Suicide 'shouldn't involve medics'

VIEWPOINT
David Jeffrey
Palliative care expert

Physician assisted suicide has been legal for a decade in the US state of Oregon.

But palliative care specialist David Jeffrey says there are grave questions about whether people are being helped to die, when treatment for depression could be a highly successful alternative.

In this week's Scrubbing Up column Dr Jeffrey, who is based at the University of Edinburgh, says a patient should be free to end their life - but doctors should not be involved.

" Oregon's 1997 Death with Dignity Act legalised physician-assisted suicide (PAS) for patients in the last six months of a terminal illness.

A decade on, only one in 10 people requesting PAS proceed as far as picking up the medication.

"The provision of end-of-life care in Oregon is so different to that in the UK that it cannot be claimed to be a valid basis for any change in existing UK law"

And only half of those take the lethal drug.

In 2007, official records show 85 prescriptions were written - the most since the law was introduce - but only 46 people took the medication.

There were also three deaths in patients prescribed their drugs the previous year.

In all, three people suffered complications. One patient took three days to die.

Exaggerated need

Worryingly, none of the patients had been referred for a psychiatric assessment, even though this might have led to successful treatment, rather than suicide.

It is well established that depression is a common cause of suicidal wishes and that around 25% of patients with terminal cancer have treatable depression.

Furthermore, recent research from Oregon published in the British Medical Journal shows the Act failed to protect some depressed patients who died from lethal ingestion.

It is also commonly assumed that patients who carry out PAS must be suffering terrible pain.

However, the patients who use PAS in Oregon are generally not in pain, but wish to use PAS simply so that they can control the timing of their death.

The report found the major concerns of those undertaking PAS were loss of autonomy, being less able to take part in activities they enjoyed and loss of dignity (86%).

Other reasons include fear of being a burden and that they might experience pain at the end of their lives.

Oregon physicians describe patients requesting PAS as having strong personalities, characterised by determination and inflexibility.

"There is a lack of trust in the medical establishment amongst many African-Americans "


These patients have always had a marked need for control throughout their lives and cannot bear having to depend on others, so palliative care has no appeal for them.

The question here is not one of the patient's right to commit suicide, but whether this small group of people who have an exaggerated need for control have any right to demand the involvement of doctors, nurses and pharmacists in their suicide.

'Middle-class law'

In Oregon, care described as "hospice" or "palliative" is not comparable to UK services.

There are no specialist inpatient palliative care beds in Oregon; their hospice home care is a nursing and social care service which is limited by the financial constraints of the US health care system and is limited to end-of-life care.

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Some patients are excluded - 17% of Oregonians are not covered for health care - and even those who do qualify must forgo other treatments such as radiotherapy which are employed in the UK for the relief of difficult symptoms.

The law is discriminatory as it excludes people who are not physically capable of taking the medication.

The people who use PAS in Oregon are white middle-class well educated people.

There is a lack of trust in the medical establishment amongst many African-Americans which may account for their avoidance of PAS.

The provision of end-of-life care in Oregon is so different to that in the UK that it cannot be claimed to be a valid basis for any change in existing UK law.

In the UK patients are suffering unrelieved pain and psychosocial distress because they do not have access to the best standards of palliative care.

There is an urgent need to make palliative care available to all patients, to those with end stage cardiac failure, respiratory failure, dementia and the chronic neurological diseases such as motor neurone disease as well as to those with cancer.

This is the starting point of an ethical response to suffering at the end of life. "

David Jeffrey is the author of 'Against Physician Assisted Suicide. A palliative care perspective'.

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RELATED INTERNET LINKS
Oregon's Death with Dignity Act
Care not Killing
Dignity in Dying
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