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Physicians' Frequently Asked Questions
There is a great deal of information, and disinformation, available about the Oregon, Washington, and Vermont Death with Dignity Acts and physician-assisted dying. This section provides clear answers to questions physicians typically ask about these sometimes confusing issues. Please also refer to the FAQ pages of the Oregon Department of Human Services and Washington State Department of Health.
The Oregon Death with Dignity Act: A Guidebook for Health Care Professionals, developed by the Task Force to Improve the Care of Terminally-Ill Oregonians.
The Final Months of Life: A Guide to Oregon Resources, developed by The Task Force to Improve the Care of Terminally Ill Oregonians.
Physician-assisted death defined
Physician-assisted dying generally refers to a practice in which the physician provides a patient with a lethal dose of medication, upon the patient's request, which the patient intends to use to end his or her own life.
No. Physician-assisted dying refers to the physician providing the means for death, most often with a prescription. The patient, not the physician, will ultimately administer the lethal medication. Euthanasia generally means that the physician would act directly, for instance by giving a lethal injection, to end the patient's life. Some other practices that should be distinguished from Death with Dignity are:
Terminal sedation: This refers to the practice of sedating a terminally ill competent patient to the point of unconsciousness, then allowing the patient to die of her disease, starvation, or dehydration.
Withholding/withdrawing life-sustaining treatments: When a competent patient makes an informed decision to refuse life-sustaining treatment, there is virtual unanimity in state law and in the medical profession that this wish should be respected.
Pain medication that may hasten death: Often a terminally ill, suffering patient may require dosages of pain medication that impair respiration or have other effects that may hasten death. It is generally held by most professional societies, and supported in court decisions, that this is justifiable, as long as the primary intent is to relieve suffering.
Is physician-assisted death ethical?
The ethics of assisted death continue to be debated. Some often argue that physician-assisted dying is ethical on the grounds that it may be a rational choice for a person who is choosing to die to escape unbearable suffering. Furthermore, the physician's duty to alleviate suffering may, at times, justify the act of providing assistance with dying. These arguments rely a great deal on the notion of individual autonomy, recognizing the right of competent people to chose for themselves the course of their life, including how it will end.
Others have often argued that assisted death is unethical because it runs directly counter to the traditional duty of the physician to preserve life. Furthermore, many argue if hastened death were legal, abuses would take place. For example, many opponents falsely claim the poor or elderly might be covertly pressured to chose assisted dying over more complex and expensive palliative care options. Oregon's law went into effect in 1997 and Washington's in 2009, and throughout the laws' history, there's never been a case of coercion or undue influence related to the Death with Dignity Act. Not one.
What are the arguments in favor?
Those who argue Death with Dignity Acts are ethically justifiable offer the following arguments:
Respect for autonomy: Decisions about time and circumstances death are very personal. Every competent person should have right to choose death.
Justice: Justice requires that we "treat like cases alike." Competent, terminally ill patients are allowed to hasten death by treatment refusal. For some patients, treatment refusal will lead to more suffering. Justice requires that we should allow assisted death for these patients.
Compassion: Suffering means more than pain; there are other physical and psychological burdens. It is not always possible to relieve suffering. Allowing terminally ill people to determine the timing and manner of their deaths is a compassionate response to unbearable suffering.
Individual liberty vs. state interest: Though society has strong interest in preserving life, that interest lessens when person is terminally ill and has strong desire to end life. A complete prohibition on assisted death excessively limits personal liberty.
Openness of discussion: Assisted death already occurs, albeit in secret. For example, morphine drips ostensibly used for pain relief may be a covert form of assisted death or euthanasia. In states without Death with Dignity laws, open discussions between patients and physicians are avoided and prohibited. Legalization would promote open discussion.
What are the arguments against PAS?
Those who argue assisted dying should remain illegal often offer arguments such as these:
Sanctity of life: This argument stems from strong religious and secular traditions which disagree with assisted death on moral grounds. The US, however, is a country founded on the principal of separation of church and state, and religious institutions shouldn't limit American's end-of-life options. Why should anyone—the state, the medical profession, or anyone else—presume to tell someone else how much suffering they must endure while dying?
Passive vs. Active distinction: The argument here holds there's a difference between passively "letting die" and actively "killing." It is argued that treatment refusal or withholding treatment equates to letting die, whereas Death with Dignity laws allow terminally-ill, mentally competent people to hasten their own deaths.
Potential for abuse: Here the argument is that certain groups of people, lacking access to care and support, may be pushed into assisted death. Independent studies have found no evidence of risk to individuals in "vulnerable" groups.
Professional integrity: Here opponents point to the historical ethical traditions of medicine, strongly opposed to taking life. For instance, the Hippocratic oath states, "Be of benefit, or at least do no harm." But "harm" is different for every patient. Harm for some patients could be forcing them to die according to how their bodies decide instead of how they decide.
Fallibility of the profession: The concern raised here is that physicians will make mistakes. For instance there may be uncertainty in diagnosis and prognosis. There may be errors in diagnosis and treatment of depression, or inadequate treatment of pain. Thus the State has an obligation to protect lives from these inevitable mistakes.
What does the medical profession think of assisted death?
Surveys of individual physicians show that half believe assisted dying is ethically justifiable in certain cases. Surveys of physicians in practice show that about 1 in 5 will receive a request for assisted death sometime in their career. Somewhere between 5-20% of those requests are eventually honored.
What do patients and the general public think of physician-assisted death?
Surveys of patients and members of the general public find that the vast majority think that PAS is ethically justifiable in certain cases, most often those cases involving unrelenting suffering.
If I am a doctor, what should I do if a patient asks me for assistance in dying?
One of the most important aspects of responding to a request for assisted dying is to be respectful and caring. Virtually every request represents a profound event for the patient, who may have agonized over his situation and the possible ways out. The patient's request should be explored, to better understand its origin, and to determine if there are other interventions that may help ameliorate the motive for the request. In particular, one should address:
- motive and degree of suffering: are there physical or emotional symptoms that can be treated?
- psychosocial support: does the patient have a system of psychosocial support, and has she discussed the plan with them? accuracy of prognosis: every consideration should be given to acquiring a second opinion to verify the diagnosis and prognosis.
- degree of patient understanding: the patient must understand the disease state and expected course of the disease. This is critical since patient may misunderstand clinical information. For instance, it is common for patients to confuse "incurable" cancer with "terminal" cancer.
What if the patient's request persists?
If a patient's request for assistance in dying persists, each individual clinician must decide his or her own position and choose a course of action that is ethically justifiable. Careful reflection ahead of time can prepare one to openly discuss your position with the patient, acknowledging and respecting difference of opinion when it occurs. Organizations exist which can provide counseling and guidance for terminally ill patients. No physician, however, should feel forced to supply assistance if he or she is morally opposed to assisted death.
Source for the above information: University of Washington School of Medicine (1998) - Clarence H. Braddock III, MD, MPH, Project Director, Bioethics Education Project; Faculty, Departments of Medicine and Medical History and Ethics, with Mark R. Tonelli, MD, MA, Assistant Professor, Pulmonary and Critical Care Medicine.
Defend dignity. Take action.
You are the key to ensuring well-crafted Death with Dignity laws for all Americans. With your financial and volunteer help, the Death with Dignity National Center, a 501(c)(3), non-partisan, nonprofit organization, has been the leading advocate in the Death with Dignity movement. Individual contributions helped us pass new Death with Dignity laws in Washington and Vermont, defend the Oregon law, and provide education and outreach programs for the vitality of the Death with Dignity movement.