Interrogations on end-of-life issues are not new, and some questions have been
the subject of intense debate for centuries, such as physician-assisted suicide
and euthanasia. The novelty resides in the context they take place. The current
debate is framed by the acceptance of withholding and withdrawing life-sustaining
therapies, the self-determination movement, the promotion of choice in decision-making
at the end of life, and changes in social values.
Over the last two decades, there has been progress in the legal acknowledgement
of patients’ rights at the end of life. Patients have the right to refuse
unwanted treatment or to discontinue it once it has been started. They have
the right to forego life-sustaining therapies. There is also a recognized right
to intensive palliative care and control of pain. Should society set the limits
further and revendicate one’s right to die, to determine the time of one’s
death, according to his own values, as underlined by the physician-assisted
suicide and euthanasia issue?
The debate on physician-assisted suicide and euthanasia has been distorted
in part because of the use of ambiguous and confusing terms. Physician-assisted
suicide is best defined as "aiding or helping to bring about death for
compassionate reasons.” This definition implies that the intention is
clear (death of the patient) and the performing agent is the patient; the accessory
agent (providing the means) is the physician and the motive is usually compassion.
Although there have been many definitions of euthanasia, or more precisely many
categories (active, passive, voluntary, involuntary), it is now well-accepted
that euthanasia means to “bring or give death for compassionate reasons.”
In this case, the intention is similarly clear (death of the patient), the performing
agent is the physician or third party, and the motive is usually compassion.
The debate on euthanasia generally has been argued around the principle of autonomy,
the distinction between killing and letting die (notion of intent), the relief
of suffering, and the slippery slope argument or the arbitrariness of the limits.
Each of these considerations may be used to support or oppose euthanasia.
Assisted suicide or euthanasia implies the right to be relieved from pain and
suffering, as well as the right to die. For many, it is seen as the extrapolation
of the principle of autonomy: one can choose the moment and means of one's death.
The debate struggles with the appropriateness of limits to autonomy: limits
in its application and limits in scope—limits in its application since
so many factors can interfere with the decision-making process especially in
the fragile state of patients with advanced illness. What are the real motives?
How informed, coerced, fearful is the patient? What about medical uncertainties?
Limits in scope since autonomy relates to alterity: autodetermination is not
absolute, and death is neither a right nor a good but an ineluctable fatality.
Advocates of euthanasia and physician-assisted suicide may draw comparisons
between withholding and withdrawal of treatment, neglecting the distinction
between killing and letting die. This is difficult to justify. Although killing
and letting die are similar in regards to end result, e.g., the death of the
patient, they differ in their intent. Death is the unplanned but foreseen result
in withholding and withdrawal of treatment, as opposed to the intended effect
in euthanasia and alterity. Intent or purpose is traditionally used by the law
to distinguish between two acts that have the same result. It is one of the
fundamental concepts of law and also in ethics through the principle of double
Each person has a set of personal reasons for the desire to hasten death. Unrelieved
or unrelievable pain may not be the major or sole reason for requests for physician-assisted
death. Instead, depression, unrelieved psychosocial distress, loss of dignity,
loss of control, other quality-of-life issues, and perceived burden on the family
are the most common justifications. How can we ensure that these aspects have
been investigated and answered?
The potential for abuse of euthanasia and physician-assisted suicide is expressed
by those opposed to these practices. Evidence for abuse of euthanasia may be
found in different reports. The Dutch data include 0.8% of deaths without explicit
and repeated requests from the patient (in one-half of these cases there may
have been previous discussions with the patient about such measures) (Van der
Mass et al., 1991). Data from the U.S. have shown that 19% of critical care
nurses had engaged in some form of euthanasia or PAS, at times without physician
supervision or outside the hospital (Asch, 1996). These observations also raise
the “slippery slope” argument. If physician-assisted suicide or
euthanasia becomes common practice, it may not be possible to limit these practices
to terminal illness or to those capable of providing fully informed consent.
Determination of guidelines or safeguards remains difficult and somewhat illusory
since the underlying concepts are ill-defined. What is intolerable pain? What
is a terminal condition? Is the consent really informed? In a society that prioritizes
cost control, there is even a concern that policy makers or healthcare professionals
would be tempted to shorten a lengthy incurable illness.
Physician-assisted suicide and euthanasia are legal in the Northern Territory
of Australia but remain illegal in most countries. In the Netherlands, physician-assisted
suicide and euthanasia are illegal but have been permitted under certain guidelines.
In the United States, the legal status of physician-assisted suicide varies
across the states. Oregon is the only U.S. state where physician-assisted suicide
is legal. The United States Supreme Court ruled that there is no constitutionally
guaranteed right to physician-assisted suicide or euthanasia and, therefore,
no constitutional right to die.
Is the desire to legalize physician-assisted suicide and euthanasia simply
a reflection of the failure of our healthcare system to treat pain and diagnose
and treat depression, to support patients’ dignity and help them to find
or maintain a sense of meaning in their trajectory? We must be guarded against
making physician-assisted suicide or euthanasia a placebo to an existential
distress or a desertion from humanness. Mastering death and the meaning of life
and suffering is beyond the scope of medicine.
In the clinical setting, a request for physician-assisted suicide or euthanasia
should be taken seriously. It is important to clarify the request, assess the
underlying motives, re-emphasize the commitment to symptom control and provision
of palliative care, and discuss alternatives. Our society greatly needs to improve
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