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 Physician-Assisted Suicide and Euthanasia


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 effect.

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 end-of-life care.


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