Physician-Assisted Suicide and Behavioral Economics
By Arjun Khanna
As the American population ages, the debate about the ethics of physician-assisted suicide for terminal patients becomes more important.
Proponents of legalizing of physician-assisted suicide argue the practice is ethically justifiable because it can alleviate prolonged physical and emotional suffering associated with debilitating terminal illness. Opponents claim that legally sanctioned lethal prescriptions might destroy any remaining desire to continue living – a sign of society having “given up” on the patient.
Ultimately, these arguments rest on differing opinions regarding the effect of this policy on the patient’s wellbeing. The challenge, then, is to determine how legalization of physician-assisted suicide would affect the wellbeing of terminally ill patients and their medical decision-making.
Outside of philosophical arguments, examination of an interesting finding regarding physician-assisted suicide – know as “The Oregon Paradox” – can add an interesting dimension to the debate. The paradox is the finding that when terminal patients in Oregon receive lethal medication (under Oregon’s Death with Dignity Act), they often feel a sense of greater wellbeing and a desire to live longer. In 2010, of 96 patients requested lethal medication, only 61 actually took it. Even more interesting are the many anecdotal accounts of terminal patients, upon receiving lethal medication, that feel a surge of wellbeing and a desire to persevere through their illness.
Why is this this the case? Looking at this question from an expected-utility perspective suggests that given the option to terminate their own life, terminal patients will decide how long they want to live by comparing the value they expect to gain from the rest of their lives to the expected intensity of their suffering. At the point where future utility is expected to be negative – that is, when the patient’s condition becomes so intolerable that living any longer is not worth the cost – the patient would choose to end life if the option were available.
The critical point from this perspective is that patients choose the amount of time they are willing to continue living with their illness, which will depend how quickly they deteriorate. If the rate of deterioration is slower than expected, then patients should delay terminating their lives; if the rate of deterioration is faster than expected, patients should desire to end their lives quicker.
But now let us say that patients have been prescribed lethal medication and have the option of ending their lives at any point of their choosing. As before, patients don’t want to choose a time too soon or too distant, but with the power to control the end of their lives they no longer have a reason to err on the side of haste! The patients can now wake up every day with the comfort of knowing that they do not have to suffer through pain or stress they might find intolerable.
Being given the option to determine the time of our own death can transform patients from powerless victims of their illness to willing survivors of it. Together, the importance of feeling in control and the ability to reduce (but not eliminate) uncertainty about rate of deterioration adds an interesting new dimension to the underlying ethical debate and seems to provide credence to the benefits of legalized physician-assisted suicide.
It is clear is that we need a greater understanding of the decision-making of patients at the end of their lives, and that with this improved understanding we can construct policy to better protect their wellbeing (for an interesting recent movie on this topic see “How to Die in Oregon”).
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References:
Lee, Li Way, 2010. “The Oregon Paradox” Journal of Socio-Economics. 39(2):204-208.
Turman, S.A., 2007. The Best Way to Say Goodbye: A Legal Peaceful Choice at the End of Life. Life Transitions Publications.
My latest book, The Upside of Irrationality, explores some positive and some negative ways that irrationality plays out in our lives.
I’m not sure that this is such a paradox. Naturally people feel better if they are freer. “Take what you like, says God. And pay for it” http://allagatha.blogspot.com/2010/01/spanish-proverb.html
However this is not such a happy moral situation for the physician, taught “First, do no harm” http://en.wikipedia.org/wiki/Primum_non_nocere. Fear of pain and fear of what we may be transformed into by pain and illness is an illusion that our youth-obsessed society builds up. Even worse, the prospect that we may be an economic burden to others rather than a proud wealth-creator and giver is terrible in our money-oriented world.
The first step towards being free is to realise that your dignity does not rest on being young or wealthy, that the stumbling stone in your life which irritates you will be the corner-stone on which you build the house of your life. You don’t need a lethal injection to die to the world and its stupidity. Get some faith.
Matt Schofield said, “However this is not such a happy moral situation for the physician, taught “First, do no harm””.
If you have never been in absolute, exquisite pain, you have no frame of reference. Also, what harm does the physician do by pumping a failing body full of chemicals complete with side effects? It has nothing to do with a lack of ‘faith’ – often the patient’s body is ready to stop, yet the medical professionals insist on artificial prolongation of life. One of the precepts is, yes, “to be in the world but not of it”. Another is, “to be free of intellectual pride”. Get some humility.
I guess you need to include in the concept of “Do no harm” the idea of psychological harm and suffering, including the pain that comes with a terminal illness. By not upping pain medications to a level that becomes dangerous, you are causing a patient harm with your suffering.
Many physicians recognise this.
The current standard appears to be palliative care — make the dying person as comfortable as possible which may result in someone becoming unconscious. Hospice workers may go to great lengths to assist the person.
I’ve seen mention of the phenomena of feeling relief immediately after one makes a difficult decision but has not yet taken any action. I’m wondering if the “surge of wellbeing” — asserting that one is in control — might be a variation on this.
Interesting perspective Dan. Not taking sides I can simply say I agree with the premise that choice empowers and might actually increase the deisre to live. On a personal level I saw this when I was a competitive bodybuilder. I would follow a very strict diet for a nset umber of days then I had a day where I could eat whatever I wanted. It seemed like all I thought about until that day was eating. But, once the day arrived I quite often found myself waiting to eat, sometimes for several days, because I might want to enjoy pizza while watching a certain show in TV (no tivo back then). I knew the freedom to eat made all the difference and tremendously lessened the tempation I was feeling before.
I appreciate Matt’s comments. How many of those people who requested lethal medication did so because they didn’t want to be a burden to their friends and family? And how many of the ones who took the medication did so for the same reason? It is an intellectually lazy exercise to generalize about these 96 people. Read up on each of their individual cases. Talk to their doctors, friends, and families. Better yet, go back in time and perform a brain scan on each of them. Then you can tell me who was empowered and who was frightened out of their minds. Please do not reduce this debate to ideas when there are people involved, each with individual (and largely unknowable) brain chemistry.
I think this article makes a lot of sense. I know that I can’t think of any situation where I would personally prefer to have *fewer* options available to me. I think it should be a fundamental human right to have an “out” at the end of one’s life – you are going to die *anyway*, so why not at a time of your choosing.
I live in California, and I sincerely hope that someday we will stop worrying so goddam much about gay marriage and pass a “Die with Dignity” proposition.
A very nice article!
This idea is also illuminated through Ariely’s essay “Painful Lessons”
In this article Ariely was referring to a painful operation he had while in the hospital. He said that knowing the “end point” of the pain helps patients to cope with their pain:
“…having the “knowledge” that the pain will end once a target has been reached, is likely to help patients
manage their own coping abilities– reducing their
overall pain and prolonging the period of time a
treatment can be sustained. In addition, knowledge of an endpoint can also increase the feeling of control as well as decrease levels of fear and dread, all of which can lead to beneficial outcomes.”
The same idea can be applied to physician-assisted suicide; When people are “in control” of their pain they usually feel better and their feeling of hopelessness is gone.
Great Article,
George
Makes sense.
My Father asked me to kill him (bowel cancer, lymphatic tumours, colostomy bag, chemo etc and so on), there’s no euthanasia (anymore) in Australia so I had to help remotely (with some assistance from Exit, they can provide advice and a plastic bag). It didn’t go well.
He survived and then died alone, unable to speak, in a hospice months later. If he’d had the medical support and facility to choose his own time, he would definitely have had a more bearable last 12 months.
He mightn’t even have used it, but knowing the option was there would probably have been more effective palliative care than the morphine he was taking.
As a sidenote on this topic, palliative care is very under-valued and under-appreciated. I have nothing but respect for the health professionals who work in those settings. Wonder if that’s a topic to consider – the economics of those that work in psychologically tough professions, like prison warders, nurses, doctors, psychologists.
As the wife of a physician and a Dr of Sociology who has been a part of many discussions and lectures where students are always willing to tell me first do no harm, I feel that people are willing to use that oath to suit their own agenda.
My Husband is the son of a doctor and all five of his siblings are doctors and three of the five have married doctors. Our circle of friends is composed largely of medical professionals and nearly all of them have been complicit in, or enacted euthanasia.
They believe that alleviating suffering is preventing the harm they swore they would not do. Euthanasia has been a part of Medicine since the beginning, it’s been a part of social interactions even longer.
The true harm comes about when we use advances in Medicine to prolong a life artificially without any real quality of life.
If a human being wants to choose the time and manner of their death, providing it harms no one else. Who are we, or who is anyone to deny them that?
Brilliant. From this perspective, it seems quite clear that physician assisted suicide should be legalized. What’s the flipside (aside from anything having to do with religion)? Being raised Lutheran, though I haven’t been to church since I was 13, it’s still so hard to shake the feeling that it’s somehow “wrong,” even when logically it seems so obviously beneficial.
And, it does seem a little strange that we find the idea of keeping a beloved pet alive while suffering abhorrent – but it’s a given that we humans have to battle it out to the bitter end!
This topic is so much easier to talk about in the abstract, than in the specific.
When it comes to humans, I’m in the “theory” camp. Have not been close to this problem in any way. I can read stories from people who spend time at the edge of this line: Atul Gawande on Treating a Dying Patient and realize that the problem is complicated.
I have had to implement some principles for my animals, having “missed” the need for euthanasia twice and learned the hard way that there are definitely worse outcomes than that last trip to the vet. Sometimes, death itself is painful. Heart attacks hurt.
Here’s where I got stuck in the blog post, though:
Necessary, but not sufficient. Add:
–and how much support and trust they have for and from the people around them.
I think some of the focus on euthanasia is a way to hide the fear of being needful, dependent, and lonely. For many people (absolutely not “all,” however), we’d do better to work on connection and love and acceptance.
Q: Of all the people who die in the US every year, how many / what % die in a manner that could be affected by a P-Asstd-Suicide law?
You are forgetting potential biological responses to the lethal medication. Many people feel a profound sense of peace in near death experiences – perhaps a burst release of endorphins or oxytocin. These may give a manufactured love of life and everything around.
1. I think it limits choices to two: live or die, win or lose, etc. I find this to be a very effective coping strategy…with drawbacks.
2. Do people with two choices check less than people with multiple choices?
With the cocktail, do patients pick one set period of time to check like once a week? Without the cocktail, do patients constantly check? Do they constantly ask themselves can I continue multiple times a day?
3. The patients who got the cocktail should show increased signs of risk-seeking and self-destructive behavior?
The irony is not lost. In my opinion at least, the drawback to win/lose thinking is people get bored with everything in between and force things into win/lose situations. Conversation with a friend at work: “Driving my motorcycle really fast relaxes me. Granted, you’re taking your life into your own hands. One false move and your dead.”
4. I expect people who are directly affected by the issue to give me practical arguments. I expect people who are not directly affected by the issue to tell me their values.
This is the real bummer of the whole deal. Doesn’t matter how much evidence you present. For unaffected people, it’s a chance to tell you how great they are because they believe in XYZ. For what it’s worth, one five-minute walk through an Alzheimer’s ward profoundly changed my views.
I could never understand why people make such a big deal out of this question. Everyone’s got an option to jump off a bridge, or equivalent, so providing a lethal injection to those who can’t “jump” otherwise, is simply extending their physical capabilities by medical means.
Sure, some highly suicidal bridges now have helplines, hoping to talk jumpers out of the deed, but hospitals could provide similar services. At the end of the day, it’s everyone’s right to do whatever they want, and live (or die) with the consequences.
Arjun, really fascinating. I hadn’t heard of the Oregon Paradox and had never thought of things from that perspective but it seems extremely logical and something I would have thought would have been mentioned more in the debate. Would love to see more research on this down the road.
This doesn’t seem quite right. You would let a patient take cyanide, which would releive his pain by death, but not let him take heroin which releives his pain while he is alive.
Speaking of pain relief by death, why isn’t the wholesale slaughter of people considered a blessing. The dead suffer no more, and living do not have to put up with them either.
Something seems wrong here.
I recently read a similar study, not about suicide but about the will to live that showed that patients statistically survived beyond key holidays when close to the end. Similar to how Jefferson survived until July 4 to see the 50th anniversary of the Declaration. I think this supports this line of thinking, but takes the next step to suggest that we can will our lives to survive a little longer when we have something to live for…something like control of ones own fate would count, I think
Without understanding the extent of this type of decision making, I have told suicidal people (I am a psychologist) for many years: You know–you always have the choice to kill yourself….and no one can take that away from you…which means you don’t have to do it right now….you could try some other things first…and you’ll still have that choice waiting for you if you choose it.” It really works. The patient relaxes, doesn’t feel in such a hurry to do it and opens himself to the other choices. Now I understand why this works so well.
Arjun, an interesting view that the perceived control over one’s destiny is as important as the act of control itself. Related to your hypothesis is the work of David Glass, Behavioral consequences of adaptation to controllable and uncontrollable noise, 1971.
A laboratory experiment was conducted to investigate the behavioral consequences of adaptation to high-intensity aperiodic noise, under conditions where subjects believed or did not believe they had indirect control over termination of the noise. The findings showed that among a group of college males, the work of adapting to uncontrollable, in contrast to controllable noise resulted in heightened overall tension.
In essence, if we believe we can control our environment, even if we do not take control, we have a greater sense of well-being. I believe this is why, in part, the Oregon Assisted Suicide law is so important.
I recently wrote a research paper for my English Comp class on this subject, and I was given an assignment to publish part of my paper, so here I am.
Regarding the “do no harm” issue..in my research, I was surprised to learn that palliative care in the final stages of illness consists mainly of administering heavy doses of pain medications in order to keep the patient comfortable. A frequent side effect of the combination of these medications is decreased respiration, which ultimately results in hastening death, and is a fairly common and accepted practice. It is referred to as “double effect.” Here is a brief excerpt from my paper about it:
According to the Stanford Encyclopedia of Philosophy, “the doctrine (or principle) of double effect is often invoked to explain the permissibility of an action that causes a serious harm, such as the death of a human being, as a side effect of promoting some good end. It is claimed that sometimes it is permissible to cause such a harm as a side effect (or “double effect”) of bringing about a good result even though it would not be permissible to cause such a harm as a means to bringing about the same good end. This reasoning is summarized with the claim that sometimes it is permissible to bring about as a merely foreseen side effect a harmful event that it would be impermissible to bring about intentionally.”
I believe that doing harm has two sides that are equally complicated. Harm can come from not treating an illness, but also from continuing to treat an illness when all hope is lost and the patient is just suffering.
This is the conclusion from my paper:
In a modern world where we, as Americans, are given the right to life, liberty and the pursuit of happiness, if we are faced with the undeniable truth that our lives are going to end due to a terminal illness, why are we not also given the right to choose to hasten death with the assistance of our doctors in a safe, humane, and dignified manner? No one should have to endure months or weeks of excruciating pain. No family should have to suffer needlessly while watching their loved one wither away into a shell of their former existence. No one should be forced to burden their family with financial obligations related to palliative or hospice care simply because no other options exist. Ancient ways of thinking should not be compelling, justifiable reasons why the option of assisted suicide should not be present. With the public emergence of Dr. Kevorkian in the early 1990’s, the need for another alternative became glaringly clear. Further, with the implementation of legal assisted suicide procedures in Oregon, Washington and Montana, the example for successful framework has already been provided. If a competent terminally ill patient chooses to hasten death in order to avoid pain or suffering or to maintain dignity in the manner in which death occurs, assisted suicide should be a legal option in all states.