Vulnerable patients not at greater risk with legal PAS

Data in Oregon, Netherlands show no 'slippery slope'

It's a slippery slope say those who oppose legalizing physician-assisted suicide (PAS): Legalizing PAS will create disproportionate death rates among groups such as the elderly, uninsured, mentally ill, and poor. But a team of international ethicists say data don't support that concern.

A study of PAS in Oregon and the Netherlands showed that legalizing PAS did not result in a disproportionate number of deaths among the elderly, poor, women, minorities, uninsured, minors, chronically ill, less educated, or psychiatric patients, says Margaret Battin, PhD, a University of Utah bioethicist and professor of philosophy and internal medicine.

"Fears about the impact on vulnerable people have dominated debate about physician-assisted suicide," says Battin. "We find no evidence to support those fears where this practice already is legal."

The study found that of 10 patient groups studied, only AIDS patients used PAS at elevated rates.1

Is the slope slippery?

Battin and her colleagues sought to establish whether there is merit to the "slippery slope" argument, which has raised concern even among proponents of legalized PAS.

"Would these patients be pressured, manipulated, or forced to request or accept physician-assisted dying by overburdened family members, callous physicians, or institutions concerned about their own profits?" the researchers ask.

The researchers focused on two places where physicians can legally help patients end their lives: Oregon and the Netherlands.

Oregon is the only state in the United States where PAS is legal. The Death with Dignity Act was approved by voters in 1994 and 1997, and upheld by the U.S. Supreme Court in 2006. In the nine years following enactment of the law, 456 patients obtained lethal prescriptions from physicians, and 292 actually used the drugs to end their lives, accounting for 0.15% of all deaths in the state during that period.

The Netherlands enacted a law in 2002 allowing doctors to prescribe medication for suicide or to perform "voluntary active euthanasia," in which the physician, rather than the patient, administers life-ending medication. Unlike Oregon's law, the Dutch PAS law does not require that the patient be diagnosed with a terminal illness, but must be facing "intolerable suffering." Battin and her colleagues found that of 136,000 deaths annually in the Netherlands, about 1.7% are by voluntary active euthanasia, 0.1% by PAS, and 0.4% are what researchers called "extralegal" because they involve patients who did not make a request to die at the time of their deaths, but either made requests before losing competence or were deemed by surrogates to be "suffering intolerably."

The researchers noted that in both Oregon and the Netherlands, people who received a doctor's help in dying averaged 70 years old, and 80% were cancer patients.

Underprivileged not the majority

The researchers divided their findings into three categories:

  • Direct evidence that elderly people, women, and the uninsured do not die in disproportionate numbers where PAS is legal, but AIDS patients do. (The insurance data apply only to Oregon; all citizens of the Netherlands are insured.)
  • Direct and inferred evidence that PAS does not kill disproportionate numbers of people who are poor, uneducated, racial and ethnic minorities, minors, or people with chronic physical or mental disabilities or chronic but not terminal illnesses.
  • Inferred and sometimes contested evidence that shows people with psychiatric illness — including depression and Alzheimer's disease — are not likely to die in lopsided numbers.

"Those who received physician-assisted dying … appeared to enjoy comparative social, economic, educational, professional, and other privileges," the researchers write.

Of AIDS patients who died in Oregon in the nine years following the passage of the Death with Dignity Act, six died with the assistance of physicians, 2% of all PAS deaths during that time. But AIDS patients were 30 times more likely to take advantage of the PAS law than non-AIDS patients who died of chronic respiratory disorders, Battin reports.

"We've known for a long time from studies elsewhere that rates of assisted dying outside the law were much higher in people with AIDS," particularly in areas with large, supportive gay communities such as San Francisco, Battin says. "It's not a surprise to find high rates where physician-assisted dying is legal.

"We found no evidence to justify the grave and important concern often expressed about the potential for abuse."

The report on the study is available on-line at


  1. Battin MP, van der Heide A, Ganzini L, et al. Legal physician-assisted dying in Oregon and the Netherlands: Evidence concerning the impact on patients in vulnerable groups. J Med Ethics 2007;33:591-597.


For more information, contact:

  • Margaret Battin, PhD, distinguished professor of philosophy and adjunct professor of internal medicine, division of medical ethics, University of Utah, Salt Lake City. Phone (801) 581-6608. E-mail: