What should we tell medical students and residents about euthanasia and assisted suicide?

Abstract

‘I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan’

Hippocratic oath (National Institutes of Health, 2002)

Introduction

Discussion about end-of-life issues has been the domain of bioethics, philosophy, religion, medicine, and law over many years (Coughennower, 2003; Manu, 2010; Pellegrino, 1991; Van Der Maas et al., 1991). Euthanasia refers to the intentional termination of a patient’s life by a physician or nurse. Physician-assisted suicide is the provision by a physician of the means by which patients can end their own lives. Although someone other than the patient supplies the means, the patient is the individual who acts to end his life. Euthanasia and assisted suicide are perhaps the most passionately and bitterly debated issues in medical ethics today.

Euthanasia and assisted suicide are illegal in many countries including Australia, Canada, Hungary, Italy, New Zealand, Norway and the UK, but legal in The Netherlands (de Wachter, 1989; Humphry, 2011; Marker, 2011; Payne, 2001). The Supreme Court of the United States ruled in 1997 that there is no constitutional right to assistance in committing suicide, thus allowing states to make laws permitting or prohibiting assisted suicide (Payne, 2001). Currently, assisted suicide is illegal in almost all US states (Marker, 2011). Euthanasia is prohibited in the USA.

We are teaching medical students, residents, fellows, and other trainees. What should we tell them about euthanasia and assisted suicide?

Suicidality is a manifestation of psychiatric illness

We should tell our trainees that suicidal ideation, intent, and plan are usually associated with psychiatric pathology (Hirschfeld and Russell, 1997; Mann, 2002; Sher, 2004). Over 90% of people who commit suicide have a diagnosable psychiatric disorder, and most individuals who attempt suicide have a psychiatric illness (Hirschfeld and Russell, 1997; Mann, 2002; Sher, 2004). The most common psychiatric condition associated with suicide or serious suicide attempts is depression. Personality disorders, alcohol and substance abuse, anxiety disorders, schizophrenia, and bipolar disorder are also frequently associated with suicidal behavior.

Patients who desire death during a serious or terminal illness are usually suffering from treatable depression (Breitbart, 1987; Breitbart, 1990). A review of the psychiatric consultation data at Memorial Sloan–Kettering Cancer Center in New York demonstrated that one-third of suicidal cancer patients had major depression, about 20% suffered from a delirium, and 50% were diagnosed with an adjustment disorder with both anxious and depressed features at the time of evaluation (Breitbart, 1987; Breitbart, 1990). Among patients with advanced disease and significantly impaired physical function, symptoms of severe depression increased to 77% (Breitbart, 1987). It is important to note that psychiatric disorders are commonly associated with alterations in pain processing, whereas chronic pain may impair emotional and neurocognitive functioning (Elman et al., 2011).

Many very sick people suffer from post-traumatic stress disorder (PTSD) (Bienvenu and Neufeld, 2011). The importance of the PTSD concept to medically ill patients has not been fully appreciated but is becoming increasingly clear. For example, 1 month after myocardial infarction prevalence rates for PTSD are between 4% and 24% (Doerfler, 1997; Pedersen et al., 2002; Pedersen et al., 2003; Roberge et al., 2010). It is likely that many very ill patients suffer from a combination of depression and PTSD which can be conceptualized as post-traumatic mood disorder (PTMD) (Sher, 2005; Sher, 2009). PTMD is associated with suicidal behavior (Sher, 2005; Sher, 2009).

A request for assisted suicide is usually a call for help and a sign of depression (Greene, 2006). It is a call for positive alternatives as solutions for real, difficult problems. Individuals requesting assisted suicide are far more likely to be suffering from psychological distress than unbearable physical pain. It has been pointed out that when patients requesting a physician’s assistance to die ‘are treated by a physician who can hear their desperation, understand the ambivalence that most feel about their request, treat their depression, and relieve their suffering, their wish to die usually disappears’ (Hendin and Foley, 2008).

The wish to die is not stable over time. Suicidal intent is typically transient. Of those who attempt suicide but are stopped, less than 4% go on commit suicide in the next 5 years (Rosen, 1976) and less than 11% will kill themselves over the next 35 years (Dahlgren, 1977). Suicide attempts and ideation occur in approximately 0.7% and 5.6%, respectively, of the general US population (Crosby et al., 1999). In comparison, in the USA, the annual incidence of suicide in the general population is approximately 11 suicides for every 100,000 persons, or 0.011% of the total population per year (Miniño et al., 2002). This indicates that most people who have suicidal ideation never kill themselves. Most of the people who wish to kill themselves at one time will feel different after improvement in their psychiatric disorder and/or after receiving help with other problems.

We do not solve problems by getting rid of the people to whom the problems happen. The more difficult but humane solution to human suffering is to address the problems, such as depression or pain. Pain is controllable. Modern medicine can control pain. A person who wants to kill themselves to avoid pain does not need euthanasia or assisted suicide. This person usually needs a physician who is well trained in pain management.

It is important to educate our trainees that to endure a wretched quality of life may require more efforts that some people have. We cannot always get rid of extreme wretchedness, which often is not only pain. For example, some people find the prospect of relying on other human beings to change their clothing or to empty their bedpan incompatible with the minimum level of human dignity that they wish to endure. Some people, in excellent health, intend to seek a comfortable death if they were to become very ill and disabled.

The issue of autonomy

Respect for a patient’s autonomy is considered an essential bioethical principle (Ersek, 2004; Thomasma, 1996). An autonomous decision is a decision that is made freely and in full knowledge and understanding of the information necessary to make such a decision.

Proponents of assisted suicide suggest that a competent adult has the right to self-determination, including the right to die (Ersek, 2004; Thomasma, 1996). Individuals can make judgments about the quality of their life and decide their own course of action, which may include assisted suicide or euthanasia.

Opponents of assisted suicide state that suicide is not a medical act, and assisted suicide has nothing to do with autonomy (Ersek, 2004; Randall and Downie, 2010; Thomasma, 1996). Autonomy is the right to refuse medical treatment, not the right to a non-medical act performed by a physician.

Estimation of life expectancy

Our trainees should know that it is impossible to predict the life expectancy of a particular patient (Arguments Against Euthanasia, 2011; Christakis and Iwashyna, 1998). Some people diagnosed as terminally ill don’t decease for years, if at all, from the diagnosed illness. Observations indicate that only cancer patients show a predictable deterioration, and even then, it is only in the last several weeks of life. With every illness other than cancer, prediction is unreliable. Prognoses are based on statistical averages, which are almost useless in determining what will happen to an individual patient. Some people may be mistakenly diagnosed as terminal but have many meaningful years of life ahead.

An incentive to save money

Our students, residents, and other trainees should understand that financial matters may play a role in the promotion of euthanasia and assisted suicide (Arguments Against Euthanasia, 2011; Golden and Zoanni, 2010; Sulmasy et al., 1998). The cost of the lethal medication used for euthanasia or assisted suicide is far cheaper than the cost of treatment for most medical conditions. The motivation to save money by denying treatment already presents a considerable danger. This danger is much larger where euthanasia and/or assisted suicide are legal. In some countries, governments and insurance companies may put pressure on physicians and hospital administrators to avoid life-saving measures or recommend euthanasia or assisted suicide.

Attitude of medical professionals to assisted suicide and euthanasia

We should tell our trainees that very many of our colleagues do not accept euthanasia or assisted suicide. European studies suggest that very many physicians are against any form of active hastening of the dying process, and against the legalization of euthanasia and physician-assisted suicide (Gielen et al., 2008). A study in Finland has shown that voluntary euthanasia is ethically acceptable for just 3–9% of physicians (Ryynänen et al., 2002). For 73% of general practitioners in Northern Ireland, physician-assisted suicide is ethically unacceptable (McGlade et al., 2000). Only 12% of geriatricians in the UK are willing to assist a patient when they intend to commit suicide (Clark et al., 2001). Only 2.1% of Greek physicians support euthanasia or assisted suicide (Parpa et al., 2006).

A systematic literature review of research studies regarding physicians’ attitudes to euthanasia in the United States has shown that responses to the acceptance of assisted suicide ranged from 14% to 66%, whereas euthanasia acceptance responses varied from 23% to 63% (Dickinson et al., 2005). Most Canadian physicians oppose euthanasia and assisted suicide (Suarez-Almazor et al., 1997). A survey of physicians in Sudan has found that the majority (85%) strongly oppose assisted suicide and euthanasia, while 15% say they should be performed only in certain situations, subject to strict safeguards (Ahmed et al., 2001).

The World Medical Association, the American Medical Association and its state affiliates, the American College of Physicians, the American Cancer Society, and many other medical societies and organizations around the world oppose the legalization of euthanasia and assisted suicide (American Medical Association, 2011; Arguments Against Euthanasia, 2011; Golden and Zoanni, 2010; World Medical Association, 2011). The World Medical Association asserts: ‘Physician-assisted suicide, like euthanasia, is unethical and must be condemned by the medical profession’ (World Medical Association, 2011). The American Medical Association states in its code of ethics:

‘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. Patients should not be abandoned once it is determined that cure is impossible’ (American Medical Association, 2011).

In its position statement, the American Nurses Association declares:

‘The American Nurses Association believes that the nurse should not participate in assisted suicide. Such an act is in violation of the Code for Nurses with Interpretive Statements (Code for Nurses) and the ethical traditions of the profession’ (American Nurses Association, 1994).

Studies have shown that physicians’ negative attitudes toward euthanasia and physician-assisted suicide are related to a possibility of pressure on patients, reluctance to decide about life and death, uncertainty about prognosis, religious opposition, and the obtainability of good palliative care (Kuuppelomäki, 2000; Maitra et al., 2005; Parpa et al., 2006; Ryynänen et al., 2002). Many physicians believe that most patients will stop asking for euthanasia or assisted suicide as soon as they feel the benefits of decent palliative care (Parpa et al., 2006; Ryynänen et al., 2002). It is important to note that there are physicians who consider that the wish to leave this life is not invariably a morbid state.

Conclusion

There are a lot of clinical and moral questions related to euthanasia and assisted suicide. In good teaching, we should help our trainees to identify these questions.

We want medical trainees to understand that euthanasia and assisted suicide are a rejection of the importance and value of human life. Helping someone die is never beneficent because it violates the sanctity of life.

Researchers and clinicians should focus on the development of new methods of prevention and treatment of illnesses to allow people to live long, high-quality lives. Permitting physicians to kill patients may rob the health care system of the motivation to make serious improvements in the care of sick people.

We want our trainees to become healers not killers. Our healing profession should not be transformed into a killing profession. The physician, dressed in white, according to the Hippocratic oath, is obliged to save the life and not to kill. Society in general, and medicine in particular, have obligations to protect the value of life and the most vulnerable members of society such as the old, the disabled, the sick, the poor, and other potentially vulnerable groups. We want current and future medical professionals to adhere to the highest ethical standards of our noble profession.

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