From the Center for Outcomes and Policy Research, Division of Cancer Epidemiology and Control, Dana-Farber Cancer Institute, Boston, Mass (Dr Emanuel and Ms Daniels); Center for Research Methodology and Biometrics, Cancer Research Center, American Medical Center, Denver, Colo (Dr Fairclough); and the Center for Survey Research, University of Massachusetts, Boston (Dr Clarridge).
Context.— Despite intense debates about legalization, there are few data examining
the details of actual euthanasia and physician-assisted suicide (PAS) cases
in the United States.
Objective.— To determine whether the practices of euthanasia and PAS are consistent
with proposed safeguards and the effect on physicians of having performed
euthanasia or PAS.
Design.— Structured in-depth telephone interviews.
Setting and Participants.— Randomly selected oncologists in the United States.
Outcome Measures.— Adherence to primary and secondary safeguards for the practice of euthanasia
and PAS; regret, comfort, and fear of prosecution from performing euthanasia
Results.— A total of 355 oncologists (72.6% response rate) were interviewed on
euthanasia and PAS. On 2 screening questions, 56 oncologists (15.8%) reported
participating in euthanasia or PAS; 53 oncologists (94.6% response rate) participated
in in-depth interviews. Thirty-eight of 53 oncologists described clearly defined
cases of euthanasia or PAS. Twenty-three patients (60.5%) both initiated and
repeated their request for euthanasia or PAS, but 6 patients (15.8%) did not
participate in the decision for euthanasia or PAS. Thirty-seven patients (97.4%)
were experiencing unremitting pain or such poor physical functioning they
could not perform self-care. Physicians sought consultation in 15 cases (39.5%).
Overall, oncologists adhered to all 3 main safeguards in 13 cases (34.2%):
(1) having the patient initiate and repeat the request for euthanasia or PAS,
(2) ensuring the patient was experiencing extreme physical pain or suffering,
and (3) consulting with a colleague. Those who adhered to the safeguards had
known their patients longer and tended to be more religious. In 28 cases (73.7%),
the family supported the decision. In all cases of pain, patients were receiving
narcotic analgesia. Fifteen patients (39.5%) were enrolled in a hospice. While
19 oncologists (52.6%) received comfort from having helped a patient with
euthanasia or PAS, 9 (23.7%) regretted having performed euthanasia or PAS,
and 15 (39.5%) feared prosecution.
Conclusions.— Intractable pain or poor physical functioning seem to be nearly absolute
requirements for physicians to perform euthanasia or PAS. Only one third of
cases are performed consistently with proposed safeguards. For some patients,
end-of-life care that includes opioid analgesia and hospice care does not
obviate their desire for euthanasia or PAS. While the majority of physicians
seem comforted by their actions, some experience adverse consequences from
having performed euthanasia or PAS.
ONCE AGAIN, euthanasia and physician-assisted suicide (PAS) have become
controversial social issues,1- 5
prompting substantial empirical research. There have been numerous surveys
of physicians in Australia, Britain, Canada, the Netherlands, the United States,
and other countries.1,6- 19
These surveys have tended to focus on attitudes toward euthanasia and PAS
and how frequently these interventions have been performed. Few studies have
elucidated the actual details of the practices of euthanasia and PAS. The
largest of such studies have been conducted in the Netherlands.9,11
We have identified only 2 studies in the United States examining the details
of actual euthanasia or PAS cases.16,18
To provide additional empirical data on the actual practices of euthanasia
and PAS in the United States, we conducted in-depth interviews with US oncologists
who, on screening questions, acknowledged performing these interventions.
Using a method modeled on the Remmelink study in the Netherlands,9,11 the in-depth interviews focused on
whether practice is consistent with proposed safeguards and the effects on
the physicians themselves of performing these interventions.
We identified 4 proposed primary safeguards that have usually been required
in the Netherlands, incorporated into US proposals on PAS, and endorsed by
advocates of euthanasia and PAS1,20- 25;
they include the following: (1) the patient must be terminally ill; (2) the
patient must be competent and initiate and repeatedly request euthanasia or
PAS; (3) the patient must be experiencing severe pain and/or suffering; and
(4) the patient must be evaluated by another physician, who may be a psychiatrist.
Several secondary safeguards have been suggested but usually not as requirements,
as follows: (1) optimal pain and palliative care services have been provided
to the patient; (2) the physician and patient have a long-standing relationship;
and (3) the patient's family has been informed and supports the decision.
We also examined the effects on physicians of performing euthanasia
or PAS. It has been reported that among Dutch "physicians who had practiced
euthanasia [many] mentioned that they would be most reluctant to do so again."9 And in a television program reporting a euthanasia
case, the Dutch physician who performed euthanasia noted that:
To kill someone is something very far reaching and that is something
that nags at your conscience. . . . I wonder what it would be like not to
have these cases in my practice. Perhaps I would be a much more cheerful person.
To kill someone is something very far reaching and that is something
that nags at your conscience. . . . I wonder what it would be like not to
have these cases in my practice. Perhaps I would be a much more cheerful person.
We focused on oncologists because the Dutch data demonstrate that 80%
of patients receiving euthanasia have cancer.9,11
In addition, proposals to legalize euthanasia or PAS in the United States
typically require the patients to have 6 months or less to live, making oncology
patients the largest group of patients for whom euthanasia and PAS would be
an option if legalized.23- 25
Therefore, in the United States, oncologists are most likely to administer
Participant selection has previously been described.26
In brief, no participants were paid to participate. We selected 2 samples:
(1) all adult medical, gynecological, and surgical oncologists from Connecticut,
Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont and (2) from
all 44 non-New England states and the District of Columbia, we randomly selected
10% of medical oncologists listed in the 1993 American Society
of Clinical Oncology Directory.26 Of
the 498 oncologists selected, 3 had died, 5 were retired, and 1 was hospitalized.
Of the 489 eligible oncologists, 115 refused to participate, 7 could not be
traced, and 12 could not be interviewed before the study ended. We completed
355 interviews for a response rate of 72.6%.
All 355 oncologists who participated in the initial interview were contacted
6 to 12 months later for a follow-up interview. In both the initial and follow-up
interviews, oncologists were asked 2 screening questions: "Have you ever actually
injected drugs to intentionally end a patient's life?" and "Have you ever
actually prescribed drugs to a patient knowing the patient intended to use
them to end his or her life?" Oncologists who answered yes to either of these
questions were given an in-depth interview. Except for being conducted on
the telephone, the in-depth interviews were modeled on the methods of the
Remmelink report, asking oncologists about their most recent case of euthanasia
Survey development occurred in 6 steps: (1) literature search, (2) focus
groups, (3) instrument creation, (4) cognitive pretesting, (5) behavioral
pretesting, and (6) reliability assessment. The extensive pretesting ensured
content and construct validity, test-retest reliability, and comprehensibility.
Because the terms euthanasia and PAS can be ambiguous and emotionally charged, they were replaced by
the carefully worded and pretested phrases described above.1,26
Specially trained interviewers from the Center for Survey Research, University
of Massachusetts, Boston, conducted all interviews on the telephone.
Oncologists were informed that their responses would be kept confidential
and that personal identifiers linked to the survey would be destroyed prior
to any publication. All files with participants' names, telephone numbers,
and survey identification numbers have been destroyed.
As previously reported, there were no differences between New England
and national oncologists on 98% of the survey questions, so responses were
combined for analysis.26 The characteristics
of oncologists who participated or never reported participating in euthanasia
or PAS were compared using analysis of variance for age; the Cochran Mantel-Haenszel χ2 test for ordered categorical variables, level of religious belief,
and number of requests for euthanasia or PAS in the last year; and the χ2 test of independence for unordered categorical variables, sex, religious
affiliation, race, and ever having been asked to perform euthanasia or PAS.
Candidate-independent variables that were used in multivariate logistic regression
analyses of the use of primary safeguards, regret, fear of prosecution, and
other outcomes included oncologist age, sex, race, religion, level of religious
beliefs, length of physician-patient relationship, consistency with primary
safeguards, whether the patient was experiencing pain or receiving opioid
analgesia, and whether the patient's family supported a decision for euthanasia
The institutional review boards at the Dana-Farber Cancer Institute
and the University of Massachusetts approved the study.
Of the 355 participating oncologists, 56 (15.8%) reported ever participating
in either euthanasia or PAS on the screening questions (Figure 1).26 Of these 56 oncologists,
only 3 refused to participate in the in-depth interviews (94.6% response rate).
Three indicated that the event occurred so long ago that they could not recall
the details of the case to answer the in-depth questions. During the interviews,
7 oncologists' answers indicated that they did not perform euthanasia or PAS
but either terminated life-sustaining treatments or increased narcotics for
pain relief with the unintended result of hastening a patient's death. Also,
5 cases were situations in which patients overdosed on medications they previously
possessed without asking their physician for information about ending their
lives or requesting a prescription to end their lives. Overall, the in-depth
interview revealed that for 12 (21.4%) of 56 oncologists who indicated that
they had "intentionally ended a patient's life," the actual cases were not
consistent with established definitions of euthanasia or PAS.1
Therefore, all subsequent analyses are based on the in-depth interviews of
the 38 oncologists (10.7% of 355 interviewed oncologists) in which the description
of cases is clearly consistent with accepted definitions of euthanasia or
PAS. There were no significant differences regarding age, sex, race, religion,
or geography between oncologists who reported performing euthanasia and PAS
and those who did not (Table 1).
However, oncologists who performed euthanasia or PAS were significantly less
likely to report themselves as religious and more likely to receive requests
for these interventions.26
Of the 38 oncologists, 28 (73.7%) reported that they "prescribed drugs
. . . knowing the patient intended to use" them for suicide (PAS), 2 (5.3%)
claimed they "injected drugs . . . to intentionally end a patient's life"
(euthanasia), and 8 (21.1%) reported doing both. However, the details provided
in the in-depth interviews indicated that in 7 cases (18.4%), the intervention
that was identified by the oncologist as PAS was more accurately characterized
as euthanasia. Misclassified cases usually occurred because oncologists did
not actually inject medications to end the patient's life, but wrote an order
for a nurse to inject intravenous medications to end the patient's life. Therefore,
of the 38 cases, 17 (44.7%) appeared to be euthanasia, 20 (52.6%) were PAS,
and 1 (2.6%) case remained ambiguous.
Many oncologists indicated that they were more comfortable playing a
"passive" rather than "active" role in ending patients' lives, believing that
writing a prescription and letting the patient decide constitutes a passive
role, as indicated in the following responses: "I philosophically find it
difficult to take an active role. I'm willing to take a passive role. I think
injecting drugs is active. Allowing [a patient the] means to end [his or her]
own life is passive. I am comfortable with that." "[The] patient requested
narcotics and asked if she took more than the prescribed amount would she
die. I told her yes . . . I will help control and treat pain, but I'm not
going to actually take any action [to end patients' lives]."
Among the patients who received euthanasia or PAS, 60.5% were women.
The dominant diagnoses were lung cancer (8 [21.1%]), breast cancer (5 [13.2%]),
prostate cancer (4 [10.5%]), leukemia or lymphoma (4 [10.5%]), and human immunodeficiency
virus infection (3 [7.9%]). In all cases, patients were deemed to be terminally
ill, ie, having 6 months or less to live.
In 3 (15%) of the 20 PAS cases, patients explicitly asked for information
about how to commit suicide; usually the patients possessed medications and
asked the physicians about how much to take to end their lives. In 4 (20%)
of the 20 PAS cases, the patients never used the medication for suicide. In
an additional 15% of the PAS cases, the attempted suicide failed. By physicians'
estimates, 50% of patients had their life shortened by 1 month or less.
In about 75% of cases, pain (29), dependency (28), or emotional burden
on the patient's family (28) were reported by oncologists as the dominant
motivating factors. Frequently (in 16 cases [42.1%]), all 3 factors were reported
simultaneously. In 3 cases (7.9%), concerns about financial burdens played
a key role in motivating euthanasia or PAS. In 1 case (2.6%), the family wanted
to "get it over with."
In the vast majority of cases (78.9%), narcotics were used to end the
patients' lives. In 7 cases (18.4%), barbiturates were used; in 2 cases (5.3%),
benzodiazepines were used. Muscle relaxants and potassium chloride were each
used in 1 case (2.6%). In 5 cases (13.2%), multiple medications were used.
Table 2 presents the proportion
of these 38 cases in which the practices were consistent with proposed primary
safeguards. (Since all patients were terminally ill, this safeguard was not
included.) In 30 cases (78.9%), patients initiated the request for euthanasia
or PAS; in 23 cases (60.5%), patients both initiated and repeated their requests.
Thus, in 7 cases, patients did not repeat their requests. In 5 cases (13.2%),
the family and in 1 case (2.6%), the physician initiated the request for euthanasia
or PAS. In 6 cases (15.8%), the patient neither initiated nor discussed the
decision about euthanasia or PAS and in 2 cases (5.3%), the patient was unconscious
at the time of euthanasia. In all but 1 case (97.4%), the patients were experiencing
substantial physical symptoms. Oncologists often stated that pain and poor
quality of life were necessary to justify committing euthanasia or PAS, as
indicated in the following responses: "The pain, the quality of life, the
duration of life are all factors [in the decision]." "The pain lasted hours
In 15 cases (39.5%), the oncologist discussed the request for euthanasia
or PAS with another physician, although the patient was not necessarily examined
by the other physician. In 2 cases (5.3%), the patient received a psychiatric
evaluation. In 2 cases (5.3%), the patients refused oncologists' referrals
for a psychiatric evaluation.
Overall, in 13 cases of euthanasia and PAS (34.2%), practices were consistent
with all the proposed primary safeguards. In 23 cases (60.5%), patients initiated
and repeated their request for euthanasia or PAS and also had severe physical
symptoms. Multivariate logistic analysis revealed that oncologists' actions
were significantly more likely to be consistent with primary safeguards the
longer they had a relationship with the patient (P=.008).
There was a trend that did not reach statistical significance, indicating
that more religious oncologists were more likely to adhere to the primary
Table 3 presents the proportion
of cases in which the practices were consistent with proposed secondary safeguards.
All patients experiencing pain were being treated with opioid analgesia; in
only 3 cases (7.9%) did this adequately control the pain. In addition, 15
patients (39.5%) were receiving hospice care at the time of euthanasia or
PAS. The retrospective nature of the study precluded assessment of the quality
of these palliative care interventions. In over 80% of cases, physicians had
known the patients for whom they provided euthanasia or PAS for more than
6 months. For many physicians, having a long-term relationship with the patient
was critical to their willingness to perform euthanasia or PAS: "There must
be an on-going relationship with the patient and family." "I think you have
to know the patient well." In 28 cases (73.7%), the family initiated the request
or supported the decision for euthanasia or PAS. In 1 case (2.6%), the family
was opposed to the decision; in an additional 10 cases (26.3%), the decision
was not discussed with the family.
A majority of oncologists (54.0%) found comfort in knowing they "helped
a patient end his or her life the way the [patient] wished" (Table 4). A quarter of oncologists (9) regretted performing euthanasia
or PAS. While some of these oncologists (5) also feared prosecution, it is
clear from the interviews that in all cases the regret resulted from concerns
other than prosecution. One oncologist regretted his action because "a daughter
had not said good-bye" to her mother. Another thought "the patient might have
benefited from living to the end." Others expressed worries about "playing
God a little bit too much" and a sense that ending a patient's life made physicians
feel "conflicted, at odds with myself [and my role]." In none of these cases,
did the form of death—euthanasia or PAS—predict the reason for
regret. In none of the cases in which the physicians expressed regret was
the patient unconscious.
A third of oncologists (12) felt that the "emotional burden associated
with [their euthanasia and PAS] decision . . . affected the way they practice
medicine." Importantly, many (5) felt it made them listen to their patients
with more sympathy: "It makes me more open to listen to subsequent patients."
I am "much more aware of the patient's emotional and physical needs apart
from their medical needs." Conversely, the others (6) said the emotional burden
was adverse. For some it made them avoid situations that might create a request
for euthanasia or PAS. One physician felt so "burned out" he moved from the
city in which he was practicing to a small town. Another said, "I have the
luxury of being in academic medicine which has allowed me to be exposed to
these difficult situations relatively infrequently."
Nearly 40% (15) of oncologists who had performed euthanasia or PAS feared
prosecution. There were no significant differences in age, sex, geography,
religion, or level of religious belief, between those oncologists who feared
prosecution and those who did not. A similar proportion of oncologists who
feared prosecution had performed euthanasia (39.1%) as those who did not fear
prosecution. This fear neither prevented the oncologists from performing these
interventions nor from answering questions about their case with an interviewer;
none reported legal proceedings.
This study provides additional empirical data on the actual performance
of euthanasia and PAS by US physicians that challenge the claims advanced
by both proponents and opponents of euthanasia and PAS. Seven implications
First, in as many as a third of responses, physicians may have been
confused or may have misclassified or misrepresented their actions, suggesting
that data on the performance of euthanasia and PAS not collected through in-depth
interviews are unreliable. More than 12 (20%) of 56 oncologists, who in screening
questions reported that they intentionally ended a patient's life, revealed
through the in-depth interviews actions such as withholding life-sustaining
treatments and providing narcotics for pain relief that shortened a patient's
life, which are neither euthanasia nor PAS. Some of the confusion and misclassification
could be a result of poor survey questions. However, our questions were carefully
crafted and extensively pretested. The wording of our questions is similar
to that used in most other careful surveys,13- 18
and are more precise than the questions used in some other surveys.1 More likely, physicians may be uncertain and confused
as to whether increasing narcotics for pain control, withholding blood transfusions,
or giving prescriptions for medications that could be used to overdose constitute
"intentionally ending a patient's life." Regardless, these data suggest that
existing surveys of US physicians and physicians from other countries may
significantly overstate, by more than 20%, the actual practice of euthanasia
Second, in at least 7 cases, physicians identified an action ending
a patient's life as PAS, but in-depth interviews revealed it to be euthanasia.
In many of the cases, a physician wrote an order leaving a hospice or hospital
nurse or even a family member to perform the actual injecting of the life-ending
medication. As survey data and comments during our in-depth interviews indicate,
many more physicians find PAS more acceptable than euthanasia because it seems
to connote a passive rather than an active life-ending role.1,13- 18,26
Thus, identifying their action as PAS rather than as euthanasia diminishes
the importance of the physician's role, thereby decreasing physicians' psychological
burden. Such data suggest existing studies may significantly understate the
proportion of cases that are euthanasia.
While laws permitting PAS but prohibiting euthanasia may have appeal
by providing a barrier to the "slippery slope," there may be serious practical
Despite significant education through public debate, media attention, and
many articles in both medical journals and the lay press, physicians and others
may not accurately distinguish PAS from euthanasia. These data warn that if
PAS is legalized, physicians may unintentionally and unknowingly commit many
cases of euthanasia believing they are performing a legal act of PAS, thus
creating potential enforcement problems. This is just a caution because with
legalization it is conceivable that additional instructional efforts may successfully
educate physicians about the differences between PAS and euthanasia.
A third important implication of these data is the inconsistent adherence
to well-accepted safeguards. Extending the results of Back et al16
and Meier et al,18 we found that being severely
ill—either having pain despite narcotic medications or extremely poor
physical functioning—is nearly an absolute requirement for oncologists
to perform euthanasia or PAS. Conversely, oncologists' practices were not
as consistent with the proposed safeguards ensuring that the requests were
initiated by the patient, voluntary, and well considered. Most worrisome is
that in 15.3% of cases, the patients were not involved in the decision but
families wanted the patients' lives ended. This lack of involvement even occurred
in cases where the patients were conscious and could have participated in
the decision. Meier et al18 also reported that
in some cases family members made the request for euthanasia and that in other
cases patients were confused more than half the time. Therefore, both the
US and Dutch data suggest that despite safeguards, in 15% to 20% of cases,
physicians are willing to provide euthanasia even without patient involvement
in the decision when there are severe physical symptoms.9- 11
The illegal status of euthanasia and PAS may itself prevent adherence to the
primary safeguards and legalization may improve adherence to these safeguards.
In the Netherlands, minimizing legal barriers has increased reporting of euthanasia
cases, although it did not measurably affect euthanasia performed on patients
with compromised mental capacity who could neither contemporaneously request
nor consent to euthanasia.11 Again, these data
warn that safeguards meant to ensure patient autonomy could be violated in
a significant minority of cases making nonvoluntary or involuntary euthanasia
a concomitant of permitting voluntary euthanasia or PAS.27
Like Back et al16 and Meier et al,18 we found a lack of consultation. Because euthanasia
and PAS were illegal when the interviews were conducted, it is understandable
that US physicians may be unwilling to consult a colleague about a request.
Nevertheless, we found that 40% of physicians did discuss their cases with
colleagues. More important, there was very little use of psychiatric evaluations
despite the fact that a physician can refer a patient for psychiatric evaluation
without revealing that a request for euthanasia or PAS prompted the evaluation.
Contrary to available data, physicians may believe that it is "natural" or
"normal" for terminally ill patients to be depressed and not take measures
for evaluation and treatment of depression.28- 30
These data are worrisome because depression is one of the leading predictors
of interest in euthanasia or PAS.16,26,31,32
While we do not know how many of these patients were depressed, in at least
1 case reported here, the physician felt the patient was depressed. The data
suggest that laws like Oregon's, which permit PAS but do not mandate a psychiatric
evaluation, may not lead to adequate detection and care of mental illness
among patients requesting PAS.33 We also found
that in 2 cases, patients refused to receive psychiatric care despite a physician's
recommendation. Laws permitting euthanasia or PAS must consider how to respond
to patient refusal of such evaluations.23- 25
A fourth implication of this study is that, contrary to claims by some
opponents of euthanasia and PAS, use of palliative care is not necessarily
an effective response to patients' request for euthanasia and PAS. Of the
patients who received these interventions, all patients experiencing pain
received opioid analgesia and almost 40% were enrolled in hospice programs.
Because of the retrospective nature of our interviews, we could not evaluate
the quality of the pain care or hospice. Nevertheless, at least use of these
palliative measures did not necessarily obviate desire for euthanasia or PAS.
A fifth implication is that there will be failures of PAS. We found
that in 15% of PAS attempts the patient failed to die. Such failures of PAS
may occur because physicians do not know what medications to prescribe to
end patients' lives17 or because patients do
not take the life-ending medications appropriately. Indeed, one problem may
be the reported use of morphine for PAS, which is reported in the Netherlands
not to be the optimal agent. If PAS is legalized, educational efforts on the
appropriate drugs to use may be necessary. In addition, how to handle these
failed PAS attempts is problematic. In the Netherlands, the ethos is that
physicians should be within close proximity and be willing to perform euthanasia
if the PAS attempt fails.11,20
This approach is unlikely to work in the United States. First, it appears
that if any life-ending intervention will be legalized it will permit PAS
Thus, euthanasia to remedy a failed PAS case is likely to remain illegal.
Further, our data and other surveys suggest that many physicians who are willing
to perform PAS are often unwilling to perform euthanasia.1,13- 18,26
Physicians may find being near and willing to perform euthanasia if the PAS
attempt fails too active. Legalizing PAS but not euthanasia could create serious
difficulties in addressing the failed PAS attempt.
Sixth, like Back et al,16 we found that
some patients did not use a prescription for PAS, suggesting that the prescription
did serve as "psychological insurance"34; having
the control afforded by the prescription without ending one's life was sufficient
for some patients. Our data suggest that this occurs in 20% of PAS cases,
whereas Back et al16 reported 39% of patients
did not use a prescription for PAS. The differences may just be random variation
because of the small numbers of interviews and cases of PAS, or it may be
because of the different survey methods (written vs in-depth interviews) used
and the higher response rates in this study.
Finally, like Meier et al,18 we found
that the majority of oncologists would perform euthanasia and PAS again in
a similar case and received comfort from having helped a patient. Nevertheless,
a significant minority of oncologists experience substantial problems from
their actions. In almost a quarter of cases, physicians regretted performing
euthanasia or PAS after the incident and in almost 1 in 6 cases, physicians
experienced emotional distress. Importantly, distress and regret did not seem
linked with either fear of prosecution or performing euthanasia. Given that
euthanasia and PAS are irreversible acts, such a high frequency of regret
should be a cause of concern. In many cases, physicians who regretted the
decision consulted colleagues, and in other cases the regret resulted from
effects on the family that might not have been anticipated. In at least a
few cases, the emotional distress seemed significant. One oncologist went
so far as to move to another city and others changed their practices to avoid
caring for patients who might request euthanasia or PAS.
This study has several limitations. The number of physicians interviewed
who performed euthanasia or PAS is small, meaning that proportions of responses
have wide confidence intervals, the conclusions must be provisional and tentative,
and it is difficult to identify predictors of actions. However, because of
the low rate at which physicians perform euthanasia and PAS and the costs
of conducting in-depth interviews, studies on these practices will inherently
involve relatively small numbers of cases. Indeed, the other 2 studies of
these practices in the United States reported data from written responses
of 52 and 81 physicians without follow-up in-depth interviews16,18
and the well-regarded Dutch studies report interviews of 215 physicians who
actually performed euthanasia or PAS.9,11
A second limitation is that these data may not generalize to nononcologists.
Some physicians treating patients with the acquired immunodeficiency syndrome
(AIDS) report performing euthanasia or PAS at higher rates.19
And many of the patients who have been assisted by Dr Jack Kevorkian have
had neurological diseases, such as amyotrophic lateral sclerosis. However,
cancer causes more than 10 times as many deaths in the United States as AIDS
and more than 20 times as many deaths as neurological diseases. More important,
the Dutch data suggest that 80% of euthanasia or PAS patients will have cancer,
while less than 5% will be patients with neurological diseases. Consistent
with this, nononcology specialists report performing euthanasia and PAS much
less frequently than oncologists.16,18
A third limitation is that despite reassurances of confidentiality,
physicians might be inhibited from discussing these illegal actions. The high
response rates in the initial interviews (72.6%) and follow-up interviews
(94.6%) make this seem unlikely. Finally, while the safeguards we identified
are accepted by ethicists and those actively engaged in the debate about euthanasia
and PAS,1,23- 25
we are applying the standards after the fact. These safeguards are not legally
mandated and what precisely is required may be unclear to practicing physicians.
If euthanasia and/or PAS were legalized, the practice environment might change
and physicians' awareness of and adherence to safeguards could be substantially
different. Thus, these data can only warn about areas that might be problematic
if interventions are legalized.
This study provides additional data on the practice of euthanasia and
PAS in the United States. It suggests that (1) even with well-crafted questions,
existing data may overstate the practices of euthanasia and PAS; (2) physicians
frequently confuse euthanasia with PAS; (3) practices are frequently inconsistent
with proposed safeguards, although having severe physical symptoms seems a
strong requirement for physicians to perform euthanasia or PAS; (4) for some
patients, receiving opioid analgesia and/or hospice care does not obviate
the desire for euthanasia or PAS; (5) there are some unsuccessful attempts
at PAS; and (6) a significant minority of physicians experience regret and
emotional distress at having performed euthanasia or PAS.
Emanuel EJ, Daniels ER, Fairclough DL, Clarridge BR. The Practice of Euthanasia and Physician-Assisted Suicide in the United StatesAdherence to Proposed Safeguards and Effects on Physicians. JAMA. 1998;280(6):507-513. doi:10.1001/jama.280.6.507