The Core of Compassion in Physician-Assisted Suicide

At the time of his death, the 104-year-old ecologist was hailed as his country’s oldest scientist — still practicing research while in reasonably good health for his age.

None of the marvel that came from his living legacy, nor the fact he had loving family and friends across 2 continents, were enough to supplement the simple fact that Goodall no longer wanted to live. He told the press just a day before his suicide that, at his age and even at ages younger than his, “one wants to be free to choose the death and when the death is the appropriate time.”

What popularized Goodall’s death was not only that he chose it, but multiple physicians agreed to it.

With no terminal illness or near-sighted risk of disease, Goodall was granted a physician-assisted suicide in a country he reached with the aid of advocacy group Exit International. His motivation was a lack of mobility and independence, and he had no grand schemes to publicize his decision beyond the attention it drew. According to reports, his last words were, “This is taking an awfully long time” while listening to Beethoven’s Symphony No. 9. Goodall did not desire a funeral nor memorial service, and he didn’t believe in an afterlife. His desires started and ended with a humane death.

Switzerland has become something of a hub for physician-assisted suicide tourism. According to national statistics, the annual rate has boomed from 297 deaths in 2008 to 965 in 2015 — the most recent year of data available. Forms of the practice have also become legal — and therefore, more common — in countries like the Netherlands, Belgium, Germany, Luxembourg, Colombia, and Canada.

In the United States, physician-assisted suicide is limited to state-by-state discretion, and the rhetoric surrounding its practicality and morality can burn as bright as any other national debate. Ironically, both sides tend to call for the same thing: humanity.

The American Way

Just last month, Hawaii became the seventh and latest state to adopt physician-assisted suicide. Governor David Ige signed the “Our Care, Our Choice Act” into law, joining Colorado, Oregon, Vermont, Washington, and the District of Columbia as the only US territories to allow the practice. The bill was championed by national advocacy group Compassion & Choices, which expressed that just because it’s now law, doesn’t mean the choice is for everyone.

Using the Hawaiian word for the state’s residents, spokesperson Aubrey Hawk said the new law “need not be exercised, but we will be a more compassionate state for making it accessible to our terminally ill kama‘aina who so desperately need it.”

Though Hawaii became among a small population of US states with approved laws, its government was more than 2 decades behind the first push physician-assisted suicide legislation — Oregon’s “Death with Dignity Act” was introduced in 1994 and became state law in 1997.

It may soon not be the most recent state to adopt law, however. New Jersey is currently on its third go-around trying to pass legislation on physician-assisted suicide. Its history in consideration to the practice comes from an emotional case from the state Supreme Court: In 1975, Karen Ann Quinlan, then 21, fell into an irreversible coma after consuming alcohol and tranquilizers at a party. Her parents successfully lobbied for the right to remove her from a respirator a decade after the incident, with the court officially ruling that parents and guardians maintain the right to end artificial life supports when the case shows there is no hope for patient recovery.

What may muddy the perception of physician-assisted suicide for legislators in New Jersey and other states, however, is where the burden of responsibility of death truly lies. The Medical Society of New Jersey (MSNJ) notes that such state laws attempt to make it clear that the patient — not the physician — is ending the life.

“But duties in such cases are not and cannot be so clear cut, putting physicians in precarious positions,” wrote the organization in a recent statement. “Though this is clearly the safest setting, it leads to the core issue in the bill.”

It’s a sentiment similar to that maintained by the American Medical Association (AMA), which has expressed opposition to physician-assisted suicide legalization for as long as it has been publicly considered in the US. Since the association’s first ethical guidance released in 1994, it has supported the notion that assisted suicide will ultimately 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,” the AMA’s Code of Medical Ethics read. “Instead of engaging in assisted suicide, physicians must aggressively respond to the needs of patients at the end of life.”

The AMA calls for physicians to respond to patient end-of-life cases by not abandoning patients once it is determined a cure cannot be found, respecting patients’ autonomy, providing through communication and emotional support, and providing appropriate comfort care and adequate pain control.

Where It Comes From

Ana Maria Lopez, MD, MPH, President of the American College of Physicians (ACP), has an interesting comparative to the discussion surrounding physician-assisted suicide. The fear she see expressed in death is like the fear she could hear in potential mothers discussing giving birth for the first time.

“People used to see death, be close to it — and now we don’t, so there’s a lot of fear around it,” Lopez said. “There’s a lot of uncertainty about the unknown. But by really talking about it and preparing people, and I do think of it akin to birth. It’s 2 major transitions for human beings, birth and death. And how wonderful as a physician, to be able to be there and to help folks during that time.”

Lopez added the 2 processes call for the same physician-patient resolutions: by providing information, education, and the resources to form a partnership between the parties. She lauded organizations such as the AMA, which she said practice empathy with consideration to physician-assisted suicide.

It’s a consideration California governor Jerry Brown also gave prior to signing the state End of Life Option Act into law in 2015, noting in a letter to the state assembly that he would not know what he do if he were dying in prolonged and excruciating pain.

“I am certain, however, that it would be a comfort to be able to consider the options afforded by this bill,” Brown said. “And I wouldn’t deny that right to others.”

Though the sentiments of legislators such as Brown and Ige have been amplified by the practice’s recent progress, research shows public support is still behind.

Data Versus Stories

In a 2016 study, researchers from Pennsylvania, the Netherlands, and Belgium shared their evaluations of attitudes and practices surrounding both euthanasia and physician-assisted suicide. What they found was that US public support for both practices plateaued between 47% and 69% since the 1990s — fittingly, when states first began approving bills supporting the physician-assisted suicide.

They also found that less than 20% of surveyed physicians had reported receiving a request for euthanasia or physician-assisted suicide, and among that group, just 5% complied.

In the physician-assisted suicide-legalized states of Washington and Oregon, less than 1% of licensed physicians wrote prescriptions for physician-assisted suicide in an observed one-year period. Patients who were prescribed the treatment were also enrolled in hospice or palliative care. The most common patient characteristics were older age, white ethnicity, good education background, and with a debilitating disease such as cancer.

Researchers found no evidence that vulnerable patients received euthanasia or physician-assisted suicide at higher rates than the general population.

Another study, from the US this year, evaluated patients with serious advanced illnesses who voluntarily stopping eating and drinking (VSED) to quicken their deaths. Researchers found that this practice is at least initially controlled by the patient’s actions, but should be weighed on top of the possible palliative treatments and an assessment of the patient’s capacity to make decisions.

Study author Timothy E. Quill, MD, told MD Magazine these patients were generally dying and debilitated, and suffered from symptoms that disabled them from participating in meaningful life experiences. They may not have suffered severe amounts of pain, but they were limited in how much they could live. That doesn’t mean a physician couldn’t still reject this option from a patient.

“There is no obligation to participate in VSED if it would violate an individual clinician’s fundamental principles,” Quil said. “Duty would be to search for common ground with the patient and family for ways to respond to the patient’s situation; if common ground cannot be found, then the patient should have the opportunity to switch to a more receptive physician.”

Quil and his team concluded that VSED, while not illegal in the US, is still an “ethically controversial” concept.

Whether physician-assisted suicide becomes more prominent in the US may be entirely driven by the anecdotes — in the sub-one percent of cases that come to fruition are where the stories of Goodall, Quinlan, and others come from. Another anecdote recently hailed from Canada, a country already fully capable of practicing medically-assisted death. Kieran L. Quinn, MD, and Allan S. Detsky, MD, PhD, both from Toronto, published an essay last year that detailed their role in assisting in a patient’s death.

He was a kind Newfoundland-based man with gastric cancer, who on the day of his death was surrounded by at least 10 loved ones. Quinn and Detsky noted the man was tired but outwardly grateful for the role they were about to play. In 5 minutes the procedure was complete, and the patient had found peace. So did his physicians.

“’Today we did a good thing,’ one of us remarked to the other during a mentoring moment when leaving the hospital that evening,” the physicians wrote. “We’re not sure if we’ll ever do this again, but we believe that in this circumstance it was the right care, for the right patient, at the right time.”