In this issue of Palliative & Supportive Care, we are
pleased to present recent work from Dr. E.R. Goy et al. (“Oregon
hospice nurses and social workers' assessment of physician
progress in palliative care over the past 5 years”) regarding
their observations of the impact of the legalization of
physician-assisted suicide in the state of Oregon. In 1977, Oregon
enacted the Death with Dignity Act, which legalized physician-assisted
suicide for terminally ill patients. In the past 5 years, a relatively
small number of terminally ill patients in Oregon have requested
assisted suicide and, after evaluation, were provided with physician
assistance (Ganzini et al., 2002).
The debate surrounding the legalization of physician-assisted suicide
in the United States had been quite contentious and resulted in a
landmark United States Supreme Court decision that declared that there
was, in fact, no constitutionally based “right to die.”
This decision was a victory of sorts for opponents of legalized
physician-assisted suicide and euthanasia; however, the decision opened
the way for individual states to pursue their own policies and laws
regarding these matters. Oregon was the first, and is still the only
state, to have had voter approval and enactment of a law legalizing
physician-assisted suicide. Opponents of legalization of
physician-assisted suicide and/or euthanasia from the hospice and
palliative care community were opposed, in part, because of concerns
that legalizing such an option would erode efforts to improve
palliative care in the United States and lead to dangerous abuses of a
very vulnerable population.
One of the unintended consequences of the early debates around
physician-assisted suicide, prior to the U.S. Supreme Court decision in
1996, was an increased public awareness of hospice and palliative care
as alternatives to assisted suicide and euthanasia. A resulting surge
in private philanthropic foundation support for palliative care program
development and research, as well as a concurrent mobilization of
medical associations/societies and governmental research
institutional interest in palliative care issues and research, were an
unexpected, but positive, outcome of this divisive debate. Similarly,
observers in Oregon have described what they call the “silver
lining” (Lee & Tolle, 1996) that
resulted from the enactment of the Oregon Death with Dignity Act
(ODDA). Since the enactment of the ODDA, many attempts have been made
to improve palliative care in Oregon, including enhancement of the
medical school curriculum in end-of-life care, the development of more
hospital-based palliative care programs, a rise in statewide
conferences on end-of-life care, and efforts to reduce barriers to
access to hospice care. Since the passage of the ODDA, physicians
describe themselves as having improved their knowledge regarding
palliative care and use of opioids (Ganzini et al.,
2001). The article by Goy et al. in this issue of Palliative
& Supportive Care suggests that, based on hospice nurses'
and hospice social workers' observations, physicians have improved
their palliative care skills since the enactment of the ODDA.
Currently hospice organizations in Oregon provide care to
approximately 40% of those who die in the state. Interestingly, 87% of
Oregonians who have requested assisted suicide have been in hospice
care. One might question then whether the quality of palliative care
available has very much to do with whether an individual patient
pursues and ultimately attains physician assistance in suicide.
Researchers have made the argument that when it comes to addressing the
legal rights of patients who truly want physician-assisted suicide or
euthanasia, we are really speaking of an extremely small percentage of
terminally ill patients, perhaps less than 1% of those who are dying
(Chochinov & Wilson, 1995; Emanuel, Fairclough, & Emanuel, 2000). This suggests
that the issue of legalizing or not legalizing physician-assisted suicide is
essentially an irrelevant issue to the vast majority of patients who are
terminally ill. Researchers (Breitbart et al., 1996,
2000; Chochinov et al.,
1995) have further demonstrated that the issues that drive
interest in physician-assisted suicide are not related to medical
prognosis or even pain control, but rather to issues of depression,
social support, and hopelessness.
Although it may be somewhat encouraging to read that the legalization
of physician-assisted suicide in Oregon may have led to some perceived
improvement in physician skills and attitudes towards palliative care,
what clearly is not evident is an appreciation for the absolute
necessity of increasing the public's and the health care
providers' awareness of the important psychiatric and existential
issues that are at the heart of the despair that leads terminally ill
patients to see physician-assisted suicide or euthanasia as the only
alternative available to ease their suffering. It is our hope that this
journal, Palliative & Supportive Care, can increase
awareness of the importance of these psychiatric, psychosocial, and
existential issues in end-of-life care.
