assisted suicide research paper topics

Choosing Death over Suffering

Informing patients about physician aid-in-dying .

For the first time, many physicians, regardless of specialty, are being forced to consider what the standard of care will be for informing patients about “assisted suicide” or "physician aid-in-dying ” (PAD). The American Medical Association (AMA) Code of Medical Ethics does not condone physician participation, calling the practice “fundamentally incompatible with the physician’s role as healer.”  [1]  As an alternative to PAD, the AMA advocates aggressive multidisciplinary interventions including emotional support and adequate pain control.  [2]

Although the AMA is opposed to the practice of PAD, a 2010 survey of more than 21,000 medical professionals found that the majority of the doctors surveyed (54 percent) favored a patient’s right to physician aid-in-dying.  [3]  As of this writing, PAD has been legalized or available through court ruling in seven states (California, Colorado, Hawaii, Oregon, Montana, Vermont, Washington) and the District of Columbia; New Jersey is passing legislation following suit in August, followed by Maine in September. As more states legalize PAD and the AMA continues to affirm it to be unethical, many physicians will have to decide whether to follow the ethical cannon of their profession or allow patients to exercise their rights under the law. In light of the rapid expansion of PAD as an end-of-life option, the medical community needs to determine an ethical standard for informing patients about the choices available to them.

Diagnosed with amyotrophic lateral sclerosis (ALS),  Craig Ewert  made the decision to choose how he would spend his final days, and ultimately end his life. Mr. Ewert and his wife traveled to Switzerland where, with the legal assistance of a physician, he died at age fifty-nine by consuming a lethal dose of pentobarbital. Prior to his death, Mr. Ewert stated, “At this point, I’ve got two choices . . . if I go through with it, I die, as I must at some point. If I do not go through with it, my choice is essentially to suffer and to inflict suffering on my family and then die—possibly in a way that is considerably more stressful and painful than this way (physician aid-in dying). So, I’ve got death, and I’ve got suffering and death. You know, this makes a whole lot of sense to me.”  [4]

Mr. Ewert’s story is not unique. Since 1997, over 2,000 Americans have made the decision to end their lives with the help of a physician, rather than to suffer during the end stages of terminal illnesses.  [5]  Twenty years ago, PAD was illegal in all fifty states. In 1997, Oregon became the first state to legally allow terminally ill patients the option to hasten death by taking a prescription medication.  [6]  Many more states have attempted to pass legislation legalizing PAD, including a Ballot initiative in Massachusetts.  [6]  However, no standard of care yet exists to guide physicians and patients during the medical decision-making process about the option of physician aid in dying at the end of life. This poses an ethical quandary for providers.

Enshrined in the principle of informed consent are two ideas. First is the patient’s legal right to make the decisions that affect his or her medical care. [6] , [7] , [8]  Second, the patient has a right to know about the options available from which to choose. Because most patients are not experts in medical matters, the physician is obligated to disclose relevant information so the patient can make an “informed” decision about his or her treatment. [6] , [7] , [8]  Traditionally, the information that a physician has a duty to disclose has been based on the customs and traditions of the community. [6] , [7] , [8]  Essentially, physicians are responsible to disclose only information about care and treatment options that are customarily disclosed within the physicians’ and patients’ community. In the case of PAD, in places where it is not legal, physicians have not customarily informed patients of this option. As more states legalize PAD and the practice becomes more ethically accepted, it is important to determine a standard of care to guide physicians.

When determining an ethical standard of discussing physician aid in dying during medical decision-making, it is important to begin with the caveat that physicians are not ethically obligated to assist a patient in ending his or her life, even if the physician informs the patient of the right to do so. Physicians have the right to conscientious objection, that is, the right to recuse him or herself from treating a patient when he or she religiously or ethically opposes the treatment option, and when the physician’s recusal will not compromise the quality, efficiency, or equitable delivery of the patient’s care.  [9]  Thus, the question of whether a physician ought to inform a patient about the possibility of PAD is separate from whether the physician is obligated to help assist a patient who wants to exercise this medical decision.

Since the AMA does not condone PAD, but more than half of physicians surveyed support this option, a disconnect exists between the ethical values put forth in the AMA Code of Medical Ethics and the values of practicing physicians. While physicians are not legally or ethically bound to provide PAD, in places where the practice is legal, the AMA’s position against this practice presents physicians with the dilemma of choosing between the doctrine of informed consent what is ethical and what is legal when advising patients on end-of-life medical options. Although PAD may be a legally accepted option in many states, it is not universally condoned as an ethical practice within the medical profession. The question of whether physicians ought to inform patients of a controversial medical intervention is not new. Several years ago, when Plan B, an emergency contraceptive pill, was released as a secondary form of birth control, pharmacists and physicians around the country were forced to determine whether they would provide Plan B to their patients.  [9]  Although it was uniformly legal to provide Plan B, the medical community determined that physicians could decline to prescribe it and pharmacists could decline to provide it to patients. However, providers who refused were ethically required to direct patients to a provider who would provide Plan B.  [9]

In the case of PAD, if the patient approaches their doctor about this option, physicians who contentiously object to providing it should direct patients to providers who are willing to discuss this option. The question of whether physicians are ethically obligated to bring this option to the patient’s attention in the first place as part of the informed consent process during medical decision-making is more complex. The AMA has issued an official opinion that "[p]atients have the right to receive information and ask questions about well-considered decisions about care.”  [10]  Thus, a physician’s right to conscientious objection does not trump the patient’s right to informed consent in medical decision-making.

In order to support physicians in these difficult end-of-life decisions, one approach may be to have palliative care physicians discuss this option with patients. Palliative care providers have special training in how to talk about the dying process and may be the best physician to have this discussion with dying patients. Although, asking palliative care physicians—given their specialized training and ability to handle dying patients—to have these difficult conversations may be the best practical idea, this approach as a matter of policy has the potential to create a stigma about palliative care and the role these physicians play in the death and dying process. Palliative care physicians work to help improve quality of life and alleviate suffering during the end of life without intentionally hastening death.  [10]  Aiding patients in dying is in direct contention with the goals of palliative care as aid in dying intrinsically hastens death. If palliative care becomes associated with the act of hastening death, the specialty may face the unintended consequence of patients fearing palliative care.

Another option for ensuring patients are appropriately informed of their end-of-life options is to have a non-physician approach patients, similar to the role the  Organ Procurement and Transplantation Network  plays during organ procurement. Yet another would be to create a national registry of physicians willing and able to assist patients who indicate an interest in learning more about assisted death options. This could be accomplished by creating a centralized mechanism for patients to inquire about PAD, as suggested by Prokopetz and Lehmann.  [11]

Establishing a standard of care for the informed consent process is important in ensuring that all patients are informed about available, appropriate, and ethical end-of-life care options. Although the AMA denounces aid in dying as an unethical practice, physicians may argue that if PAD is legal in their state of practice and presenting end-of-life care is appropriate for the patient, then physicians should be allowed to present this choice without condemnation from his or her accrediting body. Allowing each physician to individually determine whether he or she is comfortable having the conversation about PAD options may be seen as protecting physician’s individual conscience. However, such a policy may result in an unjust provision of care in that all patients will not be uniformly informed about the end-of-life care possibilities. And although providing information about PAD may make some physicians uncomfortable, this standard does not deviate from established ethical norms of informed consent, such as the responsibility of physicians to inform patients that abortion is an option (even if the physician contentiously objects to performing abortions).

Providing patients with all end-of-life care options, including PAD as a routine part of the informed consent process will allow the greatest number of patients to consider this option. In states where PAD is legal, standing informed consent doctrines justify requiring physicians to give patients this information as part of the informed consent process; it is harder to justify this practice in states where PAD is not legal. In states where PAD is not legal, physicians should at least have the discretion to inform patients who would benefit from this information about options in states where PAD is legally available. In allowing physicians the option to discuss physician aid in dying, more patients will have the ability to consider this option when making end-of-life decisions.

Amber R. Comer, PhD, JD , can be reached at comer(at)iu.edu.

[1]  American Medical Association. Principles of Medical Ethics. Physician-Assisted Suicide, Code of Medical Ethics Opinion 5.7.  American Medical Association (Chicago, IL: 2017) https://www.ama-assn.org/delivering-care/ethics/physician-assisted-suicide .

[2]  American Medical Association. P rinciples of Medical Ethics. Code of Medical Ethics: Caring for Patients at the End of Life, Chapter 5.  American Medical Association (Chicago, IL: 2017) https://www.ama-assn.org/delivering-care/ethics/code-medical-ethics-caring-patients-end-life .

[3]  Span, Paula. "Physician Aid in Dying Gains Acceptance in the U.S."  New York Times . (New York City, NY) Jan. 16, 2017.

[4]  Zaritsky, John, dir.  The Suicide Tourist 2010, 11  " The Suicide Tourist." Aired on March 2, 2010 on Frontline PBS.  https://www.pbs.org/wgbh/pages/frontline/suicidetourist/ . 

[5]  Oregon Health Authority. Oregon Death with Dignity Act: 2015 Data Summary.  Oregon Health Authority (OR: 2016)  https://www.oregon.gov/oha/ph/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Documents/year18.pdf . 

[6]  Beauchamp, Tom L., James F. Childress.  Principles of Biomedical Ethics  (New York: Oxford University Press, 1979) 56-96.

[7]  Faden, Ruth and Tom L. Beauchamp.  A History and Theory of Informed Consent  (New York: Oxford University Press, 1986)

[8]  Lidz, Charles W., Paul S. Appelbaum, and Alan Meisel. "Two Models of Implementing Informed Consent."  JAMA Internal Medicine  148, no. 6 (1988): 1385-1389. https://doi.org/10.1001/archinte.1988.00380060149027 .

[9]  Wicclaid, Mark R..  Conscientious Objection in Health Care: An Ethical Analysis  (New York: Cambridge University Press, 2011).

[10]  American Academy of Hospice and Palliative Medicine. Statement on Physician-Assisted Dying.  American Academy of Hospice and Palliative Medicine (Chicago, IL: 2016)  http://aahpm.org/positions/pad . 

[11]  Prokopetz, Julian and Lisa Soleymani Lehmann. "Redefining Physicians’ Role in Assisted Dying."  New England Journal of Medicine  367, no. 5 (2012): 97-99. https://doi.org/10.1056/NEJMp1205283 .

Related Articles

Facing the Future

Face transplantation is a novel procedure with a promising future

Ethics of Emergency Preparedness

How might bioethical principals inform patient care during disasters or emergencies?

What Really Matters

Dylan Marashi reviews Arthur Kleinman's "What Really Matters: Living a Moral Life Amidst Uncertainty…

© 2024 by the President and Fellows of Harvard College

• Research article
• Open access
• Published: 14 May 2019

A qualitative study on existential suffering and assisted suicide in Switzerland

• Marie-Estelle Gaignard   ORCID: orcid.org/0000-0001-8473-448X 1 , 2 &
• Samia Hurst 1  

BMC Medical Ethics volume  20 , Article number:  34 ( 2019 ) Cite this article

87k Accesses

24 Citations

23 Altmetric

Metrics details

In Switzerland, people can be granted access to assisted suicide (AS) on condition that the person whose wish is to die performs the fatal act, that he has his decisional capacity and that the assisting person’s conduct is not selfishly motivated. No restrictions relating to the ground of suffering are mentioned in the act. Existential suffering as a reason for wanting to die, however, gives raise to controversial issues. Moreover, existential suffering lacks definition and no consensus exists on how to evaluate and manage it. This study explores the perspectives of care professionals and volunteers from a “right-to-die organization” on existential suffering as a motive for assisted suicide requests.

A qualitative study based on face-to-face interviews was conducted with twenty-six participants: palliative care and primary care providers as well as EXIT right-to-die organization volunteers. Elements from the grounded theory approach were used.

The twenty-six participants described existential suffering in a multiplicity of individual ways. In total, sixty-three stories were recounted. Their representations were grouped into eight categories: physical decline and its consequences, loneliness, fear of the future, life is over, loss of social significance, loss of hope for a better future, being a financial burden and loss of pleasurable activities. According to all participants, suffering coming from the loss of self-identity was always linked to physical decline, as if one’s image completely defined someone’s identity. Society’s perception of old people and vulnerable people were also often questioned. Another interesting point was that only four stories referring to a “pure” existential suffering were found. This suffering was related to a feeling that life has come to an end, without identification of any other related restriction or suffering.

Conclusions

Existential suffering is multifaceted. Legislators and right-to-die organisations have to address the question of what make a AS acceptable. The plurality of existential suffering implies the need of a very personalized care. A better understanding of what it is made of could provide a “toolbox” to people concerned by these requests, helping them to explore it in order to offer suffering people a wider range of alternatives.

Peer Review reports

Existential suffering is frequent in seriously ill patients [ 1 ], an important factor affecting quality of life [ 2 ], one of the reasons why some patients request assisted suicide (AS). [ 3 ] The acceptability of requests for AS motivated by existential suffering are, however, controversial. [ 3 , 4 , 5 , 6 ] This controversy is rendered more difficult by vagueness regarding what people understand the definition of existential suffering to be. Indeed, it is often simply described as “being tired of life”, “distress” that arises when the meaning and value of one’s life is unclear » [ 7 ], and despite the increasing focus on existential concerns over the past decade, its definition still lacks consistency and there is no consistency on how to evaluate or treat it. A recent article reviewed the definition of existential suffering and suggested that it could be understood as an incapacitating state of despair resulting from an inner realization that life is futile and without meaning. [ 8 ] In 2011, a review identified 56 definitions of the term “existential suffering”. [ 9 ] The authors emphasized relevant themes such as: the loss of meaning or purpose in life, hopelessness, feeling of loneliness, fear of being a burden, fear of future, loss of social role functioning. They also pointed out the difficulty in distinguishing existential suffering from spiritual concerns or from psychological symptoms such as depression.

Switzerland has what may well be the most liberal legislation on AS in the world, making the question of where to set the limits in practice even more relevant. [ 10 ] Only three conditions are needed in this country to access AS: first, the person whose wish is to die has to perform the fatal act; second, this person has to have her/his decisional capacity; finally, the conduct of the assisting person must have no selfish motive. It should also be noted that the prescription of lethal drugs are subject to the Federal Narcotics Act. [ 11 ] This law leaves an important place to individual freedom and permits the “right-to-die organizations” in Switzerland to define the boundaries of their practice within the legal framework. In 2016, 928 people died from AS in Switzerland and a 2013 study showed that physician-assisted death counted for 1.1% of all death. [ 12 , 13 ] Although the legislation does not examine the reason for requesting AS, the motive “existential suffering” often gives raise to controversial issues. What, then, makes a case of AS morally acceptable? Suffering is surely not limited to disease status. If we consider relief from suffering to be one of the central considerations for AS, it is reasonable to think that the acceptability of a request should not exclusively depend on the diagnosis of an incurable or terminal disease. [ 14 , 15 ]

Professional definitions of existential suffering were examined in 2004 [ 16 ], but to our best knowledge no study has been performed about their perspectives when this existential pain or suffering is part of the request for AS in a country where it is legal. Moreover, no study has been conducted to see how those people confront it, how they actually manage this kind of suffering. This is why, in the context of this particular legislation, we asked care professionals and volunteers from a “right-to-die organization” (EXIT Suisse Romande) who are confronted to assisted suicide to tell us about their experiences regarding existential suffering as being the reason for the request. Asking them first about their representations of existential suffering then enabled us to progressively build the conversation around their attitudes when confronted to it. We hope that their responses can be used to inform the debates in Switzerland and elsewhere about assisted suicide and in particular about the controversy around the acceptability of existential suffering as being the reason for an AS request. In this paper, we present the first part of our study. Before discussing the acceptability of existential suffering as a motive for AS requests, it is essential to clearly understand what this kind of suffering is and who are the people who endure it and request AS. This study could also stimulate thoughts about preferable alternatives that could be offered to these suffering people.

Study design

We chose a qualitative design, face-to-face interviews, for this study because of the lack of insights on how to manage existential suffering when it’s part of the request for assisted suicide. Elements from the grounded theory approach were used to develop a conceptual model derived from the data.

We contacted a full spectrum of persons that we thought to be the most commonly involved in end-of-life care and assisted suicide and we included them into three groups (volunteers from a Swiss “right-to-die organization”, palliative care providers and primary care providers). A snowball sampling was used and each participant was contacted either by email or phone and explanations were provided regarding the goals and the modalities of our study. We also asked them if they felt concerned by this issue and if they consented to participate. No additional selection criteria was taken into account.

Data collection

After this first contact, we collected data through face-to-face interviews done by the main research at a location chosen by the participant (most of the time at their office). Concise information about the study was given before an informed consent was signed (written consent). At the beginning of each interview, the participants were asked their age, gender, job, and how many years of experience they had. We used a semi-structured interview guide (Additional file 1 : Table 1). Interviews ranged from twenty to fifty minutes depending on participants’ experiences with deliberating about assisted suicide and existential suffering. All interviews were tape-recorded and then transcribed verbatim.

Data analysis

We proceeded in three steps: open coding, axial coding and selective coding. As a first step, we used open coding which means breaking down data to examine and conceptualize it into codes. We therefore labelled phrases from the participants. In this example of open coding, a palliative care provider talks about a patient she used to see at home because of chronic pain and who one day shared with her her desire to request AS: “… and who had planned for a long long time to call EXIT with the explanation that she finally had very little company, that her existence didn’t serve anybody anymore and that it finally was her only option.” We labelled this phrase as an example of “loneliness”, “feeling useless” and “loss of hope for a better future”. Three codes were used here.

Axial coding was the second step of our analysis. It consisted of reassembling our codes into broader categories in order to better understand the facets and associations between them. We for example associated the codes “physical decline”, “dependency” and “hurt self” found in different testimonies as being part of the wider category “physical decline and its consequences”. Indeed, according to all participants dependency and hurt self were always a consequence of physical decline.

Selective coding was used only for the code “life is over” because it was found to be a core category and it was important to better clarify its relationship with the other codes.

Two full recordings were double coded and discussed together at different stages during the analysis, to ensure that codes well represented the testimonies of the participants and were suitably associated with others into wider categories. After coding 21 interviews, no newer codes appeared and thus we were satisfied that data saturation had been reached for the main results presented here. [ 17 , 18 ] All quotations were translated from the original French by the authors. People identification is mentioned as follows: Pn (Participant number) / PallCP (Palliative Care Providers) or PrimCP (Primary Care Providers) or EV (EXIT Volunteer).

Protection of human participants

This study was exempted from ethics review by the president of the CCER (Commission Cantonale d’Ethique de la Recherche, Swiss Cantonal Ethics Committee) because the study entailed no more than minimal risks and was outside the scope of the Swiss Federal Act (Human Research Act, HRA) on research with human participants.

The participation was voluntary and did not involve the collection of personally identifiable information.

Participants

Participant characteristics are described in Additional file 1 : Table 2. Between January and April 2016, twenty-seven professionals were contacted to participate in this study. Only one did not answer our request, therefore twenty-six people participated altogether. This included four physicians, one nurse, one physiotherapist, one nurse’s aid, two psychologists, one social worker and two hospital chaplains of a palliative care unit. In addition, we interviewed six volunteers from a Swiss “right-to-die organization” ( EXIT Suisse Romande ), one physician and three nurses from a palliative care mobile team, two general practitioners and a nurse, as well as the person responsible for recreation in a retirement home. The participants varied in gender, age and years of experience.

Professionals’ perspectives on existential suffering as a reason for requesting assisted suicide

Providers from palliative care and primary care, as well as volunteers from EXIT , described existential suffering in a multiplicity of very individual ways. In total, they recounted sixty-three stories. When referring to existential suffering, most of them described a life that wasn’t worth living any longer and/or a life that did not make sense anymore, for many different reasons. The coding of their statements resulted in eight categories that were ranked according to the frequency of their occurrence: physical decline and its consequences, loneliness, fear of the future, life is over, loss of social significance, loss of hope for a better future, being a financial burden, and loss of pleasurable activities (Additional file 1 : Table 3).

Physical decline and its consequences

A vast majority of the participants referred to experiences regarding physical decline and feelings that can result from this decline. The codes grouped in this category are thus: physical decline itself, dependency and hurt self. Each of those includes sub-codes that are listed in Additional file 1 : Table 3.

Physical decline itself and dependency were the two most represented codes in this category. Below is an example of how physical decline can lead to a request for AS:

“( … ) but finally the problem (for her) was the anal incontinence, she didn’t want to continue (living) so she asked us (to assist her) and told us: “Now it’s my limit. I am already blind, deaf, I can’t move anymore and now this (the incontinence). That’s enough!”” (P19/EV).

According to this participant, the reason why this person wanted to die was because of a too damaged physical condition. Actually, most of the participants considered physical decline as being a trigger for existential suffering, in that it induces dependency, pain, loss of pleasurable activities, hurt self or loss of hope. Moreover, we found that the idea of dependency was always linked to physical decline and this is why dependency was included in this category. A palliative care provider illustrates it:

“On the other hand, I had the feeling that for this woman, beyond a certain limit, it was no longer acceptable. She was too damaged, too dependent. You could see it. So, she preferred stepping down before becoming too dependent on nursing.” (P15/PallCP).

This quote shows that dependency was actually considered by this participant as unbearable. It was relevant in many other testimonies.

Participants also pointed out the fact that dependency can induce a diminished perception of someone’s own image and that suffering originates from this feeling. “Hurt self”, one of the codes in this category, is illustrated in the following example:

“The caregivers also play an important role because they frequently are the confidants of patients during the bathing, during their physical activities. It’s often here that patients talk about their suffering regarding their loss of autonomy, their physical decline. It’s often what we hear. One’s self-image also plays an important role in this kind of decision. Patients often tell us: « I don’t recognize myself ».” (P16/PallCP).

“I don’t recognize myself” puts into question the notion of self-identity and it was actually always mentioned this way. This statement signal the role of one’s image or physical appearance defining one’s identity. All participants spoke of deteriorating physical appearance as inducing a loss of one’s self identity. Another participant expresses it differently while talking about an illness that can be the turning point of a change in self-identity:

“There is a relevant element. It’s that often the illness, the severe illness, irrupted into these people’s life and this constituted a threshold . And rightly there often is a fracture between the “before of who I was once” and the “now” where people often take an « ill person » identity. And their identity is now limited to the issue of being ill.” (P8/PallCP).

When participants talked about physical decline, dependency or hurt self, there was another relevant idea to point out. The fact that all the sufferings induced by those conditions can be partly explained by how people perceive them. Here is an illustration by one palliative care provider:

“( … ) I’m convinced that the way society perceives those people who are not productive anymore, ( … ), with cognitive trouble, (those people) becoming a financial burden and the ones becoming diminished or incontinent, is a problem.” (P10/PallCP).

This notion that how people perceive old age or dependency is to some extent responsible for those multiple and different types existential sufferings was recurrent.

Loneliness was the second most mentioned component of existential suffering with nearly two-third of participants who talked about it. According to many participants, loneliness seems to be a significant cause for requesting AS. This is illustrated by a general practitioner talking about one of the last discussions she had with one of her patients:

“( … ) and I told her "I’d just like to know something honestly. If you were with children, grandchildren, would you do that? (request AS). She told me “Surely not”; and I told her “So, it is really (because of) loneliness?” And she told me “Yes”” (P24/PrimCP).

Loneliness was also often described as a loss of human contact. A hospital chaplain talked about solutions that could be proposed to people demanding AS due to existential suffering in these terms:

“So, I think of the possibilities, of activating a greater human proximity, because it’s actually often what is lacking. This lack of connection, this lack of contact. But it is also because this is what people often wanted. Because they arrived to this type of loneliness.” (P5/PallCP).

She actually referred to a kind of “chosen loneliness” contrary to the one induced by the loss of a loved one. Another participant illustrates it:

“She didn’t necessarily have pain, but it’s true that her treatment was quite heavy for her. And in addition, the fact that she was deeply mourning her husband. So, it’s true, I don’t know what exactly motivated her wish to commit suicide”. (P6/PallCP).

This palliative care provider did not exactly understand why his patient requested AS but suggested that loneliness might be partly responsible for it.

Fear of the future

The codes of this category are: fear of a terrible agony, fear of being placed into a retirement home, fear of the unknown, fear of the hospital and anxiety. The fear of an imagined agony was linked most of the times to past experiences, as a nurse put it:

“By digging a bit what was worrying him, it was the memory of his spouse who died from an oncologic illness. She was very young at the time and she was screaming out in pain. And he was leaving the house in order to not hear her screaming out of pain. This had a big impact on him. His fear was really linked to the fact that medicine couldn’t address many of the symptoms, pain in particular.” (P11/PallCP).

The fear of being placed into a retirement home was also expressed a few times and was often linked to the fear of physical decline and dependency as a general practitioner explained:

“( … ) and they had talked about a placement in a retirement home. And I’d say that for many elderly persons this is something, this placement in a retirement home is a “bête noire”. Because it means total decline for them.” (P25/PrimCP).

The other codes within this category were less salient but taken together they pointed to the fact that sufferings were emerging here from a kind of fear of going on living in a state of unbearable decay. Not only was there a fear of potential future suffering but this anticipation itself was a source of current suffering that would lead to a wish to die.

Life is over

This category was mentioned by more than one-third of the participants. It was often described as being tired of life. Although it was often linked to other sufferings, it needed to be differentiated because it really referred to a fully aware reasoning: “My life has come to an end”. Here an example:

“He tells me: “Do you understand? My world shrinks, you can do whatever you want. ( … ) I know that I will be soon coming to an end. I hope everything is going to be alright and that someone will help me if not.” This is an objective observation. He is 91 years old.” (P20/EV).

It is in this category that we found what we can call a kind of “pure” existential suffering. A suffering without identification of any other related ones. Only four of twenty-six participants talked about it and it was described in four out of sixty-three stories. An EXIT volunteer illustrated it:

“But it concerns more the people in the retirement homes. Except this woman who clearly said that she didn’t want to find a spouse again and that her life was finished. That she had a beautiful life, with her husband, that she had raised her children, that she had grandchildren who were going well. So she had done it all and said “so I can leave now””. (P19/EV ).

It sounds like this woman had accomplished what she had to and was ready to die. No physical decline, no dependency. A little bit of loneliness maybe.

Loss of social significance

Loss of social significance was mentioned by eight out of twenty-six participants and was especially described as a feeling of uselessness. Here is an illustration of how this feeling could be experienced as a deep suffering:

“I also think that there is something else we didn’t talk about: this feeling of uselessness. Everything that refers to « me feeling useful », or « me feeling useless », « not serving purpose », is a big suffering.” (P5/PallCP).

The loss of usefulness in family and society was described by participants as linked to the process of aging. And, as mentioned before for the code “Hurt self”, many participants pointed out the fact that society, our culture, might be partly responsible for these feelings such as expressed by a primary care provider:

“( … ) the big existential suffering for many people is this feeling of useless (ness). It doesn’t happen in the cultures where elderly remain integrated in the family, where they can even look after the grandchildren or participate in the activities. Those people (in Switzerland) are lonely.” (P25/PrimCP).

Loss of hope for a better future

Loss of hope for a better future being a cause of a life that is not worth living anymore had the same relevance as the loss of social significance. As one can imagine, the description of what a better future is, is highly personal and plural. This category refers to a feeling that the future will be worse than the present life. Here is an example of a conversation between an EXIT volunteer and someone he helped to die:

“Well, I have to (request AS).” And I told her: “How is that? Why do you have to?” And she told me: “Yes I have to because I don’t have remission anymore.” Yes, it’s true. “Her diagnosis was clear, her remission was finished, her disease reappeared and she did not want to live through that.” (P19/EV).

This woman wanted to requested AS because all she could expect from this point was suffering.

Being a financial burden

The fact that being a financial burden could be a cause of existential suffering and lead to a AS request was stated by six out of twenty-six participants. It was often described as one more form of suffering on top of an already distressful daily life. Like other categories and codes, being a financial burden was described as closely related to the way society perceives old age, dependency or physical decline such as explained by an EXIT volunteer:

“ what those people generally fear is loneliness, and the fact of becoming a burden and being a high cost to society, as we can hear it and read it in newspapers. They also talk about this, and I always tell them “It’s not a reason. You worked; you don’t have to worry because you are expensive. You’re no more expensive than anyone else.”” (P18/EV).

This participant highlights the fact that the concern of becoming a burden might be caused by media’s perception in these people.

Loss of pleasurable activities

The loss of pleasurable activities was the least mentioned category and was often linked to other categories. However, it was important to highlight it because the loss of pleasures and joys of life was directly described as leading to a life that isn’t worth living anymore. Here is an illustration:

“She found that it was not enough to be more or less fit again. And, above all, she gave up visiting Museums in Europe and she loved to do this in the past. So, she came back one day to terminate her life simply because her goals in life couldn’t be achieved any more. Because of physical or psychological problems.” (P12/PallCP) .

In the story of this patient, life wasn’t worth living any longer mainly because her condition prevented her from enjoying museum visits, which used to be the greatest pleasure in her daily life. Hence, life did not make sense anymore for her.

One of the purposes of this study was to deepen the understanding of existential suffering from the perspectives of professionals (palliative and primary care providers) and Right-to-die organization volunteers when it is part of the request for AS, especially in a country like Switzerland, where it is legal. Our study found that existential suffering included physical decline and its consequences, loneliness, fear of the future, life is over, loss of social significance, loss of hope for a better future, being a financial burden and loss of pleasurable activities, all of which were intertwined with the impression that life had lost its meaning and/or was not worth living anymore.

Suffering coming from a “diminished perception of one’s own image” or from a “loss of self-identity” was always linked to physical decline, which could be a decline in the physical ability to invest life, a profound alteration in physical appearance, or both. In a society that gives great importance to physical appearance, as aging represents a slow loss of a culturally self-identity because one stops to be a productive and contributing member of society, physical decline leads to an even deeper fracture of identity. The loss of vitality separates one from a past life in which one could enjoy the body and depend on it. It also shuts the door on desires and hopes for the future.

According to our participants, society was somehow responsible at least in part for existential suffering. Perceptions of old age or physical decline are influenced by social contexts, they shape the way we see ourselves, and this can lead to deep suffering. A form of internalised ageism could be at work in these situations. [ 19 ] More pragmatically, lack of the sort of social support required to maintain relationships, a sense of self, and well-being may have played a role as well. [ 20 ]

Finally, we found that in most cases existential suffering consisted of different, and sometimes compounded, losses of the dimensions of life. Requests for suicide assistance in such cases were described as emanating from persons who were as if shut out from components of their own existence; a finding similar to the description by Sjöberg and colleagues of older patients’ narratives of being “disconnected from life”. [ 21 ] Despite this, a minority of cases did seem to represent what might be termed “pure” existential suffering, or a feeling that life was meaningless or over, without identification of any specific restrictions in the components of it. This was present in just four of sixty-three stories. These findings are relevant to the status of existential suffering as a possible justification for AS. Cases where life is -sometimes severely- restricted are morally significantly different from those where this is not the case. Existential suffering as a motive for suicide assistance requests often leads to controversial issues. This is partly due to questions regarding whether existential suffering is sufficiently severe, rather than a name given to situations where a decision to ask for death may have been made too lightly. Our findings suggest that most suicide assistance requests for reasons of existential suffering are made by people who are indeed suffering in readily recognizable ways. This is also what the few data from EXIT right-to-die organization on motives for AS requests tend to demonstrate. Even though existential suffering might be present in all requests, and this is something current data does not capture, a serious illness is always present. [ 22 ] Suicide assistance requests motivated by “pure” existential reasons raises different issues. Such cases are of course controversial, and viewed alternately as irrational, as cases where the true causes of suffering remain unrecognized, or as instances of “existential maturity” in facing our own mortality. [ 23 ] Our findings suggest that these situations do exist but only count for a small number of AS requests motivated by existential suffering. In these rare cases, the only justification, recognized by the Swiss law, for offering such assistance is to not have selfish motive and to respect the Federal Narcotics Act. The law actually does not specify requirements in terms of suffering. However, this year, the SAMS (Swiss Academy of Medical Sciences), which provides healthcare professionals with recommendations on ethics issues, published new guidelines on the management of dying and death. They stated that the assisting person has to verify five requirements, including that the “symptoms of disease and/or functional impairments are a source of intolerable suffering” for the patient. [ 24 ] For the first time, the institution provided healthcare professionals with more specific requirements in terms of suffering for requesting AS.

By probably providing the first in-depth published account on this studied group in this particular legal framework, our study contributes to the literature in several ways. It adds content to the definition of existential suffering. Existential suffering is not solely related to being tired of living. It comprises different forms of suffering, and sometimes combines them. As the recent integrated literature review concludes: “Although ambiguity in these definitions may be justifiable given the broad range of similarity in terminology, clinical clarity may be necessary given the current challenges of treating this form of suffering, and a general consensus that it has not been well defined or treated is also required”. [ 9 ] Clinical clarity is essential. It could provide a kind of “toolkit” to people concerned by this question. Based on our findings, we could for example imagine a questionnaire investigating at least these eight categories of existential suffering. This would help care providers and volunteers from “right-to-die organizations” to better understand the suffering experienced by the persons they are taking care of and, in this way, help them to propose more personalized and more appropriate care. Recognizing existential suffering to be plural could help to identify the different actors needed to assist individual patients.

This study has several limitations. First, as in all qualitative research, some intrusion of the researcher’s biases is inevitable. To reduce this effect, some of the interviews were double-coded and all the codes and categories were discussed together. Furthermore, an on-going and reflective research journal recorded the first researcher’s impressions to make sure to stay as close possible to what the participants wanted to share. Our sample size was small, and our participants were recruited exclusively in the French-speaking part of Switzerland. Our results cannot be generalized. However, as our sample of participants is quite representative of the people concerned by the question, it would be interesting to see whether our findings are transferable to other palliative care units, to other primary care providers and to other “right-to-die organizations” in Switzerland. As such, it might help to build a consensus on evaluating and treating existential suffering. Finally, our study focused on the perspectives of care providers and EXIT volunteers, and not on those of people requesting AS. We found, however, that their perspectives were not so distant from the ones of people actually requesting AS, particularly regarding the aspects of loneliness, dependency, hopelessness, loss of life’s meaning and loss of self-identity. [ 5 , 6 , 25 ]

Representations by the palliative care and primary care providers and volunteers from EXIT on existential suffering are multiple. They include the notion of physical decline and its consequences, loneliness, fear of the future, life is over, loss of social significance, loss of hope for a better future, being a financial burden and loss of pleasurable activities. To our knowledge, no study had been conducted yet on the perspectives of these people in a country like Switzerland, where AS is legal and where different groups of people have to confront it and try to respond to it. Our study might be helpful in providing a better understanding of existential suffering to and help identify a wider range of alternatives to offer these suffering people, rather than simply thinking of limiting the conditions for an acceptable AS.

Abbreviations

assisted suicide

Commission Cantonale d’Ethique de la Recherche (Swiss Cantonal Ethics Committee)

EXIT Volunteer

name of a swiss right-to-die organization

Palliative Care Providers

Participant number

Primary Care Providers

Swiss Academy of Medical Sciences

Roze des Ordons AL, Sinuff T, Stelfox HT, Kondejewski J, Sinclair S. Spiritual distress within inpatient settings - A scoping review of patient and family experiences. J Pain Symptom Manage. 2018.

Bernard M, Strasser F, Gamondi C, Braunschweig G, Forster M, Kaspers-Elekes K, et al. Relationship between spirituality, meaning in life, psychological distress, wish for hastened death, and their influence on quality of life in palliative care patients. J Pain Symptom Manage. 2017;54(4):514–22.

Article   Google Scholar  

Rodríguez-Prat A, Balaguer A, Booth A, Monforte-Royo C. Understanding patients’ experiences of the wish to hasten death: an updated and expanded systematic review and meta-ethnography. BMJ Open. 2017;7(9):e016659.

Rurup ML, Onwuteaka-Philipsen BD, Jansen-van der Weide MC, van der Wal G. When being ‘tired of living’ plays an important role in a request for euthanasia or physician-assisted suicide: patient characteristics and the physician’s decision. Health Policy. 2005;74(2):157–66.

Dees MK, Vernooij-Dassen MJ, Dekkers WJ, Vissers KC, van Weel C. « Unbearable suffering »: a qualitative study on the perspectives of patients who request assistance in dying. J Med Ethics. déc 2011;37(12):727–734.

Bruns F, Blumenthal S, Hohendorf G. Assisted suicide in Germany : medical diagnoses and personal reasons of 117 decedents. Dtsch Med Wochenschr. 2016;141(4).

Lo C, Panday T, Zeppieri J, Rydall A, Murphy-Kane P, Zimmermann C, et al. Preliminary psychometrics of the Existential Distress Scale in patients with advanced cancer. Eur J Cancer Care (Engl). nov 2017;26(6).

Grech A, Marks A. Existential suffering part 1: definition and diagnosis #319. J Palliat Med. 2017;20(1):93–4.

Boston P, Bruce A, Schreiber R. Existential suffering in the palliative care setting: an integrated literature review. J Pain Symptom Manage. 2011;41(3):604–18.

Hurst SA, Mauron A. Assisted suicide in Switzerland: clarifying liberties and claims. Bioethics. 2017;31(3):199–208.

Federal Act of 3 October 1951 On narcotics and psychotropic substances (narcotics act, NarcA) [internet]. Available on : https://www.admin.ch/opc/en/classified-compilation/19981989/index.html

Swiss Health Observatory (OSBAN). Available on : https://www.obsan.admin.ch/fr/indicateurs/suicide

Bosshard G, Zellweger U, Bopp M, Schmid M, Hurst SA, Puhan MA, et al. Medical End-of-Life Practices in Switzerland: A Comparison of 2001 and 2013. JAMA Intern Med. 2016;176(4):555–6.

ten Have H. Euthanasia: moral paradoxes. Palliat Med. 2001;15(6):505–11.

Bueno-Gómez N. Conceptualizing suffering and pain. Philos Ethics Humanit Med PEHM. 2017;12(1):7.

Strang P, Strang S, Hultborn R, Arnér S. Existential pain—an entity, a provocation, or a challenge? J Pain Symptom Manage. 2004;27(3):241–50.

How Many Interviews Are Enough?: An Experiment with Data Saturation and Variability - Greg Guest, Arwen Bunce, Laura Johnson, 2006 [Internet]. [cité 10 avr 2018]. Available on: http://journals.sagepub.com/doi/abs/10.1177/1525822X05279903

O’Reilly M, Parker N. ‘Unsatisfactory Saturation’: a critical exploration of the notion of saturated sample sizes in qualitative research. Qual Res. 2013;13(2):190–7.

Abrams D, Russell PS, Vauclair M, Swift HJ. Grey Matters–A Survey of Ageism across Europe: EU Briefing and Policy Recommendations. 2011;

Lloyd A, Kendall M, Starr JM, Murray SA. Physical, social, psychological and existential trajectories of loss and adaptation towards the end of life for older people living with frailty: a serial interview study. BMC Geriatr. 20 2016;16(1):176.

Sjöberg M, Beck I, Rasmussen BH, Edberg A-K. Being disconnected from life: meanings of existential loneliness as narrated by frail older people. Aging Ment Health. 17 juill 2017;1–8.

EXIT right-to-die organization. 2014 Report. Available on: https://exit-romandie.ch/pdf/bul61.pdf

Emanuel LL, Reddy N, Hauser J, Sonnenfeld SB. « And Yet It Was a Blessing »: The Case for Existential Maturity. J Palliat Med. avr 2017;20(4):318–327.

Guidelines: Management of dying and death [Internet]. [cité 1 nov 2018]. Available on: https://www.samw.ch/en/Ethics/Ethics-in-end-of-life-care/Guidelines-management-dying-death.html

Verhofstadt M, Thienpont L, Peters G-JY. When unbearable suffering incites psychiatric patients to request euthanasia: qualitative study. Br J Psychiatry J Ment Sci. 2017;211(4):238–45.

Download references

Acknowledgments

The authors wish to thank the participants in the study for their time and willingness to be interviewed. They would also like to show their gratitude to Paola Ricci for reviewing the initial manuscript and to their colleagues, Dr. Marinette Ummel and Prof. Alex Mauron, who provided insight and expertise that greatly improved the manuscript.

MEG conducted this work without funding as part of her Master Degree in Medicine. The Institute for Ethics, History, and the Humanities at the Geneva University Medical School provided access to library facilities and SH’s salary. The Institute had no role in designing the study, nor in its execution, analyses, interpretation and in writing the manuscript.

Availability of data and materials

The data that support the findings of this study are available on request from the first author [MEG], subject to institutional and participant consent. The data are not publicly available because they contain information that could compromise research participant privacy and because such release was not included in the participant consent process.

Author information

Authors and affiliations.

Institute for Ethics, History, and the Humanities, Institute for Biomedical Ethics, Geneva University Medical School, Rue Michel-Servet, 1, 1211, Geneva, Switzerland

Marie-Estelle Gaignard & Samia Hurst

Department of Oncology, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland

Marie-Estelle Gaignard

You can also search for this author in PubMed   Google Scholar

Contributions

MEG collected, analyzed and interpreted the data and drafted the manuscript. SH contributed to project design, the development of the data collection instrument, and data analysis. Both authors read and approved the final manuscript.

Corresponding author

Correspondence to Marie-Estelle Gaignard .

Ethics declarations

Ethics approval and consent to participate.

This study was exempted from ethics review by the president of the CCER (Swiss Cantonal Ethics Committee) because the study entailed no more than minimal risks and was outside the scope of the Swiss Federal Act (Human Research Act, HRA) on research with human participants. The participation was voluntary and did not involve the collection of personally identifiable information. Participants signed a written consent.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Additional file

Additional file 1:.

Table 1. Interview guide. The semi-structured interview guide used to collect data. Table 2. Participant characteristics Number of participants and their demographics. Table 3. Results. Representations of existential suffering by the palliative care and primary care providers and volunteers from EXIT right-to-die organization. (DOCX 17 kb)

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/ ), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Cite this article.

Gaignard, ME., Hurst, S. A qualitative study on existential suffering and assisted suicide in Switzerland. BMC Med Ethics 20 , 34 (2019). https://doi.org/10.1186/s12910-019-0367-9

Download citation

Received : 07 November 2018

Accepted : 17 April 2019

Published : 14 May 2019

DOI : https://doi.org/10.1186/s12910-019-0367-9

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

BMC Medical Ethics

ISSN: 1472-6939

• General enquiries: [email protected]

• Advanced search

Advanced Search

Physician-Assisted Suicide: Considering the Evidence, Existential Distress, and an Emerging Role for Psychiatry

• Find this author on Google Scholar
• Find this author on PubMed
• Search for this author on this site
• Info & Metrics

Physician-assisted suicide (PAS) is one of the most provocative topics facing society today. Given the great responsibility conferred on physicians by recent laws allowing PAS, a careful examination of this subject is warranted by psychiatrists and other specialists who may be consulted during a patient's request for PAS. In this article, recent evidence regarding the implementation of PAS in the United States and The Netherlands is reviewed. Support is found for some concerns about PAS, such as the possibility that mental illness occurs at higher rates in patients requesting PAS, but not for other concerns, such as the fear that PAS will be practiced more frequently on vulnerable populations (the slippery-slope argument). These data and common arguments for and against PAS are discussed with an emphasis on the tension between values, such as maximizing patient autonomy and adhering to professional obligations, as well as the need for additional research that focuses more directly on the patient-centered perspective. Implications of the available evidence are discussed and lead to a consideration of mental anguish in terminally ill patients including aspects of existential distress and an acknowledgment of the importance of tailoring end-of-life care to the distinct set of values and experiences that shape each patient's perspective. The article concludes with a discussion of an expanding role for psychiatrists in evaluating patients who request PAS.

Religious condemnation and moral disapproval of suicide by society were associated with its criminalization in most societies before modern times. 1 However, views toward suicide changed during the 19th and 20th centuries, coincident with the emergence of psychiatry as an autonomous discipline in which practitioners could diagnose and treat anxiety, depression, and other ailments contributing to suicide. In addition, modern sociological theory describing suicide as a social ill reflecting widespread alienation and anomie facilitated a growing cultural sensitivity to the plight of the mentally ill. Scientific advancements in our understanding of mental illness thus implied that suicide was caused by social or psychological forces often beyond the control of individuals and contributed to the decriminalization of suicide. 1 , 2

Modern laws in the United States allowing physician-assisted suicide (PAS), defined as the practice of a physician providing a competent patient with a prescription for medication for the patient to use with the primary intention of ending his life, are thought to have emerged from a growing dissatisfaction with the medical profession and the development of a national right-to-die movement. 3 The right-to-die sentiment developed in parallel with skepticism of medical authority, beginning in 1967 with the creation of the first living will that allowed patients to make decisions about their end-of-life care years in advance. 4

Currently, assisted suicide is legal in the United States in only four states: Oregon, Washington, Montana, and Vermont. However, it has been a source of controversy in many other states for some time, as voter initiatives for legalizing assisted suicide were introduced and defeated in California, Michigan, and Maine over a period from the early 1990s until 2000. In recent time, legislatures in Connecticut and New Jersey have proposed bills to legalize assisted suicide. These repeated recent efforts in support of assisted suicide and the strident opposition that typically results keep the question in the American public's mind as one of vital importance.

It should be noted that the phrase physician-assisted suicide is itself not without controversy. Proponents of the practice prefer the term aid in dying to describe doctor-provided assistance to patients who want to end their lives. Although I appreciate the sentiment behind such arguments, in this article, I will use PAS to describe the practice, as it is the term predominantly used in the medical context.

As PAS implies, modern attitudes toward death and dying consider the subject of assisted suicide to fall within the purview of medical practice, despite the American Medical Association's opposition to PAS on the grounds that it is antithetical to a doctor's role as healer. 5 U.S. physicians remain sharply divided on assisted suicide, with opposition to the practice associated with increased religiosity and certain moral and ethics-based principles. 6 , – , 8 Oregon's Death With Dignity Act clearly delineates the role of physicians as the primary gatekeepers of assisted suicide in enumerating responsibilities for the attending physician such as ensuring that each patient who requests aid in dying is capable, acts voluntarily, makes an informed decision, and is dying of a terminal disease (defined as an incurable and irreversible disease that will produce death within six months). The grave responsibility conferred by Oregon's Death With Dignity Act suggests that psychiatrists and other physicians who may be consulted to opine on the integrity of a patient's request for aid in dying must think deeply about their views on the subject.

The impassioned debate over PAS spans a wide range of disciplines and reflects the incendiary nature of the question. Arguments for and against PAS touch on many basic moral beliefs and illustrate the tension among values such as autonomy, paternalism, fairness, and the value of human life. Although the controversy can be described in political, social, and medical terms, an individual's feelings on the subject can often be reduced to a simple moral conviction about whether a person can aid another in ending his life. Debates that turn on such basic beliefs tend to divide people deeply, and the resultant conversation is often characterized by rhetoric and ideology. Over time and with the further polarization of views, common ground and compromise often seem unlikely.

However, although it is often overlooked or dismissed in these cases, scientific evidence has the opportunity to inform our thinking on matters that evoke moral and ethics-related questions. While not dispositive, evidence can characterize the conditions and consequences associated with different viewpoints. Some of the most contentious aspects of the debate over assisted suicide include fears or questions that can be illuminated with actual evidence.

In this article, I will review the recent evidence that pertains to the arguments for and against PAS and suggest avenues for future research. I will then discuss implications of the available evidence and consider mental suffering in terminally ill patients as comprising aspects of existential distress (i.e., concerns related to feelings of hopelessness, futility, and meaninglessness; anxiety about death; and disruption of personal identity), as well as acknowledge the importance of tailoring end-of-life care to the distinct set of values and experiences that shape each patient's perspective. Finally, I will explore an emerging role for psychiatrists in evaluating patients who request PAS.

In this section I will review some of the recent data that address some of the open questions and fears regarding PAS. An important caveat is that most of the evidence is taken from studies conducted in Oregon and The Netherlands, and moreover, many of the studies involve the work of Linda Ganzini, a professor of psychiatry and medicine at Oregon Health and Science University. This is not to imply a particular bias on the part of the studies mentioned in this article, but rather to characterize the current state of evidence as limited by region and principal investigator.

Psychiatric Illness in Patients Who Request PAS

One basic question that frames the debate on assisted suicide is the extent to which patients who request PAS have a treatable psychiatric illness. Ganzini et al . 9 interviewed a cross section of patients who requested a physician's aid in dying under Oregon's Death with Dignity Act and found that one in four had clinical depression. In another study, physicians in Oregon who received requests from patients for aid in dying reported that 20 percent of them were depressed. 10 The results of these studies imply that a significant minority of patients who request aid in dying have depression. However, of all patients who received a prescription for a lethal drug in Oregon since 1997, just under 7 percent were referred for a psychiatric evaluation. Ganzini and colleagues also studied health care providers and family members in Oregon and found that these groups thought that depression was rarely a factor influencing requests for PAS. 9 , 11 , 12 Together, these findings raise the concern that clinicians and family members may fail to detect signs and symptoms of depression in these patients.

For purposes of comparison, a recent systematic review found that, in The Netherlands, the rate of depression in patients whose requests for euthanasia were honored was similar to that in the surrounding population of seriously ill patients, but that the presence of depression was a significant factor in refusals of requests for euthanasia, suggesting that the Dutch system may be successful in screening out many requests motivated by depression. 13 Moreover, with regard to the overall prevalence of depressive symptoms in the terminally ill population, one study of terminally ill patients with cancer found that 59 percent of those with a serious and pervasive desire to die had significant symptoms of depression, versus only 8 percent of those without such a desire. 14 This result is consistent with other research that has found an increased association between an expressed desire for a hastened death and symptoms of depression, 15 implying a higher probability that patients who request PAS have depression. These findings suggest the importance of screening such parents carefully for evidence that mental illness may be interfering with their decision-making capacity.

Impact on Vulnerable Patients: the Slippery Slope

Another concern that can be illuminated by evidence is the question of the slippery slope that leads to abuse. Many have expressed apprehension that abusive pressures would disproportionately affect vulnerable patients, such as those whose capacities for decision-making are compromised by cognitive impairment or lack of education, those who are subject to social prejudice, or those who may have been socially conditioned to think of themselves as less deserving of care. 16 Ultimately, there is concern that these pressures would result in an increased risk of death by PAS among vulnerable persons compared with the risk in other populations.

Battin et al. 16 explored this question by examining data collected in jurisdictions where assisted dying is legal, such as Oregon and The Netherlands, and by looking for evidence that the lives of people in groups identified as vulnerable were more frequently ended with assistance from a physician than those of other populations. Their findings were limited by substantial differences in methodologies in source studies and difficulties in determining with certainty the actual incidence of assisted dying in several of the vulnerable groups studied. However, they found no evidence of heightened risk of death by physician assistance in the elderly, women, uninsured people, the poor, racial and ethnic minorities, people with low educational status, minors, patients with psychiatric illness, and patients with chronic nonterminal illness.

Although conclusive proof about the impact of legalized assisted suicide on vulnerable patients would entail studies of higher complexity, duration, and comprehensiveness, Battin et al. certainly provided a first-pass look at the slippery-slope question. At this stage, there appears to be no evidence to support the fear that assisted suicide disproportionately affects vulnerable populations. Instead, the available data indicate that people who die with a physician's assistance are more likely to be members of groups with higher social, economic, educational, and professional status.

Patients' Experience of PAS

Other aspects of the debate on assisted suicide that can be informed by evidence are those related to the tension between autonomy and paternalism. In essence, paternalism presupposes that doctors are better able to act in patients' best interests than the patients are themselves. One way to examine the question of whether patients are indeed capable of making decisions about dying is to compare the quality of death and dying in patients who request PAS with that of those who do not.

Smith et al. 17 sought to determine whether there was a difference in the quality of the dying experience, from the perspective of family members, among patients in Oregon who received lethal prescriptions, those who requested but did not receive lethal prescriptions, and those who did not pursue physician-assisted dying. Altogether, they noted few significant differences between the groups in items that measured domains such as connectedness, transcendence, and overall quality of death. However, they did observe that families reported that patients who received lethal prescriptions had higher quality ratings on items measuring symptom control (e.g., control over surroundings and control of toileting) and higher ratings on items related to preparedness for death (e.g., saying goodbye to loved ones) than those who did not pursue physician-assisted death. Their conclusion was that the quality of death experienced by those who received lethal prescriptions was no worse than that of those who did not pursue PAS, and in some areas, family members rated it as better. In another study, Georges et al. 18 used retrospective interviews with relatives to describe the experiences of patients who died by euthanasia (EAS) or PAS in The Netherlands and found that, according to relatives, EAS had a positive impact on the quality of the end of their loved one's life in 92 percent of cases, primarily by preventing or ending suffering.

One interpretation of the findings of these studies is that in those patients who opt for it, assisted suicide contributes favorably to the experience of their relatives. This inference is supported by evidence from other studies showing no differences in mental health outcomes in family members of patients in Oregon who had requested physician aid in dying compared with family members of patients in Oregon who died of terminal illness. 19 However, although information regarding the experience of family members of patients who opt for PAS may be important in influencing social norms regarding the acceptability of PAS, these data do not speak to the central question of patient autonomy. In fact, it is arguable that the aforementioned studies are irrelevant to the patient-centered perspective, in that they do not directly assess patients' experiences of PAS. In this sense, sufficient research into this and other questions regarding PAS seems to be lacking.

Current State of Research on PAS

As mentioned earlier, most of the clinical studies performed in the United States are associated with the work of one researcher (Ganzini). The relative paucity of research on PAS compared with other areas of medicine implies that there may be a reluctance to study it. Reasons for this reluctance include the taboo associated with PAS, the small number of states that have legalized it, a reliance on using rhetoric or ideology to argue points for or against it rather than actual evidence, and finally, a fear by doctors that research may lead to changes that would restrict, rather than inform, the care that they provide. The identification of the impediments to research in this realm may itself be a consideration for future study, as this may provide a clear path to encouraging more research on PAS.

Another important open question regarding PAS that has not been directly addressed by research to date is the quality of the dying experience of patients who opt to die in this way. Research that directly assessed the patient's experience leading up to death by PAS would clarify questions about the well-being of patients who died by this method and, in doing so, provide evidence potentially in support of PAS as a form of care. Such evidence would be vital for several reasons. For example, it could confirm the sense that physician supporters of PAS have that PAS is a valid form of health care that does indeed improve patients' well-being. Moreover, it would address fears that PAS is inconsistent with the medical dictum to “first, do no harm,” for if it could be shown more clearly that PAS improves the experience of dying for patients, it could be argued that the essence of PAS is to relieve suffering rather than to kill or cause harm. Finally, data taken directly from the patient-centered perspective would address concerns that may be raised about the ability of patients to predict their future mental state accurately, as depressed patients have been shown to have more negatively biased mood predictions, 20 which in turn could adversely affect their ability to make decisions about end-of-life care. 21 Evidence that patients who opt for PAS experience increased well-being up to the time of death would support the belief that, for selected patients, such end-of-life decisions could be consistent and authentic.

The evidence reviewed offers support for some fears with regard to assisted suicide and seems to refute others. One study found no evidence to support the slippery-slope fear that assisted suicide would eventually be used prejudicially on vulnerable populations. 16 Also, researchers found that families of persons who used assisted suicide felt more prepared for and accepting of their loved one's death and in other ways had mental health outcomes that were no worse than those in families of persons who died of other causes. 19

However, data from multiple sources indicate that the concern that depression is often missed or overlooked in patients seeking assisted suicide may be valid. For example, although only a small percentage of patients who request assisted suicide are actually referred to psychiatrists, around 20 percent of those who request assisted suicide have depression. Moreover, health care providers and family members underestimate the extent to which depression is a factor in requests for aid in dying. 9 , – , 12 , 22 From one perspective, this finding implies a need for mandating more frequent referrals to psychiatrists to evaluate patients for evidence that mental illness may have interfered with their decision-making capacity.

On the other hand, psychiatrists and physicians in general may be overly inclined to pathologize suicidal ideation and depression in patients who request aid in dying. Most people with major depression retain competence to make medical decisions, 23 and the legalization of PAS reflects an acceptance that active hastening of death can be a valid choice in terminal illness, implying that PAS can be a valid choice despite the presence of depression. 13 It follows that, although the expression of suicidal ideation may indeed be pathologic in most settings in which it is observed, the conditions that characterize terminal illness may truly be distinct, as patients can reasonably interpret such a diagnosis as a death sentence. One would anticipate that no matter how psychologically healthy a patient might be, it would be understandable for that person to experience feelings of despair, demoralization, and existential distress (i.e., concerns related to feelings of hopelessness, futility, or meaninglessness; anxiety about death; and a disruption of personal identity) in response to receiving a diagnosis of terminal illness.

The Evaluation and Treatment of Existential Distress

Researchers have explored the concept of existential distress in terminally ill patients and have found that their concerns are often related to themes such as loss of control, loss of continuity, and acceptance and preparation. 24 Some have resolved to address the plight expressed by these patients by emphasizing the importance of finding “meaning” at the end of life. Breitbart and colleagues 25 describe psychotherapeutic approaches intended to explore spiritual and existential themes through a meaning-oriented approach that encourages the dying patient to find meaning and purpose in living until death and promotes a patient's personal agency and responsibility.

Chochinov and colleagues 26 have studied the psychological experience of terminally ill patients and have proposed that a fractured sense of dignity can be diagnosed, quantified, associated with a decreased quality of life, and treated with dignity-conserving therapies, such as maintaining autonomy by participating in decisions about care or contributing to something that might serve as a lasting legacy.

Although these researchers have offered therapies that promote continued life, their findings also imply alternative solutions to the existential dilemma facing the terminally ill. For example, important values such as autonomy and dignity would appear to be served with the practice of assisted suicide as well. In fact, assisted suicide might plausibly be a choice that resolves the existential dilemma of terminal illness and its attendant helplessness and hopelessness. Choosing the time and manner of one's death could be a way of symbolically wresting back the reins of the course of one's life. After all, if the healthy among us face up to our finite lives by making choices about how to live, it may also be reasonable for those facing their imminent demise to determine the conditions of their death.

The use of assisted suicide to resolve the existential distress of the terminally ill gains additional support from the work of Chochinov et al. 26 on the concept of dignity in this population. They found that, although there were many common elements shared in different patients' definitions of dignity, there were also important distinctions. For example, some patients valued a “fighting spirit” and “railing against their illness,” whereas others valued acceptance. Some patients spoke of their distress at the thought of having to rely on others for their care, whereas others raised fears related to the anticipation that their death would cause their loved ones pain.

The findings of Chochinov et al . highlight the diverse set of values and manifold experiences within the terminally ill population and imply that treatments aiming to improve these patients' well-being would have to take into account their various desires and perspectives. After deep consideration and reflection on his goals and wishes, as well as careful evaluation to rule out the possibility that pathologic motivations (such as severe mental illness) may be playing a role in his decision, a patient may ultimately decide that assisted suicide is the best way to end his life.

A Role for Psychiatry

These findings imply a potential role for psychiatrists in evaluating patients who request PAS. However, this perspective, too, is not without its complications. Psychiatrists themselves are divided in their support for assisted suicide, with surveys indicating that about two-thirds of U.S. psychiatrists believe that it should be permitted in certain circumstances. 27 , 28 Moreover, most psychiatrists believe that a single independent psychiatric examination would be insufficient to determine a patient's capacity to decide on PAS, 28 especially given previously mentioned concerns about the general difficulty humans have in accurately forecasting their future mental state. 20 , 21

It must be acknowledged that mandated or multiple independent psychiatric examinations would have the effect of increasing the labor and time associated with ensuring the integrity of a patient's request for PAS, which in turn may serve as an impediment to the overall process. Moreover, terminally ill patients may feel stigmatized by being mandated to undergo a psychiatric examination. In Australia, Kissane et al. 29 found that mandated psychiatric assessments for patients requesting euthanasia or PAS sometimes leads them to withhold key information because they see the psychiatric assessment as a legal hurdle to be overcome, suggesting also that mandated psychiatric assessments may compromise the relationship between psychiatrist and patient.

Yet, the push for more extensive evaluations by psychiatrists in this context is understandable. Concerns about a patient's capacity to make reasoned decisions about treatment are likely to be raised in circumstances where a patient expresses a desire for an intervention with unfavorable outcomes and high risk. 30 In addition, some physicians may feel uncomfortable participating in PAS without a more comprehensive evaluation. 28 Thus, in instances where a patient's capacity is in serious question, multiple independent evaluations from consulting psychiatrists over time may be indicated.

For the purpose of guiding a psychiatrist's evaluation of a patient who has requested PAS, Muskin 31 emphasized a psychodynamic approach to exploring the complexity contained in a patient's request to die, which could be interpreted as a communication to the patient's doctor, a method of control over aspects of the patient's life or death, rage or revenge, an expression of hopelessness, or even an expression of guilt, self-punishment, or atonement. A psychiatrist's role as expert in exploration would also include evaluating the effect of psychiatric or medical disease on a patient's decision-making capacity, as well as clarifying communications among treatment team, family, and patient to minimize the possibility of undue influence on a patient's ultimate decision. Finally, a psychiatrist may simply bear witness to and acknowledge the validity of the patient's emotional experience, thereby offering relief by way of empathy. The expertise of psychiatrists in these important areas thus suggests that they would be well suited to provide careful guidance to a patient as he explores his feelings, desires, and values in the service of making authentic decisions about end-of-life care.

In the final analysis, however, a psychiatrist's impressions of the integrity of a patient's request for PAS may turn on the psychiatrist's conception of rational suicide. Thus, it seems critical for psychiatrists to ponder the psychological constituents of rational suicide. Muskin's article 31 is useful in summarizing the questions necessary for a sufficient exploration of a patient's request for PAS, but additional work is warranted to delineate the essential features of rational suicide. The conception set forth by Tomasini 32 of rational suicide as instrumentally rational, autonomous, born of stable goals, and not due to mental illness offers a potential starting point, but in its brevity, it also implies that patients who possess these basic qualities may differ greatly. The challenge will then be for consulting psychiatrists to immerse themselves in a patient's psychological experience with the goal of ensuring that the request is emotionally appropriate, purposive, free of undue influence, and consistent over time with the patient's stated goals, values, and preferences.

Although the arguments and evidence reviewed herein may influence some to change their views on assisted suicide, there are undoubtedly those who will remain steadfast in their beliefs. That strong arguments can be made on both sides of the debate and strident disagreement continues suggests that the question of assisted suicide may touch on something deeper than any single ideology.

In medicine, it may be especially difficult to feel comfortable with helping a patient commit suicide, given that some may equate PAS with killing rather than healing. For this and other reasons, which may be religiously or philosophically derived, certain physicians may feel that it is against their code of ethics to participate in assisted suicide. The question of assisted suicide can also raise feelings of personal failure, as if medicine has nothing left to offer patients, although as implied by the arguments outlined in this article, assisted suicide could instead function as a vital form of care for someone who is suffering.

Indeed, for our purposes in medicine, it is this latter perspective that forms the raison d ' etre of PAS. Rather than merely seeking to maximize patient autonomy in some abstract sense, physicians are experts in the service of patients' health and are therefore obligated to practice PAS only when it is deemed to be in the interest of patients' well-being and not solely in the service of patient autonomy or preference satisfaction. This approach obviates the absurd implication of prioritizing maximization of autonomy over our professional obligations and moreover serves as a useful framework with which to deny the practice of PAS in other conditions, such as chronic, nonterminal illness, in which physicians would feel that PAS would not constitute appropriate care.

In fact, the fear that assisted suicide could eventually be used in such cases is fundamentally unsettling to many. When the philosopher Albert Camus 33 said, “There is but one truly serious philosophical problem and that is suicide,” he was identifying one of the most basic fears that humans can have. Camus' statement highlights the fact that, at one point or another in our lives, we all must confront our mortality and the question of whether life is worth living. As fellow humans and in psychiatry in particular, we hope that each person is able to resolve this dilemma in a way that allows him to live life in a satisfying, meaningful way. Assisted suicide seems to flout that basically pro-life view, but on closer examination, its purpose is instead to relieve suffering in imminently terminal cases where it is thought that no other treatment could reasonably hope to do the same. Our charge as physicians is to encourage an honest, scientific inquiry into the questions raised by PAS that is commensurate with the ideological fervor that surrounds the debate and, as psychiatrists, to ensure that patients struggle valiantly and honestly before making a decision in that direction.

Disclosures of financial or other potential conflicts of interest: None.

• © 2015 American Academy of Psychiatry and the Law
• Levenson JL ,
• 5. ↵ American Medical Association . Opinion 2.211—PAS . Chicago : American Medical Association , June 1994 . Available at https://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion2211.page/ . Accessed on February 3, 2013
• Emanuel EJ ,
• Fairclough D ,
• Clarridge BC ,
• Curlin FA ,
• Ganzini L ,
• Nelson HD ,
• Harvath TA ,
• Jackson A ,
• Carlson B ,
• Simopolous N ,
• Chochinov HM ,
• Wilson KG ,
• Breitbart W ,
• Rosenfeld B ,
• Battin MP ,
• van der Heidi A ,
• Georges J-J ,
• Onwuteaka-Philipsen BD ,
• Muller MT ,
• Dobscha SK ,
• 22. ↵ Oregon Death With Dignity Act Annual Report . Oregon Public Health Division . January 14 , 2013 . Available at http://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Documents/year15.pdf . Accessed on February 3, 2013
• Appelbaum PS
• Poppito C ,
• Gibson SR ,
• McClement ,
• Kissane DW ,
• Justin O'Brien

In this issue

• Table of Contents
• Index by author

Thank you for your interest in recommending The Journal of the American Academy of Psychiatry and the Law site.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Citation Manager Formats

• EndNote (tagged)
• EndNote 8 (xml)
• RefWorks Tagged
• Ref Manager

• Tweet Widget
• Facebook Like
• Google Plus One

Jump to section

Related articles, cited by..., more in this toc section.

• Attitudes of Forensic Fellowship Psychiatry Directors towards an Applicant Match
• Suicide Prevention Effects of Extreme Risk Protection Order Laws in Four States
• Mental Health and Social Correlates of Reincarceration of Youths as Adults

Similar Articles

• University of Wisconsin–Madison
• University of Wisconsin-Madison
• Research Guides
• College Undergraduate Research Group
• Bioethics: An Undergraduate Research Guide
• Assisted Suicide

Bioethics: An Undergraduate Research Guide : Assisted Suicide

• Writing, Citing, & Research Help
• Animal Rights
• Chemical and Biological Weapons
• Food Shortages/Food Supply
• Genetic Engineering
• Medical Ethics
• Stem Cell Research
• Newspaper Source Plus Newspaper Source Plus includes 1,520 full-text newspapers, providing more than 28 million full-text articles.
• Newspaper Research Guide This guide describes sources for current and historical newspapers available in print, electronically, and on microfilm through the UW-Madison Libraries. These sources are categorized by pages: Current, Historical, Local/Madison, Wisconsin, US, Alternative/Ethnic, and International.

Organizations

• Assisted Suicide An ERGO website dedicated to assisted suicide and the rights of the terminally ill.
• Death with Dignity National Center Organization that leads the defense of the Oregon Death with Dignity Law.
• ERGO (Euthanasia Research and Guidance Organization) A pro-euthanasia organization.
• Euthanasia.com A pro-life organization that provides information on euthanasia and physician-assisted suicide.
• The World Federation of Right to Die Societies An international federation consisting of 38 right to die organizations from 23 countries.

About Assisted Suicide

This Research Guide provides resources related to the medical, legal and ethical issues of assisted suicide. Assisted suicide is an active form of euthanasia, while passive euthanasia ("the right to die") involves withholding of life support so that a terminally ill patient may die a natural death.

Try searching these terms using the resources linked on this page: assisted suicide, assisted suicide and law*, assisted suicide and ethic*, physician assisted suicide, euthanasia, right to die, euthanasia and law*, euthanasia and ethic*, palliative care, euthanasia and religio*

Overview Resources - Background Information

• Euthanasia and Physician Assisted Suicide Information on ethical, legal, and religious issues and the status of euthanasia and physician assisted suicide in the U.S. and other countries around the world.
• Opposing Viewpoints Resource Center Opposing Viewpoints Resource Center (OVRC) provides viewpoint articles, topic overviews, statistics, primary documents, links to websites, and full-text magazine and newspaper articles related to controversial social issues.
• Voluntary Euthanasia Article from the Stanford Encyclopedia of Philosophy on voluntary euthanasia and the arguments for and against it.
• CQ Researcher Contains weekly in-depth reports that cover the most current and controversial issues of the day with complete summaries, insight into all sides of the issues, bibliographies and more.

Articles - Scholarly and Popular

• Academic Search Includes scholarly and popular articles on many topics.
• PsycINFO Includes articles on psychology topics.
• Health Source: Nursing/Academic Includes articles on health and medical topics.

Statistics and Data

• << Previous: Animal Rights
• Next: Chemical and Biological Weapons >>
• Last Updated: Jun 7, 2024 5:02 PM
• URL: https://researchguides.library.wisc.edu/bioethicsURG

Home — Essay Samples — Social Issues — Human Rights — Assisted Suicide

Assisted Suicide Essay Examples

Types of assisted suicide essays.

• Argumentative Essay: An argumentative essay on assisted suicide requires the writer to take a stance on the topic and provide evidence to support their argument. This type of essay should clearly state the writer's position on the topic and provide evidence to support it.
• Persuasive Essay: A persuasive essay on assisted suicide is similar to an argumentative essay, but the writer's goal is to persuade the reader to their side. This type of essay should provide compelling evidence and present a strong argument to convince the reader to agree with the writer's position.
• Research Essay: A research essay on assisted suicide requires the writer to conduct extensive research on the topic and provide evidence to support their argument. This type of essay should present a balanced view of the topic and provide evidence to support both sides of the argument.

Physician assisted suicide essay: arguments you can use

Arguments for assisted suicide, arguments against assisted suicide, how to write an assisted suicide essay.

• Choose a Topic: Select a specific topic related to assisted suicide, such as the ethics of assisted suicide, the right to die, or the legal aspects of assisted suicide.
• Research: Conduct extensive research on the topic to gather relevant information and evidence to support your argument.
• Create an Outline: Create an outline of your essay, including the introduction, body paragraphs, and conclusion. Use headings and subheadings to organize your ideas.
• Write the Introduction: The introduction should provide an overview of the topic and clearly state the purpose of the essay. It should also provide background information on assisted suicide and introduce the main arguments.
• Write the Body Paragraphs: The body paragraphs should provide evidence to support your argument. Use examples and statistics to back up your claims. Use headings and subheadings to organize your ideas.
• Write the Conclusion: The conclusion should summarize the main points of the essay and provide a final perspective on the topic of assisted suicide. It's important to reiterate the thesis statement and emphasize the key arguments made throughout the essay.

Final Words

Hook examples for assisted suicide essays, anecdotal hook.

Imagine a terminally ill patient, wracked with pain and suffering, faced with the choice of ending their life on their terms. This is the ethical dilemma of assisted suicide.

Question Hook

Should individuals have the right to decide when and how they die? Delve into the complex and controversial issue of assisted suicide.

Quotation Hook

"Dying is not a crime." — Jack Kevorkian. Explore the viewpoints of advocates like Kevorkian who argued for the right to assisted suicide.

Statistical or Factual Hook

Each year, thousands of terminally ill patients grapple with the decision of whether to pursue assisted suicide. Examine the prevalence and legality of this practice worldwide.

Definition Hook

What exactly is assisted suicide, and how does it differ from euthanasia? Explore the nuances of these terms and their ethical implications.

Rhetorical Question Hook

Is assisted suicide an act of compassion or a slippery slope towards unethical practices? Analyze the moral dilemmas surrounding this end-of-life choice.

Historical Hook

Trace the history of assisted suicide, from ancient civilizations to contemporary debates, to understand the evolution of public opinion and legislation.

Contrast Hook

Contrast the perspectives of patients seeking assisted suicide with those of medical professionals, religious leaders, and lawmakers who may oppose it.

Narrative Hook

Step into the shoes of a terminally ill patient considering assisted suicide, and explore the emotional and ethical challenges they face in making this decision.

Shocking Statement Hook

Prepare to confront deeply divisive ethical questions about the right to die with dignity. Assisted suicide is a topic that sparks passionate debates and raises profound moral concerns.

Physician-assisted Suicide (pas)

Discussion of whether assisted suicide is morally acceptable, made-to-order essay as fast as you need it.

Each essay is customized to cater to your unique preferences

+ experts online

Analysis of The Arguments for and Against Assisted Suicide

The issues why physician-assisted suicide should not be legalized, my views on the issue of assisted suicide, understanding suicide: causes, signs, and prevention strategies, let us write you an essay from scratch.

• 450+ experts on 30 subjects ready to help
• Custom essay delivered in as few as 3 hours

The Issue of The Legalization of Assisted Suicide

Human euthanasia as an assisted suicide, ethical issues related to the right to physician-assisted suicide, a controversy over the issue of physician assisted suicide, get a personalized essay in under 3 hours.

Expert-written essays crafted with your exact needs in mind

The Flaws in The Legalization of Assisted Suicide for The Terminally Ill Patient in Ryan Anderson's The Heritage Foundation

Ethical dilemma in nursing: abortion and euthanasia, the popularity of euthanasia among the american population, euthanasia, assisted dying and the right to die, euthanasia has a positive influence: arguments, medical assistance in dying in canada, euthanasia and mercy killing, legalization of euthanasia in sri lanka, a moral interpretation of euthanasia and murder, the moral and ethical views on the goal of euthanasia, euthanasia: the actions of the so called gods, an introduction to the different types of euthanasia, the need to accept laws to allow assisted suicides, the views of euthanasia as an immoral crime or an act of moral compassion, science and technology for disease control, discussion on whether human euthanasia should be made illegal, analysis of physician-assisted suicide (pas) in terms of bioethics, patients denied the right to euthanasia, a debate over allowing physician assisted suicide, the moral dilemma of euthanasia, relevant topics.

• Human Trafficking
• Gun Control
• Police Brutality
• Death Penalty
• Gay Marriage
• Same Sex Marriage
• Child Labour

By clicking “Check Writers’ Offers”, you agree to our terms of service and privacy policy . We’ll occasionally send you promo and account related email

No need to pay just yet!

Bibliography

We use cookies to personalyze your web-site experience. By continuing we’ll assume you board with our cookie policy .

• Instructions Followed To The Letter
• Deadlines Met At Every Stage
• Unique And Plagiarism Free

• Homework Help
• Essay Examples
• Citation Generator
• Writing Guides
• Essay Title Generator
• Essay Topic Generator
• Essay Outline Generator
• Flashcard Generator
• Plagiarism Checker
• Paraphrasing Tool
• Conclusion Generator
• Thesis Statement Generator
• Introduction Generator
• Literature Review Generator
• Hypothesis Generator
• Human Editing Service
• Essay Hook Generator
• Assisted Suicide Essays

Assisted Suicide Essays (Examples)

Filter by keywords:(add comma between each), example essays.

Assisted Suicide Is a Suicide Committed by

Assisted suicide is a suicide committed by someone with assistance from someone other than themselves, many times a Physician. Assisted suicide is typically delivered by lethal injection. The drugs are setup and provided to the patient and the patient has the choice as to when they deliver them by pressing a button themselves. This is a controversial topic that has both proponents and opponents for various the reasons. The most controversial suicides are those in which the patient does not have the ability to press a button themselves and someone must complete the process for them. It has been argued that this is no longer assisted suicide, but murder. This research will explore the topic of assisted suicide and the many facets of the legal and moral issues. Assisted suicide differs from euthanasia. In assisted suicide the person assisting only provides the means and drugs necessary. In euthanasia the person's life…...

mla References Andre, C & Valesquez, M. (2010). Assisted Suicide: Right or Wrong? Santa Clara University. Retrieved August 5, 2012 from   http://www.scu.edu/ethics/publications/iie/v1n1/suicide.html  Euthanasia.com (2012). History of Assisted Suicide. Retrieved August 5, 2012 from   http://www.euthanasia.com/history.html . Gorsuch, N. (2009)The Future of Assisted Suicide and Euthanasia. Princeton University press. Healthcare.gov. (2012). Patient's Bill of Rights. Retrieved August 5, 2012 from   http://www.healthcare.gov/law/features/rights/bill-of-rights/index.html

Assisted Suicide Should Be a Legal Right

Assisted suicide should be a legal right. The grounds for this claim include the fact that modern medicine has made it possible to extend life artificially, allowing for people to survive beyond their body's capacity for wellness. Other grounds for ensuring the rights of citizens to death with dignity include the essentially libertarian underpinnings of American society. Currently, only the states of ashington and Oregon allow physicians to assist patients with a dignified death. The United States cannot dictate laws related to assisted suicide in other countries, but can set a normative precedent that highlights the need for more compassionate and wise approaches to ending a life. The primary arguments against assisted suicide are religious ones, which have no place in determining American law. Scare tactics related to assisted suicide can easily be dismissed. There are several ways that doctors can be trained and supervised so that no assisted suicide…...

mla Works Cited Andre, Claire and Velasquez, Manuel. "Assisted Suicide: A Right or a Wrong?"Santa Clara University Markkula Center for Ethics. Retrieved online:   http://www.scu.edu/ethics/publications/iie/v1n1/suicide.html  Humphry, Derek. "Liberty and Death." Assisted Suicide. Retrieved online:   http://www.assistedsuicide.org/liberty_and_death_manifesto_right_to_die.html  Topping, Alexandra and Jones, Sam. "Locked-in syndrome sufferer wins high court hearing for his right to die." The Guardian. 12 Mar 2012. Retrieved online:   http://www.guardian.co.uk/society/2012/mar/12/locked-in-syndrome-sufferer-court-hearing

Assisted Suicide When We Think of Assisted

Assisted Suicide hen we think of assisted suicide, most of us immediately think of Dr. Jack Kevorkian, the retired pathologist who was sentenced to two terms of imprisonment in 1999 for helping a man suffering from a terminal disease to die (Humphrey 2002). Assisted suicide is a very passionate issue of debate in this country. There are numerous ethical and moral considerations aside from the legal aspects of the practice. The topic is as controversial as abortion and capital punishment. Most everyone has a deep-rooted belief one way or the other, they are either for or against, few ride the middle ground. It has been my observation that those in favor of pro-life are more likely to favor capital punishment and oppose assisted suicide, and those in favor of abortion and assisted suicide are more likely to oppose the death penalty. It is indeed a passionate issue and will continue to…...

mla Works Cited Center For Ethics & Professionalism." American College of Physicians. American Society of Internal Medicine.   http://www.acponline.org/ethics/ethicman.htm .(accessed07-11-2002). Death With Dignity." Oregon Death with Dignity Center. 2002.   http://www.dwd.org/community/resources.asp . A accessed 07-11-2002).

Assisted Suicide Should Be Legalized There Is

Assisted suicide should be legalized. There is no rational argument against it, only cartoonish arguments based on superstition and feigned morality. In the real world, we all must die, and there is no case, either moral or intellectual, that one can make to argue that we should not have the right to control our final moments. Over the course of this essay, I will illustrate in no uncertain terms that the right to die with dignity is a right reserved for the individual alone, and that no amount of interference on the part of external parties -- especially not those who are entirely unaffected by the death in question -- can be justified. The American Medical Association (2013) frames the issue as one of ethics. It deems the issue as a threat to "the very core of the medical profession's ethical integrity." It argues that physician-assisted suicide is "fundamentally inconsistent" with…...

mla References: AMA. (2013). Physician-assisted suicide. American Medical Association. Retrieved May 5, 2013 from   http://www.ama-assn.org/resources/doc/code-medical-ethics/2211b.pdf  Ertelt, S. (2013). Connecticut pro-lifers try to stop bill to ok assisted suicide. LifeNews.com Retrieved May 5, 2013 from   http://www.lifenews.com/2013/01/16/connecticut-pro-lifers-try-to-stop-bill-to-ok-assisted-suicide/  NEMJ. (2013). Physician-assisted suicide. New England Journal of Medicine. Vol. 368 (2013) 1450-1452.

Assisted Suicide the Issues Susan

A postive life is described as being able to keep memories alive as well as have the feeling of being needed. Alieviated suffering pertains to physical well-being, psychological well-being and personal stratigies to relieve pain. Managing life when ill refers to the facility to be in charge of the situation and to be reflective. If we consider the quality of life enjoyed be Wolf's father at the end of his struggle with cancer a strong case can be made that he had every reason to request that the process of his death be accelerated. Though he was able to function in each of these areas in some capacity, the capacity was severly limited by his illness. At the end he did not even possess the ablity to swallow perscribed lethal medication, and was beyond this method of assissted suicide. Besides quality of life ther are other factors that must be considered…...

mla References Johansson, C.M., Axelsson, B., & Danielson, E. (2005, October). Living with incurable cancer at the end of life -- patient's perceptions on quality of life. Cancer Nursing, Vol. 29, No. 5, 391-399. Webster, B. (2009 July 14). Assisted suicide/voluntary euthanasia. International debate education center. Retrieved January 5, 2012, from http://www.idebate.org/debatabase/topic_details.php?topicID=55 Wolf, S.M. (2008 September - October). Confronting physician-assisted suicide and euthanasia: my father's death. Hasting center report. In FindArticles. Retrieved January 5, 2012, from   http://findarticles.com/p/articles/mi_go2103/is_5_38/ai_n30913055/

Assisted Suicide or Called Euthanasia Is an

Assisted Suicide, or called Euthanasia, is an issue that has long been debated whether it should be acceptable and made legal, or not. The concern that many delivers as to whether or not Assisted Suicide should be made legal is this question that many poses -- Is it ethical and moral to help someone who suffers from a terminal disease to die earlier? In medical practice, Assisted Suicide is the process of helping a patient who suffers from a terminal disease to end his sufferings. This is done by terminating any system which supports and sustains the life of the patient. Thus, causing the patient to die. There are two types of Assisted Suicide that is medically considered in countries where the practice is legal. These are voluntary and involuntary suicide. Involuntary Suicide is practiced to patients where there is no more hope to live due to the physical state of unconciousness,…...

mla Bibliography Earll, Carrie G. Physician-Assisted Suicide and Euthanasia. 2001. Focus on Social Issues Online. 2004.   http://www.family.org/cforum/fosi/bioethics/euthanasia/a0027997.cfm  B.A. Robinson. Euthanasia and Physician-Assisted Suicide: All Sides

Assisted Suicide California Once Again

However, research shows that even though suicide risk may be increased in cancer patients, it only accounts for only a small minority of deaths (Storm et. al., 1992). When cancer patients do try to commit suicide or actually commit the act, they have some major psychiatric disorders, particularly depression (Breitbart, 1990) study of 100 men with AIDS, the "interest" in physician-assisted suicide was predicted by high levels of psychological distress and the experience of terminal illness of a friend or relative, as well as a perception of lower levels of social support. No significant association existed between interest in assisted suicide and severity of the disease (Breitbart, 1990). Chochinov et. al analyzed the desire for death with over 100 terminally ill cancer patients and found only 8.5% had a lasting and clinical desire for death, and of these 59% were depressed, compared with 8% of those without a stated…...

mla References Breitbart, W. (1990) Cancer Pain and Suicide. Advances in Pain Research and Therapy. 16: 399 Hendin, H. (1994) Seduced by Death: Doctors, Patients, and the Dutch Cure. Issues in Law and Medicine 10: 123 Muskin, P.R. (1998). The Request to Die: Role for a Psychodynamic Perspective on Physician-Assisted Suicide, JAMA 279: 323, 327 Moskowitz, E. (2003) the Consensus on Assisted Suicide. Hastings Center Report

Assisted Suicide the Fright of

Besides, the people who are against assisted suicide disagree that physicians have been conferred immense authority, which can be mistaken or immoral. The competence of taking decisions on issues of life and death must rest where it ultimately belongs -with the Almighty, not physicians. (Should an incurably-ill patient be able to commit physician-assisted suicide?) a case has been made that even though cautious and dependable professional behavior relating to assisted suicide is being given and reasonable safety procedures as well for the patients concerned, likely survivors and community in totality are been taken into account, a lot of cases exist where the anticipated excellence is a distant dream, therefore assistance with suicide becomes very risky. (Diekstra, 1995) Conclusion To conclude, the present argument regarding euthanasia and assisted suicide possesses the capability to make out society into a unilateral one, however it can also have an encouraging influence in case it assists…...

mla References Braddock, Clarence H; Tonelli, Mark R. (1998) "Physician-Assisted Suicide" Ethics in Medicine. University of Washington School of Medicine. Retrieved at Accessed on 15 November, 2004 http://eduserv.hscer.washington.edu/bioethics/topics/pas.html. Carr, William H.A. (September-October, 1995) "A Right to Die - Physician-Assisted Suicide - Includes a Discussion of the So-Called Physician's Oath in a 1990's Context" Saturday Evening Post. pp: A4-5 Diekstra, RF. (May, 1995) "Dying in Dignity: The Pros and Cons of Assisted Suicide" Psychiatry Clinical Neuroscience. Volume: 49 Supplementary 1; pp: 139-148 Gates, Thomas J. (15 May, 1997) "Euthanasia and Assisted Suicide: A Family Practice Perspective" American Family Physician. Volume: 12; No: 1; pp: 58-63

Assisted Suicide Society Law Ethics

Suicide, assisted or otherwise, is a contentious issue in modern society. While most people would be upset if a loved one killed himself or herself, there is nonetheless widespread recognition that people's right to autonomy might supersede such concerns, especially when the choice is between a dignified death by suicide and a prolonged and painful terminal illness. However, there are still those who disagree and who believe that suicide is always or usually wrong. This ongoing debate is reflected in laws, societal values, and the philosophy of ethics. Euthanasia, from the Greek words for "good death," is an old concept: in Sir Thomas More's Utopia, written in the time of Henry the Eighth, citizens of Utopia may end their lives with permission from religious and governmental officials (Minois 2001, 67). The concept of medically-assisted suicide is a largely late twentieth century invention (Minois 2001, 328). Proponents argue that -- despite…...

mla References Braw, E. (2013). Should a sick child be allowed to choose death? Belgians think so. Newsweek, December 5, 2013. http://www.newsweek.com/should-sick-child-be-allowed-choose-death-belgians-think-so-223851 Buchanan, RT. (2015). Right to die: Belgian doctors rule depressed 24-year-old woman has right to end her life. The Independent, July 2, 2015.   http://www.independent.co.uk/news/people/right-to-die-belgian-doctors-rule-depressed-24-year-old-woman-has-right-to-end-her-life-10361492.html  Gayle, D. (2013). Transsexual, 44, elects to die by euthanasia after botched sex-change operation turned him into a 'monster'. The Daily Mail, October 1, 2013.   http://www.dailymail.co.uk/news/article-2440086/Belgian-transsexual-Nathan-Verhelst-44-elects-die-euthanasia-botched-sex-change-operation.html  Minois, G. (2001). History of suicide: Voluntary death in western culture. Baltimore: Johns Hopkins.

Assisted Suicide in the United States

Brittany Maynard Case The case of Brittany Maynard is a fairly textbook one when it comes to the discussions that center on doctor-assisted suicide and euthanasia in general. There are indeed cases where the death of a patient is a certainty. However, the devil is in the details as some people believe that they have to suffer out their final days while others, such as Brittany Maynard, feel that they should have at least some control over their own destiny. These people feel that they should be able to die "with dignity" and on their own terms rather than having to wait for death to come and for suffering to occur as that date approaches. However, there are some medical, legal and ethical considerations that have to be taken seriously when it comes to someone committing suicide and involving one or more other people in the same. While "death with dignity"…...

mla References Bahan, I. (1997). Physician-assisted suicide. Above all else do no harm. Tennessee Medicine: Journal of The Tennessee Medical Association, 90(2), 45-46. Campbell, C. S., & Black, M. A. (2014). Dignity, death, and dilemmas: a study of Washington hospices and physician-assisted death. Journal Of Pain And Symptom

Moral Issues Surrounding Assisted Suicide

Assisted Suicide The ethical and moral issues surrounding assisted suicide are presented in this paper through interviews and research. Assisted suicide has always been a controversial subject and it continues to be controversial although there are people who believe it is moral, ethical, and should be made legal. My Neighbor and Friend -- Ms. Rogers -- Interviewed February 4, 2015 Ms. Rogers is a 55-year-old Caucasian widow who lives in my neighborhood. She graciously agreed to be asked questions as to her views on assisted suicide, and so an interview was scheduled. She was asked about her personal moral values and her religious beliefs regarding voluntary assisted suicide, and she said that she is a devout Christian and thus, she said that only God can give life, and only God can take it away. Her views are very much shared by many Christians and people of other faiths, so it was no surprise to…...

Ethics Assisted Suicide What Is Assisted Suicide

Ethics: Assisted Suicide What is Assisted Suicide? ecent Issues Theories: Is it Ethical? The Death with Dignity Act (DWDA) The Deontology Argument Virtue Ethics The Velma Howard Case (Assisted Suicide) Peter Williams Case Ethics: Assisted Suicide Physician-assisted suicide, is this really an ethical technique? A lot of people feel strongly on both sides of this concern. However, on April 13, 1999, the most known doctor executed an assisted suicide, Dr. Jack Kevorkian, was given a sentenced of ten to twenty-five years in prison after being charged with second degree murder and three to seven years for using controlled substance (Colbert, 2013). Assisted suicide normally takes place when a person commits suicide but they are getting help from another person. Physician-assisted suicide normally has no pain involved, as many would comment, the most passive way for a person to expire. With that said. Is it ethical? This essay will examine the ethics behind assisted suicide. What is Assisted Suicide? According to Dictionary.com, the…...

mla References Callahan, D. (2009). Organized obfuscation: Advocacy for physician-assisted suicide. The Hastings Center Report, 23(9), 67-89. Colbert, J.A. (2013). Physician-assisted suicide -- polling results. The New England Journal of Medicine,, 34(9), 396. Friend, M.L. (2011). Physician-assisted suicide: Death with dignity? Journal of Nursing Law, 14(3), 34-36. Groenewoud, J.H.-P. (2009). Clinical problems with the performance of euthanasia and physician-assisted suicide in the netherlands. The New England, 23(9), 123-125.

Ethical Issues of Assisted Suicide and Euthanasia

Ethical Issues of Assisted Suicide and Euthanasia The ethical issues relating to assisted suicide and euthanasia have captured the attention of the public. The topic of Euthanasia is a contentious one and it inescapably incites strong emotional argument and gives rise to tough beliefs that do not straight away lend themselves to consensual harmony. It is improbable that a decision can be reached which will meet with universal support whenever such clashes of values exist, with apparently little middle ground. It is hard for anyone to anticipate accord on this issue in a society with a plurality of extensively varying moral opinions and faiths. There is an urgent need for the issue of active voluntary euthanasia to be addressed in spite of the difficulties in this area. (Otlowski, 1997) A constant stress of media attention and increasing anxiety about control at life's end has created severe concern of legalizing the issue of…...

mla REFERENCES "About Implementing Humane Euthanasia in NM Animal Shelters" Retrieved from http://www.nmanimalcontrol.com/euthanasia/HEPP/FAQ.html#_edn10 Accessed on 28 July, 2005 "Arguments in favor of euthanasia" Retrieved from http://www.bbc.co.uk/religion/ethics/euthanasia/euth_rights.shtml Accessed on 28 July, 2005

Doctor Assisted Suicide

Physician-assisted suicide should be legalized in all of America. The issue of physician-assisted suicide, from time to time, makes the rounds of the mainstream media, most recently with the case of Brittany Maynard, the terminal cancer patient who at the age of 29 used physician-assisted suicide. She had moved from California to Oregon in order to be able to do this, as the practice is not yet legal in her home state (The Telegraph, 2014). Her decision was criticized by the Vatican, and religion does often form the philosophical underpinning of the resistance to physician-assisted suicide in Western countries. There are different arguments in favor of physician-assisted suicide. One, currently being used by civil liberties activists before the Supreme Court of Canada, holds that equality rights are being violated because the sick are unable to end their own lives in the same way that the physical-abled can, and that suicide is…...

mla References Andorno, N. (2013). Physician-assisted suicide should be permitted. New England Journal of Medicine Vol. 368 (15) 1451-1452 Back, A., Wallace, J., Starks, H., & Pearlman, R. (1996). Physician-assisted suicide and euthanasia in Washington State. Journal of the American Medical Association. Vol. 275 (12) 919-925. Boudreau, J. & Somerville, M. (2013). Physician-assisted suicide should not be permitted. New England Journal of Medicine Vol. 368 (15) 1450-1451 Cholbi, M. (2012). Suicide. Stanford Encyclopedia of Philosophy. Retrieved November 25, 2014 from   http://plato.stanford.edu/entries/suicide/

Against Assisted Suicide There Are

If the act of killing another is imply universally banned, the definition of ethical action is greatly simplified, and all gray areas are decided on the side of caution. The above areas of concern are very real; there is evidence that non-voluntary euthanasia occurs in other countries where assisted suicide is an accepted medical practice (Debate, 2009). Mental health is often in issue with chronic diseases and end-of-life care, and determining when people are capable of making the choice of assisted-suicide is an impossible task -- some would even argue that the request itself is evidence of mental unhealthy, and should be interpreted as a request for better care (APA, 2001; True Compassion, 2009). John Stuart Mill, who wrote directly and explicitly in opposition to Kant with his Utilitarian ethics, believed that it was only the effects of an action that determined its morality: "the influence of actions on happiness…...

mla References APA. (2001). "End-of-life issues and care." Accessed 7 March 2009. http://www.apa.org/pi/eol/arguments.html#2 Braddock, C. & Tonelli, M. (1998). "Physician-assisted suicide." Ethics in medicine. University of Washington school of medicine official website. Accessed 7 March 2009.   http://depts.washington.edu/bioethx/topics/pas.html  Debate." (2009). Euthanasia.com. Accessed 7 March 2009.   http://www.euthanasia.com/debate.html  Mill, J. (1871). Utilitarianism. London: Longman, Greens, Reader, and Dyer.

Can you help me with a thesis statement on an essay about end of life?

These statements can serve as a foundation for essays that explore various dimensions of end-of-life care, including ethical considerations, the impact of technology, the importance of palliative care, and the role of family and caregivers. Each thesis sets the stage for a detailed discussion on its respective topic, allowing for a deep dive into the complexities and nuances involved in end-of-life care and decision-making.

"The implementation of advanced care planning significantly improves end-of-life care by ensuring that individuals' preferences and values are respected, highlighting the need for more widespread adoption of these practices in healthcare settings."

"While technological advancements in medicine have....

I need some suggestions for ethical issues essay topics. Can you offer any?

1. The use of genetic engineering in creating designer babies 2. The ethics of animal testing in scientific research 3. The impact of social media on privacy and ethical boundaries 4. The ethical implications of artificial intelligence and automation in the workforce 5. The ethical considerations of data mining and surveillance in the digital age 6. The ethical responsibilities of pharmaceutical companies in pricing and distributing life-saving medications 7. The ethics of factory farming and its impact on animal welfare and the environment 8. The ethical dilemmas surrounding end-of-life care and physician-assisted suicide 9. The ethical implications of technology companies manipulating user data for profit 10. The ethical considerations....

Unsure if my physician assisted suicide thesis statement is focused enough. Would you give feedback?

"Physician-assisted suicide, a controversial and morally complex subject, has sparked intense debate, raising ethical concerns and highlighting the need for compassionate and individualized end-of-life care." Your thesis statement does a good job outlining the general topic of physician-assisted suicide and hinting at the moral complexities and ethical considerations involved. However, it could be strengthened by clearly stating your position or main argument on the subject. Are you in favor of physician-assisted suicide under certain circumstances, or do you believe it should never be allowed? Having a clear stance will help focus your research and writing, making your thesis statement more impactful.....

Need help refining a thesis statement about the physician assisted suicide?

Thesis: Physician-assisted suicide, as a controversial topic surrounding end-of-life decisions, necessitates a comprehensive exploration of moral, ethical, and legal aspects in order to understand the potential benefits and consequences it may have on terminally ill patients and healthcare providers. One way to refine the thesis statement could be to focus on the specific impact of physician-assisted suicide on patients and healthcare providers. For example: Revised Thesis: The moral, ethical, and legal considerations surrounding physician-assisted suicide raise important questions about the impact it has on terminally ill patients and healthcare providers, underscoring the need for a more nuanced examination of its implications on....

Sign Up for Unlimited Study Help

Our semester plans gives you unlimited, unrestricted access to our entire library of resources —writing tools, guides, example essays, tutorials, class notes, and more.

Right to Die

About right to die, narrow the topic.

• Articles & Videos
• MLA Citation This link opens in a new window
• APA Citation This link opens in a new window

• Is euthanasia ethical?
• Is "terminal sedation" slow euthanasia?
• Should euthanasia be a personal decision  or should it be regulated by the government?
• Will legalized euthanasia lead to a rise in involuntary cases?
• What burdens does a terminal illness place on families?
• Would improved pain management techniques reduce requests for assisted suicides?
• Is terminal care bankrupting the health care system?
• Can medical technology prolong life past the point at which life can be considered worth living?
• Who should make decisions about terminally ill patients—the patient, the doctor, or the family?
• Research specific legal cases of euthanasia such as Karen Quinlan (1976-1985), Nancy Cruzan (1990), Terri Schiavo (2005) or the work of Dr. Jack Kevorkian.
• Research Oregon's Death with Dignity Act.
• Next: Library Resources >>
• Last Updated: Sep 11, 2024 2:17 PM
• URL: https://libguides.broward.edu/Right_to_Die

• About The Journalist’s Resource
• Follow us on Facebook
• Follow us on Twitter
• Criminal Justice
• Environment
• Politics & Government
• Race & Gender

Expert Commentary

Physician-assisted suicide: Research roundup

2012 research review of relevant studies and data on assisted suicide and policies related to this issue, both in the United States and around the globe.

Republish this article

This work is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International License .

by Alexandra Raphel, The Journalist's Resource December 3, 2012

This <a target="_blank" href="https://journalistsresource.org/health/physician-assisted-suicide-research-roundup/">article</a> first appeared on <a target="_blank" href="https://journalistsresource.org">The Journalist's Resource</a> and is republished here under a Creative Commons license.<img src="https://journalistsresource.org/wp-content/uploads/2020/11/cropped-jr-favicon-150x150.png" style="width:1em;height:1em;margin-left:10px;">

Physician-assisted suicide is legal in only two U.S. states, yet requests to doctors for such help remain common across the country. As the 2012 PBS Frontline documentary “The Suicide Plan” notes, there is an “underground world” that has “added new layers of moral and legal complexity to one of the most polarizing issues in America.”

The practice has been legal in Oregon and Washington since 1997 and 2009, respectively. Montana’s state Supreme Court ruled in 2009 that assisted suicide was legal, though the practice remains contested. In February 2012, Georgia’s Supreme Court struck down a law aimed at controlling information about assisted suicide. Efforts to legalize the practice have failed in states such as Massachusetts, California, Hawaii and Maine. Internationally, the practice is only legal in a handful of countries, including Belgium, the Netherlands and Switzerland.

Though there are many assumptions about this issue on both sides of the “right-to-die” or “death with dignity” debates, detailed data from places where the practice is legal can help inform further discourse — and what it would mean to implement such a law. For example, a study in the New England Journal of Medicine examined the cases of the 23 Oregon citizens who received prescriptions for lethal medication during the state’s first year under the new law; a follow-up study also explored the Oregon experience during the second year.

Between 1997 and 2011, 935 Oregon citizens have been issued lethal prescriptions and 596 have consequently died, according to Oregon Health Authority data . Between 2009 and 2011 in Washington state, 255 people have participated in the state’s “Death with Dignity” program and 241 have died as part it, according to state figures .

The following are research studies that provide in-depth perspective on these issues:

“Prevalence of Depression in Granted and Refused Requests for Euthanasia and Assisted Suicide: A Systematic Review” Levene, I.; Parker, M. Journal of Medical Ethics , 2011, 37:4, 205-11.

Findings : “It is unclear whether depression increases the probability of making a request for euthanasia/PAS, but in the Netherlands most requests in depressed patients are rejected, leaving a depression rate in cases that is similar to the surrounding population. Less evidence is available elsewhere, but some level of depression has been identified in patients undergoing euthanasia/PAS in all the countries studied. Whether the presence of depression is ever compatible with an ethical decision on euthanasia/PAS is discussed.”

“Dignity in End-of-Life Care: Results of a National Survey of U.S. Physicians” Antiel, Ryan M; Curlin, Farr A. Journal of Pain and Symptom Management , September 2012, Vol. 44, Issue 3, 331-339.

Abstract: “Two thousand practicing U.S. physicians, from all specialties, were mailed a survey. Main measures included physicians’ judgments about an end-of-life clinical scenario (criterion variable), attitudes about the concept of dignity (predictors), and their religious characteristics (predictors). Responses were received from 1032 eligible physicians (54%). Nine (90%) of 10 physicians reported that dignity was relevant to their practice. After controlling for age, gender, region, and specialty, physicians who judged that the case patient had either some dignity or full dignity, and who agreed that dignity is given by a creator, were all positively associated with believing that the patient’s life was worth living (odds ratio 10.2, 95% confidence interval …) Respondents who strongly agreed that “all living humans have the same amount of dignity” were also more likely to believe that the patient’s life was worth living ([odds ratio] 1.8, 95% C.I. 1.2-2.7). Religious characteristics also were associated with believing that the case patient’s life was worth living.… U.S. physicians view the concept of dignity as useful. Those views are associated with their judgments about common end-of-life scenarios in which dignity concepts may be relevant.”

“The First Five Years of Euthanasia Legislation in Belgium and the Netherlands: Description and Comparison of Cases” Rurup, M.L.; Smets, T.; Cohen, J.; Bilsen, J.; Onwuteaka-Philipsen, B.D.; Deliens, L. Palliative Medicine , 2012, 26:1, 43-9

Abstract: “ The Netherlands and Belgium legalized euthanasia in 2002. In this study we describe and compare cases of reported euthanasia and physician-assisted suicide in the first five years of legislation. The databases of the cases reported in Belgium and the Netherlands were made available by the review committees. We compared characteristics of all cases reported between September 2002-December 2007. In the Netherlands 10,319 cases were reported, in Belgium 1,917. Gender and age distributions were similar in both countries. Most patients suffered from cancer (83-87%), but patients more often suffered from diseases of the nervous system in Belgium (8.3% vs. 3.9%). In the Netherlands, reported euthanasia more often occurred at home compared with Belgium (81% vs. 42%), where it occurred more often in hospital (52% vs. 9%). In the Netherlands, all cases were based on the oral request of a competent patient. In Belgium, 2.1% of the reported cases was based on an advance directive. We conclude that countries debating legislation must realise that the rules and procedures for euthanasia they would agree upon and the way they are codified or not into law may influence the practice that develops once the legislation is effected or what part of that practice is reported.”

“Dying Cancer Patients’ Own Opinions on Euthanasia: An Expression of Autonomy? A Qualitative Study” Karlsson, M.; Milberg, A.; Strang, P. Palliative Medicine , 2012, 26:1, 34-42.

Abstract:  “Deliberations on euthanasia are mostly theoretical, and often lack first-hand perspectives of the affected persons. Sixty-six patients suffering from cancer in a palliative phase were interviewed about their perspectives of euthanasia in relation to autonomy. The interviews were transcribed verbatim and analysed using qualitative content analysis with no predetermined categories. The informants expressed different positions on euthanasia, ranging from support to opposition, but the majority were undecided due to the complexity of the problem. The informants’ perspectives on euthanasia in relation to autonomy focused on decision making, being affected by (1) power and (2) trust. Legalization of euthanasia was perceived as either (a) increasing patient autonomy by patient empowerment, or (b) decreasing patient autonomy by increasing the medical power of the health care staff, which could be frightening. The informants experienced dependence on others, and expressed various levels of trust in others’ intentions, ranging from full trust to complete mistrust. Dying cancer patients perceive that they cannot feel completely independent, which affects true autonomous decision making. Further, when considering legalization of euthanasia, the perspectives of patients fearing the effects of legalization should also be taken into account, not only those of patients opting for it.”

“Characteristics of Patients Requesting and Receiving Physician-assisted Death” Meier, D.E.; Emmons, C.A.; Litke, A; Wallenstein, S; Morrison R.S. Archives of Internal Medicine , July 2003, 14;163(13):1537-42.

Abstract: “Of 1,902 respondents (63% of those surveyed), 379 described 415 instances of their most recent request refused and 80 instances of the most recent request honored. Patients requesting assistance were seriously ill, near death, and had a significant burden of pain and physical discomfort. Nearly half were described as depressed at the time of the request. The majority made the request themselves, along with family. In multivariate analysis, physicians were more likely to honor requests from patients making a specific request who were in severe pain (odds ratio, 2.4; 95% confidence interval, 1.01-5.7) or discomfort (odds ratio, 6.5; 95% confidence interval, 2.6-16.1), had a life expectancy of less than 1 month (odds ratio, 4.3; 95% confidence interval, 1.7-10.8), and were not believed to be depressed at the time of the request (odds ratio, 0.2; 95% confidence interval, 0.1-0.5)…. Persons requesting and receiving assistance in dying are seriously ill with little time to live and a high burden of physical suffering.”

“Content of Health Status Reports of People Seeking Assisted Suicide: A Qualitative Analysis” Imhof, L.; Bosshard, G.; Fischer, S.; Mahrer-Imhof, R. Medicine, Health Care and Philosophy , 2011, 14:3, 265-72.

Abstract : “Two right-to-die organisations offer assisted suicide in Switzerland. The specific legal situation allows assistance to Swiss and foreign citizens. Both organisations require a report of the person’s health status before considering assistance. This qualitative study explored these reports filed to legal authorities after the deaths of individuals in the area of Zurich. Health status reports in the legal medical dossiers of the deceased were analysed using content analysis and Grounded Theory. From 421 cases of assisted suicide (2001-2004), 350 reports on health status were filed. Many cases contained diagnosis lists only. Other reports had more elaborate reports revealing that some physicians were aware about the patient’s death wish and the intention to solicit assisted suicide. Physicians’ attitudes ranged from neutral to rather depreciative. Few physicians openly referred the patient to the organisations and supported the patient’s request by highlighting a history of suffering as well as reporting understanding and agreement with the patient’s wish to hasten death. In the health status reports five categories could be identified. Some files revealed that physicians were aware of the death wish. The knowledge and recognition of the patient’s death wish varied from no apparent awareness to strongly supportive. This variety might be due to difficulties to discuss the death wish with patients, but might also reflect the challenge to avoid legal prosecution in the country of origin. To require comparable health status reports as requirements for the right-to-die organisations might be difficult to pursue.”

“Is Continuous Sedation at the End of Life an Ethically Preferable Alternative to Physician-Assisted Suicide?” Raus, Kasper; Stercyx, Sigrid; Mortier, Freddy. The American Journal of Bioethics, 2011, 11:6, 32-40. doi: 10.1080/15265161.2011.577510.

Abstract: “The relatively new practice of continuous sedation at the end of life (CS) is increasingly being debated in the clinical and ethical literature. This practice received much attention when a U.S. Supreme Court ruling noted that the availability of CS made legalization of physician-assisted suicide (PAS) unnecessary, as CS could alleviate even the most severe suffering. This view has been widely adopted. In this article, we perform an in-depth analysis of four versions of this “argument of preferable alternative.” Our goal is to determine the extent to which CS can be considered to be an alternative to PAS and to identify the grounds, if any, on which CS may be ethically preferable to PAS.”

“Attitudes Towards Euthanasia and Assisted Suicide: A Comparison Between Psychiatrists and Other Physicians”

Levy, Tal Bergman; Azar, Shlomi; Huberfeld, Ronen; Siegel, Andrew M.; Strous, Rael D. Bioethics, 2012, doi: 10.1111/j.1467-8519.2012.01968.

Abstract: “Euthanasia and physician assisted-suicide are terms used to describe the process in which a doctor of a sick or disabled individual engages in an activity which directly or indirectly leads to their death. This behavior is engaged by the healthcare provider based on their humanistic desire to end suffering and pain. The psychiatrist’s involvement may be requested in several distinct situations including evaluation of patient capacity when an appeal for euthanasia is requested on grounds of terminal somatic illness or when the patient is requesting euthanasia due to mental suffering. We compare attitudes of 49 psychiatrists towards euthanasia and assisted suicide with a group of 54 other physicians by means of a questionnaire describing different patients, who either requested physician-assisted suicide or in whom euthanasia as a treatment option was considered, followed by a set of questions relating to euthanasia implementation. When controlled for religious practice, psychiatrists expressed more conservative views regarding euthanasia than did physicians from other medical specialties. Similarly female physicians and orthodox physicians indicated more conservative views. Differences may be due to factors inherent in subspecialty education. We suggest that in light of the unique complexity and context of patient euthanasia requests, based on their training and professional expertise psychiatrists are well suited to take a prominent role in evaluating such requests to die and making a decision as to the relative importance of competing variables.”

“Assisted Suicide: Why Psychiatrists Should Engage in the Debate” Hotopf, Matthew; Lee, William; Price, Annabel. The British Journal of Psychiatry, 2011 , 198, 83-84. doi: 10.1192/bjp.bp.110.083634.

Abstract:  “There is an increasing appetite for a change in the law to allow assisted suicide. This editorial suggests that psychiatrists should engage in the debate because the issues at stake will affect us, and we are likely to have a significant part to play were the law to be changed. We suggest that there are three main areas where psychiatrists’ expertise may be informative: (a) the extent to which safeguards to limit the availability of assisted dying to target groups can be applied safely and fairly, including to individuals with psychiatric disorders; (b) the complexities inherent in assessing mental capacity; and (c) the degree to which individuals adapt or change their desires, particularly in relation to suicidal behaviours.”

“Legalisation of Euthanasia or Physician-assisted Suicide: Survey of Doctors’ Attitudes” Seale, C. Palliative Medicine , 2009, 23:3, 205-12.

Abstract: “This study reports U.K. doctors’ opinions about legalisation of medically assisted dying (euthanasia and physician-assisted suicide), comparing this with the U.K. general public. A postal survey of 3,733 U.K. medical practitioners was done. The majority of U.K. doctors are opposed to legalisation, contrasting with the U.K. general public. Palliative medicine specialists are particularly opposed. A strong religious belief is independently associated with opposition to assisted dying. Frequency of treating patients who die is not independently associated with attitudes. Many doctors supporting legalisation also express reservations and advocate safeguards; many doctors opposing legalisation believe and accept that treatment and nontreatment decisions may shorten life. It is hoped that future debates about legalisation can proceed with this evidence in mind.”

“Autonomy-based Arguments against Physician-assisted Suicide and Euthanasia: A Critique”   Sjöstrand, Manne; Helgesson, Gert; Eriksson, Stefan; Juth, Niklas. Medicine, Health Care and Philosophy , 2011, doi:10.1007/s11019-011-9365-5.

Abstract : “Respect for autonomy is typically considered a key reason for allowing physician assisted suicide and euthanasia. However, several recent papers have claimed this to be grounded in a misconception of the normative relevance of autonomy. It has been argued that autonomy is properly conceived of as a value, and that this makes assisted suicide as well as euthanasia wrong, since they destroy the autonomy of the patient. This paper evaluates this line of reasoning by investigating the conception of valuable autonomy. Starting off from the current debate in end-of-life care, two different interpretations of how autonomy is valuable is discussed. According to one interpretation, autonomy is a personal prudential value, which may provide a reason why euthanasia and assisted suicide might be against a patient’s best interests. According to a second interpretation, inspired by Kantian ethics, being autonomous is unconditionally valuable, which may imply a duty to preserve autonomy. We argue that both lines of reasoning have limitations when it comes to situations relevant for end-of life care. It is concluded that neither way of reasoning can be used to show that assisted suicide or euthanasia always is impermissible.”

“Reporting of Euthanasia and Physician-assisted Suicide in the Netherlands: Descriptive Study” Buiting, H.; van Delden, J.; Onwuteaka-Philpsen, B.; Rietjens, J.; Rurup, M.; van Tol, D.; Gevers, J.; van der Maas, P.; van der Heide, A. BMC Medical Ethics , 2009, 10:18.

Findings : “Physicians reported that the patient’s request had been well-considered because the patient was clear-headed (65%) and/or had repeated the request several times (23%). Unbearable suffering was often substantiated with physical symptoms (62%), function loss (33%), dependency (28%) or deterioration (15%). In 35%, physicians reported that there had been alternatives to relieve patients’ suffering which were refused by the majority. The nature of the relationship with the consultant was sometimes unclear: the consultant was reported to have been an unknown colleague (39%), a known colleague (21%), otherwise (25%), or not clearly specified in the report (24%). Review committees relatively often scrutinized the consultation (41%) and the patient’s (unbearable) suffering (32%); they had few questions about possible alternatives (1%).”

“Trends and Determinants of End-of-life practices in ALS in the Netherlands” Maessen, M.; Veldink, J.H.; Onwuteaka-Philipsen, B.D.; de Vries, J.M.; Wokke, J.H.; van der Wal, G.; van den Berg, L.H. Neurology , 2009, 73:12, 954-61.

Abstract: “In the Netherlands, the proportion of patients with amyotrophic lateral sclerosis (ALS) who choose the option of euthanasia or physician-assisted suicide (PAS) is relatively high (20%). The objective of this study was to determine which factors influence end-of-life practices in ALS and whether rates are changing over time. In a cohort survey, 204 physicians and 198 informal caregivers (response rates 75% and 80%) of patients with ALS who died between 2000 and 2005 filled out questionnaires of the end-of-life circumstances of the patient. Results were compared with those of a similar study performed during the period 1994-1998. Results: In 2000-2005, 16.8% of the patients decided on euthanasia or PAS compared to 20.2% in 1994-1998. Thirty-one (14.8%) patients died during continuous deep sedation (CDS) in 2000-2005. Euthanasia or PAS, but not CDS, were significantly associated with religion not being important to the patient, being more educated, and dying at home. Euthanasia or PAS were not associated with quality of care items or symptoms of depression. Loss of function was similar in both groups. Informal caregivers of patients who died after euthanasia or PAS more frequently reported fear of choking (p = 0.003), no chance of improvement (p = 0.001), loss of dignity (p = 0.02), being dependent on others (p = 0.002), and fatigue (p = 0.018) as reasons for shortening life. Hopelessness was associated with euthanasia or PAS, as with CDS.”

“To Die, to Sleep: US Physicians’ Religious and Other Objections to Physician-Assisted Suicide, Terminal Sedation, and Withdrawal of Life Support” Curlin, Farr A.; Nwodim, Chinyere; Vance, Jennifer L.; Chin, Marshall H.; Lantos, John D. American Journal of Hospice and Palliative Care , 2008, 25, 112-120.

Abstract: “This study analyzes data from a national survey to estimate the proportion of physicians who currently object to physician-assisted suicide (PAS), terminal sedation (TS), and withdrawal of artificial life support (WLS), and to examine associations between such objections and physician ethnicity, religious characteristics, and experience caring for dying patients. Overall, 69% of the US physicians object to PAS, 18% to TS, and 5% to WLS. Highly religious physicians are more likely than those with low religiosity to object to both PAS (84% vs. 55%,  P < .001) and TS (25% vs 12%,  P  < .001). Objection to PAS or TS is also associated with being of Asian ethnicity, of Hindu religious affiliation, and having more experience caring for dying patients. These findings suggest that, with respect to morally contested interventions at the end of life, the medical care patients receive will vary based on their physicians’ religious characteristics, ethnicity, and experience caring for dying patients.”

Tags: ethics, research roundup

About The Author

Alexandra Raphel

• Assisted Suicide: A Right or a Wrong?
• Markkula Center for Applied Ethics
• Focus Areas
• Bioethics Resources

Assisted Suicide

A right or a wrong.

Is assisted suicide right or wrong? The issue is looked at through many perspectives and arguments.

Matthew Donnelly loved life. But Matthew Donnelly wanted to die. For the past thirty years, Matthew had conducted research on the use of X-rays. Now, skin cancer riddled his tortured body. He had lost his nose, his left hand, two fingers on his right hand, and part of his jaw. He was left blind and was slowly deteriorating. The pain was unrelenting. Doctors estimated that he had a year to live. Lying in bed with teeth clenched from the excruciating pain, he pleaded to be put out of his misery. Matthew wanted to die now. His pleas went unanswered. Then, one day, Matthew's brother Harold, unable to ignore Matthew's repeated cry, removed a .30 caliber pistol from his dresser drawer, walked to the hospital, and shot and killed his brother. Harold was tried for murder.

Rapid and dramatic developments in medicine and technology have given us the power to save more lives than was ever possible in the past. Medicine has put at our disposal the means to cure or to reduce the suffering of people afflicted with diseases that were once fatal or painful. At the same time, however, medical technology has given us the power to sustain the lives (or, some would say, prolong the deaths) of patients whose physical and mental capabilities cannot be restored, whose degenerating conditions cannot be reversed, and whose pain cannot be eliminated. As medicine struggles to pull more and more people away from the edge of death, the plea that tortured, deteriorated lives be mercifully ended grows louder and more frequent. Californians are now being asked to support an initiative, entitled the Humane and Dignified Death Act, that would allow a physician to end the life of a terminally ill patient upon the request of the patient, pursuant to properly executed legal documents. Under present law, suicide is not a crime, but assisting in suicide is. Whether or not we as a society should pass laws sanctioning "assisted suicide" has generated intense moral controversy.

Supporters of legislation legalizing assisted suicide claim that all persons have a moral right to choose freely what they will do with their lives as long as they inflict no harm on others. This right of free choice includes the right to end one's life when we choose. For most people, the right to end one's life is a right they can easily exercise But there are many who want to die, but whose disease, handicap, or condition renders them unable to end their lives in a dignified manner. When such people ask for assistance in exercising their right to die, their wishes should be respected.

Furthermore, it is argued, we ourselves have an obligation to relieve the suffering of our fellow human beings and to respect their dignity. Lying in our hospitals today are people afflicted with excruciatingly painful and terminal conditions and diseases that have left them permanently incapable of functioning in any dignified human fashion. They can only look forward to lives filled with yet more suffering, degradation, and deterioration. When such people beg for a merciful end to their pain and indignity, it is cruel and inhumane to refuse their pleas. Compassion demands that we comply and cooperate.

Those who oppose any measures permitting assisted suicide argue that society has a moral duty to protect and to preserve all life. To allow people to assist others in destroying their lives violates a fundamental duty we have to respect human life. A society committed to preserving and protecting life should not commission people to destroy it.

Further, opponents of assisted suicide claim that society has a duty to oppose legislation that poses a threat to the lives of innocent persons. And, laws that sanction assisted suicide inevitably will pose such a threat. If assisted suicide is allowed on the basis of mercy or compassion, what will keep us from "assisting in" and perhaps actively urging, the death of anyone whose life we deem worthless or undesirable? What will keep the inconvenienced relatives of a patient from persuading him or her to "voluntarily" ask for death? What will become of people who, once having signed a request to die, later change their minds, but, because of their conditions, are unable to make their wishes known? And, once we accept that only life of a certain quality is worth living, where will we stop? When we devalue one life, we devalue all lives. Who will speak for the severely handicapped infant or the senile woman?

Finally, it is argued that sanctioning assisted suicide would violate the rights of others. Doctors and nurses might find themselves "pressured" to cooperate in a patient's suicide. In order to satisfy the desires of a patient wanting to die, it's unjust to demand that others go against their own deeply held convictions.

The case for assisted suicide is a powerful one--appealing to our capacity for compassion and an obligation to support individual choice and self determination. But, the case against assisted suicide is also powerful for it speaks to us of a fundamental reverence for life and the risk of hurling down a slippery slope toward a diminished respect for life. With legislation in the offing, we're compelled to choose which values are most important and to cast our vote.

This article was originally published in Issues in Ethics - V. 1, N.1 Fall 1987

• Download PDF
• Share X Facebook Email LinkedIn
• Permissions

Physician-Assisted Suicide and the Perils of Empirical Ethical Research

• 1 The Kennedy Institute of Ethics, Departments of Medicine and Philosophy, Georgetown University, Washington, DC
• Original Investigation Trends in Medical Aid in Dying in Oregon and Washington Luai Al Rabadi, MD; Michael LeBlanc, PhD; Taylor Bucy, BS; Lee M. Ellis, MD; Dawn L. Hershman, MD, MS; Frank L. Meyskens Jr, MD; Lynne Taylor, MD; Charles D. Blanke, MD JAMA Network Open

Al Rabadi et al 1 compare statistics on physician-assisted suicide (PAS) available from public databases for the states of Washington and Oregon and find similar profiles and trends, which is unsurprising given the similarity of the laws and demographic characteristics of these states. Among the unanswered questions are what such a study can contribute to medical ethics (about PAS or any other ethical controversy) and what the limits are of such work.

First, it should be noted that the medical literature is, in general, favorably disposed toward the empirical and the new. Although this predilection is often advantageous for scientific progress, it introduces a problematic bias when applied to ethical questions. The appeal of the study by Al Rabadi et al 1 is that it is empirical, and by comparing data from 2 states for the first time, it can be considered novel. Because there are new reports each year and the practice of PAS is legal in only a few states, descriptive reports about PAS are published frequently. This means, however, that articles defending the ethical status quo (ie, against PAS) tend to be shut out of the medical literature because they are not reporting anything new and, therefore, cannot have any data. The result is an impression of growing acceptance of PAS, but it really represents an artifact of a scientific bias.

The frequent publication of statistics on PAS and euthanasia also imparts another implicit ethical bias. Although conducting health services research about an ethically disputed question appears ethically neutral, one already presumes without argument that the service to be delivered is ethically good. Therefore, the standards for assessing good and bad within the framework assumed by the research are limited to questions of access, efficiency, effectiveness, implementation, safety, and regulation. This takes the central ethical question of whether the service ought to be delivered in the first place off the table, suppressing critical ethical debate. Frequent publication of studies like that by Al Rabadi et al 1 have the effect of “normalizing” the practice, inuring readers to the practice and concealing ethical concerns.

Moreover, data cannot tell a society or a profession what ought to be done—a consequence of what philosophers call the fact-value distinction. Empirical reports alone cannot answer normative ethical questions. Whether just 1 person or 100 000 persons legally avail themselves of lethal prescriptions cannot tell us whether the practice is right or wrong.

Likewise, the language used by empirical investigators can obscure the ethical issues at stake. Language can shape people’s attitudes and approaches toward controversial questions. There is no scientific basis for deciding on terminology, except, perhaps, marketing science. The language around PAS includes such terms as “death with dignity,” “assisted dying,” “assisted death,” and “hastened death.” Al Rabadi et al 1 use the phrase “medical aid in dying.” These terms are imprecise. Giving a dying person an aspirin might count as aid in dying every bit as much as 5 g of secobarbital. These terms obscure distinctions of both ethical and empirical importance but have been shown to improve public opinion polls in favor of the practice. Serious proponents of PAS, such as the philosopher Peter Singer, 2 prefer to describe it as a form of rational suicide and do not shy away from the most accurate description.

The public databases on which the study of Al Rabadi et al 1 relies are not designed for research. They rely on self-reported data supplied by clinicians, who are generally not present at the time of ingestion of the fatal dose of drug by the patient and have an incentive to make their own roles look good. These data have never been validated, to my knowledge. The information collected is purposefully thin to protect prescribers’ confidentiality. There are no data on unreported cases. The health department is not permitted to investigate any allegations of abuse. 3 Although these laws do suggest referral to psychiatrists if there are questions about the patient’s decisional capacity, and it is known that large numbers of terminally ill patients, including those seeking PAS, are depressed, since 2003, only 0% to 4% of such patients have been sent for psychiatric referral. 3 There are also data suggesting, for instance, that large numbers of patients who ingest these drugs are at least transiently awake and suffering, leading to calls for anesthesiologists to administer euthanasia using advanced medical monitoring techniques as the only way to ensure the sought-after peaceful death. 4 Contrary to the characterization of Al Rabadi et al, 1 Sinmyee et al 4 are advocates, not opponents, of PAS and euthanasia. These concerns make the conclusion of Al Rabadi et al 1 that PAS in Oregon and Washington is safe, reliable, and effective an invalid inference.

What We Know

At present, the number of reported cases, following the law, remains small but increasing steadily. Those who make use of the law tend to be white, wealthy, and educated. 1 , 3 Despite public arguments that PAS is needed to avoid excruciating pain and other symptoms, the reasons attributed to patients who seek PAS are not uncontrolled symptoms but lost autonomy, independence, and control. 1 , 3 About one-third of patients die without taking the drugs, 3 which may suggest that patients only wanted the security of having a way out, but it could equally indicate that they died before using the drugs or changed their minds about using them. A small (but growing) number of physicians write the prescriptions. 3 For example, one of the authors of the study by Al Rabadi et al 1 wrote 15% of all PAS prescriptions in Oregon in 2018. 5

There is also much that we do not know. We have few direct, valid studies of the patients and practitioners. We do not know how many cases are unreported to the databanks. We do not know how many patients are pressured into obtaining prescriptions. We do not know how many patients engage in “doctor shopping,” finding someone who will agree to their request if turned down by a given physician. We do not really know how often the process goes awry. We know little about the after-effects on practitioners and family, although there are reports of posttraumatic stress disorder. 6 We also need more data on suicide contagion, because preliminary reports 7 suggest increased rates of suicide in the general population of states that have legalized PAS.

Slippery Slopes?

Safeguards built into the law are coming to be seen as barriers. As already noted, few patients are ever referred to psychiatrists. A new law in Oregon (Oregon Senate Bill 579) now allows a patient to bypass the waiting period and take the pills within 2 days, and legislation has been passed by the Oregon House (Oregon House Bill 2217) to allow injection of lethal drugs, a hair’s breadth away from euthanasia. 5 There are increasing calls for permitting patients with dementia to be able to authorize their deaths through advance directives. In Belgium and the Netherlands, 5% of all deaths are by euthanasia and the indications have expanded to include psychiatric illness and life completion. 8 , 9 Euthanized patients are now regular sources for organ donation. 10 Although there is no empirical proof that the United States will follow these trends if PAS is more widely adopted, the logic that justifies PAS inexorably points in this direction. Studying these trends empirically will not prevent them from occurring. Are we willing to entertain a serious ethical debate, based on reasoned argument, or will we be content merely to file empirical reports on whatever fate befalls us?

Published: August 9, 2019. doi:10.1001/jamanetworkopen.2019.8628

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2019 Sulmasy DP. JAMA Network Open .

Corresponding Author: Daniel P. Sulmasy, MD, PhD, Kennedy Institute of Ethics, Healy 419, Georgetown University, 3700 O St NW, Washington, DC 20057 ( [email protected] ).

Conflict of Interest Disclosures: None reported.

See More About

Sulmasy DP. Physician-Assisted Suicide and the Perils of Empirical Ethical Research. JAMA Netw Open. 2019;2(8):e198628. doi:10.1001/jamanetworkopen.2019.8628

Manage citations:

© 2024

Select Your Interests

Customize your JAMA Network experience by selecting one or more topics from the list below.

• Academic Medicine
• Acid Base, Electrolytes, Fluids
• Allergy and Clinical Immunology
• American Indian or Alaska Natives
• Anesthesiology
• Anticoagulation
• Art and Images in Psychiatry
• Artificial Intelligence
• Assisted Reproduction
• Bleeding and Transfusion
• Caring for the Critically Ill Patient
• Challenges in Clinical Electrocardiography
• Climate and Health
• Climate Change
• Clinical Challenge
• Clinical Decision Support
• Clinical Implications of Basic Neuroscience
• Clinical Pharmacy and Pharmacology
• Complementary and Alternative Medicine
• Consensus Statements
• Coronavirus (COVID-19)
• Critical Care Medicine
• Cultural Competency
• Dental Medicine
• Dermatology
• Diabetes and Endocrinology
• Diagnostic Test Interpretation
• Drug Development
• Electronic Health Records
• Emergency Medicine
• End of Life, Hospice, Palliative Care
• Environmental Health
• Equity, Diversity, and Inclusion
• Facial Plastic Surgery
• Gastroenterology and Hepatology
• Genetics and Genomics
• Genomics and Precision Health
• Global Health
• Guide to Statistics and Methods
• Hair Disorders
• Health Care Delivery Models
• Health Care Economics, Insurance, Payment
• Health Care Quality
• Health Care Reform
• Health Care Safety
• Health Care Workforce
• Health Disparities
• Health Inequities
• Health Policy
• Health Systems Science
• History of Medicine
• Hypertension
• Images in Neurology
• Implementation Science
• Infectious Diseases
• Innovations in Health Care Delivery
• JAMA Infographic
• Law and Medicine
• Leading Change
• Less is More
• LGBTQIA Medicine
• Lifestyle Behaviors
• Medical Coding
• Medical Devices and Equipment
• Medical Education
• Medical Education and Training
• Medical Journals and Publishing
• Mobile Health and Telemedicine
• Narrative Medicine
• Neuroscience and Psychiatry
• Notable Notes
• Nutrition, Obesity, Exercise
• Obstetrics and Gynecology
• Occupational Health
• Ophthalmology
• Orthopedics
• Otolaryngology
• Pain Medicine
• Palliative Care
• Pathology and Laboratory Medicine
• Patient Care
• Patient Information
• Performance Improvement
• Performance Measures
• Perioperative Care and Consultation
• Pharmacoeconomics
• Pharmacoepidemiology
• Pharmacogenetics
• Pharmacy and Clinical Pharmacology
• Physical Medicine and Rehabilitation
• Physical Therapy
• Physician Leadership
• Population Health
• Primary Care
• Professional Well-being
• Professionalism
• Psychiatry and Behavioral Health
• Public Health
• Pulmonary Medicine
• Regulatory Agencies
• Reproductive Health
• Research, Methods, Statistics
• Resuscitation
• Rheumatology
• Risk Management
• Scientific Discovery and the Future of Medicine
• Shared Decision Making and Communication
• Sleep Medicine
• Sports Medicine
• Stem Cell Transplantation
• Substance Use and Addiction Medicine
• Surgical Innovation
• Surgical Pearls
• Teachable Moment
• Technology and Finance
• The Art of JAMA
• The Arts and Medicine
• The Rational Clinical Examination
• Tobacco and e-Cigarettes
• Translational Medicine
• Trauma and Injury
• Treatment Adherence
• Ultrasonography
• Users' Guide to the Medical Literature
• Vaccination
• Venous Thromboembolism
• Veterans Health
• Women's Health
• Workflow and Process
• Wound Care, Infection, Healing

Get the latest research based on your areas of interest.

Others also liked.

• Register for email alerts with links to free full-text articles
• Access PDFs of free articles
• Manage your interests
• Save searches and receive search alerts

Suicide Experts Identify Six Questions to Guide Research in Next Decade

Information & authors, metrics & citations, view options, information, published in.

• prioritized research agenda
• Jed Foundation
• Thomas Insel
• National Institute of Mental Health

Export Citations

If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu .

View options

Login options.

Already a subscriber? Access your subscription through your login credentials or your institution for full access to this article.

Not a subscriber?

Subscribe Now / Learn More

PsychiatryOnline subscription options offer access to the DSM-5-TR ® library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development.

Need more help? PsychiatryOnline Customer Service may be reached by emailing [email protected] or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.).

Share article link

Copying failed.

PREVIOUS ARTICLE

Next article, request username.

Can't sign in? Forgot your username? Enter your email address below and we will send you your username

If the address matches an existing account you will receive an email with instructions to retrieve your username

Create a new account

Change password, password changed successfully.

Your password has been changed

Reset password

Can't sign in? Forgot your password?

Enter your email address below and we will send you the reset instructions

If the address matches an existing account you will receive an email with instructions to reset your password.

Your Phone has been verified

As described within the American Psychiatric Association (APA)'s Privacy Policy and Terms of Use , this website utilizes cookies, including for the purpose of offering an optimal online experience and services tailored to your preferences. Please read the entire Privacy Policy and Terms of Use. By closing this message, browsing this website, continuing the navigation, or otherwise continuing to use the APA's websites, you confirm that you understand and accept the terms of the Privacy Policy and Terms of Use, including the utilization of cookies.

Euthanasia and Assisted Suicide

• Keywords and Search Terms

Background Sources

Specialized.

• Find Your Own Background Sources

Search Terms

Main Term(s):  euthanasia, assisted suicide Related Terms:  right to die, advance directives (medical care), do-not-resuscitate orders, withholding treatment Broader Terms:  suicide Narrower Terms:  terminal care, medical ethics

• Euthanasia (Research Starters)
• Assisted Suicide (CQ Researcher)
• Euthanasia (Times Topics)
• Assisted Suicide (Times Topics)
• Physician-assisted Suicide: Research Roundup (Journalist's Resource)
•   Ship Discovery Search This link opens in a new window This library database serves as a search engine to search most library databases at the same time, including magazine and journal databases, e-book collections, and the library catalog. News databases are not included in a comprehensive way. Supplement this with direct searching of ProQuest Newstand and Lexis Nexis Academic. Search results default to items that the library owns, either in online or print format. Remove the "Available in Library Collection" limiter to retrieve items available through interlibrary loan. more... less... Access on-campus or off-campus with your ShipID
• Academic Search Ultimate This link opens in a new window Academic Search Complete is our most important general database. covering all subject areas. It is useful for research in all classes, as it includes 26+ million newspaper, magazine, and journal articles, with 50% of these immediately available in full-text. more... less... Access from on campus or off campus with Ship ID. Contents indexed in Ship Library Discovery Search.
• ProQuest Global Newsstream This link opens in a new window One of the most comprehensive news databases in the world, ProQuest Global Newstream includes access to over 3000 news sources, including 2,200 newspapers, as well as blogs, podcasts, websites and news wire feeds worldwide. more... less... Development note - alt link use stats: (91 total hits, 33 since 7/2012 -- 10 /2012)
• Library Guide to Current News Sources This mobile-friendly guide provide excellent access to the best high-quality new sources.
• Westlaw This link opens in a new window This library database is one of the world's largest full-text databases, including very extensive news, legal, and business information. Along with ProQuest Newstand, it is our primary source of news information. more... less... Access from on campus or off campus with Ship ID.
• Humanities Source This link opens in a new window Humanities Source is designed to meet the needs of students, researchers and educators interested in all aspects of the humanities. The collection includes full text for more than 1,400 journals, with citations to over 3.5 million articles, including book reviews. Coverage in Humanities Source includes worldwide content pertaining to literary, scholarly and creative thought.
• SocINDEX with Full Text This link opens in a new window Covers scholarly publications in sociology, social work, criminal justice, and related fields. Contains >2.5 million articles and other materials (70% in full text) with deep coverage from 1960 and some back to 1882. more... less... Access from on campus or off campus with Ship ID.
• Philosopher's Index This link opens in a new window Covers all aspects of philosophy, including ethics, aesthetics, social philosophy, political philosophy, epistemology, metaphysics and logic. Contains indexing and abstracts from books and journals of philosophy and related fields. more... less... Access from on campus or off campus with Ship ID. Admin note: 49 total hits on PI (EBSCO) link, 24 hits on Proquest link (FY14-15)

Find Your Own Sources

Library background databases.

• CQ Researcher This link opens in a new window Library database that covers the most important and controversial issues of the day. Contains the full text of CQ Researcher, a weekly publication. Each issue provides a comprehensive overview and background essay, data tables and graphs, chronology, pro-con starter, and list of major research and advocacy groups. Includes extensive lists of sources and hot-linked footnotes throughout. more... less... Access from on campus or off campus with Ship ID.

Quality Web Sources

High quality web source finder.

Use this search tool to find high quality web sources for your research. You can limit by In-Depth Journalism, Newpaper Topic Guides, Science News, CRS (Congressional Research Service) Reports, and Web Directories. Please Note : Several ads will appear first in the results list.

In-Depth Journalism

• ProPublica ProPublica is a freely available website produced by a major online non-profit news organization dedicated to in-depth investigative reporting about current issues in the public interest. ProPublica features two kinds of reporting: Investigations, which include a series of in-depth articles about a topic (often between 15 and 30 articles - major topics range from dozens to 100+ articles). MuckReads are shorter reports featuring investigative journalism from other news agencies. Major areas of interest include, among others: healthcare and the health industry, fracking, censorship, money and politics, and financial and economic issues.
• Reveal: The Center for Investigative Reporting Reveal is a freely available website and the online media platform for the Center for Investigative Journalism, a major online non-profit news organization, founded in 1977, and dedicated to in-depth investigative reporting about current issues in the public interest. They publish series of investigative reports on a topic (typically between 10 and 20). Major areas of coverage include: criminal justice, the environment, guns, health care, labor and employment, national security, religion, surveillance and privacy, and veterans.
• Center for Public Integrity The Center for Public Integrity is a freely available website produced by a major online non-profit news organization dedicated to in-depth investigative reporting about current issues in the public interest, with a special focus on accountability and fairness, especially in terms of the role and influence of money. Topics featured include politics and elections, national security business, the environment, juvenile justice and health.
• National Public Radio (NPR) NPR is one of the most important freely-available sources of investigative journalism. It includes excellent topical pages but these are not easily browseable on the website. Use the High Quality Web Source Finder search box to locate the topical pages for your issue.
• Journalist's Resource This very high quality web site, located at Harvard's Shorenstein Center on Media, Politics and Public Policy and sponsored by leading academic journalism programs, guides journalists and other researchers to find scholarly sources related to many of the most important topics in the news. Whenever the source is not available in full-text, use the discovery layer or library A-Z journal list to get library access to the article or to order it on interlibrary loan.

Newspaper Topic Guides

A number of important national newspapers have topic or issue sections of their website that bring together all the paper's articles on particular topics. The leading example of this is "Times Topics" from the New York Times. Each topic guide/section has a search tool that lets you refine your search.

Unfortunately, these sections are often not easy to browse or locate on the newspaper websites. Use the "High Quality Web Source Finder" search box above to search for your topic. Then choose the Newspaper Topic Guides tab to look for these in the New York Times, Los Angeles Times, and Chicago Tribune. If you should hit a pay wall when browsing these newspapers, simply search for articles from any of these three papers using the ProQuest Newstand library database.

• Science News
• Science Daily

Congressional Research Service Reports (CRS Reports)

The Congressional Research Service (CRS) is the public policy research division of Congress. It issues detailed research reports on a very wide range of issues. CRS doesn't maintain its own website, but its reports are available through several organizations and libraries.

• EveryCRSReport.com Website that attempts to make all CRS reports easily available to the public. The result of a bi-partisan movement to get Congress to pass a bill requiring open access.
• Congressional Research Service Reports (University of North Texas) The University of North Texas maintains a freely available digital library collection of Congressional Research Service reports, with the goal "to provide integrated, searchable access to many of the full-text CRS reports that have been available at a variety of different web sites since 1990" -- website. Best search tool for finding CRS reports. Update holdings of specific reports through the Federation of American Scientists or through a web search on the name of a report.
• Congressional Research Service Reports Archive (Federation of American Scientists) As a public service, the Federation of American Scientists maintains this free archive of CRS reports.

Web Directories

• Public Policy Issues and Groups (Vanderbilt Univ.) This freely available website produced by the Vanderbilt University Libraries provides an alphabetical topical directory to important websites on some 50 current issues. These guide pages typically include sections for these kinds of web resources: Basic Sites, Government, International, News, Statistics, Interest Groups and Research Centers and Other Educational Sites.
• Last Updated: Aug 15, 2024 1:40 PM
• URL: https://library.ship.edu/euthanasia

Contact the Ezra Lehman Memorial Library

• Shippensburg on Facebook
• Shippensburg on Twitter **// -->
• Shippensburg on YouTube
• Shippensburg on Instagram

Numbers, Facts and Trends Shaping Your World

Read our research on:

Full Topic List

Regions & Countries

Publications

• Our Methods
• Short Reads
• Tools & Resources

Read Our Research On:

Death & Dying

Striking findings from 2023.

Here’s a look back at 2023 through some of our most striking research findings.

Spirituality Among Americans

Overall, 70% of U.S. adults describe themselves as spiritual in some way, including 22% who are spiritual but not religious. An overwhelming majority of U.S. adults (83%) say they believe that people have a soul or spirit in addition to their physical body. And 81% say there is something spiritual beyond the natural world, even if we cannot see it.

Many Americans report interacting with dead relatives in dreams or other ways

46% of Americans report that they’ve been visited by a dead family member in a dream, while 31% report having been visited by dead relatives in some other form.

Few Americans Blame God or Say Faith Has Been Shaken Amid Pandemic, Other Tragedies

In the new survey, the Center attempted for the first time to pose some of these philosophical questions to a nationally representative sample of U.S. adults, finding that Americans largely blame random chance – along with people’s own actions and the way society is structured – for human suffering, while relatively few believers blame God or voice doubts about the existence of God for this reason.

Americans lost more years of life to COVID-19 in 2020 than to all accidents combined in a typical year

In 2020 alone, the coronavirus was responsible for about 380,000 deaths and roughly 5.5 million years of lost life in the United States.

Most Americans believe in heaven … and hell

72% of Americans believe in heaven, while 58% believe in hell.

California legalizes assisted suicide amid growing support for such laws

Two-thirds of Americans say doctors should be allowed by law to assist patients who are terminally ill and living in severe pain to commit suicide.

Americans of all ages divided over doctor-assisted suicide laws

Brittany Maynard, a 29-year-old woman with terminal brain cancer, has gone public with her plans to take her own life. Most Americans say there are circumstances in which a patient should be allowed to die, but the public is split on laws about doctor-assisted suicide.

Proposed law would clarify who gets access to a deceased person’s digital accounts

The Uniform Law Commission, a body of lawyers who produce uniform legislation for states to adopt, recently drafted the “Fiduciary Access to Digital Assets Act (FADA),” which would grant fiduciaries broad authority to access and control digital assets and accounts.

Chart of the Week: How Americans die, by the numbers

Americans aren’t dying like they used to. They’re living longer, and more are dying of natural causes. In 2010, nearly one-third of all deaths (31%) came from people ages 85 and older – a big improvement from 1968, when the 85+ age cohort made up just 12.6% of all deaths.

REFINE YOUR SELECTION

• Michael Lipka (4)
• Tom Rosentiel (3)
• Maeve Duggan (2)
• Patricia Tevington (2)
• Asta Kallo (1)
• Becka A. Alper (1)
• Caryle Murphy (1)
• George Gao (1)
• Justin Nortey (1)
• Katherine Schaeffer (1)
• Manolo Corichi (1)
• Michael Rotolo (1)
• Sandra Stencel (1)
• Stephanie Kramer (1)

Research Teams

• Religion (23)
• Science (11)
• Politics (4)
• Internet and Technology (2)
• Social Trends (2)

901 E St. NW, Suite 300 Washington, DC 20004 USA (+1) 202-419-4300 | Main (+1) 202-857-8562 | Fax (+1) 202-419-4372 |  Media Inquiries

Research Topics

• Email Newsletters

ABOUT PEW RESEARCH CENTER  Pew Research Center is a nonpartisan, nonadvocacy fact tank that informs the public about the issues, attitudes and trends shaping the world. It does not take policy positions. The Center conducts public opinion polling, demographic research, computational social science research and other data-driven research. Pew Research Center is a subsidiary of The Pew Charitable Trusts , its primary funder.

© 2024 Pew Research Center

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

The PMC website is updating on October 15, 2024. Learn More or Try it out now .

• Advanced Search
• Journal List

Legalizing euthanasia or assisted suicide: the illusion of safeguards and controls

Euthanasia or assisted suicide—and sometimes both—have been legalized in a small number of countries and states. In all jurisdictions, laws and safeguards were put in place to prevent abuse and misuse of these practices. Prevention measures have included, among others, explicit consent by the person requesting euthanasia, mandatory reporting of all cases, administration only by physicians (with the exception of Switzerland), and consultation by a second physician.

The present paper provides evidence that these laws and safeguards are regularly ignored and transgressed in all the jurisdictions and that transgressions are not prosecuted. For example, about 900 people annually are administered lethal substances without having given explicit consent, and in one jurisdiction, almost 50% of cases of euthanasia are not reported. Increased tolerance of transgressions in societies with such laws represents a social “slippery slope,” as do changes to the laws and criteria that followed legalization. Although the initial intent was to limit euthanasia and assisted suicide to a last-resort option for a very small number of terminally ill people, some jurisdictions now extend the practice to newborns, children, and people with dementia. A terminal illness is no longer a prerequisite. In the Netherlands, euthanasia for anyone over the age of 70 who is “tired of living” is now being considered. Legalizing euthanasia and assisted suicide therefore places many people at risk, affects the values of society over time, and does not provide controls and safeguards.

1. INTRODUCTION

Euthanasia is generally defined as the act, undertaken only by a physician, that intentionally ends the life of a person at his or her request 1 , 2 . The physician therefore administers the lethal substance. In physician-assisted suicide ( pas ) on the other hand, a person self-administers a lethal substance prescribed by a physician.

To date, the Netherlands, Belgium, and Luxembourg have legalized euthanasia 1 , 2 . The laws in the Netherlands and Luxembourg also allow pas . In the United States, the states of Oregon and Washington legalized pas in 1997 and 1999 respectively, but euthanasia remains illegal 3 . The situation in the state of Montana is currently unclear; a bill legalizing pas was passed by the state legislature in 2010, but was recently defeated by the state’s Senate Judiciary Committee.

In the Netherlands, euthanasia and pas were formally legalized in 2001 after about 30 years of public debate 1 . Since the 1980s, guidelines and procedures for performing and controlling euthanasia have been developed and adapted several times by the Royal Dutch Medical Association in collaboration with that country’s judicial system. Despite opposition, including that from the Belgian Medical Association, Belgium legalized euthanasia in 2002 after about 3 years of public discourse that included government commissions. The law was guided by the Netherlands and Oregon experiences, and the public was assured that any defects in the Dutch law would be addressed in the Belgian law. Luxembourg legalized euthanasia and pas in 2009. Switzerland is an exception, in that assisted suicide, although not formally legalized, is tolerated as a result of a loophole in a law dating back to the early 1900s that decriminalizes suicide. Euthanasia, however, is illegal 4 . A person committing suicide may do so with assistance as long as the assistant has no selfish motives and does not stand to gain personally from the death. Unlike other jurisdictions that require euthanasia or assisted suicide to be performed only by physicians, Switzerland allows non-physicians to assist suicide.

In all these jurisdictions, safeguards, criteria, and procedures were put in place to control the practices, to ensure societal oversight, and to prevent euthanasia and pas from being abused or misused 5 . Some criteria and procedures are common across the jurisdictions; others vary from country to country 5 , 6 . The extent to which these controls and safeguards have been able to control the practices and to avoid abuse merits closer inspection, particularly by jurisdictions contemplating the legalization of euthanasia and pas . The present paper explores the effectiveness of the safeguards and the “slippery slope” phenomenon.

2. SAFEGUARDS AND THEIR EFFECTIVENESS

2.1. voluntary, written consent.

In all jurisdictions, the request for euthanasia or pas has to be voluntary, well-considered, informed, and persistent over time. The requesting person must provide explicit written consent and must be competent at the time the request is made. Despite those safeguards, more than 500 people in the Netherlands are euthanized involuntarily every year. In 2005, a total of 2410 deaths by euthanasia or pas were reported, representing 1.7% of all deaths in the Netherlands. More than 560 people (0.4% of all deaths) were administered lethal substances without having given explicit consent 7 . For every 5 people euthanized, 1 is euthanized without having given explicit consent. Attempts at bringing those cases to trial have failed, providing evidence that the judicial system has become more tolerant over time of such transgressions 5 .

In Belgium, the rate of involuntary and non-voluntary euthanasia deaths (that is, without explicit consent) is 3 times higher than it is in the Netherlands 8 , 9 . (“Involuntary euthanasia” refers to a situation in which a person possesses the capacity but has not provided consent, and “non-voluntary euthanasia,” to a situation in which a person is unable to provide consent for reasons such as severe dementia or coma). A recent study found that in the Flemish part of Belgium, 66 of 208 cases of “euthanasia” (32%) occurred in the absence of request or consent 10 . The reasons for not discussing the decision to end the person’s life and not obtaining consent were that patients were comatose (70% of cases) or had dementia (21% of cases). In 17% of cases, the physicians proceeded without consent because they felt that euthanasia was “clearly in the patient’s best interest” and, in 8% of cases, that discussing it with the patient would have been harmful to that patient. Those findings accord with the results of a previous study in which 25 of 1644 non-sudden deaths had been the result of euthanasia without explicit consent 8 .

Some proponents of euthanasia contend that the foregoing figures are misrepresentative, because many people may have at some time in their lives expressed a wish for or support of euthanasia, albeit not formally. The counterargument is that the legal requirement of explicit written consent is important if abuse and misuse are to be avoided. After all, written consent has become essential in medical research when participants are to be subjected to an intervention, many of which pose far lesser mortality risks. Recent history is replete with examples of abuse of medical research in the absence of explicit informed consent.

2.2. Mandatory Reporting

Reporting is mandatory in all the jurisdictions, but this requirement is often ignored 11 , 12 . In Belgium, nearly half of all cases of euthanasia are not reported to the Federal Control and Evaluation Committee 13 . Legal requirements were more frequently not met in unreported cases than in reported cases: a written request for euthanasia was more often absent (88% vs. 18%), physicians specialized in palliative care were consulted less often (55% vs. 98%), and the drugs were more often administered by a nurse (41% vs. 0%). Most of the unreported cases (92%) involved acts of euthanasia, but were not perceived to be “euthanasia” by the physician. In the Netherlands, at least 20% of cases of euthanasia go unreported 7 . That number is probably conservative because it represents only cases that can be traced; the actual number may be as high as 40% 14 . Although reporting rates have increased from pre-legalization in 2001, 20% represents several hundred people annually.

2.3. Only by Physicians

The involvement of nurses gives cause for concern because all the jurisdictions, with the exception of Switzerland, require that the acts be performed only by physicians. In a recent study in Flanders, 120 nurses reported having cared for a patient who received life-ending drugs without explicit request 15 . Nurses performed the euthanasia in 12% of the cases and in 45% of the cases without explicit consent. In many instances, the physicians were absent. Factors significantly associated with a nurse administering the life-ending drugs included the nurse being a male working in a hospital and the patient being over 80 years of age.

2.4. Second Opinion and Consultation

All jurisdictions except for Switzerland require a consultation by a second physician to ensure that all criteria have been met before proceeding with euthanasia or pas . In Belgium, a third physician has to review the case if the person’s condition is deemed to be non-terminal. The consultant must be independent (not connected with the care of the patient or with the care provider) and must provide an objective assessment. However, there is evidence from Belgium, the Netherlands, and Oregon that this process is not universally applied 10 , 13 . In the Netherlands, for example, a consultation was not sought in 35% of cases of involuntary euthanasia 7 . In 1998 in the Netherlands, 25% of patients requesting euthanasia received psychiatric consultation; in 2010 none did 16 . Moreover, non-reporting seems to be associated with a lack of consultation by a second doctor 14 .

In Oregon, a physician member of a pro-assisted-suicide lobby group provided the consultation in 58 of 61 consecutive cases of patients receiving pas in Oregon 17 . This raises concerns about the objectivity of the process and the safety of the patients, and raises questions about the influence of bias on the part of these physicians on the process.

Networks of physicians trained to provide the consultation role when euthanasia is sought have been established in the Netherlands (Support and Consultation on Euthanasia in the Netherlands) and Belgium [Life End Information Forum ( leif )] 18 . Their role includes ensuring that the person is informed of all options, including palliative care. However, most leif physicians have simply followed a 24-hour theoretical course, of which only 3 hours are related to palliative care, hardly sufficient to enable a leif member to provide adequate advice on complex palliative care needs 19 . The development of expertise in palliative care, as in any other specialty, requires a considerable amount of time. In the United Kingdom, it involves a 4-year residency program, and in Australia and the United States, 3 years.

Oregon requires that a patient be referred to a psychiatrist or psychologist for treatment if the prescribing or consulting physician is concerned that the patient’s judgment is impaired by a mental disorder such as depression. In 2007, none of the people who died by lethal ingestion in Oregon had been evaluated by a psychiatrist or a psychologist 20 , despite considerable evidence that, compared with non-depressed patients, patients who are depressed are more likely to request euthanasia and that treatment for depression will often result in the patient rescinding the request 21 – 23 . In a study of 200 terminally ill cancer patients, for example, the prevalence of depressive syndromes was 59% among patients with a pervasive desire to die, but only 8% among patients without such a desire 21 . Despite that finding, many health professionals and family members of patients in Oregon who pursue pas generally do not believe that depression influences the choice for hastened death 24 .

A recent Oregon-based study demonstrated that some depressed patients are slipping through the cracks 25 . Among terminally ill patients who received a prescription for a lethal drug, 1 in 6 had clinical depression. Of the 18 patients in the study who received a prescription for the lethal drug, 3 had major depression, and all of them went on to die by lethal ingestion, but had been assessed by a mental health specialist.

There is evidence, therefore, that safeguards are ineffective and that many people who should not be euthanized or receive pas are dying by those means. Of concern, too, is the fact that transgressions of the laws are not prosecuted and that the tolerance level for transgressions of the laws has increased. Moreover, as the next section will explore, the boundaries of what constitutes “good” practices with respect to euthanasia and pas continue to change, and some of the current practices would just a few decades ago have been considered unacceptable in those jurisdictions that have legalized the practices.

3. THE “SLIPPERY SLOPE” ARGUMENT

The “slippery slope” argument, a complex legal and philosophical concept, generally asserts that one exception to a law is followed by more exceptions until a point is reached that would initially have been unacceptable. The “slippery slope” argument has, however, several interpretations 26 , some of which are not germane to the euthanasia discussion. The interpretations proposed by Keown in 2002 27 appear very relevant, however. He refers to these collectively as a “practical slippery slope,” although the term “social slippery slope” may be more applicable. The first interpretation postulates that acceptance of one sort of euthanasia will lead to other, even less acceptable, forms of euthanasia. The second contends that euthanasia and pas , which originally would be regulated as a last-resort option in only very select situations, could, over time, become less of a last resort and be sought more quickly, even becoming a first choice in some cases.

The circumvention of safeguards and laws, with little if any prosecution, provides some evidence of the social slippery slope phenomenon described by Keown 5 , 28 . Till now, no cases of euthanasia have been sent to the judicial authorities for further investigation in Belgium. In the Netherlands, 16 cases (0.21% of all notified cases) were sent to the judicial authorities in the first 4 years after the euthanasia law came into effect; few were investigated, and none were prosecuted 5 . In one case, a counsellor who provided advice to a non-terminally ill person on how to commit suicide was acquitted 29 . There has therefore been an increasing tolerance toward transgressions of the law, indicating a change in societal values after legalization of euthanasia and assisted suicide.

In the 1987 preamble to its guidelines for euthanasia, the Royal Dutch Medical Association had written “If there is no request from the patient, then proceeding with the termination of his life is [juristically] a matter of murder or killing, and not of euthanasia.” By 2001, the association was supportive of the new law in which a written wish in an advance directive for euthanasia would be acceptable, and it is tolerant of non-voluntary and involuntary euthanasia 7 , 30 , 31 . However, basing a request on an advance directive or living will may be ethically problematic because the request is not contemporaneous with the act and may not be evidence of the will of the patient at the time euthanasia is carried out.

Initially, in the 1970s and 1980s, euthanasia and pas advocates in the Netherlands made the case that these acts would be limited to a small number of terminally ill patients experiencing intolerable suffering and that the practices would be considered last-resort options only. By 2002, euthanasia laws in neither Belgium nor the Netherlands limited euthanasia to persons with a terminal disease (recognizing that the concept of “terminal” is in itself open to interpretation and errors). The Dutch law requires only that a person be “suffering hopelessly and unbearably.” “Suffering” is defined as both physical and psychological, which includes people with depression. In Belgium, the law ambiguously states that the person “must be in a hopeless medical situation and be constantly suffering physically or psychologically.” By 2006, the Royal Dutch Medical Association had declared that “being over the age of 70 and tired of living” should be an acceptable reason for requesting euthanasia 32 . That change is most concerning in light of evidence of elder abuse in many societies, including Canada 33 , and evidence that a large number of frail elderly people and terminally ill patients already feel a sense of being burden on their families and society, and a sense of isolation. The concern that these people may feel obliged to access euthanasia or pas if it were to become available is therefore not unreasonable, although evidence to verify that concern is not currently available.

In Oregon, although a terminal illness with a prognosis of less than 6 months to live has to be present, intolerable suffering that cannot be relieved is not a basic requirement (again recognizing that the concept of “intolerable suffering” is in itself ambiguous). This definition enables physicians to assist in suicide without inquiring into the source of the medical, psychological, social, and existential concerns that usually underlie requests for assisted suicide. Physicians are required to indicate that palliative care is a feasible alternative, but are not required to be knowledgeable about how to relieve physical or emotional suffering.

Until 2001, the Netherlands allowed only adults access to euthanasia or pas . However, the 2001 law allowed for children aged 12–16 years to be euthanized if consent is provided by their parents, even though this age group is generally not considered capable of making such decisions 5 . The law even allows physicians to proceed with euthanasia if there is disagreement between the parents. By 2005, the Groningen Protocol, which allows euthanasia of newborns and younger children who are expected to have “no hope of a good quality of life,” was implemented 34 , 35 . In 2006, legislators in Belgium announced their intention to change the euthanasia law to include infants, teenagers, and people with dementia or Alzheimer disease 36 .

In Belgium, some critical care specialists have opted to ignore the requirement that, in the case of non-terminally-ill patients, an interval of 1 month is required from the time of a first request until the time that euthanasia is performed. One specialist reported that, in his unit, the average time from admission until euthanasia was performed for patients that seemed to be in a “hopeless” situation was about 3.5 days 37 . Beneficence, this specialist argued, was the overriding principle.

Initially, euthanasia in the Netherlands was to be a last-resort option in the absence of other treatment options. Surprisingly, however, palliative care consultations are not mandatory in the jurisdictions that allow euthanasia or assisted suicide, even though uncontrolled pain and symptoms remain among the reasons for requesting euthanasia or pas 38 . Requests by the Belgian palliative care community to include an obligatory palliative care consultation (“palliative filter”) were denied 19 . From 2002 to 2007 in Belgium, a palliative care physician was consulted (second opinion) in only 12% of all cases of euthanasia 31 . Palliative care physicians and teams were not involved in the care of more than 65% of cases receiving euthanasia. Moreover, the rates of palliative care involvement have been decreasing. In 2002, palliative care teams were consulted in 19% of euthanasia cases, but by 2007 such involvement had declined to 9% of cases. That finding contradicts claims that in Belgium, legalization has been accompanied by significant improvements in palliative care in the country 39 . Other studies have reported even lower palliative care involvement 8 , 13 . It must be noted that legalization of euthanasia or pas has not been required in other countries such as the United Kingdom, Australia, Ireland, France, and Spain, in which palliative care has developed more than it has in Belgium and the Netherlands.

The usefulness of a single palliative care assessment has been challenged—even when it is an obligatory requirement, as is the case at the University Hospital of the Canton of Vaud, Lausanne, Switzerland (the first hospital to allow, in 2005, assisted suicide in Switzerland 40 ) 41 . Among U.K. palliative care physicians, 63% feel that a single assessment is insufficient to fully evaluate and address the needs of a person requesting euthanasia or pas 42 . A similar number of U.K. psychiatrists have expressed similar concerns 43 , 44 , and only 6% of Oregon psychiatrists are comfortable providing consultations for patients requesting pas 45 .

Originally, it was the view of the Supreme Court of the Netherlands, the Royal Dutch Medical Association, and the ministers of Justice and Health that euthanasia would not be an option in situations in which alternative treatments were available but the patient had refused them. When this view conflicted with the accepted ethical principle that patients are allowed to refuse a treatment option, the law was altered to allow access to euthanasia even if the person refused another available option such as palliative or psychiatric care. One consequence of the change is that, the appropriateness of suicide prevention programs may begin to be questioned, because people wanting to commit suicide should, on the basis of autonomy and choice, have the same rights as those requesting euthanasia.

There are other examples that a “social slippery slope” phenomenon does indeed exist. In Switzerland in 2006, the university hospital in Geneva reduced its already limited palliative care staff (to 1.5 from 2 full-time physicians) after a hospital decision to allow assisted suicide; the community-based palliative care service was also closed (JP. Unpublished data). Of physicians in the Netherlands, 15% have expressed concern that economic pressures may prompt them to consider euthanasia for some of their patients; a case has already been cited of a dying patient who was euthanized to free a hospital bed 46 . There is evidence that attracting doctors to train in and provide palliative care was made more difficult because of access to euthanasia and pas , perceived by some to present easier solutions, because providing palliative care requires competencies and emotional and time commitments on the part of the clinician 47 , 48 . At the United Kingdom’s parliamentary hearings on euthanasia a few years ago, one Dutch physician asserted that “We don’t need palliative medicine, we practice euthanasia” 49 . Compared with euthanasia cases, cases without an explicit request were more likely to have a shorter length of treatment of the terminal illness 10 .

Advocates of euthanasia have largely ignored these concerns about the “social slippery slope” and have opted to refute the “slippery slope” argument on the basis that legalizing euthanasia and pas has not led to exponential increases in cases of euthanasia or pas or in a disproportionate number of vulnerable persons being euthanized 7 , 26 , 30 . However, there is evidence that challenges those assertion.

The number of deaths by euthanasia in Flanders has doubled since 1998 30 . Of the total deaths in this Flemish-speaking part of Belgium (population 6 million), 1.1%, 0.3%, and 1.9% occurred by euthanasia in 1998, 2001, and 2007 respectively 30 (about 620, 500, and 1040 people respectively in those years). The requirement of the law to report euthanasia cases (aided by laxity in prosecuting cases that fall outside the requirement) may explain some, but not all, of the increase 31 . Chambaere et al. 10 reported in the Canadian Medical Association Journal that in Belgium, euthanasia without consent had decreased from 3.2% in 1998 to 1.8% in 2007. But a closer review of the original study shows that the rate had declined to 1.5% in 2001 and then increased again to 1.8% in 2007 30 .

In Holland, the overall rate of euthanasia was 1.7% of all deaths in 2005, down from 2.4% and 2.6% in 2001 and 1995 respectively, but no different from 1990 when the rate was 1.7% 7 . However, the Dutch government’s official statistics indicate a rise of 13% in 2009 compared with 2008; euthanasia now accounts for 2% of all deaths. Given the increasing numbers, interest in developing facilities that provide euthanasia (similar to those of the Swiss pro–assisted suicide group Dignitas) has recently been increasing. In Oregon, although the number of cases of pas remain very small relative to the population, the rate has been increasing: 24 prescriptions were written in 1998 (16 of which led to deaths by pas ), 67 prescriptions in 2003 (43 of which led to deaths by pas ), and 89 in 2007 50 .

In Belgium, the rates of involuntary and non-voluntary euthanasia have decreased; together they accounted for 3.2%, 1.5%, and 1.8% of all deaths in 1998, 2001, and 2007 respectively (1800, 840, and, 990 people respectively in those years) 30 . In the Netherlands, the rate decreased from 0.7% in 2001 to 0.4% in 2005 7 . The actual rate is probably higher, given the large number of unreported cases. Notwithstanding the decrease, the rates are perturbing.

Battin et al. 51 examined data from Oregon and the Netherlands and concluded, as have others 30 , that there was no evidence that vulnerable people, except for people with aids , are euthanized disproportionately more. “Vulnerable” was defined in that study as individuals who are elderly, female, uninsured, of low educational status, poor, physically disabled or chronically ill, younger than the age of majority, affected with psychiatric illnesses including depression, or of a racial or ethnic minority. Finlay and George challenged the study on the basis that vulnerability to pas or euthanasia cannot be categorized simply by reference to race, sex, or other socioeconomic status. Other characteristics, such as emotional state, reaction to loss, personality type, and the sense of being a burden are also important 52 . Patients are also vulnerable to the level of training and experience that their physicians have in palliative care and to the personal views of their physicians about the topic. For example, one study showed that the more physicians know about palliative care, the less they favour euthanasia and pas 53 .

Two recent studies further contradict the findings by Battin and colleagues. Chambaere et al. found that voluntary and involuntary euthanasia occurred predominantly among patients 80 years of age or older who were in a coma or who had dementia 10 . According to them, these patients “fit the description of vulnerable patient groups at risk of life-ending without request.” They concluded that “attention should therefore be paid to protecting these patient groups from such practices.” In another study, two of the factors significantly associated with a nurse administering life-ending drugs were the absence of an explicit request from the patient and the patient being 80 years of age or older 15 .

4. THE RESPONSE

What can be done, then, when the best of palliative care is unable to address suffering?

Zylicz, a palliative care specialist who has worked extensively in the Netherlands with people requesting euthanasia and pas , provides a taxonomy to understand the reasons underlying the requests and provides stepping stones for addressing the requests. The requests can be classified into five categories (summarized by the abbreviation abcde ) 54 :

• Being afraid of what the future may hold
• Experiencing burnout from unrelenting disease
• Having the wish and need for control
• Experiencing depression
• Experiencing extremes of suffering, including refractory pain and other symptoms

Strategies are available to begin to address severe refractory symptoms, to treat depression, and to deal with the fear that some people have of what the future with a terminal disease may hold. Approximately 10%–15% of pain and other physical symptoms (such as dyspnea and agitated delirium) cannot be controlled with first- and second-line approaches and become refractory. For these symptoms, there is the option of palliative sedation. Palliative sedation is defined as “the monitored use of medications intended to induce a state of decreased or absent awareness (unconsciousness) in order to relieve the burden of otherwise intractable suffering in a manner that is ethically acceptable to the patient, family and health-care providers in patients that are imminently dying” 55 . Its intent is not to hasten death, which differentiates it from euthanasia. The goal is to achieve comfort at the lowest dose of sedative possible (usually with midazolam infusion, not with opioids) and at the lightest level of sedation. Some patients therefore achieve comfort at light levels of sedation, allowing them to continue interacting with family; in others, comfort is achieved only at deep levels of sedation.

Studies have shown that losing a sense of dignity and hope and taking on a sense of burden prompt some people to seek euthanasia and pas 21 – 23 , 56 . Strategies to improve the sense of dignity, based on empirical studies that have explored the concept of dignity within palliative care, have been shown to work 57 . Similar strategies need to be developed in the areas of hope and burden.

Given effective palliation, including palliative sedation for patients with refractory symptoms, the only remaining issue is that of legalizing “on-demand” euthanasia and pas when there is no terminal disease or when the person is tired of living or has a mental illness. Legalizing euthanasia and assisted suicide in these circumstances is most concerning and would have major implications over time, including changing a society’s values and making suicide prevention programs redundant because people wishing to commit suicide would then be entitled to do so.

In 30 years, the Netherlands has moved from euthanasia of people who are terminally ill, to euthanasia of those who are chronically ill; from euthanasia for physical illness, to euthanasia for mental illness; from euthanasia for mental illness, to euthanasia for psychological distress or mental suffering—and now to euthanasia simply if a person is over the age of 70 and “tired of living.” Dutch euthanasia protocols have also moved from conscious patients providing explicit consent, to unconscious patients unable to provide consent. Denying euthanasia or pas in the Netherlands is now considered a form of discrimination against people with chronic illness, whether the illness be physical or psychological, because those people will be forced to “suffer” longer than those who are terminally ill. Non-voluntary euthanasia is now being justified by appealing to the social duty of citizens and the ethical pillar of beneficence. In the Netherlands, euthanasia has moved from being a measure of last resort to being one of early intervention. Belgium has followed suit 37 , and troubling evidence is emerging from Oregon specifically with respect to the protection of people with depression and the objectivity of the process.

The United Nations has found that the euthanasia law in the Netherlands is in violation of its Universal Declaration of Human Rights because of the risk it poses to the rights of safety and integrity for every person’s life. The UN has also expressed concern that the system may fail to detect and to prevent situations in which people could be subjected to undue pressure to access or to provide euthanasia and could circumvent the safeguards that are in place.

Autonomy and choice are important values in any society, but they are not without limits. Our democratic societies have many laws that limit individual autonomy and choice so as to protect the larger community. These include, among many others, limits on excessive driving speeds and the obligation to contribute by way of personal and corporate income taxes. Why then should different standards on autonomy and choice apply in the case of euthanasia and pas ?

Legislators in several countries and jurisdictions have, in just the last year, voted against legalizing euthanasia and pas in part because of the concerns and evidence described in this paper. Those jurisdictions include France, Scotland, England, South Australia, and New Hampshire. They have opted to improve palliative care services and to educate health professionals and the public.

6. CONFLICT OF INTEREST DISCLOSURES

The author has no financial conflict of interest to declare.

7. REFERENCES