The American Geriatrics position on physician-assisted suicide (PAS)
REDUCING THE RISK OF SUICIDE IDEATION
BY MANAGING PAIN AND TREATING
Barbara Rubel, MA, CBS, CPBC
Griefwork Center, Inc.
Those suffering physical or mental illnesses need options other then suicide. Many studies examine the relationship between suicide and schizophrenia, anxiety and substance abuse. This article will explore how the proper treatment of pain, whether emotional or physical, reduces suicide ideation. The underlying illness is a significant factor. By addressing the pain and the underlying depression caused by this factor, we decrease the risk of suicide ideation. Hendin (1995) writes that "a man in his 30's who was HIV positive but who had no symptoms and might not have developed them for years was helped to die, without any effort to address the terror behind his desire to end his life"(p. 2). My own father, a 65-year-old retired New York City Police Officer died by a self inflicted gun shot wound to his head. His suicide note indicated that he could not live with the pain caused by deteriorating disks.
The 30-year-old man infected with the HIV virus could not see past his fear of death. If oneís suffering is psychological, social or spiritual and has caused depression, the person may not see any other way out of the dark tunnel other than suicide. My father was suffering from untreated symptoms and pain unmanaged. In the film, Fatal Mistakes (Kingsley 1997) narrator Mariette Hartley stated, that Alex Greenwald "didnít need a doctor to help him die. He took care of that himself. What his family believes he needed was a doctor to help him live, to restore his mental health and to relieve his suffering." The cases cited above and the studies suggest that the underlying stressor must be found and treated. Physicians must develop a better response to pain management and depression.
On March 21, 1996 Dr. Herbert Hendin, medical director of the American Suicide Foundation, sent a letter to The New York Times. He cited a 1989 Swedish study showing that when chronically ill patients attempted suicide, their overburdened families often did not want them resuscitated. When society relieved the familyís burden by sending in home care helpers, however, most patients wanted to live, and their families wanted them to live too (Hendin 1995, 175). What this clearly suggests is that people do not want to end their lives, they want to end their pain. If physicians do not prescribe adequate pain medication, and do not treat the depression, the patients may end their lives or begs for mercy. The fear, then, is that mercy only appears as suicide, rather than as pain management and support.
All too often the patient asks his physician to help him die when what they really are asking for is to help them live without pain. Physicians can control the pain symptoms by prescribing barbiturates and narcotics. The Federal Controlled Substance Act regulates the use of these medications. There are many ways to deal with physical pain, such as acupuncture, massage, drugs, corrective surgery, spinal cord stimulation, exercise, support groups and physical therapy. After reviewing the literature, one can see that the assistance can come in forms of compassionate care and education rather then suicide.
SOCIETYíS VIEW OF SUICIDE, EUTHANASIA,
AND PHYSICIAN ASSISTED SUICIDE
Researchers are exploring societyís view of suicide, euthanasia, and physician assisted suicide (PAS). Some studies have used questionnaires, using small samples with low response rates, and opinion polls, telephone interviews using large sampling. Participants in the studies are made aware of the differences between euthanasia, suicide, and physician assisted suicide. Domino, Kempton & Cavender (1997, 249) define PAS as any action designed to terminate the life of a seriously ill individual who requests such assistance. The physician provides the means in which the patient dies. The physician does not personally intervene and the patient ends his own life. Euthanasia refers to the physicianís intervention, whereby an active role is taken in ending the patientís life. The physician eases his patientís suffering and allows for a good death.
There are several types of suicide. "Discussed" assisted suicide is where the physician discusses alternatives and encourages all options. "Accepted" assisted suicide is where little if any discussion of options is discussed. "Encouraged" assisted suicide is where the physician encourages ending oneís life and may provide the means to do so. Lastly, "Suicide," where the individual finds the means himself and ends his life with or without the knowledge of others. In these situations, the patient is clearly saying he or she wants his or her emotional or physical pain alleviated and that he or she cannot live with the pain or the depression that clouds their judgment.
The patientís family may include people of both and various ages. Each has his or her own attitude about death and dying and brings his own belief system to his response. The role of the physician becomes one of treating the illness and the pain associated with that illness, and providing information and support to the patientís family. The physicianís attitudes and those of the patientís family members play a role in suicide ideation.
Using a variety of instruments, researchers have found that attitudes about suicide and PAS depend upon religious views, age, politics, gender and race. Seidlitz and colleagueís study (as cited in Morris, 1997, 410) found that males, Whites, and less religious individuals held more lenient attitudes toward suicide. A physician plays a major role in the care of his or her patient. If the physician is male, White and not religious, and is approached by his patient regarding suicide, his attitude can affect the patientís decision to end his life. Studies have found that psychiatrists were most likely to support PAS than any other medical specialty. Psychiatrists have a high suicide rate. Sigmund Freud, one of the best-known psychiatrists, died by suicide. Suffering from cancer, he ended his pain on September 26, 1939.
Studies have found that those working closely with the terminally ill desire to prolong life and to relieve their patientsí suffering by finding the means other than suicide. The studies show that a majority of physicians donít favor euthanasia or PAS, and most are unwilling to participate in the ending of their patientís life. Dickenson, et al. (1998, 211) report that attitudes toward assisted suicide and euthanasia among physicians in South Carolina and Washington were very similar. Hematologists and Oncologists were the least supportive of euthanasia and PAS. Psychiatrists, who have the least contact with terminally-ill patients, are the strongest proponents of euthanasia and PAS.
Shneidman (as cited in Lester & Leenaars, 1996) maintains that "physicians and other health professionals need the courage and wisdom to work on a personís suffering at a phenomenological level and to explore such questions as ĎHow do you hurt?í and ĎHow may I help you?í They should then do whatever is necessary, using a wide variety of legitimate tactics. . .to reduce that personís self-destructive impulses"(p. 181). Addressing the self-destructive impulses and the pain is the first step in prevention.
Studies suggest that young adults in our society view the seriously ill with compassion. I believe there is a "conspiracy of compassion" among those who believe that if one is old and sick and appears mentally competent, suicide should be considered. Domino, Kempton & Cavenderís (1997) study of 118 college students report that the majority favor PAS and a substantial majority (81 percent) disagree with the statement that a person does not have the right to end their life, and agree (79 percent) that it would be important to determine that a person who requests physician assisted suicide is mentally competent. Approximately two out of three respondents agree that PAS is acceptable for the seriously ill (65 percent), for the elderly with serious medical conditions (67 percent), and about the same proportion (64 percent) would favor laws to make PAS legal in the United States (p. 250). This indicates that no one has to live in pain or suffer needlessly. If we educate society about pain management and suicide, the results of this study might be very different. Young adults may find that there are other compassionate options other then suicide for older adults with serious medical conditions.
Another study reported by Domino, Kempton, and Cavender (1997) of thirty adult caregivers suggests that they are less accepting of PAS than younger college students. There is some conflict in the findings as 71 percent of the students and caregivers would consider suicide if they were seriously ill, however, they believe that a person does not have the right to end their life." This shows that if those sampled were seriously ill, they would find the means to end their life. The challenge is to be able to live with the serious illness and have oneís physical, emotional, social and spiritual needs met. With the knowledge that a hospice team or a similar program was in place for the seriously ill, the results of the findings might be different.
Domino et al., (1997) asked participants to agree or disagree with the following statement: "The laws should allow physicians to assist senior citizens in committing suicide in cases where a person has been diagnosed with an incurable disease and is suffering from severe unrelenting suffering"(p. 248). Strong disagreement came from 23 percent of the subjects; 22 percent disagreed, 26 percent agreed and 15 percent strongly agreed, with 14 percent not knowing. Safeguards must be in place, not only for senior citizens but for anyone of legal age. Dickinson, Lancaster, Sumner & Cohen (1998) report the following:
The safeguards do not take into account that men and women are not mentally competent when they are in excruciating agony. Within the six month life expectancy, their quality of life can involve family, friends, and members of the clergy to offer support and guidance. Unfinished business and goodbyes are shared. Physicians should be adept at offering pain medication as the patient requires it. Within the waiting period, patient and family should receive counseling and given options.
Physicians consider several factors when deciding whether suicide is justified. The final decision is agreed upon by the hospital ethics committee. Dickenson et al. (1998) found that of 1,119 physicians attitudes toward suicide "less than one third believed that hastening death should be restricted to the adult population, and less than one-fourth felt that if the patient has adequate pain control and quality of life, but external factors lead to a request to end his/her life, a fatal overdose may still be appropriate" (p. 211).
Wooddell and Kaplan (1998) indicated that "despite the present lack of criminality, suicide is not at present a "right" of U.S. citizens under the common law of the Constitution (NY Task Force, 1993). On the other hand, assisted suicide is a specific statutory offense in thirty-two of the fifty states. In the remaining states, the crime of assisting a suicide is generally prosecuted a manslaughter or homicide"(p. 220). Whether it is against the law or not, the physician should be held responsible for managing the physical or emotional pain of his patient. He should also understand the tolerance for physical pain in depressed individuals.
Orbachís study (as cited in Orbach, et al. 1996) found that high tolerance for physical pain is a mediating process in self-destruction. High tolerance for pain may facilitate (but not cause) suicidal acting out under conditions of severe stress and anguish. Similarly, Schneidman (1980, as cited in Orbach et al. 1996) concludes that detachment from bodily sensations is one of the necessary conditions for the suicidal act to take place.
THE NEED TO EXAMINE
SOCIETAL FACTORS CONCERNING
PAIN MANAGEMENT AND DEPRESSION
Effective communication among family, patient and physician is essential to reducing suicide ideation. A study by Ferrell et al. (as cited in Ingham & Foley 1998) found that "in addition to patient related factors, family perceptions of pain, caregiver burden, caregiver moods, and differences in caregiver experiences of pain are all factors which may impact upon pain management" (p.93). The studies show that it is a combination of these factors that contribute to suicide ideation.
The family fears
The patient fears
The physician fears
In the case of terminally ill prisoners, physicians have been concerned about addictive abuse. Physicians fear that the use of these drugs might hasten death, when in fact, the controlled substances, relieving pain, helps the patient to live. Breitbart & Storeyís studies (as cited in Maull 1998) found that some physicians have been overly conservative in prescribing opioid drugs for terminally ill prisoners due to an exaggerated concern about the potential for addictive abuse, but more and more physicians are coming to understand that the need for effective pain management greatly outweighs such concerns. No matter where the setting, in hospice, prison, a hospital or home, the terminally ill should have their pain managed appropriately. Physician, patient, and family should be made aware of the importance of medication and the effective treatment of pain.
The findings of the literature review clearly show that there is a need to end suffering, and the means to the end does not have to be suicide. Further research can be explored concerning regulations and limiting doctorís constraints in ways to treat pain, and educating the public about their rights. Assistance can be offered to those who fear death, fear of becoming a burden to family, and fear of losing their dignity. Research should focus on depression that stems from physical pain. The most important research statement asked on a rating scale should be: "If your physician can manage your physical or emotional pain would you want to die?" Pain and suffering affect oneís physical function and social interaction. Oneís coping mechanisms, support system and physicianís powerful influence, are important considerations that should be addressed in the research. These attachments can keep one from ending his life when he is overwhelmed with pain.
"Chronic pain is real, unremitting, and demoralizing"(Chronic Pain 1997). When physicians in our society alleviate the pain, they fill the individualís landscape with hope. That hope stems from the knowledge that their physician has effectively reduced their suffering. They have offered their patient a meaningful existence through good medicine, whether they are terminally ill or have many years of life ahead of them. There is hope that their life will end naturally, and not by their own hand or that of their physician. "The leadership in palliative care in this country and abroad is coming from physicians who are strongly opposed to euthanasia. They know that ultimately physician-assisted suicide and euthanasia are bad medicine-bad for doctors, bad for patients, and bad for society" (Hendin 1998, 243).
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