A scientific approach to a complex issue
Earlier this week, Fairleigh Dickinson University reported new survey data showing that a slim majority (51%) of New Jerseyans support the state’s Death with Dignity Act. This bill would permit physician-assisted suicide (PAS) for individuals diagnosed with a terminal illness and a prognosis of less than six months to live.
PAS refers to the situation in which a physician indirectly participates in a patient’s suicide by providing the means — typically in the form of a medication prescription — while the patient administers the lethal dose himself or herself. This is in contrast to euthanasia, in which the physician directly participates in a patient’s suicide, such as by administration of a lethal injection.
Discussion of PAS in both legislative and popular media forums is often clouded by political agendas, strong personal emotions, and public misinformation about suicide. Support tends to vary depending on an individual’s political affiliation, race, and other demographic characteristics. Rather than taking a rigid, myopic stance on this complicated issue, it is crucial to consider what we know about PAS scientifically. This is especially true when the outcome at stake is a major change in public health policy, as is the case in the Death with Dignity Act.
First of all, how many people might we expect would try to take advantage of such a bill should it become law? In a 2000 JAMA paper by Emanuel and colleagues, the authors found that out of “988 terminally ill patients, a total of 60.2% supported euthanasia or PAS in a hypothetical situation, but only 10.6% reported seriously considering euthanasia or PAS for themselves.” This is consistent with the Fairleigh Dickinson poll in which a majority of respondents (53%) said that, hypothetically, they would want legal recourse for PAS. The proportion of individuals who would actually consider PAS if it were available is likely far lower.
The depression problem
A major confound in researching or discussing PAS or euthanasia is the fact that many terminally ill patients who are considering suicide are also suffering from depression, which may be caused by, dynamically related to, or independent of their medical condition. Depression is serious but treatable, and therefore must be disentangled from the serious, untreatable diseases that afflict terminally ill patients considering PAS. Looking again to the Emanuel et al. study, participants who were depressed were more likely to consider euthanasia or PAS, and were more likely to change their minds. Depression — unlike a terminal disease — ebbs and flows, though patients caught up in it may be in a poor position to reflect on the more transient nature of their pain. Screening for depression and the provision of appropriate psychological and/or psychopharmalogical treatment therefore seem like essential components of any protocol related to PAS. While there are stipulations in the Death with Dignity Act for consultation with a psychologist or psychiatrist, it is at the physician’s discretion to make the referral rather than being a mandatory step in the process. If psychological evaluation is required before bariatric surgery, perhaps it should also be required before suicide?
The matter of patients changing their minds raises another fundamental question about PAS legislation: would such a bill expedite suicides for individuals who might have otherwise decided against it later? The Death with Dignity Act requires a minimum of 15 days between a patient’s initial and second request for PAS, at which point the physician must offer the patient a chance to rescind and a second physician must sign off on the whole decision. According to the Emanuel et al. study, among the small group of terminally ill patients who reported seriously considering euthanasia or PAS, half of them had changed their minds when followed up a few months later. This draws some concern over whether 15 days is adequate to allow those who initiate a request for PAS but will ultimately change their minds the time they need to decide that they in fact do not want to die by suicide.
The other side
While the extant research certainly leads us to question and critique several aspects of the Death with Dignity Act, a scientific argument can also be made for the potential value of this kind of legislation. Perhaps unsurprisingly, a 1996 paper by Back and colleagues suggested that some physicians occasionally provide PAS services even when they are illegal in the physician’s state — in other words, PAS is happening already, but without any official checks and balances. State legislation would at the very least provide a standardized and well-documented protocol for physicians to follow, rather than them quietly taking it upon themselves to decide whether a patient is in the proper state of mind to consent to dying.
In the end, there are no easy solutions in the PAS debate; thoughtful, humanistic, and scientifically rigorous perspectives are needed to illuminate all sides of the issue. As the Fairleigh Dickinson poll showed, public attitudes toward the Death with Dignity Act are highly divided. The more we understand this issue, the more likely we as a society can make informed decisions on legislation that impacts how we think about and deal with suffering and death.