In this issue of Palliative & Supportive Care, we are pleased to present recent work from Dr. E.R. Goy et al. (“Oregon hospice nurses and social workers' assessment of physician progress in palliative care over the past 5 years”) regarding their observations of the impact of the legalization of physician-assisted suicide in the state of Oregon. In 1977, Oregon enacted the Death with Dignity Act, which legalized physician-assisted suicide for terminally ill patients. In the past 5 years, a relatively small number of terminally ill patients in Oregon have requested assisted suicide and, after evaluation, were provided with physician assistance (Ganzini et al., 2002).

The debate surrounding the legalization of physician-assisted suicide in the United States had been quite contentious and resulted in a landmark United States Supreme Court decision that declared that there was, in fact, no constitutionally based “right to die.” This decision was a victory of sorts for opponents of legalized physician-assisted suicide and euthanasia; however, the decision opened the way for individual states to pursue their own policies and laws regarding these matters. Oregon was the first, and is still the only state, to have had voter approval and enactment of a law legalizing physician-assisted suicide. Opponents of legalization of physician-assisted suicide and/or euthanasia from the hospice and palliative care community were opposed, in part, because of concerns that legalizing such an option would erode efforts to improve palliative care in the United States and lead to dangerous abuses of a very vulnerable population.

One of the unintended consequences of the early debates around physician-assisted suicide, prior to the U.S. Supreme Court decision in 1996, was an increased public awareness of hospice and palliative care as alternatives to assisted suicide and euthanasia. A resulting surge in private philanthropic foundation support for palliative care program development and research, as well as a concurrent mobilization of medical associations/societies and governmental research institutional interest in palliative care issues and research, were an unexpected, but positive, outcome of this divisive debate. Similarly, observers in Oregon have described what they call the “silver lining” (Lee & Tolle, 1996) that resulted from the enactment of the Oregon Death with Dignity Act (ODDA). Since the enactment of the ODDA, many attempts have been made to improve palliative care in Oregon, including enhancement of the medical school curriculum in end-of-life care, the development of more hospital-based palliative care programs, a rise in statewide conferences on end-of-life care, and efforts to reduce barriers to access to hospice care. Since the passage of the ODDA, physicians describe themselves as having improved their knowledge regarding palliative care and use of opioids (Ganzini et al., 2001). The article by Goy et al. in this issue of Palliative & Supportive Care suggests that, based on hospice nurses' and hospice social workers' observations, physicians have improved their palliative care skills since the enactment of the ODDA.

Currently hospice organizations in Oregon provide care to approximately 40% of those who die in the state. Interestingly, 87% of Oregonians who have requested assisted suicide have been in hospice care. One might question then whether the quality of palliative care available has very much to do with whether an individual patient pursues and ultimately attains physician assistance in suicide. Researchers have made the argument that when it comes to addressing the legal rights of patients who truly want physician-assisted suicide or euthanasia, we are really speaking of an extremely small percentage of terminally ill patients, perhaps less than 1% of those who are dying (Chochinov & Wilson, 1995; Emanuel, Fairclough, & Emanuel, 2000). This suggests that the issue of legalizing or not legalizing physician-assisted suicide is essentially an irrelevant issue to the vast majority of patients who are terminally ill. Researchers (Breitbart et al., 1996, 2000; Chochinov et al., 1995) have further demonstrated that the issues that drive interest in physician-assisted suicide are not related to medical prognosis or even pain control, but rather to issues of depression, social support, and hopelessness.

Although it may be somewhat encouraging to read that the legalization of physician-assisted suicide in Oregon may have led to some perceived improvement in physician skills and attitudes towards palliative care, what clearly is not evident is an appreciation for the absolute necessity of increasing the public's and the health care providers' awareness of the important psychiatric and existential issues that are at the heart of the despair that leads terminally ill patients to see physician-assisted suicide or euthanasia as the only alternative available to ease their suffering. It is our hope that this journal, Palliative & Supportive Care, can increase awareness of the importance of these psychiatric, psychosocial, and existential issues in end-of-life care.