Study Methodology Questioned

The article “Some With Depression Able to Get Assisted Suicide” in the December 5, 2008, issue addresses a legitimate concern, but the study being reported on involved a questionable instrument, narrow interpretation, and biased language.

Physician aid-in-dying in Oregon, under the Death With Dignity Act (DWDA), has been closely observed in the decade of its operation. Fears that patients without insurance, with chronic disabilities, or with less education would be pressured into hastening death have proved groundless. The study in the Psychiatric News report used an instrument for assessing depression that was neither designed for, nor tested with, terminally ill patients. The conclusion focuses on three of 18 patients who tested as depressed, without distinguishing between clinical depression and competency to decide on end-of-life care. The authors wrote that because a sixth of the patients manifested signs or symptoms of depression, increased psychiatric vigilance was needed.

In Oregon in 2007, 85 prescriptions to hasten death were written by 45 physicians; of the 85 patients, 46 hastened death, 26 died of illness, and 13 were alive at the end of the year. These deaths are not classified as suicide—nor should they be. Assisted suicide is illegal in every state, including Oregon.

Unlike suicidal patients for whom preventive measures are indicated, these patients want to live but face certain death within months or weeks. DWDA provides control and reassurance with psychological benefits: half of those who receive a prescription do not use it.

Oregon has excellent end-of-life care, including high rates of hospice enrollment and death at home—90 percent for DWDA patients. They and their loved ones, realistically accepting the prognosis, take a measure of control to achieve a peaceful, dignified ending, which they urge we not confuse with “assisted suicide.” The term “suicide” is inapt and pejorative, denigrating both patient and doctor who, in appropriate circumstance, use a law that is supported by a majority of Americans and several professional organizations: the American Public Health Association, the American Women's Medical Association, and the American Medical Student Association. Last November a DWDA in Washington state won handily in a referendum.

Over a decade, many observers have found that the Oregon law lessens depression by empowering patients and may prevent suicide in patients who have a terminal diagnosis with an unpredictable life expectancy. How else to explain the fact that 15 of 18 in the study sample did not test positive for depression, even though they faced imminent death? I submit that Oregon doctors, two of whom must certify the patient's terminal status and mental competence, are able to evaluate competence and the need for psychiatric consultation. Indeed, psychiatric consultation would, in many cases, constitute a burden and an insult to dying patients and their families. Better studies are needed to weigh the psychiatric benefits along with risks in what is a major innovation in palliative care.