Letter to the Editor
Nov 2018

Added Points of Concern About Caring for Dying Patients

Annette Hanson, MD, Ron Pies, MD, and Mark Komrad, MD
AMA J Ethics. 2018;20(11):E1107-1109. doi: 10.1001/amajethics.2018.1107.


If there is any doubt that the legalization of assisted suicide has changed the ethos of medicine, that question should be settled by Craig and Dzeng’s article, “How Should Physicians Care for Dying Patients with Amyotrophic Lateral Sclerosis?” As psychiatrists and ethicists, we appreciate Craig and Dzeng’s attempt to highlight some central ethical issues involved in end-of-life care. However, we are deeply troubled by the article’s implicit message: namely, that physicians are acting ethically when they help patients kill themselves in such a way as to avoid legal liability. In our view, that self-serving calculation serves physicians’ interests—not patients’ well-being. We are also troubled by several critical omissions in the fictional Dr S’s evaluation and clinical management of “Donald”—a patient with amyotrophic lateral sclerosis (ALS) and extreme physical limitations who is requesting what the American College of Physicians rightly terms “physician-assisted suicide” (PAS).1

In the case, Dr S worries that despite these extreme physical limitations, Donald might somehow still be able to kill himself in a protracted or violent way, and he considers a lethal prescription to be an acceptable alternative means of death. Some proponents of assisted suicide assert that patients who seek medically assisted death are so determined to die that they will merely find another method if denied a prescription. Jones and Paton2tested this method-substitution theory and found, on the contrary, that having an assisted suicide law on the books did nothing to reduce the rate of “natural” (ie, nonassisted) suicides. States that offered physician-assisted suicide had no reduction in nonassisted suicides.2 Conversely, states without assisted suicide laws had similar increases in nonassisted suicides as states with the laws.2 However, having an assisted suicide law on the books does increase total state suicide rates by 11.79% when a range of factors are controlled for.2 Indeed, evidence from Oregon suggests there might be a “contagion” effect, owing to highly publicized cases of PAS, such as that of Brittany Maynard.3

Craig and Dzeng write that their fictional patient must pass through “rigorous psychological testing” in order to obtain a lethal script. Yet neither Washington State nor Oregon have legislated mandatory psychological evaluation or testing for patients who request assisted suicide.4,5 In reality, only 3.5% of Oregon patients given prescriptions were referred for psychiatric evaluation in 2017.4 In The Oregon Death with Dignity Act: A Guidebook for Health Care Professionals, the Task Force to Improve the Care of Terminally-Ill Oregonians acknowledges that, in practice, the act’s statutory safeguards do not adequately protect people with mental illness.6Nor do assisted suicide laws require a voluntary referral for mental health care as part of the informed consent process.

In the fictionalized vignette, Dr S never explores factors in Donald’s request that could stem from subtle forms of coercion, such as pressure from family members to end his life. Nor is there any assessment of cognitive distortions that might be clouding the patient’s judgment. Instead, in the case, Donald’s apparent motivations are rather credulously accepted at face value. Nor does Dr S offer Donald mental health care and counseling in his discussion of treatment alternatives. This is particularly worrying, given that 35% to 50% of ALS patients have cognitive deficits related to decision-making capacity.7

The authors are concerned about the “significant harm” that can come from denying a patient’s autonomy and agency, and “the potential harms of refusing to prescribe lethal drugs.” Yet they cite no empirical data showing that a physician’s refusal to prescribe lethal medication leads to any type of “significant harm.” As psychiatrists, we recognize that temporary limitations on patient autonomy and agency—coupled with empathic counseling—can lead to continued life, re-engagement, and a renewed sense of meaning even in the face of a terminal illness.


  1. Sulmasy LS, Mueller PS. Ethics and the legalization of physician-assisted suicide: an American College of Physicians position paper. Ann Intern Med. 2017;167(8):576-578.
  2. Jones DA, Paton D. How does legalization of physician-assisted suicide affect rates of suicide? South Med J. 2014;108(10):599-604.

  3. Dore MK. In Oregon, other suicides have increased with the legalization of physician-assisted suicide. Choice Illusion Montana.  http://www.choiceillusionmontana.org/2017/09/by-margaret-k.html. Published August 18, 2017. Accessed August 9, 2018.

  4. Oregon Health Authority. Oregon Death with Dignity Act 2017 data summary.  https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Documents/year20.pdf. Published February 9, 2018. Accessed August 14, 2018.

  5. Washington State Department of Health. Washington State Death with Dignity Act report.  https://www.doh.wa.gov/Portals/1/Documents/Pubs/422-109-DeathWithDignityAct2017.pdf. Published March 2018. Accessed August 14, 2018.

  6. Task Force to Improve the Care of Terminally-Ill Oregonians. The Oregon Death with Dignity Act: A Guidebook for Health Care Professionals. Center for Ethics in Health Care, Oregon Health & Science University. http://www.ohsu.edu/xd/education/continuing-education/center-for-ethics/ethics-outreach/upload/Oregon-Death-with-Dignity-Act-Guidebook.pdf. Published March 1998. Updated December 2008. Accessed August 14, 2018.

  7. Irwin D, Lippa CF, Swearer JM. Cognition and amyotrophic lateral sclerosis (ALS). AM J Alzheimers Dis Other Demen. 2007;22(4):300-312.


AMA J Ethics. 2018;20(11):E1107-1109.



Conflict of Interest Disclosure

The author(s) had no conflicts of interest to disclose.

The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.