A qualitative study in this week’s issue of THE LANCET provides a new insight into why patients request euthanasia or physician-assisted suicide. Results of the study have implications for both clinicians and policymakers in the controversial issue of end-of-life care.
The question of why people desire euthanasia or assisted suicide has not been coherently answered by previous research. James Lavery and colleagues from the National Institutes of Health, Bethesda, USA, did a qualitative study of 32 people with HIV-1 or AIDS, who were enrolled in the HIV-1 Ontario Observational Database at Sunnybrook and Women’s College Health Sciences Centre, Toronto, Ontario, Canada. The investigators elicited participants’ experiences of deliberation about euthanasia or assisted suicide, and the meaning of these experiences with in-depth, face-to-face interviews.
Two main factors affected participants’ desire for euthanasia and assisted suicide: disintegration, a physical dimension arising from the deterioration in patients’ physical health and body functions; and loss of community, a social dimension which was defined as progressive diminishment of opportunities to initiate and maintain close personal relationships. Combination of these fundamental factors resulted in patients’ perceived loss of self; euthanasia and assisted suicide were seen by participants as means of limiting loss of self.
In an accompanying Commentary (p 344), Anthony Back and Robert Pearlman from the University of Washington, Seattle, USA, point out that these findings have important implications for both clinicians and policymakers. Anthony Back comments: “For clinicians, this work is a kind of road map into the world of a person with a life-threatening illness who is considering physician-assisted suicide. The complexity of loss of self suggests why simpler explanations, such as pain, depression, or high-control personality, each fail as individual explanations for the desire for assisted suicide. This complexity underscores the need for clinicians to consider the evaluation of a request for physician-assisted suicide as an important clinical skill. For policymakers, Lavery and colleagues point out that policies asking clinicians to make judgments about whether a patient has “intolerable suffering” do not address the loss of community described in this study. What they do not point out is that policies requiring clinicians to decide whether a patient has suffered enough, or has lost enough, or is isolated enough, are judgments that cannot be captured neatly in policy guidelines. What policymakers could do in responding to physician-assisted suicide would be to require that availability of reasonable palliative care be taken into account in any patient’s decision-making process about assisted suicide. Such a requirement could set a benchmark standard for palliative care that would be useful in the USA, where expert palliative care is not reliably available. However, even discussing policies that presume that physician-assisted suicide is allowable in some circumstances is enough to push more than a few hot buttons.”
Contact: Dr James V Lavery ,Division of Advanced Studies and Policy Analysis,Fogarty International Center,National Institutes of Health,Building 16 Room 211,16 Center Drive MSC 6705,Bethesda Maryland 20892-6705,USA;T) 1-301-496-1739;F)1-301-496-8496;E) lavery@mail.nih.gov
Dr Anthony Back, Vaterans Affairs Puget Sound Health Care System, University of Washington, Seattle WA 98108, USA; T) 1-206-277-1044; F)1-206-277-2689; E) tonyback@u.washington.edu
Journal
The Lancet