Physician-Assisted Suicide and Euthanasia
by Carrie Gordon Earll
Should physicians be granted the power to intentionally end the lives of their patients? Recent proposals to legalize physician-assisted suicide have raised this question and triggered intense legal, medical and social debate.
For some individuals, the debate is fueled by their fear that medical technology may someday keep them alive past the time of natural death. However, this concern is unfounded for mentally competent adults who have a legal right to refuse or stop any medical treatment. It is also important to recognize that today’s health care climate lends itself more to undertreatment than overtreatment.
However, the present debate is not about refusing treatment or taking extraordinary measures. The issue is whether physicians should be allowed to intentionally kill their patients, either by providing the means of death or ending the patient’s life by the doctor’s hands. There is a tremendous distinction between allowing someone to die naturally when medical technology cannot stop the dying process and causing someone to die through assisted suicide or euthanasia. The question is one of intent: Is the intention to cause the death of the patient?
The terms “physician-assisted suicide” and “euthanasia” are often used interchangeably. However, the distinctions are significant. The act of physician-assisted suicide involves a medical doctor who provides a patient the means to kill him or herself, usually by an overdose of prescription medication.
Meanwhile, euthanasia involves the intentional killing of a patient by the direct intervention of a physician or another party, ostensibly for the good of the patient or others. The most common form of euthanasia is lethal injection. Euthanasia can be voluntary (at the patient’s request), nonvoluntary (without the knowledge or consent of the patient) or involuntary (against his or her wishes).
Euthanasia is illegal in the United States. Physician-assisted suicide is illegal by statute or common law in most states. Oregon and Washington State allow physician-assisted suicide. Montana law may provide a defense for a doctor charged with such an action.
In 1997, the U.S. Supreme Court ruled that there is no federal constitutional right to physician-assisted suicide. However, the decision does not address individual state constitutions, which could be interpreted by other courts to include a state right to physician-assisted suicide.
Many state legislatures have tackled this issue in recent years, with more than 25 rejecting bills to legalize physician-assisted suicide and nearly a dozen states adopting new laws to ban it. No state legislature has voted to legalize physician-assisted suicide.
Oregon approved a ballot initiative to legalize physician-assisted suicide in 1994 and reaffirmed the vote in 1997. Five other attempts to legalize physician-assisted suicide (or euthanasia) through ballot initiative (California in 1988 and 1992, Washington State in 1991, Michigan in 1998, and Maine in 2000) all failed.
In 2008, Washington State approved physician-assisted suicide by ballot measure. In Montana, a 2009 state Supreme Court ruling did not legalize physician-assisted suicide but rather may provide a defense for a physician charged with homicide involving a patient.
Stories Behind the Issue
Supporters often use emotional stories of terminally ill patients suffering in the final days of life to justify legalizing physician-assisted suicide. These stories communicate that an early, premeditated death is the best, and perhaps the only, option for the patient. However, a growing number of medical professionals who work with dying patients are speaking out to dispute this perception. Consider the following statements:
If we treat their depression and we treat their pain, I’ve never had a patient who wanted to die.
William Wood, M.D., clinical director of the Winship Cancer Center at Emory University in Atlanta, as published in Time, April 15, 1996, p. 82.
I simply have never seen a case nor heard of a colleague’s case where it (physician-assisted suicide) was necessary. If there is such a request, it is always dropped when quality care is rendered.
Linda Emanuel, M.D., Ph.D., director of the American Medical Association’s Institute on Ethics, as published in “The New Pro-Lifers,” The New York Times Magazine, July 21, 1996.
In my clinical practice, I have been asked by suffering patients to aid them in death because of severe pain. I have had the opportunity to see these requests for aid in death fade with adequate pain control, psychological support, provision of family support, and with the promise that their symptoms would be controlled throughout the dying process.
Kathleen Foley, M.D., chief of pain service at Memorial Sloan-Kettering Cancer Center in New York City, as part of her testimony before the House Judiciary Subcommittee on the Constitution, Washington D.C., April, 1996.
Reasons to Oppose Physician-Assisted Suicide
There are many reasons for opposing attempts to legalize such actions. Here are a few:
- Acceptance of physician-assisted suicide sends the message that some lives are not worth living.
Social acceptance of physician-assisted suicide tells elderly, disabled and dependent citizens that their lives are not valuable. Doctors who list death by assisted suicide among the medical options for a terminally or chronically ill patient communicate hopelessness, not compassion.
- The practice of physician-assisted suicide creates a duty to die.
Escalating health-care costs, coupled with a growing elderly population, set the stage for an American culture eager to embrace alternatives to expensive, long-term medical care. The so-called “right to die” may soon become the “duty to die” as our senior, disabled and depressed family members are pressured or coerced into ending their lives. Death may become a reasonable substitute to treatment and care as medical costs continue to rise.
- There are better medical alternatives.
Terminally ill patients do not need to suffer a painful death. Today’s pain management techniques can provide relief for up to 95 percent of patients, thus offering true death with dignity.1, 2, 3 In addition, these same techniques can lessen pain and other symptoms for all patients. Another alternative is palliative care through hospice, which addresses the physical, emotional and spiritual needs of dying patients and their families.
- Physician-assisted suicide ignores what may be a legitimate cry for help.
Suicidal thoughts often indicate the presence of severe depression. A study of terminally ill hospice patients found only those diagnosed with depression considered suicide or wished death would come early. Patients who were not depressed did not want to die.4 Depression can and should be treated.
- Physician-assisted suicide gives too much power to doctors.
Assisted suicide does not give the patient autonomy. It gives the power to the doctor. The doctor essentially decides if you live or die, and doctors can make mistakes. Consider a survey of Oregon physicians published in the February 1, 1996, issue of New England Journal of Medicine. Researchers found one half of the physicians responding were not confident they could predict that a patient had less than six months to live. One third were not certain they could recognize depression in a patient asking for a lethal dose of medication. Yet, these are the same doctors who, under Oregon’s law legalizing physician-assisted suicide, are allowed to assist in a patient’s death if they can recognize depression and predict patient death within six months.
- The practice of physician-assisted suicide threatens to destroy the delicate trust relationship between doctor and patient.
Every day patients demonstrate their faith in the medical profession by taking medications and agreeing to treatment on the advice of their physicians. Patients trust that the physicians’ actions are in their best interest with the goal of protecting life. Physician-assisted suicide endangers this trust relationship.
- Physician-assisted suicide opens the door to euthanasia abuses.
Allowing physicians to cross the line into killing does not stop with willing patients who request it. A case in point is in The Netherlands where doctors have practiced physician-assisted suicide and euthanasia for more than a decade. Two Dutch government reports, conducted in 1990 and 1995, found that, on average, 26 percent of euthanasia deaths in Holland were “without the explicit consent of the patient.” In 1995, 21 percent of the patients who were killed without consent were competent.5, 6
Dutch physicians have also extended the practice of euthanasia to include comatose patients, handicapped infants and healthy but depressed adults. In 1996, a Dutch court found a physician guilty of euthanizing a comatose patient at the request of the patient’s family. Although the court determined the patient was not suffering and did not ask to die, the doctor was not punished.7
In 1995, Dutch physician Henk Prins was convicted of giving a lethal injection to a baby born with a partly formed brain and Spina bifida. The court refused to punish Prins.8 Likewise, though psychiatrist Boudewijn Chabot was found guilty in 1994 of prescribing a fatal dose of sleeping pills for a woman who was suffering from depression, Chabot was not penalized.9 That same year, the Dutch Supreme Court ruled that physician-assisted suicide might be acceptable for patients with unbearable suffering but no physical illness. A 1996 survey of Dutch psychiatrists found 64 percent of those responding “thought physician-assisted suicide for psychiatric patients could be acceptable.”10
1K.M. Foley, “The Treatment of Cancer Pain,” The New England Journal of Medicine (1985): 313, pp. 84-95. 2I.R. Byock, “Kevorkian: Right Problem, Wrong Solution” [Letter to the Editor], The Washington Post, January 1994, p. A23. 3D. Colburn, “Assisted Suicide: Doctors, Ethicists Examine the Issues of Pain Control, Comfort Care and Ending Life,” The Washington Post, 14 September 1993, p. Z7. 4S. Barakat, J.H. Brown, P. Henteleff, C.J. Rowe, “Is It Normal for Terminally Ill Patients to Desire Death?” American Journal of Psychiatry (1986): 143:2, pp. 208-211. 5P.J. Van Der Maas, J.J.M. Van Delden, L. Pijenborg, Euthanasia and Other Medical Decisions Concerning the End of Life (Amsterdam: Elsevier Science Publishers, 1992), pp. 73, 75, 181-182. 6P.J. Van Der Maas, G. Van Der Wal, I. Haverkate, et al. “Euthanasia, Physician Assisted Suicide, and Other Medical Practices Involving the End of Life in the Netherlands, 1990-1995,” New England Journal of Medicine (1996): 335, pp. 1699-1705. 7“The Dutch Guidelines,” Newsday, 1997, p. A6. 8“Doctor Freed in ‘Justified’ Mercy Killing,” Chicago Tribune, 27 April 1995, p. N21; “Murder Charge Proved Against Euthanasia Doctor, but Case Dismissed,” Associated Press, 27 April 1995. 9“Doctor Unpunished for Dutch Suicide,” New York Times, 22 June 1994, p. 10A. 10J.H. Groenewoud, P.J. Van der Maas, G. Van Der Wal, et al., “Physician-Assisted Death in Psychiatric Practice in the Netherlands,” New England Journal of Medicine(1997): 336, p.1796.
This article was originally posted in June 1996.
Carrie Gordon Earll is the Senior Policy Analyst for Bioethics at CitizenLink (an affiliate of Focus on the Family) and a fellow with the Center for Bioethics and Human Dignity.