Doctor-aided suicide: No slippery slope

Of 10 "vulnerable groups" examined in the study, only AIDS patients used doctor-assisted suicide at elevated rates.

"Fears about the impact on vulnerable people have dominated debate about physician-assisted suicide. We find no evidence to support those fears where this practice already is legal," says the study's lead author, bioethicist Margaret Battin, a University of Utah distinguished professor of philosophy and adjunct professor of internal medicine.

The study will be published in the October 2007 issue of the Journal of Medical Ethics. Battin conducted the research with public health physician Agnes van der Heide, of Erasmus Medical Center, Rotterdam; psychiatrist Linda Ganzini at Oregon Health & Science University, Portland; and physician Gerrit van der Wal and health scientist Bregje Onwuteaka-Philipsen, of the VU University Medical Center, Amsterdam. Van der Wal currently is inspector general of The Netherlands Health Care Inspectorate, which advises that nation's health minister.

The research deals with the so-called "slippery slope" argument that has been made by critics of doctor-assisted suicide and has raised concern even among proponents. The argument is that by making it legal for medical doctors to help certain patients end their lives, vulnerable people will die in disproportionately large numbers.

"Would these patients be pressured, manipulated or forced to request or accept physician-assisted dying by overburdened family members, callous physicians, or institutions or insurers concerned about their own profits"" the researchers asked.

The American College of Physicians said in 2005 that it was "concerned with the risks that legalization [of physician-assisted suicide] posed to vulnerable populations, including poor persons, patients with dementia, disabled persons, those from minority groups that have experienced discrimination, those confronting costly chronic illnesses, or very young children."

Tracking down data on physician-assisted deaths

Battin and her colleagues wanted to look at what actually has happened in two places where it is legal for doctors to help patients end their lives:

• Oregon is the only U.S. state where physician-assisted dying is legal. The Oregon Death with Dignity Act was passed by voters in 1994 and 1997, survived numerous challenges and was upheld by the U.S. Supreme Court in 2006. The law allows doctors to prescribe lethal medications to patients who have been diagnosed by two physicians as having a terminal illness and less than six months to live.

In the first nine years after the law took effect, 456 patients received lethal prescriptions and 292 of those actually used the drugs to kill themselves. That is 0.15 percent of all deaths in Oregon during the same period.

• The Netherlands has a 2002 law that allows doctors to prescribe medication for suicide or perform "voluntary active euthanasia," in which the physician rather than the patient administers life-ending medication. Dutch law does not require terminal illness, but "you have to be facing intolerable suffering," Battin says. Physician-assisted suicide and voluntary active euthanasia have been openly tolerated in the Netherlands since the 1980s under guidelines from the courts and medical groups.

Of 136,000 deaths annually in the Netherlands, about 1.7 percent are by voluntary active euthanasia, 0.1 percent by physician-assisted suicide and 0.4 percent are "extralegal" because they involve patients with no current explicit request to die, but who either made one before becoming incompetent or are perceived to be suffering intolerably.

Battin's team analyzed data on assisted suicide and voluntary active euthanasia in the Netherlands during 1985-2005 -- data taken from four government studies and several smaller ones. They analyzed Oregon Department of Human Services annual reports for 1998-2006, and surveys of physicians and hospice professionals.

Those who ask to die are not the underprivileged

The findings fell into three categories, based on the strength of the data. The researchers found:

• Direct evidence that elderly people, women and uninsured people do not die in disproportionate numbers where physician-assisted death is legal, but AIDS patients do. (The insurance data is from Oregon only; everyone is insured in the Netherlands.)
• Evidence that is partly direct and partly inferred showing that physician-assisted death does not kill disproportionate numbers of people who are poor, uneducated, racial and ethnic minorities, minors, or people with chronic physical or mental disabilities or chronic but not terminal illnesses.
• Evidence that is based on inference or that is partly contested showing that people with psychiatric illness -- including depression and Alzheimer's disease -- are not likely to die in lopsided numbers.

"Those who received physician-assisted dying ... appeared to enjoy comparative social, economic, educational, professional and other privileges," the researchers write.

The researchers noted that in both Oregon and the Netherlands, people who received a doctor's help in dying averaged 70 years old, and 80 percent were cancer patients.

As for AIDS, during nine years of the Oregon Death with Dignity Act, only six patients with the disease died with physician assistance -- 2 percent of all deaths under the law. Yet, the researchers write, "persons with AIDS were 30 times more likely to use assisted dying" than a comparable group of non-AIDS patients who died of chronic respiratory disorders.

In a cohort of 131 homosexual men in Amsterdam who were diagnosed with AIDS between 1985 and 1992, and who died by 1995, 22 percent died via physician-assisted suicide or euthanasia. The rate may be lower now since the advent of medicines that make it possible for many patients to live with AIDS as a long-term chronic illness.

"We've known for a long time from studies elsewhere that rates of assisted dying were much higher in people with AIDS," particularly in areas with large, supportive gay communities such as San Francisco, Battin says.

"We've known for a long time from studies elsewhere that rates of assisted dying outside the law were much higher in people with AIDS," particularly in areas with large, supportive gay communities such as San Francisco, Battin says. "It's not a surprise to find high rates where physician-assisted dying is legal."