Assessing Physician Compliance with the Rules for Euthanasia and Assisted Suicide

Abstract

When any state or country considers permitting physician assisted suicide or euthanasia, one of the most important questions to be faced is how to make sure that physicians comply with the rules and stay within the allowed limits. Data suggest that the Dutch system for assuring physician compliance has thus far worked poorly, as that system relies largely on physician self-report. The Oregon system also relies largely on physician self-report. Oregon has created no mode of data collection to assess what proportion of cases are actually being reported. Oregon’s annual assessment of practice under its statute permitting physician-assisted suicide fails to capture cases that physicians do not report. Thus, we have no way at present to evaluate Oregon’s statistics and reported practice of physician-assisted suicide.

In the Netherlands, after a patient dies from euthanasia or assisted suicide, the physician must complete a report and notify the municipal pathologist of a death from nonnatural causes. The pathologist then performs an autopsy and prepares a report, which goes to the public prosecutor. Thus, physician reporting is the trigger for review. To the credit of the Dutch, their researchers have repeatedly assessed whether this system works - whether physicians in the Netherlands comply with requirements to report performing assisted suicide and euthanasia. In 1990 and 1995 less than half of physicians reported. By 2001, the percentage of physicians reporting was still only 54%. In this issue of the Archives of Internal Medicine, Jansen-van der Weide and colleagues report on a survey of Dutch general practitioners conducted 2000-02. The written questionnaire asked these physicians about the number of requests for assisted suicide and euthanasia received in the last year, how the physician handled them, and characteristics of the last explicit request received in the past 18 months. Remarkably, this study finds high levels of physician compliance with the rules. Sadly, there are substantial reasons to doubt this reassurance. All physicians being surveyed were either recently trained in the rules as consultants or the target of a project to encourage them to use these consultants and follow the rules. There was no control group, and retrospective self-report was the only data collection method. This is not an adequate basis for assessing whether physician practice actually complies with the rules. Persuasive assessment cannot rest on physician retrospective self-reports after training in the rules as consultants or encouragement to use such consultants and follow the rules.

The ultimate question remains - if you permit physicians to take life deliberately by assisting suicide or performing euthanasia, can you control the practice? Can you keep it within agreed boundaries? Can you avoid sliding down the slippery slope? These are questions of great importance that demand sophisticated study. We do not yet know the answers.

Keywords: Physician-assisted suicide, euthanasia, physician compliance, physician reporting, empirical studies, Dutch data, Netherlands, Oregon, health law, bioethics