Emotional and psychological effects of physician-assisted suicide and euthanasia on participating physicians.

• Author: Stevens, Kenneth R., Jr.

Abstract: This is a review and evaluation of medical and public literature regarding the reported emotional and psychological effects of participation in physician-assisted suicide (PAS) and euthanasia on the involved physicians.

Materials and Methods: Articles in medical journals, legislative investigations and the public press were obtained and reviewed to determine what has been reported regarding the effects on physicians who have been personally involved in PAS and euthanasia.

Results and Discussion: The physician is centrally involved in PAS and euthanasia, and the emotional and psychological effects on the participating physician can be substantial. The shift away from the fundamental values of medicine to heal and promote human wholeness can have significant effects on many participating physicians. Doctors describe being profoundly adversely affected, being shocked by the suddenness of the death, being caught up in the patient's drive for assisted suicide, having a sense of powerlessness, and feeling isolated. There is evidence of pressure on and intimidation of doctors by some patients to assist in suicide. The effect of countertransference in the doctor-patient relationship may influence physician involvement in PAS and euthanasia. Conclusion: Many doctors who have participated in euthanasia and/or PAS are adversely affected emotionally and psychologically by their experiences.

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The report by The New York State Task Force on Life and the Law stated: "Many physicians and others who oppose assisted suicide and euthanasia believe that the practices undermine the integrity of medicine and the patient-physician relationship. Medicine is devoted to healing and the promotion of human wholeness; to use medical techniques in order to achieve death violates its fundamental values. Even in the absence of widespread abuse, some argue that allowing physicians to act as 'beneficent executioners' would undermine patients' trust, and change the way that both the public and physicians view medicine." (1)

The counter-argument has been expressed by Margaret Battin and Timothy Quill, editors of a book favoring legalization of PAS. These PAS advocates have stated that there is no evidence that PAS "legalization would corrupt physicians and thus undermine the integrity of the medical profession," and that "there is substantial evidence to the contrary." (2)

Purpose

When new treatments or procedures in medicine are developed, they are scrutinized to determine if there are adverse or harmful effects associated with them. In the same way, physician-assisted suicide and euthanasia deserve to be evaluated to determine if they have adverse or harmful effects. Instead of focusing on the involved patients, this investigation focuses on the reported effects on the doctors who are involved in assisted suicide and euthanasia.

This investigation's focus is to determine what has been reported regarding the following questions:

* What have been the emotional and psychological effects of participation in PAS and euthanasia on the involved doctors?

* What have they expressed to others regarding their experiences?

* Are physicians being pressured, intimidated or psychologically influenced to assist in suicide or perform euthanasia?

* What has happened to doctors who have written prescriptions? Have they continued to be involved with assisted suicide with other patients after the experience with the first patient or have they stopped their involvement?

Materials and Methods

Since the passage of Oregon's assisted suicide law in 1994, the author has gathered and archived articles from medical journals, legislative investigations, and the public press regarding assisted suicide and euthanasia. This collection of articles numbers into the thousands, including dozens of books on the subject. Other articles were identified and obtained using PubMed and the following search words: "euthanasia, assisted suicide, physicians, responses, psychological, emotional." These publications were reviewed and analyzed to obtain information regarding the above questions.

Results and Discussion

The Netherlands

Doctors in the Netherlands who have had experience with assisted suicide and euthanasia, have expressed concerns regarding the effects on doctors. A report from the Netherlands stated: "Many physicians who had practiced euthanasia mentioned that they would be most reluctant to do so again." (3)

Emanuel stated that "in a television program reporting a euthanasia case, the Dutch physician who performed euthanasia noted that: 'To kill someone is something far reaching and that is something that nags at your conscience.... I wonder what it would be like not to have these cases in my practice. Perhaps I would be a much more cheerful person.'" (4)

The American Medical News reported the following comments from Pieter Admiraal, a leader of Holland's euthanasia movement: "'You will never get accustomed to killing somebody. We are not trained to kill. With euthanasia, your nightmare comes true.'" (5)

In 1995-96, 405 Dutch doctors were interviewed regarding their feelings after their most recent case of euthanasia, assisted suicide, life ending without an explicit request, and alleviation of pain and other symptoms with high doses of opioids. The percentage of doctors expressing feelings of discomfort were: 75% following euthanasia, 58% following assisted suicide, 34% following life ending without an explicit request, and 18% for alleviation of pain with high doses of opioids. Fifty percent of the euthanasias and 40% of the assisted suicides were followed by "burdensome" feelings; and 48% of the euthanasia and 49% of the assisted suicide cases were followed by emotional discomfort. The willingness to perform physician-assisted death again was 95% after euthanasia and 82% for life ending without an explicit request. (6) The doctors sought support afterwards following 43% of the euthanasia cases and following 16% of cases involving ending life without an explicit request.

Evidence reported by the British House of Lords Select Committee on the Assisted Dying for the Terminally Bill in 2005 includes the following candid responses by Dutch physicians and ethicists to questions from the committee:

Q1250 Response by Dr. Legemaate: "No physician ever likes performing euthanasia."

Q1350 Question by Baroness Finlay: "The first time that you performed euthanasia, how did you feel about it as a clinician?"

Response by Dr. Van Coevorden: "Awful."

Q 1351 Response by Dr. Mensingh van Charente: "It is not a normal medical treatment. You are never used to it."

Q1535 Question by Baroness Finlay: "Looking after complex patients can be exhausting. It can be physically and emotionally exhausting. I certainly know of a case where a patient was almost pressured by the doctor, by being offered euthanasia. I wondered if that reflected the doctor's personal distress and whether you have come across cases where the doctor is thinking of euthanasia as the only solution?"

Response by Dr. Zylicz: "I was giving consultations in several situations like this, when the GP was calling me about a patient with gastrointestinal obstruction. He said, 'The problem is that the patient is refusing euthanasia.' I said, 'What happened?' He said, 'In the past, all these kinds of situations, when people were intractably vomiting, I solved by offering euthanasia. Now this patient does not want it, and I do not know what to do.' That was really striking. Providing euthanasia as a solution to every difficult problem in palliative care would completely change our knowledge and practice, and also the possibilities that we have.... This is my biggest concern in providing euthanasia and setting a norm of euthanasia in medicine: that it will inhibit the development of our learning from patients, because we will solve everything with euthanasia."

Q1539 Response by Professor Jochemsen: "I know from physicians who are opposed to performing euthanasia that they are afraid of saying so when applying for jobs and trying to find a post as a physician. In certain circumstances, that will make it much more difficult for them to...