Category: Suicide, Euthanasia, and Assisted Suicide

The Effects of Physician Assisted Death on Physicians

Physician assisted death is a topic that has been debated worldwide for many years. According to the American Medical Association, physician assisted death can be defined as “when a physician facilitates a patient’s death by providing the necessary means and/or information to enable the patient to perform the life-ending act.”[1]In the United States, it is only legal in six states. When thinking about physician assisted death, many people directly jump to the effects it has on patients and their families – but what about the effects it has the on the doctors involved in the process?

Physicians are expected to do what is best when it comes to their patients, which should include taking the patient’s request into consideration. When a patient who is in their right mind and has less than 6 months to live asks to be given medications that will kill them, how should a physician respond? Some factors that determine their response is their own personal religion or customs or also even the medical community and the customs that lay within it.

Before becoming a doctor, you are sworn in on the Hippocratic oath, which says “I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan.”[2] Even though doctors must swear by this oath and stick to it their entire career, there are still some doctors that go against it and participate in AID (Aid in Dying) techniques. What the oath doesn’t encompass is how medical culture will change as time progresses, and what will become the new cultural norm in the new day and age.

50 years ago, if a physician was interviewed about their stance on physician assisted suicide, there would be an instant opposition. Likewise, 50 years ago medicine wasn’t as advanced as it is now and also didn’t have as many possibilities. Medicine was still heavily influenced by religion and personal customs that kept care to be as preventative and life saving as possible instead of trying to keep the person in control of their body and its care. Medical care has moved from only going to one doctor for all illness/sickness, to going to a different doctor per part of the body.[3]  When there is a separation in the different doctors and what they care for, there is also a divide in which doctors will support PAD (Physician Assisted Death) and which will deny a patient of this choice due to their own beliefs.[4]

Many physicians who are religious have a conflict with supporting PAD because in some religions, it has been declared wrong for any man to take another’s life and not suffer the consequences for it. In fact, the Roman Catholic church has completely disapproved of it and has stated that it would be better to live until natural death than to help someone die using medicine.[5][6]Most Christian denominations have followed suit and hold the same standards for their Christian physicians. The main reasoning for this is because “God has forbidden it” [7], meaning that any type of unnatural death (including murder and suicide) is “an attack on the sovereignty of God.”[8]Christian beliefs also state that “human life is special”[9], and to take another’s life using any method is wrong and devalues that life.

In eastern religions, such as Hinduism and Buddhism, mortal life is seen as a cycle living, dying, and being reborn again, with the ultimate goal being to be liberated from this cycle.[10] If a physician practicing either of these religions participated in PAD, they would have guilt from possibly interfering with another person’s cycle of life, but also from violating the principle of ahimsa.[11]This principle states that you should never harm a living being, even if they are asking to die. These two eastern religions also believe in karma, which would lead to the physician being negatively affected by satisfying their patient’s request to die.

 

The cycle of life in the Hindu faith

While physicians will or will not participate in PAD because of personal beliefs, there are some physicians that do participate in PAD because of the other options available to the patient. When a patient is terminally ill and has accepted their fate, there is most certainly a period of depression that follows due to their succumbing to the loss of their autonomy. A physician with the duty of palliative care is required to make the end of life process for the patient as pain free as possible. Physicians are also obligated to give the best care possible to their patients and give them the full range of options for their end of life care.[12]Physicians who decide to participate in PAD are going outside of medical norms and giving patients back their autonomy that they lost when they were diagnosed with a terminal illness. For some physicians, their decision to provide PAD is not only going outside of what their beliefs normally are, but also what can be seen as morally wrong by some in the medical community. From here it is important to look into the ethical problems faced by physicians.

As noted earlier, six US states, along with Washington D.C, have legalized PAD with ideas and arguments of autonomy. To emphasize the increasing moral issues at hand, there have been at least thirty-six other states that have also attempted to introduce this law and legalize PAD but without success.[13]

Physician assisted death is a fairly new technique that has not only recently been implemented in several U.S states, but among multiple other countries as well.[14]

Consequently, it is in these states and countries, with possibly many more to come, where physicians are faced with the moral and ethical dilemmas of following through with the aid in the death of their patient.

The main ethical/moral issue that arise through physician assisted death is that in which physicians cannot fulfil their traditional role as a healer and comforter. An immediate consequence of this dilemma is where a physician cannot maintain their trusting, professional relationship with the patients/surrounding community, ultimately destroying their ancient role in society.

As described by the first principle of medical ethics presented by the American Medical Association, a physician must be “dedicated” to giving every patient “competent care” while upholding all aspects of human rights.[15] Thus, by providing the drugs in a quantity that causes a patient’s death, an ethical paradox emerges. Instead of providing care for an individual, the physician is essentially facilitating a means of harm. Two alternatives are present that can avoid this ethical dilemma. One option being the forgoing of life-sustaining treatment and treatment through proper pain control as mentioned previously. It is through these alternatives, labeled as “human, legal, and morally proper”, that suicide can be ultimately avoided.[16] While the forgoing of a life-sustaining treatment system might seem equivalent to PAD, Lois Snyder Sulmasy points out that this is not intended to hasten death but instead points to an “acceptance” of death as a “natural” response to the disease.[17] Seen here, the intent of an action is critical in upholding the ethical concerns of physicians and an intent to kill contradicts their ethical duties of beneficence and nonmaleficence. Intent also parallels with the provision of pain control. It is in this provision where a doctor, while acknowledging that death may come sooner as a side effect, pledges to never intentionally hasten the patient’s death. Yang argues that PAD disregards the most “universal moral junction,” do not kill, by writing a prescription with the intent to kill the patient.[18]

Trust is essential for the physician-patient bond that is so important in our medical society today. In relation to palliative care, the ethical boundary against a physician intentionally causing the patient’s death is what allows patients to be able to request and accept pain medication without fear of an intentional overdose that would hasten their death. In addition, this gives physicians room to operate freely and distribute the medications as they see fit. Many professional organizations have taken the stance of opposition upon the legalization of PAD including the NHCPO, ACP, and AMA. Specifically, the AMA (the largest national doctors’ group) believes that this would cause societal problems as it is “fundamentally incompatible with the physician’s role as healer” and would be “impossible to control.”[19] To put it another way, the physician’s societal role as a healer with ethical responsibilities, could be diminished to that simply of a provider of services at the patients’ expense.

Physicians can lose their professionality and established role in society with the onset of physician assisted death. More so, they must disregard their ethical standards in which they would intentionally end a patients life, an action completely contradictory to a doctors morals. For these reasons it would be more ethical to, with the patient’s permission, practice palliative care or withhold/withdraw life-sustaining treatment.

In order to fully understand the effects of physician assisted suicide on doctors, the issue must be explored from the scientific perspective. Many physicians hold the value of the Hippocratic Oath close to their hearts each day that they go to work. When doctors are faced with the controversial method of physician assisted death, it can have lasting psychological impacts on them. This is an important issue to address because as it is stated in a study done in Washington State, “Patient requests for physician-assisted suicide and euthanasia are not rare.” [20]

In 2001, a study was done in the Netherlands investigating the emotional impacts physicians experienced after having performed euthanasia or having participated in medical end-of-life decisions. 42% of the physicians reported feelings of discomfort from participation in the event, 28% of which specifically reported feelings of guilt. However, after the death of the patient, 52% of the physicians felt comforted afterwards, 44% of which reported feelings of satisfactions and 13% reporting relief. After all was said and done, only 5% of participating physicians had doubts about their actions, and none had regrets. 95% said that they would perform the act again in a similar situation. Despite the fact that physician assisted suicide can be uncomfortable for the physician, after the fact it may provide physicians with “a feeling of having contributed to the quality of the dying process.” [21]

In 2007, Kenneth R. Stevens published an article in which he cumulatively analyzed data regarding the emotional and psychological effects of physician assisted suicide on doctors. 24% of the physicians surveyed in the United States reported that they regretted performing euthanasia or physician assisted suicide, which is significant compared to the 0% of physicians in the 2001 Netherlands study that stated that said they had regrets about their actions. 16% of the United States physicians stated that “the emotional burden of performing euthanasia or PAS adversely affected their medical practice.” [22] Many physicians stated that they felt hopeless, isolated, and even disappointed. Dr. Peter Reagan, an American doctor interviewed about his experience in participating in physician assisted death states, “I think the most important thing is for doctors to understand how huge of an experience it’s going to be for them and that they must have ways of dealing with it themselves.”[23]

Due to the strong psychological impacts of physician assisted suicide on doctors, many doctors choose to immediately dissociate with that patient if that is a path that they are considering. Even the mere suggestion of physician assisted suicide can be “so disturbing to some physicians that they disengage from or avoid their patients.” [24] However, not only can this lead to the patient feeling isolated, this can also lead to the physician feeling isolated. Additionally, physicians may even lose satisfaction with their work when they leave emotions unaddressed. An American doctor, who will be referred to as Dr. P, had a critical patient who suggested the idea of physician assisted death. Rather than helping the patient make an educated decision, Dr. P decided to stop seeing the patient because she couldn’t deal with the burden that would be put on her. Not only was the patient left in the dark, Dr. P was saddened and disappointed that she could not have done more.

In order to avoid situations like Dr. P’s, it is important to have a trusting doctor-patient relationship in which there is a mutual understanding of feelings. If the doctor shuts out the patient, the patient may be left unable to to make the right decision for themselves. The doctor can also seek peers for advice if they do not feel comfortable talking to the patient. The “importance of open discussions, both with patients and with others” [25] is a crucial part of the decision-making process for the physician. There is no way to avoid the negative emotions surrounding physician assisted death, but it better to talk through concerns rather than simply avoid addressing the situation. As stated by Dr. Peter Regan, “I did what I felt was right, given bad choices.” [26]

A diagram of the doctor-patient relationship with respect to physician assisted death. [26]

Of course, different physicians will react in different ways to the idea of participating in physician assisted death. Some doctors refuse to perform the act at all, while others have done it multiple times and would do it again if the circumstances called for it. When physician assisted suicide is performed, a strong, trusting doctor-patient relationship must be established in order minimize lasting psychological effects on doctors.

Through analysis of physician assisted death from an ethical, scientific, and cultural perspective, it is clear that physician assisted suicide significantly impacts doctors. In considering physician assisted suicide, physicians are faced with ethical dilemmas and choices that may go against cultural norms, as explained through religious beliefs. This can have lasting psychological impacts on doctors, proving the necessity for strong doctor-patient relationships.

Blake Matthews

Brianna Ramgeet

Katherine Acierno

 

[1].”Physician-Assisted Suicide.” American Medical Association. Accessed March 25, 2019. https://www.ama-assn.org/delivering-care/ethics/physician-assisted-suicide.

[2].”Greek Medicine – The Hippocratic Oath.” U.S. National Library of Medicine. February 07, 2012. Accessed April 06, 2019. https://www.nlm.nih.gov/hmd/greek/greek_oath.html.

[3].Henry Cha. “A Culture of Health Reaches Far Beyond the Doctor’s Office.” HCIactive. December 23, 2017. Accessed April 08, 2019. https://www.hciactive.com/a-culture-of-health-reaches-far-beyond-the-doctors-office/.

[4].Quill, Timothy E., MD, and Margarett P. Battin, MFA, PhD. “Physician-assisted Dying: Understanding, Evaluating, and Responding to Requests for Medical Aid in Dying.” UpToDate. Accessed April 04, 2019. https://www.uptodate.com/contents/physician-assisted-dying-understanding-evaluating-and-responding-to-requests-for-medical-aid-in-dying#H2168049655.

[5]”Ethics – Euthanasia: Religion and Euthanasia.” BBC. Accessed April 08, 2019. http://www.bbc.co.uk/ethics/euthanasia/religion/religion.shtml.

[6]”Religion and Spirituality.” Death With Dignity. Accessed April 04, 2019. https://www.deathwithdignity.org/learn/religion-spirituality/.

[7]”Ethics – Euthanasia: Religion and Euthanasia.” BBC. Accessed April 08, 2019.

[8]“Ethics,” BBC

[9]“Ethics,” BBC

[10]“Ethics,” BBC

[11]“Ethics,” BBC

[12]Buchman, Sandy. “Why I Decided to Provide Assisted Dying: It Is Truly Patient Centred Care.” Bmj, 2019, L412. Accessed April 8, 2019. doi:10.1136/bmj.l412. https://www.bmj.com/content/364/bmj.l412.short?rss=1&utm_term=1-B&utm_content=americas&utm_campaign=tbmj&utm_medium=cpc&utm_source=trendmd

[13]Wicht, Edward, Rohini Mehta, and Sarah Anne Kleinfeld. “PHYSICIAN AID-IN-DYING: UPDATES FOR GERIATRIC PSYCHIATRISTS: Session 100.” The American Journal of Geriatric Psychiatry 27, no. 3 (2019): S3. https://doi.org/10.1016/j.jagp.2019.01.137

[14]Radbruch, Lukas, Carlo Leget, Patrick Bahr, Christof Müller-Busch, John Ellershaw, Franco de Conno, and Paul Vanden Berghe. “Euthanasia and Physician-Assisted Suicide: A White Paper from the European Association for Palliative Care.” Palliative Medicine 30, no. 2 (February 2016): 104–16. doi:10.1177/0269216315616524

[15]Riddick Jr, Frank A. “The code of medical ethics of the American Medical Association.” (2003): 6-10. http://www.ochsnerjournal.org/content/ochjnl/5/2/6.full.pdf

[16]Kelly, David F. 1995. Alternatives to physician-assisted suicide. American Journal of Otolaryngology–Head and Neck Medicine and Surgery 16 (3): 181-5. https://www.sciencedirect.com/science/article/pii/0196070995900993

[17]Sulmasy, Lois Snyder, and Paul S. Mueller. “Ethics and the Legalization of Physician-Assisted Suicide: An American College of Physicians Position Paper.” Annals of Internal Medicine 167, no. 8 (2017): 576. doi:10.7326/m17-0938.

[18] Yang, Y. Tony, and Farr A. Curlin. 2016. Why physicians should oppose assisted suicide. Jama 315 (3): 247-8. https://jamanetwork.com/journals/jama/article-abstract/2482333

[19]”Physician-Assisted Suicide.” American Medical Association. Accessed April 08, 2019. https://www.ama-assn.org/delivering-care/ethics/physician-assisted-suicide

[20]Back AL, Wallace JI, Starks HE, Pearlman RA. Physician-Assisted Suicide and Euthanasia in Washington State: Patient Requests and Physician Responses. JAMA.1996;275(12):919–925. doi:10.1001/jama.1996.03530360029034 https://jamanetwork.com/journals/jama/article-abstract/399087

[21]Haverkate, Ilinka, PhD, Agnes Van Der Heide, MD, PhD, Bregje D. Onwuteaka‐Philipsen, PhD, Paul J Van Der Maas, MD, PhD, and Gerrit Van Der Wal, MD, PhD. “The Emotional Impact on Physicians of Hastening the Death of a Patient.” Medical Journal of Australia. November 01, 2001. Accessed March 30, 2019. https://onlinelibrary.wiley.com/doi/abs/10.5694/j.1326-5377.2001.tb143707.x

[22]Kenneth R. Stevens (2006) Emotional and Psychological Effects of Physician-Assisted Suicide and Euthanasia On Participating Physicians, The Linacre Quarterly, 73:3,203-216, DOI: 10.1080/20508549.2006.11877782 https://www.tandfonline.com/doi/pdf/10.1080/20508549.2006.11877782

[23]Kenneth (2006), 203-216

[24]Meier, Diane E., MD, Anthony L. Back, MD, and R. Sean Morrison, MD. “The Inner Life of Physicians and Care of the Seriously Ill.” JAMA. December 19, 2001. Accessed April 2, 2019. https://www.researchgate.net/publication/11612706_The_inner_life_of_physicians_and_care_of_the_seriously_ill.

[25]Jennifer R. Voorhees, Judith A. C. Rietjens, Agnes van der Heide, Margaret A. Drickamer, Discussing Physician-Assisted Dying: Physicians’ Experiences in the United States and the Netherlands, The Gerontologist, Volume 54, Issue 5, October 2014, Pages 808–817,https://doi.org/10.1093/geront/gnt087https://academic-oup-com.libproxy.lib.unc.edu/gerontologist/article/54/5/808/626967

[26]Kenneth R. Stevens (2006) Emotional and Psychological Effects of Physician-Assisted Suicide and Euthanasia On Participating Physicians, The Linacre Quarterly, 73:3,203-216, DOI: 10.1080/20508549.2006.11877782 https://www.tandfonline.com/doi/pdf/10.1080/20508549.2006.11877782

 

Differences, Arguments and Cross-cultural Viewpoints

What are the differences between Suicide and Euthanasia? What are the arguments for and against it? How do viewpoints differ cross-culturally?

Euthanasia and physician assisted suicide are both contentious issues, with the heart of the argument lying at morality and legalization. The viewpoints mentioned below, for and against euthanasia, provide only a simple framework of the ethical concerns surrounding this topic. This post will not only delve deeper into the various types and differences of euthanasia and physician assisted suicide, but will also take a look at how viewpoints differ cross-culturally.

Physician assisted suicide and euthanasia tend to overlap. There have been many issues that have followed the creation and legalization of euthanasia and physician-assisted suicide. However, each of them also differs from the other. There are many different types of euthanasia and assisted-suicide and many different ways they can be administered. The traditional distinction states that it is passive whenever a physician allows a patient to die due to withholding or withdrawing their care. It is active whenever a physician administers lethal medicine, causing death to the patient. Voluntary euthanasia occurs whenever a person has euthanasia in their will as their desired course of treatment. However, involuntary occurs whenever a patient cannot make the decision for themselves and dies against their will. Physician-assisted suicide, however, a patient decides to end their own life with help from their physician. Active physician-assisted suicide occurs whenever the physician performs the act that leads to the death of the patient. In passive physician-assisted suicide, the physician provides the patient with the means of dying and the patient performs the act. As of right now, involuntary euthanasia is not legal and many medical practices have faced many controversies because of the expansion of voluntary active euthanasia and physician-assisted suicide.[1]

Many different countries have different medical and ethical opinions as well. The Belgian Integral Palliative Care Act states that high-quality palliative care, open to the act of advancing death, when suffering cannot be relieved and proves intolerable to the desolate dying patient. This ensures that patients will be treated as best as they should during their death. This act helps to set the medical standards of the care of people experiencing life-limiting illnesses and advancing death if they wish to do so. It is because of this that medical students are taught to be bright and sensitive and are obliged to provide their patients with autonomy. [2] In 2000, euthanasia was legalized in the Netherlands and in 2002, Belgium. In the United States, the state of Oregon legalized physician assisted suicide in 1997. Both of these countries are still continuing to develop their ideas about euthanasia and physician-assisted suicide. To address these issues, they asked questions at polls so they could be better prepared to address them.[3] In Britain, the medical origin of physician-assisted suicide and euthanasia was in 1901. Harry Haiselden was the first physician to publicly support assisted suicide as well as involuntary euthanasia. The increase in secularism and acceptance of Darwinism each allowed this idea to become more acceptable. However, still today, this is a very controversial topic. Since the Scientific Revolution, intellectuals have been testing the limits of science. Often, this causes scientists to push borders of the natural world without considering other spheres of knowledge. Earlier, the definition of euthanasia was providing pain relief to dying patients, but quickly transitioned to the hastening of death. It was even favored to kill people with disabilities. This happened in Germany in 1870 when Ernst Haeckel felt as if weak and sick people should not be able to reproduce. He believed this because people that were weak and sick caused a decreased chance in survival and inhibits adaptation. In America, this debate took off in 1915 Chicago. A case of a baby that who was severely deformed at birth was publicized. The family was talked out of a life-saving surgery and the baby died 5 days later. Harry Haiselden used this as his platform for passive euthanasia. [4] Whenever euthanasia and assisted suicide were introduced, they were only used for terminally ill patients. However, it was argued that non-terminally ill patients suffered just as bad and, in some cases, worse than patients that were terminally ill. They also suffered longer because their illness did not kill them, even if it was debilitating. In each act that has been passed in Oregon, California, and Washington, terminal diseases are defined as diseases that are incurable and irreversible, have been medically confirmed, and will cause death within six months. [1]

Right now, psychology is quickly becoming a field in which the effects of euthanasia and physician-assisted suicide are being evaluated. In Belgium and the Netherlands, psychiatric conditions that are resistant to treatment can be treated with euthanasia or physician-assisted suicide. The criteria include that the physician is convinced that the request is voluntary as well as well-thought out, the patient is currently suffering to an unbearable extent with no signs of improvement, and no other alternatives can be offered to relieve their symptoms. An independent physician must also be consulted and medical care and attention must be performed as the act is occurring. This is becoming increasingly popular because psychiatrists have begun arguing that suffering caused by psychiatric illnesses can be just as intense as suffering that comes with terminal illnesses. [5]

Euthanasia, sometimes referred to as a good death from the Greek meaning, and assisted suicide suggest a difference in the degree to which the doctor is involved. Physician assisted suicide (PAS) includes making lethal means available to the patient to be used at the time of the patient’s choosing, whereas euthanasia includes the physician taking the active role to carry out the patients request by delivering the lethal substance to the patient directly.[6]Both are considered the most controversial end of life decisions, causing much cultural debate on the fundamental issues of humanism.  PAS and euthanasia are legalized in four Western countries: the Netherlands, Belgium, Luxemburg, and Switzerland; one South American country: Columbia; and in two North American countries: Canada and the United States, in Oregon, Washington, Montana, and Vermont.  With the increase in population, the cases for chronic disease increases, as well, causing an increase in the number of PAS and euthanasia cases each year and an increase in the number of countries that legalize PAS and euthanasia.  Many countries, including Brazil and the United Kingdom, have not yet legalized PAS and euthanasia but the debate is timely to due this increase in chronic disease with the increase of population as a whole.[7] Not only do countries not want to legalize euthanasia and PAS because of the increase of chronic disease, but also because of religious beliefs within cultures.  Cross-culturally, PAS and euthanasia are both viewed as the same type of murder despite the many differences that they have.[8]

 

In this video, a Swiss lesbian theorist Michèle Causse who was suffering from a non-lethal bone disease chose to have assisted suicide. A medicine is given to her in liquid form and she drinks it. This is legal in Switzerland and two people are there with her and she is able to talk and eat as she is waiting for the medicine to activate. https://www.youtube.com/watch?v=l-_uEmdmSsY

 

Even though Euthanasia is banned in Denmark, it is still a contested topic. This film not only presents various ethical perspectives towards euthanasia, but gives the religious, philosophical and scientific evidence for individuals to have those viewpoints.

Both in the Eastern world and the Western world, religious beliefs, such as Islam, Judaism, and Catholicism, figure heavily into the acceptance of physician assisted suicide leading many people to believe that “only God should decide the time of death.”[9]Studies have shown that Muslims are most strongly opposed to euthanasia and PAS, followed by Catholics, Protestants, and those that have no religious affiliation, proving religion as a strong predictor of opposition to euthanasia and assisted suicide. Along with patient beliefs, the religious beliefs of healthcare workers also contribute significantly to their attitudes regarding PAS and euthanasia.  While ending the life of one suffering from a terminal illness, it is likely that this is becoming increasingly culturally sanctioned, with both physicians and patients struggle with cultural taboos on physician assisted suicide, euthanasia, and whether it is considered murder. In the United States, the general public seems to prefer that physicians perform the act, whereas physicians prefer the patient to do it, meaning that those that are involved with PAS and euthanasia are very reluctant to get involved and are sure that they are terminally ill and certain of this decision. [10]The result of heavy religious views in culture leads to the disappearance of distinct differences between the Western and Eastern parts of the world.[11]

An image taken by author and pastor, Paul Holt, who believes that all people should have the right to assisted suicide and to be able to determine when they would like to die. [12]
Intersect Project shows a video dealing with how Christians should think about the issue of assisted suicide and euthanasia in an interview with Erik Clary. [13]

The topics of euthanasia and assisted suicide are ones that are wrapped with much ethical discussion and debate. Advocates of euthanasia believe that the right to die is personal choice and that one whom is suffering should not have to be kept alive against the individual’s will. [14]On the other hand, euthanasia and PAS can be perceived to abuse autonomy and human rights. Kant and Mill [15]renowned philosophers, believe that the principle of autonomy prohibits the intentional ending of the conditions needed for autonomy—this includes ending one’s life. Additionally, it has been argued that euthanasia is seldom autonomous and sincerely a personal choice because terminally ill patients may not have the ability to express their rational mind.[16]

Individual’s against suicide may view suicide as an easy-way out for doctors because it could render the doctor as carefree and as one that does not want to address the patient’s’ problems. In terms of legalization, society often sees doctors as “healers” so when initiating suicide comes into play, there is controversy.  However, the caveat to this belief would be that a physician should heal until death is imminent then shift to healing to relieving suffering—in accordance to the patient’s wishes. Many view PAS and euthanasia as beneficent: ending one’s life is better than suffering unbearably.[17] Those against specifically active euthanasia and physician assisted suicide also may believe that it undermines the doctor-patient relationship by destroying trust built between the two. The doctor’s role in administering euthanasia “would compromise the objectives of the medical profession” 16—and thus diminish trust and confidence between the doctor and patient.

http://www.jamesrachels.org/ : James Rachels, a philosopher, who published one of the most salient articles on the euthanasia debate in the New England Journal of Medicine.

Based on a utilitarian argument by James Rachel, there is no difference between killing and letting die: this fundamentally makes active and passive euthanasia morally equivalent. Rachel also argues that active euthanasia is more humane than passive euthanasia due to active euthanasia’s “quick and painless” lethal injection. On the contrary, passive euthanasia can result in a “relatively slow and painful death.”[18]

Euthanasia and physician-assisted suicide are both very controversial topics that cause a lot of debate in many countries throughout the world. In societies around the world today, these topics have seemed to overlap and have become to greatly correlate with one other. It is within these certain societies that specific choices are made, in terms of these measures, either enabling certain patients to access to them or denying their access. These decisions are made based upon ethical, cultural, religious, or even scientific viewpoints of the leaders in these countries.

 

Prinal Patel, Breah Walker, Lindsey Farr

 

 

Endnotes:

[1] Varelius, Jukka. “Active and Passive Physician-Assisted Dying and the Terminal Disease Requirement”. Bioethics, 30(9), 2016. pp 663-671. Accessed April 1, 2019. https://onlinelibrary.wiley.com/doi/abs/10.1111/bioe.12282

[2] Boisvert, Marcel. “Physician-Assisted Suicide and Euthanasia”. The Permanente Journal, 16(2),(2012). pp 75-76. Accessed April 1, 2019. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3383171/

[3]  Marcoux, Isabelle, Brian L. Mishara, and Claire Durand. 2007. “Confusion between Euthanasia and Other End-of-Life Decisions: Influences on Public Opinion Poll Results.” Canadian Journal of Public Health 98 (3), 2007. pp 235-239. https://www.ncbi.nlm.nih.gov/pubmed/17626391

[4] Weikart, Richard. “Does Science Sanction Euthanasia or Physician- Assisted Suicide?”. Human Life Review. 2016. Accessed April 1, 2019. https://search.proquest.com/docview/1797892576?pq-origsite=summon

[5] Steinbock, Bonnie. “Physician-Assisted Death and Severe, Treatment-Resistant Depression”. Hastings Center Report, 47(5), 2017. pp 30-42. Accessed April 1, 2019. https://doi.org/10.1002/hast.768

[6] Math, Suresh Bada, and Santosh K. Chaturvedi. “Euthanasia: Right to Life vs Right to Die.” The Indian Journal of Medical Research. December 2012. Accessed March 31, 2019. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3612319/

[7] Castro, Mariana Parreiras Reis, Antunes, Guilherme Cafure, et al. June 13,2016. Accessed March 31, 2019. http://www.scielo.br/scielo.php?pid=S1983-80422016000200355&script=sci_arttext&tlng=en.

[8] Chowdhury, Rezawana. Summer 1012. Accessed March 31, 2019. https://stars.library.ucf.edu/cgi/viewcontent.cgi?referer=https://www.google.com/&httpsredir=1&article=2323&context=honorstheses1990-2015

[9] Pierre, Joseph M. “Culturally Sanctioned Suicide: Euthanasia, Seppuku, and Terrorist Martyrdom.” World Journal of Psychiatry. March 22, 2015. Accessed March 31, 2019. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4369548/.

[10] Pierre, Joseph M. World Journal of Psychiatry. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4369548/.

[11] Nortje, Nico. “Cultural Perspective on Euthanasia.” Research in Psychology and Behavioral Sciences. January 23, 2013. Accessed March 31, 2019. http://pubs.sciepub.com/rpbs/1/5/3/index.html.

[12] Holt, Paul. “The Culture of Death Expands to Suicide.” Paul Holt Ministries. February 16th. Accessed March 24, 2019. http://www.paulholtministries.com/2015/02/26/the-culture-of-death-expands-to-assisted-suicide/

[13] Clary, Erik. “Physician Assisted Suicide: What Christians Need to Know.” Southeastern Baptist Theology Seminary. December 1, 2016. Accessed March 24, 2019.

[14] Irwin, Michael. “Euthanasia: The Right to Die Should Be a Matter of Personal Choice.” August 19, 2013. https://www.mirror.co.uk/news/uk-news/euthanasia-right-die-should-matter-2182127.

[15] Gwyther, Elizabeth, and Debbie Norval. “Ethical Decisions in End-of-Life Care.” CME 21, no. 5 (May 2003): 267-72. https://webcache.googleusercontent.com/search?q=cache:ZfJ6pw9rGnEJ:https://www.ajol.info/index.php/cme/article/download/43894/27413+&cd=1&hl=en&ct=clnk&gl=us&client=firefox-b-1-d

[16] Goldman, Lee, and Andrew Schafer. “Bioethics in the Practice of Medicine.” In Goldman’s Cecil Medicine, 4-9. 23rd ed. USA.

[17] Patterson, Rachael, and Katrina George. “Euthanasia and Assisted Suicide: A Liberal Approach versus the Traditional Moral View.” J Law Med 12, no. 4 (May 2005): 494-510. https://www.ncbi.nlm.nih.gov/pubmed/15957592

[18] Rachels, James. “Active and Passive Euthanasia.” New England Journal of Medicine 292, no. 2 (January 9, 1975): 78-80. https://webcache.googleusercontent.com/search?q=cache:XhNhdeBEDf4J:https://sites.ualberta.ca/~bleier/Rachels_Euthanasia.pdf+&cd=11&hl=en&ct=clnk&gl=us&client=firefox-b-1-d

The Role of the Doctor in Physician-Assisted Suicide

A diagram illustrating the countries where physician-assisted suicide is legal. https://euthanasia.procon.org/view.resource.php?resourceID=000136

Physician-assisted suicide, whereby a physician assists a patient in the ending of one’s life, has long been an ethical debate both in the United States and around the world. The idea of a physician assisting a patient in the termination of one’s life concerns not only the ethics of the practice, but has scientific and cultural ramifications as well. Physician-assisted suicide is currently legal in seven countries and in seven states within the United States, with other countries and states currently debating legalizing it. [1] In 2006, the United States Supreme Court ruled that physician-assisted suicide cases should be left up to the individual states. [2] Oregon was the pioneer in this arena with the “Death with Dignity” act, and many states are now considering similar measures.  This controversial issue will remain a hotly contested topic with people having passionate opinions about it on both sides of the debate.

A map of the United States illustrating the states where physician-assisted suicide is legal and illegal. To this date, only 7 states have legalized physician-assisted suicide. https://euthanasia.procon.org/view.resource.php?resourceID=000132

Physician-assisted suicide, once considered taboo, is now making its way into mainstream society. Fairly recently, states such as Oregon, have made physician-assisted suicide legal, and many other states are now voting on legalizing the practice as well. These discussions bring into focus the debate of whether it is ethical for a physician to knowingly and intentionally provide a person with either the knowledge, the means, or both, that will enable one to successfully commit suicide when faced with a terminal disease. Over twenty years ago, Dr. Jack Kevorkian, also known as Dr. Death, rose to prominence as an outspoken proponent of physician-assisted suicide; claiming to have helped more than 130 terminally ill patients end their life. He was arrested, convicted and ultimately served eight years in prison for assisting patients in ending their life. He continually defended his ideas stating that “dying is not a crime” and presented a platform for his beliefs and ideals. [3]

Dr. Kevorkian explaining his “suicide machine” and the right to die movement.

Decades after Dr. Kevorkian first came to prominence, the debate continues to rage on, with arguments both for and against the idea that a physician can assist a patient in terminating his/her life. A key element of the debate focuses on the ethics of this practice, stating that a physician is compelled to do no harm, and helping a patient to terminate his/her life is the very definition of harm. The “do no harm” argument stems from the Hippocratic Oath; and although the words “do no harm” never actually appear in the Oath, the concept exists throughout the oath that is taken by almost all physicians.  However, what does this concept mean in relation to today’s advancements within medicine? The Oath was written in the 5th century B.C. [4] Both medicine and ethics have changed considerably over these past centuries, yet the idea of a physician doing no harm remains integral in the practice of medicine. What does “do no harm” actually mean in an ethical sense? If a terminally ill patient is in pain with no chance of survival, is it ethical to let him/her suffer if he/she wants to end his/her life? This is the essence of the ethical dilemma that exists, and the one that states are currently debating.

The Hippocratic Oath that doctors recite at their White Coat Ceremony. https://www.alamy.com/stock-photo-hippocratic-oath-1938-135089098.html

The Hippocratic Oath is often used as leverage in the argument opposing physician-assisted suicide. The Hippocratic Oath specifically states, “I will not give a lethal drug to anyone if I am asked nor will I advise such a plan.” [5] This statement is unambiguous in its message and is a powerful argument for those against a physician assisting a dying patient in committing suicide. Taking this oath in its literal text would seem to prove the point that it is unethical for a physician to provide a patient with either the knowledge or lethal prescriptions, that would allow that patient to terminate his/her own life. Yet, the Oath also states that there is an “art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife.” [6] If warmth and sympathy are to be given to a dying patient who requests that he/she be allowed to die, how is a physician denying this request deemed to be ethical?

In addition to the Hippocratic Oath, a second central ethical issue raised regarding physician-assisted suicide revolves around the medical ethics adhered to by doctors. Medical ethics are what establish the duties of a physician to his/her patient, perhaps even more than the law. There are a few principles that a physician must follow including beneficence, acting in the patient’s best interest; nonmaleficence, avoiding or minimizing harm; autonomy, a patient has the right to control what happens to his/her body; and justice, the need to try and be as fair as possible. [7] It is crucial to examine these ethical principles in order to determine whether it is ethical or not for a doctor to aid in physician-assisted suicide.

Autonomy is the right for a person to make his/her own decisions. Regarding autonomy, medical ethics support a patient’s right to refuse treatment, even if it is lifesaving treatment. [8] Some may argue that a physician aiding his/her patient in assisted suicide is an act of compassion as he/she is respecting the choice that his/her patient has made. However, others argue that respect for autonomy is not the only ethical principle that should be followed; and it must be balanced with beneficence and nonmaleficence. [9] Although both proponents and opponents of physician-assisted suicide agree that a patient’s autonomy is important and needs to be respected, it is also important to note that it is not absolute. Those in favor of a physician being able to assist in suicide claim that it is an act of compassion and respect a patient’s choice and therefore fulfills the obligation of non-abandonment. Those in favor further their argument stating that physicians are indeed assisting in patients’ suicide even when it is not legal, and the legalization of this act would result in standardization, monitoring and more transparency. [10] Contrary, those against also use medical ethical principles to further their argument claiming that it would require physicians to breach specific prohibitions such as nonmaleficence and beneficence. Breaking these prohibitions is not what the role of a physician, or healer is. Much like most controversial subjects, both proponents and opponents of physician-assisted suicide, can and do cite ethics as the reason for their beliefs in what is the ethical choice.

The ethical perspective of physician-assisted suicide certainly presents an intriguing angle on such a contentious topic. However, the ethical perspective does not consider the principles certain societies hold. Analyzing physician-assisted from a cultural perspective permits a true understanding of the way a society’s unique culture dictates formal legislation regarding the legality of physician-assisted suicide. Japan and Belgium provide useful cultural insight because their stances are on opposite ends of the debate spectrum. Japan is particularly interesting because they lack a firm stance on physician-assisted suicide and euthanasia. Legislature in Japan is largely based on a cultural concept called ikigai. This roughly translates to a “life worth living”. To put this idea more plainly, writers have described ikigai as “joy and a sense of well-being from being alive” and of realizing the value of being alive”. One cohort study conducted in Japan found that lack of ikigai contributed to increased risk of all-cause mortality [11]. These are the principles that guide medical professionals and legislators in Japan when it comes to physician-assisted suicide. However, they have been unable to formalize anything because of the considerable distrust surrounding medical professionals in Japan. Interview accounts have found that many people in Japan carry the sentiment of doctors being untrustworthy. The phrase “I wa kin Jitsu Nari” is used because it describes medicine as a money-making scheme[12]. This cultural distrust surrounding physicians has prevented people from accepting physician-assisted death as a reasonable course of action [13]. Other countries have made changes concerning the legality of physician-assisted suicide, but Japan has yet to present a concrete point of view.

Graph highlighting an increase in Euthanasia cases since 2003. https://d3i6fh83elv35t.cloudfront.net/newshour/app/uploads/2015/01/euthanasiabelgium.jpg

Japan’s conservative culture contrasts Belgium where principles of physician-assisted are exceedingly liberal. The  Belgian Act on Euthanasia of May 28, 2002, legalized euthanasia and physician-assisted suicide for competent adults. A more recent in 2014 act even opened physician-assisted suicide to those under 18 if they suffered from “constant and unbearable physical or mental suffering that cannot be alleviated” [14]. Such liberal laws reflect a culture that accepts physician-assisted death as a viable path for people to take. Despite these laws, there is not necessarily complete agreement in support of physician-assisted death. A recent documentary from PBS provided an account of several cases where physician-assisted death was utilized in Belgium. The first instance involves a young woman who suffers from chronic depression and took advantage of the assisted death laws. Doctors highlight the simplicity of the act of requesting euthanasia. The only necessary step is to provide “their name, the date, and why they want euthanasia”[15]. Belgium was the first nation to give children access to physician-assisted suicide. This liberal culture does not come without controversy. Belgium provides people considerable autonomy. This eliminates any chance for fellow family members or friends to have a say in the decision. The documentary describes a situation where an older woman has chosen physician-assisted suicide. However, her son does not believe she is in the right state of mind to make such a decision. Clearly, this is where a liberal culture may backfire. Another study conducted found that restrictive policies on physician-assisted death is not in the best interest of the patient. In Belgium, where there is very little restriction on physician-assisted death, doctors openly discuss the drugs used and the process with the patient [16]. This open communication about assisted death allows for a smoother process that retains patient autonomy.

 Japan and Belgium were specifically described because they represent two countries that stand at opposite ends of the assisted suicide debate. The Japanese are skeptical about the medical profession and this distrust seeps into physician-assisted death laws. Meanwhile, in Belgium, doctors have comfortable conversations with their patients who can completely determine when they wish to participate in physician-assisted death. Evidently, unique culture amongst regions and people motivate how policy is enacted and how people perceive sensitive topics such as death.

In order for physician-assisted suicide to be considered as an option, a patient must fulfill certain requirements. [17] They must be in the right state of mind, the request must be voluntary and in no way can they be coerced into making the decision, and the life expectancy needs to be six months or less.  The condition must also be determined to be terminal by at least two physicians. After all of the requirements have been met, the patient is able to receive medication to help them end their life.  

There are specific medications that are used in order for this procedure to occur.  [18] In a study conducted in the Netherlands, where physician-assisted suicide is legal, they looked at what kinds of drugs are used in the life-ending procedure.  In the majority of cases where euthanasia was intended, a barbituate to induce a coma was given first, and then a neuromuscular relaxant was given. In most of the cases of euthanasia in the Netherlands, a physician was the one who administered the drugs.  A physician was also continuously present for the majority of cases in the study.

Many scientific questions arise when it comes to physician-assisted suicide. [19] One of the first questions that comes up is how is assisted-suicide compatible with medical practice?  All medical doctors take the Hippocratic Oath and are required to do no harm to others. By helping hasten death, wouldn’t they be going against this Oath?  In the states that have legalized physician aid in death, there are accommodations that allow physicians to opt out of this practice if they do not want to do it.  Another question that arises is does this practice devalue human life? When looking at data collected from the annual reports of the Oregon Death with Dignity Act, it shows that patients are primarily motivated by dying with dignity and retaining their self-respect.  These answers shift from social decisions to that of the individual.

There have also been many studies that were conducted to see how “vulnerable” groups would be affected by physician aid in dying.  [20] One of the studies focused on different socio-economic groups, which consisted of women, elderly, poor, and different races.  Some people feared that physician-assisted suicide would target these vulnerable groups. The study concluded that there was no evidence that the law would be abused.  

The last scientific question to be brought up is the effects physician-assisted suicide has on family members of the patient who is seeking life-ending medication.  [21] Although assisted suicide has been legal for a while in Oregon, there is little known about the effects on the family members.  In the survey that was conducted, families’ mental health was looked at after the death of the family member. Families of patients who died of lethal injection and families of patients who died from cancer were both surveyed.  When comparing the family members of those who did and did not request aid in dying, there was no difference in primary mental health. The study showed that when a person requested aid in dying, the family felt more prepared to accept the death of their loved one.  The study concluded that there are not negative effects on family members, but that the opposite might occur. They have greater acceptance of death.

Physician assisted suicide has been an ongoing debate for decades. This contentious debate has ethical, cultural and scientific ramifications concerning whether a physician should be allowed to aid a terminal patient in the ending of his/her life. Many states are contemplating whether they should legalize physician assisted suicide, but due to the controversial nature of the subject, there will continue to be strong opinions both for and against the idea. After the Death with Dignity Act was legalized in Oregon, other states have been able to follow and adopt the model that was successfully implemented there. This has resulted in an increase in the number of states that are now considering the legalization of physician assisted suicide, such as Washington, California, Colorado, Montana, and others. As medical technology advances, the medical community is going to have to address these difficult topics. The question cannot just be how our society prolongs a life, but also how our society deals with the inevitable end of a life, and honors the wishes of the patient.

Pod 2: Katie Somosky, Karan Ravi, Sydney Beck

Footnotes

[1] “Euthanasia and Physician Assisted Suicide around the World,” chart, accessed April 1, 2019, https://euthanasia.procon.org/view.resource.php?resourceID=000136.

[2] Kate Pickert, “Assisted Suicide,” Time, last modified March 3, 2009, accessed April 3, 2019, http://content.time.com/time/nation/article/0,8599,1882684,00.html

[3] Monica Davey, “Kevorkian Speaks After His Release from Prison,” The New York Times, accessed April 1, 2019, https://www.nytimes.com/2007/06/04/us/04kevorkian.html.

[4] “Modern Hippocratic Oath Holds the Underlying Values of Medicine in a Digital World,” last modified July 13, 2018, accessed April 1, 2019, https://medschool.ucla.edu/body.cfm?id=1158&action=detail&ref=1056.

[5] Amal Ababneh, “Physician Assisted Suicide for Terminally Ill Patients: An Argumentative Essay,” Journal of Palliative Care & Medicine, [1], https://www.researchgate.net/profile/Amal_Ababneh/publication/327266188_Physician_Assisted_Suicide_for_Terminally_Ill_Patients_An_Argumentative_Essay/links/5c51df8ea6fdccd6b5d4ef9f/Physician-Assisted-Suicide-for-Terminally-Ill-Patients-An-Argumentative-Essay.pdf.

[6] Peter Tyson, “The Hippocratic Oath Today,” PBS, last modified March 27, 2001, accessed April 1, 2019, https://www.pbs.org/wgbh/nova/article/hippocratic-oath-today/.

[7] Ababneh, “Physician Assisted,” [2].

[8] Lois Snyder Sulmasy and Paul S. Mueller, “Ethics and the Legalization of Physician-Assisted Suicide,” Annals of Internal Medicine, October 17, 2017, https://annals.org/aim/fullarticle/2654458/ethics-legalization-physician-assisted-suicide-american-college-physicians-position-paper.

[9] Lois Snyder Sulmasy, “Ethics and the Legalization of Physician-Assisted Suicide,” Annals of Internal Medicine, June 5, 2018.

[10] Sulmasy and Mueller, “Ethics and the Legalization,”

[11] Sone, Toshimasa, Naoki Nakaya, Kaori Ohmori, Taichi Shimazu, Mizuka Higashiguchi, Masako Kakizaki, Nobutaka Kikuchi, Shinichi Kuriyama, and Ichiro Tsuji. 2008. “Sense of Life Worth Living (Ikigai) and Mortality in Japan: Ohsaki Study.” Psychosomatic Medicine70 (6): 709–15. https://doi.org/10.1097/psy.0b013e31817e7e64.

[12] Lock, Margaret. 1995. “Contesting the Natural in Japan: Moral Dilemmas and Technologies  of Dying.” Culture, Medicine, and Psychiatry19 (1): 1–38. https://doi.org/10.1007/bf01388247.

[13]  Kai, Katsunori. 2010. “Chapitre 10. Euthanasia and Death with Dignity in Japanese Law.” Journal International De Bioéthique21 (4): 135. https://doi.org/10.3917/jib.214.0135.

[14] Watson, R. 2014. “Belgium Extends Euthanasia Law to Children.” Bmj348 (feb18 6). https://doi.org/10.1136/bmj.g1633.

[15].  NewsHour, PBS. 2015. “The Right to Die in Belgium: An Inside Look at the World’s Most Liberal Euthanasia Law.” YouTube. YouTube. January 15, 2015. https://www.youtube.com/watch?v=eo8Hn0DEcpw.

[16] Inghelbrecht, E., J. Bilsen, F. Mortier, and L. Deliens. 2009. “Nurses’ Attitudes towards End-of-Life     Decisions in Medical Practice: a Nationwide Study in Flanders, Belgium.” Palliative Medicine23 [1](7): 649–58. https://doi.org/10.1177/0269216309106810.

[17] Rurup, Mette. “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. February 05, 2005. Accessed April 05, 2019 https://www.sciencedirect.com/science/article/pii/S0168851005000072.

[18] Groenewoud, Johanna. “Clinical Problems with the Performance of Euthanasia and Physician-assisted Suicide in the Netherlands.” ProQuest. February 24, 2000. Accessed April 05, 2019. https://search.proquest.com/docview/223932584/fulltextPDF/5D87F33976BE40A6PQ/1?accountid=14244.

[19] Gostin, Lawrence. “Physician-Assisted Dying A Turning Point?” UNC Chapel Hill Libraries. January 19, 2016. Accessed April 05, 2019. https://jamanetwork-com.libproxy.lib.unc.edu/journals/jama/fullarticle/2482336.

[20] Preston, Robert. “Physician-assisted Suicide-a Clean Bill of Health?” OUP  Academic. July 13, 2017. Accessed April 05, 2019. https://academic.oup.com/bmb/article/123/1/69/3958775.

[21]Ganzini, Linda. “Mental Health Outcomes of Family Members of Oregonians Who Request Physician Aid in Dying.” Journal of Pain and Symptom Management. September 24, 2009. Accessed April 05, 2019. https://www.sciencedirect.com/science/article/pii/S0885392409007076.

Modern Stigma Towards Euthanasia

The terms ‘lethal injection,’ ‘physician-assisted suicide,’ ‘mercy killing,’ ‘death with dignity,’ and more are all turns of phrase commonly interchanged. But, do they really mean the same thing? How do people today view this kind of death? Is it moral? It is these kinds of questions that commonly circulate around the conversation of assisted death.

Euthanasia and Physician-Assisted Suicide (PAS) are two terms that are most frequently and incorrectly exchanged. Both fall under the larger umbrella of assisted death. Euthanasia, however, is specifically defined as a “deliberate intervention undertaken with the express intention of ending a life in order to relieve intractable suffering” [1]. Within that, there are two different types of euthanasia: active and passive. In active euthanasia, one directly and intentionally causes the death of the patient. Passive euthanasia, on the other hand, causes death of a patient through the withholding or removal of life support. Assisted suicide, or PAS, is known as when a physician provides assistance and the means of death to people that are looking to hasten their passing. There is often a blurred line between these assisted death cases.

Jack Kevorkian posing with his homemade “suicide machine”

Jack Kevorkian, for example, was a physician who facilitated the suicide of several people under his care. If a terminally ill patient requested his help, he attached a “homemade suicide machine” that injected a lethal dose of drugs when activated. Since he technically did not directly cause the death, he evaded criminal conviction until he finally did personally administer the drug to a patient without any arms or legs. Due to illegality, Kevorkian was convicted of second degree murder by voluntary active euthanasia [2]. There is a third type of assisted death―palliative sedation―which is when, with consent, a patient is sedated to the point of unconsciousness/death to prevent further pain and suffering. Most of the modern controversy lies around PAS and euthanasia, with PAS being much more widely accepted. In contrast, euthanasia is strongly debated by many people in the modern medical and public world alike.

Regarding the medical field today, euthanasia is largely controversial. There lies a difference between moralities and doctoral obligation for physicians requested to do the task. In one study, 256 physicians in Rhode Island were asked questions regarding their thoughts on euthanasia; all were asked to simulate a scenario in which a patient with respiratory problems was reaching respiratory failure. From the study, 86% agree to give the patient narcotics that would ease his/her suffering and possibly cause respiratory compromise, 59% agreed that they would turn the respirator off if the patient was wholly dependent with no hope of coming off, 9% agreed to give the patient a lethal prescription amount to end his/her life, and 1% agreed to administer lethal injection. This provides interesting results―neither PAS nor euthanasia are entirely popular among such physicians surveyed, but very few agreed to physically carry out the task. However, 28% of respondents agreed that they would comply with more requests if lethal administration was legal[3].

For hundreds of years, the topic of euthanasia has been under debate in the scientific community. A main argument that has prevailed among those against it is the fact that euthanasia disobeys one of the main oaths one takes when one becomes a doctor.  The Hippocratic Oath, originally from the time of Hippocrates from 460-377 B.C., is credited with the clause “do no harm.” This standard was typically recited at the end of a medical student’s graduation [4]. It has since been modernized but is currently known to be:

“Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty.” [5]

This oath, in short, declares that a physician will not take the life of his/her patient. It is for this role as a professional that many healthcare providers today are against or hesitant to readily carry out the action of euthanasia.

Among the medical community, autonomy is a term that is undisputedly vital in the actions of a physicians. Patient autonomy is the idea that doctors have an obligation to “provide competent patients with the opportunity to make an informed decision about their medical treatment”―in short, informed consent [3]. Determining the autonomy of end-of-life decisions is commonly ambiguous in the medical field, but to the majority, the patient’s wishes regarding life and death issues should usually be followed. This is either with or without the physician’s support behind the decision. Those who would not comply simply justify their withholding to their moral beliefs/obligations. It is interesting to observe that when the death of the patient is indirect, many more are likely to respect patient autonomy than if the death was directly caused (lethal pain medication dosage & lethal injection). This puts controversy in the belief that the physicians’ first priority is the wishes of those being treated.


The ethics of autonomy and other viewpoints on euthanasia play a significant role in how it is viewed by the modern community. The word ‘euthanasia’ itself can have differing definitions, and it may seem unclear to the general public what it actually is. The word ‘euthanasia’ is “derived from the Greek eu and thanatos, which translates as ‘good death’ or ‘dying well,’” which gives the connotation of positivity [6]. Descriptions of euthanasia contrast the positive roots of the word due to the darkness in ending a life. A portion of the negative modern stigma towards euthanasia is derived from the possibility that it may be forcing death upon an unwilling participant, either against their will, not knowing their will, or with a lack of consent from the patient. Death and dying generally creates grief in the American society, causing a lack of support for the act.

When creating legislation for euthanasia, the ethical principle of autonomy is paramount. Autonomy is the notion that the people should be able to make the choices for their own lives as much as possible. In the United States, there is a lack of uniform law for euthanasia, unlike countries such as the Netherlands and Belgium. This lack in decision leads to deep debates about what should be done. After all, the morals of a physician can align with aiding “in any way possible to prolong life and to heal, not to take life away,” where “many physicians refuse to practice euthanasia and it is often difficult to find someone who will do it” [7]. With that said, the United States does not authorize euthanasia based on the previously mentioned standards for physicians. Instead, there is an option of PAS that can be taken advantage of in a few states―California, Colorado, Hawaii, Montana, Oregon, Vermont, and Washington―but this statute only allows for the prescription of life ending medication to be written, not to be administered by the physician themselves [8]. This is where the definition of euthanasia can be murky, as the United States may not technically have a policy for euthanasia in place, but physicians in some states can still assist in aid-in-dying. The unclear policy is unfair to the public because it can be seen as deceiving, triggering concern for people who can no longer make autonomous decisions and the possibility that they may be taken advantage of. To minimize issues with the process of aid in dying, the general protocol in the few states that allow it is the need for two oral requests and a written request, with several waiting periods in between [8]. These procedures are put into place to ensure that physicians obtain the full consent of the patient and to ensure the patient is of sound mind in order to minimize any ethical challenges associated with aid-in-dying.

States in the US with legalized physician-assisted suicide

While there is a portion of the American public that supports aid-in-dying, there is also a proportion of opposition that believes that any shortening of life is immoral because there are other ways to alleviate pain, such as palliative care and hospice services. The extreme opposition also note that euthanasia and aid-in-dying can open the door to abuse of the law, comparing it to the Nazi extermination and slow starvation of physically warped, mentally defective, incurably sick, and unproductive people [9]. There is a fear that “physicians will no longer try their best to give comfort and care to the patients near the end of life,” and that it is only a method of ridding the world of ‘inadequate people’ [10].

However, patients do “have the autonomous right to make decisions concerning the ends of their lives” and their “physicians have an obligation to act in the patient’s best interest as determined by the patient in concert with the advice of the physician” [10]. It is expected that the checks and balances system within the medical field will play an important role in the advancement of euthanasia and aid-in-dying laws in the United States, so it does not become corrupt. It is important to note that the patient may also factor in their financial situation to the decision of requesting aid-in-dying. Living on medication and/or constant use of a machine is expensive and can wipe a family clean of any savings or assets. Not allowing a terminally ill patient the right to make the decision of death is taking away their ability to possibly save their family from the distress of being able to afford the patient’s end of life care. Some argue that it should not be “the role of the doctor to prolong life to the very last second, but to seek to restore a patient’s state of health, and if that is not possible, then to alleviate suffering,” which includes the intensified suffering caused by financial hardship [7].

The ethical dilemma of ‘when is it acceptable to perform euthanasia?’ arises during the debate of the policy. Who should be allowed to take advantage of the law: only those with a terminal illness, or those with mental or emotional pain caused by a mood disorder, too? Considering all aspects of the advancement in policy will allow for a more content public opinion. Giving a precise definition to the medical procedures of euthanasia and aid-in-dying is also key to educating the public on what the legislation is actually for. Euthanasia sparks great debate because of its clash with our ethical standards in the United States, specifically the right of autonomy. People feel that they should have the choice in their death, particularly in extreme cases of a terminal diagnosis.


Allowing for a standard of choice in death varies from culture to culture. In many European countries, the past decade has had an “increasing debate about the acceptability and regulation of euthanasia and other end-of-life decisions in medical practice” [11]. People in Europe are wishing to die a ‘good death’ which is “now being connected to choice and control over the time, manner, and place of death” [12]. This is connected with the option of euthanasia, which is becoming a popular new concept in several countries; the legalization of euthanasia in the Netherlands, Belgium, and Luxembourg has sparked an intense debate across Europe.  

Euthanasia is the practice of intentionally ending a life to relieve pain and suffering of a person. Physician-administered euthanasia “describes a situation where a doctor administers a lethal dosage of drugs to a patient, at the patient’s request, in order to bring about his or her death” [13]. In many countries, this practice is considered illegal; however, “the Netherlands is one of the few places in the world where euthanasia and physician-assisted suicide are legal under specific circumstances” [14].

           The Netherlands and Belgium passed a law in 2001 that created an exception to the Criminal Code. Under the Code, it is illegal to end another person’s life or assist in their suicide. However, the 2001 Act created an exception where the Code would not apply “if a physician had terminated the life, or assisted the suicide, of a patient on request and if certain ‘due care’ criteria had been observed” [13]. This was the legalization of active voluntary euthanasia. Article 2 of this act states that the patient’s request is ‘voluntary and well-considered’ as well as their suffering being ‘lasting and unbearable.’  

           There is a key difference between the Netherlands and the United States regarding euthanasia. The Dutch 2001 law allows physician-administered euthanasia as well as physician assisted suicide, while only a few states in the United States allow it. Euthanasia is considered illegal, so the patient must consume the life-ending medication prescribed by the physician solely by themselves and without the help of others.  Although euthanasia is legal in the Netherlands it has posed some concern about the overuse of the life-ending treatment. There have been three times as many deaths from physician-administered euthanasia and PAS. There was a total of 49,287 deaths from euthanasia or assisted suicide within the 15-year period from 2002 to 2016 [13]. Within this data, there is a large predominance of physician administered euthanasia (96%) being used over physician assisted suicide.

           Canada has also legalized patient administered euthanasia, and the overwhelming majority of deaths were also by physician administered euthanasia.  Canada legalized the use of euthanasia because citizens claimed that not allowing them to make choices regarding their own body was taking away their right of liberty; “the court ruled that the right to liberty requires that the person is free to make decisions regarding his own body and medical treatment-it’s an aspect of the right to autonomy and self-determination” [15]. A possibility for the difference between the use of PAE and PAS can be “with its direct involvement of a doctor in administering injections of lethal drugs and its placing of the patient in the position of passive recipient rather than active ingestor” [16]. The legalization of physician administered suicide has had drastic effects on the increase of deaths in countries where it is legalized.  

           As mentioned previously, euthanasia is a widely debated topic.  To test and compare attitudes towards euthanasia, Joachim Cohen used data from the 1999-2000 wave of the European Values Study to collect people’s attitudes of euthanasia from 33 different European countries. This dataset gives insight to a range of social, political, cultural, and economic differences between different populations of people; the questionnaire contained more than 300 questions that tested a number of independent variables including social class, educational level, religious beliefs, country of residence, etc.  The dependent variable in the study was the acceptance of euthanasia. The total number of respondents was 41,125.

           The acceptance of euthanasia varied greatly across the different countries. For example, the Netherlands, France, Sweden, and Belgium generally accepted euthanasia, while Poland, Romania, Turkey, and Malta did not. Combining all 33 European countries together, the mean score for acceptance on a scale from 1 to 10 was just below a 5 [11]. The data also showed that men were more accepting of euthanasia than women. Furthermore, the acceptance decreased linearly with age, but increased with education level.  The acceptance also decreased as the level of religious belief was increased.

           There were also country-specific differences in euthanasia acceptance. Roman Catholics are usually less favorable towards euthanasia than other large Christian groups such as Protestants or Orthodox. The study supported previous findings that religion is a major factor related to euthanasia attitudes, as they consider euthanasia immoral.  People who do not belong to a religious group are seen to be as the most accepting towards euthanasia.

Religious beliefs by country related to acceptance of euthanasia.

           The data concluded that there is not a common European attitude towards euthanasia. There are countries who have a public opinion that accepts euthanasia, while other countries have a public opinion that do not. “Given the sometimes very country-specific character of attitudes towards euthanasia, each country will have its own debate, influenced by its cultural backgrounds” [11].

The myriad perspectives one could take on the principle of euthanasia causes much of the confusion that surrounds it. There are scientific, ethical, and cultural stances to take; the medical directive, morality, and societal differences all play a role in the modern stigma around this concept of death. The notion of ‘do no harm’ is constantly questioned when direct physician involvement comes into play. The majority of physicians themselves seem to be against the fact of taking another’s life, even if it does provide relief and reflect their patient’s wishes. Being clear about the definition of euthanasia, and other forms of physician assisted suicide, and having a uniform protocol to follow is essential in the success of the legislation that coincides with ethical standards. Working with the patient and respecting the patient’s right to autonomy is also crucial in a successful practice. Although there are many different cultural differences regarding the acceptance of euthanasia, personal factors, such as: education level, age, and religion play a factor in supporting or disagreeing with the concept of euthanasia. Currently, in a vast majority of societies, euthanasia is not an acceptable practice. However, as the world continues to progress in technology and overall education, the legislation is subject to change.

 

Catie Drawdy, Katie Hawkes, and Avery Twyman

 

Works Cited

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[2] Perry, Joshua E. “Right to Die.” In Culture Wars in America: An Encyclopedia of Issues, Viewpoints, and Voices, edited by Roger Chapman, and James Ciment. 2nd ed. Routledge, 2013. http://libproxy.lib.unc.edu/login?url=https://search.credoreference.com/content/entry/sharpecw/right_to_die/0?institutionId=1724

[3] Fried, TR, MD Stein, and PS O’Sullivan. 1993. “Limits of Patient Autonomy. Physician Attitudes and Practices Regarding Life-Sustaining Treatments and Euthanasia.” Archives of Internal Medicine 153 (March): 722–28. https://doi.org/10.1001/archinte.153.6.722.

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[11] Cohen, Joachim, Isabelle Marcoux, Johan  Bilson, Patrick Deboosere, Gerrit Van der Wal , and   Luc Deliens. 2006. “European Public Acceptance of Euthanasia: Socio-Demographic and Cultural Factors Associated with the Acceptance of Euthanasia in 33 European Countries.” Social Science and Medicine 63 (3): 743–56. http://vb3lk7eb4t.search.serialssolutions.com/?ctx_ver=Z39.88-2004&ctx_enc=info%3Aofi%2Fenc%3AUTF-8&rfr_id=info%3Asid%2Fsummon.serialssolutions.com&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Ajournal&rft.genre=article&rft.atitle=European+public+acceptance+of+euthanasia%3A+Socio-demographic+and+cultural+factors+associated+with+the+acceptance+of+euthanasia+in+33+European+countries&rft.jtitle=Social+Science+%26+Medicine&rft.au=Cohen%2C+Joachim&rft.au=Marcoux%2C+Isabelle&rft.au=Bilsen%2C+Johan&rft.au=Deboosere%2C+Patrick&rft.date=2006&rft.pub=Elsevier+Ltd&rft.issn=0277-9536&rft.eissn=1873-5347&rft.volume=63&rft.issue=3&rft.spage=743&rft.epage=756&rft_id=info:doi/10.1016%2Fj.socscimed.2006.01.026&rft.externalDocID=doi_10_1016_j_socscimed_2006_01_026&paramdict=en-US

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[14] Lo, Bernard. 2012. “Euthanasia in the Netherlands: What Lessons for Elsewhere?” The Lancet  380 (9845): 169–70. https://www.sciencedirect.com/science/article/pii/S0140673612611283.

[15] Grondelski , John  . 2015. “Euthanasia in Canada: An Interview with Margaret A. Somerville.” Human Life Review  41 (2): 67–75. https://search.proquest.com/docview/1698997079?pq-origsite=summon

[16] Warner, Teddy, and Laura Weiss Roberts. 2001. “Uncertainty and Opposition of Medical Students Toward Assisted Death Practices.” Journal of Pain and Symptom Management  22 (2): 657–67. https://www.sciencedirect.com/science/article/pii/S0885392401003141?via%3Dihub.

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