Since The Death with Dignity Act was passed in Oregon in 1993, the topic of “physician aided suicide,” “medical aid in dying,” “physician aid in dying,” or “death with dignity,” has been a controversial one. Every now and then we get asked our opinions on the subject addressing suicide with community groups. This has always been a difficult question to respond to because we work so hard to prevent the tragedy of suicide. We understand that Death with Dignity has some similarities, but also some major fundamental differences from suicide. In late October, the American Association for Suicidology (AAS) released an official statement about their stance which included several distinct differences between traditional “suicide” and “physician aid in dying.”
Before we dive into the main differences between suicide and physician aid in dying (PAD), it’s important to understand the current PAD process. In those states that have legalized PAD, such as Oregon, Washington, and Vermont, there have been guidelines established under U.S. law to safeguard this process against abuse. For example, when a patient makes the decision to end their life early, their decision must be well-documented in order to protect against impulsivity. Law currently requires two oral requests separated by a 15-day waiting period, as well as a written request that is signed in the presence of two witnesses. There must also be a serious medical reason for this decision, including a terminal illness and/or intolerable, unbearable, or irremediable suffering. In addition to these two requirements, the patient must also be examined by two separate physicians in order to confirm their terminal diagnosis and physical state. The patient’s main physician is also required to provide the patient with all feasible alternatives to PAD including comfort care, hospice care, and pain control.
The following are the main points of differences established by the American Association for Suicidology:
1. In the case of physician aid in dying, the individual does not necessarily want to die. Instead, they have a terminal illness where death is imminent. Making the decision of PAD would bring on death a little sooner, but in an easier, less painful way, in accordance with the patient’s wishes and values. According to a study in Netherlands, a patient who dies by PAD forgoes an average of about 3.3 weeks of life.
In contrast, suicidal ideation is generally brought on by severe psychological pain where the person cannot enjoy life or see that things may be better in the future. The term “suicide” implies “self-destruction” and the act is often self-violent and often painful. Suicide cuts a life significantly shorter than PAD.
2. In PAD, the patient facing imminent death often experiences intensified emotional bonds with loved ones and develop a deeper meaning of life as theirs begins to come to an end. Unlike suicide, most people who die by PAD, die surrounded by loved ones. Where as a person who dies by suicide generally dies alone and is often experiencing a sense of loneliness, isolation, and loss of meaning at the time of their death.
3. Suicide is more common among people with a mental health condition and can be a complex byproduct of impaired thinking, cognitive distortion, impaired problem-solving, anxiety, agitation, personality disorders, and/or helplessness and hopelessness.
In contrast, if there is a question whether the patient who has a terminal illness may be experiencing a mental health condition that is affecting their decision to end their life, a psychologist or psychiatrist is required to evaluate the patient. If it is determined that the patient is in fact being influenced by a mental health condition, such as depression, they are ineligible by law for PAD.
4. The legal status and consequences of the two acts are different. In the U.S., the statutes in the states that recognize “End of Life Options” or “Death with Dignity” laws assert that such death “shall not, for any purpose, constitute suicide, assisted suicide, mercy killing, or homicide under the law.” Deaths under these laws are not recorded as suicide on the death certificates, but as death from the underlying terminal condition. Therefore, the terms “physician aided suicide” or “medical assisted suicide” should be deleted from use.
In addition, physician aid in dying does not incur the same substantial forensic costs as a suicide death investigation does, due to the amount of physician documentation required during the process.
5. According to studies in Oregon and Netherlands, the impact of PAD on the bereaved tends to be less severe than in other deaths, including suicide. Suicide loss survivors however, have a high risk for complicated grief, post-traumatic stress disorder, and are at an increased risk for suicide themselves.
6. Death by suicide is still widely stigmatized and misunderstood by the general population, leaving a considerable burden for those left behind. In contrast, in communities where the Death with Dignity Act is legalized, it is widely accepted within the community and society at large.
In conclusion, suicide and physician aid in dying are conceptually, medically, and legally a different phenomenon with an uncertain amount of overlap between the two. The American Association for Suicidology and The Kim Foundation are dedicated to preventing suicide, which has no bearing on physician aid in dying or medical aid in dying.
Jill Hamilton, Senior Project Coordinator, The Kim Foundation
Jill Hamilton has been a Project Coordinator at The Kim Foundation since 2014. She graduated with a Bachelor’s Degree in Journalism and a Speech Communication Minor from The University of Nebraska at Omaha in 2009. Since working at the foundation, she has become an active member of the Nebraska State Suicide Prevention Coalition and The Metro Area Suicide Prevention Coalition, Nebraska LOSS Advisory Committee, The Early Childhood Mental Health Coalition, is Chair of the Nebraska LOSS Teams Conference Planning Committee, and serves as the Outreach Coordinator for the Metro Area LOSS Team.