Psychosomatics 39:18-23, February 1998
© 1998 The Academy of Psychosomatic Medine
Assisted Suicide and AIDS Patients
A Survey of Physicians' Attitudes
Zhila Haghbin, M.D.,
Jon Streltzer, M.D., and
George P. Danko, Ph.D.
Received October 4, 1996; revised January 29, 1997; accepted March 18, 1997. From the Department of Psychiatry, John A. Burns School of Medicine, University of Hawaii, Honolulu. Address reprint requests to Dr. Streltzer, 1356 Lusitana Street, Fourth Floor, Honolulu, HI 96813.
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ABSTRACT
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Physicians' attitudes about assisted suicide were assessed by using a vignette of an acquired immune deficiency syndrome (AIDS) patient who requests a lethal injection. Of the 389 respondents, 34% received at least 1 request for assisted suicide; 9% had requests from an AIDS patient; and 41% had at least indirectly assisted a terminal patient to die in actual practice. Thirty-three percent of the respondents agreed to the authors' hypothetical patient's request for a lethal injection. Medical and personal experiences did not determine attitudes that were somewhat influenced by ethical beliefs and religious commitment. The study confirms previous findings that many physicians underestimate the effect of depressive illness on rational decision making concerning assisted suicide requests.
Key Words: Assisted Suicide • Physician-Assisted Death • AIDS • HIV • Euthanasia • Right to Die
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INTRODUCTION
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The acquired immune deficiency syndrome (AIDS) epidemic has caused about 300,000 deaths in the United States,1 and it has been accompanied by profound medical and social ramifications. AIDS has been cited as the disease most likely to make the case for euthanasia.2 An Australian survey of AIDS patients indicated 90% would like to have the option of euthanasia available,3 and in a recent study of 378 ambulatory human immunodeficiency virus (HIV)-infected patients in New York, 55% acknowledged considering physician-assisted suicide as an option.4 In Amsterdam, the incidence of assisted suicide is 3% in the general population, but as high as 35% in AIDS patients.5
Assisted suicide differs from euthanasia in the degree to which physicians participate in the process, although there is no clear consensus in defining these terms. In the United States, the majority of states have criminalized assisted suicide, most by specific legislation. A physician is prohibited from intentionally causing death regardless of a patient's wishes, quality of life, severity of pain, or prognosis, yet no physician has been convicted of a crime in relation to helping a suffering patient die. In fact, several public polls and surveys of physicians and HIV- infected patients5–9 indicate that the majority believe that assisted suicide should be legalized, at least in some circumstances.
While anecdotal accounts of physician-assisted suicide of AIDS patients are common in the United States,10, 11 limited empirical data on such incidents in the context of AIDS exists. The only two studies11, 12 to directly examine physicians' attitudes found from 10.7% to 27.7% of the physicians we surveyed would agree to assist the death of a hypothetical AIDS patient.
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ROLE OF PSYCHIATRY
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Although psychiatrists are frequently involved in the management of AIDS patients, few empirical studies examine the role of psychiatric consultation in the management of assisted-suicide requests of such patients. The psychiatric literature has primarily focused on the influence of reversible psychological conditions and the effect of psychiatric illness on rational decision making of those patients who request assistance in dying.5, 13, 14 Surveys of physicians' attitudes toward euthanasia and assisted suicide have mainly focused on legal issues,7–9 and only a few have included psychiatrists in their sample, or have examined the role of mental illness in the management of requests of assisted suicide.9
The purpose of this study, conducted in 1995, was twofold: 1) to determine the frequency of requests for assistance in dying from AIDS patients and 2) to determine the participation by physicians in such practices. In addition, the study sought to examine the attitudes of physicians toward assisted suicide of AIDS patients and how such attitudes are influenced by professional and personal characteristics. Also, the study sought to explore the use of psychiatric consultation in a hypothetical setting of a request for assisted suicide from an AIDS patient.
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METHODS
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Sample
A list of all licensed physicians in the state of Hawaii was obtained from the Hawaii Medical Association; not selected were radiologists, pediatricians, and those not practicing clinical medicine. The first 1,000 physicians listed alphabetically in the association's directory (reaching the middle of the letter "M") and all 176 residents in training from the selected specialties were included. Questionnaires were mailed to these 1,176 physicians, followed by a reminder letter 1 week later. A coding system ensured anonymity. Thirty-three percent (389) of the questionnaires were returned completed.
Measures
A 4-page questionnaire was developed containing a case vignette that describes a dying AIDS patient who asks his physician for a lethal injection (see Appendix 1 for case of "Mr. A."). The questions measured the likelihood of agreement to assist in death, to relieve pain to the point of high death risk, and to obtain consultations, including psychiatric evaluation. Demographics and practice-related data were also collected. Three Likert-type scales were used to measure life satisfaction, religious commitment, and death anxiety (a new "Death Anxiety Scale" was developed specific to a physician population).
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RESULTS
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Characteristics of the Respondents
The respondents were 81.1% male and 18.9% female, with a mean age of 45.9 (standard deviation=[SD] 11.8); 75.6% were married, 13.8% single, and 10.7% were divorced/separated/widowed; and 4.2% acknowledged being homo- or bisexual. Ethnicity distribution was 52.9% Caucasian, 15.6% Chinese, 13.3% Japanese, and 15.1% other/mixed. Designated religions included 30.6% Protestant, 19.2% Catholic, 7.3% Buddhist, 4.4% Jewish, 15.0% other, and 23.3% none. Major specialty groups included primary care 29.8%, medical subspecialty 17.5%, surgery 15.9%, psychiatry 15.1%, and obstetrics-gynecology 9.9%. The response rate of all specialty groups was similar, except surgery, which had a low response of 16%. Of the subjects polled, 7.6% reported treating greater than 50 terminally ill cases per year, 23.0% reported 11–50 cases, 54.8% 1–10 cases, and 14.6% had seen no terminally ill cases.
Frequencies of Diagnosis: The Case of Mr. A.
No psychiatric illness was endorsed by 72.2%, 24.9% stated "Mr. A." has a depressive illness, and 2.9% selected another diagnosis.
Frequencies of Utilization of Consultation
One or more consultations would be obtained by 61.4% of the respondents. Fifty percent would consult a psychiatrist, 43.9% a colleague, 20.7% a religious figure, 12.6% the Hemlock Society, and 10.6% the hospital ethics committee. Of the nonpsychiatrists who diagnosed depression, one-third would not consult a psychiatrist.
Frequencies of Requests for Assisted Suicide
Thirty-four percent of the physicians reported encountering a patient request for assistance in dying; 9% of these requests were from AIDS patients. There was a significant difference in frequency by specialty ( 2=26.34, df=7, P<0.001), with primary care and medical subspecialty physicians reporting more such requests.
Frequencies of Taking a Direct orIndirect Role That Resultedin a Suffering Patient's Death
Forty-one percent of the physicians reported the experience of at least taking an indirect role in ending a suffering patient's life. Again, the results varied by specialty (2=35.37, df=7, P<0.001), with primary care and medical subspecialties reporting the most likelihood (54%–57%). Methods described by physicians that resulted in ending a patient's life included increasing the dose of pain medication (30%), disconnecting the respirator (24%), stopping other means of life support (27%), and other (8%).
Thirty-three percent of the physicians were likely to agree to the hypothetical patient's request for a lethal injection, 56% disagreed, and 11.1% were unsure.
A multiple regression analysis using "intention to assist suicide" as the dependent variable and several predictor variables were entered into the equation in stepwise fashion. The "best model" accounted for about 42% of the variance. Ethical beliefs had the greatest relative influence, followed by age, a history of assisting a patient to die, and religious commitment, which were weaker predictors. The squared multiple correlations (R) and standardized beta weights (B) of all variables retained in the model are shown in Table 1.
The majority of the respondents (58.3%) believed that assisted suicide is ethical, while 12.5% were unsure. Of those (29.1%) who responded "no" to the question "do you believe that assisted suicide is ethical," only 2% agreed to assist the hypothetical AIDS patient, whereas 53.5% of those who responded "yes" agreed to assist in Mr. A.'s suicide. Thus, the belief that assisted suicide is ethical was necessary, but not sufficient, for agreement to assist suicide. Because ethical beliefs and agreement to assist suicide were highly correlated, a second stepwise multiple regression was performed omitting ethical beliefs as a predictor variable. The "best model" now accounted for about 15% of the variance. The squared multiple correlations (R) and standardized beta weights (B) are shown in Table 2.
For those subjects who did not agree to give a lethal injection to "Mr. A.," the frequencies of responses to the question, "How much risk would you take to increase the narcotic dose, to relieve pain, knowing that it might result in death," revealed that 36.4% would take a none-to-minimal risk, 24.9% would take moderate risk, and 38.7% would take high risk.
A multiple regression analysis was conducted using several independent variables thought to be influential predictors of responses to the dependent variable "risk of death." This stepwise solution retained 5 variables, which explained about 23% of the variance. The most influential predictor was the experience of having taken a direct or indirect role in ending a suffering patient's life. The squared multiple correlations (R) and standardized beta weights (B) of all variables in the equation are shown in Table 3.
Reasons given for the decisions about assisting suicide and for increasing the dose of narcotics in the case of Mr. A. are shown in Table 4.
Other Measures
Religious commitment, satisfaction with life, and death anxiety were only weakly associated with "intention to assist" and "risk of death." The religious commitment scale had a significant negative correlation (r=-0.27, P<0.001) with "intention to assist."
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DISCUSSION
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A major finding of the study is that a significant proportion of physicians encountered requests for assistance in dying both from AIDS patients and other dying patients. Furthermore, assisting (at least indirectly) a suffering patient to end his/her life is a common clinical experience, particularly among the primary care and medical subspecialties. While 58% of those surveyed believe it is ethical to assist in dying, only 33% of them agreed to give a lethal injection to the hypothetical AIDS patient. This finding suggests that physicians evaluate each case independently; another possible explanation is that even though they believe that assistance with suicide is ethical, some would not do it themselves. Of those physicians who would not assist suicide, approximately two-thirds indicated that they would raise the dose of narcotics for pain, even if it carried a moderate-to-high risk of death.
Increasing the dose of pain medication was the most common method reported by 41% of those who acknowledged at least indirectly assisting death. "Professional values that emphasize relief of pain and suffering" was the most frequent reason (80%) given by the respondents for justification of their actions in assisting suicide and for increasing the dose of narcotics of Mr. A. in the case vignette. These findings indicate that these physicians are committed to relieving pain, even in situations that involve the risk of their patient dying.
It is noteworthy that professional experience with dying patients had little relationship to the physicians' opinions on management of requests for assisted death and that personal experience with death of family members or friends from either terminal illness or AIDS also did not affect their decisions. Similarly, personal traits, including "life satisfaction" and "death anxiety," showed no relation to physicians' decisions about assisting suicide or increasing the dose of narcotics.
As a group, physicians have a low degree of religious commitment. One might expect that religion would have a powerful effect on attitudes of physicians who have strong religious commitment; however, our data indicates that religious affiliation and religious commitment were only weakly associated. Catholics and the subjects with higher degrees of religious commitment were less willing to assist in suicide, but this factor explained only a small amount of variance.
The case of Mr. A. was designed to depict a clinical presentation of a dying AIDS patient; although his symptoms could be explained by his medical condition alone, they show significant overlap with those of a depressive illness, including weight loss, anhedonia, decreased activity, depressive thoughts, loss of hope, and suicidal thoughts. Given this substantial overlap of depressive symptoms and end-stage wasting syndrome associated with AIDS, it is alarming how little emphasis our respondents placed on ruling out a depressive illness in Mr. A.; nevertheless, this finding is consistent with previous research demonstrating that major depressive illness is underdiagnosed in patients who request assistance in dying14 and that a substantial minority of physicians have been reported to lack confidence in diagnosing depression.8 Fortunately, the importance of considering depressive illness has been acknowledged and has been consistently incorporated into current laws designed to sanction assisted suicide (e.g., Oregon, the Northern Territories of Australia, and The Netherlands). The lack of recognition of depressive illness does not entirely account for failure to obtain psychiatric consultation. Other possibilities would include a belief that depression in this case is "natural" and understandable, discomfort when making a psychiatric referral, bias against psychiatric intervention, and barriers associated with managed care.
A significant limitation of this study is the response rate of 33%, which makes possible that our sample might not be representative of physicians overall and limits the generalizibility of our findings. However, comparison with similar surveys is somewhat reassuring. Physicians' surveys with response rates of 57%–74%.7–9, 15 all reproduced almost identical mean age and gender ratio characteristics. Furthermore, similar results have been reported with regard to belief that assisted suicide is ethical8, 9 and highlights the frequency of physicians' indirect involvement in ending a patient's life.7, 9, 15 The study was also limited by its scope. We did not factor in the physicians' expertise in pain management or potential negative attitudes toward homosexuality and AIDS. Our vignette did not allow a comparison of attitudes if the patient had been female, an ethnic minority, or elderly.
The AIDS epidemic is confronting medical professionals with perplexing ethical, legal, and clinical challenges in relation to euthanasia. Our study reveals that requests for assisted suicide are common, and often come from AIDS patients. Even though physicians not infrequently participate in assisting a suffering patient to end his/her life, there seems to be no consistent approach toward resolving a patient request for assistance in dying. Attitudes toward assisted suicide appear to be influenced to some extent by religious and ethical beliefs, but only minimally by personal and professional experiences. Based on the findings from physicians' responses to a hypothetical case of a request for assisted suicide in our study, it appears that psychiatry, particularly consultation-liaison psychiatry, is an underused specialty in the management of such patients.
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ACKNOWLEDGMENTS
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This paper was presented at the 149th Annual Meeting of the American Psychiatric Association, New York, May 4–9, 1996.
The authors thank Dr. George Burnell for valuable consultation; Dr. Naleen Andrade, Dr. Jane Waldron, and Dr. Anita Gerhard for their scholarly advice and guidance; Carol Nordquist for contribution to statistical analysis; and the Barbee Foundation for generous support of this study.
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REFERENCES
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F. Mortier, J. Bilsen, R. H. Vander Stichele, J. Bernheim, and L. Deliens
Attitudes, Sociodemographic Characteristics, and Actual End-of-Life Decisions of Physicians in Flanders, Belgium
Med Decis Making,
November 1, 2003;
23(6):
502 - 510.
[Abstract]
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ABSTRACT
INTRODUCTION
