Suicide, Euthanasia, And Physician–Assisted Suicide

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Suicide, Euthanasia, And PhysicianAssisted Suicide


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 (18561950), Bertrand Russell (18721970), and H. G. Wells (18661946). 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 (18651936), who had been seriously ill for several years, was relieved of his sufferings by his physician, with the approval of his wife, Queen Mary (18671953).

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; 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 (18651943) and Karl Binding (18411920), 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 (18891945) 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.


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 (354430) 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 (19251970) publicly committed seppuku. During World War II (19391945) 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 CapitalTough 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.

Death rates for suicide, by sex, race, Hispanic origin, and age, selected years, 19502004

[Data are based on death certificates]
Sex, race, Hispanic origin, and age1950a1960a197019801990200020032004
All personsDeaths per 100,000 resident population
All ages, age-adjustedb13.212.513.112.212.510.410.810.9
All ages, crude11.410.611.611.912.410.410.811.0
Under 1 year**
14 years**
514 years0.
1524 years4.55.28.812.313.210.29.710.3
1519 years2.
2024 years6.
2544 years11.612.215.415.615.213.413.813.9
2534 years9.
3544 years14.314.216.915.415.314.514.915.0
4564 years23.522.020.615.915.313.515.015.4
4554 years20.920.720.015.914.814.415.916.6
5564 years26.823.721.415.916.012.113.813.8
65 years and over30.024.520.817.620.515.214.614.3
6574 years29.623.020.816.917.912.512.712.3
7584 years31.127.921.219.124.917.616.416.3
85 years and over28.826.
All ages, age-adjustedb21.220.019.819.921.517.718.018.0
All ages, crude17.816.516.818.620.417.117.617.7
Under 1 year**
14 years**
514 years0.
1524 years6.58.213.520.
1519 years3.55.68.813.818.113.011.612.6
2024 years9.311.519.326.825.721.420.220.8
2544 years17.217.920.924.024.421.321.921.7
2534 years13.414.719.825.024.819.620.620.4
3544 years21.321.022.122.523.922.823.223.0
4564 years37.134.430.023.724.321.323.523.7
4554 years32.031.627.922.923.222.424.424.8
5564 years43.638.132.724.525.719.422.322.1
65 years and over52.844.038.435.041.631.129.829.0
6574 years50.539.636.030.432.222.723.422.6
7584 years58.352.542.842.356.138.635.134.8
85 years and over58.357.442.450.665.957.547.845.0
All ages, age-adjustedb5.
All ages, crude5.
Under 1 year**
14 years**
514 years0.
1524 years2.
1519 years1.
2024 years3.
2544 years6.26.610.
2534 years4.
3544 years7.57.711.
4564 years9.910.
4554 years9.910.
5564 years9.910.
65 years and over9.
6574 years10.
7584 years8.
85 years and over8.

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

Death rates for suicide, by sex, race, Hispanic origin, and age, selected years, 19502004

[Data are based on death certificates]
Sex, race, Hispanic origin, and age1950a1960a197019801990200020032004
White male cDeaths per 100,000 resident population
All ages, age-adjustedb22.321.120.820.922.819.119.619.6
All ages, crude19.017.618.019.922.018.819.519.6
1524 years6.68.613.921.423.217.916.917.9
2544 years17.918.521.524.625.422.923.923.8
4564 years39.336.531.925.
65 years and over55.846.741.
6574 years53.242.038.732.534.224.325.224.2
7584 years61.955.745.545.560.241.137.537.1
85 years and over61.961.345.852.870.361.651.448.4
Black or African American male c
All ages, age-adjustedb7.58.410.011.412.810.09.29.6
All ages, crude6.
1524 years4.94.110.512.315.
2544 years9.812.616.119.219.614.314.313.7
4564 years12.713.012.411.813.
65 years and over9.09.98.711.414.911.59.211.3
6574 years10.011.38.711.114.711.18.39.8
7584 yearsd***10.514.412.111.315.0
85 years and over*******
American Indian or Alaska Native male c
All ages, age-adjustedb19.320.116.016.618.7
All ages, crude20.920.915.917.119.5
1524 years45.349.
2544 years31.227.824.530.130.8
4564 years**15.49.516.0
65 years and over*****
Asian or Pacific Islander male c
All ages, age-adjustedb10.
All ages, crude8.
1524 years10.813.
2544 years11.
4564 years13.09.79.710.011.1
65 years and over18.616.815.417.515.1
Hispanic or Latino male c,e
All ages, age-adjustedb13.710.39.79.8
All ages, crude11.
1524 years14.710.911.212.8
2544 years16.211.210.911.0
4564 years16.
65 years and over23.419.515.615.9
White, not Hispanic or Latino male e
All ages, age-adjustedb23.520.221.021.0
All ages, crude23.120.421.621.6
1524 years24.419.518.219.0
2544 years26.425.126.826.8
4564 years26.824.027.427.4
65 years and over45.433.933.132.1
White female c
All ages, age-adjustedb6.
All ages, crude5.
1524 years2.
2544 years6.
4564 years10.610.913.
65 years and over9.

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-

TABLE 6.1 Death rates for suicide, by sex, race, Hispanic origin, and age, selected years, 19502004 [Data are based on death certificates]
Sex, race, Hispanic origin, and age1950a1960a197019801990200020032004
Category not applicable.
* Rates based on fewer than 20 deaths are considered unreliable and are not shown.
Data not available.
a Includes deaths of persons who were not residents of the 50 states and the District of Columbia.
b Age-adjusted rates are calculated using the year 2000 standard population. Prior to 2003, age-adjusted rates were calculated using standard million proportions based on rounded population numbers. Starting with 2003 data, unrounded population numbers are used to calculate age-adjusted rates.
c The race groups, white, black, Asian or Pacific Islander, and American Indian or Alaska Native, include persons of Hispanic and non-Hispanic origin. Persons of Hispanic origin may be of any race. Death rates for the American Indian or Alaska Native and Asian or Pacific Islander populations are known to be underestimated.
d In 1950, rate is for the age group 75 years and over.
e Prior to 1997, excludes data from states lacking an Hispanic-origin item on the death certificate.
Notes: Starting with Health, United States, 2003, rates for 19911999 were revised using intercensal population estimates based on the 2000 census. Rates for 2000 were revised based on 2000 census counts. Rates for 2001 and later years were computed using 2000-based postcensal estimates. Figures for 2001 include September 11-related deaths for which death certificates were filed as of October 24, 2002. Age groups were selected to minimize the presentation of unstable age-specific death rates based on small numbers of deaths and for consistency among comparison groups. In 2003, seven states reported multiple-race data. In 2004, 15 states reported multiple-race data. The multiple-race data for these states were bridged to the single-race categories of the 1977 Office of Management and Budget standards for comparability with other states. Data for additional years are available.
SOURCE: Table 46. Death Rates for Suicide, by Sex, Race, Hispanic Origin, and Age: United States, Selected Years 19502004, in Health, United States, 2007. With Chartbook on Trends in the Health of Americans, Centers for Disease Control and Prevention, National Center for Health Statistics, November 2007, (accessed January 30, 2008)
Black or African American female cDeaths per 100,000 resident population
All ages, age-adjustedb1.
All ages, crude1.
1524 years1.8*
2544 years2.
4564 years2.
65 years and over**2.6**
American Indian or Alaska Native female c
All ages, age-adjustedb4.
All ages, crude4.
1524 years***8.310.5
2544 years10.7*
4564 years*****
65 years and over*****
Asian or Pacific Islander female c
All ages, age-adjustedb5.
All ages, crude4.
1524 years*
2544 years5.
4564 years7.
65 years and over*
Hispanic or Latino female c,e
All ages, age-adjustedb2.
All ages, crude2.
1524 years3.
2544 years3.
4564 years2.
65 years and over***1.8
White, not Hispanic or Latino female e
All ages, age-adjustedb5.
All ages, crude5.
1524 years4.
2544 years7.
4564 years8.
65 years and over7.

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,, 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, 19701997 (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

TABLE 6.2 Suicidal ideation and suicide attempts and injuries among students in grades 912, by sex, grade level, race, and Hispanic origin, selected years, 19912005 [Data are based on a national sample of high school students, grades 912]
Sex, grade level, race, and Hispanic origin19911993199519971999200120032005
Percent of students who seriously considered suicidea
9th grade17.617.718.216.111.914.711.912.2
10th grade19.518.016.714.513.713.813.211.9
11th grade25.320.621.716.613.714.112.911.9
12th grade20.718.316.313.515.613.713.211.6
Not Hispanic or Latino
Black or African American13.315.416.710.611.
Hispanic or Latino18.017.915.717.113.612.212.911.9
9th grade40.330.934.428.924.426.222.223.9
10th grade39.731.632.830.
11th grade38.428.931.
12th grade30.727.323.923.621.218.918.018.0
Not Hispanic or Latino
Black or African American29.424.522.222.018.817.214.717.1
Hispanic or Latino34.634.134.130.326.126.523.424.2
Percent of students who attempted suicide a
9th grade4.
10th grade3.
11th grade4.
12th grade3.
Not Hispanic or Latino
Black or African American3.
Hispanic or Latino3.
9th grade13.814.414.915.
10th grade12.
11th grade8.713.611.411.37.511.510.011.0
12th grade7.
Not Hispanic or Latino
Black or African American9.411.
Hispanic or Latino11.619.721.014.918.915.915.014.9
Percent of students with an injurious suicide attempt a,b
9th grade1.
10th grade0.
11th grade1.
12th grade0.
Not Hispanic or Latino
Black or African American0.
Hispanic or Latino0.

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

TABLE 6.2 Suicidal ideation and suicide attempts and injuries among students in grades 912, by sex, grade level, race, and Hispanic origin, selected years, 19912005 [Data are based on a national sample of high school students, grades 912]
Sex, grade level, race, and Hispanic origin19911993199519971999200120032005
a Response is for the 12 months preceding the survey.
b A suicide attempt that required medical attention.
Notes: Only youths attending school participated in the survey. Persons of Hispanic origin may be of any race.
SOURCE: Table 62. Suicidal Ideation, Suicide Attempts, and Injurious Suicide Attempts among Students in Grades 912, by Sex, Grade Level, Race, and Hispanic Origin: United States, Selected Years 19912005, in Health, United States, 2007. With Chartbook on Trends in the Health of Americans, Centers for Disease Control and Prevention, National Center for Health Statistics, November 2007, (accessed January 30, 2008)
9th grade2.
10th grade2.
11th grade2.
12th grade2.
Not Hispanic or Latino
Black or African American2.
Hispanic or Latino2.
Percentage of high school students who attempted suicide and whose suicide attempt required medical attention, by sex, race/ethnicity, and grade, 2005
Attempted suicidea, bSuicide attempt treated by a doctor or nursea, b
a During the 12 months preceding the survey.
b One or more times.
c Non-Hispanic.
SOURCE: Adapted from Danice K. Eaton et al., Table 18. Percentage of High School Students Who Actually Attempted Suicide and Whose Suicide Attempt Resulted in an Injury, Poisoning, or Overdose That Had to Be Treated by a Doctor or Nurse, by Sex, Race/Ethnicity, and GradeUnited States, Youth Risk Behavior Survey, 2005, in Youth Risk Behavior SurveillanceUnited States, 2005, Morbidity and Mortality Weekly Report, vol. 55, no. SS-5, June 9, 2006, (accessed February 2, 2008)

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

Percentage of high school students who attempted suicide and whose suicide attempt required medical attention, by sex and selected U.S. sites, 2005
Attempted suicidea,bSuicide attempt treated by a doctor or nurseb
State surveys
New Hampshire10.
New Jersey
New Mexico14.710.
New York8.
North Carolina13.312.713.1
North Dakota8.
Rhode Island10.
South Carolina11.110.811.
South Dakota14.37.611.
West Virginia12.

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

TABLE 6.4 Percentage of high school students who attempted suicide and whose suicide attempt required medical attention, by sex and selected U.S. sites, 2005
Attempted suicidea,bSuicide attempt treated by a doctor or nurseb
a During the 12 months preceding the survey.
b One or more times.
c Not available.
SOURCE: Adapted from Danice K. Eaton et al., Table 19. Percentage of High School Students Who Actually Attempted Suicide and Whose Suicide Attempt Resulted in an Injury, Poisoning, or Overdose That Had to Be Treated by a Doctor or Nurse, by SexSelected U.S. Sites, Youth Risk Behavior Survey, 2005, in Youth Risk Behavior SurveillanceUnited States, 2005, Morbidity and Mortality Weekly Report, vol. 55, no. SS-5, June 9, 2006, (accessed February 2, 2008)
Local surveys
Baltimore, MD11.410.411.
Boston, MA10.
Broward County, FL11.
Charlotte-Mecklenburg, NC11.512.612.1
Chicago, IL9.
Dallas, TX12.
DeKalb County, GA11.
Detroit, MI10.
District of Columbia15.
Hillsborough County, FL10.
Los Angeles, CA17.
Memphis, TN13.38.611.
Miami-Dade County, FL11.
Milwaukee, WI9.911.710.
New Orleans, LA11.
New York City, NY11.
Orange County, FL11.
Palm Beach County, FL7.
San Bernardino, CA16.110.813.
San Diego, CA12.56.910.
San Francisco, CA13.58.611.
Percentage of high school students who felt sad or hopeless, who seriously considered attempting suicide, and who made a suicide plan, by sex, race/ethnicity, and grade, 2005
Felt sad or hopelessa, bSeriously considered attempting suicidebMade a suicide planb
a Almost every day for2 weeks in a row so that they stopped doing some usual activities.
b During the 12 months preceding the survey.
c Non-Hispanic.
SOURCE: Adapted from Danice K. Eaton et al., Table 16. Percentage of High School Students Who Felt Sad or Hopeless, Who Seriously Considered Attempting Suicide, and Who Made a Plan about How They Would Attempt Suicide, by Sex, Race/Ethnicity, and Grade?Youth Risk Behavior Survey, 2005, in Youth Risk Behavior Surveillance?United States, 2005, Morbidity and Mortality Weekly Report, vol. 55, no. SS-5, June 9, 2006, (accessed February 2, 2008)
TABLE 6.6 Percentage of high school students who felt sad or hopeless, who seriously considered attempting suicide, and who made a suicide plan, by sex and selected U.S. sites, 2005
Felt sad or hopelessa, bSeriously considered attempting suicidebMade a suicide planb
State surveys
New Hampshire32.717.624.918.
New Jerseyc
New Mexico36.221.028.722.414.618.518.712.815.7
New York35.319.327.318.99.814.412.57.910.2
North Carolina32.320.726.518.712.515.615.410.813.1
North Dakota25.315.520.318.911.915.414.69.912.2
Rhode Island34.117.225.717.410.714.013.38.811.0
South Carolina33.923.228.616.912.814.915.112.113.6
South Dakota29.323.626.424.613.619.117.815.016.5
West Virginia34.424.729.621.012.716.915.19.812.4

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.

TABLE 6.6 Percentage of high school students who felt sad or hopeless, who seriously considered attempting suicide, and who made a suicide plan, by sex and selected U.S. sites, 2005
Felt sad or hopelessa, bSeriously considered attempting suicidebMade a suicide planb
a Almost every day for 2 weeks in a row so that they stopped doing some usual activities.
b During the 12 months preceding the survey.
c Not available.
SOURCE: Adapted from Danice K. Eaton et al., Table 17. Percentage of High School Students Who Felt Sad or Hopeless, Who Seriously Considered Attempting Suicide, and Who Made a Plan about How They Would Attempt Suicide, by Sex?Selected U.S. Sites, Youth Risk Behavior Survey, 2005, in Youth Risk Behavior Surveillance?United States, 2005, Morbidity and Mortality Weekly Report, vol. 55, no. SS-5, June 9, 2006, (accessed February 2, 2008)
Local surveys
Baltimore, MD34.622.629.016.810.313.813.59.911.8
Boston, MA36.822.730.
Broward County, FL40.223.932.
Charlotte-Mecklenburg, N32.521.427.015.711.013.414.710.512.6
Chicago, IL31.923.828.015.010.512.913.47.410.6
Dallas, TX39.220.930.219.110.414.815.610.012.8
DeKalb County, GA33.520.627.318.08.513.414.88.411.7
Detroit, MI37.520.129.718.48.914.214.25.710.4
District of Columbia26.316.921.814.37.310.811.26.38.7
Hillsborough County, FL39.524.031.919.911.515.816.911.314.2
Los Angeles, CA43.621.632.625.57.616.419.36.813.0
Memphis, TN34.119.327.117.48.813.316.07.211.7
Miami-Dade County, FL37.521.529.516.87.011.913.07.410.2
Milwaukee, WI39.625.332.615.99.012.413.510.812.1
New Orleans, LA31.923.227.910.912.911.98.910.29.6
New York City, NY40.324.332.320.010.315.313.69.911.9
Orange County, FL37.621.629.717.710.
Palm Beach County, FL32.323.327.815.211.313.311.48.39.9
San Bernardino, CA47.726.537.623.311.817.919.912.016.1
San Diego, CA40.826.333.823.012.117.516.39.813.0
San Francisco, CA33.121.827.318.410.

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.


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

TABLE 6.7 Annual suicide rates among persons aged 1024 years, by age group, method, sex, and year, 19902004 [Per 100,000 population in sex-age group]
1014 years1519 years2024 years
Sex/yearAll methodsaFirearmHanging/suffocationbPoisoningcAll methodsFirearmHanging/suffocationPoisoningAll methodsFirearmHanging/suffocationPoisoning
a Includes cutting, jumping, burning, drowning, and other or unspecified methods.
b Includes self-inflicted asphyxiation and ligature strangulation.
c Includes intentional drug overdose and carbon monoxide exposure.
** Unstable rate based on 20 or fewer deaths.
SOURCE: Table. Suicide Rates for Youths and Young Adults Aged 10?24 Years, by Age Group, Method, Sex, and Year?National Vital Statistics System, United States, 1990?2004, in Suicide Trends among Youths and Young Adults Aged 10?24 Years?United States, 1990?2004, Morbidity and Mortality Weekly Report, vol. 56, no. 35, September 7, 2007, (accessed February 2, 2008)

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

TABLE 6.8 Number of suicide deaths and suicide death rates, 2005
Mechanism of suicideNumber of deathsRate of death (per 100,000 population)
SOURCE: Adapted from Hsiang-Ching Kung et al., Table 18. Number of Deaths, Death Rates, and Age-Adjusted Death Rates for Injury Deaths According to Mechanism and Intent of Death: United States, 2005, in Deaths: Final Data for 2005, National Vital Statistics Reports, vol. 56, no. 10, January 2008, (accessed January 30, 2008)
All mechanisms32,63711.0
Other specified, classifiable3280.1
Other specified, not elsewhere classified2280.1
All transport1130.0

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 822, 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 19982005 and 57% in 2006), fifty-five to eighty-four years old (76% in 19982005 and 79% in 2006), and white (97% in 19982005 and 98% in 2006). More than 40% were college graduates (42% in 19982005 and 41% in 2006) and had a primary diagnosis of cancer (80% in 19982005 and 87% in 2006, close to the figures of the Jansen-van der Weide, Onwuteaka-Philipsen, and van der Wal study).

TABLE 6.9 Characteristics and end-of-life care of DWDA (Death with Dignity Act) patients who ingested lethal medication, Oregon, 19982006
Characteristics2006 (N = 46)a19982005 (N = 246)aTotal (N = 292)a
Male (%)26 (57)131 (53)157 (54)
Female (%)20 (43)115 (47)135 (46)
1834 (%)0 (0)3 (1)3 (1)
3544 (%)1 (2)7 (3)8 (3)
4554 (%)2 (4)26 (11)28 (10)
5564 (%)10 (22)45 (18)55 (19)
6574 (%)11 (24)72 (29)83 (28)
7584 (%)15 (33)72 (29)87 (30)
85+ (%)7 (15)21 (9)28 (10)
Median years (range)74 (3696)69 (2594)70(2596)
White (%)45 (98)239 (97)284 (97)
Asian (%)0 (0)6 (2)6 (2)
American Indian (%)0 (0)1 (<1)1 (<1)
Hispanic (%)1 (2)01 (<1)
Marital status
Married (%)23 (50)110 (45)133 (46)
Widowed (%)8 (17)55 (22)63 (22)
Divorced (%)10 (22)64 (26)74 (25)
Never married (%)5 (11)17 (7)22 (8)
Less than high school (%)4 (9)21 (9)25 (9)
High school graduate (%)11 (24)71 (29)82 (28)
Some college (%)12 (26)52 (21)64 (22)
Baccalaureate or higher (%)19 (41)102 (42)121 (41)
Metro counties (%)b18 (39)95 (39)113 (39)
Coastal counties (%)c2 (4)19 (8)21 (7)
Other western counties (%)19 (41)117 (48)136 (47)
East of the Cascades (%)7 (15)15 (6)22 (8)
Underlying illness
Malignant neoplasms (%)40 (87)196 (80)236 (81)
Lung and bronchus (%)6 (13)48 (20)54 (18)
Pancreas (%)7 (15)20 (8)27 (9)
Breast (%)2 (4)23 (9)25 (9)
Colon (%)3 (7)16 (7)19 (7)
Prostate2 (4)13 (5)15 (5)
Other (%)20 (43)76 (31)96 (33)
Amyotrophic lateral sclerosis (%)3 (7)20 (8)23 (8)
Chronic lower respiratory disease (%)0 (0)11 (4)11 (4)
HIV/AIDS (%)1 (2)5 (2)6 (2)
Illnesses listed below (%)d2 (4)14 (6)16 (5)
End of life care
Enrolled (%)35 (76)213 (87)248 (86)
Not enrolled (%)11 (24)31 (13)42 (14)
Private (%)29 (64)151 (62)180 (62)
Medicare or Medicaid (%)15 (33)90 (37)105 (36)
None (%)1 (2)2 (1)3 (1)

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:

TABLE 6.9 Characteristics and end-of-life care of DWDA (Death with Dignity Act) patients who ingested lethal medication, Oregon, 19982006
Characteristics2006 (N = 46)a19982005 (N = 246)aTotal (N = 292)a
End-of-life concerns e
Losing autonomy (%)44 (96)207 (86)251 (87)
Less able to engage in activities making life enjoyable (%)44 (96)206 (85)250 (87)
Loss of dignity (%)f35 (76)96 (82)131 (80)
Losing control of bodily functions (%)27 (59)138 (57)165 (57)
Burden on family, friends/caregivers (%)20 (43)90 (37)110 (38)
Inadequate pain control or concern about it (%)22 (48)54 (22)76 (26)
Financial implications of treatment (%)07 (3)7 (2)
PAS process
Referred for psychiatric evaluation (%)2 (4)34 (14)36 (13)
Patient died at
Home (patient, family or friend) (%)43 (93)232 (94)275 (94)
Long term care, assisted living or foster care facility (%)2 (4)11 (4)13 (4)
Hospital (%)1 (1)1 <1)
Other (%)1 (2)2 (1)3 (1)
Lethal medication
Secobarbital (%)31 (67)105 (43)136 (47)
Pentobarbital (%)15 (33)137 (56)152 (52)
Other (%)4 (2)4 (1)
Health-care provider present when medication ingested g
Prescribing physician (%)15 (33)48 (28)63 (29)
Other provider, prescribing physician not present (%)23 (51)92 (54)115 (53)
No provider (%)7 (16)31 (18)38 (18)
Regurgitated (%)4 (9)12 (5)16 (6)
Seizures (%)
Awakened after taking prescribed medication (%)0 (h)1 (h)1 (h)
None (%)40 (91)229 (95)269 (94)
Emergency medical services
Called for intervention after lethal medication ingested (%)
Calls for other reasons (%)i1 (2)3 (1)4 (1)
Not called after lethal medication ingested (%)45 (98)239 (99)284 (99)
  • 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%)
TABLE 6.9 Characteristics and end-of-life care of DWDA (Death with Dignity Act) patients who ingested lethal medication, Oregon, 19982006
Characteristics2006 (N = 46)a19982005 (N = 246)aTotal (N = 292)a
N = the number of patients (total sample size).
a Unknowns are excluded when calculating percentages.
b Clackamas, Multnomah, and Washington counties.
c Excluding Douglas and Lane counties.
d Includes aortic stenosis, alcoholic hepatic failure, cardiomyopathy, congestive heart failure, corticobasal degeneration, diabetes mellitus with renal complications, digestive organ neoplasm of unknown behavior, emphysema, endocarditis, hepatitis C, myelodysplastic syndrome, organ-limited amyloidosis, pulmonary disease with fibrosis, scleroderma, and Shy-Drager syndrome.
e Affirmative answers only (don't know included in negative answers). Available for 17 patients in 2001.
f First asked in 2003.
g The data shown are for 20012006. Information about the presence of a health care provider/volunteer, in the absence of the prescribing physician, was first collected in 2001. Attendance by the prescribing physician has been recorded since 1998. During 19982006, the prescribing physician was present when 35% of the patients ingested the lethal medication.
h Historically, the annual report tables list information on patients who died as a result of ingesting medication prescribed under the provisions of the Death with Dignity Act. Because one patient regained consciousness after ingesting the lethal medication and then died 14 days later from his/her illness rather than from the medication, the complication is recorded here but the patient is not included in the total number of physician assisted suicide (PAS) deaths.
i Calls included three to pronounce death and one to help a patient who had fallen.
j Note that an extended period of time may elapse from the patient's first request until the attending physician writes a prescription for the lethal medication.
SOURCE: Table 1. Characteristics and End-of-Life Care of 292 DWDA Patients Who Died after Ingesting a Lethal Dose of Medication, by Year, Oregon, 19982006, in Death with Dignity Act2006 Report, Oregon Department of Human Services, March 2007, (accessed February 2, 2008)
Timing of PAS event
Duration (weeks) of patient-physician relationship
Duration (days) between 1st request and deathj
Minutes between ingestion and unconsciousness
Minutes between ingestion and death
Range (minutes hours)1 min16.5 hrs4 min48 hrs1 min48 hrs
  • Meaningless suffering (38%)
  • Dependency (38%)

Even though patients nearing death have concerns about physical pain and suffering, they are also highly focused on loss of dignity, loss of control, and being a burden or dependent on others.

Jansen-van der Weide, Onwuteaka-Philipsen, and van der Wal note some of the same reasons patients requested assistance in dying. The three most often cited reasons for requesting euthanasia or physician-assisted suicide were pointless suffering (75%), deterioration or loss of dignity (69%), and weakness or tiredness (60%). Depression was the reason most likely to have influenced a patient to request assistance in dying and not wanting to burden his or her family was the second-most influential factor.

To gain an additional perspective on why terminally ill people in Oregon pursue assisted suicide, Linda Ganzini, Elizabeth R. Goy, and Steven K. Dobscha conducted a study to determine family members' perceptions of the reasons behind these requests and published their findings in Why Oregon Patients Request Assisted Death: Family Members' Views (Journal of General Internal Medicine, vol. 23, no. 2, February 2008). Their findings are similar to the results of studies previously cited in this chapter. According to family members, the most important reasons their loved ones requested assisted suicide was to control the circumstances of their death, because they feared not only a loss of dignity but also a poor quality of life with little independence and ability to care for themselves in the future. Conversely, family members reported that the least important reasons their loved ones requested assisted suicide included depression, financial concerns, and poor social support.


End-of-Life Choices

On July 21, 2003, the Hemlock Society officially became End-of-Life Choices. The organization advocates for legislation to allow Americans to live with the freedom of choosing a dignified death and informs and educates the public about the right to die.

End-Of-Life Choices was founded as the Hemlock Society in 1980 by Derek Humphry (1930), a British journalist. In 1975 Humphry helped his wife take her own life to end the pain and suffering caused by her terminal bone cancer. Humphry recounted this incident in Jean's Way: A Love Story (1978). The book launched his career in the voluntary euthanasia movement two years later.

In 1991 Humphry published Final Exit: The Practicalities of Self-Deliverance and Assisted Suicide for the Dying. The suicide manual, which was on the New York Times best-seller list for eighteen weeks, gives explicit instructions on how to commit suicide. Even though Humphry insisted that his how-to book was written only for those who were terminally ill, and not for those suffering from depression, some physicians were concerned about how the book would affect those suffering from depression. In October 1991, while Final Exit was selling out at bookstores, Humphry's second wife, Ann Wickett, whom he had divorced the year before, committed suicide. She had been diagnosed with cancer and was reportedly depressed. The third edition of Final Exit was published in 2002.

Humphry retired from the Hemlock Society in 1992, but his more recent activities have also sparked controversy. In 1999 he recorded a video depicting a variety of methods for committing suicide. Though it had been available from the Hemlock Society USA for several months, the video drew even more criticism when it aired on public television in Oregon a number of times in 2000. Critics asserted that this airing provided dangerous information, particularly to people who were depressed or mentally ill and to children.

In 2004 Humphry published The Good Euthanasia Guide 2004: Where, What, and Who in Choices in Dying. Much of the book describes international suicide laws.

Jack Kevorkian

Jack Kevorkian (1928) first earned the nickname Dr. Death when, as a medical resident, he would photograph patients at the time of death to gather data that would help him differentiate death from coma, shock, and fainting. During his study and residency, he suggested unconventional ideas, such as the harvesting of organs from death-row inmates. His career as a doctor was also checkered (Kevorkian's own word) and notable for controversy.

In the late 1980s Kevorkian retired from pathology work and pursued an interest in the concept of physician-assisted suicide, becoming one of its best-known and most passionate advocates. He constructed the Mercitron, a machine that would allow a patient to press a red button and self-administer a lethal dose of poisonous potassium chloride, along with thiopental, a painkiller. Raphael Cohen-Almagor notes in A Circumscribed Plea for Voluntary Physician-Assisted Suicide (Annals of the New York Academy of Sciences, vol. 913, no. 1, September 2000) that Kevorkian claims to have assisted in over 130 suicides.

The first patient to commit suicide with Kevorkian's assistance and his Mercitron was Janet Adkins. Adkins, a Hemlock Society member, sought Kevorkian's aid because she did not want to wait until she lost her cognitive abilities to Alzheimer's disease. In June 1990 Adkins committed suicide in Kevorkian's van in a public campground.

In 1991 Kevorkian assisted in the deaths of two Michigan women on the same day. Sherry Miller, aged forty-three, had multiple sclerosis, and Marjorie Wantz, aged fifty-eight, complained of a painful pelvic disease. Neither one was terminally ill, but court findings showed that they both suffered from depression. In 1996 Kevorkian was tried for the assisted deaths of Miller and Wantz under the common law that considers assisted suicide illegal. Common law against assisted suicide means there is a precedent of customs, usage, and court decisions that support prosecution of an individual assisting in a suicide. Kevorkian was acquitted.

He continued to draw media attention with increasingly controversial actions. In February 1998 twenty-one-year-old Roosevelt Dawson, a paralyzed university student, became the youngest person to commit suicide with Kevorkian's help. In June 1998 Kevorkian announced that he was donating kidneys from Joseph Tushkowski, a quadriplegic whose death he had assisted. His actions were denounced by transplant program leaders, medical ethicists, and most of the public. The organs were refused by all medical centers and transplant teams.

In October 1998 Kevorkian euthanized fifty-two-year-old Thomas Youk, a man afflicted with Lou Gehrig's disease, at the patient's request. Kevorkian video-taped the death and gave the video to the CBS television show 60 Minutes for broadcast. The death was televised nationwide in November 1998 during primetime and included an interview with Kevorkian. He taunted Oakland County, Michigan, prosecutors to file charges against him. They did, and Kevorkian was convicted of second-degree murder in March 1999. On April 13, 1999, the seventy-year-old retired pathologist was sentenced to ten to twenty-five years in prison. While in prison, Kevorkian staged three hunger strikes and was subjected to force-feeding by prison officials. Kevorkian was released from prison on June 1, 2007, due to good behavior, and in March 2008 he announced plans to run for Congress in Michigan.


In general, physician-assisted suicide is seen as being at odds with the work of doctors and nurses. In Physician-Assisted Suicide (Annals of Internal Medicine, vol. 135, no. 3, August 7, 2001), the American College of PhysiciansAmerican Society of Internal Medicine (ACPASIM) states its position on physician-assisted suicide. The organization notes that it does not support the legalization of physician-assisted suicide. In addition, the ACPASIM explains that not only would the routine practice of physician-assisted suicide raise serious ethical concerns but also it would undermine the patient-physician relationship and the trust necessary to sustain it.

In 2005 the ACP again officially opposed physician-assisted suicide. The organization's formal position statement on this topic was published within the fifth edition of Ethics Manual ( The statement reads:

The College does not support legalization of physician-assisted suicide. After much consideration, the College concluded that making physician-assisted suicide legal raised serious ethical, clinical, and social concerns and that the practice might undermine patient trust and distract from reform in end of life care. The College was also concerned with the risks that legalization posed to vulnerable populations, including poor persons, patients with dementia, disabled persons, those from minority groups that have experienced discrimination, those confronting costly chronic illnesses, or very young children. One state, Oregon, has legalized the practice of physician-assisted suicide, and its experience is being reviewed. Other states might legalize this practice, but the major emphasis of the College and its members, including those who might lawfully participate in the practice, must focus on ensuring that all persons facing serious illness can count on good care through to the end of life, with prevention or relief of suffering, commitment to human dignity, and support for the burdens borne by family and friends. Physicians and patients must continue to search together for answers to the problems posed by the difficulties of living with serious illness before death, without violating the physician's personal and professional values, and without abandoning the patient to struggle alone.

In 1994 the American Nurses Association's (ANA; 2008, position statements on assisted suicide and active euthanasia were adopted by its board of directors. The ANA believes that the nurse should not participate in assisted suicide. Such an act is in violation of the Code for Nurses with Interpretive Statements (Code for Nurses) and the ethical traditions of the profession. Nurses, individually and collectively, have an obligation to provide comprehensive and compassionate end-of-life care which includes the promotion of comfort and the relief of pain, and at times, forgoing life-sustaining treatments. The ANA also believes that the nurse should not participate in active euthanasia because such an act is in direct violation of the Code for Nurses with Interpretive Statements (Code for Nurses), the ethical traditions and goals of the profession, and its covenant with society. Nurses have an obligation to provide timely, humane, comprehensive and compassionate end-of-life care.

The American Medical Association (AMA) updated its position statement on physician-assisted suicide in 1996. The AMA (2007, states: Allowing physicians to participate in assisted suicide would cause more harm than good. Physician-assisted suicide is fundamentally incompatible with the physician's role as healer, would be difficult or impossible to control, and would pose serious societal risks.


As of May 2008, Oregon was the only state with a law allowing physician-assisted suicide and then only in limited circumstances. Attempts to allow assisted suicide have been defeated in California, Maine, Michigan, Washington, and Wyoming. In addition, an assisted suicide proposal was shelved in the Hawaii legislature.

The Oregon Death with Dignity Act

In November 1994 Oregon voters approved Measure 16 by a vote of 51% to 49%, making Oregon the first state in the Union to legalize physician-assisted suicide. Under the Oregon Death with Dignity Act (ODDA), a mentally competent adult resident of Oregon who is terminally ill (likely to die within six months) may request a prescription for a lethal dose of medication to end his or her life. At least two physicians must concur on the terminal diagnosis, and the patient must request the medication in writing, witnessed by two individuals who are neither related to the patient nor are caregivers of the patient. The patient must take the medication him- or herself.

Between 1994 and 1997 the ODDA was kept on hold due to legal challenges. In November 1997 Oregonians voted to defeat a measure to repeal the 1994 law. Immediately after this voter reaffirmation of the ODDA, the U.S. Drug Enforcement Administration (DEA) warned Oregon doctors that they could be arrested or have their medical licenses revoked for prescribing lethal doses of drugs. The DEA administrator Thomas Constantine (1938), who was under pressure from some members of Congress, stated that prescribing a drug for suicide would be a violation of the Controlled Substances Act (CSA) of 1970 because assisted suicide was not a legitimate medical purpose. Janet Reno (1938), who was then the U.S. attorney general, overruled Constantine and decided that that portion of the CSA would not apply to states that legalize assisted suicide. Those opposed to the practice observed that Reno's ruling was inconsistent with other rulings, citing the government's opposite ruling in states that have legalized marijuana for medical use. (Reno maintained that the prescription of marijuana was still illegal, regardless of its medicinal value.)

In response to the DEA decision, Congress moved toward the passage of the Pain Relief Promotion Act. This law would promote the use of federally controlled drugs for the purpose of palliative care but would prevent their use for euthanasia and assisted suicide. In 2000 the U.S. House of Representatives passed the bill, but the U.S. Senate did not. The act never became law.

On November 6, 2001, John D. Ashcroft (1942), who succeeded Reno as the U.S. attorney general, overturned Reno's 1998 ruling that prohibited the DEA from acting against physicians who use drugs under the ODDA. Ashcroft said that taking the life of terminally ill patients is not a legitimate medical purpose for federally controlled drugs. The Oregon Medical Association and the Washington State Medical Association opposed Ashcroft's ruling, and even physicians opposed to assisted suicide expressed concern that the ruling might compromise patient care and that any DEA investigation might discourage physicians from prescribing pain medication to patients in need.

The state of Oregon disagreed so vehemently with Ashcroft's interpretation of the CSA that on November 7, 2001, Oregon's attorney general filed suit, claiming that Ashcroft was acting unconstitutionally. A November 8, 2001, restraining order allowed the ODDA to remain in effect while the case was tried.

On April 17, 2002, Judge Robert E. Jones (1927) of the U.S. District Court for the District of Oregon ruled in favor of the ODDA. His decision read, in part:

State statutes, state medical boards, and state regulations control the practice of medicine. The CSA was never intended, and the [U.S. Department of Justice] and DEA were never authorized, to establish a national medical practice or act as a national medical board. To allow an attorney generalan appointed executive whose tenure depends entirely on whatever administration occupies the White Houseto determine the legitimacy of a particular medical practice without a specific congressional grant of such authority would be unprecedented and extraordinary. Without doubt there is tremendous disagreement among highly respected medical practitioners as to whether assisted suicide or hastened death is a legitimate medical practice, but opponents have been heard and, absent a specific prohibitive federal statute, the Oregon voters have made the legal, albeit controversial, decision that such a practice is legitimate in this sovereign state.

The Justice Department appealed the ruling to the Ninth Circuit Court of Appeals. On May 26, 2004, the court stopped Ashcroft's attempts to override the Oregon law. The divided three-judge panel ruled that Ashcroft overstepped his authority when he declared that physicians who prescribe lethal drug doses are in violation of the CSA and when he instructed the DEA to prosecute the physicians. In addition, the court noted that Ashcroft's interpretation of the CSA violated Congress's intent.

In February 2005 the U.S. Supreme Court agreed to hear the Bush administration's challenge of the ODDA. On January 17, 2006, the Court let stand Oregon's physician-assisted suicide law. The High Court held that the CSA does not allow the Attorney General to prohibit doctors from prescribing regulated drugs for use in physician-assisted suicide under state law permitting the procedure. Writing for the majority, Justice Anthony M. Kennedy (1936) stated that both Ashcroft and Alberto Gonzales (1955), who replaced Ashcroft as the U.S. attorney general, did not have the power to override the Oregon physician-assisted suicide law. Kennedy also added that it should not be the attorney general who determines what is a legitimate medical purpose for the administration of drugs, because the job description for the attorney general does not include making health and medical policy.

ANALYSIS OF THE EFFECTS OF THE ODDA. In March 1998 an Oregon woman in her mid-eighties who had terminal breast cancer ended her life with a lethal dose of barbiturates. Hers was the first known death under the ODDA. By the end of 2006, a total of 292 people had reportedly committed suicide with a doctor's assistance under the ODDA. According to the Oregon Department of Human Services, in Summary of Oregon's Death with Dignity Act2006 (March 2007,, sixty-five Oregon patients requested and received lethal medications in 2006. Of these patients, thirty-five took the medications and died in 2006. In addition, eleven patients with prescriptions from an earlier year took their medications and died, bringing the total of DWDA deaths to forty-six in 2006. (See Figure 6.2.) Prescriptions for lethal medication increased every year from 1998 to 2003 and have since leveled off.

Table 6.9 shows that over 90% of patients who died under the ODDA did so at home. A small percentage died in long-term care or other similar facilities. Other than a few instances in which the lethal medication was regurgitated, medical complications have been few.


The Netherlands

Euthanasia became legal in the Netherlands on April 10, 2001. Before that date, active euthanasia was a criminal offense under article 293 of the Dutch Penal Code, which read, He who takes the life of another person on this person's explicit and serious request will be punished with imprisonment of up to twelve years or a fine of the fifth category. At the same time, however, section 40 of the same penal code stated that an individual was not punish-able if he or she was driven by an irresistible force (legally known as force majeure) to put another person's welfare above the law. This might include a circumstance in which a physician is confronted with the conflict between the legal duty of not taking a life and the humane duty to end a patient's intolerable suffering.

ORIGIN OF OPEN PRACTICE. In 1971 Geertruida Postma granted an elderly nursing home patient's request to die by injecting the patient with morphine and ending her life. The patient was her seventy-eight-year-old mother, who was partially paralyzed and was tied to a chair to keep her from falling. Postma was found guilty of murder, but her penalty consisted of a one-week suspended jail sentence and one-year probation. This light sentence encouraged other physicians to come forward, admitting that they had also assisted in patients' suicides.

Two years later the Royal Dutch Medical Association announced that, should a physician assist in the death of a terminally ill patient, it was up to the court to decide if the physician's action could be justified by a conflict of duties. In Alkmaar, Netherlands, Piet Schoonheim helped the ninety-five-year-old Marie Barendregt to die in 1982 by using a lethal injection. Barendregt, who was severely

disabled, had initially signed an advance directive refusing artificial (life-prolonging) treatment. Schoonheim assisted in Barendregt's death with the knowledge of the patient's son and after consultation with two independent physicians. In 1984 the Dutch Supreme Court, ruling on this well-known Alkmaar case (the court case is referred to by the name of the city where the trial took place), found Schoonheim not guilty of murder.

Since then, until euthanasia was legalized, each euthanasia case brought under prosecution was judged on its individual circumstances. The force majeure defense ensured acquittal, while compliance with certain guidelines for performing euthanasia laid down by the Royal Dutch Medical Association and the Dutch courts in 1984 protected physicians from prosecution.

On April 10, 2001, the Dutch Parliament voted forty-six to twenty-eight to legalize physician-assisted suicide by passing the Termination of Life on Request and Assisted Suicide (Review Procedures) Act. Arguments in favor of the bill included public approval ratings of 90%. In May 2001 the results of a Dutch public opinion poll revealed that nearly half of respondents favored making lethal drugs available to older adults who no longer wanted to live.

MONITORING OF EUTHANASIA AND PHYSICIAN-ASSISTED SUICIDE. Bregje D. Onwuteaka-Philipsen et al. explain in Dutch Experience of Monitoring Euthanasia (British Medical Journal, vol. 331, no. 7518, September 24, 2005) that euthanasia and physician-assisted suicide have been monitored in the Netherlands since 1994, with the first review procedure given approval by the Dutch government in 1991. Even though euthanasia and physician-assisted suicide were not yet legal in that country, physicians were required to report cases and would not be prosecuted if they met the requirements for prudent practice that had been developed. The substantive requirements asserted that the patient's request must be voluntary and well considered, the patient's condition must be unbearable and hopeless, no acceptable alternatives for treatment are available, and the method is medically and technically appropriate. The procedural requirements asserted that another doctor is consulted before proceeding and that the case is reported as an unnatural death. The procedure was evaluated in 1996, and a new system was introduced in 1998, but euthanasia and physician-assisted suicide remained illegal.

In 2001, along with legalizing euthanasia and physician-assisted suicide, the Termination of Life on Request and Assisted Suicide (Review Procedures) Act established a revised review procedure. Throughout the review changes, the requirements for prudent practice did not change and were the main focus of review. The purpose of the review process was to have physicians report on euthanasia and physician-assisted suicide and to follow prudent practice.

Euthanasia in Belgium

The Belgian Act on Euthanasia passed in 2002 after the Dutch law, making Belgium the second country to legalize euthanasia. The law applies to competent adults who have an incurable illness causing unbearable, constant suffering and to patients in a persistent vegetative state who made their wishes known within the previous five years in front of two witnesses. It allows someone to terminate the life of another at his or her voluntary, well-considered, and repeated request, but does not allow physician-assisted suicide. All acts of euthanasia must be reported.

Switzerland Allows Assisted Suicide but Not Euthanasia

Euthanasia is not legal medical treatment in Switzerland as it is in Oregon, Belgium, and the Netherlands, but the country does not punish suicide assisted by physicians or people with no medical training if they conducted the act for altruistic reasons. Assisted suicide is a crime if motivated by financial gain or by selfish or negative reasons.

Assisted suicide is not considered an appropriate part of medical practice by the Swiss Academy of Medical Sciences, so physicians generally do not assist in suicides of the terminally ill. Members of EXIT (the Swiss Society for Humane Dying) are allowed to help terminally ill Swiss residents commit suicide in their home. In January 2006 the Vaud University Hospital Center in Lausanne began allowing EXIT to help patients already admitted to the hospital and who could no longer go home to take their own life.

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Suicide, Euthanasia, And Physician–Assisted Suicide

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