New York Times News Service
c. 1998 New York Times Company
Thursday, April 23, 1998
In Survey, Few Doctors Admit To Helping Terminal Patients Die
By SHERYL GAY STOLBERG
WASHINGTON - In the intense debate over physician-assisted suicide, one
question has always gone unanswered: How often does it occur? Now, the first
national survey to examine how frequently doctors help people kill themselves
finds that while patients often ask for help, they rarely get it.
Nearly one in five doctors who care for seriously ill and dying people
reported that they had been asked, on one or more occasions, for assistance in
speeding a patient's death, either by writing prescriptions for lethal drugs or
delivering a lethal injection.
But a little more than 3 percent said they had ever written the
prescriptions, mostly to patients who had less than six months to live. And
just under 5 percent said they had administered lethal injections to patients
on their deathbeds - a figure that the study's authors said reflected "the
double effect," in which pain-killers, given to relieve suffering at the end of
life, also hasten the patient's death. The margin of sampling error was plus or
minus one percentage point, but varied for other questions.
"It is odd that there is such strong public support for legalization of
assisted suicide, and we find there is so little of this actually occurring,"
said Dr. Diane E. Meier, an associate professor of geriatrics at the Mount
Sinai School of Medicine in New York, who is the study's lead author.
The majority of doctors who granted the requests to hasten death said they
had done so only once or twice in their careers. That translates into a very
small number of patients affected, said Dr. Kathleen M. Foley, director of the
Project on Death In America, a foundation in Manhattan that sponsors research
on the end of life. She could not provide a precise figure but estimated that
only a fraction of 1 percent of the 2.4 million Americans who die each year do
so with help from their doctors. "However you do the numbers," she said, "it's
One reason it is so rare is that it is illegal. When the doctors were asked
if they would write lethal prescriptions, defined as assisted suicide, if it
were legal, 36 percent said they would. And 24 percent said they would
administer lethal injections, defined as euthanasia, if the law permitted it.
The study, which appears Thursday in The New England Journal of Medicine, is
renewing the divisive debate over legalization. Proponents and opponents (Dr.
Meier, an early proponent, has since changed her mind) interpret its findings
in different ways, with advocates for legalization saying the study confirms
that the practice exists underground and should be brought out in the open.
"This might be acceptable from a physician's perspective, but from a
patient's perspective it is absolutely unacceptable," said Barbara Coombs Lee,
executive director of Compassion in Dying, a group based in Portland, Ore.,
that sought unsuccessfully to have the Supreme Court declare a constitutional
right to die. "There is no way to assure that patients who are truly desperate
are getting to the physicians who are willing to break the law."
Polls have consistently shown that a majority of Americans, from 60 percent
to 70 percent, support making assisted suicide legal for patients who are
mentally competent and have less than six months to live. So far, only one
state, Oregon, has done so, in an experiment that is being watched closely
around the nation.
Although other surveys have tried to assess the prevalence of physician-
assisted suicide, they have been limited to doctors who treat cancer and AIDS
patients, or those in states where the issue was in the forefront. A 1995
survey in Oregon found that seven percent of doctors had written lethal
prescriptions, while a 1994 survey of New England cancer specialists found that
13.5 percent had.
None of those studies was as carefully conducted or statistically sound as
Dr. Meier's research, said Dr. Joann Lynn, who directs the Center for Care of
the Dying at George Washington University. "For the first time, we have a
survey you can rely on," she said. "The ones done before have used really
indefensible questions and sampling techniques."
Dr. Meier and her colleagues - among them Dr. Timothy Quill, the Rochester,
N.Y., doctor whose personal account of helping a patient die became the subject
of public debate - surveyed doctors in 10 specialties. All had experience in
caring for patients at the end of life. Of the 3,102 doctors who were mailed
surveys, 1,902 responded,
and their answers were anonymous.
Though Dr. Meier said the survey, conducted in 1996, proved assisted suicide
was so rare that public policy changes - either legalization or the drafting of
medical guidelines for the practice of assisted suicide - were not necessary,
Quill took the opposite view.
"Patients are wanting to talk to the doctor about this," he said. "We are in
these conversations on a regular basis and in the current environment, all are
occurring in secret."
The study identified a variety of reasons why doctors help their patients
die. Severe discomfort, other than pain, was the most common reason, followed
by loss of dignity, fear of uncontrollable symptoms, actual pain, loss of
meaning in life, being a burden to one's family and dependency on others.
Doctors in the West were significantly more likely than those in other parts
of the country to receive requests for lethal prescriptions, and doctors older
than 45 were significantly more willing to give lethal injections, and were
more likely to have received requests to do so than younger doctors.
In comparing patients who had received prescriptions for lethal drugs to
those who had received lethal injections, the study found dramatic differences.
Most who received drugs met the standards set by the Oregon law; they were
mentally competent and 98 percent were estimated to have less than six months
Nearly all, 95 percent, asked for the medication themselves. And nearly all,
97 percent, were men - a finding Dr. Meier could not explain. "It's either that
women aren't asking or that doctors don't think their requests are serious or
worth responding to."
The patients who had received lethal injections, on the other hand, were much
closer to death. Virtually all of them died in the hospital; 96 percent were
estimated to have less than a week to live, and 59 percent were estimated to
have less than a day. The majority were unable to speak for themselves; more
than half the requests were made by their family members.
While the researchers asked doctors specifically if they gave the injections
"with the primary intention of ending the patient's life," both the authors and
outside experts said that many of the doctors who acknowledged doing so were
probably confused about whether the injections had caused death.
In 17 percent of the cases involving lethal injection, the medication used
was potassium chloride, whose only purpose is to stop the heart from beating.
The remaining 83 percent of the patients received opioids, which are used to
relieve pain but may also speed the dying process.
"You have this vision of the executioner with his hood, but is not anything
like that," said Dr. Lynn. "This is a very murky, blurry situation when the
family says to the doctor, 'Isn't there something you can do?' "
That murkiness was reflected in the written comments of the doctors, who were
given a blank page at the end of the survey to record their thoughts. "I would
not give a patient a lethal injection or prescription," one wrote. "I have,
however, hastened a person's death while trying to relieve suffering at the end