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Kufe DW, Pollock RE, Weichselbaum RR, et al., editors. Holland-Frei Cancer Medicine. 6th edition. Hamilton (ON): BC Decker; 2003.

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Holland-Frei Cancer Medicine. 6th edition.

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Assisted Suicide and Euthanasia

, MD, PhD and , MD, MPH.

Historical Perspective

The ethics of euthanasia have been a contentious issue since the beginning of medicine.118 The Hippocratic Oath takes a strong stand against euthanasia, requiring doctors to pledge never to “give a deadly drug to anybody if asked for it, nor…make a suggestion to this effect.”6 In ancient Greece and Rome, this position was the minority view as it was common for physicians to participate in euthanasia and physician-assisted suicide (PAS). The modern debate about euthanasia can be dated from 1870, when a nonphysician, Samuel Williams, argued for euthanasia in front of the Birmingham Speculative Club.118 This speech sparked debate about legalizing euthanasia among American and British physicians in the late nineteenth century.118 In 1905, a bill was introduced into the Ohio state legislature to legalize euthanasia, but was defeated.118 The contemporary debate became more intense and public with the growing acceptance of terminating life-sustaining care, the permissibility of euthanasia in the Netherlands, the Kevorkian suicide machine, and the publication in 1988 of the article “It's over, Debbie.”119 To clarify the debate, we (1) review the definitions of key terms, (2) delineate the arguments for and against euthanasia and PAS, (3) review the US Supreme Court's ruling, (4) review the data on euthanasia and PAS in the Netherlands, and (5) review what we know about the practices in other countries.


Much confusion surrounds the debates about euthanasia and PAS because of imprecise terminology. Table 79-4 summarizes the essential definitions. Importantly, so-called passive euthanasia is actually the withdrawal or withholding of life-sustaining medical interventions and is widely accepted as both ethical and legal. In addition, so-called indirect euthanasia, increasing narcotics to ease a patient's pain even if this has the consequence of hastening the patient's death, has generally been deemed both ethical and legal.120 Almost all commentators agree that involuntary, and nonvoluntary active euthanasia are unethical because they end the life of a patient without consent. Consequently, the focus of debate in the United States is on PAS and voluntary, active euthanasia. To avoid confusion, use of the term euthanasia should be restricted to voluntary, active euthanasia.

Table 79-4. Definitions of Assisted Suicide and Euthanasia.

Table 79-4

Definitions of Assisted Suicide and Euthanasia.

Ethical Standards Regarding Euthanasia and Assisted Suicide

Proponents typically cite four reasons to justify PAS or euthanasia.121–123 First, it is claimed that euthanasia ensures patients' autonomy.122,123 Individuals have different values and goals in life; we protect patient autonomy by permitting patients to pursue their goals. A proper death is as essential to a person's goals and values as any other choice. Hence, to respect patients' autonomy, we must respect patients' wishes regarding the manner and timing of their death through euthanasia and PAS.122,123 Second, it is argued that for some patients the dying process inflicts significant pain and suffering and that euthanasia or PAS may relieve them of these burdens. Hence, euthanasia or PAS furthers beneficence or the well being of sick patients.123 Indeed, for some people just knowing there is the possibility of having euthanasia or PAS may be psychologically beneficial, even if they ultimately never use these interventions. Third, proponents argue that euthanasia is morally indistinguishable from the accepted practices of withholding and withdrawing life-sustaining care.122,123 This is because the final result, the death of a patient, is the same in either scenario and because there is no moral difference between acts of omission and acts of commission. From a moral standpoint, there is no difference between merely letting nature take its course and actively killing a patient if the patient consciously and knowingly requests his or her life be terminated. Finally, it is argued that the adverse practical consequences of legalizing euthanasia or PAS are too speculative and hypothetical to determine whether to permit euthanasia or PAS. Indeed, permitting euthanasia or PAS should enhance the physician-patient relationship, because it means physicians will provide whatever care, including euthanasia or PAS, that is necessary for dying patients.

Opponents of euthanasia and PAS offer four parallel arguments.124,125 First, opponents claim that autonomy does not justify euthanasia or PAS.124–126 Autonomy does not mean a person should be permitted to do anything he or she wishes, especially those actions that end the ability to act autonomously.126 On this basis, we do not permit voluntary dueling or voluntary enslavement. In addition, even if a person wants to commit suicide, it is another issue entirely to permit others to help. Second, beneficence may not justify euthanasia or PAS. Many terminally ill patients experience inadequately treated pain, fatigue, and depression. If we treated these symptoms adequately, few people would have extreme pain and suffering that would justify euthanasia or PAS.124,125 Third, it is argued that there is an ethical distinction between acts of omission and acts of commission. Evaluating the ethics of an act does not only depend on its final result, but we also must evaluate how that result was produced and the intention of the actors.124 There are ethical and legal differences between cases in which a person was killed by mistake and cases in which the killing was premeditated. Similarly, there is a difference between stopping a medical treatment and letting a patient die and intentionally and actively injecting the patient with a medication to cause his or her death. Finally, opponents note a variety of adverse consequences that might result from legalizing euthanasia or PAS, including disruption of the physician-patient relationship, intrusion of the courts into terminating care decisions, coercion of terminally ill patients to commit euthanasia or PAS, and extension of euthanasia to children, mentally incompetent patients, and others.125

US Supreme Court Ruling on Euthanasia and PAS

In June 1997, the US Supreme Court ruled unanimously that there is no constitutional right to euthanasia or PAS.89 Many of the justices wrote separate opinions and many seemed sympathetic to the notion of PAS and euthanasia, even if they did not deem it a constitutional right. The majority view—written by Chief Justice Rehnquist—drew a distinction between the right to withdraw or withhold life-sustaining treatments as a liberty interest in being free of unwanted bodily invasion versus the right to PAS, which does not contain a liberty interest.89 Others inquired whether a right to PAS might be viewed as a right to death with dignity but, nevertheless, rejected the notion of a constitutional right to PAS.89 The unanimity of the ruling suggests that it is unlikely to be overturned in the future. Importantly, the Supreme Court did not view PAS or euthanasia as inherently unconstitutional, and thus, it permitted individual states, such as Oregon, to legalize these interventions.

Within weeks of the Supreme Court ruling, Florida's state supreme court ruled also that there is no state constitutional right to PAS.127 Similarly, other state supreme courts have ruled that PAS is not a fundamental right.128 Also, Michigan and Maine rejected state referenda to legalize PAS. Oregon has enacted its Death with Dignity Act and as of 2001 has had 91 cases of PAS.129,130

Euthanasia and PAS in the Netherlands

Recently, the Netherlands legalized euthanasia and PAS. Several safeguards must be adhered to, including that (1) the patient has unbearable pain and suffering that cannot be medically relieved; (2) the patient is competent and repeatedly makes a request to have his or her life ended; and (3) the physician consults a second physician.131,132

The Dutch government commissioned detailed studies of the practices of euthanasia and PAS in 1990 and again in 1995, and individual researchers have conducted many other studies.133–135 These studies show that just over 50% of Dutch physicians have participated in euthanasia or PAS at some point in their careers and 29% within the previous 2 years.133,134 Indeed, only approximately 12% of Dutch physicians indicated that they would never perform euthanasia or PAS.133,134 According to the latest data, approximately 9,700 patients explicitly request euthanasia or PAS each year. And approximately 2.3% of all deaths in the Netherlands are by euthanasia, 0.4% are by PAS, and 0.7% are deaths in which active measures are taken to end the patient's life without the patient's explicit request.134 Thus, approximately, 3.4% of all deaths in the Netherlands, or 4,600 deaths annually, are by euthanasia or PAS.134 Importantly, 80% of these cases involve patients with cancer, 3% involve patients with cardiovascular disease, and 4% involve patients with neurologic diseases.134 Between 1990 and 1995, the frequency of euthanasia and PAS cases increased from 2.2% to 2.7% of all deaths, although the frequency of intentional deaths without the patient's explicit request remained constant at 0.7% to 0.8% of all deaths.133,134

Empirical Data Regarding Euthanasia and PAS

While the Dutch studies of euthanasia and PAS are the most valid and reliable, data are accumulating on the attitudes and practices of euthanasia and PAS in the United States and other countries.136 Surveys indicate that a majority of the American public is willing to support euthanasia and PAS in hypothetical cases and for terminally ill patients with pain.110,121 Support is lower when the question involves euthanasia or PAS for reasons other than pain.110 Interestingly, this high level of support for euthanasia and PAS has been constant since the mid-1970s and has not increased with the debates over the last 15 years.136,137 Similar differences have been reported among Canadians. In addition, while there are conceptual distinctions between euthanasia and PAS, the American public makes no distinction between euthanasia and PAS; the same proportion support both interventions for the same situation.110 Importantly, people who are religious, Catholics, those older than 65 years of age, and African Americans are much less likely to support euthanasia or PAS. Support among American physicians is significantly less than among the public.110 In almost all surveys, less than half of American physicians support euthanasia or PAS; and significantly fewer support euthanasia than support PAS. Furthermore, there is evidence that at least among American oncologists support for both euthanasia and PAS has declined significantly, by as much as 75%, over the last few years.138

Surveys in a number of countries in which euthanasia and PAS are illegal indicate that physicians receive requests for these interventions and do perform them. In Britain, it has been reported that 45% of physicians have been asked to hasten death.139 In Alberta, Canada, 20% of physicians reported receiving requests for active euthanasia. In the United States, many physicians have received requests for euthanasia and PAS, but different studies provide vastly different estimates of the frequency.110,121,138,140–142 Among non-oncologists in the United States, it is reported that between 18.3% and 26% have received requests for euthanasia or PAS.140,141 Reports among oncologists indicate that between 43% and 62.9% of oncologists have received requests for euthanasia or PAS.110,136,142

In Britain, 32% of physicians indicated that they have “taken active steps to bring about the death of a patient,” although this may include terminating life-sustaining interventions.139 Again, in the United States, there is a large difference between oncologists and other physicians. Among non-oncologists, it is reported that approximately 1.7% to 4.7% had performed euthanasia and 3.3% to 4.6% had performed PAS in their career.140,141 Among oncologists, it is reported that 3.7% to 4% had performed euthanasia, while 10.8% to 18% had performed PAS in their career.110,142 In the last 12 months, 4% of oncologists performed either euthanasia or PAS. Importantly, if they do perform these interventions, they do so rarely. The median number of euthanasia cases is two in a career as is the median number of PAS cases.140 If these data on the proportion of physicians who have performed euthanasia and PAS and the frequency with which they perform these events are accurate, they suggest a very low number of cases of euthanasia and PAS in the United States. If 4% of American oncologists (400 oncologists) perform 1 to 2 cases of euthanasia or PAS per year, then there are fewer than 1,000 cases per year, a tiny fraction of the 2.4 million Americans who die annually.

All available data indicate that the vast majority of cases of PAS and euthanasia involve oncology patients. For instance, in Oregon, 77% of all patients who used PAS between 1998 and 2001 suffered from cancer.129,130,143 Importantly, contrary to expectations, the data from these countries, as well as surveys of patients who might be eligible for euthanasia or PAS—patients with cancer,110 human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS),144 and amyotrophic lateral sclerosis145—indicate that pain is not the main motivating factor behind the desire for euthanasia or PAS. For instance, among the Oregon patients who died in the first year of the law, only 1 of 15 (6.7%) had uncontrolled pain, which is less than the 35% of the control patients (data on pain have not been published for subsequent years).143 Data suggest that shortness of breath is the physical symptom most consistently associated with requests for euthanasia or PAS. More importantly, depression, psychological distress, and hopelessness appear to be the main symptoms motivating patients' desires for euthanasia or PAS.110,144,145

Finally, the existing data suggest certain problems. One is the failure of cases of PAS. In the Netherlands, approximately 20% of PAS cases do not result in the patient's death.134 And in the United States, one report indicates that 15% of PAS cases result in failure.136,146 How these cases are handled is unknown. In 2001, Oregon reported that in 2 of 21 cases there were problems because one patient vomited up the medicine, and in the other case, the patient lived 37 hours after taking the drug, suggesting that the patient died of natural causes rather than the medication.129 In addition, while the majority of physicians who participate in euthanasia and PAS report satisfaction with their action, between 10% and 20% of physicians report regret at having participated in these interventions.141 The long-term sequelae for these physicians and the consequences for the families of patients who die by euthanasia or PAS are not known.

Responding to Patient's Request for Euthanasia or Physician-Assisted Suicide

When a physician receives a request for euthanasia or PAS, the initial response should be to reassess the patient's circumstances, including physical symptoms, psychological symptoms, social supports, spiritual fulfillment, and caregiving needs (see Figure 79-1).114,115 Special attention should be devoted to assessing depression and the extent of caregiving needs, as data suggest that these are strongly associated with patients' interest in euthanasia and PAS. The physician should also reassess whether additional interventions, including palliative care consultations, psychiatric evaluations, skilled or unskilled home healthcare services, and pastoral services, are required. A psychiatric evaluation can be obtained without necessarily revealing that a request for euthanasia or PAS prompted concern. Obviously, the patient and family should also be reassured that the physician will not abandon the patient and will provide care and attend to the patient's symptoms and needs.

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By agreement with the publisher, this book is accessible by the search feature, but cannot be browsed.

Copyright © 2003, BC Decker Inc.
Bookshelf ID: NBK13381


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