Background Although there have been many studies of physician-assistedsuicide and euthanasia in the United States, national data arelacking.
Methods In 1996, we mailed questionnaires to a stratified probabilitysample of 3102 physicians in the 10 specialties in which doctorsare most likely to receive requests from patients for assistancewith suicide or euthanasia. We weighted the results to obtainnationally representative data.
Results We received 1902 completed questionnaires (responserate, 61 percent). Eleven percent of the physicians said thatunder current legal constraints, there were circumstances inwhich they would be willing to hasten a patient's death by prescribingmedication, and 7 percent said that they would provide a lethalinjection; 36 percent and 24 percent, respectively, said thatthey would do so if it were legal. Since entering practice,18.3 percent of the physicians (unweighted number, 320) reportedhaving received a request from a patient for assistance withsuicide and 11.1 percent (unweighted number, 196) had receiveda request for a lethal injection. Sixteen percent of the physiciansreceiving such requests (unweighted number, 42), or 3.3 percentof the entire sample, reported that they had written at leastone prescription to be used to hasten death, and 4.7 percent(unweighted number, 59), said that they had administered atleast one lethal injection.
Conclusions A substantial proportion of physicians in the UnitedStates in the specialties surveyed report that they receiverequests for physician-assisted suicide and euthanasia, andabout 6 percent have complied with such requests at least once.
There are strong arguments for and against easing the legalconstraints on physician-assisted suicide and euthanasia inthe United States. Public-opinion polls suggest that a majorityof people favor legalization.1 Currently proposed regulatoryguidelines2,3,4,5 may bear little relation to the range of clinicalcircumstances in which physicians care for patients who arenear the end of life. Decisions about legislation and proposedsafeguards should be responsive to the experiences of patientsand doctors. We surveyed a representative sample of U.S. physicianswith a high likelihood of caring for dying patients, in orderto assess the prevalence of requests for assistance with suicideor euthanasia and of compliance with such requests.
Methods
The survey was self-administered, anonymous, and conducted bymail. We drew a stratified probability sample of physiciansfrom the American Medical Association's June 1996 master fileof all physicians practicing in the United States. The sampleincluded only doctors of medicine who were less than 65 yearsold or had graduated from medical school after 1960, if agewas unknown. Physicians with office and hospital practices andthose in the public and private sectors were included. The groupof physicians from whom the sample was drawn represents approximately40 percent of all practicing U.S. physicians under the age of65 years. The sample was drawn from 10 specialties, selectedon the basis of previous surveys6,7 as those in which physiciansare likely to receive requests from patients for assistancein hastening death. Physicians were eligible if they had atleast one of the specialty codes as their primary, secondary,or tertiary specialty. A sample of 3102 physicians was selected.Specialists thought to be most likely to receive requests wereoversampled.
For each specialty, the initial sample size, population size,sampling rate, and number of respondents are shown in Table 1.The numbers of respondents are based on the specialties reportedon the completed questionnaires. Since the questionnaires wereanonymous, there was no way to link this information to theoriginal sample and the specialty codes from the master file.The number of respondents reporting family or general practiceor other as their primary specialty was larger than the numberinitially selected in these specialties. The sample of respondentswas weighted to account for these differences.
Table 1. Sample Size, Sampling Rate, and Response Rate According to Specialty.
Questionnaire
The closed-ended questionnaire (available from the authors onrequest) was developed with the use of focus groups and cognitiveinterviewing 8 of physicians, some of whom had identified themselvesas having received requests from patients for assistance inhastening death. The questionnaire was subsequently validatedwith the use of a "seeded sample" design in which physiciansknown or thought to have engaged in physician-assisted suicideor euthanasia through their communication with one of the investigatorswere anonymously included. Two controls for each of these physicianswere identified from the American Medical Association's masterfile on the basis of age, region of the country, city size,and specialty. The validation procedure showed that 20 of the24 case physicians reported having engaged in either physician-assistedsuicide or active euthanasia, as compared with 2 of 30 controlphysicians.
Assisted suicide was defined as "the practice of providing acompetent patient with a prescription for medication for thepatient to use with the primary intention of ending his or herown life." Active euthanasia was defined as "the practice ofinjecting a patient with a lethal dose of medication with theprimary intention of ending the patient's life." Respondentswere asked, "Was there an explicit request for assistance indying, or was the request somewhat indirect?" "Explicit" and"indirect" were not further defined.
We mailed the questionnaire in August 1996. The cover letterexplained that there were no codes that could be used to linka completed questionnaire to a particular respondent. This statementwas reinforced by a detailed pledge of anonymity from the investigators,printed on the cover of the questionnaire. We instructed therecipients to return the enclosed reply postcard, which containedthe respondent's identification number, separately from thecompleted questionnaire, in order to prevent telephone callsreminding the respondent to return the questionnaire. A $2 billwas enclosed as an incentive. Four weeks after the initial mailing,a second questionnaire, including a sharpened pencil, was mailedto physicians who had not returned the reply postcard. Fourweeks after the second mailing, physicians who had not returneda postcard were telephoned to remind them to do so. Two weekslater, a second call was made, if necessary.
We received 1627 completed questionnaires (response rate, 52percent). A third questionnaire was then sent to the 761 physicianswho had not returned a postcard. This mailing included a $50check made payable to the physician and a letter of endorsementfrom the American College of Physicians. There were 275 completedresponses to the third mailing.
The study was reviewed and approved by the institutional reviewboard of the Mount Sinai School of Medicine.
Sample Weights
The data from the completed questionnaires were weighted toaccount for the differences in selection probabilities amongstrata. The final weights reflected adjustments for differencesbetween self-reported specialty and selected specialty, nonresponses,and differences in age and sex between physicians who completedthe questionnaire and the overall population of licensed U.S.physicians. Unless otherwise stated, all results reported areweighted data.
Statistical Analysis
Multiple logistic-regression analysis9 was performed to determinethe relation between the characteristics of the physicians andtheir views and actions with respect to assistance in hasteningdeath. First, we performed a single-variable analysis in whichthe specialty was compared with each predictor variable. Allpredictor variables for which P values were 0.15 or less inthe single-variable analysis were examined jointly in the nextstep of model building. Variables that were no longer of evenborderline significance (P>0.10) when the other variableswere entered were eliminated from the model. Religious affiliationand specialty were forced into all models — religion inorder to control for the effect of religious affiliation onfrequency of prayer, and specialty because it was the stratificationvariable.
Results
Characteristics of the Physicians
Of the 3102 physicians originally mailed a questionnaire, 81were ineligible: 75 were not actively practicing medicine, and6 were older than 65 years. We received 1951 questionnairesfrom eligible respondents, including some that were blank. Therewere 1902 completed questionnaires (response rate, 61 percent).The respondents to the third mailing, which included a financialincentive, did not differ significantly from the respondentsto the initial mailings, in terms of demographic characteristicsor responses to questions about participation in assisted suicideor lethal injection. Respondents and nonrespondents were similarwith respect to age, sex, and region of the country, althoughthere were some differences in the distribution of specialties(P = 0.001 by the chi-square test), with a larger proportionof respondents who were infectious-disease specialists (16 percent,vs. 10 percent of the nonrespondents) and a smaller proportionwho were general internists (9 percent vs. 15 percent). Table 2shows the demographic and professional characteristics ofthe respondents.
Table 2. Characteristics of the 1902 U.S. Physicians Who Responded to the Survey.
Willingness to Provide Assistance
Eleven percent of the physicians (95 percent confidence interval,9 to 12 percent) reported that under current legal constraints,there are circumstances in which they would prescribe a medicationfor a competent patient to use with the primary intention ofending his or her life; 36 percent (95 percent confidence interval,34 to 38 percent) said they would prescribe a medication ifit were legal to do so. Seven percent of the respondents (95percent confidence interval, 4 to 10 percent) said that undercurrent legal constraints, there are circumstances in whichthey would administer a lethal injection to a competent patient;24 percent (95 percent confidence interval, 23 to 26 percent)said they would do so if the practice were legal.
Requests for Assistance
Of the respondents, 18.3 percent (unweighted number, 320) reportedhaving received a request from a patient for medication to usewith the primary intention of ending the patient's life (Table 3),with a median of three such requests since the physicianentered practice. Fewer physicians (11.1 percent; unweightednumber, 196) reported having received a request for a lethalinjection, with a median of four such requests since the physicianentered practice.
Table 3. Requests for Physician-Assisted Suicide or Euthanasia and Compliance with Requests.
Compliance with Requests for Assistance
Only the 320 physicians who reported having received a requestfrom a patient for a prescription for a lethal dose of medicationwere asked if they had ever written such a prescription. Sixteenpercent of these respondents (unweighted number, 42), or 3.3percent of the entire sample, reported that they had writtena prescription for a lethal dose of medication, with a medianof 2 such prescriptions (range, 1 to 25) since they enteredpractice; 59 percent of the patients used the prescriptionsto end their lives.
All the respondents were asked whether they had ever given apatient a lethal injection (Table 3); 4.7 percent (unweightednumber, 59) reported that they had done so, with a median of2 instances (range, 1 to 150) in which they had administeredlethal injections since entering practice.
Most Recent Request Honored
The 81 respondents (weighted proportion, 6.4 percent) who reportedhaving acceded to at least one request for assistance with suicideor a lethal injection were asked to describe the most recentcase (Table 4). Forty-seven percent of these respondents wrotea prescription for the purpose of hastening death, and 53 percentadministered a lethal injection. The perceived reasons for therequest were discomfort other than pain (reported by 79 percentof the respondents), loss of dignity (53 percent), fear of uncontrollablesymptoms (52 percent), actual pain (50 percent), loss of meaningin their lives (47 percent), being a burden (34 percent), anddependency (30 percent). The reasons given for acceding to therequest were severe discomfort other than pain (reported by78 percent of the respondents), the untreatability of the symptoms(72 percent), a life expectancy of less than six months (69percent), and severe pain (29 percent).
Table 4. Characteristics of 81 Patients Who Received a Prescription for a Lethal Dose of Medication or a Lethal Injection.
Seventy-one percent of the physicians describing the most recentrequest for assistance in hastening death initially respondedto the request by prescribing more analgesics (reported by 68percent of the respondents), using less aggressive life-prolongingtherapy (30 percent), discussing the request with colleagues(27 percent), prescribing antidepressants (25 percent), tryingto dissuade the patient (22 percent), requesting a second opinion(18 percent), or obtaining a psychiatric consultation (2 percent).
The medications prescribed in lethal doses were opioids (in75 percent of cases) and barbiturates (in 25 percent). The medicationsused for lethal injection were opioids (in 83 percent of cases)and potassium chloride (in 17 percent).
Of the 38 physicians who reported their most recent experiencewith a lethal injection, 43 percent administered it themselves,and 57 percent asked someone else to do so (a nurse in 57 percentof cases and another physician in 32 percent) or ordered anincrease in the dose of an intravenous sedative or analgesicalready being administered (in 11 percent of cases).
Characteristics of Patients Receiving Assistance
Although 95 percent of the requests for a prescription weremade by the patients themselves, 54 percent of the requestsfor a lethal injection were made by a family member or partner(Table 4). Requests for a lethal injection were characterizedas indirect rather than explicit in 79 percent of cases. Fivepercent of the patients who received prescriptions and 7 percentof those who received lethal injections were described as "confused50% or more of the time," but we did not ask whether the patientwas unable to communicate at the time of the decision to hastendeath. Ninety-eight percent of the patients receiving a prescriptionwere estimated to have less than six months to live, and 48percent were estimated to have less than four weeks; 95 percentwere not hospitalized at the time of the request. Ninety-sixpercent of the patients receiving a lethal injection were estimatedto have less than a week to live, and 59 percent were estimatedto have less than 24 hours; virtually all the patients diedin the hospital. Most patients receiving either type of assistancehad family or friends who were closely involved at the timeof the request (83 percent of those receiving a prescriptionand 95 percent of those receiving a lethal injection). In everycase of assisted suicide or euthanasia, the physician believedthat the request reflected the patient's wishes. The proportionsof patients receiving a prescription who would have met thespecific clinical and procedural criteria of the Oregon Deathwith Dignity Act10 are shown in Table 4.
Predictors of Willingness to Provide Assistance and Provision of Assistance
Religious affiliation (Table 5) was associated with having givena lethal injection, as well as with the willingness to prescribea lethal dose of medication or give a lethal injection. Catholicphysicians were least likely and Jewish physicians or thosewith no religious affiliation were most likely to be willingto provide assistance or to have actually done so. Physicianswho prayed less frequently were more willing to provide assistanceor to have done so than physicians who prayed more frequently,except that frequency of prayer was not associated with lethalinjection. The frequency of requests for a prescription wassignificantly associated with geographic region, with physiciansin the West most likely to have received such requests. Doctors45 years of age or older were more willing to give a lethalinjection under current legal constraints (data not shown) andwere more likely to have received such requests than youngerdoctors. Men were significantly more likely than women to havewritten a prescription for a lethal dose of medication.
Table 5. Variables Predicting Willingness to Provide Assistance, Requests for Assistance, and Compliance with Requests.
Specialty was a significant predictor of both willingness toprovide assistance under current law (data not shown) and thereceipt of at least one request for assistance (Table 5). Pulmonologists,geriatricians, and general internists were most likely to bewilling to give either a prescription for a lethal dose of medicationor a lethal injection. Geriatricians and oncologists were morelikely to have received requests for a prescription, whereaspulmonologists were more likely to have received requests fora lethal injection (Table 6).
Table 6. Willingness to Provide Assistance, Requests for Assistance, and Compliance with Requests, According to Specialty.
Discussion
We found that requests for assisted suicide or euthanasia arefrequently made to physicians who practice in specialties inwhich they are likely to care for dying patients and that thedecision to honor such a request is not rare in the United States.The prevalence of ever having acceded to a request for a prescriptionfor a lethal dose of medication was 3.3 percent in our sampleas compared with 7 percent in Oregon7 in 1995, 13.5 percentamong New England oncologists11 in 1994, and 18 percent amongMichigan oncologists12 in 1993. The prevalence of ever havingprovided a lethal injection was 4.7 percent in our study, ascompared with 4 percent in Michigan12 and 1.8 percent amongoncologists in New England.11
Our study showed that several factors were associated with physicians'participation in hastening death, including region of practice,religion, and specialty. Repeated ballot measures and the attendantdebate over the legalization of physician-assisted death inCalifornia, Oregon, and Washington may have led to a higherfrequency of requests received by physicians in those statesand may have influenced their willingness to honor the requests.7,10Whereas our study suggests that Jewish physicians are more likelyto be willing to provide assistance than other physicians, twoprior studies13,14 have shown that Jewish (as well as Catholic)physicians are less willing than others to withdraw life support.Also, unlike prior surveys,6,7,11,12 in which oncologists werethe specialists most likely to receive requests for assistancewith dying and most willing to provide such assistance, in oursurvey, other specialists were most likely to receive such requestsand most willing to honor them.
We surveyed a national probability sample of physicians in awide variety of specialties. Prior surveys have been limitedto specialists who care for high-risk patients, such as oncologists11,12and specialists in the acquired immunodeficiency syndrome,15or to states where there has been considerable publicity associatedwith ballot measures (Washington and Oregon)6,7,16 or Dr. JackKevorkian's repeated provision of assistance to patients (Michigan).12,17In addition, we assessed the validity of the survey instrumentin eliciting honest answers about controversial and illegalacts by pilot testing in a group of physicians known to haveparticipated in physician-assisted suicide or euthanasia.
Our results are limited to physicians in the selected specialties.To the extent that physicians in these specialties are morelikely to receive requests for assistance with suicide or euthanasia,the prevalence estimates are higher than those for all practicingphysicians. Conversely, to the extent that the respondents werereluctant to report illegal actions, we may have underestimatedthe actual frequency of physician-assisted death. Although theresponse rate in our study was more than 60 percent and wassimilar to that in other recent studies,6,7,11,12,15 it is possiblethat the nonrespondents and the respondents differed.18 Finally,although lethal injection was carefully defined as injectionof a lethal dose "with the primary intention of ending the patient'slife," some respondents may have confused this action with terminalsedation (i.e., the use of analgesic or sedative agents to induceunconsciousness and relieve suffering).
What are the implications of these data for the current debateover the legalization of physician-assisted death? First, asubstantial number of physicians in the United States have receivedone or more requests for assistance with suicide or euthanasia.Educational efforts are needed to prepare physicians to explorethe meaning of such a request19 and to assess the patient'smental state and the adequacy of palliative care before respondingto it. Second, legalization could lead to a large increase inthe willingness of physicians to participate in the hasteningof death and perhaps to an increase in its prevalence. Third,the majority of patients who request assistance with suicideappear to satisfy many of the criteria currently proposed asregulatory safeguards for this practice.2,3,10,20
Our findings with respect to lethal injection point to a differentpattern of decision making. The finding that 54 percent of patientsreceiving a lethal injection did not make the request themselvessuggests that physicians and family members felt compelled tointervene with a decision to hasten death. The majority of thesepatients had less than 24 hours to live, were experiencing severediscomfort or pain, and were in the relatively public settingof the hospital, with family members who were closely involvedat the time of death. Sedation may have been used appropriatelyfor refractory symptoms in the last hours of life, but in theabsence of detailed descriptions of the circumstances surroundingthese requests and actions, cautious interpretation is warranted.Although the fact that respondents reported these cases as examplesof lethal injection suggests that their primary intention wasto hasten death, the use of sedation for refractory symptomsin patients near death may have led some physicians to reportactions intended to relieve suffering that were also intendedto hasten death.21
Additional research on the circumstances in which doctors honorrequests to hasten death should evaluate the possibility thatbetter access to palliative care might obviate some of theserequests22,23 as well as clarify the practical implicationsof establishing regulatory guidelines. We evaluated physicians'practices during a time when medical education in palliativecare was largely unavailable and such care was sporadicallydelivered.23 The prevalence of requests for assistance in hasteningdeath and of compliance with such requests may differ in communitieswhere palliative care is easily accessible.
Supported by grants from the Greenwall Foundation, the NationalInstitute for Nursing Research (1RO3NR03109), and the GerbodeFoundation. Drs. Meier and Morrison are Faculty Scholars ofthe Open Society Institute's Project on Death in America. Dr.Morrison is a Brookdale National Fellow.
We are indebted to Jeri Mulrow for her work on sample design,selection, and weighting; and to Robert N. Butler, M.D., JoannLynn, M.D., Kathleen Foley, M.D., Susan D. Block, M.D., andthe Faculty Scholars of the Open Society Institute's Projecton Death in America for their review and comments.
Source Information
From the Departments of Geriatrics and Adult Development (D.E.M., R.S.M., C.K.C.) and Biomathematical Sciences (S.W.), Mount Sinai School of Medicine, New York; the National Opinion Research Center, University of Chicago, Chicago (C.-A.E.); and the University of Rochester, Rochester, N.Y. (T.Q.). The views expressed in this article do not necessarily reflect those of the University of Rochester or its Department of Medicine.
Address reprint requests to Dr. Meier at Box 1070, Mount Sinai School of Medicine, New York, NY 10029.
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