Physician-assisted suicide and financial coercion

By Mitchell T. Wallin – – Sunday, July 5, 2015

Earlier this year, legislation was introduced to the D.C. Council that would legalize physician-assisted suicide in our nation’s capital for an adult patient diagnosed with a terminal condition and less than six months to live. Although this initiative has been introduced in 24 states this year (not passing in any so far), its passage in the District of Columbia this year risks setting a dangerous precedent for the rest of the nation.

Self-determination and pain relief are the primary arguments by proponents of physician-assisted suicide. These principles of autonomy and beneficence are clearly important in discussions at the end of life. But can this specific piece of legislation protect those who need it the most, such as those with mental illness, and those easily subject to coercion, such as seniors? As a practicing physician for the past 25 years and based on the experience of similar practices around the world, I have serious concerns with this bill.

First, this legislation does not require a patient to be screened and evaluated for mental illness prior to receiving a lethal drug prescription. Suicide is the 11th leading cause of death in the United States and is largely associated with clinical depression and other treatable mental health conditions. A recent study found 1 in 6 terminally ill patients in Oregon had depression and still received a prescription for a lethal drug. Also, only a small minority of patients who have died by physician-assisted suicide in Oregon were referred for psychiatric evaluation. This is inexcusable in light of the effective treatments for mental health disorders. After treatment, many patients might be willing to consider other options in the last phase of life.

Second, safe implementation of physician-assisted suicide cannot be assured. A review of the Dutch experience by Johanna Groenewoud identified problems in 30 percent of all cases in the Netherlands. These included delays in the completion of death of up to one week and technical problems in 10 percent of cases. The true complication rate is difficult to determine due to the high rate of non-reporting of case outcomes both in Europe and Oregon. For many, there is no assurance of a peaceful death with assisted suicide.

Third, coercion in physician-assisted suicide by family, finances and altruism have insidious power — and this bill has no protections against it. An early physician-assisted death often brings the promise of financial gain and other benefits to those left behind. For example, a large estate or the cessation of health care expenditures for the dying patient could motivate family members or insurance companies to advocate for assisted suicide. Even Derek Humphrey, founder of the Hemlock Society, has admitted that “economics, not the quest for broadened individual liberties or increased autonomy, will drive assisted suicide to the plateau of acceptable behavior.” For the vulnerable patient pushed by financial or altruistic arguments, the right to physician-assisted suicide quickly becomes the duty to die. This forces terminally ill patients to justify their existence and destroys the physician-patient relationship.

Assisted-suicide proponents have focused on the choice of death and minimized how one might experience the final phase of life. Coordinated palliative care and hospice can address most needs of dying patients. When required, pain management can be optimized and palliative sedation implemented. Surgeon and author Atul Gawande has stated in his insightful book, “Being Mortal,” that the ultimate goal should not be a good death but a good life to the very end. He cites the rising rates of assisted suicide in the Netherlands and the limited development of hospice programs as a failure. As a physician, I can’t help but to agree.

There are too few conversations about the end of life between patients with terminal illness and health care providers. When these discussions take place, recent studies have shown improved quality of life, fewer patients dying in intensive care units and higher use of hospice care. These outcomes are positive developments, but more can and should be done to engage terminal patients in living to the fullest during the last phase of life.

Current physician-assisted suicide practices fail to protect the mentally ill and have significant safety concerns and coercive incentives. Also, it is nearly impossible to predict a terminal diagnosis accurately. The so-called “death with dignity” should not trump vulnerable patients or the public good. Physician-assisted suicide shouldn’t happen in our nation’s capital — or anywhere else, for that matter.

Mitchell T. Wallin is attending neurologist at the Veterans Affairs Medical Center in Washington, D.C., and associate professor of neurology at Georgetown University School of Medicine.