing them to a combination of therapy and medication to address the depression?

This is a thorny hypothetical, but luckily experience tells us that patients who choose PAD don’t do it impulsively, and they are not motivated by despair. In fact, their choices seem to be driven primarily by a desire to assert control over their lives.

In February, the Journal of General Internal Medicine published a survey of family members of 83 patients who chose physician-assisted death in Oregon and found that “the most important reasons that their loved ones requested physician-assisted death…were wanting to control the circumstances of death and die at home, and worries about loss of dignity and future losses of independence, quality of life, and self-care ability.” Somewhat surprisingly, the survey found that patients’ families did not rate “physical symptoms” as being important to their relatives’ decisions to choose death. Other sources of life stress were similarly unimportant: family members of patients who chose PAD reported that the “least important reasons their loved ones requested physician-assisted death included depression, financial concerns, and poor social support.”

In other words, patients don’t seem to choose PAD as some sort of desperate escape from physical or emotional hardship. They simply decide that they want to go out with dignity, and on their own terms. This may still be an uncomfortable prospect for some people, but it punches a big hole in the argument that legalizing physician-assisted death invites people to make short-sighted decisions in a state of irrational despair.

In the end, it’s tough to say anything about the future of physician-assisted death with certainty. For both the public and doctors, the demographics of who does and doesn’t support the practice suggests that we’re headed for a heated debate. Nevertheless, the growth of hospice care, the aging of America, and recent developments in Washington State may well signal a shift in how we conceive of death—and how doctors and patients can deal with it.

What do Health Beat readers think about physician-assisted death? Should it be legal? Does it conflict with the duties of doctors? Let us know in the comments section of this post.