argumentative essay on assisted suicide

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 is a food, health, and lifestyle writer.

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The Argument for Assisted Suicide

A variety of arguments have been made in support of the legalization of assisted suicide. While different arguments may resonate more deeply with some people than with others, all of the points discussed here are valid parts of the intense debate that exists surrounding the topic of euthanasia.

One of the most well known arguments presented by advocates of assisted suicide is the right to die. The United States government grants its citizens most fundamental rights as an inherent part of liberty. In fact, the Ninth Amendment to the United States Constitution grants all fundamental rights not already granted in other parts of the Constitution. It is clear, then, why there is such a strong case for Americans to possess the right to die.

According to RighttoDie.uslegal.com , the right to die is defined as, “various issues related to the decision of whether an individual should be allowed to die, when s/he could continue to live with the aid of life support, or in a diminished or enfeebled capacity.” In essence, it means that a person should legally be allowed to commit suicide before dying a natural death or even refuse to receive care that would extend their life.

The right to die is one of the most prevalent arguments for the legalization of euthanasia.

There is, however, contradictory regulation that seems to exclude the right to die from the ninth amendment, at least from a medical professional’s perspective. The Hippocratic Oath , which has been used by physicians as a code of ethics for more than two thousand years, is generally taken by all physicians. Part of the oath reads: “I will follow that method of treatment, which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to anyone if asked, nor suggest any such counsel.”

Some argue, however, that the Hippocratic Oath is outdated and is in large no longer appropriate in a medical world that has witnessed tremendous technological and political change. Still others, including Dr. Philip Nitschke, assert that, just as other parts of the oath have been adapted for modern to meet standards, the phrase “do no harm” is in dire need of reevaluation. He questions:

“Does not doing harm mean that we should prolong a life that the patient sees as a painful burden? Surely, the ‘harm’ in this instance is done when we prolong the life, and ‘doing no harm’ means that we should help the patient die.”

Dr. Nitschke’s logic here is sound, yet disputable (we’ll get to that next week). Ultimately, advocates argue that the a literal interpretation of the oath does not aptly represent the principles applied to legal controversies today, and that if we were to abide by such a literal interpretation, practices such as abortion and any type of surgery at all would also be prohibited.

Scholars widely believe that the ancient Greek physican Hippocrates or one of his students wrote the oath

Pallative care is a widely used term in the euthanasia debate. BBC defines palliative care as, “physical, emotional and spiritual care for a dying person when cure is not possible.” The question is whether it is possible that achieve such quality in palliative care is enough to prevent a person from feeling any need to contemplate euthanasia. Since, in all likelihood, not all symptoms can be mollified, the question of whether of not legalizing euthanasia would undermine the quality of palliative care that hospice patients receive.

Advocates for the legalization of assisted suicide contend that euthanasia in no way precludes doctors from providing the best palliative care to suffering patients. In fact, if anything, it enables them demonstrate respect for the patient’s autonomy. Administering euthanasia is not, they say, an easier option for caregivers than providing palliative care, as some critics suggest. As Dr. Evert van Leeuwen puts it, “There is no ‘either-or’ with respect to these options. Every appropriate palliative option available must be discussed with the patient and, if reasonable, tried before a request for assisted death can be accepted.”

Palliative care is an important consideration in the debate surrounding euthanasia.

In many cases, arguments against assisted suicide reference euthanasia as a slippery slope to murder or make an analogy between murder and euthanasia. Murder, however, infringes on a person’s rights by taking away the essential element of choice. No such infringement exists when it is the person who chooses death. In the midst of heated arguments, some have even ventured to say that those who argue to preserve life are removed from the decision, as they are not experiencing the consequences of the patient’s illness first hand. Besides, a 2005 study conducted in the Netherlands suggests that only 0.4% of euthanasia was administered without consent from the patient.

For proponents of assisted suicide, the ultimate assessment of the debate is that, as autonomous beings, people deserve the right to determine their own death in the face of irrepressible pain and suffering. Death is one of the most personal events in life. As highly acclaimed author and right-to-die activist Jack Kevorkian put it, “death is not a crime.” In many states, however, this statement is being put to the test.

Renowned pathologist Jack Kevorkian

2 thoughts on “ The Argument for Assisted Suicide ”

One of the interesting aspects of this argument is the debate about the legality of suicide. If assisted suicide is not legal, I feel that people who want to end their suffering and commit suicide will still do so, just in other manners. Therefore, I think either way, the patient is going to do what they want, and accomplish the task they set out to do. If they are told that they cannot end their life medically, I believe that some will then in turn shoot themselves, hang themselves, or even poison themselves in order to accomplish the same task. Therefore, the argument gets fishy when discussing the legality of suicide.

The addition of palliative care to the euthanasia debate certainly adds and interesting twist. Ideally, perfect palliative care would prevent a patient from even considering euthanasia because they would not be in pain and would be peacefully preparing emotionally for death. However, with the malicious nature of most terminal illnesses, this is often not the case. If one argues that people truly have the right to die as they wish, then the option of palliative care must be explored before assisted suicide can even be considered. Under the Hippocratic Oath, palliative care is definitely the better option as it does not attempt to prolong life but still upholds the underlying respect for life.

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What Is the Debate Over Physician-Assisted Suicide?

The debate over the ethics and legality of physician-assisted suicide (PAS) is a long-standing and highly charged one. Notable legal challenges in the United States include Washington v. Glucksberg  and Vacco v. Quill, both in 1997 and both of which upheld bans on PAS in Washington State and New York.

On the opposite side of the debate, Oregon enacted the first law legalizing PAS with the passing of the Oregon Death with Dignity Act in 1994. Since then, California, Colorado, Hawaii, Maine, Montana, New Jersey, New Mexico, Vermont, Washington, and Washington D.C. joined Oregon in enacting similar legislation.

Abroad, PAS in various forms (and with various restrictions) is currently legal in Australia, Austria, Belgium, Canada, Colombia, Ecuador, Germany, Jersey, the Netherlands, New Zealand, Portugal, Scotland, and Spain. Though attempts were made to lift assisted suicide bans, it is still illegal in Denmark, England, France, Ireland, South Africa, Switzerland, and Wales, among others.

This article takes a look at both sides of the debate over physician-assisted suicide, including the "morality" of PAS and whether it violates or supports the Hippocratic Oath ("first, do no harm").

What Is Physician-Assisted Suicide?

Physician-assisted suicide (PAS) is defined as the voluntary termination of one's own life by the administration of a lethal substance with the direct or indirect assistance of a physician . In the United States, a physician is a licensed practitioner with a doctor of medicine (MD) or doctor of osteopathic medicine (DO)  degree.

PAS is not the same thing as euthanasia . Euthanasia takes place when a physician performs the intervention; with PAS, the physician provides the necessary means and the patient performs the act.

There are arguments for and against PAS based on ethics (the designated code of conduct for professions like medicine), mortality (the subjective designation of right or wrong), and legality (the interpretation of law).

Legal Challenges to Consent Laws

Many who opposed PAS are concerned that if assisted suicide is allowed, euthanasia won't be far behind and may lead to "mercy killings" in which people are euthanized without consent. These include people who are on life support, have serious mental illness, or are otherwise unable to grant informed consent for such actions.

Those who endorse PAS consider such conjecture inflammatory, arguing that the enactment of such laws goes against every constitutional law in place to ensure patient autonomy and self-determination. This includes the right to refuse or accept any medical procedure protected by the Due Process Clause of the Fourteenth Amendment.

Proponents of PAS further argue that a ban on assisted suicide restricts a patient's right of self-determination, namely by denying the choice to "die with dignity."

Moreover, physicians are not required by law to assist in the ending of a patient's life. They can conscientiously refuse and are protected by law to do so.

Violation of the Hippocratic Oath

The Hippocratic Oath is an oath of ethics historically taken by physicians that was written between the fifth and third centuries BC. Central to the oath is the phrase primum non nocere (meaning “first, do no harm”).

Opponents of PAS believe that the participation of a physician in a patient's suicide is the definition of harm and directly contradicts the oath. Doing so, they argue, is equivalent to "killing" or "murder."

Proponents of PAS argue that "death" and "harm" are not synonymous and neither are "suicide" and "murder." Many of these terms are legally defined and, as such, are not seen to be equivalent in the eyes of the law.

Countering this argument is the word "harm," which is legally defined as the "loss or damage of a person's physical well-being." While this may suggest the loss of life is "harm," the Hippocratic Oath is ultimately a principle rather than and law and the use of the term in the context is subject to debate.

Limit of Patient Autonomy

It was determined in the case of Bouvia v. Superior Court in 1986 that “the right to die is an integral part of our right to control our own destinies so long as the rights of others are not affected.”

The lawyers for Elizabeth Bouvia, a young quadriplegic woman who suffered from cerebral palsy , successfully argued that a person could not be forced to stay alive (in this case, through forced feeding) if their quality of life is severely and irreparably in decline. Doing so essentially deprives a patient of autonomy, including the right to die.

Opponents of PAS, many of whom would oppose forced feeding, nevertheless regard the Bouvia case and PAS as non-equivalent. Central to the argument is that PAS is not a completely autonomous act; it requires the assistance of another person.

Proponents of PAS counter that there is equivalence and that forcing a person to live with extreme, intractable suffering is unethical. By denying PAS, these same individuals may be forced to take extreme and violent actions to end their lives (and possibly fail).

Alternatives Make PAS Unnecessary

Palliative care is the practice of increasing comfort and easing pain and physical and emotional suffering in people with severe illness. Hospice care is a form of palliative care where comfort and pain control are provided when life-extending treatment is no longer desired.

Proponents of PAS argue that palliative and hospice care are humane and provide people the means to die with dignity if they are terminally ill.

Opponents of PAS counter that this excludes many with severe illnesses who will not improve and are exposed to needless suffering. They argue that PAS is an entirely different issue unrelated to palliative or hospice care.

Under the law, only people with six months or less to live are afforded coverage under Medicare and most other insurance. Palliative care can last for years. PAS, on the other hand, is the legal means to end a person's suffering whose life may or may not end soon.

Moreover, some people in hospice care choose to stop life-extending treatment because of the financial burden it places on their families. Supporters of PAS contend that the same choice should be afforded to people with severe, intractable illnesses who may also want to protect their families from financial harm.

Risk of 'Suicide Contagion'

Suicide contagion is an increase in suicide and suicidal behaviors as a result of exposure to suicide or suicidal behaviors within one’s family, from peers, or through media reports.

Opponents of PAS argue that providing a person with the legal means to end their life may promote suicide as a "solution" and encourage others to do the same.

Proponents of PAS point out that suicide contagion is not associated with a desire to end one's life for long-standing medical reasons but rather a response to emotional trauma, such as the suicide of someone the person was close to.

Studies investigating suicide rates after the passing of PAS laws have thus far found no association. A multi-center review of studies published in 2022 concluded that "no study has found a negative association between assisted suicide and non-assisted suicide."

In fact, one study from Oregon found a reduction in suicide rates among other males following the passage of that state's law.

In addition, there is no evidence that people "rush" to get PAS once laws are enacted. While the number of assisted suicides in Oregon has increased from 16 in 1998 to 278 in 2023, the rate of increase has been slow and gradual. Over 25 years, only 2,454 assisted suicides have been performed in the state.

PAS May Benefit Insurers and Others

There are some who argue that PAS will benefit insurers who can "save money" by avoiding the cost of life-extending treatments that could last for years. Over time, insurers may not only promote PAS to their patients but encourage it.

To date, there is no evidence of that occurring. While it is true that the cost of treating an illness like cancer can cost tens of thousands of dollars (and sometimes more), there is little evidence that insurers are "eager" to fund PAS.

A study published in the American Journal of Public Health found that many insurers will not cover the cost of a lethal dose of Seconal (secobarbital), a barbiturate drug most commonly used in PAS. As such, people are more often denied access to PAS due to the cost, particularly poor people.

Federal law currently prohibits Medicare, Medicaid, or any other government insurance from paying for or covering any expense associated with assisted suicide even in states where PAS is allowed.

Moreover, given the relatively modest number of patient-assisted suicides to date—as of 2022, 2,422 in California, 2,454 in Oregon, 291 in Washingon, 246 in Colorado, and 17 in Vermont—there is currently no indication that insurance practices have shifted from life-extending treatments to PAS.

Patient's Judgement May be Clouded by Depression

A concern frequently shared among people whose loved ones chose to stop life-saving treatment is that they are "just depressed" and will eventually change their minds.

The same concerns are shared among many opponents of PAS who express fears that not enough may be done to screen people for depression and other psychiatric illnesses who might otherwise avoid PAS if they are properly treated.

While it is true that a person with severe, intractable illness is almost certain to have a certain degree of anxiety or depression, proponents of PAS argue that the medical workup prior to the approval of PAS is extensive and intended to take that into account.

In California, for example, a person wanting to pursue PAS must be evaluated by a psychiatrist or licensed psychologist in addition to obtaining a confirmed diagnosis of a terminal illness with a life expectancy of less than months. Some states require multiple diagnoses from multiple providers.

To date, less than 1% of people who underwent PAS in Oregon were diagnosed with a mental illness. However, all were diagnosed with a terminal illness in which they were expected to live for less than six months.

Physician-assisted suicide remains a hotly contested topic despite laws allowing for it in 10 U.S. states and the District of Columbia. Arguments for and against assisted suicide include limits on patient autonomy, interpretation of the Hippocratic Oath, insurance coercion, whether current regulations are sufficient or lacking, and how current laws may affect future ones.

Connecticut General Assembly. Suicide - assisted: court cases; federal laws/regulations .

Patients Rights Council. Assisted suicide laws in the United States .

Congress.gov. Amdt14.S1.6.5.1 Right to Refuse Medical Treatment and Substantive Due Process .

Ahlzen R. Suffering, authenticity, and physician assisted suicide . Med Health Care Philos. 2020;23(3):353–359. doi:10.1007/s11019-019-09929-z

American Medical Association. Bouvia v. Superior Court: quality of life matters .

National Institute on Aging.  What are palliative care and hospice care?

Centers for Medicare and Medicaid Services.  Medicare Hospice Benefits .

Doherty AM, Axe CJ, Jones DA. Investigating the relationship between euthanasia and/or assisted suicide and rates of non-assisted suicide: systematic review . BJPsych Open. 2022 Jul;8(4):e108. doi:10.1192/bjo.2022.71

Regnard C, Worthington A, Finlay I. Oregon Death with Dignity Act access: 25 year analysis , BMJ Support Palliat Care . 2023 Oct 3:spcare-2023-004292. doi:10.1136/spcare-2023-004292

Buchbinder M. Access to aid-in-dying in the United States: shifting the debate from rights to justice . Am J Public Health. 2018 June;108(6):754–759. doi:10.2105/AJPH.2018.304352

Centers for Medicare and Medicaid Services. Assisted Suicide Funding Restriction Act of 1997 .

CNN. Physician-assisted suicides fast facts .

National Academies of Sciences, Engineering, and Medicine. Conceptual, legal, and ethical considerations in physician-assisted death . In: Physician-Assisted Death: Scanning the Landscape: Proceedings of a Workshop . Washington, D.C.: National Academies Press; 2017.

Braverman D, Marcus B, Wakim P, Mercurio M, Kopf G. Healthcare professionals’ attitudes about physician-assisted death: An analysis of their justifications and the roles of terminology and patient competency . Journal of Pain and Symptom Management .  2017 Oct;54(4):538-545.e3. doi:10.1016/j.jpainsymman.2017.07.024

Centers for Disease Control and Prevention. Hospice care. Updated 07/06/16.

Emanuel EJ, Onwuteaka-Philipsen BD, Urwin JW, Cohen J. Attitudes and practices of euthanasia and physician-assisted suicide in the United States, Canada, and Europe . JAMA . 2016 Jul 5;316(1):79-90. doi:10.1001/jama.2016.8499. Erratum in: JAMA. 2016 Sep 27;316(12):1319

By Angela Morrow, RN Angela Morrow, RN, BSN, CHPN, is a certified hospice and palliative care nurse.

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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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• Peer review
• Ole Hartling , former chairman
• Danish Council of Ethics, Denmark
• hartling{at}dadlnet.dk

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 they affect other people. Although healthy people find it difficult to imagine themselves in situations where they do not decide freely, it is also true that all of us are vulnerable and dependent on others.

Yet autonomy in relation to assisted dying is often viewed in the same way as our fundamental right to choose our own course in life. If we are able to control our lives, then surely we can also control our death. Autonomy with respect to your own death, however, is already halved: you can choose to die if you don’t want to live, but you cannot choose to live if you are about to die.

Decisions about your own death are not made in normal day-to-day contexts. The wish to die arises against a backdrop: of desperation, a feeling of hopelessness, possibly a feeling of being superfluous. Otherwise, the wish would not be there. Thus, it is under these circumstances that the right to self-determination is exercised and the decision is made. Such a situation is a fragile basis for autonomy and an even more fragile basis for decision making. The choice regarding your own death is therefore completely different from most other choices usually associated with the concept of autonomy.

Here are just some of the critical matters that would arise if assisted dying were legalised.

A duty to die

The possibility of choosing to die would inhabit everyone’s consciousness—the patient, the doctor, the relatives, and the care staff—even if not formulated as an out-and-out offer. But if a law on assisted dying gives the patient a right to die, that right may turn into a duty to die. How autonomously can the weakest people act when the world around them deems their ill, dependent, and pained quality of life as beyond recovery?

Patients can find themselves directly or indirectly under duress to choose that option if they consider themselves sufficiently pained and their quality of life sufficiently low. Patients must be at liberty to choose assisted dying freely, of course—that is how it is presented—but the point is that the patient cannot get out of having to choose. It has been called the “prison of freedom.”

Internalised external pressure

Pressure on the patient does not have to be direct or articulated. As pointed out by the US professor of biomedical ethics Daniel Sulmasy it may exist as an “internalised external pressure.” 2 Likewise, the French bioethicist Emmanuel Hirsch states that individual autonomy can be an illusion. The theologian Nigel Biggar quotes Hirsch saying that a patient “may truly want to die, but this desire is not the fruit of his freedom alone, it may be—and most often is—the translation of the attitude of those around him, if not of society as a whole which no longer believes in the value of his life and signals this to him in all sorts of ways. Here we have a supreme paradox: someone is cast out of the land of the living and then thinks that he, personally, wants to die.” 3

The end of autonomy

An inherent problem of autonomy in connection with assisted dying is that a person who uses his or her presumed right to self-determination to choose death definitively precludes himself or herself from deciding or choosing anything. Where death is concerned, your right to self- determination can be exerted only by disposing of it for good. By your autonomy, in other words, you opt to no longer have autonomy. And those around must respect the right to self-determination. The respect refers to a person who is respected, but this is precisely the person who disappears.

Danish philosopher Johannes Sløk, who supported legalisation, said, “The actual concept of death has no content, for death is the same as nothing, and one cannot choose between life and nothing. Rather, therefore, one must speak of opting out; one opts out of life, without thereby choosing anything else. Death is not ‘something other’ than life; it is the cessation or annihilation of life.”

Autonomy is a consistent principle running through the care and management of patients and is enshrined in law. However, a patient’s autonomy means that he or she has the right to decline any treatment. It does not entail a right to have any treatment the patient might wish for. Patients do not have the right to demand treatment that signifies another’s duty to fulfil that right. If that were so, autonomy would be the same as “autocracy”—rule of the self over others. Even though patients have the right to reject any intervention, they do not have the right to demand any intervention. Rejecting any claim that the person might make is not a violation of a patient’s self- determination—for example, there may be sound medical reasons for not complying with a demand. The doctor also has autonomy, allowing him or her to say no. Refusing to kill a person or assist in killing cannot be a violation of that person’s autonomy.

The killing ban

Assisted dying requires the doctor’s moral and physical help. It is a binding agreement between two people: the one who is to be killed and the one who is to kill or assist in killing. But our society does not condone killing as a relationship between two legally competent, consenting people. Exemptions from the killing ban involve war or self-defence and are not justified on the grounds that the killing is done for the “benefit” of someone else.

Valuation of a life

If the action is to be decriminalised, as some people wish, it means the doctor will have to enter into deliberations and arguments for and against a request for assisted dying each time. That is, whether he or she is willing to grant it. The alternative would be to refer the patient to another doctor who might be willing to help—that doctor would still have to assess whether the patient’s life was worth preserving.

Thus, autonomy is not the only factor or even always the key factor when deciding whether assisted dying can be granted. It is not only the patient’s own evaluation that is crucial. The value of the patient’s life must also be assessed as sufficiently low. This demonstrates the limitation of the patient’s self-determination.

Relieving suffering

If a competent and legally capable person must have the option of voluntarily choosing assisted dying in the event of unbearable suffering, why does suffering have to be a requirement? The answer is straightforward: our concepts of assisted dying imply that compassion must form a crucial aspect of the decision—mercy killing and compassionate killing are synonyms. But this leads instantly to the question of why we should not also perform assisted dying on people who are not in a position to ask for it themselves but are also suffering.

Some people find the reasoning unproblematic. It stands to reason that relieving suffering is a duty after all. But in this context it is not unproblematic, because it effectively shifts the focus from the autonomy claimed. According to prevailing ideas about autonomy, patients initially evaluate their quality of life themselves, but ultimately it is those around them who end up gauging that quality and the value of their life. That is to say, the justification for assisted dying is borne on the premise that certain lives are not worth living rather than the presence of a request. The whole point is that in the process, respect for the right to self-determination becomes relative.

Autonomy is largely an illusion in the case of assisted dying. 1 A patient overwhelmed by suffering may be more in need of compassion, care, and love than of a kind offer to help end his or her life. It is not a question of whether people have a right to say that they are unworthy. It is a question of whether they have a right to be believed when saying it.

Ole Hartling is a physician of over 30 years standing, doctor of medical sciences at the University of Copenhagen, professor of health promotion at the University of Roskilde, and an author and co-author of several books and scientific articles published mainly in Scandinavia. Between 2000 and 2007 he was a member of the Danish Council of Ethics and its chair for five years. During this time, the council extensively debated the ethics of euthanasia and assisted dying.

Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

• Gastmans C ,
• MacKellar C

We have a right to die with dignity. The medical profession has a duty to assist

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Euthanasia represents one of the oldest issues in medical ethics. It is forbidden in the original Hippocratic Oath, and has consistently been opposed by most religious traditions since antiquity – other than, incidentally, abortion, which has only been formally banned by the Catholic Church since the middle of the 19th century.

Euthanasia is a wide topic with many dimensions. I will limit myself in this article to the issue of assisted death, which seems to me to be one of the most pressing issues of our time.

Desmond Tutu, emeritus archbishop of Cape Town, raised it again on his 85th birthday in an article in the Washington Post. He wrote:

I have prepared for my death and have made it clear that I do not wish to be kept alive at all costs. I hope I am treated with compassion and allowed to pass onto the next phase of life’s journey in the manner of my choice.

Assisted death can take the form of physician assisted suicide (PAS) . Here a suffering and terminal patient is assisted by a physician to gain access to a lethal substance which the patient himself or herself takes or administers. If incapable of doing so, the physician – on request of the patient – administers the lethal substance which terminates the patient’s life.

The latter procedure is also referred to as “voluntary active euthanasia” (VAE). I will not deal with the issue of involuntary euthanasia –where the suffering patient’s life is terminated without their explicit consent -– a procedure which, to my mind, is ethically much more problematic.

Passive form of euthanasia

The term “voluntary active euthanasia” suggests that there also is a passive form of euthanasia. It is passive in the sense that nothing is “actively” done to kill the patient, but that nothing is done to deter the process of dying either, and that the termination of life-support which is clearly futile, is permitted.

However, the moral significance of the distinction between “active” and “passive” euthanasia is increasingly questioned by ethicists. The reason simply is the credibility of arguing that administering a lethal agent is “active”, but terminating life support (for example switching off a ventilator) is “passive”. Both clearly are observable and describable actions, and both are the direct causes of the patient’s death.

There are a number of reasons for the opposition to physician assisted suicide or voluntary active euthanasia. The value bestowed on human life in all religious traditions and almost all cultures, such as the prohibition on murder is so pervasive that it is an element of common, and not statutory, law.

Objections from the medical profession to being seen or utilised as “killers” rather than saviours of human life, as well as the sometimes well-founded fear of the possible abuse of physician assisted suicide or voluntary active euthanasia, is a further reason. The main victims of such possible abuse could well be the most vulnerable and indigent members of society: the poor, the disabled and the like. Those who cannot pay for prolonged accommodation in expensive health care facilities and intensive care units.

Death with dignity

In support of physician assisted suicide or voluntary active euthanasia, the argument is often made that, as people have the right to live with dignity, they also have the right to die with dignity. Some medical conditions are simply so painful and unnecessarily prolonged that the capability of the medical profession to alleviate suffering by means of palliative care is surpassed.

Intractable terminal suffering robs the victims of most of their dignity. In addition, medical science and practice is currently capable of an unprecedented prolongation of human life. It can be a prolongation that too often results in a concomitant prolongation of unnecessary and pointless suffering.

Enormous pressure is placed upon both families and the health care system to spend time and very costly resources on patients that have little or no chance of recovery and are irrevocably destined to die. It is, so the argument goes, not inhumane or irreverent to assist such patients – particularly if they clearly and repeatedly so request – to bring their lives to an end.

I am personally much more in favour of the pro-PAS and pro-VAE positions, although the arguments against do raise issues that need to be addressed. Most of those issues (for example the danger of the exploitation of vulnerable patients) I believe, can be satisfactorily dealt with by regulation.

Argument in favour of assisted suicide

The most compelling argument in favour of physician assisted suicide or voluntary active euthanasia is the argument in support of committing suicide in a democracy. The right to commit suicide is, as far as I am concerned, simply one of the prices we have to be willing to pay as citizens of a democracy.

We do not have the right, and we play no discernible role, in coming into existence. But we do have the right to decide how long we remain in existence. The fact that we have the right to suicide, does not mean that it is always (morally) right to execute that right.

It is hard to deny the right of an 85-year-old with terminal cancer of the pancreas and almost no family and friends left, to commit suicide or ask for assisted death. In this case, he or she both has the right, and will be in the right if exercising that right.

Compare that with the situation of a 40-year-old man, a husband and father of three young children, who has embezzled company funds and now has to face the music in court. He, also, has the right to commit suicide. But, I would argue, it would not be morally right for him to do so, given the dire consequences for his family. To have a right, does not imply that it is always right to execute that right.

My argument in favour of physician assisted suicide or voluntary active euthanasia is thus grounded in the right to suicide, which I think is fundamental to a democracy.

Take the case of a competent person who is terminally ill, who will die within the next six months and has no prospect of relief or cure. This person suffers intolerably and/or intractably, often because of an irreversible dependence on life-support. This patient repeatedly, say at least twice a week, requests that his/her life be terminated. I am convinced that to perform physician assisted suicide or voluntary active euthanasia in this situation is not only the humane and respectful, but the morally justified way to go.

The primary task of the medical profession is not to prolong life or to promote health, but to relieve suffering. We have a right to die with dignity, and the medical profession has a duty to assist in that regard.

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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.

The debate was judged on the logic, coherence, and evidence in arguments, as well as flair in presentation. Although the debaters may not have necessarily agreed with their allocated side, the debate format required them to acknowledge a particular school of thought and present the key arguments behind it. Oxford, who opposed the motion, was awarded the victory in the debate; however, this does not mean that the judges believe that position ought to become public policy.

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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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Arguments against Euthanasia and Physician Assisted Suicide

This essay about the ethical and societal concerns surrounding euthanasia and physician-assisted suicide (PAS) examines the significant implications of legalizing these practices. It highlights how such measures could potentially undermine trust in the medical profession, where doctors are traditionally seen as protectors of life. The piece also explores the slippery slope argument, suggesting that expanding criteria for euthanasia could diminish the focus on improving mental health and palliative care. Additionally, it addresses the risks of coercion and undue influence on vulnerable individuals, emphasizing the need to protect those who might feel pressured into making life-ending decisions. Cultural and religious perspectives on the sanctity of life are discussed, reinforcing the idea that interventions should prioritize enhancing life quality rather than hastening death. The essay argues for strengthening support systems that enhance life quality for all individuals.

How it works

Euthanasia and physician-assisted suicide (PAS) have sparked intense debate across various spheres of society, raising complex ethical questions and concerns about the implications of such practices. Despite arguments favoring the right to die with dignity, there are robust counterpoints that caution against the adoption of these measures.

One of the foremost concerns is the integrity and fundamental role of the medical profession. Historically, the ethos of healthcare providers is to preserve life and alleviate suffering without causing harm. Introducing the practice of ending life as a medical option could potentially warp this perception, leading to a diminished trust in healthcare professionals.

Such a shift might make patients question whether their well-being is genuinely at the forefront of their doctor’s priorities.

Additionally, there’s the slippery slope argument. Initially intended for terminal illnesses, the criteria for euthanasia and PAS might gradually expand to include less critical conditions, potentially normalizing suicide as a solution for various lesser adversities. This could lead to a reduction in the development and funding of comprehensive mental health and palliative care services, which are crucial for improving quality of life.

Vulnerability and coercion are also significant ethical issues. There’s a real danger that societal, economic, or familial pressures could influence an individual’s decision-making capacity regarding their own life. Particularly at risk are those in socioeconomically disadvantaged situations, the elderly, or those with disabilities, who might feel an undue burden to opt for euthanasia or PAS.

Furthermore, many cultural and religious frameworks uphold the sanctity of life, advocating for natural death processes. These perspectives argue that the act of taking life, regardless of the circumstances, conflicts with the intrinsic value attributed to human existence. This viewpoint maintains that life should be preserved and that interventions should focus on support and palliative care, enhancing life quality rather than shortening its duration.

In essence, while the argument for euthanasia and PAS might seem to offer a compassionate choice for those suffering, it’s imperative to consider the broader ethical, cultural, and social ramifications. Strengthening systems that support life quality at all stages should be a priority, ensuring that decisions about life’s end are made with the utmost care and integrity.

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• Open access
• Published: 13 April 2024

Assisted dying: principles, possibilities, and practicalities. An English physician’s perspective

• Robert Twycross 1 , 2  

BMC Palliative Care volume  23 , Article number:  99 ( 2024 ) Cite this article

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It seems probable that some form of medically-assisted dying will become legal in England and Wales in the foreseeable future. Assisted dying Bills are at various stages of preparation in surrounding jurisdictions (Scotland, Republic of Ireland, Isle of Man, Jersey), and activists campaign unceasingly for a change in the law in England and Wales. There is generally uncritical supportive media coverage, and individual autonomy is seen as the unassailable trump card: ‘my life, my death’.

However, devising a law which is ‘fit for purpose’ is not an easy matter. The challenge is to achieve an appropriate balance between compassion and patient autonomy on the one hand, and respect for human life generally and medical autonomy on the other. More people should benefit from a change in the law than be harmed. In relation to medically-assisted dying, this may not be possible. Protecting the vulnerable is a key issue. Likewise, not impacting negatively on societal attitudes towards the disabled and frail elderly, particularly those with dementia.

This paper compares three existing models of physician-assisted suicide: Switzerland, Oregon (USA), and Victoria (Australia). Vulnerability and autonomy are discussed, and concern expressed about the biased nature of much of the advocacy for assisted dying, tantamount to disinformation. A ‘hidden’ danger of assisted dying is noted, namely, increased suffering as more patients decline referral to palliative-hospice care because they fear they will be ‘drugged to death’.

Finally, suggestions are made for a possible ‘least worse’ way forward. One solution would seem to be for physician-assisted suicide to be the responsibility of a stand-alone Department for Assisted Dying overseen by lawyers or judges and operated by technicians. Doctors would be required only to confirm a patient’s medical eligibility. Palliative-hospice care should definitely not be involved, and healthcare professionals must have an inviolable right to opt out of involvement. There is also an urgent need to improve the provision of care for all terminally ill patients.

Peer Review reports

The Parliamentary Office of Science and Technology in the United Kingdom (UK) defines Assisted Dying (AD) as:

The involvement of healthcare professionals in the provision of lethal drugs intended to end a patient’s life at their voluntary request, subject to eligibility criteria and safeguards. It includes healthcare professionals prescribing lethal drugs for the patient to self-administer (‘physician-assisted suicide’) and healthcare professionals administering lethal drugs (‘euthanasia’) [ 1 ].

This reflects the definitions used in medical and ethical literature, and will be used in this paper. However, confusingly, the pro-AD organization Dignity in Dying ( https://www.dignityindying.org.uk/ ) limits AD to physician-assisted suicide (PAS) in patients with a prognosis of less than 6 months. Equally confusing is the decision by the House of Commons Health and Social Care Committee (UK) to use of the term ‘assisted dying/assisted suicide’ (AD/AS) when talking about any type of physician-assisted death [ 2 ].

Historically, the demand for AD stems from the fact that the suffering of terminally ill people is not always relieved and, for some people, there is a level of existence below which they would wish to die. At present, AD is available in all or parts of around 12 countries [ 3 ], amounting to about 4% of the world’s population. In some, both PAS and euthanasia are permitted, in others just PAS. Eligibility criteria and safeguards vary.

This article focuses on England and Wales (E&W) where, over the last 20 years, numerous attempts have been made to legalize PAS. For those with reservations about such developments, it may seem that they have only two choices: either to ‘go with the flow’ or, conversely, actively campaign against any form of AD. However, there is a third option: active involvement in the debate, seeking positively to influence any proposed legislation. Devising a law which is ‘fit for purpose’ is definitely not an easy matter [ 4 ]. Existing AD laws are not uniform, and the consequences of legislation will depend on the model under consideration [ 3 ].

The over-riding utilitarian consideration is that more people should benefit from a change in the law than be harmed. In relation to AD, this may not be possible. At the very least, any AD law must aim to achieve an appropriate balance between compassion and patient autonomy on the one hand, and respect for human life generally and medical autonomy on the other. Protecting the vulnerable is a key issue. Likewise, not impacting negatively on societal attitudes towards the disabled and frail elderly, particularly those with dementia.

The present situation

Although the inquiry by the Health and Social Care Committee of the House of Commons in 2023 extended to AD generally [ 2 ], for more than 20 years all the Bills introduced into Parliament have been limited to PAS. For a cluster of reasons, it seems that some form of PAS is likely to become legal in E&W within the next few years. The very supportive media coverage gives the impression that PAS is ‘a concept whose time has come’. Pro-AD activists claim that there is overwhelming public support. Every few months, a celebrity announces their intention to avail themselves of the services of Dignitas in Switzerland when ‘the time comes’, with renewed extensive media attention. Individual autonomy (‘self-rule’) is regarded as an unassailable trump card: ‘my life, my death’. AD Bills are at various stages of preparation in neighbouring jurisdictions (Scotland, Republic of Ireland, Isle of Man, Jersey); this adds to the growing sense of inevitability [ 5 , 6 , 7 , 8 ].

Some surveys have suggested that over 80% of the population in the UK are in favour of AD, although a recent one limited to PAS gave the lower figure of 65% [ 9 ]. It should also be noted that, in a survey in 2021 on behalf of the UK All-Party Parliamentary Group for Dying Well, 10% of respondents thought AD meant providing hospice-type care to people who are dying, and 42% that it meant giving people who are dying the right to stop life-prolonging treatment. Fewer than half (43%) of respondents knew what the term ‘assisted dying’ actually meant [ 10 ]. This suggests that claims about the level of public support for AD should be interpreted with caution.

Existing models of physician-assisted suicide (PAS)

Switzerland, Oregon (USA), and Victoria (Australia) represent three models of PAS. In the USA, although the laws may not be completely identical in other states where PAS is permitted, they are all based on Oregon’s. Likewise in Australia, they are based on Victoria’s. Benelux and Canada will not be discussed because, in those countries, AD is almost always euthanasia.

In all three models, a doctor prescribes the lethal prescription after confirming the person has mental capacity, is aware of alternatives such as palliative-hospice care (PHC), the request is enduring, was not made under duress, and that the medical eligibility criteria are met. But in other respects, the models differ. In Switzerland, there is no prognostic limit, and no residency requirement. Suffering is not specifically mentioned in Oregon, just a prognosis of less than six months. Following a federal lawsuit in 2022, residency is no longer a requirement. In Victoria, residency and both suffering and a limited prognosis (generally six months but 12 months for neurodegenerative conditions) are prerequisites. The number of safeguards increases progressively across the three models.

Switzerland

In Switzerland, although four out of 26 cantons have laws concerning access to PAS in healthcare institutions, there is no federal law. However, it is possible throughout the country because of the wording in the Swiss Criminal Code (1942) which states that an offence is committed only if assistance is for selfish motives . In the absence of such motives, the assisting person is not criminally liable. Taking advantage of this loophole, two not-for-profit organisations called EXIT (German- and French-speaking, respectively) were set up in 1982 to facilitate PAS for residents in Switzerland with incurable progressive disease. Subsequently, Dignitas was set up to meet the needs of non-residents.

The Swiss Academy of Medical Sciences (SAMS) provides ethical guidance to doctors in its document Management of Dying and Death (revised 2022) [ 11 ]. The section on PAS is helpfully discussed within the general context of care of the dying. For example, it is stressed that:

‘The true role of physicians in the management of dying and death… involves relieving symptoms and supporting the patient. Their responsibilities do not include offering assisted suicide, nor are they obliged to perform it. Assisted suicide is not a medical action to which patients could claim to be entitled, even if it is a legally permissible activity’ [ 11 ].

The 2022 revised guidance has extended the eligibility for assisted suicide considerably. The former requirement that ‘the patient’s illness justifies the assumption that the end of life is near or can be expected to be near’ has been replaced by ‘the symptoms of disease and/or functional impairments are a source of intolerable suffering for the patient’ [ 11 ]. One reason for this change may be the fact that a review of practice from 1999 to 2018 indicated that over 50% of cases probably had not met the key criterion of a short life expectancy [ 12 ]. In this same period, the number of deaths by PAS rose steadily from 0.2 to 1.8% of all deaths [ 13 ].

For doctors willing to be involved, their role is limited to assessing the person’s decision-making capacity, confirming the constancy of their request, providing a statement about their medical condition, and subsequently prescribing a lethal dose of pentobarbital. The prescription is collected from the pharmacy by a volunteer from EXIT or Dignitas on the day of the assisted suicide. Most deaths take place at home or, in the case of Dignitas , in a room provided by the organisation. At present, because many hospices and palliative care units do not allow PAS on their premises, most patients return home for this. However, in French-speaking areas, hospitals increasingly allow PAS if a discharge is impractical. For those who return home, in case of a change of mind, their bed is kept available until confirmation of death has been received. Everything is carefully documented, and the police are notified immediately after the person has died.

Oregon’s Death with Dignity Act (DWDA) came into effect in 1997 and is held up by some as an example of how a PAS law can be safely enacted – described as ‘tried and trusted’ by Dignity in Dying . However, an analysis of the annual reports issued by the Oregon Health Authority between 1998 and 2023 gives grounds for caution [ 14 ]. Indeed, the Danish Ethics Council concluded recently that the Oregon model is not ‘sufficiently clear in [its] delineations, fair in [its] justifications for access, or sound in terms of control mechanisms’ [ 3 ].

Originally the DWDA was limited to residents but, in 2022, a federal lawsuit (brought by an Oregon doctor) forced a change which allows non-residents to access PAS within the state [ 14 ]. The DWDA allows people ≥ 18 years of age diagnosed with a terminal illness and expected to die within six months to end their lives through the self-administration of a lethal dose of drugs prescribed by a doctor. A Coordinating doctor and a Consulting (specialist) doctor determine whether the person is medically eligible, is not acting under duress, and that the request is enduring. The Oregon Health Authority must be informed when a prescription is written by the Coordinating doctor. The lethal dose can be collected by the patient or their representative and kept at home until the patient decides that the time has come to take it – without further reference to their doctor. In this model, there is no reference to ‘intolerable suffering’.

Only about 2/3 of the issued prescriptions are used. In Oregon over 25 years, the three most frequently reported end-of-life concerns behind the request for PAS have been a decreasing ability to participate in enjoyable activities (90%), loss of autonomy (90%), and loss of dignity (72%) – all more existential than medical. Inadequate pain control, or concern about it, featured in only 28%. Most patients (92%) died at home, and 91% were enrolled in hospice care (mostly home-based in the USA), although the nature and extent of that care is not specified [ 15 ].

In 2022, 146 doctors wrote 431 lethal prescriptions (1–51 prescriptions per doctor; most just one or two). Prescribing doctors were present at the time of death for 13% of the patients; other healthcare providers for another 13%, and volunteers for 18%. One patient died in hospital, and one in a hospice facility. Where known, time from ingestion until death ranged from 3 min to nearly 3 days, with a median time of 52 min. Almost all involved the drug combination DDMA (diazepam, digoxin, morphine, amitriptyline) ± phenobarbital. In 2022, AS accounted for 0.6% of all deaths.

In 2017, an unsuccessful Bill was introduced to allow surrogates to administer the drugs to those who had subsequently lost decisional capacity after receiving a lethal prescription, with proposals to extend the DWDA to allow euthanasia for those with dementia and those incapable of swallowing drugs.

Concern has been expressed that most of those dying by PAS are clients of Compassion and Choices , the AD advocacy organisation in Oregon, and discussion of alternatives may have been limited, particularly as the association between the patient and the prescribing doctor is sometimes < 1 week (median 3 months). A review of five patients whose details are in the public domain revealed inadequate exploration of their concerns and a bias in favour of PAS [ 16 ]. Further, despite a known incidence of depression of up to 40% in those with a genuine desire to hasten death, only three patients (0.7%) in 2022 were referred for psychological or psychiatric evaluation. Some patients have delayed ingesting the lethal medication for 2–4 years, thereby emphasizing the difficulty of determining the likely prognosis.

Victoria, Australia

The Voluntary Assisted Dying (VAD) law came into effect in 2019 [ 17 ]. Unlike Oregon, legislators had the benefit of 20 years of experience in other countries where AD Bills have been introduced and/or laws passed. As in Oregon, two doctors are involved: the Coordinating doctor, who initially informs the person about end-of-life-care options and supports, then assesses the person’s eligibility, and whether the request is voluntary and enduring; and the Consulting doctor, who re-assesses the patient’s request. Both doctors must be either a vocational general practitioner or a member of a specialist college, and one must have at least five years post-fellowship experience and experience in the patient’s condition.

Institutions can forbid VAD on their premises, and involvement by doctors is voluntary. Those volunteering must undertake the mandatory online ‘approved assessment training’ required by the law before they can participate [ 18 ]. Of those across the state who have volunteered, around 300 have ‘currently active’ profiles, representing about 1% of the total medical workforce; 60% are General Practitioners (GPs) [ 17 ]. Much of the work is unremunerated. Coordinating an application through to a patient’s death can take up to 60 h of a doctor’s time. As a result, because of inevitable time constraints, some doctors report undertaking less than ideal assessments and/or not being able to see their other patients because of the VAD workload [ 19 ].

Although the primary focus is PAS, the law extends to euthanasia (‘practitioner administration’) if a person is incapable of swallowing the medication. In this case, the lethal drugs are administered intravenously by the Coordinating doctor, who can delegate this duty to the Consulting doctor subject to agreement by both parties. The person must have an advanced, progressive, incurable disease or medical condition that is expected to cause death within six months, or 12 months for neurodegenerative conditions, and is causing suffering that cannot be relieved to an extent considered tolerable to the person. The Victorian Government claims that, with 68 safeguards, the law is the safest and most conservative in the world [ 20 ]. However, the safeguards are not all aimed at patient safety; some, such as conscientious objection provisions, are explicitly labelled as ‘practitioner protections’. Although the process is complex, non-medical ‘Care Navigators’ are available to guide patients through the process. After initiating the process themselves, a person has to make three separate requests to end their life: an initial verbal request, a second written and witnessed request, and a final verbal request. The time between the first and final request must be at least 9 days.

The most striking safeguard is that doctors and other healthcare professionals are forbidden to initiate discussions about AD. They can only respond to a patient’s direct request for information. There is guidance as to what may or may not constitute a direct request, which needs to be specific and explicit. This is intended to avoid coercion or suggestion, but not to discourage discussion. Requests can only be initiated by the person and cannot be done via telehealth [ 18 ]. The Voluntary Assisted Dying Statewide Pharmacy Service have sole responsibility for checking for necessary authorisation permits, and preparing and supplying the lethal drugs. The cocktail of drugs is delivered in a locked box to eligible patients in their homes across the state, and a contact person is appointed who will be responsible for returning the medication if unused after the person has died. A list of instructions on how to mix and drink the lethal drugs are included. As in Oregon, people drink the lethal dose at a time of their choosing. In 2021–2022, AD deaths amounted to 0.58% of all deaths.

• Vulnerability

In October 2023, the Danish Ethics Council published a report in response to a request from the Danish Parliament’s Health Committee to issue a statement which could be included as part of the basis for the Danish Parliament’s discussions of and decision on the citizens’ proposal that there should be legislation permitting AD [ 3 ]. The Council concluded that: ‘The only thing that will be able to protect the lives and respect of those who are most vulnerable in society will be an unexceptional ban’ . It pointed out that AD risks causing unacceptable changes to basic norms in society, the health care system and human outlook more generally. The very existence of an offer of AD will decisively change ideas about old age, infirmity, dying, and quality of life. In the Council’s opinion, if AD becomes an option, there is too great a risk that it will become an expectation aimed at certain groups in society.

Vulnerability is seen in all strata of society, often stemming from social isolation and a sense of helplessness and hopelessness. The most vulnerable include those who feel a burden. Those in despair will be more likely to make a request for AD, and no law can prevent this. Vulnerability is also associated with a lack of continuity in care. When life is hard, everyone without exception needs reliable, trustworthy human support to enable them to cope. The most fundamental human fear is that we will be abandoned, and the corresponding fundamental hope is that we will not be. Non-abandonment is dependent on continuity of care – not just reactive but pro-active with, for example, a ‘hot-line’ to a named GP and/or nurse. Without this, patients feel abandoned and worthless; symptoms escalate coupled with a sense of despair. In contrast, continuity of care affirms to patients that they still matter and that they are still persons of worth.

Unfortunately, continuity of care is increasingly difficult to access in the UK now that the National Health Service (NHS) is understaffed and overworked, particularly in Primary Care. In recent years, access to one’s named GP has become much harder, sometimes impossible. Arranging an appointment has generally become more complicated – now often necessitating an online request, to be ‘triaged’, with a response promised within 24 h. It is challenging and off-putting. Without ready access, people feel abandoned and hopeless, resulting in despair.

Some of the most vocal opponents of PAS are among the disabled and disability associations because they fear that its availability, even if limited to the terminally ill, will have a negative impact on attitudes to disability. ‘Disableism’ is rife in Britain, with its tendency to value the worth of a life in terms of its economic utility to society. PAS could well lead to a further narrowing down of what is viewed as a liveable and dignified life, with some people’s lives being considered worthless, merely an economic drain on society’s resources. Even in the UK, access to quality PHC is still patchy. Pressure to opt for AD would most likely increase as the health budget becomes further squeezed. Based on experience in other countries, it is naïve to believe that an incremental widening of the eligibility criteria will not happen. In this connection, it should be noted that, in the Netherlands, the mainstream political parties have expressed support for the Completed Life Initiative [ 21 ]. If this became law, this would permit euthanasia for those over the age of 74 who are ‘tired of life’. Thus, legalising AD should not simply be regarded as a small step to bring relief to a few. In terms of possible unwanted consequences, it is a massive step.

A further problem is the inability of many doctors to relinquish the goal of ‘fixing the problem’. This can lead to a feeling of failure, and an inclination to withdraw – with death seen as the only way to deal with the suffering. Doctors who cannot switch from a cure to a comfort modus operandi when it is appropriate may well unconsciously coerce patients towards AD. There are numerous anecdotes supporting this contention [ 22 ]. Such unwitting abuse is also linked to unconscious bias stemming from the doctor’s own fear of death [ 23 ]. It will become a bigger problem if the expectation shifts towards routinely informing potentially eligible patients about AD as one of their options to be considered. In Canada, the Canadian Association of MAiD Assessors and Providers (CAMAP) recommends that all who might qualify for MAiD (Medical Assistance in Dying) should be told about it as an option [ 24 ]. Offering MAiD to a patient who has not raised it could be interpreted as meaning that their suffering is likely to become intolerable, and that MAiD is the recommended way out, thereby impacting negatively on the patient’s resilience. On the other hand, a total prohibition on raising the subject, as in Victoria, could prevent someone from exercising their legal right through ignorance [ 25 ].

Hidden danger: AD resulting in more suffering?

Even in the absence of AD, some people decline referral to PHC despite unrelieved pain and/or other distressing symptoms because they fear they will be ‘drugged to death’. This is a real phenomenon well-known to PHC professionals (in fact, PHC typically prolongs survival by weeks or months as a result of, inter alia , improved comfort, sleep, and appetite.) This unfounded fear will most likely be enhanced if AD is legalized, particularly if PHC is involved.

Autonomy in medicine is based on a partnership between doctors and patients, each respecting the autonomy of the other [ 26 ]. This relational model of decision-making incorporates mutual respect and trust, dialogue, and informed negotiation. It contrasts with ‘consumer autonomy’ where the patient demands specific interventions from the doctor, regardless of established medical norms. In this scenario, the doctor is reduced to being an agent for carrying out a patient’s preferences (‘my legal right’) – a technician, no longer a professional. It becomes a transactional relationship (that of purchaser and supplier) rather than a partnership.

It is generally accepted that people have the right to self-determination provided their actions do not harm others. However, exercising personal autonomy (‘self-rule’) means making a choice. Informed choice requires reliable information about relevant options. Without this, autonomy is not valid. Disturbingly, official reports about AD do not specify the nature of the PHC received by those opting for AD. What is known is that to varying degrees there is poor access to palliative care in all the jurisdictions where AD is permitted. For example, in Canada, only half of the population are able access any form of palliative care [ 27 ].

Further, the extent to which an autonomously expressed wish for AD should be acted on must be balanced against the rights of the other people involved, notably the family and health professionals. From a medical point of view, AD will always be a ‘last resort’ option: a patient must be suffering from intractable symptoms and/or functional impairment caused by an incurable disease with no realistic expectation of relief within an acceptable time frame. Medical involvement would be unethical, for example, in healthy elderly people simply ‘tired of life’ [ 11 ].

It is imperative that conscientious objection by doctors and other healthcare professionals is guaranteed, as in the three models of AS described above. Lord Joffe, who introduced two AD Bills in the House of Lords 15–20 years ago, is reputed to have said that, if doctors objected to AD, they should be forced to comply, thereby revealing a total misunderstanding of the doctor’s professional role. Such high-handedness feels threatening . If Lord Joffe’s suggestion was adopted, it would turn doctors into technicians. In 2012, the White Paper, Equity and Excellence: Liberating the NHS set out a vision of a health service which puts patients and the public first, where ‘no decision about me, without me’ is the norm. It included proposals to give patients more say over their care and treatment with more opportunity to make informed autonomous choices. The slogan should be applied equally to doctors in relation to AD. Indeed, the British Medical Association (BMA) states that any legislation to permit AD should be based on an ‘opt-in’ model, so that only those doctors who positively choose to participate can do so. Doctors who opt in to provide the service should also be able to choose which parts of the service they are willing to provide (e.g. assessing eligibility and/or prescribing and/or administering drugs to eligible patients) [ 28 ].

In 2020, the BMA surveyed its members about their attitudes to AD [ 29 ]. The response rate was only 19%, thereby casting doubt on whether the results truly represent the views of the membership. In the answers to ‘In principle, do you support or oppose a change in the law to permit doctors to prescribe drugs for eligible patients to self-administer to end their own life?’, 50% said they would support, 39% would oppose, and 11% were undecided. (For administration by doctors (euthanasia), only 37% were in favour, 46% against, 17% undecided.) When broken down into specialties, in relation to AS, Palliative Medicine doctors were 76% against, 14% in favour, and 10% undecided. There were also majorities against in Clinical and Medical Oncology, Gastroenterology, Geriatric Medicine, Renal Medicine, Respiratory Medicine, and General Practice [ 29 , pp. 103–105].

In contrast, respondents who had voted for legal change contained a majority of retired doctors, medical students and those in specialties which involve little or no contact with terminally or otherwise incurably ill patients. It seems that the more doctors are involved in caring for dying patients, the greater the likelihood that they will oppose a change in the law. Further, in relation to AS, when asked if they would personally be willing to participate, a majority said they would not (45% vs. 36%, and 19% undecided) [ 29 ]. Previously in 2019, in a survey by the Royal College of Physicians of London, 85% of Palliative medicine doctors were against a change in the law, a similar number said they would refuse to participate in AD, and only 5% were willing to assist suicide themselves [ 30 ].

These figures may seem bizarre. Why should doctors working in PHC be those most strongly against a change in the law, and would want not to be involved? After all, these are the doctors most likely to witness suffering at the end of life. It is often claimed that opposition to AD stems from blindly accepted religious dogma. However, as in other areas of medicine, many palliative care doctors are not religious. (And don’t forget Humanists against Assisted Suicide and Euthanasia [ 31 ]). But whatever the reasons, the fact remains that most PHC doctors are against a change in the law and would strongly object if any form of AD was integrated into PHC.

Perhaps the answer to this conundrum can be found in a recent Swiss study of PHC doctors, ‘ How is it possible that at times we can be physicians and at times assistants in suicide? ’ [ 32 ]. All the doctors interviewed stated that PHC and assisted suicide are diametrically opposed approaches, based on different philosophies. In PHC, there is a commitment to non-abandonment : ‘Whatever happens, we will stay beside you every step of the way. Together we will get through this’. Compassionate presence and compassionate listening together demonstrate that the patient still matters and is still a person of worth. This is the essence of palliative care. It lightens the patient’s load of cares by, inter alia , decreasing their isolation and sense of worthlessness. In such an environment almost all patients lose their wish to hasten death. This is the essence of PHC, and it is difficult to switch to an alternative approach. It is difficult, if not impossible, to work looking in two diametrically opposite directions .

• Disinformation

Regrettably, those campaigning for AD consistently underestimate the potential harms associated with a change in the law [ 4 , 24 ]. Further, using the phrase ‘dying with dignity’ to describe AD, although a brilliant tactical move, is tantamount to disinformation. Likewise, naming the PAS statute in Oregon as the ‘Death with Dignity Act’. These phrases are also widely used in the media. As a result, many people now imagine that anything other than AD will be extremely distressing and undignified. In fact, ‘dying with dignity’ is equally applicable to quality end-of-life care. ‘Dignity in care’ is used as a way of describing the human side of medical care generally – with many scientific studies demonstrating what dignity means to patients and ways of enhancing it [ 33 ].

The choice of patients’ stories used to support the case for AD is also disturbing. Some are clear examples of poor care. If poor care is driving people to contemplate AD, this is not a truly autonomous decision, but one forced on the patient because of the absence of choice. Equally upsetting have been examples of patients with motor neurone disease/amyotrophic lateral sclerosis (MND/ALS). It has been suggested that the only alternative to AD is suffocating to death in great distress when non-invasive assisted ventilation (NIV) is discontinued at the patient’s request. This is fearmongering and causes great unnecessary distress. There is a well-established protocol for individually-tailored anticipatory sedation to allow a patient to be unaware while they die following the removal of assisted ventilation [ 34 ].

Seeking the ‘least worse’ option

Given the widespread disquiet felt by doctors, a law with minimal medical involvement would be the most equitable , such as in Switzerland and Oregon. This makes good sense given that the three most frequently reported end-of-life concerns behind the request for PAS in Oregon are more existential than medical: a decreasing ability to participate in enjoyable activities (90%), loss of autonomy (90%), and loss of dignity (72%) [ 15 ]. The Swiss model is unlikely to appeal to legislators in E&W, even though theoretically it could simply mean changing the Suicide Act 1961. At present this states that, without exception, it is an offence to assist or encourage another person’s suicide.

The most recent PAS Bill introduced in the UK Parliament was in 2021 by Baroness Meacher in the House of Lords. A novel feature in the Bill was the need for the patient’s eligibility and voluntary request to be ratified by the High Court (Family Division) before the lethal drug(s) could be dispensed. As in Oregon, there was no mention of suffering, just a terminal illness with an expected prognosis of under six months. Psychiatric illness alone, including depression, was specifically excluded as an eligibility criterion. However, it would not simply be a case of a patient receiving a lethal prescription to use as and when they decide (as in Oregon and Victoria). The prescription would be delivered by a doctor (or authorised nurse) immediately before self-administration who would remain while the patient self-administered the medicine and has died (or decided not to take the medicine). The doctor/nurse would prepare the lethal dose for self-administration and, if necessary ‘prepare a medical device’ (a syringe and intravenous cannula) to facilitate this and ‘assist the person to ingest or otherwise self-administer the medicine’. As in Victoria, the process would consume many hours of medical time.

Judging by its website, Dignity in Dying seems to be favouring an ‘Oregon mark 2’ law. Like the Meacher Bill, this would include ratification by the High Court of all requests for PAS. However, it is not clear whether the lethal drug(s) would be delivered to the patient’s home for use ‘just in case’ as in Oregon or mimic the more complicated Meacher Bill.

Its website also states that ‘doctors, patients and the public need to have confidence that the law on AD will work in practice, will be safe and will remain unchanged’. In relation to this latter point, given all the available evidence, this is wishful thinking. The case for AD is stronger in relation to degenerative neurological disorders with a longer prognosis. Some people with progressive brain failure (dementia) will want to register for AD while they still have capacity, to be actioned when they are no longer able to interact meaningfully with those around them. However, this can lead to problems if they become distressed at attempts to administer oral or intravenous drugs [ 35 ].

Conclusions

Any form of AD will have collateral harmful consequences for both medical care and society in general. The challenge is to find the ‘least worse’ option. A lack of readily available high-quality palliative care will always be coercive, there will always be abuse, the boundaries of the law will always be stretched, and a wrong diagnosis will mean that some people will die unnecessarily [ 12 , 24 ].

It is imperative that conscientious objection by doctors and other healthcare professionals is guaranteed in law and fully respected in practice. PAS should not be seen as part of healthcare provision. The BMA also holds this view [ 28 ]. One way to achieve this would be for PAS to be delegated to a stand-alone Department for Assisted Dying , completely separate from the NHS and with its own budget. Victoria almost achieves this with its combination of Care Navigators, mandatory training for participating doctors, and a separate Voluntary Assisted Dying Statewide Pharmacy Service . It could be overseen by lawyers or judges and operated by trained technicians [ 36 ]. Doctors would be required only to confirm that a patient is medically eligible. Requests would be carefully processed without interfering in a patient’s clinical care, and in a way which would not undermine suicide prevention policies. Other options have proposed incorporating, for example, a review panel comprising a lawyer, a healthcare professional and an ethicist, backed up if necessary by an ombudsman [ 37 , 38 ].

Further, alongside a de-medicalised model of AS, there is an urgent need to improve the provision of care for all terminally ill patients [ 39 ]. Dignity in Dying’s website states that ‘As well as campaigning to change the law on assisted dying we also support better end-of-life care which is accessible to all.’ Regrettably, there is no evidence of active campaigning on its part in this respect.

Data availability

All the data referred to are in the public domain.

Abbreviations

assisted dying

assisted suicide

British Medical Association

Death with Dignity Act (Oregon, USA)

England and Wales

general practitioner (primary care doctor)

medical assistance in dying

motor neurone disease/amyotrophic lateral sclerosis

National Health Service (England and Wales)

non-invasive ventilation

physician-assisted suicide

palliative-hospice care

Swiss Academy of Medical Sciences

United Kingdom

voluntary assisted dying

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Acknowledgements

The author acknowledges with gratitude the advice received from Aaron Wong (Australia) and Martyna Tomczyk (Switzerland), and the helpful suggestions made by the two referees.

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The author is one of the pioneers of hospice and palliative care in the UK, working first as Research Fellow in Therapeutics at St Christopher’s Hospice, London, in the early 1970s, followed by 25 years in Oxford at a hospice/palliative care unit in one of the University Hospitals. For many years he was Head of the WHO Collaborating Centre for Palliative Care. He has taught in over 40 countries and is the author or editor of several widely acclaimed textbooks, notably the Palliative Care Formulary.

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Twycross, R. Assisted dying: principles, possibilities, and practicalities. An English physician’s perspective. BMC Palliat Care 23 , 99 (2024). https://doi.org/10.1186/s12904-024-01422-6

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• Assisted dying
• Physician assisted suicide
• England and wales

BMC Palliative Care

ISSN: 1472-684X

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Against Assisted Suicide

• Cynthia M.A. Geppert, MD, PhD, MA, MPH, MSBE, DPS, MSJ
• Annette Hanson, MD

Should psychiatrists help patients end their own lives, even if it is technically legal?

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FROM OUR READERS

We would like to respond to the article " A New Question in End-of-Life Ethics " by Strouse, Battin, Bostwick, et al. 1 Their article in turn addresses an earlier essay on suicidal ideation and behavior in oncology patients. 2

Strouse et al place forms of actively hastening death under the rubric of medical aid in dying (MAID), noting that 10 states and the District of Columbia have now legalized MAID, and that “all current state laws explicitly stipulate that such deaths are not suicide.” Their letter argued for a distinction between decisions to “directly hasten one’s own death” in the context of terminal illness, and what they called “conventional suicides.” Citing work including a statement from the American Association of Suicidology (AAS), Strouse et al argued that suicide is not the same as physician aid in dying, and that—allowing for some overlap—the 2 acts differ on the level of psychopathology. They further suggested clinicians distinguish between conventional suicide and MAID, so that they may “work skillfully and humanely with cancer patients, especially those who are expressing doubts about proposed treatment, or articulating a preference for hastened death.”

We respect Strouse and his colleagues’ clinical experience and humane intentions. However, as psychiatrists, medical ethicists and a palliative care physician (Dr Geppert), we find this thesis deeply troubling. In particular, the focus on state laws ignores the central ethical question of whether physicians’ helping patients kill themselves is ever justified in the context of terminal illness or in any other circumstance.

What Is Legal vs What Is Right

The notion that 22% of the US population live in a state where MAID is legal is a demographic fact, not a value claim. As Daniel P. Sulmasy, MD, has observed, “data cannot tell a society or a profession what ought to be done” and neither can legislation. This is a consequence of what philosophers call the fact-value distinction . Sulmasy has said, “Whether just 1 person or 100,000 persons legally avail themselves of lethal prescriptions cannot tell us whether the practice is right or wrong.” 3

The mere fact that some state legislatures have passed statutes redefining suicide, such that MAID is not suicide, does not prove that this redefinition is conceptually or ethically justified; in fact, several judicial decisions have held this opinion. In 2017, the New York Court of Appeals held that “suicide has long been understood as ‘the act or an instance of taking one’s own life voluntarily and intentionally’ ... Aid-in-dying falls squarely within the ordinary meaning of the statutory prohibition on assisting a suicide.” 4 Similarly, in 2016, the New Mexico Supreme Court held that the prohibition against assisted suicide unambiguously covered self-induced death in situations such as those described by Strouse et al. 5 Furthermore, in Washington v. Glucksberg (521 US 702, 1997), the US Supreme Court permitted laws prohibiting assisted suicide because of the states’ compelling interest in suicide prevention, effectively equating assisted suicide with suicide.

While redefining suicide averts legal liability for physicians providing MAID, it does not change the essentially unethical nature of the act itself. The term medical aid in dying fundamentally means helping patients kill themselves. This is why the American College of Physicians rejects the term and explicitly endorses the term physician-assisted suicide/PAS . 6 Perhaps even more significant, following a comprehensive evaluation by the Council on Ethical and Judicial Affairs, the American Medical Association (AMA) House of Delegates rejected the term aid in dying and elected to retain the term physician assisted suicide in all AMA documents and references . 7 Indeed, the process typically described as MAID in no sense aids dying; on the contrary, it rapidly converts an ill individual into a dead one. This is substantively different than the withdrawal of heroic but nonbeneficial or inappropriate measures, such as the use of ventilators that merely prolong the dying process in the final stages of a terminal illness.

Finally, statutorily declaring that self-induced death via a physician’s assistance is not suicide may soothe the consciences of legislators and allow payouts on life insurance policies; but, perversely, it may also incentivize some terminally ill patients to kill themselves. Furthermore, as Sulmasy 3 notes, preliminary reports suggest increased rates of suicide in the general population of states that have legalized PAS. Specifically, “legalizing PAS has been associated with an increased rate of total suicides relative to other [non-PAS] states, and no decrease in non-assisted suicides.” 8 Similarly, suicide rates in the Netherlands (where medical euthanasia is legal) have accelerated, compared to neighboring countries that have not legalized medical euthanasia. 9

Taking One’s Own Life is Suicide

Redefining suicide to exclude PAS in the context of terminal illness represents a radical linguistic maneuver that flies in the face of ordinary language, expressed over thousands of years. The Latin suicidium— from which the English word suicide is derived—means the act of killing oneself intentionally or voluntarily. To be clear: we do not deny that there are often psychological and motivational differences between those with terminal illnesses who take their own lives and those who do so in the context of severe psychiatric illness, as the AAS statement details. But in both instances, the act is that of suicide .

As philosopher Gerald Dworkin, PhD, has put it 10 :

[A] s a philosopher, I feel an obligation to point out that, as a conceptual matter, there is nothing inaccurate or false about stating that a person who takes a drug, knowing that it will cause her death, and takes it because it will cause her death, is committing suicide on any reasonable conceptual analysis of what suicide is.

The hijacking of ordinary language is becoming increasingly common, such that comforting euphemisms like assisted dying have replaced the more troubling ordinary language term assisted suicide . 11 Accordingly, one might reasonably wonder if the insistence that MAID not be described as suicide betrays some cognitive dissonance regarding the practice, especially on the part of psychiatrists whose duty is to prevent suffering patients from taking their own lives. The ambivalence of many physicians who carry out MAID has been well-documented. 12

Cognitive Distortions, but No Mandated Treatment

Furthermore, most MAID laws do not require treatment for serious medical conditions, even when it is available to the patient. For example, a patient whose metastatic cancer stands a reasonably good chance of remission with aggressive treatment, but who nevertheless chooses MAID , is not required by state laws to undergo the treatment. 13 Choosing assisted suicide in such a scenario may superficially appear to be a rational choice; but may instead represent a decision grounded in certain cognitive distortions that also characterize so-called conventional suicide. Importantly, this may be so, even in the absence of a diagnosed psychiatric disorder.

For example, Tomer T. Levin, MD, and Allison J. Applebaum, PhD, noted that some cancer patients may make erroneous assumptions, like, “No one can help me” or “No one understands what I am going through.” 14 Such cognitive distortions may respond favorably to cognitive behavioral interventions and potentially avert or abort a request for PAS. Indeed, it has been found that “Requests for physician-assisted suicide are unlikely to persist when compassionate supportive care is provided.” 6

Unfortunately, in almost every US jurisdiction where PAS is allowed, no attempt to offer treatment by a mental health professional is required by law; and the psychiatrist’s role is typically relegated to ruling out mental illness and certifying competency for PAS. 15

The Issue Is Not Intractable Pain and Suffering

As Daniel P. Sulmasy, MD, PhD, noted, “Despite public arguments that PAS is needed to avoid excruciating pain and other symptoms, the reasons attributed to patients who seek PAS are not uncontrolled symptoms but lost autonomy, independence, and control.” 3,16 These are forms of psychological distress which, in our view, are best managed with supportive and empathic counseling and/or cognitive behavioral interventions, provided to patients and their families—not by prescribing lethal drugs. Indeed, as Levin and Applebaum pointed out 14 :

[T]he root of many patients’ desire for a hastened death may reside in dysfunctional thoughts such as, ‘I get claustrophobic in small spaces like coffins’ and ‘I deserve to die.’ Exploring such cognitions by asking, ‘What are your biggest fears about death and dying?’ will allow the cognitive therapist to reframe dysfunctional thoughts. For example, if the patient worries that death is always painful based his perception of his grandfather’s death in 1975, the therapist might explore how good pain management can facilitate a more peaceful death and contrast the state of palliative care in 1975 versus the advances of the present day.

The Precautionary Principle

Even the AAS acknowledges that there is an “undetermined amount of overlap” between the 2 categories of physician aid in dying and conventional suicide. 17 Accordingly, we believe that the same precautionary principle that governs public health ought to apply to MAID requests. 18

This means erring on the side of caution and treating MAID requests from patients with terminal illnesses with the same degree of psychiatric scrutiny and concern that we would bring to any patient’s expressed wish to die. However, in most states, psychiatric assessment is not mandated in the MAID process and does not occur unless specifically requested by the evaluating physician who has initiated the MAID process.. This rarely happens. For example, in Oregon in 2020, only 0.8% of patients who were prescribed lethal medication were referred for psychiatric evaluation. 19

Moreover, the fairly subtle cognitive distortions described by Levin and Applebaum are unlikely to be detected in a superficial assessment of mental competence. It is no contradiction or paradox to argue, as we have, that pronouncing a patient qualified or competent for MAID is a violation of psychiatric ethics, since this unethically colludes with the process of aiding a patient’s suicide. Psychiatric involvement in end-of-life care is indeed essential, but it should remain well outside the procedures and processes involved in MAID deliberations. 20

Reducing Stigma vs Shifting it to the Other

Strouse et al emphasized that, “Most importantly, they [MAID laws] are intended by lawmakers to help avoid the stigma of suicide.” we agree that there is societal stigma associated with suicide, as the AAS recognizes. This, the AAS asserts, is in contrast to attitudes surrounding physician aid in dying 17 : “Death by suicide is often associated with substantial social stigma... [whereas] where it is legal, PAD is typically well accepted within the community and society at large.”

We infer from their commentary that Strouse et al would agree with the AAS claim (and co-author Margaret Battin, PhD, is a signatory to the AAS statement). Although well-intentioned, the AAS position and that of Strouse et al may have the unintended effect of increasing stigma directed toward those who attempt or complete a non-MAID suicide. In our view, creating a binary distinction between MAID and conventional suicide tends to marginalize individuals in the conventional group as “the Other.” This position may suggest to the general public that suicidal individuals with mental illness value their lives less than those with terminal physical illnesses—a claim we reject.

Indeed, as numerous suicide prevention websites note : “Most suicidal people do not want to die. They are experiencing severe emotional pain, and are desperate for the pain to go away.” 21 We would suggest that the same may be said of at least some individuals with cancer who seek MAID. Whenever complex ethical dilemmas are formulated as black-and-white categories, the many grey instances are often misclassified, with tragic consequences.

In short, the AAS position may have the perverse effect of merely shifting societal stigma from one group—those with terminal medical conditions—to those whose suicidal behavior occurs in the context of psychiatric disorders. We do not need such a 2-tiered classification, in which there are good and bad methods of taking one’s own life.

Moreover, we believe that such a dichotomy would likely magnify disparities in end-of-life care in resource-poor areas, where MAID would be far less expensive than sustaining palliative care. The AAS position may also weaken the motivation and rationale for suicide prevention, during a period when suicide rates have been rising in the US. 22 We believe that efforts to promote MAID would be better directed toward destigmatizing the mental illnesses that underlie the majority of suicides and toward bolstering the availability of state-of-the-art palliative care.

Concluding Thoughts

The American College of Physicians has said 23 :

Physician-assisted suicide is neither a therapy nor a solution to difficult questions raised at the end of life. On the basis of substantive ethics, clinical practice, policy, and other concerns, the ACP does not support legalization of physician-assisted suicide. … However, through high-quality care, effective communication, compassionate support, and the right resources, physicians can help patients control many aspects of how they live out life's last chapter.

Like the ACP, we reject the implication that merely legalizing MAID somehow means that it is consistent with ethical medical practice. Quite the contrary. As physician and ethicist Leon Kass , MD, has pointedly cautioned: “We must care for the dying, not make them dead.” 24

Dr Pies is professor emeritus of psychiatry and lecturer on bioethics and humanities, SUNY Upstate Medical University; clinical professor of psychiatry, Tufts University School of Medicine; and Editor in Chief emeritus of Psychiatric Times TM (2007-2010). Dr Komrad is a psychiatrist on the Johns Hopkins Hospital in Baltimore, Maryland; a clinical assistant professor of psychiatry at the University of Maryland; and a member of the teaching faculty at Tulane University in New Orleans, Louisiana. Dr Geppert is a professor in the Department of Psychiatry and Internal Medicine and director of ethics education at the University of New Mexico School of Medicine in Albuquerque. She is also a health care ethicist with the Ethics Consultation Service of the Veterans Administration National Center for Ethics in Health Care, and an adjunct professor of bioethics at the Alden March Bioethics Institute of Albany Medical College, and serves as the Ethics Editor for Psychiatric Times TM . Dr Hanson is Director, Forensic Psychiatry Fellowship, University of Maryland, Baltimore, MD.

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24. Kass LR. Dehumanization triumphant. Conn Med . 1996;60(10):619-620

Further reading

Canetto SS, McIntosh JL. A comparison of physician-assisted/Death-with-Dignity death and suicide patterns in older adult women and men . Am J Geriatr Psychiatry . June 11, 2021. Accessed June 23, 2021.

Komrad MS. Are physicians who assist in suicide betraying their professional values? Psychiatric Times . June 15, 2021. Accessed June 23, 2021.

Pies RW, Hanson A. Twelve myths about physician assisted suicide and medical aid in dying. HCP Live . July 7, 2018. Accessed June 23, 2021. https://www.hcplive.com/view/twelve-myths-concerning-medical-aid-in-dying-or-physicianassisted-suicide

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• Ann Med Surg (Lond)
• v.75; 2022 Mar

Euthanasia and assisted suicide: An in-depth review of relevant historical aspects

Yelson alejandro picón-jaimes.

a Medical and Surgical Research Center, Future Surgeons Chapter, Colombian Surgery Association, Bogotá, Colombia

Ivan David Lozada-Martinez

b Grupo Prometheus y Biomedicina Aplicada a las Ciencias Clínicas, School of Medicine, Universidad de Cartagena, Cartagena, Colombia

Javier Esteban Orozco-Chinome

c Department of Medicine, RedSalud, Santiago de Chile, Chile

Lina María Montaña-Gómez

d Department of Medicine, Keralty Salud, Bogotá, Colombia

María Paz Bolaño-Romero

Luis rafael moscote-salazar.

e Colombian Clinical Research Group in Neurocritical Care, Latin American Council of Neurocritical Care, Bogotá, Colombia

Tariq Janjua

f Department of Intensive Care, Regions Hospital, Minnesota, USA

Sabrina Rahman

g Independent University, Dhaka, Bangladesh

End-of-life care is an increasingly relevant topic due to advances in biomedical research and the establishment of new disciplines in evidence-based medicine and bioethics. Euthanasia and assisted suicide are two terms widely discussed in medicine, which cause displeasure on many occasions and cause relief on others. The evolution of these terms and the events associated with their study have allowed the evaluation of cases that have established useful definitions for the legal regulation of palliative care and public policies in the different health systems. However, there are still many aspects to be elucidated and defined. Based on the above, this review aimed to compile relevant historical aspects on the evolution of euthanasia and assisted suicide, which will allow understanding the use and research of these terms.

• • The history of euthanasia and assisted suicide has been traumatic.
• • The church and research have been decisive in the definition of euthanasia.
• • The legal framework on the use of euthanasia and assisted suicide has been strengthened.

1. Introduction

Euthanasia and assisted suicide are two topics discussed throughout history, mainly because they fall within the scope of life as a human right, which has been universally defended for many years [ 1 ]. However, the mean of the word euthanasia as good death generates conflicts at social, moral, and ethical levels. Mainly because death is a loss, it is difficult to understand it as something positive and; additionally, several historical events such as the Nazi experiments related the term euthanasia more to murder than to a kind and compassionate act [ 1 ]. More current texts mention that euthanasia is the process in which, through the use or abstention of clinical measures, the death of a patient in an incurable or terminal condition can be hastened to avoid excessive suffering [ 2 ].

The difference between euthanasia and assisted suicide is that in the latter, the patient takes the final action; however, both practices can be combined in the term assisted death [ 2 ]. At present, several countries authorize assisted death, including Holland, Luxembourg, and Canada [ 3 ]. Belgium and Colombia have regulations that decriminalize only euthanasia; other places where assisted suicide is legal are Switzerland and five states of the United America states, specifically Oregon, Vermont, Washington, California, and Montana [ 2 , 3 ]. Spain recently joined the list of countries that have legislated on euthanasia through the organic law March 2021 of March 24 that regulates euthanasia in that state in both public and private institutions [ 4 ]. The fact that more and more countries were joining the legislation on euthanasia and assisted suicide has brought to light the opinion of thinkers, politicians, philosophers, and physicians. Several nations have initiated discussions on the matter in their governmental systems. Latin America is trying to advance powerfully in this medical-philosophical field. Currently, in Chile, the “Muerte digna y cuidados paliativos” law, which seeks to regulate the issue of euthanasia and assisted suicide in the country, is being debated in Congress [ 5 ].

It is essential to know the point of view of physicians on euthanasia and assisted suicide, especially taking into account that these professionals who provide care and accompany patients during this moment, which, if approved, would involve the medical community in both public and private health systems. Although it seems easy to think that physicians have a position in favor of the act of euthanasia because they are in direct and continuous contact with end-of-life situations, such as palliative care, terminally ill, and critically ill patients. It is important to remember that the Hippocratic medical oaths taken at the time of graduation of professionals are mostly categorical in mentioning the rejection of euthanasia and assisted suicide [ 6 ]. Furthermore, it is also important to note that many of the oldest universities in the Western world originated through the Catholic Church; and just this creed condemns the practice of euthanasia and continues to condemn it to this day. This situation generates that many medical students in these schools have behaviors based on humanist principles under the protection of faith and religion and therefore reject the possibility of euthanasia [ 7 , 8 ].

The relevance of the topic and the extensive discussion that it has had in recent months due to the COVID-19 pandemic added to the particular interest of bioethics in this topic and the need to know the point of view of doctors and other health professionals on euthanasia and assisted suicide.

2. Origin and meaning of the term euthanasia

The word euthanasia derives from the Greek word “eu” which means good, and the word “thanatos” which means death; therefore, the etymological meaning of this word is “good death”. Over time the evolution of the meaning has varied; even as we will see below was considered a form of eradication of people categorized under the designation of leading a less dignified life. Assisted suicide is a condition in which the patient is the one who carries out the action that ends his life through the ingestion of a lethal drug but has been dispensed in the context of health care and therefore called assisted. This care is provided by a physician trained in the area. However, it requires the prior coordination of a multidisciplinary team and even the assessment by an ethics committee to determine that the patient is exercising full autonomy, free from coercion by the situation he/she is living and free from the fatalistic desires of a psychiatric illness [ 9 ]. In a more literary sense, the word euthanasia meaning of “giving death to a person who freely requests it in order to free himself from suffering that is irreversible and that the person himself considers intolerable” [ 9 ].

Some authors go deeper into the definition and consider that for the meaning of euthanasia, are necessary to consider elements that are essential in the word itself; such as the fact that it is an act that seeks to provoke death and that carried out to eliminate the suffering in the person who is dying. Other elements with a secondary character in the definition are the patient's consent (which must be granted respecting autonomy and freedom in the positive and negative sense; that means the fact must be not be coerced in any way). Another element is the terminal nature of the disease, with an irreversible outcome that generates precariousness and a loss of dignity. The third secondary element is the absence of pain of the death through the use of drugs such as high-potency analgesics, including opioids, high-potency muscle relaxants, and even anesthetic drugs. Finally, the last element is the health context in which the action is performed (essential in some legislations to be considered euthanasia) [ 10 ]. According to the World Health Organization, the union of these two components is the current definition of euthanasia, which describes as “the action performed by a person to cause the painless death of another subject, or not preventing death in case of terminal illness or irreversible coma. Furthermore, with the explicit condition that the patient must be suffering physical, emotional, or spiritual and that affliction is uncontrollable with conventional measures such as medical treatments, analgesics, among others; then the objective of euthanasia is to alleviate this suffering” [ 11 ]. Unfortunately, the term euthanasia has been misused over the years, and other practices have been named with this word. An example of this situation occurred during the Nazi tyranny when the word euthanasia concerned the murder of people with disabilities, mental disorders, low social status, or gay people. At that time, euthanasia was even a simultaneous practice to the Jewish genocide [ 11 ].

Not only has the term been misused; also exists an enormous variability of terms to refer to euthanasia. For example, the laws created to regulate euthanasia have different names around the world; in the Netherlands (Holland), the law that regulates this practice is known as the law of termination of life; in Belgium, it is called euthanasia law, in France, it is called euthanasia law too. In Oregon (USA), it is called the death with dignity act; in California, it is the end of life option act. In Canada is called the medical assistance in dying act. Victoria (Australia) is the voluntary assisted dying bill, but all these denominations refer to the already well-known term euthanasia [ 11 ].

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 Catholic Church; mainly in the Middle Age, where following the thought of St. Thomas Aquinas, self-induced death or death contemplated by own will, was condemned. Later, with the renaissance age and the resurgence of science, technology, and the arts, the term euthanasia made a transition to a form similar to what we know today from thinkers such as Thomas More and Francis Bacon. Finally, the first signs of eugenics were known in London, Sweden, Germany, and the United States in the twentieth century. There was a relationship with the term euthanasia that was later used interchangeably, especially in the Nazi regime, to denote a form of systemic murder that sought to eradicate those who were not worthy of living a life.

Since the sixties, with emblematic cases, the path towards the decriminalization of euthanasia began in some countries, especially concerning the cessation of extreme support measures in cases of irreversible illness or a terminal condition. The practice has progressed to the appearance of laws on euthanasia in several countries.

4. Euthanasia and assisted suicide in ancient times

In book III of Plato's “The Republic”, the author stated that those who live their lives amidst illnesses and medicines or who were not physically healthy should be left to die; implying that it was thought that people in these conditions suffered so much that their quality of life diminished, which seemed understandable to these thinkers. However, other authors such as Hippocrates and his famous Hippocratic oath sought the protection of the patient's life through medicine, especially in vulnerable health conditions prone to fatal outcomes. This Hippocratic oath is the same oath that permeates our times and constitutes an argument among those who mark their position against euthanasia and assisted suicide [ 12 , 13 ].

Other texts that collect thoughts of Socrates and his disciple Plato point out that it was possible and well understood to think of ceasing to live in the face of a severe illness; to consider death to avoid a long and torturous agony. This fact is compatible with the conception of current euthanasia since this is the end of this health care procedure [ 13 ].

In The Republic, the text by Plato, the physician Heroditus is also condemned for inventing a way to prolong death and over manage the symptoms of serious illnesses, which is currently known as distanasia or excessive treatment prolongs life. This kind of excessive treatment prolongs the sick person's suffering, even leading him to maintain biological signs present but in a state of alienation and absolute dependence on medical equipment such as ventilators and artificial feeding [ 13 ]. However, the strongest indication that Euthanasic suicide was encouraged in Greece lies in other thinkers such as the Pythagoreans, Aristotelians, and Epicureans who strongly condemned this practice, which suggests that it was carried out repeatedly as a method and was therefore condemned by these thinkers [ 12 , 13 ]. According to stoicism, the pain that exceeded the limits of what was humanly bearable was one of the causes for which the wise man separates himself from life. Referring to one of the nuances that euthanasia touches today, that is, at a point of elevated suffering, the dignity and essence of the person are lost, persisting only the biological part but in the absence of the person's well-being as a being. In this sense, Lucius Seneca said that a person should not love life too much or hate it; but that person should have a middle ground and end their life when they ceased to perceive life as a good, worthy, and longed-for event [ 1 , 12 ].

During the Roman Empire and in the territories under its rule, it was believed that the terminally ill who commit suicide had sufficient reasons to do so; so since suicide caused by impatience and lack of resolution to pain or illness was accepted, when there was no access to medicines. In addition, there was little development in medicine during that time, and many of the sick died without treatment [ 12 ]. This situation changed later with the emergence of the Catholic church; in this age, who attempted against own life, was deprived of burial in the ground. Saint Augustine said that the suicide was an abominable and detestable act; from 693 AD, anyone who attempted against his physical integrity was excommunicated. Rejecting to the individuals and their lineage, depriving them of the possibility of attending the funeral and even expelled from cities and stripped of the properties they owned [ 12 , 13 ].

4.1. Euthanasia and assisted suicide in the Middle Age

During the Middle Age, Catholicism governed the sciences, arts, and medicine; the sciences fell asleep. Due to this solid religious tendency and the persistence of Augustinian thought, suicide was not well seen. It was not allowed to administer a lethal substance to a person to end the suffering of a severe or terminal illness [ 9 , 12 ]. People who took their own lives at this time could not be buried “Christianly”; therefore, they did not have access to a funeral, nor to the accompaniment of their family in a religious rite. Physical suffering and pain were then seen as a path to glorification. Suffering was extolled as the form that god purified the sin, similar to the suffering that Jesus endured during his Calvary days. However, a contrary situation was experienced in battles; a sort of short dagger-like weapon was often used to finish off badly wounded enemies and thus reduce their suffering, thus depriving them of the possibility of healing and was called “mercy killing” [ 12 ].

5. Euthanasia in renaissance

With the awakening of science and philosophy, ancient philosophers' thoughts took up again, giving priority to man, the world, and nature, thus promoting medical and scientific development. In their discourse, Thomas More and Francis Bacon refer to euthanasia; however, they give a eugenic sense to the concept of euthanasia, similar to that professed in the book of Plato's Republic. It is precise with these phylosophers that the term euthanasia got its current focus, referring to the acceleration of the death of a seriously ill person who has no possibility of recovery [ 12 ]. In other words, it was during this period that euthanasia acquired its current meaning, and death began to be considered the last act of life. Therefore, it was necessary to help the dying person with all available resources to achieve a dignified death without suffering, closing the cycle of life that ends with death [ 13 , 14 ].

In his work titled “Utopia”, Thomas More affirmed that in the ideal nation should be given the necessary and supportive care to the dying. Furthermore, in case of extraordinary suffering, it can be recommended to end the suffering, but only if the patient agrees, through deprivation of food or with the administration of a lethal drug; this procedure must be known to the affected person and with the due permission of authorities and priests [ 12 , 13 ]. Later, in the 17th century, the theologian Johann Andreae, in his utopia “Christianopolis”, contradicts the arguments of Bacon and Moro, defending the right of the seriously ill and incurably ill to continue living, even if they are disturbed and alienated, advocating for the care based on support and indulgence [ 15 , 16 ]. Similarly, many physicians rejected the concepts of Plato, Moro, and Bacon. Instead, they focused on opposing euthanasia, most notably in the nineteenth century. For example, the physician Christoph Hufeland mentioned that the doctor's job was only to preserve life, whether it was a fate or a misfortune, or whether it was worth living [ 16 ].

5.1. Euthanasia in the 20th century

Before considering the relevant aspects of euthanasia in the 20th century, it is vital to highlight the manuscript by Licata et al. [ 17 ], which narrates two episodes of euthanasia in the 19th century. The first one happened in Sicily (Italy) in 1860, during the battle of Calatafimi, where two soldiers were in constant suffering, one because he had a serious leg fracture with gangrene, and the other with a gunshot wound. The two soldiers begged to be allowed to die, and how they were in a precarious place without medical supplies, they gave them an opium pill, which calmed them until they died [ 17 ]. The second episode reported by Licata et al. [ 17 ] was witnessed by a Swedish doctor named Alex Munthe; who evidenced the pain of many patients in a Parisian hospital. So he decided to start administering morphine to help people who had been seriously injured by wolves and had a poor prognosis; therefore, the purpose of opioid use was analgesia while death was occurring.

It is also important to highlight the manuscript entitled “Euthanasia” by S. Williams published in 1873 in “Popular Science Monthly”, a journal that published texts by Darwin, Edison, Pasteur, and Beecher. This text included the report for the active euthanasia of seriously ill patients without a cure, in which the physicians were advised to administer chloroform to these patients or another anesthetic agent to reduce the level of consciousness of the subject and speed up their death in a painless manner [ 16 ].

Understanding that euthanasia was already reported in the nineteenth century, years after, specifically in 1900, the influence of eugenics, utilitarianism, social Darwinism, and the new currents of thought in England and Germany; it began in various parts around the world, projects that considered the active termination of life, thus giving rise to euthanasia societies in which there were discussions between philosophers, theologians, lawyers, and medical doctors. Those societies discussed diverse cases, such as the tuberculous patient Roland Gerkan, who was considered unfit and therefore a candidate to be released from the world [ 16 ]. The scarcity of resources, famine, and wars were reasons to promote euthanasia as a form of elimination of subjects considered weak or unfit, as argued in texts such as Ernst Haeckel's. However, opponents to the practice, such as Binding and Hoche, defended the principle of free will in 1920 [ 16 ].

5.2. Euthanasia in the time of the Nazis

As mentioned above, the term euthanasia was misused during this period; approximately 275,000 subjects (as reported at the Nuremberg International Military Tribunal 1945–1946), who had some degree of physical or mental disability, were killed during Adolf Hitler's Euthanasia program [ 13 ]. However, the Nazis were not the first to practice a form of eugenics under the name of euthanasia, since the early 1900s in London had already begun the sterilization of the rejected, such as the blind, deaf, mentally retarded, people with epilepsy, criminals, and rapists. This practice spread to different countries like Sweden and the United States [ 13 , 16 ].

For the Nazis, euthanasia represented the systematic murder of those whose lives were unworthy of living [ 13 ]. The name given to this doctrine was “Aktion T4”. At first and by law, from 1939, the hospitals were obliged to account for all disabled newborns, which led to the execution of more than 5000 newborns utilizing food deprivation or lethal injection [ 12 , 18 ].

A year before that law, in 1938, one of the first known cases of euthanasia in children arose in Germany. That history called the story of child K, in which it was the father of the minor who asked Hitler in writing for euthanasia for his son because the child had a severe mental disability and critical morphic disorders. Hitler gave his consent to carry out the procedure on child K, and thus the program began to spread throughout the Aleman territory. Since then, physicians and nurses had been in charge of reporting the newborns with alterations, arising the “Kinderfachabteilugen” for the internment of children who would be sentenced to death after a committee's decision [ 12 , 18 , 19 ]. A list of diseases and conditions that were considered undesirable to be transmitted to Hitler's superior Aryan race was determined; thus, any child with idiocy, mongolism, blindness, deafness, hydrocephalus, paralysis, and spinal, head, and hip malformations were eligible for euthanasia [ 19 ].

Subsequently, the program was extended to adults with chronic illness, so those people were selected and transported by T4 personnel to psychiatric sanatoriums strategically located far away. There, the ill patients received the injection of barbiturate overdoses, and carbon monoxide poisoning was tested as a method of elimination, surging the widely known gas chamber of the concentration camp extermination; this situation occurred before 1940 [ 12 , 19 ]. Again, physicians and nurses were the ones who designated to the patients to receive those procedures; in this case, these health professionals supported Nazi exterminations. They took the patients to the sanatoriums, where psychiatrists evaluated them and designated with red color if they should die and with a blue color if they were allowed to live (this form of selection was similar in children) [ 12 , 13 , 19 ]. In this case, the pathologies considered as criteria for death were those generating disability such as schizophrenia, paralysis, syphilis with sequelae, epilepsy, chorea, patients with chronic diseases with many recent treatments, subjects of non-German origin and individuals of mixed blood [ 19 ]. Once in the sanatoriums, they were informed that they would undergo a physical evaluation and take a shower to disinfect themselves; instead, they were killed in gas chambers [ 12 , 13 ]. Despite the church's action in 1941 against Nazis and after achieving suspension of the Aktion T4 project; the Nazi supporters kept the practices secretly, resuming them in 1942, with the difference that the victims were killed by lethal injection, by an overdose of drugs, or left to starve to death, instead of the use of gas chambers. This new modified form of euthanasia, which did not include gas chambers, became known as “savage euthanasia” [ 12 , 13 , 19 ].

5.3. Euthanasia since the 1960s

In September 1945, trials began for crimes perpetrated by Nazi supporters; the victorious Allied forces conducted these trials at the end of the war. During these tribunals, cases of human experimentation were identified and the public exposure of the Nazi euthanasia program. After the Nuremberg trials and the abolition of Nazi experiments, a series of seven documents emerged, among which the Nuremberg code containing the ten basic principles for human research stood out [ 20 , 21 ].

After these judgments, biotechnology was accelerated, with the apparition of new techniques to intervene in the health-disease process. Additionally, the increase in life expectancy and the appearance of diseases that chronically compromise the state of health of people generated a change in the conception of the critically ill patient and the terminal state of life [ 20 , 21 ]. Cases such as Karen Ann Quinlan brought to the forefront the issue of euthanasia and precisely the control of extreme treatment measures. Karen, a young American woman, was left in a vegetative state due to severe neurological damage following alcohol and barbiturate intoxication. After six months in that state and under the guardianship of a Catholic priest, Karen's parents requested the removal of the artificial respirator, arguing that in her state of consciousness prior to the incident, she had stated that she disagreed with artificially maintaining life in comatose patients. The hospital refused to remove the ventilator, arguing the legal issues for the date, and the parents went to court, which in the first instance granted the hospital the right. Nevertheless, the New Jersey Supreme Court granted Karen Ann's right to die in peace and dignity. Despite the withdrawal of the artificial respirator, he continued to live until 1985, when he finally died [ [21] , [22] , [23] ].

Another important case was Paul Brophy, which also occurred in the United States. Paul was a firefighter in Massachusetts and went into a deep coma due to the rupture of a basilar artery aneurysm; initially, his family advocated for support measures but later requested the hospital to disconnect these means to allow death, as Paul had indicated when he was still conscious. The hospital refused to carry out this procedure, so the family went to court, where the removal of the support measures (gastrostomy) was initially denied. Hence, the family went to the state supreme court, achieving the transfer of Paul to another medical center where the gastrostomy was removed, leading to his death within a few days [ 23 ].

The case of Arthur Koestler, an influential English writer and activist diagnosed with Parkinson's disease and later with leukemia, who served as vice-president of the voluntary euthanasia society (Exit) and wrote a manual book with practical advice for euthanasia called “Guide to Self-Liberation”. He stood out because he applied one of his advice and ingested an overdose of barbiturates, causing his self-death. According to his writings, Koestler was not afraid of death but of the painful process of dying [ 23 ]. In this sense, it was a relevant case because it involved someone who held an important position in an association that advocated euthanasia, in addition to being the author of several works, which made him a recognized public figure [ 23 ].

Baby Doe was a case that also occurred in the United States; it was a small child with Down syndrome who had a tracheoesophageal fistula and esophageal atresia; in this case, surgery was necessary. On the advice of the obstetrician, the parents did not allow surgery, so the hospital managers took the case before a judge who ruled that parents could decide to perform or not the surgery. The case was appealed before a county judge who upheld the parents' power to make the decision, in the course of which the case became public and many families offered to take care of the child; however, before the case reached the supreme court, the child died at six days of age [ 23 ].

In the case of Ingrid Frank, a German woman who was in a quadriplegic state by a traffic accident, who initially sought rehabilitation but later insisted on being allowed to die; it was provided with a drink containing a cyanide solution that she drank. At the same time, she was filmed, which shows a kind of assisted suicide. For that reason, this is another case that deals with this issue and is important to know as background in the development of euthanasia and assisted suicide [ 22 , 23 ].

6. Current and future perspectives

The definition of brain death, the rational use of the concept of euthanasia and assisted suicide, and scientific literacy are the objectives of global bioethics to regulate euthanasia and assisted suicide, which can be accessible in all health systems [ [24] , [25] , [26] , [27] , [28] , [29] , [30] ]. End-of-life care will continue to be a subject of debate due to the struggle between biomedical principles, the different existing legal frameworks, and the general population's beliefs. Medical education and preparation in the perception of death, especially of a dignified death, seems to be the pillar of the understanding of the need to develop medical-legal tools that guarantee the integrity of humans until the end of their existence [ 31 , 32 ]. This is the reason why the new generations of physicians must be trained in bioethics to face these ethical conflicts during the development of their professional careers.

In addition, although the conception of bioethics belongs to the Western world, it is crucial to take into account the point of view of other cultures and creeds, for example, a study carried out in Turkey, where nursing students were questioned, found that many of them understood the reasons for performing euthanasia; however, they know that Islam prohibits it, as well as its legislation, and therefore they would not participate in this type of procedure [ 33 ]. Furthermore, Christianism and Islam prohibit euthanasia, but Judaism also prohibits it; in general, the so-called Abrahamic religions are contrary to any form of assisted death, whether it is active euthanasia, passive, or assisted suicide [ 34 ].

7. Conclusiones

The history and evolution of euthanasia and assisted suicide have been traumatic throughout human history. The church, politics, and biomedical research have been decisive in defining these concepts. Over the years, the legal framework and bioethical concepts on euthanasia have been strengthened. However, there is still much work to educate the general population and health professionals about end-of-life care and dignified death.

It is also important to remember that life is a concept that goes beyond biology. Currently, bioethics seeks to prioritize the concept of dignity, which must be linked to the very definition of life. Although the phrase is often heard that it is not necessary to move to be alive, what is important is that person feels worthy even if they have limited movement. The person's treatment must be individualized in bioethics since each individual is a unique unit. Therefore, medical paternalism must be abandoned. Instead, the subject must be more involved to understand their context and perception of life and dignity.

Ethical approval

It is not necessary.

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Author contribution.

All authors equally contributed to the analysis and writing of the manuscript.

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Not commissioned, externally peer reviewed.

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Sabrina Rahman. Independent University, Dhaka, Bangladesh. [email protected] .

Declaration of interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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‘I’m dying, you’re not': Those terminally ill ask more states to legalize physician-assisted death

Deb Robertson, who is terminally ill, advocates for medical-assisted death. A practice already allowed in ten states while over a dozen states are debating bills to legalize it.

Deb Robertson sits for a portrait at her Lombard, Ill. home, Thursday, March 21, 2024. She didn’t cry when she learned two months ago that the cancerous tumors in her liver were spreading, portending a tormented death. But later, she cried after receiving a call that a bill moving through the Illinois Legislature to allow certain terminally ill patients to end their own lives with a doctor’s help had made progress. (AP Photo/Charles Rex Arbogast)

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Deb Robertson looks at a wall crafts with her chemo caps at her Lombard, Ill. home, Thursday, March 21, 2024. She didn’t cry when she learned two months ago that the cancerous tumors in her liver were spreading, portending a tormented death. But later, she cried after receiving a call that a bill moving through the Illinois Legislature to allow certain terminally ill patients to end their own lives with a doctor’s help had made progress. (AP Photo/Charles Rex Arbogast)

Deb Robertson kisses her wife Kate Koubek, as they prepare for a meal with family and friends at their Lombard, Ill., home Saturday, March 23, 2024. Robertson didn’t cry when she learned two months ago that the cancerous tumors in her liver were spreading, portending a tormented death. But later, she cried after receiving a call that a bill moving through the Illinois Legislature to allow certain terminally ill patients to end their own lives with a doctor’s help had made progress. (AP Photo/Charles Rex Arbogast)

Deb Robertson shows a collage of her and her wife Kate Koubek at their Lombard, Ill. home, Thursday, March 21, 2024. She didn’t cry when she learned two months ago that the cancerous tumors in her liver were spreading, portending a tormented death. But later, she cried after receiving a call that a bill moving through the Illinois Legislature to allow certain terminally ill patients to end their own lives with a doctor’s help had made progress. (AP Photo/Charles Rex Arbogast)

Deb Robertson sits with her 12 year-old dog Mazi in the hallway before a meal with family and friends at her Lombard, Ill., home Saturday, March 23, 2024. Robertson didn’t cry when she learned two months ago that the cancerous tumors in her liver were spreading, portending a tormented death. But later, she cried after receiving a call that a bill moving through the Illinois Legislature to allow certain terminally ill patients to end their own lives with a doctor’s help had made progress. (AP Photo/Charles Rex Arbogast)

Shannon Rodriguez, right, shows off a tattoo made of her mother Deb Robertson’s handwriting “Love You More” and sunflower at Robertson’s Lombard, Ill., home Saturday, March 23, 2024. Robertson didn’t cry when she learned two months ago that the cancerous tumors in her liver were spreading, portending a tormented death. But later, she cried after receiving a call that a bill moving through the Illinois Legislature to allow certain terminally ill patients to end their own lives with a doctor’s help had made progress. (AP Photo/Charles Rex Arbogast)

Deb Robertson smiles as she converses with her son Jake before a BBQ with family and friends at her Lombard, Ill., home Saturday, March 23, 2024. She didn’t cry when she learned two months ago that the cancerous tumors in her liver were spreading, portending a tormented death. But later, she cried after receiving a call that a bill moving through the Illinois Legislature to allow certain terminally ill patients to end their own lives with a doctor’s help had made progress. (AP Photo/Charles Rex Arbogast)

Deb Robertson, right, kisses her wife of over 40 years, Kate Koubek as they prepare for a BBQ with family and friends at their Lombard, Ill., home Saturday, March 23, 2024, in Lombard, Ill. Robertson didn’t cry when she learned two months ago that the cancerous tumors in her liver were spreading, portending a tormented death. But later, she cried after receiving a call that a bill moving through the Illinois Legislature to allow certain terminally ill patients to end their own lives with a doctor’s help had made progress. (AP Photo/Charles Rex Arbogast)

Deb Robertson, left, reacts to a card made for her by a student of her daughter Shannon Rodriguez, right, as her son Jake and niece Emma watch before a BBQ with family and friends at her Lombard, Ill., home Saturday, March 23, 2024. She didn’t cry when she learned two months ago that the cancerous tumors in her liver were spreading, portending a tormented death. But later, she cried after receiving a call that a bill moving through the Illinois Legislature to allow certain terminally ill patients to end their own lives with a doctor’s help had made progress. (AP Photo/Charles Rex Arbogast)

A card made for Deb Robertson by a student of Robertson’s daughter Shannon Rodriguez is seen at Robertson’s Lombard, Ill., home Saturday, March 23, 2024. She didn’t cry when she learned two months ago that the cancerous tumors in her liver were spreading, portending a tormented death. But later, she cried after she received a call that a bill moving through the Illinois Legislature to allow certain terminally ill patients to end their own lives with a doctor’s help had made progress. (AP Photo/Charles Rex Arbogast)

Deb Robertson stands for a portrait in the living room of her Lombard, Ill. home, in front of a reproduction of Creation of Adam painting by Michelangelo, Thursday, March 21, 2024. Robertson didn’t cry when she learned two months ago that the cancerous tumors in her liver were spreading, portending a tormented death. But later, she cried after receiving a call that a bill moving through the Illinois Legislature to allow certain terminally ill patients to end their own lives with a doctor’s help had made progress. (AP Photo/Charles Rex Arbogast)

Gary Drake, left, his son Mitch Drake, and Mitch’s mother Cindy Jackson pose for a picture on Jan. 4, 2024, in Jacksonville, Fla. Mitch Drake flew to Oregon with his father in February, where physician-assisted death is allowed for out-of-state patients who are terminally ill and meet certain requirements. He thanked him for the life he’d given him, and they said their goodbyes. (Courtesy of Mitch Drake via AP)

Gary Drake and his son Mitch Drake pose for a picture in Portland, Ore., on Feb. 13, 2024. Mitch Drake flew to Oregon with his father in February, where physician-assisted death is allowed for out-of-state patients who are terminally ill and meet certain requirements. He thanked him for the life he’d given him, and they said their goodbyes. (Courtesy of Mitch Drake via AP)

This Jan. 28, 2017 photo provided by Rod Azama shows his wife Susan relaxing with her dog Sunny at home in Silver Spring, Md. Eight states and Washington D.C. allow physician-assisted death for certain terminally ill patients, like Susan Azama., but only for their own residents. Vermont and Oregon permit any qualifying American to travel to their state for the practice, so the Maryland resident traveled to Oregon. (Rod Azama via AP)

This undated photo provided by Rod Azama shows Azama with his wife Susan Azama at a party in Md. Eight states and Washington D.C. allow physician-assisted death for certain terminally ill patients, like Susan Azuma, but only for their own residents. Vermont and Oregon permit any qualifying American to travel to their state for the practice, so the Maryland resident traveled to Oregon. (Rod Azama via AP)

Gary Drake and his youngest granddaughter Azalee Drake, 5, pose for a picture on Jan. 4, 2024, in Jacksonville, Fla. Drake’s son Mitch Drake flew to Oregon with his father in February, where physician-assisted death is allowed for out-of-state patients who are terminally ill and meet certain requirements. He thanked him for the life he’d given him, and they said their goodbyes. (Courtesy of Mitch Drake via AP)

DENVER (AP) — On a brisk day at a restaurant outside Chicago, Deb Robertson sat with her teenage grandson to talk about her death.

She’ll probably miss his high school graduation. She declined the extended warranty on her car. Sometimes she wonders who will be at her funeral.

Those things don’t frighten her much. The 65-year-old didn’t cry when she learned two months ago that the cancerous tumors in her liver were spreading, portending a tormented death.

But later, she received a call. A bill moving through the Illinois Legislature to allow certain terminally ill patients to end their own lives with a doctor’s help had made progress.

Then she cried.

Deb Robertson sits for a portrait at her Lombard, Ill. home, Thursday, March 21, 2024. (AP Photo/Charles Rex Arbogast)

“Medical-aid in dying is not me choosing to die,” she says she told her 17-year-old grandson. “I am going to die. But it is my way of having a little bit more control over what it looks like in the end.”

That same conversation is happening beside hospital beds and around dinner tables across the country, as Americans who are nearing life’s end negotiate the terms with themselves, their families and, now, state lawmakers .

Deb Robertson looks at a wall with her chemo caps at her Lombard, Ill. home, Thursday, March 21, 2024. (AP Photo/Charles Rex Arbogast)

At least 12 states currently have bills that would legalize physician-assisted death. Eight states and Washington, D.C., already allow it, but only for their own residents. Vermont and Oregon permit any qualifying American to travel to their state for the practice. Patients must be at least 18 years old, within six months of death and be assessed to ensure they are capable of making an informed decision.

Two states have gone in the opposite direction. Kansas has a bill to further criminalize those who help someone with their physician-assisted death. West Virginia is asking voters to enshrine its current ban into the state constitution.

That patchwork of laws has left Americans in most states without recourse. Some patients choose to apply for residency in a state where it’s legal. Others take arduous trips in the late-stage throes of disease to die in unfamiliar places and beds, far from family, friends and pets.

It was late at night when Rod Azama awoke to his wife crawling on the floor, screaming. Pain from her cancer had punched through the heavy morphine dose.

This undated photo provided by Rod Azama shows Azama with his wife Susan Azama at a party in Md. (Rod Azama via AP)

“Let me die,” screamed his wife, Susan.

As Rod rushed to hold her, the cries faded to repeated mumbles. “Heaven,” she said, again and again.

Susan, 68, pieced through her life’s belongings — family heirlooms, photos, an antique spinning wheel — touching the memories a final time. Then she decided where their next lives would be.

She said goodbye to her constant sidekick, a small, fluffy Maltipoo named Sunny. Rod packed the dog’s favorite toy, a stuffed bunny, as a reminder for Susan, who had to leave Sunny behind.

Then the two flew to Oregon.

The issue is contentious . Opponents, including many religious groups and lawmakers, have moral objections with the very concept of someone ending their life. Even with safeguards in place, they argue, the decision could be made for the wrong reasons, including depression or pressure from family burdened by their caretaking.

“It’s normalizing suicide, and it’s incentivizing individuals to end their lives,” said Danielle Pimentel of Americans United for Life . Pimentel raised concerns that pain isn’t the top reason people choose an early departure, adding that policy should focus on bettering end-of-life care.

This Jan. 28, 2017 photo provided by Rod Azama shows his wife Susan relaxing with her dog Sunny at home in Silver Spring, Md. (Rod Azama via AP)

Two national organizations lobbying for the bills argue it’s about autonomy and compassion, some power over one’s preordained exit.

“It comes down to the right of an individual to control their own end of life decisions free from government intervention or religious interference,” said Goeff Sugerman, national campaign strategist Death with Dignity .

Even though it’s illegal in most states, a 2018 Gallup poll showed more than two-thirds of Americans support physician-assisted death.

Only a small fraction of Americans nationwide, about 8,700, have used physician-assisted death since Oregon became the first state to legalize it in 1997, according to the advocacy group Compassion & Choices . Most are cancer cases; others include heart and respiratory diseases. A third of people prescribed the medications don’t end up using them.

Gary Drake planned to. He began a Facebook post on Feb. 13 with “RIP.” The 78-year-old was referring to himself. He was off to Oregon, and wouldn’t be responding to any more messages and calls.

“I’m too busy and weak to do much more in this lifetime,” he wrote.

Gary Drake, left, his son Mitch Drake, and Mitch’s mother Cindy Jackson pose for a picture on Jan. 4, 2024, in Jacksonville, Fla. (Courtesy of Mitch Drake via AP)

The jovial businessman from Florida had watched a close friend decline from late-stage lung cancer, driving him to and from chemotherapy, until his friend shot himself. When Drake received a diagnosis around Christmas that his own lung, bone and kidney cancer would end his life within six months, he didn’t deliberate long.

He signed off on Facebook: “I love you all, say a prayer for me, and I’ll see you on the other side. Bon Voyage.”

The finality of the post prompted a flood of comments, as if he were attending his own funeral.

“I know my dad and George are waiting to have a drink with you,” someone wrote.

Gary Drake and his son Mitch Drake pose for a picture in Portland, Ore., on Feb. 13, 2024. (Courtesy of Mitch Drake via AP)

Less than three years ago Drake wouldn’t have had the option. Oregon’s residency requirement was rolled back in 2022 and Vermont’s ended last year , after successful federal lawsuits argued it was unconstitutional for states to deny the service to non-residents.

While debates to legalize the bills are playing out in Kentucky, Delaware, Maryland and Iowa, among others, the advocacy organization Compassion & Choices is using the courts to try to remove residency requirements.

“People are dying right now who don’t have the luxury for endless deliberation,” said Kim Callinan, CEO and president of the group.

While California has a bill before lawmakers that would allow out-of-staters to access the procedure, that provision in a Colorado bill was stripped out. Three states, including Colorado, have proposals to expand in-state access, such as allowing advanced practice registered nurses, not just doctors, to prescribe the medication.

As Robertson discussed the topic with her grandson over noodles, he got teary eyed. If it became legal in Illinois tonight, would his grandmother be gone tomorrow? How does it differ from suicides that left empty seats at his school?

A card made for Deb Robertson by a student of Robertson’s daughter Shannon Rodriguez is seen at Robertson’s Lombard, Ill., home Saturday, March 23, 2024. (AP Photo/Charles Rex Arbogast)

Robertson reassured him it would be the very last option as she embarks on a new chemo treatment. Then she explained the safeguards.

Typically, two doctors must confirm that a patient has six months to live. The patient must verbally request it twice with a waiting period that varies by state, and submit a written request with witnesses. At three meetings, a physician assesses the patient to ensure they are able to make an informed decision. The patient can be referred to a psychologist for an assessment if there are concerns.

Patients must take the medication themselves. They lose consciousness within a few minutes and usually die within a few hours.

Eventually the teenager met her eyes. “Granny, I support whatever you choose to do,” he said.

Robertson was glad she had the conversation. “When you just think of the words ‘medical-aid dying,’ a 17-year-old gets stuck on the ‘dying’ part,” she said.

Deb Robertson stands for a portrait in the living room of her Lombard, Ill. home, in front of a reproduction of Creation of Adam painting by Michelangelo, Thursday, March 21, 2024. (AP Photo/Charles Rex Arbogast)

Dr. Jess Kaan is no stranger to the controversy and fixation on the “dying” part. Living on the border between Oregon and Washington, she has worked on over 200 cases between the two states. A quarter of those traveled to Oregon.

Kaan has faced condemnation even from some fellow doctors, who accuse her of violating the Hippocratic oath of “do no harm.” Kaan’s own mother is aghast on religious grounds, and though it’s become a major part of Kaan’s life, the two have only spoken about it once.

For Kaan, it’s a simple argument. She recalled watching a hospitalized patient with Lou Gehrig’s disease, or amyotrophic lateral sclerosis, slowly decline, tormented by an inexorable feeling of suffocation, until she died.

“She didn’t die the death she wanted to die,” Kaan said.

“I’m just so convinced that death itself is not the enemy per se,” she said. “For me, the ethical principles upon me are beneficence, in that I feel that the relief of suffering is really what I’m supposed to do as a physician.”

As Drake prepared to fly to Oregon after posting on Facebook, he told his 12-year-old granddaughter that their special word would be “LuLu,” a tease over her obsession with the clothing brand Lululemon. Every time she saw it, he said, that would be him looking down from above.

“The last conversation she had with him was like any normal conversation that she’s ever had with him. And that’s the way she’ll be able to remember him,” said his son, Mitch Drake, 38.

Mitch flew to meet up with his father in Oregon in February. He thanked him for the life he had given him. They said their goodbyes.

Gary Drake drank the medicine as they played his song request: “Toes,” by Zac Brown Band.

He put the cup down and sang.

“I got my toes in the water, ass in the sand

Not a worry in the world, a cold beer in my hand

Life is good today

Life is good today.”

Then he fell asleep.

Bedayn is a corps member for the Associated Press/Report for America Statehouse News Initiative. Report for America is a nonprofit national service program that places journalists in local newsrooms to report on undercovered issues.