Why Some Terminally Ill Choose Suicide

A detailed analysis of the first year's experience with Oregon's physician-assisted suicide law suggests that the worst fears of some of the law's opponents haven't been borne out. Terminally ill patients who chose to end their lives under the law were more concerned about losing their autonomy than about suffering unbearable pain or financially ruining their families, according to the analysis, which was published in this week's New England Journal of Medicine.

In October 1997, Oregon became the first and only U.S. state to legalize physician-assisted suicide for terminally ill people. At the time, critics warned the so-called "Death with Dignity Act" would cause a disproportionate number of poor people or patients with fear of extreme pain to commit suicide, while those who could afford good care or were less afraid would stay alive longer. To minimize these risks, a number of safeguards were built into the law: The patient, not the doctor, had to administer the fatal dose; two physicians had to agree to prescribe the lethal barbiturate dose; the patient had to request the prescription three times over more than 15 days; and the patient had to be informed about hospice and other care options.

A year after the law took effect, medical epidemiologist Gene Chin and his colleagues at the Oregon Health Division (the state's public health agency) compared 15 people who took the lethal doses with 43 who died from similar terminal illnesses, to find out why some choose to end their lives and others don't. Detailed questionnaires filled out by the patients' physicians revealed that the two groups were similar in most respects; people who opted for suicide were not disproportionately less educated, underinsured, on Medicaid, or afraid of pain, says Chin. But the suicide group had worried more about being bedridden and incontinent: 80% of them, compared with 40% of the control patients, had told their doctors they feared losing control over their lives. "What was driving this was a strong need for autonomy," Chin says.

But some experts disagree. "That conclusion is not warranted by the data," says psychiatrist Herbert Hendin, medical director of the American Foundation for Suicide Prevention, who contends that information supplied by doctors could be deceptive because patients might not disclose their true motivation. But forensic pathologist Cyril Wecht of DuquesneUniversity in Pittsburgh calls the study "valid and credible." "It points out several commonly held misconceptions," he says.