Suicide, Euthanasia, And Physician–Assisted Suicide

BACKGROUND

The eleventh edition of Merriam-Webster's Collegiate Dictionary defines the term euthanasia, which derives from the Greek for “easy death,” as “the act or practice of killing or permitting the death of hopelessly sick or injured individuals … in a relatively painless way for reasons of mercy.” This present-day definition differs from that of the classical Greeks, who considered euthanasia simply “one mode of dying.” To the Greeks, euthanasia was a rational act by people who deemed their life no longer useful. That these individuals sought the help of others to end their life was considered morally acceptable.

The movement to legalize euthanasia in England began in 1935 with the founding of the Voluntary Euthanasia Society by well-known figures such as George Bernard Shaw (1856–1950), Bertrand Russell (1872–1970), and H. G. Wells (1866–1946). In 1936 the House of Lords (one of the houses of the English Parliament) defeated a bill that would have permitted euthanasia in cases of terminal illness. Nonetheless, it was common knowledge that physicians practiced euthanasia. The same year, it was rumored that King George V (1865–1936), who had been seriously ill for several years, was “relieved of his sufferings” by his physician, with the approval of his wife, Queen Mary (1867–1953).

The Euthanasia Society of America was established in 1938. In 1967 this group prepared the first living will. Renamed the Society for the Right to Die in 1974, it merged in 1991 with another organization called Concern for Dying, and the two became Choice in Dying (CID). Even though the CID took no position on physician-assisted suicide, it “advocated for the rights of dying patients.” It also educated the public about the importance of advance directives and end-of-life issues. In 2000 the CID dissolved, although many of its staff remained to found Partnership for Caring, which continued its programs. The organization's goal was to guarantee that Americans have access to quality end-of-life care. In early 2004 Partnership for Caring merged with Last Acts, a coalition of professional and consumer organizations that work to improve end-of-life care. The merged organization was named Last Acts Partnership, and its mission was to provide education, service, and counseling to people who needed accurate and reliable information about end-of-life care. Last Acts Partnership was also an advocate for policy reform in end-of-life issues. In 2005 Last Acts Partnership ceased its activities and all rights and copyrights to material produced by Partnership for Caring, Last Acts, and Last Acts Partnership were legally obtained by the National Hospice and Palliative Care Organization (NHPCO; http://www.nhpco.org/templates/1/homepage.cfm). As of May 2008, the NHPCO was still operating.

Euthanasia and the Nazis

The Nazis' version of euthanasia was a bizarre interpretation of an idea espoused by two German professors, Alfred Hoche (1865–1943) and Karl Binding (1841–1920), in their 1920 book Die Freigabe der Vernichtung lebensunwerten Lebens (The Permission to Destroy Life Unworthy of Life). While initially advocating that it was ethical for physicians to assist in the death of those who requested an end to their suffering, the authors later argued that it was also permissible to end the lives of the mentally retarded and the mentally ill.

Some contemporary opponents of euthanasia fear that a society that allows physician-assisted suicide may eventually follow the path of the Nazi dictator Adolf Hitler's (1889–1945) euthanasia program, which began with the killing of physically and mentally impaired individuals and culminated in the annihilation of entire religious and ethnic groups considered by the Nazis to be unworthy of life. However, those supporting euthanasia argue that unlike the murderous Nazi euthanasia program designed by Hitler and his followers, twenty-first-century proposals are based on voluntary requests by individuals in situations of physical suffering and would be sanctioned by laws passed by democratic governments.

Distinguishing between Euthanasia and Physician-Assisted Suicide

In the United States the debate over euthanasia distinguishes between active and passive euthanasia. Active euthanasia, also called voluntary active euthanasia by those who distinguish it from the kind of euthanasia practiced by the Nazis, involves the hastening of death through the administration of lethal drugs, as requested by the patient or another competent individual who represents the patient's wishes.

By contrast, passive euthanasia involves forgoing medical treatment, knowing that such a decision will result in death. This action is not considered illegal because the underlying illness, which is permitted to run its natural course, will ultimately cause death. It is generally accepted in the United States that terminally ill individuals have a right to refuse medical treatment, as do those who are sick but not terminally so. However, some people think that allowing patients to forgo medical treatment is a practice tantamount to enabling suicide and is therefore morally reprehensible.

The debate about euthanasia in the United States has been expanded to include the question of whether a competent, terminally ill patient has the right to physician-assisted suicide, in which a physician provides the means (such as lethal drugs) for the patient to self-administer and commit suicide. The distinction between the two actions, euthanasia and physician-assisted suicide, is at times difficult to define: for example, a patient in the latter stages of amyotrophic lateral sclerosis (also known as Lou Gehrig's disease) is physically unable to kill him- or herself; there-fore, a physician who aids in such a person's suicide would technically be performing euthanasia.

SUICIDE

Different Cultures and Religions

Different religions and cultures have viewed suicide in different ways. Ancient Romans who dishonored themselves or their families were expected to commit suicide to maintain their dignity and, frequently, the family property. Early Christians were quick to embrace martyrdom as a guarantee of eternal salvation, but during the fourth century St. Augustine of Hippo (354–430) discouraged the practice. He and later theologians were concerned that many Christians who were suffering in this world would see suicide as a reasonable and legitimate way to depart to a better place in the hereafter. The view of the Christian theologian St. Thomas Aquinas (1225?–1274) is reflected in Catechism of the Catholic Church (2003) by the Catholic Church, which states that “suicide contradicts the natural inclination of the human being to preserve and perpetuate his life … [and] is contrary to love for the living God.”

Even though Islam and Judaism also condemn the taking of one's own life, Buddhist monks and nuns have been known to commit suicide by self-immolation (burning themselves alive) as a form of social protest. In a ritual called suttee, which is now outlawed, widows in India showed devotion to their deceased husbands by being cremated with them, sometimes throwing themselves on the funeral pyres, although it was not always voluntary. Widowers (men whose wives had died), however, did not follow this custom.

Quasi-religious reasons sometimes motivate mass suicide. In 1978 more than nine hundred members of a group known as the People's Temple killed themselves in Jonestown, Guyana. In 1997 a group called Heaven's Gate also committed mass suicide in California. The devastating terrorist attacks of September 11, 2001, were the result of a suicidal plot enacted by religious extremist groups. Suicide bombings in other parts of the world have also been attributed to extremist groups that have twisted or misinterpreted the fundamental tenets of Islam to further their political objectives.

The Japanese people have traditionally associated a certain idealism with suicide. During the twelfth century samurai warriors practiced voluntary seppuku (ritual self-disembowelment) to avoid dishonor at the hands of their enemies. Some samurai committed this form of slow suicide to atone for wrongdoing or to express devotion to a superior who had died. Even as recently as 1970, the famed author Yukio Mishima (1925–1970) publicly committed seppuku. During World War II (1939–1945) Japanese kamikaze pilots inflicted serious casualties with suicidal assaults in which they would purposely crash their planes into enemy ships, killing themselves along with enemy troops.

Suicide is still practiced in modern Japan. For example, in 1998 several government officials and businessmen hanged themselves in separate incidents involving scandals that attracted public attention. The reasons given for the suicides ranged from proclaiming innocence to assuming responsibility for wrongdoing. However, Japan's high level of suicides goes beyond such practices. According to the article “A Suicide Every 15 Minutes” (New Zealand Herald, February 25, 2008), in 2008 Japanese government statistics revealed that more than thirty thousand suicides had occurred in that country each year from 1998 to 2006. Reasons proposed for the high number of Japanese suicides include bullying at school, online suicide pacts, unemployment, and old age, with the root cause being depression. Eric Prideaux reports in “World's Suicide Capital—Tough Image to Shake” (Japan Times, November 20, 2007) that among the Group of Eight countries (Canada, France, Germany, Italy, Japan, Russia, the United Kingdom, and the United States) Japan ranks first in the number of female suicides annually and second in male suicides annually after Russia. Both Japan and the United States have about the same number of suicides each year, but Japan has half the population.

Suicide in the United States

Except for certain desperate medical situations, suicide in the United States is generally considered an unacceptable act, the result of irrationality or severe depression. It is often referred to as a permanent solution to a short-term problem.

In spite of this generally held belief, suicide was the eleventh-leading cause of death in the United States in 2005. (See Table 4.1 in Chapter 4.) There were nearly 1.9 times as many suicides as homicides that year. Nevertheless, since 1950 the national suicide rate has dropped from 13.2 suicides per 100,000 people to 10.9 per 100,000 in 2004. (See Table 6.1.) However, the 2004 rate is up from a low of 10.4 suicides per 100,000 in 2000.

GENDER AND RACIAL DIFFERENCES. In 2004 the suicide rate for men (18 people per 100,000) was four times that for women (4.5 people per 100,000). (See Table 6.1.) Over the decades, the male suicide rate has ranged from

3.5 to 4.5 times as high as the female suicide rate, except for 1970. In that year the female suicide rate was up, resulting in the male suicide rate being only 2.7 times that of the female suicide rate.

The racial group with the lowest suicide rate in 2004 was African-American females (1.8 per 100,000), followed closely by Hispanic females (2 per 100,000). (See Table 6.1.) In addition, adults aged seventy-five to eighty-four years had the lowest suicide rate of all age groups.

CIRCUMSTANCES OF SUICIDE. The National Vital Statistics System, which is a part of the Centers for Disease Control and Prevention (CDC), collects data from the fifty states, two cities (New York City and Washington, D.C.), and five territories (Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Common-

wealth of the Northern Mariana Islands). Each is responsible for registering vital events: births, deaths, marriages, divorces, and fetal deaths. Suicide data are compiled as part of the death data.

To add more specificity to violent death data, the CDC instituted the National Violent Death Reporting System (NVDRS) in 2002. In “National Violent Death Reporting System State Profiles” (August 9, 2007, http://www.cdc.gov/ncipc/profiles/nvdrs/state_profiles.htm), the CDC states that the NVDRS is a state-based system that collects information on the numbers and kinds of violent deaths along with details regarding those deaths. Six states joined the NVDRS initially and by 2004 seven states were members. The CDC received funding in 2006 to expand the system to seventeen states. Eventually, the system will include the fifty states, all U.S. territories, and the District of Columbia.

Figure 6.1 shows the percentage of suicide cases by selected circumstances as reported by the NVDRS in

2003 and 2004. These data are collected from a variety of sources, including death certificates, police reports, medical examiner and coroner reports, and crime laboratories. Because people may have more than one reason for committing suicide, the figures for each year do not total 100%. The two most common reasons found for suicide in 2003 and 2004 were depression and other mental health problems.

RURAL VERSUS URBAN SUICIDE RATES. Gopal K. Singh and Mohammad Siahpush compare in “Increasing Rural-Urban Gradients in U.S. Suicide Mortality, 1970–1997” (American Journal of Public Health, vol. 92, no. 7, July 2002) the suicide rates in rural and urban populations in the United States. The researchers report that the rate of suicide in rural populations of males increased between 1970 and 1997, whereas the rate of suicide in urban populations of males decreased over the same period. Even though the rates are lower for females and the changes are not as dramatic, a decrease was also noted in the suicide rate for urban females, whereas the suicide rate among rural females remained relatively stable.

In explaining these differences, Singh and Siahpush suggest that both rural and urban areas have experienced profound social and demographic changes during the past three decades. However, they contend that change has affected life in rural areas more than in urban areas. They note that high levels of social isolation, as often occurs in rural areas, are correlated with high suicide rates.

In “A Review of the Literature on Rural Suicide” (Crisis, vol. 27, no. 4, 2006), Jameson K. Hirsch agrees with Singh and Siahpush's observations and suggests that high rates of suicide in rural areas are not only a U.S. phenomenon but also a global phenomenon. Hirsch concludes that “a better understanding of the relationships between rural life and culture, geographic and interpersonal isolation, economic and sociopolitical distress, and suicide may inform improved treatments for rural individuals.”

Suicide among Young People

Suicide rates among young people aged fifteen to twenty-four years nearly tripled between 1950 and 1990, from 4.5 deaths per 100,000 to 13.2 deaths per 100,000. (See Table 6.1.) Rates among young adults aged twenty-five to thirty-four years increased as well, but not as dramatically; they increased 1.7 times from 9.1 deaths per 100,000 to 15.2 deaths per 100,000. However, the young adult rates were higher than the suicide rates among young people. Suicide rates dropped from 1990 to 2000 and then remained relatively stable through 2004. In 2005 suicide was the third-leading cause of death among people aged fifteen to twenty-four and the second-leading cause of death among people aged twenty-five to thirty-four. (See Table 4.2 in Chapter 4.)

Differences exist among racial groups in suicide rates. For example, the overall suicide rate among African-American males is lower than that of white males. In the fifteen- to twenty-four-year-old age group, suicide rates for white males ranged from 1.3 to 2.1 times as high as those for African-American males from 1950 through 2004. (See Table 6.1.) In 2004 the suicide rate for white males aged fifteen to twenty-four years was 1.5 times as high as that of African-American males of the same age group (17.9 deaths per 100,000 versus 12.2 deaths per 100,000). The suicide rates for both groups of young men rose from 1950 to 1990 and decreased by 2000. The rate for white males of this age group remained relatively stable through 2004, but decreased further for African-American males in 2003 and 2004.

In 1990 the highest suicide death rate among youths aged fifteen to twenty-four was 49.1 suicides per 100,000 people among Native American or Alaskan Native males. (See Table 6.1.) By 2000 this rate fell to 26.2 per 100,000 but rose to 27.2 in 2003 and to 30.7 in 2004.

ATTEMPTED SUICIDE AMONG YOUNG PEOPLE. Males of all races and ages are more likely to die from suicide attempts than are females of the same race and age. (See Table 6.1.) However, among high school students, females

are more likely than males to attempt suicide. As shown in Table 6.2, 10.8% of female high school students attempted suicide in 2005, compared to 6% of male high school students. More female (21.8%) than male (12%) high school students seriously considered suicide. Also, more female (2.9%) than male (1.8%) high school students injured

themselves in their suicide attempts. However, in 2004 only 3.5% of females aged fifteen to nineteen years died from their suicide attempts, whereas 12.6% of males of the same age group died. (See Table 6.1.)

Even though death rates from suicide declined among young adults aged fifteen to nineteen between 1990 and 2004, the percentage of high school students who attempted suicide increased from 7.3% in 1991 to 8.4% in 2005, peaking at 8.8% in 2001. (See Table 6.1 and Table 6.2.) The percentage of students injured during a suicide attempt also rose from 1.7%in 1991 to 2.9% in 2003, with a decline to 2.3% in 2005.

The percentage of high school students who attempted suicide in 2005 was highest among ninth graders and decreased with increasing grade level. (See Table 6.3.) The percentage of suicide attempts requiring medical attention followed the same pattern: a higher percentage of the suicide attempts of ninth graders required medical attention than did those of older students, and this percentage decreased as the grade level increased. Hispanic students

were the most likely to attempt suicide and white students were the least likely. In addition, suicide attempts were the highest among high school students living in North Carolina (13.1%), Hawaii (12.9%), Arkansas (12.1%), and Connecticut (12.1%). (See Table 6.4.)

In its collection of suicide-related statistics, the CDC has data on the percentage of high school students who feel sad or hopeless, who seriously consider attempting suicide, and who make a suicide plan. In 2005, 28.5% of high school students in all grades felt sad or hopeless. (See Table 6.5.) Approximately 16.9% seriously considered attempting suicide and 13% made a suicide plan. In 2005 the states in which more than 30% of high school students felt sad or hopeless were Arizona (34.3%), Arkansas (32.4%), Hawaii (31.8%), Texas (31.4%), and Tennessee (31%). (See Table 6.6.)

Table 6.7 shows the annual suicide rates among young people by method. The use of firearms was the method most frequently used by ten- to fourteen-year-olds from 1990 to 1996 for both males and females. In 1997 and from 2000 to 2004 hanging/suffocation overtook firearms as the most frequently used method of suicide in this age group for both sexes. In addition, the use of hanging/suffocation to commit suicide more than doubled from 2003 to 2004 for females. Poisoning was generally the third most widely used method of suicide for ten- to fourteen-year-olds, but it was used much less frequently than firearms or hanging/suffocation by adolescent males. In 1990 and 1993, however, poisoning was used more frequently than hanging/suffocation by adolescent females.

In the fifteen- to nineteen-year-old age group, hanging/suffocation overtook the use of firearms as the primary

method of committing suicide in 2001 for females, but it remained the most-used method by males in this age group from 1990 through 2004. (See Table 6.7.) The use of firearms by fifteen- to nineteen-year-old males decreased steadily from 1994 to 2003, with a slight increase in 2004. Poisoning ranked low in this age group from 1990 through 2004, as it did in the ten- to fourteen-year-old group. The use of firearms was also the most widely used means of committing suicide in those aged twenty to twenty-four in 1990 to 2004. Hanging/suffocation was generally second, and poisoning third, although in some years poisoning overtook suffocation as a means of suicide for females.

In general, the use of firearms is the method most often used by youths and young adults to commit suicide, with hanging/suffocation second and poisoning third. This pattern was also seen in the general population in 2005. (See Table 6.8.) The rate of death by firearms (5.7 suicides per 100,000 people) was more than twice that of suffocation (2.4 suicides per 100,000 people), and suffocation was used 1.3 times as much as poisoning (1.9 suicides per 100,000 people). Other methods were used much less frequently.

The statistics in this section underscore the urgent need for prevention, education, and support programs to help teens and young adults at risk. The National Center for Injury Prevention and Control (NCIPC) sponsors initiatives to raise public awareness of suicide and strategies to reduce suicide deaths. Along with supporting research about risk factors for suicide in the general population, the NCIPC develops programs for high-risk populations.

SUICIDE AMONG GAY AND LESBIAN ADOLESCENTS. Susan McAndrew and Tony Warne indicate in “Ignoring the Evidence Dictating the Practice: Sexual Orientation, Suicidality, and the Dichotomy of the Mental Health Nurse” (Journal of Psychiatric and Mental Health Nursing, vol. 11, no. 4, August 2004) that the suicide rate for gay and lesbian adolescents is dramatically higher than for the general adolescent population. Adolescence (the transition to adulthood) is often a difficult period. For gay and lesbian adolescents, this transition is compounded by having to come to terms with their sexuality in a society generally unaccepting of homosexuality.

At this period in their life, when the need to confide in and gain acceptance from friends and family may be crucial, gay and lesbian adolescents are often torn between choices that do not necessarily meet either of these needs. Those who are open about their sexual orientation risk disappointing or even alienating their families and facing the hostility of their peers. Teens who choose not to disclose their homosexuality may suffer emotional distress because they have nowhere to turn for emotional support. In either scenario, despair, isolation, anger, guilt, and overwhelming depression may promote suicidal thoughts or actual suicide attempts.

In “Sexual Orientation and Risk Factors for Suicidal Ideation and Suicide Attempts among Adolescents and Young Adults” (American Journal of Public Health, vol. 97, no. 11, November 2007), Vincent M. B. Silenzio et al. analyze data from the National Longitudinal Study of Adolescent Health and determine that young adults aged eighteen to twenty-six years who identified themselves as lesbian, gay, or bisexual were more likely than young adults of the same age group who were not lesbian, gay, or bisexual to have had thoughts of suicide (17.2% versus 6.3%) and to have attempted suicide (4.9% versus 1.6%). Exact data are not available for suicide deaths of gay, lesbian, and bisexual teenagers because the sexual orientation of suicide victims is often unknown.

EUTHANASIA AND PHYSICIAN-ASSISTED SUICIDE

The U.S. Constitution does not guarantee the right to choose to die. However, the U.S. Supreme Court recognizes that Americans have a fundamental right to privacy, or what is sometimes called the “right to be left alone.” Even though the right to privacy is not explicitly mentioned in the Constitution, the Supreme Court has interpreted

several amendments as encompassing this right. For example, in Roe v. Wade (410 U.S. 113, 1973), the Court ruled that the Fourteenth Amendment protects the right to privacy against state action, specifically a woman's right to abortion. In another example in the landmark Karen Ann Quinlan case, which was based on right-to-privacy rulings by the U.S. Supreme Court, the New Jersey Supreme Court held that the right to privacy included the right to refuse unwanted medical treatment and, as a consequence, the right to die (see Chapter 8).

The Acceptability of Euthanasia and Physician-Assisted Suicide

In “When Is Physician Assisted Suicide or Euthanasia Acceptable?” (Journal of Medical Ethics, vol. 29, no. 6, December 2003), Ste´phanie Frileux et al. examine the opinion of the general public on euthanasia and physician-assisted suicide. The researchers define these terms as follows: “In physician-assisted suicide, the physician provides the patient with the means to end his or her own life. In euthanasia, the physician deliberately and directly intervenes to end the patient's life; this is sometimes called ‘active euthanasia’ to distinguish it from withholding or withdrawing treatment needed to sustain life.” Their study posed the questions: “Should a terminally ill patient be allowed to die? Should the medical profession have the option of helping such a patient to die?” Frileux et al. find that acceptability of euthanasia or physician-assisted suicide by the general public appears to depend on four factors: the level of patient suffering, the extent to which the patient requested death, the age of the patient, and the degree of curability of the illness. In general, people judged euthanasia as less acceptable than physician-assisted suicide.

Lauris C. Kaldjian et al. study in “Internists' Attitudes toward Terminal Sedation in End of Life Care” (Journal of

Medical Ethics, vol. 30, no. 5, October 2004) the attitudes of internists (doctors specializing in internal medicine) toward physician-assisted suicide and other end-of-life care issues. Most physicians in the study (96%) agreed that it is appropriate to increase pain-reducing medication when needed in end-of-life care. More than three-quarters (78%) also agreed that if a terminally ill patient has pain that cannot be managed well, terminal sedation is appropriate. (Terminal sedation means alleviating the pain and discomfort of dying people by sedating them or by providing medication that alleviates their painful or uncomfortable symptoms but that has complete sedation as a side effect. These patients are not usually given nutrition or fluids. Terminal sedation is controversial because some feel it is tantamount to euthanasia, only slower, while still being perfectly legal.) One-third (33%) agreed that physician-assisted suicide is acceptable in some circumstances.

Kaldjian et al. also note that those who reported more experience with terminally ill patients were relatively more likely to support terminal sedation but not physician-assisted suicide than those who reported less or no experience with terminally ill patients. Those most likely to support both terminal sedation and physician-assisted suicide were those with no experience with terminally ill patients. In addition, the data show that those who did not attend religious services or attended less than monthly were the most likely to support both terminal sedation and physician-assisted suicide, whereas those who attended weekly were the least likely to support both. No matter the number of terminal patients physicians cared for in the preceding year or the frequency with which they attended religious services, a large proportion supported terminal sedation but not physician-assisted suicide.

Patients Requesting Assisted Suicide and Euthanasia

Diane E. Meier et al. studied various characteristics of patients requesting and receiving euthanasia and physician-assisted suicide and reported their results in “Characteristics of Patients Requesting and Receiving Physician-Assisted Death” (Archives of Internal Medicine, vol. 163, no. 13, July 14, 2003). The 1,902 physicians who responded to the researchers' survey reported 415 recent requests for aid in dying. Of these requests, 361 (89%) came from patients alone or in conjunction with their families. Only forty-six (11%) requests came from the family alone. Of the requests, 52% were for a lethal prescription, 25% for a lethal injection, and 23% for either a prescription or an injection.

Meier et al. find that the patients requesting euthanasia or physician-assisted suicide were predominantly male (61%), forty-six to seventy-five years old (56%), and of white European descent (89%). Almost half (47%) were college graduates and had a primary diagnosis of cancer. A large number were experiencing severe pain (38%) or severe discomfort other than pain (42%). Many were described by their physicians as dependent (53%), bedridden (42%), and expected to live less than one month (28%).

Marijke C. Jansen-van der Weide, Bregje D. Onwuteaka-Philipsen, and Gerrit van der Wal reveal in “Granted, Undecided, Withdrawn, and Refused Requests for Euthanasia and Physician-Assisted Suicide” (Archives of Internal Medicine, vol. 165, no. 15, August 8–22, 2005) the characteristics of patients in the Netherlands who explicitly requested euthanasia or physician-assisted suicide from April 2000 to December 2002. As in the Meier et al. study, more than half of the patients requesting euthanasia and assisted suicide were male (54%). Most of the patients were diagnosed with cancer (90%), a greater percentage than in the Meier et al. study. Even though only 9% were diagnosed with depression, 92% were “feeling bad.”

Table 6.9 shows the characteristics of patients at the end of life in Oregon, the only state in the Union in which assisted suicide is legal. These results, which are from patients who died between 1998 and 2005 and in 2006, are similar to the results found in the Meier et al. and Jansen-van der Weide, Onwuteaka-Philipsen, and van der Wal studies. The patients who died after ingesting a lethal dose of medication were predominantly male (53% in 1998–2005 and 57% in 2006), fifty-five to eighty-four years old (76% in 1998–2005 and 79% in 2006), and white (97% in 1998–2005 and 98% in 2006). More than 40% were college graduates (42% in 1998–2005 and 41% in 2006) and had a primary diagnosis of cancer (80% in 1998–2005 and 87% in 2006, close to the figures of the Jansen-van der Weide, Onwuteaka-Philipsen, and van der Wal study).

Reasons for Assisted Suicide Requests

In “Requests to Forgo Potentially Life-Prolonging Treatment and to Hasten Death in Terminally Ill Cancer Patients: A Prospective Study” (Journal of Pain and Symptom Management, vol. 31, no. 2, February 2006), Jean-Jacques Georges et al. reveal terminal cancer patients' reasons for refusing medical treatment or for requesting that their death be hastened. The primary reasons to forgo treatment were:

• General weakness (57%)
• Hopeless suffering (52%)
• Meaningless suffering (33%)
• Loss of dignity (19%)
• Physical symptoms, such as pain and nausea (19%)
• Weakness after long medical treatment (14%) The primary reasons for a request to hasten death were:
• Loss of dignity (75%)
• Hopeless suffering (63%)
• General weakness (63%)
• Loss of control over own life (56%)
• Physical symptoms, such as pain and nausea (56%)