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Physician-Assisted Suicide: Considering the Evidence, Existential Distress, and an Emerging Role for Psychiatry

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Physician-assisted suicide (PAS) is one of the most provocative topics facing society today. Given the great responsibility conferred on physicians by recent laws allowing PAS, a careful examination of this subject is warranted by psychiatrists and other specialists who may be consulted during a patient's request for PAS. In this article, recent evidence regarding the implementation of PAS in the United States and The Netherlands is reviewed. Support is found for some concerns about PAS, such as the possibility that mental illness occurs at higher rates in patients requesting PAS, but not for other concerns, such as the fear that PAS will be practiced more frequently on vulnerable populations (the slippery-slope argument). These data and common arguments for and against PAS are discussed with an emphasis on the tension between values, such as maximizing patient autonomy and adhering to professional obligations, as well as the need for additional research that focuses more directly on the patient-centered perspective. Implications of the available evidence are discussed and lead to a consideration of mental anguish in terminally ill patients including aspects of existential distress and an acknowledgment of the importance of tailoring end-of-life care to the distinct set of values and experiences that shape each patient's perspective. The article concludes with a discussion of an expanding role for psychiatrists in evaluating patients who request PAS.

Religious condemnation and moral disapproval of suicide by society were associated with its criminalization in most societies before modern times. 1 However, views toward suicide changed during the 19th and 20th centuries, coincident with the emergence of psychiatry as an autonomous discipline in which practitioners could diagnose and treat anxiety, depression, and other ailments contributing to suicide. In addition, modern sociological theory describing suicide as a social ill reflecting widespread alienation and anomie facilitated a growing cultural sensitivity to the plight of the mentally ill. Scientific advancements in our understanding of mental illness thus implied that suicide was caused by social or psychological forces often beyond the control of individuals and contributed to the decriminalization of suicide. 1 , 2

Modern laws in the United States allowing physician-assisted suicide (PAS), defined as the practice of a physician providing a competent patient with a prescription for medication for the patient to use with the primary intention of ending his life, are thought to have emerged from a growing dissatisfaction with the medical profession and the development of a national right-to-die movement. 3 The right-to-die sentiment developed in parallel with skepticism of medical authority, beginning in 1967 with the creation of the first living will that allowed patients to make decisions about their end-of-life care years in advance. 4

Currently, assisted suicide is legal in the United States in only four states: Oregon, Washington, Montana, and Vermont. However, it has been a source of controversy in many other states for some time, as voter initiatives for legalizing assisted suicide were introduced and defeated in California, Michigan, and Maine over a period from the early 1990s until 2000. In recent time, legislatures in Connecticut and New Jersey have proposed bills to legalize assisted suicide. These repeated recent efforts in support of assisted suicide and the strident opposition that typically results keep the question in the American public's mind as one of vital importance.

It should be noted that the phrase physician-assisted suicide is itself not without controversy. Proponents of the practice prefer the term aid in dying to describe doctor-provided assistance to patients who want to end their lives. Although I appreciate the sentiment behind such arguments, in this article, I will use PAS to describe the practice, as it is the term predominantly used in the medical context.

As PAS implies, modern attitudes toward death and dying consider the subject of assisted suicide to fall within the purview of medical practice, despite the American Medical Association's opposition to PAS on the grounds that it is antithetical to a doctor's role as healer. 5 U.S. physicians remain sharply divided on assisted suicide, with opposition to the practice associated with increased religiosity and certain moral and ethics-based principles. 6 , – , 8 Oregon's Death With Dignity Act clearly delineates the role of physicians as the primary gatekeepers of assisted suicide in enumerating responsibilities for the attending physician such as ensuring that each patient who requests aid in dying is capable, acts voluntarily, makes an informed decision, and is dying of a terminal disease (defined as an incurable and irreversible disease that will produce death within six months). The grave responsibility conferred by Oregon's Death With Dignity Act suggests that psychiatrists and other physicians who may be consulted to opine on the integrity of a patient's request for aid in dying must think deeply about their views on the subject.

The impassioned debate over PAS spans a wide range of disciplines and reflects the incendiary nature of the question. Arguments for and against PAS touch on many basic moral beliefs and illustrate the tension among values such as autonomy, paternalism, fairness, and the value of human life. Although the controversy can be described in political, social, and medical terms, an individual's feelings on the subject can often be reduced to a simple moral conviction about whether a person can aid another in ending his life. Debates that turn on such basic beliefs tend to divide people deeply, and the resultant conversation is often characterized by rhetoric and ideology. Over time and with the further polarization of views, common ground and compromise often seem unlikely.

However, although it is often overlooked or dismissed in these cases, scientific evidence has the opportunity to inform our thinking on matters that evoke moral and ethics-related questions. While not dispositive, evidence can characterize the conditions and consequences associated with different viewpoints. Some of the most contentious aspects of the debate over assisted suicide include fears or questions that can be illuminated with actual evidence.

In this article, I will review the recent evidence that pertains to the arguments for and against PAS and suggest avenues for future research. I will then discuss implications of the available evidence and consider mental suffering in terminally ill patients as comprising aspects of existential distress (i.e., concerns related to feelings of hopelessness, futility, and meaninglessness; anxiety about death; and disruption of personal identity), as well as acknowledge the importance of tailoring end-of-life care to the distinct set of values and experiences that shape each patient's perspective. Finally, I will explore an emerging role for psychiatrists in evaluating patients who request PAS.

In this section I will review some of the recent data that address some of the open questions and fears regarding PAS. An important caveat is that most of the evidence is taken from studies conducted in Oregon and The Netherlands, and moreover, many of the studies involve the work of Linda Ganzini, a professor of psychiatry and medicine at Oregon Health and Science University. This is not to imply a particular bias on the part of the studies mentioned in this article, but rather to characterize the current state of evidence as limited by region and principal investigator.

Psychiatric Illness in Patients Who Request PAS

One basic question that frames the debate on assisted suicide is the extent to which patients who request PAS have a treatable psychiatric illness. Ganzini et al . 9 interviewed a cross section of patients who requested a physician's aid in dying under Oregon's Death with Dignity Act and found that one in four had clinical depression. In another study, physicians in Oregon who received requests from patients for aid in dying reported that 20 percent of them were depressed. 10 The results of these studies imply that a significant minority of patients who request aid in dying have depression. However, of all patients who received a prescription for a lethal drug in Oregon since 1997, just under 7 percent were referred for a psychiatric evaluation. Ganzini and colleagues also studied health care providers and family members in Oregon and found that these groups thought that depression was rarely a factor influencing requests for PAS. 9 , 11 , 12 Together, these findings raise the concern that clinicians and family members may fail to detect signs and symptoms of depression in these patients.

For purposes of comparison, a recent systematic review found that, in The Netherlands, the rate of depression in patients whose requests for euthanasia were honored was similar to that in the surrounding population of seriously ill patients, but that the presence of depression was a significant factor in refusals of requests for euthanasia, suggesting that the Dutch system may be successful in screening out many requests motivated by depression. 13 Moreover, with regard to the overall prevalence of depressive symptoms in the terminally ill population, one study of terminally ill patients with cancer found that 59 percent of those with a serious and pervasive desire to die had significant symptoms of depression, versus only 8 percent of those without such a desire. 14 This result is consistent with other research that has found an increased association between an expressed desire for a hastened death and symptoms of depression, 15 implying a higher probability that patients who request PAS have depression. These findings suggest the importance of screening such parents carefully for evidence that mental illness may be interfering with their decision-making capacity.

Impact on Vulnerable Patients: the Slippery Slope

Another concern that can be illuminated by evidence is the question of the slippery slope that leads to abuse. Many have expressed apprehension that abusive pressures would disproportionately affect vulnerable patients, such as those whose capacities for decision-making are compromised by cognitive impairment or lack of education, those who are subject to social prejudice, or those who may have been socially conditioned to think of themselves as less deserving of care. 16 Ultimately, there is concern that these pressures would result in an increased risk of death by PAS among vulnerable persons compared with the risk in other populations.

Battin et al. 16 explored this question by examining data collected in jurisdictions where assisted dying is legal, such as Oregon and The Netherlands, and by looking for evidence that the lives of people in groups identified as vulnerable were more frequently ended with assistance from a physician than those of other populations. Their findings were limited by substantial differences in methodologies in source studies and difficulties in determining with certainty the actual incidence of assisted dying in several of the vulnerable groups studied. However, they found no evidence of heightened risk of death by physician assistance in the elderly, women, uninsured people, the poor, racial and ethnic minorities, people with low educational status, minors, patients with psychiatric illness, and patients with chronic nonterminal illness.

Although conclusive proof about the impact of legalized assisted suicide on vulnerable patients would entail studies of higher complexity, duration, and comprehensiveness, Battin et al. certainly provided a first-pass look at the slippery-slope question. At this stage, there appears to be no evidence to support the fear that assisted suicide disproportionately affects vulnerable populations. Instead, the available data indicate that people who die with a physician's assistance are more likely to be members of groups with higher social, economic, educational, and professional status.

Patients' Experience of PAS

Other aspects of the debate on assisted suicide that can be informed by evidence are those related to the tension between autonomy and paternalism. In essence, paternalism presupposes that doctors are better able to act in patients' best interests than the patients are themselves. One way to examine the question of whether patients are indeed capable of making decisions about dying is to compare the quality of death and dying in patients who request PAS with that of those who do not.

Smith et al. 17 sought to determine whether there was a difference in the quality of the dying experience, from the perspective of family members, among patients in Oregon who received lethal prescriptions, those who requested but did not receive lethal prescriptions, and those who did not pursue physician-assisted dying. Altogether, they noted few significant differences between the groups in items that measured domains such as connectedness, transcendence, and overall quality of death. However, they did observe that families reported that patients who received lethal prescriptions had higher quality ratings on items measuring symptom control (e.g., control over surroundings and control of toileting) and higher ratings on items related to preparedness for death (e.g., saying goodbye to loved ones) than those who did not pursue physician-assisted death. Their conclusion was that the quality of death experienced by those who received lethal prescriptions was no worse than that of those who did not pursue PAS, and in some areas, family members rated it as better. In another study, Georges et al. 18 used retrospective interviews with relatives to describe the experiences of patients who died by euthanasia (EAS) or PAS in The Netherlands and found that, according to relatives, EAS had a positive impact on the quality of the end of their loved one's life in 92 percent of cases, primarily by preventing or ending suffering.

One interpretation of the findings of these studies is that in those patients who opt for it, assisted suicide contributes favorably to the experience of their relatives. This inference is supported by evidence from other studies showing no differences in mental health outcomes in family members of patients in Oregon who had requested physician aid in dying compared with family members of patients in Oregon who died of terminal illness. 19 However, although information regarding the experience of family members of patients who opt for PAS may be important in influencing social norms regarding the acceptability of PAS, these data do not speak to the central question of patient autonomy. In fact, it is arguable that the aforementioned studies are irrelevant to the patient-centered perspective, in that they do not directly assess patients' experiences of PAS. In this sense, sufficient research into this and other questions regarding PAS seems to be lacking.

Current State of Research on PAS

As mentioned earlier, most of the clinical studies performed in the United States are associated with the work of one researcher (Ganzini). The relative paucity of research on PAS compared with other areas of medicine implies that there may be a reluctance to study it. Reasons for this reluctance include the taboo associated with PAS, the small number of states that have legalized it, a reliance on using rhetoric or ideology to argue points for or against it rather than actual evidence, and finally, a fear by doctors that research may lead to changes that would restrict, rather than inform, the care that they provide. The identification of the impediments to research in this realm may itself be a consideration for future study, as this may provide a clear path to encouraging more research on PAS.

Another important open question regarding PAS that has not been directly addressed by research to date is the quality of the dying experience of patients who opt to die in this way. Research that directly assessed the patient's experience leading up to death by PAS would clarify questions about the well-being of patients who died by this method and, in doing so, provide evidence potentially in support of PAS as a form of care. Such evidence would be vital for several reasons. For example, it could confirm the sense that physician supporters of PAS have that PAS is a valid form of health care that does indeed improve patients' well-being. Moreover, it would address fears that PAS is inconsistent with the medical dictum to “first, do no harm,” for if it could be shown more clearly that PAS improves the experience of dying for patients, it could be argued that the essence of PAS is to relieve suffering rather than to kill or cause harm. Finally, data taken directly from the patient-centered perspective would address concerns that may be raised about the ability of patients to predict their future mental state accurately, as depressed patients have been shown to have more negatively biased mood predictions, 20 which in turn could adversely affect their ability to make decisions about end-of-life care. 21 Evidence that patients who opt for PAS experience increased well-being up to the time of death would support the belief that, for selected patients, such end-of-life decisions could be consistent and authentic.

The evidence reviewed offers support for some fears with regard to assisted suicide and seems to refute others. One study found no evidence to support the slippery-slope fear that assisted suicide would eventually be used prejudicially on vulnerable populations. 16 Also, researchers found that families of persons who used assisted suicide felt more prepared for and accepting of their loved one's death and in other ways had mental health outcomes that were no worse than those in families of persons who died of other causes. 19

However, data from multiple sources indicate that the concern that depression is often missed or overlooked in patients seeking assisted suicide may be valid. For example, although only a small percentage of patients who request assisted suicide are actually referred to psychiatrists, around 20 percent of those who request assisted suicide have depression. Moreover, health care providers and family members underestimate the extent to which depression is a factor in requests for aid in dying. 9 , – , 12 , 22 From one perspective, this finding implies a need for mandating more frequent referrals to psychiatrists to evaluate patients for evidence that mental illness may have interfered with their decision-making capacity.

On the other hand, psychiatrists and physicians in general may be overly inclined to pathologize suicidal ideation and depression in patients who request aid in dying. Most people with major depression retain competence to make medical decisions, 23 and the legalization of PAS reflects an acceptance that active hastening of death can be a valid choice in terminal illness, implying that PAS can be a valid choice despite the presence of depression. 13 It follows that, although the expression of suicidal ideation may indeed be pathologic in most settings in which it is observed, the conditions that characterize terminal illness may truly be distinct, as patients can reasonably interpret such a diagnosis as a death sentence. One would anticipate that no matter how psychologically healthy a patient might be, it would be understandable for that person to experience feelings of despair, demoralization, and existential distress (i.e., concerns related to feelings of hopelessness, futility, or meaninglessness; anxiety about death; and a disruption of personal identity) in response to receiving a diagnosis of terminal illness.

The Evaluation and Treatment of Existential Distress

Researchers have explored the concept of existential distress in terminally ill patients and have found that their concerns are often related to themes such as loss of control, loss of continuity, and acceptance and preparation. 24 Some have resolved to address the plight expressed by these patients by emphasizing the importance of finding “meaning” at the end of life. Breitbart and colleagues 25 describe psychotherapeutic approaches intended to explore spiritual and existential themes through a meaning-oriented approach that encourages the dying patient to find meaning and purpose in living until death and promotes a patient's personal agency and responsibility.

Chochinov and colleagues 26 have studied the psychological experience of terminally ill patients and have proposed that a fractured sense of dignity can be diagnosed, quantified, associated with a decreased quality of life, and treated with dignity-conserving therapies, such as maintaining autonomy by participating in decisions about care or contributing to something that might serve as a lasting legacy.

Although these researchers have offered therapies that promote continued life, their findings also imply alternative solutions to the existential dilemma facing the terminally ill. For example, important values such as autonomy and dignity would appear to be served with the practice of assisted suicide as well. In fact, assisted suicide might plausibly be a choice that resolves the existential dilemma of terminal illness and its attendant helplessness and hopelessness. Choosing the time and manner of one's death could be a way of symbolically wresting back the reins of the course of one's life. After all, if the healthy among us face up to our finite lives by making choices about how to live, it may also be reasonable for those facing their imminent demise to determine the conditions of their death.

The use of assisted suicide to resolve the existential distress of the terminally ill gains additional support from the work of Chochinov et al. 26 on the concept of dignity in this population. They found that, although there were many common elements shared in different patients' definitions of dignity, there were also important distinctions. For example, some patients valued a “fighting spirit” and “railing against their illness,” whereas others valued acceptance. Some patients spoke of their distress at the thought of having to rely on others for their care, whereas others raised fears related to the anticipation that their death would cause their loved ones pain.

The findings of Chochinov et al . highlight the diverse set of values and manifold experiences within the terminally ill population and imply that treatments aiming to improve these patients' well-being would have to take into account their various desires and perspectives. After deep consideration and reflection on his goals and wishes, as well as careful evaluation to rule out the possibility that pathologic motivations (such as severe mental illness) may be playing a role in his decision, a patient may ultimately decide that assisted suicide is the best way to end his life.

A Role for Psychiatry

These findings imply a potential role for psychiatrists in evaluating patients who request PAS. However, this perspective, too, is not without its complications. Psychiatrists themselves are divided in their support for assisted suicide, with surveys indicating that about two-thirds of U.S. psychiatrists believe that it should be permitted in certain circumstances. 27 , 28 Moreover, most psychiatrists believe that a single independent psychiatric examination would be insufficient to determine a patient's capacity to decide on PAS, 28 especially given previously mentioned concerns about the general difficulty humans have in accurately forecasting their future mental state. 20 , 21

It must be acknowledged that mandated or multiple independent psychiatric examinations would have the effect of increasing the labor and time associated with ensuring the integrity of a patient's request for PAS, which in turn may serve as an impediment to the overall process. Moreover, terminally ill patients may feel stigmatized by being mandated to undergo a psychiatric examination. In Australia, Kissane et al. 29 found that mandated psychiatric assessments for patients requesting euthanasia or PAS sometimes leads them to withhold key information because they see the psychiatric assessment as a legal hurdle to be overcome, suggesting also that mandated psychiatric assessments may compromise the relationship between psychiatrist and patient.

Yet, the push for more extensive evaluations by psychiatrists in this context is understandable. Concerns about a patient's capacity to make reasoned decisions about treatment are likely to be raised in circumstances where a patient expresses a desire for an intervention with unfavorable outcomes and high risk. 30 In addition, some physicians may feel uncomfortable participating in PAS without a more comprehensive evaluation. 28 Thus, in instances where a patient's capacity is in serious question, multiple independent evaluations from consulting psychiatrists over time may be indicated.

For the purpose of guiding a psychiatrist's evaluation of a patient who has requested PAS, Muskin 31 emphasized a psychodynamic approach to exploring the complexity contained in a patient's request to die, which could be interpreted as a communication to the patient's doctor, a method of control over aspects of the patient's life or death, rage or revenge, an expression of hopelessness, or even an expression of guilt, self-punishment, or atonement. A psychiatrist's role as expert in exploration would also include evaluating the effect of psychiatric or medical disease on a patient's decision-making capacity, as well as clarifying communications among treatment team, family, and patient to minimize the possibility of undue influence on a patient's ultimate decision. Finally, a psychiatrist may simply bear witness to and acknowledge the validity of the patient's emotional experience, thereby offering relief by way of empathy. The expertise of psychiatrists in these important areas thus suggests that they would be well suited to provide careful guidance to a patient as he explores his feelings, desires, and values in the service of making authentic decisions about end-of-life care.

In the final analysis, however, a psychiatrist's impressions of the integrity of a patient's request for PAS may turn on the psychiatrist's conception of rational suicide. Thus, it seems critical for psychiatrists to ponder the psychological constituents of rational suicide. Muskin's article 31 is useful in summarizing the questions necessary for a sufficient exploration of a patient's request for PAS, but additional work is warranted to delineate the essential features of rational suicide. The conception set forth by Tomasini 32 of rational suicide as instrumentally rational, autonomous, born of stable goals, and not due to mental illness offers a potential starting point, but in its brevity, it also implies that patients who possess these basic qualities may differ greatly. The challenge will then be for consulting psychiatrists to immerse themselves in a patient's psychological experience with the goal of ensuring that the request is emotionally appropriate, purposive, free of undue influence, and consistent over time with the patient's stated goals, values, and preferences.

Although the arguments and evidence reviewed herein may influence some to change their views on assisted suicide, there are undoubtedly those who will remain steadfast in their beliefs. That strong arguments can be made on both sides of the debate and strident disagreement continues suggests that the question of assisted suicide may touch on something deeper than any single ideology.

In medicine, it may be especially difficult to feel comfortable with helping a patient commit suicide, given that some may equate PAS with killing rather than healing. For this and other reasons, which may be religiously or philosophically derived, certain physicians may feel that it is against their code of ethics to participate in assisted suicide. The question of assisted suicide can also raise feelings of personal failure, as if medicine has nothing left to offer patients, although as implied by the arguments outlined in this article, assisted suicide could instead function as a vital form of care for someone who is suffering.

Indeed, for our purposes in medicine, it is this latter perspective that forms the raison d ' etre of PAS. Rather than merely seeking to maximize patient autonomy in some abstract sense, physicians are experts in the service of patients' health and are therefore obligated to practice PAS only when it is deemed to be in the interest of patients' well-being and not solely in the service of patient autonomy or preference satisfaction. This approach obviates the absurd implication of prioritizing maximization of autonomy over our professional obligations and moreover serves as a useful framework with which to deny the practice of PAS in other conditions, such as chronic, nonterminal illness, in which physicians would feel that PAS would not constitute appropriate care.

In fact, the fear that assisted suicide could eventually be used in such cases is fundamentally unsettling to many. When the philosopher Albert Camus 33 said, “There is but one truly serious philosophical problem and that is suicide,” he was identifying one of the most basic fears that humans can have. Camus' statement highlights the fact that, at one point or another in our lives, we all must confront our mortality and the question of whether life is worth living. As fellow humans and in psychiatry in particular, we hope that each person is able to resolve this dilemma in a way that allows him to live life in a satisfying, meaningful way. Assisted suicide seems to flout that basically pro-life view, but on closer examination, its purpose is instead to relieve suffering in imminently terminal cases where it is thought that no other treatment could reasonably hope to do the same. Our charge as physicians is to encourage an honest, scientific inquiry into the questions raised by PAS that is commensurate with the ideological fervor that surrounds the debate and, as psychiatrists, to ensure that patients struggle valiantly and honestly before making a decision in that direction.

Disclosures of financial or other potential conflicts of interest: None.

  • © 2015 American Academy of Psychiatry and the Law
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  • Published: 15 January 2014

Should assisted dying be legalised?

  • Thomas D G Frost 1 ,
  • Devan Sinha 2 &
  • Barnabas J Gilbert 3  

Philosophy, Ethics, and Humanities in Medicine volume  9 , Article number:  3 ( 2014 ) Cite this article

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When an individual facing intractable pain is given an estimate of a few months to live, does hastening death become a viable and legitimate alternative for willing patients? Has the time come for physicians to do away with the traditional notion of healthcare as maintaining or improving physical and mental health, and instead accept their own limitations by facilitating death when requested? The Universities of Oxford and Cambridge held the 2013 Varsity Medical Debate on the motion “This House Would Legalise Assisted Dying”. This article summarises the key arguments developed over the course of the debate. We will explore how assisted dying can affect both the patient and doctor; the nature of consent and limits of autonomy; the effects on society; the viability of a proposed model; and, perhaps most importantly, the potential need for the practice within our current medico-legal framework.

Introduction

Over the past two centuries, the United Kingdom has experienced rapid population growth associated with a substantial decline in mortality from acute infectious diseases and poor nutrition [ 1 ]. As the average life expectancy has increased, so too have the rates of debilitating chronic illness – particularly coronary artery disease and cancers [ 2 ]. These diseases require years of treatment instead of the mere days to weeks that medicine once operated within [ 2 ]. Although healthcare systems have sought to adapt to such changes, aiming to prevent and treat such disease wherever possible, debate has arisen regarding those patients in the latter stages of chronic, incurable, terminal conditions [ 3 , 4 ]. Moreover, there is increasing recognition that the patient must be at the centre of health care decision-making, such that outcomes must be tailored to their individual needs and views. By extension, assisted dying might seem a logical step to help achieve these goals within the realm of end-of-life decision making [ 5 ]. Several jurisdictions, notably Oregon (1997) and the Netherlands (2001) have already legalised assisted dying in some form. These factors have contributed to ongoing legislative discussions within Parliaments for almost a decade, with current opinion polling suggesting a majority of medical practitioners and the public in favour of physician-assisted suicide [ 6 ].

Viability of assisted dying in practice

In the UK, a model for assisted dying has been developed from the legal structure found within the Assisted Dying Bill introduced by Lord Falconer in the House of Lords in 2013 [ 7 ]. Assisted dying could only be considered under circumstances in which a patient of legal age is diagnosed with a progressive disease that is irreversible by treatment and is “reasonably expected to die within six months” [ 7 ]. Registered medical practitioners would make such decisions for patients with terminal illnesses. Addressing the technicalities of ‘assisted dying’ requires distinction between ‘physician-assisted suicide’ (offering patients medical actions or cessation of actions by which they can end their own life) and ‘euthanasia’ (whereby the medical practitioner actively induces death). In light of the strong hostility of the medical profession towards active euthanasia, this proposed model, as with previous attempts to legalise assisted dying, permitted only the former [ 8 – 10 ].

However, there is concern that such distinction may be unrealistic in practice because medical practitioners could find themselves with a patient who had failed to successfully end their own life and was subsequently left in a state of greater suffering. Were such a patient no longer able to give consent, a heavy burden would then be placed on the physician regarding how to proceed. Moreover, the practice of physician-assisted suicide might be deemed discriminatory, for example by giving only patients with good mobility control over their own method of death.

The Assisted Dying Bill 2013 included the provision that any terminal prognosis must be confirmed and attested by a second registered practitioner. The strictness of such criteria has parallels to a similar double-physician requirement when procuring a legal abortion under the 1967 Abortion Act. The stated aims of the provision in both cases are as follows: first, to check the accuracy of the prognosis upon which the decision was being made; second, to ensure that the situation meets the required criteria; and third, to check that such a decision was taken by the patient after full consideration of all available options [ 11 , 12 ]. By having a second independent doctor, the legislation ensures that all three checks are met without prejudice or mistake.

Problematic for any protocol for assisted dying is the fact that estimates of life expectancy in terminal prognoses are erroneous in 80.3% of cases [ 13 ]. Furthermore, the accuracy of such prognoses deteriorates with increased length of clinical predicted survival. Forecasts of survival times are based largely on past clinical experience, and the inherent variability between patients makes this more of an art than a science. This brings to concern both the accuracy of any prognosis meeting the six-month threshold and the validity of requests for assisted dying based partly or wholly on predicted survival times. Whilst the majority of errors in life expectancy forecasts are a matter of over-optimism and hence would not affect either of those two concerns, many cases remain unaccounted for. Overly pessimistic forecasts occur in 17.3% of prognoses; hence we must decide whether the one in six patients making a decision based on an inaccurate prognosis is too high a cost to justify the use of this system. Patients requesting an assisted death often cite future expectations of dependency, loss of dignity, or pain [ 14 ]. If the hypothetical point at which the progression of their illness means they would consider life to be not worth living is not, as informed, mere weeks away but in fact many more months, then this information would have resulted in a different decision outcome and potentiated unnecessary loss of life.

Whilst the presence of a second doctor would be expected to mitigate such forecasting errors, the anchoring bias of the initial prediction may be enough to similarly reduce the accuracy of the second estimate. It is prudent to question the true independence of a second medical practitioner, and whether this second consultation could become more of a formality, as has now become the case with abortion [ 15 ].

Another challenge for an assisted dying system would be to recognise whether patients requesting death were legally competent to make that decision. Consider that any request for suicide from a patient with clinical depression is generally categorised as a manifestation of that mental disorder, thereby lacking capacity. It is arguably impossible to separate out the natural reactions to terminal illness and clinical depression. Indeed, there is evidence that major depressive disorders afflict between 25% and 77% of patients with terminal illness [ 16 , 17 ]. Any protocol for assisted dying must first determine what qualifies as a ‘fit mental state’ for a terminal patient.

The need for assisted dying

It could be argued that a doctor’s fundamental duty is to alleviate forms of suffering in the best interests of the patient. The avoidance of physical pain, as an obvious manifestation of suffering, might explain why assisted dying would be both necessary and within the duties of a doctor to provide. The evolving principle in common law known as the ‘Doctrine of Double Effect’ offers a solution to this problem [ 18 ]. This legal judgement stated that “[a doctor] is entitled to do all that is proper and necessary to relieve pain even if the measures he takes may incidentally shorten life”. This entails that a protocol already exists for patients searching for an escape from chronic pain. Furthermore, numerous retrospective studies have revealed very little correlation between opioid dose and mean survival times: one study of over 700 opioid-treated patients found that the variation in survival time from high-dose opioid treatment is less than 10% [ 19 – 21 ]. It can therefore be said that pain alone, if appropriately managed, should never be cause for considering assisted dying as an alternative.

By contrast, the ‘Doctrine of Double Effect’ might be seen as a subjective interpretation that has been applied unequally due to a lack of specialist training or knowledge [ 22 ]. Despite this, the principle can be easily understood and poor awareness can be remedied by improvements in medical education and standardisation of protocols. Moreover, should we choose to accept arguments for assisted dying that are based upon inadequate administration of pain medication, we set a precedent for conceding shortcomings in palliative care and other end-of-life treatments. Offering hastened death could become an alternative to actively seeking to improve such failings.

Whilst much has been made of the ‘pain argument’ here, the call for assisted dying is rarely this simple. Many patients also suffer a loss of dignity, often due to their lack of mobility – the inability to relieve oneself without help is a potent example. Beyond this are additional fears of further debilitation and the emotional costs of dealing with chronic illness, both for the patient and for their relatives and friends. A study of terminal patients in Oregon showed that these were the most significant reasons behind requests for assisted suicide, the next commonest reason being the perception of themselves as a ‘burden’ [ 14 ]. Clearly, we could seek to provide balanced, compassionate medical care for these patients, and still fail to address these points.

Developments in healthcare and technology may reduce this emotional burden, but remain an imperfect solution.

Rights of patients and limitations of their autonomy

J.S. Mill’s pithy dictum describes autonomy as follows: “over himself, over his own body and mind, the individual is sovereign” [ 23 ]. Not only has the sanctity of bodily autonomy profoundly influenced the development of liberal democracies, it has also provoked a holistic shift in making our healthcare systems more patient-centred – “care that meets and responds to patients’ wants, needs and preferences and where patients are autonomous and able to decide for themselves” [ 5 ]. The ethical principle of controlling the fate of one’s own body is inherently relevant to the debate on assisted dying. It is difficult to reconcile that citizens may have the right to do almost anything to and with their own bodies– from participating in extreme sports to having elective plastic surgery – yet a terminal patient cannot choose to avoid experiencing additional months of discomfort or loss of dignity in their final months of life.

Expectation of individual liberty has been codified in law. The right to bodily autonomy has been interpreted to be included under Article 8 - the right to privacy - of the European Convention on Human Rights (ECHR) and subsequently the Human Rights Act (HRA) [ 24 , 25 ]. Moreover, the ECHR underpins the right of individuals to ‘inherent dignity’ [ 26 ]. Hence, if an individual feels that dignity is unattainable due to the progression of a terminal illness, then taking recourse though assisted dying ought to be a legitimate option.

Conversely, there are two notable oversights in this interpretation of a right to assisted dying as an extension of the principles of bodily autonomy:

First, it would be wrong to view individual liberty as absolute. The HRA allows for exceptions to Article 8 on grounds of ‘health or morals’ [ 25 ]. The principle of autonomy is not inviolable. Governments have limited such privileges for the protection of individuals and society, for example by criminalizing the use of recreational drugs or the selling of one’s own organs. The preservation of life by denying assisted dying could fall within this category.

Second, the right of autonomy is not necessarily intrinsic to human beings but, as Kant argued, is dependent on our ‘rational nature’ [ 27 ]. This concept sees autonomy as an exercise of ‘evaluative choice’ [ 27 ], requiring rationality on the part of individuals to appreciate the nature of options and their consequences. To achieve true autonomy, there must be sufficient information to make those rational decisions; this is the basis of informed consent and why it is a fundamental duty of a doctor to offer a patient an informed series of treatment options [ 28 ]. The logistical issue is that doctors are unable to advise patients regarding the point at which their situation becomes less preferable to being dead. No doctor (or individual) has any knowledge or experience of what ‘death’ may be like. Hence, in this case, the idea of exercising true autonomy through informed consent might be considered meaningless.

Legalising assisted dying by attempting to establish an absolute right to bodily autonomy may undermine other individual and group rights. Vulnerable patients may feel pressured into assisted dying because of social, emotional, or financial strains placed on family and/or friends. This is exemplified by the trend showing that the proportion of patients stating ‘relief of burden’ on others as the reason for requesting assisted dying has risen from 17% to 25% in Oregon since legalisation [ 29 ]. One could even consider the risk of assisted dying becoming an expected choice rather than a free one. Thus, assisted dying may erode the elemental right to life of terminal patients as the value of their life becomes tied to relative costs to society and to those around them.

Moreover, by creating one class of individuals for whom life is expendable, that particular view may be extended by society to all groups possessing such attributes (e.g. the permanently disabled). There would be a definite risk to the rights of these vulnerable groups in the form of society being less willing to provide for their health and social care.

It is often raised that the limited legalisation of assisted dying would inevitably become extended in scope, but this is not necessarily a flaw. Even if the right to determine the manner of death were later extended to a wider group of people, posterity may reflect positively on such a change, just as extending the franchise to women ultimately led to legislation demanding equal pay.

Effect on health professionals and their role

‘To act in the best interest of the patient’ is often cited as a central duty of the doctor [ 28 ]. This concept of ‘best interest’ guiding the doctor’s action has seen the development of two important ethical principles: beneficence and non-maleficence. Beneficence mandates that the actions of the doctor must be aimed to bring about benefit (clinical improvement) for the patient, usually measured in terms of reduced morbidity or mortality; non-maleficence requires that the doctor not carry out treatment that is likely to cause overall harm the patient [ 30 ]. These traditional ethical imperatives on a doctor both conflict with intentionally hastening the death of a patient, and a resolution of this tension would require redefining what constitutes ‘acting in the best interest’.

A further dimension is the potential reluctance of health professionals to engage in a practice that contravenes their own ethical beliefs, particularly as this would affect doctors who never entered training in the knowledge that assisting patients to die would be an expected duty. This is certainly no argument against the introduction of assisted dying; indeed, a recent survey of a cohort of NHS doctors found that 46% would seriously consider requests from patients to undertake steps to hasten death [ 31 ]. It merely expresses the point that any early model would have to account for the fact that an initial 54% of the doctors in the NHS would be required to advise qualifying patients of assisted dying as a legitimate option, despite disagreeing with it in principle.

Furthermore, doctors who agree ethically with this practice may find themselves facing conflicts of interest. It is expensive to treat chronically ill patients, particularly in the final months of life [ 32 ]. Moreover, it would be difficult for commissioners to ignore the fact that the sustained treatment of one individual could deprive many others from access to surgery or access to novel drugs. Such an argument does not suggest that doctors or any other hospital staff would treat this practice without appropriate respect or care; rather it acknowledges the need for appropriate rationing of care and questions the intentions of service providers. The perception of an ulterior motive could negatively impact patient trust. One survey showed that a reasonable minority of patients (27%) – and particularly particularly the elderly – believe that legalising assisted dying would lessen their trust in their personal physician [ 33 ]. The costs of weakened trust in the doctor-patient relationship could far outweigh the benefits of assisted dying, particularly given the importance of trust when treating a chronic patient for an extended period of time.

There is no doubt that assisted dying would empower some patients to maximise control over the timing and manner of their own death. Such expression of autonomy would surely solidify moves towards a patient-centred approach to healthcare. However, the capacity for such consensual requests remains in doubt. Clinically, the patient’s state of mind and the reliability of diagnostic predictions are of issue; philosophically, the idea of informed consent for death is contradictory. The implications for patients, physicians and society have been weighed extensively within this article. The central tenet throughout has been the balancing of an individual’s right to escape a circumstance that they find intolerable, alongside the consequential changes to their other rights, and the rights and responsibilities of third parties. Ultimately, the challenge is for us as a society to decide where this balance lies.

About the debate

The Varsity Medical Debate was started in 2008 with the aim of allowing students, professors and members of the polis, to engage in discussion about ethics and policy within healthcare. Utilising the age-old rivalry between the two Universities, the debate encourages medical students from both Oxford and Cambridge to consider and articulate the arguments behind topics that will feature heavily in their future careers.

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Acknowledgements

For Cambridge University: Hilmi Bayri (Trinity), Alistair Bolger (Jesus), Casey Swerner (St Johns).

For Oxford University: Devan Sinha (Brasenose), Thomas Frost (Lincoln), Collis Tahzib (Lincoln).

Martin Farrell (Cambridge).

Baroness Finlay: Professor of Palliative Care Medicine and former President of the Royal Society of Medicine.

Dr. Roger Armour: Vascular Surgeon and Inventor of the Lens Free Ophthalmoscope.

Mr. Robert Preston: Director of Living and Dying Well.

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Frost, T.D.G., Sinha, D. & Gilbert, B.J. Should assisted dying be legalised?. Philos Ethics Humanit Med 9 , 3 (2014). https://doi.org/10.1186/1747-5341-9-3

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thesis about assisted suicide

Susan McQuillan

Arguments for and Against Physician-Assisted Suicide

The right to legally end your own life is a heavily debated issue..

Posted September 16, 2020 | Reviewed by Gary Drevitch

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Although September is designated National Suicide Awareness Month, there are those who think about suicide 12 months of the year. They may be survivors of suicide loss—the family and friends of those who have taken their own lives—or they may be people who often contemplate suicide or have already made attempts. Articles and anecdotes of suicide published during the month of September and at other times most often focus on prevention. But there’s another side to the story.

Many people believe that ending one’s own life is a human right, particularly for those who are terminally ill and suffering from indescribable pain or impairment. In the United States, however, it is only a right for those in the nine places where physician-assisted death is now legal when strict guidelines are followed. In Oregon, Washington, Vermont, Maine, Hawaii, California, Colorado, New Jersey, or the District of Columbia, eligible, terminally ill patients can legally seek medical assistance in dying from a licensed physician. In all of these places, a physician can decide whether or not to provide that assistance. At the same time, other states—Alabama, Arizona, Georgia, Idaho, Louisiana, New Mexico, Ohio, South Dakota, and Utah—have, in recent years, strengthened their laws against assisted suicide. In 2018, for instance, Utah amended its manslaughter statute to include assisted suicide.

In a nutshell, it works like this: The patient orally requests legal medical assistance in dying from a qualified physician. That physician must assess and confirm the patient’s eligibility and also inform the patient of alternative treatments that provide pain relief or hospice care. At that point, a second physician must confirm the patient’s diagnosis and mental competence to make such a decision. If deemed necessary, either physician can require the patient to undergo a psychological evaluation. The patient must then make a second oral request for assistance. Once approved, the original physician writes a prescription for lethal medication (usually a high-dose barbiturate powder that must be mixed with water) that the patient can self-administer when and where they choose, as long as it is not in a public place. Some people never fill the prescription or fill the prescription but never take the medication. Those who do generally fall asleep within minutes and die peacefully within a few hours.

Several organizations have been formed to both support and oppose physician-assisted dying for moral, ethical, and legal reasons. Groups such as Death with Dignity and Compassion and Choices are in favor of what they call “medical aid in dying” and work to provide assistance and lobbying efforts to initiate legal “right to die” programs in every state. They support patient autonomy and choice, particularly in the case of terminal illness. To these groups and their supporters, most of whom come to this side of the issue as a result of agonizing personal experience, death with dignity is a human rights issue and those who are suffering are entitled to a peaceful death.

On the other side of the debate, groups like the Patients Rights Council and Choice Is an Illusion work to tighten laws against euthanasia and medical aid in dying. They fear a complete lack of oversight at the moment of death, as well as normalization of the process to the degree that patients will feel they must relieve their families of the burden they are inflicting by living with their illness. They are concerned that decisions will be made by others on behalf of those too ill to speak for themselves. These groups believe the job of a physician is to find ways to eliminate patients’ suffering, not the patients themselves. They do not believe a physician is qualified to make the decision to assist in ending a life.

In the end, no group really wants assisted suicide to be the final answer, but those who favor medical aid in dying see little recourse for those living with unbearable chronic pain , who are terminally ill, and who have no hope of improving the quality of their lives because medical science has not yet caught up with our modern potential for longevity.

Compassion and Choices: https://compassionandchoices.org/

Death with Dignity: https://www.deathwithdignity.org/

Patients Rights Council: http://www.patientsrightscouncil.org/site/

Choice is An Illusion: https://www.choiceillusion.org/2019/04/in-last-ten-years-at-least-nine-…

Susan McQuillan

Susan McQuillan is a food, health, and lifestyle writer.

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Euthanasia and assisted dying: the illusion of autonomy—an essay by Ole Hartling

Read our coverage of the assisted dying debate.

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As a medical doctor I have, with some worry, followed the assisted dying debate that regularly hits headlines in many parts of the world. The main arguments for legalisation are respecting self-determination and alleviating suffering. Since those arguments appear self-evident, my book Euthanasia and the Ethics of a Doctor’s Decisions—An Argument Against Assisted Dying 1 aimed to contribute to the international debate on this matter.

I found it worthwhile to look into the arguments for legalisation more closely, with the hope of sowing a little doubt in the minds of those who exhibit absolute certainty in the matter. This essay focuses on one point: the concept of “autonomy.”

(While there are several definitions of voluntary, involuntary, and non-voluntary euthanasia as well as assisted dying, assisted suicide, and physician assisted suicide, for the purposes of brevity in this essay, I use “assisted dying” throughout.)

Currently, in richer countries, arguments for legalising assisted dying frequently refer to the right to self-determination—or autonomy and free will. Our ability to self-determine seems to be unlimited and our right to it inviolable. The public’s response to opinion poll questions on voluntary euthanasia show that people can scarcely imagine not being able to make up their own minds, nor can they imagine not having the choice. Moreover, a healthy person answering a poll may have difficulty imagining being in a predicament where they simply would not wish to be given the choice.

I question whether self-determination is genuinely possible when choosing your own death. In my book, I explain that the choice will always be made in the context of a non-autonomous assessment of your quality of life—that is, an assessment outside your control. 1

All essential decisions that we make are made in relation to other people. Our decisions are affected by other people, and …

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thesis about assisted suicide

American Psychological Association Logo

Assisted dying: The motivations, benefits and pitfalls of hastening death

As physician-assisted dying becomes more available, psychologists are finding opportunities to study people’s motivations and the potential benefits and harms of aid in dying

By Kirsten Weir

December 2017, Vol 48, No. 11

Print version: page 26

13 min read

Assisted dying

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"CE Corner" is a continuing education article offered by the APA Office of CE in Psychology.

To earn CE credit, after you read this article, purchase the online exam at www.apa.org/ed/ce/resources/ce-corner .

Upon successful completion of the test — a score of 75 percent or higher — you can immediately print your CE certificate.

The test fee is $25 for members and $35 for nonmembers. The APA Office of CE in Psychology retains responsibility for the program. For more information, call (800) 374-2721.

CE credits: 1

Learning objectives: After reading this article, CE candidates will be able to:

  • Describe APA’s resolution on assisted dying. 
  • Discuss the ways depression can complicate a patient’s wish for assisted dying. 
  • Discuss research on how family and friends are affected when a loved one chooses assisted dying.

It's been two decades since Oregon enacted the nation's first Death with Dignity Act, allowing people with terminal illnesses to hasten their deaths by self-administering medications prescribed by a physician. Since then, California, Colorado, Vermont, Washington state and Washington, D.C., have passed similar statutes.

Assisted dying

Yet the topic arouses strong feelings—and raises plenty of questions. Can a person with depression rationally choose to hasten death? Would the option be less appealing if people received better care for physical symptoms and emotional distress? Could aid in dying put marginalized groups at risk?

As physician-assisted dying becomes available in more places, research psychologists are finding opportunities to study people's motivations and the potential benefits and harms of aid in dying. On the clinical side, psychologists' skills are helpful as people sort through their feelings and desires at the end of life, says Elizabeth Goy, PhD, a psychologist at the Portland VA Medical Center and associate professor at Oregon Health and Science University, and chair of the APA Working Group on End-of-Life Issues and Care.

"The very best thing we can do as psychologists is to improve communication and make sure that we are attending to the needs and suffering of patients who are at the end of life," Goy says. "Dying is universal, and it behooves all of us to have some foundational knowledge about end-of-life issues."

A new language

Goy and her colleagues on the working group were charged with updating APA's previous resolution on assisted suicide, adopted in 2001. In August, APA's Council of Representatives voted to approve the updated resolution. Like the previous resolution, the 2017 update states that APA neither endorses nor opposes assisted dying at this time.

"It was the consensus of the working group that this is a matter between the psychologist and the person considering aid in dying," says group member and Jonesville, Virginia–based psychologist James L. Werth Jr., PhD. "Psychologists have to be aware of their own biases, and if they can't be a part of the discussion without those biases getting in the way, they should refer the person to someone else. But we determined that APA shouldn't be a limiter of that discussion."

The most notable update to the resolution was linguistic. When the 2001 resolution was passed, the topic was known as "assisted suicide." Today, providers prefer the term "assisted dying" to reflect the distinction between suicide and the process of hastening death to alleviate pain and suffering.

Still, the specter of depression and suicide hangs over public opinion of assisted dying. Since Oregon first raised the possibility of legalized dying in the 1990s, researchers have grappled with the question of whether it can ever be considered a rational choice, Rosenfeld says. "Some people felt that almost everyone who seeks this option is doing so out of a rational appraisal of their situation. Others argued this is just a form of suicide and we should protect them from themselves," he says.

But research in the intervening years has suggested the truth lies in the gray area between, he adds. "Of the people who pursue this option, a sizable portion are rationally appraising their situation. And a sizable proportion are appraising it through a lens of depression."

In a study of terminally ill patients, for instance, Rosenfeld and his colleagues found that desire for death was associated with depression, and that desire decreased in patients who responded to antidepressants ( Psychosomatics , Vol. 51, No. 2, 2010). Other research, however, suggests that depression is not a major driver for most people who request aid in dying. When Oregon's law was passed, Goy teamed up with psychiatrist Linda Ganzini, MD, MPH, at Oregon Health and Science University, to study the moods, values, needs, concerns and symptom burdens of 58 Oregon residents with terminal illnesses who pursued assisted death. They found that most of those people did not have depressive disorders.

However, they also concluded that the Death with Dignity Act, as written, might fail to protect some patients with depression from making the choice to hasten death ( BMJ , Vol. 337, 2008).

Still, some advocates note that depression shouldn't ­necessarily make a person ineligible for physician-assisted death. "In the normal world of decision-making, we wouldn't say people lose autonomy to make decisions because they're moderately depressed," Rosenfeld says. Indeed, he adds, there's too little research to indicate how a person should feel or act as they approach their final days. "How cheerful should you be when you have a terminal illness?" he asks.

Some proponents of legalized aid in dying suggest that the option may be unfairly singled out because of cultural beliefs about the morality of suicide. "Assisted dying gets a lot of attention because of the values and emotions that get brought into it," says Werth. Yet many more people with serious illness end their lives through some other negotiated means, he says, such as ceasing medications, withholding food or drink, refusing life-­sustaining treatment or signing "do not resuscitate" orders. "Most people will die those ways," he says.

Regaining control

After two decades of evidence from Oregon, research is answer-ing many questions about aid in dying. That evidence suggests that the desire to hasten death often comes from wanting to maintain some power over one's own life, Goy says. "In our research, the main reason people voiced for wanting the option was that they really wanted to have control over the circumstances of dying."

The wish for control can be for a variety of reasons, they found, including loss of autonomy and function or worries about future pain ( JAMA Internal Medicine , Vol. 169, No. 5, 2009). But reassuringly, when Goy and her colleagues compared people who expressed a desire for aid in dying with others with terminal illness who did not seek that option, they found no indication that the former group was motivated by financial concerns or being a burden to their loved ones, Goy says.

Assisted dying

More research is needed to fully understand why and when some people ultimately make that choice, Shead notes. But it may be that just having the option provides a sense of control over the circumstances of one's death, allowing the person to focus on the quality of life that remains rather than fear of future suffering.

Research also shows that the choice to hasten death doesn't negatively impact surviving family members. Months or years after the death of the patients in their study, Goy and Ganzini interviewed their family­ ­caregivers. When they compared family members of those who requested aid in dying with those who did not, the researchers found no differences in depression, grief or use of mental health services. In fact, families of people who chose aid in dying reported that they felt more prepared and accepting of their loved one's death ( Journal of Pain and Symptom Management , Vol. 38, No. 6, 2009).

That could be because family discussions of hastened death often force families to discuss difficult topics they might other­wise not have spoken about, suggests Judith Gordon, PhD, a Seattle-based psychologist and clinical professor of psychology at the University of Washington who has studied end-of-life decision-making since 1996. "In this culture, there's still a lot of resistance to talking about dying, even if someone is diagnosed with a terminal disease," she says. "When people want to use this option, they need the support of their doctors and typically also want the support of their families."

Most people who receive a prescription for lethal medication talk to their families about their decision. "One of the gifts when someone makes this choice is that it brings the discussion to the table. The whole family or support group talks not just about this particular way of dying, but about all the issues related to how they feel about the death and what they will do later. It's an enormous benefit," Gordon says.

End-of-life inequity

Despite those potential benefits, critics express concerns about the possible harms of assisted death.

One worry surrounds access. So far, most of the people who have requested aid in dying are white, middle-class and typically well-educated, notes Carol Gill, PhD, APA working group member and professor of disability and human development at the University of Illinois at Chicago. "This sector of the population generally has access to options and seeks control of their life circumstances up to the end of life," she points out. "In contrast, there are underrepresented communities who have very different views of assisted dying."

The biggest concern to Gill and others is that people from disadvantaged groups might consider hastened death because their health-care needs are not being met. There are well-­documented disparities in access to health-care services, with people from lower socioeconomic backgrounds, those with lower health literacy, and members of ethnic or racial minorities being less likely to receive adequate care, including palliative care services.

"There are a number of ­marginalized populations that are legitimately concerned about whether they are getting all of the best options in care at the end of life," Goy says. "We want to be sure we are attentive to treating pain adequately and addressing emotional experiences such as hopelessness, depression and despair, so that assisted dying does not seem like the only option."

Gill says that many in the disability-rights community have expressed unease with aid in dying because of concerns that people won't receive the resources they need to live meaningful lives despite physical limitations. "There are no assisted-dying laws that guarantee those resources, and that feels discriminatory to a lot of people with disabilities," she says.

Indeed, the very idea of "death with dignity" is an affront to many people who have physical limitations that require daily assistance, Gill says. "Some right-to-die activists have written about assisted dying as an antidote for indignity that occurs at the end of life, such as needing help to dress or use the bathroom. If you're a person with functional limitations, that's a real slap in the face," she says.

For most people, including those with disabilities and those facing functional loss at the end of life, social connection is what makes life worth living, she adds. "Having a meaningful life doesn't necessarily mean that life needs to be pain-free or without physical impairment or functional limitations. What it means is to remain engaged humanly, and get enough support from others or technology to engage in the activities that matter, that make life meaningful."

Unanswered questions

Even advocates of physician-­assisted death say it's crucial that researchers continue to explore the process to ensure it's used responsibly. More work is needed to understand how terminally ill people make treatment decisions, Rosenfeld says, including the decision to end one's life. "The fact that assisted-dying laws aren't used that often has made people more confident that the law isn't being misused. But could that number go down a notch further by having more services available? That's where more research could be really informative," he says.

Gill adds that too little is known about how people make the decision to take lethal medication after they request the prescription. "We don't follow these individuals and hear what they're thinking day to day in the period before they ingest the drugs, and we don't know what happens to people who express interest but don't end up going through with it," she says.

Gill also hopes that researchers will further explore how the availability of aid in dying will affect medical practice. "Will it seem more and more reasonable for people to want their death hastened? Will we remember that life, even when it includes suffering, can still be considered meaningful given adequate support and resources? What will happen to the balance of those resources when assisted dying becomes more common?"

There's an open opportunity for psychology researchers to answer such questions, Rosenfeld says. "I think we are uniquely poised to do the kind of research that would inform these issues."

Psychologists can also fill an important role by evaluating and counseling people who have expressed a wish to pursue aid in dying. Though it's not a topic taught in graduate school, some state psychological associations have prepared guidelines for mental health professionals who do such evaluations, Gordon says. (For example, the Washington State Psychological Association issued the Washington Death with Dignity Act WSPA Guidelines for Mental Health Professionals , and the California Psychological Association recently published its guidelines, California's End of Life Option Act: CPA Guidance for Psychologists .)

Although it's not an easy job to work with people facing their final days, it is often a gratifying one, says Goy. "All of psychology comes to bear when you are working with people at the end of life. It calls for skills in every area that psychologists are trained in," she says. "There are a lot of emotions around this topic and it's ethically sensitive. The best we can do is be open to the concerns, continually be looking for data and challenge our own biases as best we can."

Further reading

APA End of Life Issues and Care www.apa.org/pi/aging/programs/eol

Physician-Assisted Dying: A Turning Point? Gostin, L.O., & Roberts, A.E., JAMA , 2016

Mental Disorders and the Desire for Death in Patients Receiving Palliative Care for Cancer Wilson, K.G., et al., BMJ Supportive & Palliative Care , 2016

The Relief of Existential Suffering Kissane, D.W., JAMA Internal Medicine , 2012

The Oregon Death with Dignity Act: A Guidebook for Health Care Professionals The Center for Ethics in Health Care, Oregon Health and Science University, 2008

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  • Assisted Suicide: A Right or a Wrong?
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Assisted Suicide

A right or a wrong.

Is assisted suicide right or wrong? The issue is looked at through many perspectives and arguments.

Matthew Donnelly loved life. But Matthew Donnelly wanted to die. For the past thirty years, Matthew had conducted research on the use of X-rays. Now, skin cancer riddled his tortured body. He had lost his nose, his left hand, two fingers on his right hand, and part of his jaw. He was left blind and was slowly deteriorating. The pain was unrelenting. Doctors estimated that he had a year to live. Lying in bed with teeth clenched from the excruciating pain, he pleaded to be put out of his misery. Matthew wanted to die now. His pleas went unanswered. Then, one day, Matthew's brother Harold, unable to ignore Matthew's repeated cry, removed a .30 caliber pistol from his dresser drawer, walked to the hospital, and shot and killed his brother. Harold was tried for murder.

Rapid and dramatic developments in medicine and technology have given us the power to save more lives than was ever possible in the past. Medicine has put at our disposal the means to cure or to reduce the suffering of people afflicted with diseases that were once fatal or painful. At the same time, however, medical technology has given us the power to sustain the lives (or, some would say, prolong the deaths) of patients whose physical and mental capabilities cannot be restored, whose degenerating conditions cannot be reversed, and whose pain cannot be eliminated. As medicine struggles to pull more and more people away from the edge of death, the plea that tortured, deteriorated lives be mercifully ended grows louder and more frequent. Californians are now being asked to support an initiative, entitled the Humane and Dignified Death Act, that would allow a physician to end the life of a terminally ill patient upon the request of the patient, pursuant to properly executed legal documents. Under present law, suicide is not a crime, but assisting in suicide is. Whether or not we as a society should pass laws sanctioning "assisted suicide" has generated intense moral controversy.

Supporters of legislation legalizing assisted suicide claim that all persons have a moral right to choose freely what they will do with their lives as long as they inflict no harm on others. This right of free choice includes the right to end one's life when we choose. For most people, the right to end one's life is a right they can easily exercise But there are many who want to die, but whose disease, handicap, or condition renders them unable to end their lives in a dignified manner. When such people ask for assistance in exercising their right to die, their wishes should be respected.

Furthermore, it is argued, we ourselves have an obligation to relieve the suffering of our fellow human beings and to respect their dignity. Lying in our hospitals today are people afflicted with excruciatingly painful and terminal conditions and diseases that have left them permanently incapable of functioning in any dignified human fashion. They can only look forward to lives filled with yet more suffering, degradation, and deterioration. When such people beg for a merciful end to their pain and indignity, it is cruel and inhumane to refuse their pleas. Compassion demands that we comply and cooperate.

Those who oppose any measures permitting assisted suicide argue that society has a moral duty to protect and to preserve all life. To allow people to assist others in destroying their lives violates a fundamental duty we have to respect human life. A society committed to preserving and protecting life should not commission people to destroy it.

Further, opponents of assisted suicide claim that society has a duty to oppose legislation that poses a threat to the lives of innocent persons. And, laws that sanction assisted suicide inevitably will pose such a threat. If assisted suicide is allowed on the basis of mercy or compassion, what will keep us from "assisting in" and perhaps actively urging, the death of anyone whose life we deem worthless or undesirable? What will keep the inconvenienced relatives of a patient from persuading him or her to "voluntarily" ask for death? What will become of people who, once having signed a request to die, later change their minds, but, because of their conditions, are unable to make their wishes known? And, once we accept that only life of a certain quality is worth living, where will we stop? When we devalue one life, we devalue all lives. Who will speak for the severely handicapped infant or the senile woman?

Finally, it is argued that sanctioning assisted suicide would violate the rights of others. Doctors and nurses might find themselves "pressured" to cooperate in a patient's suicide. In order to satisfy the desires of a patient wanting to die, it's unjust to demand that others go against their own deeply held convictions.

The case for assisted suicide is a powerful one--appealing to our capacity for compassion and an obligation to support individual choice and self determination. But, the case against assisted suicide is also powerful for it speaks to us of a fundamental reverence for life and the risk of hurling down a slippery slope toward a diminished respect for life. With legislation in the offing, we're compelled to choose which values are most important and to cast our vote.

This article was originally published in Issues in Ethics - V. 1, N.1 Fall 1987

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  • Newcastle University eTheses
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Title: Physician-assisted death in England and Wales
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Issue Date: 2014
Publisher: Newcastle University
Abstract: The thesis examines if the recent legal developments on assisted death in England and Wales have addressed the needs of society and the concerns of those seeking an assisted death. Despite assisted suicide being a crime in England and Wales, many British citizens successfully obtain an assisted suicide by travelling abroad. With the help of loved ones, they patronise right-to-die organisations in jurisdictions with more permissive laws on suicide. Meanwhile, the prosecution of those who assist a suicide is subject to an uncertain discretion of the DPP, whose prosecuting policy effectively decriminalises ‘compassionate assisted suicides’. Inconsistencies in the law on assisted death between the legal prohibition of assisted suicide, and legally permitted end-of-life medical decisions will also be examined. Whilst assisted death is a crime, physicians are legally permitted to withhold or withdraw life-sustaining treatment from patients. The extent to which a patient’s ‘quality of life’ has been a factor in these inconsistent decisions will be analysed. The thesis will show that the present prohibition against assisted suicide in England and Wales is legally and morally indefensible. Whilst investigating whether assisted suicide should be legalised in England and Wales, the thesis undertakes a comparative analysis of six jurisdictions from around the world. It also evaluates the ‘slippery slope’ argument, i.e. whether a law permitting assisted death for a restricted group of people would inevitably lead to assisted death being practised beyond that group. The thesis will conclude that there is a strong case for providing the legal option of physician-assisted suicide to patients experiencing a poor and unacceptable quality of life due to unbearable pain and suffering brought about by terminal illness.
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Gorsuch on euthanasia and assisted suicide – and abortion?

In 2004, Neil Gorsuch was awarded a doctorate in legal philosophy by the University of Oxford, the British institution where he studied as a Marshall Scholar. Gorsuch’s doctoral thesis on euthanasia and assisted suicide served as the basis for his 2006 book, “The Future of Assisted Suicide and Euthanasia.” At Gorsuch’s confirmation hearing that year , Sen. Lindsey Graham asked Gorsuch about his writings on assisted suicide and euthanasia, noting that Gorsuch had been “prolific.”

Gorsuch assured Graham that his “personal views” would have “nothing to do with the case before” him in any situation. Having said that, though, Gorsuch added that his writings on assisted suicide and euthanasia had “been largely in defense of existing law” and were “consistent with the Supreme Court’s decisions in this area and existing law in most places.”

When Gorsuch first began his studies at Oxford in the early 1990s, euthanasia and assisted suicide were both high-profile and controversial issues. In 1997, in Washington v. Glucksberg and Vacco v. Quill , the Supreme Court rejected challenges to the constitutionality of state laws banning assisted suicide. But, Gorsuch emphasized in his book, the justices who concurred in that ruling left open the question whether such laws would be unconstitutional in the specific cases of adults who were terminally ill. “Thus, far from definitively resolving the assisted suicide issue,” Gorsuch suggested, “the Court’s decisions seem to assure that the debate over assisted suicide and euthanasia is not yet over—and may have only begun.”

Gorsuch’s prediction appears to have mostly missed the mark: The debate over assisted suicide and euthanasia largely subsided in the years following the publication of his book. Assisted suicide remains illegal in 44 states, while all 50 states ban euthanasia, and there have been few signs that the issues could make their way to the Supreme Court anytime soon. But Gorsuch’s book on assisted suicide and euthanasia nonetheless remains relevant, not only for what it tells us about his views and his writings more generally, but also for what (if anything) we might be able to glean from the book that might shed more light on his views on abortion.

Much of Gorsuch’s book is devoted to an exhaustive (but not exhausting) survey of the history of assisted suicide and euthanasia, the legal and ethical arguments in favor of the two, and court cases – in the United States and the United Kingdom – dealing with the right to die. Gorsuch is sharply critical of experiments with allowing assisted suicide and euthanasia in the Netherlands and Oregon. In the Netherlands, Gorsuch observes, “it appears that, for every three or four acts of voluntary euthanasia, the Dutch regime generates one case of a patient being killed without consent.” Moreover, he continues, euthanasia and assisted suicide are often motivated less by the desire to alleviate pain or respect patient autonomy than by a physician’s subjective belief that the patient’s quality of life is “degrading” or “hopeless.”

And in Oregon, which allows “capable” adults with terminal diseases to request medication to end their lives, the law does not require physicians to refer patients who want to commit assisted suicide to mental health professionals. Gorsuch cites data raising the possibility that other factors, such as depression or isolation, rather than terminal illnesses, may be driving assisted suicide in Oregon. Reporting requirements in the state are minimal, he adds, such that “Oregon officials admit that they have no idea how often state law is violated, and no way to detect cases of abuse and mistake.” Given the many flaws in the two regimes, he points to the potential costs if assisted suicide and euthanasia were legalized more broadly – particularly the prospect that they could lead to pressure, “real or imagined,” for the poor, minorities and the elderly to commit assisted suicide, in part because of the high costs of health care in the United States.

Although Gorsuch was correct at his confirmation hearing that his book defends existing laws prohibiting assisted suicide and euthanasia, the book offers an alternative ground to justify them: “the idea that all human beings are intrinsically valuable and the intentional taking of human life is always wrong.” Dubbing his rationale the “inviolability-of-life principle,” he characterizes it as a “middle path” between two extremes – on the one hand, the idea that life is “the most important good that must always be maintained” and, on the other, the idea that a person could die or be killed based on someone else’s judgment about his quality of life.

Gorsuch’s “middle ground” would, he takes pains to emphasize, still allow terminally ill patients to refuse or discontinue treatment; it would also allow medical personnel to prescribe high doses of morphine or other painkillers when death is near. The “critical, rational moral line,” he explains, is intent. When medical personnel and the patient’s family are seeking to relieve the patient’s pain, or the patient doesn’t have a “suicidal impulse” but opts to discontinue or refuse treatment “out of a recognition of the inevitability of death,” doctors should be permitted to prescribe painkillers and discontinue treatment even when they know that death will result and may even be accelerated. But, he cautions, doctors cannot do these same things when they do so with the intent to cause the patient’s death.

Allowing doctors to prescribe an overdose of morphine or discontinue care with the intent to relieve a patient’s physical suffering, even knowing that it will also result in death, but not allowing it with the intent to cause death may seem like a somewhat artificial distinction. But, in Gorsuch’s view, the distinction would also solve a constitutional conundrum: If – as essentially all states allow – patients can refuse care or discontinue treatment, why shouldn’t they also have a right to a doctor’s assistance in committing suicide? Although other efforts by scholars and lawyers to distinguish assisted suicide and euthanasia from the right to refuse treatment fall short, Gorsuch contends, “an intent-based distinction may work sufficiently well to withstand a constitutional equal protection challenge. Assisted suicide and euthanasia differ from the right to refuse in that they necessarily entail an intent to kill and, with it, the judgment that a patient’s life is no longer worth living. Such an intention may be present in a decision to refuse treatment, but, I suggest, it need not be.”

Gorsuch devotes an entire chapter to an analysis of Planned Parenthood v. Casey , the Supreme Court’s 1992 decision reaffirming a woman’s right to an abortion, and Cruzan v. Director, Missouri Department of Health , the court’s 1990 decision upholding the state’s refusal to allow the parents of a woman in a “persistent vegetative state” to terminate treatment on her behalf. The question for Gorsuch is whether the two cases support an interest in autonomy, protected by the Constitution, that could in turn support a right to assisted suicide and euthanasia. In his view, they do not. He maintains that the court’s decision in Casey should be read more narrowly, pointing to the portion of the decision in which a plurality of the court argues “that the doctrine of stare decisis , or respect for long-settled law, required continued adherence” to the court’s 1973 decision in Roe v. Wade , which recognized a woman’s right to terminate her pregnancy.

In a footnote, Gorsuch stresses that his analysis in his book is limited to assisted suicide and euthanasia; he has no intent “to engage the abortion debate.” But he doesn’t stop at that. Instead, he acknowledges that “abortion would be ruled out by the inviolability-of-life principle I intend to set forth if , but only if , a fetus is considered a human life.” Gorsuch then seems to pull back again, reminding his readers that in Roe the Supreme Court “unequivocally held that a fetus is not a ‘person’ for purposes of constitutional law” – suggesting, perhaps, that the issue has already been taken off the table. However, when Gorsuch makes the same statement elsewhere in the book, he again cites Roe , but he also cites a dissent by Justice Byron White, for whom Gorsuch clerked. Gorsuch characterizes the White dissent as “arguing that the right to terminate a pregnancy differs from the right to use contraceptives because the former involves the death of a person while the latter does not.” Gorsuch may not share White’s view, but his decision to include it is somewhat curious given what he has elsewhere described as the court’s “unequivocal” holding.

Is Gorsuch’s reference to the White dissent a veiled hint into his own views on abortion or merely an effort to give equal time to an opposing view? It is impossible to know for certain, and we aren’t likely to learn anything more at his confirmation hearing. If Gorsuch is confirmed, we may have to wait for the next challenge to laws regulating abortion to reach the Supreme Court.

Posted in A close look at Judge Neil Gorsuch’s jurisprudence , Nomination of Neil Gorsuch to the Supreme Court

Recommended Citation: Amy Howe, Gorsuch on euthanasia and assisted suicide – and abortion? , SCOTUSblog (Mar. 16, 2017, 5:29 PM), https://www.scotusblog.com/2017/03/gorsuch-euthanasia-assisted-suicide-abortion/

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  • v.83(3); 2016 Aug

Non-faith-based arguments against physician-assisted suicide and euthanasia

Daniel P. Sulmasy

1 The Department of Medicine and Divinity School, The University of Chicago, Chicago, IL, USA

John M. Travaline

2 Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA

Louise A. Mitchell

3 Catholic Medical Association, Bala Cynwyd, PA, USA

E. Wesley Ely

4 Department of Medicine, Division of Pulmonary and Critical Care, Vanderbilt University School of Medicine, Nashville, TN, USA

5 Veteran's Affairs Geriatric Research Education and Clinical Center (GRECC) of the Tennessee Valley Healthcare System, Nashville, TN, USA

This article is a complement to “A Template for Non-Religious-Based Discussions Against Euthanasia” by Melissa Harintho, Nathaniel Bloodworth, and E. Wesley Ely which appeared in the February 2015 Linacre Quarterly . Herein we build upon Daniel Sulmasy's opening and closing arguments from the 2014 Intelligence Squared debate on legalizing assisted suicide, supplemented by other non-faith-based arguments and thoughts, providing four nontheistic arguments against physician-assisted suicide and euthanasia: (1) “it offends me”; (2) slippery slope; (3) “pain can be alleviated”; (4) physician integrity and patient trust.

Lay Summary: Presented here are four non-religious, reasonable arguments against physician-assisted suicide and euthanasia: (1) “it offends me,” suicide devalues human life; (2) slippery slope, the limits on euthanasia gradually erode; (3) “pain can be alleviated,” palliative care and modern therapeutics more and more adequately manage pain; (4) physician integrity and patient trust, participating in suicide violates the integrity of the physician and undermines the trust patients place in physicians to heal and not to harm.

Introduction

In its first issue of 2015, The Linacre Quarterly published the text of a secular debate held at Vanderbilt University School of Medicine ( Bloodworth et al. 2015 ), hoping it would re-kindle interest in formulating arguments and contribute to increasingly common discussions in society about physician-assisted suicide (PAS) and euthanasia. As that paper was offered to engender dialog, it was hoped that other reflections would follow. As it happened, around the same time that the Bloodworth publication was being prepared, a debate was held by Intelligence Squared U.S. ( Intelligence Squared 2014a ) on legalizing physician-assisted suicide featuring Professors Peter Singer and Andrew Solomon “for” and Doctors Daniel Sulmasy and Ilora Finlay “against” the legalization of PAS. 1 Herein we build upon Doctor Sulmasy's opening and closing arguments from that debate, supplemented by other non-faith-based arguments and thoughts intended to further this conversation, focusing on objections to legalizing these practices. In this manuscript, we will thus review the Bloodworth article, present the Intelligence Squared opening and closing statements “against PAS” and then expound upon four key arguments against PAS: (1) “it offends me”; (2) slippery slope; (3) “pain can be alleviated”; (4) physician integrity and patient trust.

Before getting into Doctor Sulmasy's debate points, it is worthwhile to recount some points raised in the Bloodworth article ( Bloodworth et al. 2015 ). While the debate points presented at Vanderbilt were well-received, common criticisms to some of the assertions made in that piece are worth consideration. For example, one of the main bases for Doctor Ely's argument against physician-assisted suicide and euthanasia involved an appeal to natural law. 2 Such appeal to natural law does not presuppose belief in God. The knowledge of natural law is discernible by reason and so it is not fundamentally theistic. While it is true that the Catholic Church in particular has made prominent use of natural law in formulating its ethical positions, natural law is not essentially rooted in any faith tradition (see, for example, Anderson 2005 ; Finnis 2001 ; Goyette, Latkovic, and Myers 2004 ; McInerny 1993 ; Veatch 1971 ). Nonetheless, appeal to natural law is commonly mistaken as an appeal to theism, which many in a secular society dismiss out of hand because of this misperception. These critics often forget the use of natural law reasoning by the founding fathers of the United States. The Vanderbilt debate, for instance, referenced the Declaration of Independence, which is a quintessentially natural law-based set of governing principles. Lastly, the references in that debate to C.S. Lewis from The Abolition of Man were placed strategically and without necessary dependence on Lewis's explicit arguments for theism as the ground of the natural law, and hence morality. Lewis's approach leaves natural law vulnerable to the charge of theism by those who do not accept an ultimate or transcendent justice or goodness as the rule and measure of human actions. Lewis's position regarding the theistic basis of natural law is not, however, widely accepted by natural law scholars, the authors of this paper, or the Catholic Church.

The Bloodworth article was, as billed, a mere starting point. Doctors Sulmasy and Finlay developed a sophisticated, philosophical “devil's advocate” approach that was ultimately successful. They discerned optimal premises for making the case against physician-assisted suicide and euthanasia to avowed non-theistic practitioners of medicine. It is thus our privilege to publish here Doctor Sulmasy's points to continue building the case towards truth in respecting human life nearing its end in the context of the practice of the vocation of medicine. In the tradition of St. Thomas, we take four strong arguments for PAS that arose during the debate (patient autonomy, no slippery slope, unalleviated pain, physician's duty) and argue against them. We base our arguments in reason, with the conviction that the truth in a principle can be discerned and its implications drawn out to a logical conclusion, and an error can be shown to have a contradiction at its heart.

Doctor Sulmasy's Opening Statement 3

I am a physician. Part of my job is to help people die in comfort and with dignity. But I do not want to help you, or your daughter, or your uncle commit suicide. You should not want me to. I urge you to oppose physician-assisted suicide: it represents bad ethical reasoning, bad medicine, and bad policy. I am going to concentrate on the first of these lines of argument. Ilora will take up the latter two.

We strongly support the right of patients to refuse treatments and believe physicians have a duty to treat pain and other symptoms, even at the risk of hastening death. But empowering physicians to assist patients with suicide is quite another matter—striking at the heart not just of medical ethics, but at the core of ethics itself. That is because the very idea of interpersonal ethics depends upon our mutual recognition of each other's equal independent worth, the value we have simply because we are human. Some would have you believe that morality depends upon equal interests (usually defined by our preferences) and advance utilitarian arguments based on that assumption. 4

But which is morally more important, people or their interests? As Aristotle observed, small errors at the beginning of an argument lead to large errors at the end. 5 If interests take precedence over people, then assisting the suicide of a patient who has lost interest in living certainly is morally praiseworthy. But it also follows that active euthanasia ought to be permitted. It also follows that the severely demented can be euthanized once they no longer have interests. They can also freely be experimented upon as excellent human “models” for research. It also follows that infanticide ought to be permitted for infants with congenital illness.

Many would see these conclusions as frightful, but this is not just a slippery slope. They all follow logically from arguing for assisted suicide on the basis of maximizing personal interests. So if you do not believe in euthanasia for severely disabled children or the demented, you might want to re-think your support for assisted suicide. At least if you want to be consistent.

People often argue that they need assisted suicide to preserve their dignity, but that word has at least two senses. Proponents use the word in an attributed sense to denote the value others confer on them or the value they confer on themselves. But there is a deeper, intrinsic sense of dignity.

Human dignity ultimately rests not on a person's interests, but on the value of the person whose interests they are; and the value of the person is infinite. I do not need to ask you what your preferences are to know that you have incalculable worth, simply because you are human. Martin Luther King said that he learned this from his grandmother who told him, “Martin, don't let anybody ever tell you you're not a Somebody” ( Baker-Fletcher 1993 , 23). This some-bodiness, this intrinsic worth or dignity, was at the heart of the civil rights movement.

It does not matter what a person looks like, how productive the person might be, how others view that person, or even how that person may have come to view herself. What matters is that everybody, black or white, healthy or sick, is a somebody . Assisted suicide and euthanasia require us to accept that it is morally permissible to act with the specific intention-in-acting of making a somebody into a nobody , i.e., to make them dead.

Intentions, not just outcomes, matter in ethics. Intending that a somebody be turned into a nobody violates the fundamental basis of all of interpersonal ethics—the intrinsic dignity of the human.

Our society worships independence, youth, and beauty. Yet we know that illness and aging often bring dependence and disfigurement. The terminally ill, especially, need to be reminded of their value, their intrinsic dignity, at a time of fierce doubt. They need to know that their ultimate value does not depend upon their appearance, productivity, or independence.

You see, physician-assisted suicide flips the default switch. The question the terminally ill hear, even if never spoken, is, “You've become a burden to yourself and the rest of us. Why haven't you gotten rid of yourself yet?” A good utilitarian would think this a proper question—even a moral duty.

As a physician who cares for dying patients, however, I am more fearful of the burden this question imposes on the many who might otherwise choose to live , than the modest restriction imposed on a few, when physician-assisted suicide is illegal.

Assisted suicide should not be necessary. Pain and other symptoms can almost always be alleviated. As evidence, consider that pain or other symptoms rarely come up as reasons for assisted suicide. The top reasons are: fear of being a burden and wanting to be in control ( Oregon Public Health Division 2015 , 5).

You may ask, “Why shouldn't I have this option?” And yet we all realize that society puts many restrictions on individual liberty, and for a variety of reasons: to protect other parties, to promote the common good, and to safeguard the bases of law and morality. For example, we do not permit persons to drive when drunk, or to freely sell themselves into slavery.

Paradoxically, in physician-assisted suicide and euthanasia, patients turn the control over to physicians, who assess their eligibility and provide the means. Further, death obliterates all liberty. Therefore, saying that respect for liberty justifies the obliteration of liberty actually undermines the value we place on human freedom.

Doctor Sulmasy's Closing Statement

I have been on talk shows and received call-in questions from patients who ask how I can be opposed to physician-assisted suicide when they are getting sick from chemotherapy, suffering complications from the big IV they have in their neck, have intense pain, and are spending more time in the hospital than outside it. But I ask them, why are you still getting chemotherapy? Why not have the IV removed? Why not ask for hospice or palliative care to control your pain? Why not just stay home? You should have no need for assisted suicide. 6 Most supporters of physician-assisted suicide want what opponents want—respect for their dignity and attention to their individual needs.

But we are all human beings—fragile, interdependent, and connected in bonds of mutual respect and support. Suicide is always an act of communication and has profound interpersonal implications. Many persons who raise the question of suicide are really testing the waters, asking us if we care enough to try to stop them. When we do not stop them, or even say, “I'll help you,” we confirm their deepest fears and make it difficult for them to see an alternative. And when the suicide happens, physicians and families must live for the rest of their lives with fact that they did not try to intervene.

We should not construct a society that makes assisted suicide easy or common. We should re-direct our energies towards making sure that all patients get the kind of care we all want—helping us live to the fullest even as we are dying. Vote for that kind of high quality, compassionate care at the end of life, and the sort of moral world that makes it possible, by voting No on physician-assisted suicide.

Debate Result and Some of the Arguments

Doctors Sulmasy and Finlay won the debate according to its rules, by persuading the most members of the live audience to change their minds. While the live audience in New York City began the debate with 65 percent in favor of legalizing assisted suicide, only 10 percent opposed, and 25 percent undecided, after the debate, 67 percent were in favor but 22 percent were opposed to legalization. The unofficial online polling changed from 5 percent opposed to legalization before the debate to 51 percent opposed as of March 21, 2016. (See the Results tab at Intelligence Squared 2014a )

In the rest of this article we highlight and expound upon some of the arguments against physician-assisted suicide gleaned from the debate and from the audience comments and questions following it: (1) “It offends me”; (2) the slippery slope; (3) “pain can be alleviated”; and (4) physician integrity and patient trust. We take care not to frame them within a faith-based context. While we believe that faith-based arguments are strong, our intention in arguing from reason is that all too many people are quickly dismissive of faith-based arguments. Our aim is to advance the conversation from this perspective. As noted earlier, the hope is to have new and other iterations of the pro-life arguments readily available to reach as broad a swath of people as possible, believers and non-believers alike.

“It Offends Me” Argument

Certainly everyone should strive not to be offensive to others, but whether one is offended or not, partly depends upon the person potentially offended. To offend someone is to attack, violate, or cause resentful displeasure to a person. This presupposes that the one offended recognizes the attack, violation, or resentment, and so the argument vis-à-vis assisted suicide is that when one willfully kills oneself, or requests to be killed, every other human being should rightfully be offended. Why? Because subsumed in the action of one killing oneself (or requesting to be killed) is the implied announcement that one's life (human life) is somehow not as valuable as it otherwise would be if one were not in a position to seek one's death (For to value life contradicts the act of killing, and if one values life, one does not commit suicide or ask to be killed.). To assert that one values human life, and at the same time to commit suicide is contradictory and illogical. So, to kill oneself (willfully, i.e., to distinguish this form of suicide from suicide in association with mental illness or other clinical pathology) necessarily devalues human life. And, because we are all human beings, therefore, every human being is (or should be) resentful of his or her life being devalued.

Now some may grant that killing oneself is an expression of devaluing life, but only that individual person's life, and no one else's, arguing therefore, that there is no basis for one's willful suicide (or its request) to be offensive to anyone else. The fundamental problem, however, with this reasoning is that human beings are relational (natural law). It is part of the essence of being human to exist in a relationship to another. According to Thomas Aquinas, the third precept of the natural law is “an inclination to good, according to the nature of his reason … thus man has a natural inclination … to live in society” ( Aquinas 1948 , I–II, q. 94, a. 2). And Aristotle viewed a particular relationship, that of friendship, to be a virtue and “most indispensable for life” ( Aristotle 1962/1980 , bk. 8, ch. 1). Indeed the very origin of an individual necessitates the relationship of two other human beings—a mother and a father—and a human being exists in relationships with others by his or her very nature. Human beings then are always, and essentially a part of a community of persons, and as such because of this connection with others (as part of humanity), when another person kills him- or herself or allows him- or herself to be killed, life for every other human being is cheapened (devalued). Such an action says to some degree, that life is not worth it; and although the effect on others may be seemingly miniscule, the more it happens the greater the effect on others (like compounding interest on money). Moral actions very much and very often have consequences for others, even when there appears to be no connection. 7

The Slippery Slope Argument

One of the issues brought up in the debate over physician-assisted suicide is the slippery slope argument: If physician-assisted suicide is made legal, then other things will follow, with the final end being the legalizing of euthanasia for anyone for any reason or no reason. The experience of other countries shows that this is not theoretical. The Netherlands is an example of the slippery slope on which legalizing physician-assisted suicide puts us. In the 1980s the Dutch government stopped prosecuting physicians who committed voluntary euthanasia on their patients ( Jackson 2013 , 931–932; Patel and Rushefsky 2015 , 32–33). By the 1990s over 50 percent of acts of euthanasia were no longer voluntary. This is according to the 1991 Remmelink Report, a study on euthanasia requested by the Dutch government and conducted by the Dutch Committee to Study the Medical Practice Concerning Euthanasia ( Euthanasia.com 2014 ; Patients Rights Council 2013a ; Van Der Maas et al. 1991 ). In 2001 euthanasia was made legal. And in 2004 it was decided that children also could be euthanized. According to Wesley Smith, in a Weekly Standard article in 2004, “In the Netherlands, Groningen University Hospital has decided its doctors will euthanize children under the age of 12, if doctors believe their suffering is intolerable or if they have an incurable illness.” The hospital then developed the Groningen Protocol to decide who should die. Smith comments,

It took the Dutch almost 30 years for their medical practices to fall to the point that Dutch doctors are able to engage in the kind of euthanasia activities that got some German doctors hanged after Nuremberg. For those who object to this assertion by claiming that German doctors killed disabled babies during World War II without consent of parents, so too do many Dutch doctors: Approximately 21% of the infant euthanasia deaths occurred without request or consent of parents. ( Smith 2004 )

Euthanasia in the Netherlands went from illegal but not prosecuted, to legal, to including children . And it is not stopping there ( Schadenberg 2013 ). Now, in 2011, Radio Netherlands reported that “the Dutch Physicians Association (KNMG) says unbearable and lasting suffering should not be the only criteria physicians consider when a patient requests euthanasia.” The association published a new set of guidelines, “which says a combination of social factors and diseases and ailments that are not terminal may also qualify as unbearable and lasting suffering under the Euthanasia Act.” These social factors include “decline in other areas of life such as financial resources, social network, and social skills” ( RNW 2011 ). So a person with non-life threatening health problems but who is poor or lonely can request to be euthanized.

In another example of the slippery slope to which physician-assisted suicide leads, in 2002 Belgium “legaliz[ed] euthanasia for competent adults and emancipated minors.” In February of 2014, Belgium took the next step:

Belgium legalized euthanasia by lethal injection for children…. Young children will be allowed to end their lives with the help of a doctor in the world's most radical extension of a euthanasia law. Under the law there is no age limit to minors who can seek a lethal injection. Parents must agree with the decision, however, there are serious questions about how much pressure will be placed on parents and/or their children. ( Patients Rights Council 2013b )

Some say that the US state laws concerning physician-assisted suicide are very restrictive and so there is no chance of erosion such as has happened in the Netherlands or Belgium ( Intelligence Squared 2014b , 34). Yet, if there is no moral or philosophical basis for PAS laws in the common good, then there is no telling how far changes to PAS laws will go in the future, and no stopping the changes.

“Pain Can Be Alleviated” Argument

In medicine, we talk much these days about a “good death,” not necessarily one that is completely free of suffering, but a dying process in which we are attendant to pain and symptom management, optimize clear decision making, and affirm the whole person in as dignified a manner as possible. Importantly, this can often be effectively accomplished through incorporation of palliative care services. Palliative care is a healing act adjusted to the good possible even in the face of the realities of an incurable illness. Cure may be futile but care is never futile ( Pellegrino 2001 ). With appropriate utilization of palliative care, far fewer patients would be driven by fear to request that physicians actively end their lives via PAS/E.

Proponents of assisted suicide and euthanasia posit the scenario of uncontrollable pain as a straw man for advancing their cause. Such proponents apparently view death as the ultimate analgesic. In fact, in medical practice today, pain relief is almost always possible given modern therapeutics in analgesia and the medical specialty of pain management. Since pain can be alleviated, there is no basis to assert a need for PAS because of intractable pain. This may explain in part why many requests for PAS are no longer related to or initiated because of intolerable pain, but because of fear of such intolerable pain. Further, closely related to a patient's fear of intolerable pain, and sometimes associated with a patient's fear of being abandoned ( Coyle 2004 ), is a patient's request for PAS because of not wanting to burden others. This too poses a curious contradiction, for on the one hand there is not wanting to be a burden on a loved one, and on the other hand a fear of being alone and abandoned. Such a contradiction, once considered and coupled with the fact that pain can be addressed successfully through optimal palliative care implementation, enhances the power of this argument against PAS/E.

The Oregon law was enacted on the basis of intolerable pain — no one should be forced to endure pain that is uncontrollable and unendurable. Most of us can sympathize with that, but the law is not restricted to pain, and it is not pain that is the top reason people choose physician-assisted suicide in Oregon. The state's “Death with Dignity Act Annual Report” for 2014 shows that the top reason is “losing autonomy” ( Oregon Public Health Division 2015 , 5). Concern about pain was not even the second or third reason: “Less able to engage in activities making life enjoyable” and “Loss of dignity.” It was ranked sixth out of seven, above only financial concerns, and included not only “inadequate pain control,” but also “concern about it.” These patients were not necessarily in uncontrollable pain themselves, however they were concerned about it (as are we all). But even that concern did not rank high on their list of reasons that they wanted to commit suicide. Even if the line drawn is unbearable pain, how can that be restricted to only physical pain? Who can judge that mental anguish is not unbearable pain? Or that economic distress (or anything else that causes anguish) is not unbearable pain?

Physician Integrity and Patient Trust Argument

When a patient asks a physician to assist in killing him- or herself, not only is there disrespect shown to the physician's integrity, but a contradiction is created. Asking a physician to participate in PAS undermines the principled ethic and integrity of the physician whose noble profession is defined as one of compassionate service of the patient who is vulnerable, wounded, sick, alone, alienated, afraid; and undermines the integrity or wholesomeness of the patient, who him- or herself is in desperate need of trying to achieve. To ask and expect a physician to participate in the destructive act of suicide violates both personal and professional integrity of the physician, and leaves both the patient and the physician at risk for moral confusion about what is good, true, and beautiful about the human person.

The threat of euthanasia posed by legalizing PAS also undermines trust between physician and patient.

Both euthanasia and physician-assisted suicide would undermine the medical profession by eroding the trust of patients in their physicians as caregivers. If doctors were permitted to engage in practices that harm their patients, then patients would never know if their doctors were truly acting in their best interests. ( Austriaco 2011 , 148)

Will your doctor kill you if he or she thinks you are too ill or in too much pain or unconscious? The Oath of Hippocrates has guided physicians for twenty-four hundred years. The Oath states,

I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice…
I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. ( Tyson 2001 )

Even with all the advances in medicine over the last one to two hundred years, the public perception is still that the Hippocratic Oath is an important indicator that the patient in his or her vulnerability can put trust in the physician ( Lederer 1999 , 102). Euthanasia by health-care professionals undermines that trust.

Lack of trust is not just something that may or may not happen if euthanasia is legalized. It is happening in countries that have legalized euthanasia. Austriaco points out that “many Dutch patients, before they will check themselves into hospitals, insist on writing contracts assuring that they will not be killed without their explicit consent” ( Austriaco 2011 , 148). As stated earlier, in the 1980s the Dutch government stopped prosecuting physicians who committed voluntary euthanasia on their patients. By the 1990s over 50 percent of acts of euthanasia were no longer voluntary. This has had a deleterious effect on the relationship of patients to health-care professionals. An article in 2011 in the Telegraph , a newspaper in the UK, stated that “Elderly people in the Netherlands are so fearful of being killed by doctors that they carry cards saying they do not want euthanasia” ( Beckford 2011 ). The Dutch elderly mistrust their own doctors.

Trust is not the only issue concerning the integrity of medicine: PAS also calls into question the very ends of medicine to cure and to care. Christopher Saliga, a nurse, explains that

One can rightly say that in Oregon, the balance has shifted such that respect for autonomy currently has greater weight among the principles hanging in the balance than it had prior to the legalization of assisted suicide. As a result, the contradictory patient outcomes of life and death via continued care or willful suicide respectively are considered equally valid. ( Saliga 2005 , 22–23)

Medicine and the medical profession traditionally aimed at curing and healing. Assisting in a suicide is neither cure nor healing. It pits the medical profession against itself: curing and caring versus killing.

We offer the following table of the salient points comprising the non-faith-based arguments against PAS (Table  1 ).

Table 1

ArgumentMain points
“It offends me”Life has infinite value, and PAS devalues life
Devaluation of life is offensive
Human beings are relational and share in value of life
PAS is an offense to all human beings
Slippery slopePAS in limited circumstances has led to PAS performed with markedly reduced limits (e.g., children, disabled people)
“Pain can be alleviated”Embracing excellent palliative care is the correct answer
Physician integrity and patient trustPAS undermines the integrity of both physician and patient as it is a contradiction to the patient's seeking to be well; and a violation of the principled duty of the physician to help the patient to become well
Undermined physician integrity is leading to loss of patient trust in physicians

Concluding Remarks

As the secular world pushes more and more the agenda of personal autonomy and relativism, breeches of long-held ethical standards and our oath as physicians are increasingly apparent. On this topic of PAS and euthanasia, it is worth pointing out that in the practice of critical care medicine at the highest level of academia, there are now movements to endorse “shortening of the dying process” (SDP), which is a euphemism for physician-assisted suicide at best, and in effect, a synonym for murder when unilaterally committed by a health-care professional in the absence of legal approval. In fact, in one Belgian statement, the authors endorsed using medications to end patients’ lives even in the absence of suffering ( Vincent et al. 2014 , n. 6), a practice that was found offensive and actively rebutted by a group of Dutch physicians ( Kompanje et al. 2014 ). Such SDP is a practice that was reported by 2 percent of physicians in seven European countries ( Sprung et al. 2003 ), but which is felt by 79 percent of physicians to be wrong and intolerable even if allowed by law ( Sprung et al. 2014 ). With such active conversations occurring, especially now that the Canadian Supreme Court has recently ruled in favor of physician-assisted suicide, it is more important than ever to be adept with defense of life arguments, which are also arguments in defense of the healing profession of medicine at large.

All is not lost in medicine just because we have no cure and see a patient's life nearing its end. This represents a time in which we as physicians must focus, as Edmund Pellegrino taught, on elevating human dignity and the preservation of self-worth for each and every patient:

To care, comfort, be present, help with coping, and to alleviate pain and suffering are healing acts as well as cure. In this sense, healing can occur when the patient is dying even when cure is impossible. Palliative care is a healing act adjusted to the good possible even in the face of the realities of an incurable illness. Cure may be futile but care is never futile. ( Pellegrino 2001 )

We invite others to contribute to this ongoing debate, and to continue the dialog, hoping that some of it will be captured on the pages of this journal.

Biographies

Daniel P. Sulmasy, M.D., Ph.D., is the Kilbride-Clinton Professor of Medicine and Ethics in the Department of Medicine and Divinity School; associate director of the MacLean Center for Clinical Medical Ethics in the Department of Medicine; director, Program on Medicine and Religion at the University of Chicago.

Deacon John M. Travaline, M.D., is a professor of Thoracic Medicine and Surgery at the Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA.

Louise A. Mitchell, M.T.S., M.A., is associate editor of The Linacre Quarterly , and an adjunct professor of bioethics.

E. Wesley Ely, M.D., M.P.H., is a professor of Medicine and Critical Care at Vanderbilt University, the Vanderbilt Center for Health Services Research, and associate director of Research for the Tennessee Valley VA Geriatric Research Education Clinical Center in Nashville, TN, USA.

1 Intelligence Squared U.S. is a program which presents prominent figures before a live audience debating important timely issues of our time. More information can be found at http://intelligencesquaredus.org .

2 In essence, the natural law expresses the original moral sense which enables man to discern by reason the good and the evil, the truth and the lie. Catechism of the Catholic Church (2000), n. 1954 .

3 Doctor Sulmasy's opening and closing statements are printed verbatim. A few notes and references have been added. For the transcript, see Intelligence Squared (2014b) .

4 See Singer (1993 , 13–14, 21–26, 57, 94–95).

5 Aristotle. On the heavens (I.5, 271b9–10), in The Basic Works of Aristotle , ed. Richard McKeon (New York: Random House, 1941), 404.

6 The authors' understanding of palliative care is that it is present first and foremost to help the patient (and family) live maximally in the face of life-threatening illness and, in that sense, can provide great benefit to the patient and loved ones well before he or she is imminently dying. Whenever it is deemed appropriate in the course of a patient's life and dying process, the palliative care team's focus on “iving maximally” may be best achieved by coordinating activities to optimize the patient's comfort, function, relationships, healing, dignity, and preparation for natural death.

7 Further, if we were to develop this line of reasoning in a faith-based model, it would involve the notion that there is no such thing as a private sin.

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A truck drives past the lit yellow sign of a Super 8 motel.

He Helped a Woman End Her Own Life. Was It Manslaughter, or Mercy?

They checked into a motel room in upstate New York, with a gas canister and a plan to end her decades of physical pain.

Stephen P. Miller, a former doctor, is accused of traveling across the country to help a New York woman asphyxiate herself. Credit... Bryan Anselm for The New York Times

Supported by

Ed Shanahan

By Ed Shanahan

  • July 8, 2024

A king room at the Super 8 motel in Kingston, N.Y., is a forlorn place. Mismatched night stands. An armchair with visible stains. Soggy grass outside the window.

“Resting for the journey ahead,” the do-not-disturb sign says. It shows a lone car on a two-lane road, sandy hills beneath fluffy white clouds in the distance.

Doreen Brodhead checked into just such a room in the fall, No. 102, the last one on the right at the end of a narrow, dimly lit hallway. With her was Stephen P. Miller, a former doctor from Arizona with a prison term in his past. They had gotten to know each other online.

Ms. Brodhead, a 59-year-old Kingston native, had lived with severe pain in her neck and back most of her adult life. She attributed it to her brief career as a dental hygienist. No one — not doctors or surgeons or chiropractors or acupuncturists — could fix it.

Mr. Miller, 85, was familiar with pain. As a toddler, he had been badly burned in a bathtub of scalding water, a relative said. Now, along with other ailments, he had a chronic spinal condition.

A do-not-disturb sign that says “resting for the journey ahead” hangs from a hotel door handle.

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    Physician-assisted suicide (PAS) is one of the most provocative topics facing society today. Given the great responsibility conferred on physicians by recent laws allowing PAS, a careful examination of this subject is warranted by psychiatrists and other specialists who may be consulted during a patient's request for PAS. In this article, recent evidence regarding the implementation of PAS in ...

  5. Euthanasia and assisted suicide: An in-depth review of relevant

    3. Evolution of euthanasia and assisted suicide: digging into historical events. To understand the evolution and relevance of these concepts should analyze the history of euthanasia and assisted suicide; from the emergence of the term, going through its first manifestations in antiquity; mentioning the conceptions of great thinkers such as Plato and Hippocrates; going through the role of the ...

  6. A Report of Physicians' Beliefs about Physician-Assisted Suicide: A

    Physician-assisted suicide (PAS), also known as physician aid-in-dying (AID), is one of the most contentious ethical issues facing medicine today. The American Medical Association (AMA) states that, "Physician-assisted suicide occurs when a physician facilitates a patient's death by providing the necessary means and/or information to enable ...

  7. PDF Understanding Physician Assisted Suicide: A Literature Review

    assisted suicide (PAS) is defined as a "physician providing, at the patient's request, a. prescription for a lethal dose of medication that the patient can self-administer by ingestion, with. the explicit intention of ending life" (American Academy of Hospice and Palliative Medicine, 2016).

  8. Medically Assisted Dying and Suicide: How Are They Different, and How

    The practice variously known as "medically assisted dying," "medical aid in dying," "physician aid in dying," "physician-assisted suicide," "death with dignity," and "euthanasia" has long been contentious, and the question of what to call it has become increasingly contentious as well. 1 There has been a growing push, particularly among U.S. proponents of legalizing the ...

  9. Should assisted dying be legalised?

    Moreover, the practice of physician-assisted suicide might be deemed discriminatory, for example by giving only patients with good mobility control over their own method of death. ... Colgrove J: The McKeown thesis: a historical controversy and its enduring influence. Am J Public Health. 2002, 92: 725-729. 10.2105/AJPH.92.5.725. Article Google ...

  10. Yale University EliScholar

    Yale Medicine Thesis Digital Library School of Medicine 1-1-2019 A Report Of Us Physicians' Beliefs About Physician-Assisted Suicide And A Bioethical Analysis Of The Practice Peter Theodore Hetzler Follow this and additional works at: https://elischolar.library.yale.edu/ymtdl Part of the Medicine and Health Sciences Commons Recommended Citation

  11. An autonomy-based approach to assisted suicide: a way to avoid the

    In several jurisdictions, irremediable suffering from a medical condition is a legal requirement for access to assisted dying. According to the expressivist objection, allowing assisted dying for a specific group of persons, such as those with irremediable medical conditions, expresses the judgment that their lives are not worth living. While the expressivist objection has often been used to ...

  12. Thesis Statement For Physician Assisted Suicide

    Thesis Statement For Physician Assisted Suicide. The Right to Die 1) Introduction a) Thesis statement: Physician assisted suicide offers patients a choice of getting out of their pain and misery, presents a way to help those who are already dead mentally because of how much a disease has taken over them, proves to be a great option in many ...

  13. Euthanasia and Assisted Suicide

    Currently, interest in the topics of euthanasia and assisted suicide is substantial. The success of books by Derek Humphrey and the notoriety of Jack Kevorkian are as much a reflection of changing societal values as they are a stimulus to public discussion. The magnitude of public interest is demonstrated in legislation to legalize assisted suicide, an issue that has been included on the ...

  14. Arguments for and Against Physician-Assisted Suicide

    Physician-assisted death brings up moral, ethical, and legal questions. Although September is designated National Suicide Awareness Month, there are those who think about suicide 12 months of the ...

  15. Euthanasia and assisted dying: the illusion of autonomy—an ...

    As a medical doctor I have, with some worry, followed the assisted dying debate that regularly hits headlines in many parts of the world. The main arguments for legalisation are respecting self-determination and alleviating suffering. Since those arguments appear self-evident, my book Euthanasia and the Ethics of a Doctor's Decisions—An Argument Against Assisted Dying 1 aimed to contribute ...

  16. Ethical Issue of Physician-Assisted Suicide and Euthanasia

    1. Concepts of euthanasia and physician-assisted suicide. Euthanasia is a compound derived from the Greek words "eu" (good) and "thanatos" (death), and refers to an act of dying that is peaceful, comfortable, and painless. It is the act of intentionally shortening the life of a patient who is suffering from extreme pain, at the request ...

  17. Assisted dying: The motivations, benefits and pitfalls of hastening death

    When the 2001 resolution was passed, the topic was known as "assisted suicide." Today, providers prefer the term "assisted dying" to reflect the distinction between suicide and the process of hastening death to alleviate pain and suffering. Still, the specter of depression and suicide hangs over public opinion of assisted dying.

  18. Assisted Suicide: A Right or a Wrong?

    The case for assisted suicide is a powerful one--appealing to our capacity for compassion and an obligation to support individual choice and self determination. But, the case against assisted suicide is also powerful for it speaks to us of a fundamental reverence for life and the risk of hurling down a slippery slope toward a diminished respect ...

  19. PDF An autonomy-based approach to assisted suicide: a way to avoid the

    Federal Constitutional Court justifies assisted suicide—but not euthanasia—on the basis of autonomy and declares that assisted suicide is an expression of the right to a self-determined death. This autonomy-based approach does not allow for restrictions regarding the person's suffering or medical diagnosis.

  20. Newcastle University eTheses: Physician-assisted death in England and Wales

    Issue Date: 2014. Publisher: Newcastle University. Abstract: The thesis examines if the recent legal developments on assisted death in England and Wales have addressed the needs of society and the concerns of those seeking an assisted death. Despite assisted suicide being a crime in England and Wales, many British citizens successfully obtain ...

  21. Thesis Statement For Assisted Suicide Essay

    Thesis Statement: Although people may be suffering and on the verge of death, assisted suicide should be illegal because there are many options to look upon then just looking at death. II. Major Point 1: Health may improve. A. Minor Point 1: One may take medication to improve health and help maintain their health at a decent balance.

  22. Gorsuch on euthanasia and assisted suicide

    Gorsuch's doctoral thesis on euthanasia and assisted suicide served as the basis for his 2006 book, "The Future of Assisted Suicide and Euthanasia." At Gorsuch's confirmation hearing that year, Sen. Lindsey Graham asked Gorsuch about his writings on assisted suicide and euthanasia, noting that Gorsuch had been "prolific."

  23. Non-faith-based arguments against physician-assisted suicide and

    This article is a complement to "A Template for Non-Religious-Based Discussions Against Euthanasia" by Melissa Harintho, Nathaniel Bloodworth, and E. Wesley Ely which appeared in the February 2015 Linacre Quarterly.Herein we build upon Daniel Sulmasy's opening and closing arguments from the 2014 Intelligence Squared debate on legalizing assisted suicide, supplemented by other non-faith ...

  24. He Helped a Woman End Her Own Life. Was It Manslaughter, or Mercy?

    Helping others die is called different things — assisted suicide, self-deliverance, death with dignity, medical aid in dying, a final exit — depending on the circumstances, some legal, some not.