I appreciate the opportunity to discuss with the committee our laws and practices of physician-assisted suicide in the United States. I am a practising psychiatrist and medical ethicist. In my entire career, there has really been no issue that has been so singularly important to me as this. As such, I have been expressing my professional concerns worldwide that assisted suicide is neither good medical ethics nor good public policy. In fact, I might be the only one on this invited panel who will be expressing grave concerns about these practices in the US. The committee members might therefore see my hand being raised often today.
There are only 11 jurisdictions where assisted suicide is permitted in the US. Therefore, this is not widespread. The fact is that as of the last count, there have been 270 failed attempts to introduce legislation in many states, and some have failed up to 12 times in a single state. Nine states have actually passed laws inoculating themselves against such legislation ever being introduced there in the future.
Besides the ethical and public policy controversies, these practices can go terribly wrong, legal guardrails notwithstanding. For example, in Colorado last year, three patients with anorexia were prescribed lethal medications for suicide, despite the law there limiting eligibility to terminal illnesses only. This has emboldened some Colorado attorneys who represent anorexic clients in involuntary commitment hearings to argue that assisted suicide may actually be preferable as an alternative to involuntary hospitalisation. Hearing this, some of my own psychiatric patients are now eager to expand legal eligibility to include them, which they say is only fair and in the interest of mental health parity.
In Maryland, where assisted suicide is illegal, a physician helped six non-terminally ill people to commit suicide and several were mentally ill. He has never been prosecuted. Since lethal medications are not tracked once they are dispensed, they may sit around openly in people’s homes being unused for years, without safeguards. In fact, in Colorado recently, a man whose brother was prescribed lethal medications for assisted suicide tried to sample them. He was rushed to a hospital in a coma, and needed life support.
Physician-assisted suicide in the US is anathema to most physicians. In fact, even among those doctors who endorse these procedures, very few are actually willing to provide them. As the saying goes, people want the hamburger but nobody is willing to kill the cow. In fact, lethal prescribing tends to be done mostly by a very few extremely zealous physicians who write scores of lethal scripts for patients with whom they have had a relationship for as little as a few hours after a single consultation. Last year, one doctor in Oregon wrote 51 scripts.
Several leading medical organisations concluded, and continue to conclude, that these are not ethical practices of medicine. As the members of the committee have heard, these organisations include the AMA; the American College of Physicians, ACP; the American Psychiatric Association, APA; and the American Association of Hospice and Palliative Care, AAHP. In fact, after three detailed reviews, the AMA has recommended that the term “physician-assisted suicide” continue to be used in lieu of other euphemisms like “assisted dying”. That is why I continue to use the term today.
Over time, laws have mutated, sometimes dramatically. Initial guardrails have become moving goalposts with the passing years. For example, there are shortened waiting periods between evaluation and lethal prescribing. In Oregon, medications can now be prescribed on the same day as meeting and evaluating some patients. State residency requirements are being removed so that now anyone in the US can potentially get physician-assisted suicide by travelling to Vermont or Oregon. Despite initially forbidding euthanasia, there are now several strong efforts in some states to legalise it.
There are critical missing safeguards in our various laws. For example, there are no requirements to consult a psychiatrist prior to lethal prescribing in order to rule out treatable mental disorders. In the early years in Oregon and Washington, one in three cases was optionally referred for psychiatric evaluation before prescribing. In recent years, fewer than 1% have been referred. There are no requirements anywhere that palliative care alternatives be tried or discussed. Besides, there are too few adequately trained palliative care specialists in the US. Doctor shopping is allowed; second opinions can be received from a colleague in the same practice.
In short, the experience with assisted suicide in the US has demonstrated inadequate and mutating guidelines that eventually push beyond the limited scope of the original laws; flimsy safeguards; zealous physicians who do not follow the law; and the false assumption that we can distinguish those for whom suicide should be provided from those for whom it should be prevented. Leading medical organisations have declared this bad medical ethics, and the majority of American legislators have concluded that it is poor public policy. I hope Ireland can learn from our bad example.
