Ms. I is 32 years old and has advanced gastric cancer that has resulted in constant severe pain and poorly controlled vomiting. Despite steady increases in her opioid dose, her pain has worsened greatly over the last two days. Death is imminent, but the patient pleads incessantly with the hospital staff to “put her out of her misery.”
Mr. J is a 39-year-old injection drug user with a history of alcoholism and depression. He presents at an emergency department, insisting that he no longer wishes to live. He repeatedly requests euthanasia on the grounds that he is no longer able to bear his suffering (although he is not in any physical pain). A psychiatrist rules out clinical depression.
Euthanasia has been defined as a deliberate act undertaken by one person with the intention of ending the life of another person to relieve that person’s suffering. Euthanasia may be “voluntary,” “involuntary,” or “non-voluntary,” depending on (i) the competence of the recipient, (ii) whether or not the act is consistent with the recipient’s wishes (if these are known), and (iii) whether or not the recipient is aware that euthanasia is to be performed. Assisted suicide has been defined as “the act of intentionally killing oneself with the assistance of another who deliberately provides the knowledge, means, or both” (Special Senate Committee on Euthanasia and Assisted Suicide, 1995). In “physician-assisted suicide,” a physician provides the assistance.
States all over the world have debated recently the question of whether physicians and other healthcare professionals should in certain circumstances participate in intentionally bringing about the death of a patient, and whether these practices should be accepted by society as a whole. The ethical, legal, and public-policy implications of these questions merit careful consideration.
There is considerable disagreement about whether euthanasia and assisted suicide are ethically distinct from decisions to forgo life-sustaining treatments (Gillion, 1988; Roy, 1990; Brock, 1992; Dickens, 1993; Annas, 1996) and the issue has formed the basis of a number of legal actions (Sue Rodriguez v. British Columbia (Attorney General), 1993; Quill v. Vacco, 1996; Compassion in Dying v. Washington, 1996). At the heart of the debate is the ethical significance given to the intentions of those performing these acts (Brody, 1993; Quill, 1993). Supporters of euthanasia and assisted suicide reject the argument that there is an ethical distinction between these acts and acts of forgoing life-sustaining treatment. They claim, instead, that euthanasia and assisted suicide are consistent with the right of patients to make autonomous choices about the time and manner of their own death (Brock, 1992; Angell, 1997). Opponents of euthanasia and assisted suicide claim that death is a predictable consequence of the morally justified withdrawal of life-sustaining treatments only in cases where there is a fatal underlying condition, and that it is the condition, not the action of withdrawing treatment, that causes death (Foley, 1997). A physician who performs euthanasia or assists in a suicide, by comparison, has the death of the patient as his or her primary objective. Although opponents of euthanasia and assisted suicide recognize the importance of self-determination, they argue that individual autonomy has limits and that the right to self-determination should not be given ultimate standing in social policy regarding euthanasia and assisted suicide (Callaghan, 1992). Supporters of euthanasia and assisted suicide believe that these acts benefit terminally ill patients by relieving their suffering (Brody, 1992), while opponents argue that the compassionate grounds for endorsing these acts cannot ensure that euthanasia will be limited to people who request it voluntarily (Kamisar, 1995). Opponents of euthanasia are also concerned that the acceptance of euthanasia may contribute to an increasingly casual attitude toward private killing in society (Kamisar, 1958). Most commentators make no formal ethical distinction between euthanasia and assisted suicide, since in both cases the person performing the euthanasia or assisting the suicide deliberately facilitates the patient’s death. Concerns have been expressed, however, about the risk of error, coercion, or abuse that could arise if physicians become the final agents in voluntary euthanasia (Quill et al., 1992). There is also disagreement about whether euthanasia and assisted suicide should rightly be considered “medical” procedures (Kinsella, 1991; Drickamer et al., 1997).
Most legal systems recognize a distinction between positive acts intended to cause death and passively allowing natural death to occur. The former is usually considered homicide, including murder and infanticide. Withholding and withdrawing life support can also be homicide, usually manslaughter, when there is a legal duty of maintenance. However, although physicians must render care necessary for their patients’ survival, they are usually not bound to provide treatment that in good faith they consider futile or ineffective to sustain their patients’ well-being or capacity to function at a conscious, aware level. For instance, patients who remain in a permanent or persistent vegetative state may have means of nutrition and hydration withdrawn when death is predicted to result (Airedale NHS Trust v. Bland, 1993).
A small but potentially growing number of jurisdictions allow physicians to comply with competent patients’ persistent requests that their unbearable pain be relieved by terminal means. The Netherlands pioneered medically induced death, not limited to terminal patients, by a series of judicial rulings in the 1960s and legislation enacted in 2000, and the US state of Oregon and Belgium have amended their legislation to provide conditions under which physicians may (not must) comply with competent patients’ requests by undertaking interventions intended to cause death. In the absence of such law, however, a competent patient’s consent to such an intervention is not a defense to a criminal charge of homicide or criminal negligence laid against a physician.
Assisted suicide was decriminalized in Switzerland in 1942 (Guillod and Schmidt, 2005), not necessarily limited to physicians’ assistance, but this is the exception that proves the general rule that decriminalization of individuals’ attempted suicide does not open a way to assistance, by physicians or others. Withdrawal of prohibition of attempted suicide does not create a right to an attempt (Sue Rodriguez v. Attorney-General of British Columbia, 1993), nor to assistance. Counseling and assisting suicide remain offences in most jurisdictions. However, several jurisdictions such as the Netherlands and Belgium are coming to recognize individuals’ capacity for rational choice of suicide, and the right of physicians to give assistance.
A concern regarding approaching euthanasia and medically assisted suicide through criminal law is that enforcement may be ineffective. Physicians may be justified in increasing medications for pain control, as patients’ relief from pain at given dosage levels decreases, until a toxic level is predictably reached and is the precipitating cause of death. Patients’ deaths result, however, not from their treatment but from their pathologies, which justified and even compelled the pain relief treatment (R v. Adams, 1957; Williams, 2001). Physicians who withhold indicated measures of pain relief for fear of personal accountability for their patients’ deaths are in a conflict of interest. However, prosecutors may find it impossible to show beyond reasonable doubt that physicians’ primary intentions are not pain relief but “mercy killing.”
Similarly, medications may properly be prescribed for patients’ periodic self-administration, which they may hoard and then consume at the same time in order to commit suicide. Physicians may recognize this as a risk, but it may be impossible to show beyond reasonable doubt that they intended this consequence or were negligent. Warning patients of dangers to their lives of over medication may send an ambiguous message.
A study in 1995 in Canada (Singer et al., 1995) showed that more than 75% of the general public supported voluntary euthanasia and assisted suicide in the case of patients who were unlikely to recover from their illness. Roughly equal numbers, however, opposed these practices for patients with reversible conditions (78% opposed), elderly disabled people who feel they are a burden to others (75% opposed), and elderly people with minor physical ailments (83% opposed) (Genuis et al., 1994). Results of one survey indicated that 24% of Canadian physicians would be willing to practice euthanasia and 23% would be willing to assist in a suicide if these acts were legal (Wysong, 1996). These findings are similar to the results of surveys conducted in the UK (Ward and Tate, 1994) and in Australia’s Northern Territory (Anon., 1996). Surveys of physicians in the Australian state of Victoria (Kuhse and Singer, 1988), as well as surveys in Oregon (Lee et al., 1996), Washington (Shapiro et al., 1994), and Michigan (Bachman et al., 1996) indicated that a majority of physicians in these jurisdictions supported euthanasia and assisted suicide in principle and favored their decriminalization. Physicians in certain specialties, such as palliative care, appear to be less willing to participate in euthanasia and assisted suicide than physicians in other specialties.
Approximately 3% of all deaths in the Netherlands result from euthanasia or assisted suicide (van der Maas et al., 1996). Most of these patients have cancer, though one in five patients with amyotrophic lateral sclerosis die of euthanasia or assisted suicide (Veldink et al., 2002). Physicians report that Dutch patients pursue euthanasia because of loss of dignity, “unworthy dying,” and dependence on others. Pain was mentioned as a reason for pursuing hastened death by almost half of patients, but in only 5% was it the sole reason (van der Maas et al., 1996).
In a national US sample of almost 2000 physicians, one in six reported having received a request from a patient for assistance with suicide; 11% had received a request for a lethal injection; 3% reported that they had written at least one prescription to be used to hasten death; and 4.7% said that they had administered at least one lethal injection. The most common reasons for the request were discomfort other than pain, loss of dignity, fear of uncontrollable symptoms, pain, and loss of meaning in life (Meier et al., 1998). Physicians were more likely to honor the requests of patients with severe pain or discomfort who had a life expectancy of less than one month and were not assessed as depressed at the time of the request (Meier et al., 2003).
Assisted suicide became lawful in Oregon in 1997, and each year approximately 0.1% of deaths in that state are by lethal prescription. One in six explicit requests for physician aid in dying are honored. Individuals who access lethal prescriptions under the law are well educated and socioeconomically secure compared with other Oregon decedents. Most patients are enrolled in home hospice when they receive the lethal prescription, suggesting that assisted suicide is not a substitute for palliative care. Physicians and hospice workers report that terminally ill individuals request assisted suicide to control the timing and manner of death and to avoid dependence on others. Maintaining independence appears to be a lifelong value for these patients. Uncontrolled pain is rarely a reason for requesting assisted suicide, though fears of worsening symptoms in the future are prominent. Depressive disorders underlie desire for hastened death in a variety of studies, but the prevalence of depression among Oregon residents who die by assisted suicide appears paradoxically low, and may represent underrecognition by clinicians (Ganzini et al., 2000, 2002; Ganzini and Dobscha, 2003). Physicians from Oregon who have received requests reported that the experience is emotionally intense, but those who agreed to participate rarely had regrets (Dobscha et al., 2004).
Although legal in a handful of countries and states, euthanasia and assisted suicide remain illegal and punishable by imprisonment in most jurisdictions. Physicians who believe that euthanasia and assisted suicide should be legally accepted may pursue these convictions through various legal and democratic means at their disposal: the courts and the legislature. In approaching these issues in a clinical setting, it is important to (i) thoroughly explore the reasons for the request; (ii) respect competent decisions to forgo treatment, such as discontinuing mechanical ventilation at the request of a patient who is unable to breathe independently, which is legal; (iii) support the patient’s autonomy and attempts to maintain control in other areas of life; and (iv) provide appropriate palliative measures.
The case of Ms. I involves a competent, terminally ill patient who is imminently dying and in intractable pain. The case of Mr. J involves an apparently competent patient who is not dying but is experiencing extreme mental suffering. In both cases, the physician is confronted with a possible request to participate in euthanasia or assisted suicide. Ms. I is suffering and close to death. In consultation with her and her family, the medical team should aggressively control pain and symptoms, calling on the assistance of palliative care specialists if available. Some physicians may be concerned that this type of assertive sedation and pain management may hasten death and thus constitutes euthanasia. This approach, however, is ethically permissible as long as the goal of care is to decrease suffering, euthanasia is not the physician’s intention, and death is not the means for alleviating suffering (Williams, 2001).
In the case of Mr. J, the clinical team should explore the source of his despair and respond with psychosocial support and efforts to decrease suffering that do not end the patient’s life. Despite the absence of clinical depression, assistance from mental health experts may be beneficial.
An earlier version of this chapter has appeared: Lavery, J. V., Dickens, B. M., Boyle, J. M., and Singer, P. A. (1997). Euthanasia and assisted suicide. CMAJ 156: 1405–8.