Assisted-Suicide Ruling Grants Patient Autonomy

Although the Supreme Court's decision in favor of the Oregon assisted suicide law removed obstacles for the relatively small number of patients who seek a physician's help to end their lives, some psychiatrists see its impact as much more profound.

The Supreme Court ruled 6-3 on January 17 that the Bush administration could not use a federal drug law to prosecute doctors under Oregon's one-of-a-kind physician-assisted suicide law. The Bush administration tried to prosecute Oregon doctors who prescribed overdoses to help terminally ill patients die. The ruling said federal authority to regulate aspects of medical practice does not override the 1997 Oregon law.

Adopted by Oregon voters in 1994 and reaffirmed in 1997, Oregon's Death With Dignity Act has allowed physicians to help end the lives of more than 200 seriously ill people in that state. The law lays out specific procedures for physicians to prescribe lethal doses of federally regulated medications to help mentally competent, terminally ill patients end their lives.

Former Attorney General John Ashcroft announced in November 2001 that doctors who prescribed lethal doses of drugs to assist a suicide could lose their federal licenses to prescribe all “controlled substances.” Because it would be difficult for physicians to practice medicine without such a license, a physician, a pharmacist, several terminally ill patients, and the state of Oregon sued to block enforcement of the new rule (Psychiatric News, June 7, 2002).

Implications for Pain Management

Timothy Quill, M.D., a supporter of the Oregon law and a professor of medicine and psychiatry at the University of Rochester, said the rejection of a federal challenge to the Oregon law was critical to support pain management and palliative care nationwide. In addition to upholding the Oregon law, the decision blocks any role for federal drug agents in deciding what a physician's intentions were when prescribing medication at the end of a patient's life.

“Frequently, we use very large doses of medications to control symptoms—usually with patients tolerating quite well,” said Quill.“ But if you are inexperienced and you start to second guess these issues, there could be a lot of mischief and fear in the medical community, and people would have been even more reluctant to prescribe than they already are.”

William Breitbart, M.D., a professor of psychiatry at Weill Medical College of Cornell University who studies end-of-life care, said he is very concerned about misperception of the Supreme Court ruling as an endorsement of physician-assisted suicide by those “who are depressed or in distress or despair that could be ameliorated by appropriate interventions.” But the decision also was positive, he said, because it bars federal authorities from prosecuting physicians for how they treat terminally ill patients.

“My main concern is that patients who are terminally ill not have a limitation or restriction on their physician's ability to prescribe opioids to control pain,” Breitbart said. “For someone who is terminally ill and receives opioids to control the pain and eventually dies, who is to determine whether the patient died because you prescribed opioid drugs? If determination of that is up to someone else who is not a physician, then that puts you as a physician in a very vulnerable position.”

His research has led Breitbart (Psychiatric News, January 5, 2001), an attending psychiatrist at the Psychiatry Service at Memorial Sloan Kettering Cancer Center, to believe that the vast majority of dying patients can have their symptoms ameliorated through mechanisms other than death, and the relatively small number of terminal Oregon patients who have opted for physician suicide seems to support that.

Data Show Well-Designed Program

Quill said that the small numbers of patients opting for physician-assisted suicide in the Oregon program, which requires repeated patient requests and a second physician's concurrence before a terminal dose is prescribed, shows the program is well-designed. But more importantly, the program allows larger numbers of patients to have frank discussions with their physicians about end-of-life care. The Oregon law requires careful documentation, and those suspected of mental illness are referred to a psychiatrist or mental health professional for evaluation. The program's guidelines, Quill said, achieve a good balance between safety and invasiveness.

“In Oregon you can have that conversation out in the open. You can reassure people that you will be responsive, and it is much more variable than how that conversation goes in the rest of the country,” Quill said.

Neither APA nor the Oregon Psychiatric Association has an official position on physician-assisted suicide.

Program Seems Abuse Free

Research conducted on the Oregon program, Breitbart said, shows it is conducted without abuses found in the Netherlands, where physicians assisted in the suicides of noncompetent and nonterminal patients. He does caution that research indicates that most patients who request a hastened death suffer from psychiatric issues, such as depression and existential distress like hopelessness and loss of meaning.

“There is a role for psychiatrists and mental health professionals to help deal with those issues that lead to the despair that would lead someone to request assisted suicide or to express the desire for a hastened death,” Breitbart said.

He said he hopes the decision will move the focus from the less than 1 percent who receive physician-assisted suicide to the 20 percent of dying patients who experience despair or depression that leads them to express a desire for a hastened death. More attention to and research on this larger group of patients can lead to new and better treatments, such as meaning-centered psychotherapy and dignity-preserving interventions.

Breitbart said he was impressed by how many people say they weigh the option of physician-assisted suicide but don't act on it.

“That is probably important psychologically in that they are able to not feel trapped for the last weeks or months of their lives,” he said.

Congress may still act to bar physician-assisted suicide, because the majority opinion in Gonzales v. Oregon did not block such laws. A unanimous 1997 Supreme Court ruling found that there is no constitutional right to die. That decision left room for states to set their own rules.

The majority and dissenting opinions inGonzales v. Oregonare posted at<www.law.cornell.edu/supct/html/04-623.ZS.html>. Information on Oregon's Death With Dignity Act is posted at<http://egov.oregon.gov/DHS/ph/pas/faqs.shtml>.▪