Thursday, May 10, 2007
The New England Journal of Medicine published an update (usually every 5 years) on the practice of physician-assisted death (used here to describe euthanasia (E) and physician-assisted suicide(PAS)) under the legal Netherlands Euthanasia Law (2002). There have been previously published articles in NEJM reviewing acts of hastened death in 1990, 1995, 2001, and this one covers 2005. This is the first study published covering the practice after the legalization of a previously illegal but accepted acts of euthanasia and physician-assisted suicide. One of the major additions is the authors also investigated the frequency of palliative sedation, which had previously been omitted for unclear reasons. The study stayed true to the methods of previous studies by reviewing death certificates and sending surveys to physicians (with a very impressive 78% response rate!)
This is an article that I would classify as myth-busting as a few of the major arguments against E/PAS are undermined.
1) No slippery slope. A major finding was the absence of the 'slippery slope' that many fear may come with the public/legal acceptance of physician-assisted death. The percentage of deaths attributed to physician-assisted suicide (0.1% in 2005, 0.2% in 2001) and euthanasia (1.7% in 2005, 2.5% in 2001) both decreased (statistically significant). Palliative sedation accounted for 8.2% of the deaths, but there was no comparison to the years before. Obviously the argument that E/PAS is wrong even if there is one hastened death still holds up pretty well if there are are 2 or 200 hastened deaths.
2) Less evidence of hastened death without explicit request. One of the major safeguards against the slippery slope and hastened death of those who society may no longer find 'useful' is to ensure that E/PAS is voluntary/autonomous and without coercion. One of the great fears of legalization of E/PAS is a situation like in Nazi Germany where a policy of ending 'lives not worth living' (i.e. disabled, mentally incapacitated) was tolerated. This study demonstrated this happened less in 2005 (0.4%), and most times the physician spoke with the patient about this at an earlier time, or with the family, and often times with another physician.
3) Opioids are not the medications of choice for hastening death. The great (public and medical) fear that titration of opioids for symptoms may hasten death is undermined by the fact that those who practice E/PAS in the Netherlands use medications such as neuromuscular relaxants more often than opiates. As I have been teaching students and residents lately: Opioids are powerful palliative medications to be understood and respected, not feared.
Now this is not to say there are not very strong and cogent reasons against E/PAS, but in any reasonable debate about these practices we must reference the data correctly so that our arguments either way are sound.
There is a well-written editorial by Timothy Quill, who is often called on to comment on this topic in NEJM and JAMA. He is a superb writer and his editorial makes for a good review on the subject. He does make note of the AAHPM's revised position statement of 'studied neutrality' on physician-assisted death. I am a little frustrated that the term physician-assisted death is becoming more common (AAHPM, and Oregon DWD report) because to me this term encompasses both euthanasia and physician-assisted suicide, but some use PAD to mean one or the other or both. Here is my logical understanding of this:
All euthanasia is PAD.
All PAS is PAD.
PAD includes PAS and E.
E and PAS are ethically distinct acts because there is a different 'actor' in each.
So therefore to use the term PAD is more confusing because one still has to clarify if you mean E, PAS or both.
Also, if anyone is going to be at the Nashville AAHPM Current Concepts Course, I am leading the session on Prognosis Saturday AM, feel free to say hi.
Anyway, here is my disclaimer:
(My Standard Disclaimer: Pallimed, Dr. Sinclair and his current and former employers and states do not endorse or practice euthanasia or physician-assisted suicide, but do encourage the open, non-judgmental discussion of these topics for educational and ethical discourse about this controversial area of medicine.)
Photo courtesy of flickr.com user IrenaS