Role of non-governmental organisations in physician assisted suicide

Terminology

Throughout this article we use the phrase “physician assisted suicide” to describe a procedure where a doctor lawfully provides a lethal dose of drugs to a patient for self administration. Although the description of this process as suicide continues to generate controversy in the United States,9 10 physician assisted suicide does not carry the same connotation in the Swiss culture, is often used in the academic literature, and is distinct from active euthanasia.5 11 Consequently, in the interest of consistency and comparative analysis, we have retained the term here.

Right to die organisations

Assisted suicide in Switzerland and the US (Oregon) accounts for less than 1% of all deaths (0.36% in Switzerland and 0.12% in Oregon).3 12 Most assisted suicides in both countries are facilitated through private non-profit organisations (92% and 75%, respectively).5 12 Exit is the largest Swiss organisation with independent offices in Zurich (www.exit.ch) and Geneva( www.exit-geneve.ch),2 13 and Compassion and Choices is the biggest in the US (www.compassionandchoices.org). Both are private, charitable organisations with around 50 000 members. Dignitas, a smaller Swiss non-profit organisation has gained notoriety by helping residents of Germany, the UK, and other countries.5 Although there are other right to die organisations throughout the world,14 we have concentrated on these two organisations as prototypes for societies who lawfully facilitate physician assisted suicide.2 13

Recruitment, training, and quality control

Although Exit has a team of paid staff, most of its workers are volunteers drawn from the community and recruited at seminars hosted by the organisation throughout Switzerland. People who are interested in becoming volunteers complete an application form, have an interview with Exit staff, and must pass psychological tests and in-depth interviews with two psychologists at the Institute for Psychology (Basel). Approved volunteers receive training in counselling, technical matters, and the policies and procedures of the organisation and are subject to continuing education and supervision. Volunteers are assigned a mentor, who works with them for several months to evaluate their progress. Exit says that volunteers are occasionally turned down during the screening process or are later discharged, but it is uncommon.

Compassion and Choices' recruiting methods, training, and internal controls are similar to those of Exit. Volunteers receive training from clinical nurses and doctors and are required to attend monthly case review meetings. However, volunteers do not have psychological testing. Applicants who have recently experienced a death in their family are not accepted as volunteers because of emotional considerations.

Both organisations control quality through screening and training of volunteers, adherence to eligibility and practice guidelines, retrospective review of cases, and ethics consultations. The organisations will refuse to provide consultation or support for an assisted death if the person does not meet their eligibility criteria. In these cases the person is referred to counselling, hospice, or other appropriate agency.16

In the late 1990s, after a series of internal rows and scandals that resulted in it losing several members, Exit created an ethics and a compliance committee to deal with difficult cases and to review all assisted suicides and apply what was learnt to future cases.5 13 In 2002, Exit instructed a private ethics institute to draw up a report summarising the viewpoints and experiences of its ethics committee. The box summarises the report, which was intended to improve Exit's services and was distributed to Swiss governmental and medical bodies.18 In November 2006, the Swiss National Advisory Commission on Biomedical Ethics issued recommendations regarding right to die organisations in Switzerland and the need to comply with due care.19 Compassion and Choices does not have a standing ethics committee because physician assisted suicide in Oregon is regulated by state law and doctors are the primary gatekeepers.7 15 17 However, ethics consultants are available if needed.

Regulation

Assisted suicide in Switzerland is regulated by the criminal law and the laws and policies regarding medical practice. Technically, assisting or inciting a suicide is illegal in Switzerland, and no distinction is made between doctors and other people.2 4 However, according to article 115 of the Swiss Penal Code, a person commits an offence only if he or she was motivated by selfish reasons. Moreover, since almost all assisted suicides in Switzerland are accomplished with prescribed barbiturates, Swiss doctors who write lethal prescriptions must also comply with health and drug laws.13 Although Swiss health laws do not exclude a doctor from assisting a terminally ill patient in suicide, it remains unclear whether participating in the suicide of a non-terminally ill patient would also be excluded. Nevertheless, when prescribing a lethal drug, the doctor must act with due care and document the patient's condition and decisional capacity in the medical records, along with justification for the decision.19 20

In Oregon, physician assisted suicide is regulated by the Death with Dignity Act (1997), which permits competent, terminally ill adult residents of Oregon to request a lethal prescription from their doctor for self administration.15 Self administration is mandatory, and although oral ingestion is the most common method, parenteral routes are arguably permissible for those unable to swallow.15 17 21 The act requires a 15 day waiting period, oral and written requests by the patient, and specific reporting requirements for the prescribing doctor and a dispensing pharmacist. Patients do not have to have their request validated by a mental health professional. Family notification and participation by doctors and pharmacists is voluntary, but if professionals do participate, they must complete the required paperwork.3 15 17 21

Although the law permits doctors to prescribe, pharmacists to dispense, and designated agents to take the lethal medication to the patient, any other help will generally be illegal. Although Compassion and Choices volunteers cannot provide or administer the lethal drugs, the law does seem to allow non-physicians in Oregon to mix the drugs in soft food or liquid to facilitate oral ingestion.22 23 Table 2⇓ compares the regulation of right to die organisations in Switzerland and Oregon.

Integration with medical system

In both Switzerland and Oregon, right to die organisations are inextricably intertwined in the medical system and the care of the dying. Both serve as a resource to patients, families, healthcare providers, and regulators, and, at least in Oregon, it is practically impossible for a terminally ill client not to be receiving some form of medical care. Compassion and Choices does not consider decisions about physician assisted suicide to be dichotomous but rather a choice along a continuum of options at the end of life.5 Both organisations note that their services enable clients to speak openly about suicide without fear of involuntary commitment. Compassion and Choices also believes that it has prevented violent, impulsive suicides not only through counselling, but also by urging the use of hospice, advance directives, and aggressive palliative care.5 Both organisations respect the doctor-patient relationship and its place in the medical system, as well as the primary reliance on the use of doctors in assisted suicide to assess and, if appropriate, prescribe a lethal dose of medication.5

Conclusion

Although the Swiss and US organisations have developed independently, and in different historical and cultural contexts, they are more alike than they are different. True, Oregon has a law on physician assisted suicide and the Swiss do not; and the Swiss permit anyone to assist in another's death regardless of whether they are terminally ill, whereas Oregon does not. However, when we consider the activities of both; the roles of doctors and others; and the concerns of patients, families, and regulators the differences no longer seem black and white but rather as shades of grey.

Discussions over the extent of doctors' involvement in assisted suicide will continue. Although the doctors' role is often limited to assessment and prescribing, they are still participating in an activity that many argue violates professional integrity.7 Could right to die organisations help solve the ethical problems doctors face by sharing responsibility in screening, assessment, and exploration of alternatives? Perhaps, yes. But because doctors occupy a special position in assisted suicide, the use of non-governmental organisations could also become part of the problem since organisations, like humans, are imperfect. Physician assisted suicide will always involve people other than doctors; the unanswered questions relate to the setting and extent of that involvement.