Physicians' Frequently Asked Questions

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There is a great deal of information, and disinformation, available about the Oregon and Washington 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 suicide—or more accurately, 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.

Isn't physician-assisted suicide the same as euthanasia?

No. Physician-assisted suicide 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 PAS 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 suicide ethical?

The ethics of PAS continue to be debated. Some often argue that PAS 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 suicide. 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 PAS is unethical because it runs directly counter to the traditional duty of the physician to preserve life. Furthermore, many argue if PAS were legal, abuses would take place. For instance, the poor or elderly might be covertly pressured to chose PAS over more complex and expensive palliative care options.

What are the arguments in favor of PAS?

Those who argue that PAS is ethically justifiable offer the following sorts of 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 not suffice to hasten death; only option is suicide. 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. Thus PAS may be 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. Therefore PAS should be allowed in certain cases.
• Openness of discussion: Some would argue that 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. That PAS is illegal prevents open discussion, in which patients and physicians could engage. Legalization of PAS would promote open discussion.

What are the arguments against PAS?

Those that argue that PAS should remain illegal often offer arguments such as these:

• Sanctity of life: This argument points out strong religious and secular traditions against taking human life. It is argued that assisted suicide is morally wrong because it contradicts these beliefs.
• Passive vs. Active distinction: The argument here holds that there is an important difference between passively "letting die" and actively "killing." It is argued that treatment refusal or withholding treatment equates to letting die (passive) and is justifiable, whereas PAS equates to killing (active) and is not justifiable.
• Potential for abuse: Here the argument is that certain groups of people, lacking access to care and support, may be pushed into assisted death. Furthermore, assisted death may become a cost-containment strategy. Burdened family members and health care providers may encourage option of assisted death. To protect against these abuses, it is argued, PAS should remain illegal.
• Professional integrity: Here opponents point to the historical ethical traditions of medicine, strongly opposed to taking life. For instance, the Hippocratic oath states, "I will not administer poison to anyone where asked," and "Be of benefit, or at least do no harm." Furthermore, major professional groups (AMA, AGS) oppose assisted death. The overall concern is that linking PAS to the practice of medicine could harm the public's image of the profession.
• 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 PAS?

Surveys of individual physicians show that half believe that PAS is ethically justifiable in certain cases. However, professional organizations such as the American Medical Association have generally argued against PAS on the grounds that it undermines the integrity of the profession. Surveys of physicians in practice show that about 1 in 5 will receive a request for PAS sometime in their career. Somewhere between 5-20% of those requests are eventually honored.

What do patients and the general public think of PAS?

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 suicide?

One of the most important aspects of responding to a request for PAS 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 aid-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 PAS.

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.

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