pros and cons euthanasia essay

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Pros and Cons of Physician Aid in Dying

Lydia s dugdale, barron h lerner, daniel callahan.

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To whom all correspondence should be addressed: Lydia S. Dugdale, MD, MAR, Associate Professor, Columbia University, 622 W 168 St, PH 8E-105, New York, NY, 10032; Tel: 212-305-5960, Email: [email protected] .

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Focus: Death

Collection date 2019 Dec.

This is an open access article distributed under the terms of the Creative Commons CC BY-NC license, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited. You may not use the material for commercial purposes.

The question of a physician’s involvement in aid in dying (or “assisted suicide”) is being debated across the country. This article adopts no one position because its authors hold contrasting views. It aims instead to articulate the strongest arguments in favor of aid in dying and the strongest arguments opposed. It also addresses relevant terminology and reviews the history of its legalization in the United States.

Keywords: Aid in dying, Physician-assisted suicide, End of life, Death, Dying, Ethics, Bioethics, Autonomy, Suicide

Physician aid in dying is a controversial subject raising issues central to the role of physicians. According to the American Medical Association, it occurs when a physician provides “the necessary means and/or information” to facilitate a patient’s choice to end his or her life [ 1 ].

This essay’s authors hold varying views on the ethics of aid in dying; thus, the essay explores the subject without taking a position. It addresses its terminology; history of legalization in the United States; arguments in favor of aid in dying; and arguments opposed.

Terminology

Physician aid in dying goes by many names. Perhaps the best recognized is “physician-assisted suicide.” Alternative terms include but are not limited to: death with dignity, doctor-prescribed death, right to die, and physician-assisted death. For simplicity’s sake, we use aid in dying (AID), although we recognize that there will be some who object, no matter the label.

A variety of factors have led to these various neologisms. Supplanting the word “physician” with “medical,” for example, makes it possible for non-physician clinicians to prescribe the lethal medications. Some advocates of AID prefer not to use the term “suicide;” they contend that AID is a medical practice, distinct from the act of suicide for a depressed or hopeless person [ 2 ]. By contrast, opponents maintain that the process of prematurely and deliberately ending one’s life is always suicide, regardless of motivation. Some insist that dissociating “physician-assisted suicide” from other types of suicide demeans those who die by suicide for other reasons, as if only medically-assisted suicides are legitimate [ 3 ]. People on both sides of the issue worry whether “aid in dying” or “assisted dying” might be confused with palliative, hospice, or other care of dying patients.

In the United States, physician-assisted suicide or aid in dying has always been carefully distinguished from euthanasia. Euthanasia, also called mercy killing, refers to the administration of a lethal medication to an incurably suffering patient. It may be voluntary (the patient requests it) or involuntary. Euthanasia is illegal in the United States, but voluntary euthanasia is legal in Belgium, Colombia, Luxembourg, and Canada. It is decriminalized in the Netherlands.

At risk of compounding terminology further, Canada legalized in June 2016 “medical assistance in dying” (MAiD), which includes both “voluntary euthanasia” and “medically-assisted suicide [ 4 ].”

A Brief History of Legalization in the United States

In the early 1900s, advocates argued forcefully for legalizing euthanasia, which was already being secretly practiced in the US. According to Jacob Appel’s work on this period, the eugenics movement strongly influenced discourse on euthanasia, and opponents of legalization tended to put forth practical rather than religious or moral arguments [ 5 ]. When efforts to legalize euthanasia failed, public discourse on the subject waned for many decades.

In the 1980s, the pathologist Jacob “Jack” Kevorkian began advertising in Detroit area newspapers as a death counselor [ 6 ]. He had studied the technique of Dutch physicians in the Netherlands, and created his own device with which patients could self-administer lethal medications. His first patient ended her life in 1990 while lying on a bed inside Kevorkian’s Volkswagen van. He went on to assist with some 130 deaths by suicide over the next eight years. In 1999, after Kevorkian publicly distributed a video of himself directly euthanizing a patient, he was convicted of second-degree murder and sent to prison. Although Kevorkian reignited national debate about dying, his off-putting approach and personal idiosyncrasies prevented his becoming a national leader on the issue.

Several of Kevorkian’s physician contemporaries filed suit against New York’s Attorney General, arguing that the State of New York’s prohibition against physician-assisted suicide violated the Equal Protection Clause of the Fourteenth Amendment. They argued, in effect, that the right to refuse treatment was effectively the same as the right to end one’s life. The Supreme Court ruled in response in Vacco v. Quill (1997) that there is no constitutionally-protected right to die. It left such decisions to the states. The Court also ruled in Washington v. Glucksberg (1997) that a right to aid in dying was not protected by the Due Process Clause.

Oregon became the first to pass its death with dignity law that same year. More than a decade later, Washington legalized AID in 2008. Montana decriminalized the practice a year later. Vermont legalized it in 2013.

In 2014, a young Californian named Brittany Maynard was diagnosed with an astrocytoma and became a spokesperson for the legalization of AID. She was a newlywed facing terminal illness, and her story quickly captured the public imagination. Her well-publicized death by lethal ingestion in Oregon in 2014 influenced her home state of California to legalize AID in 2015. This was subsequently followed by Colorado in 2016, the District of Columbia in 2017, Hawai'i in 2018, and New Jersey and Maine in 2019.

Pro Arguments

The two most common arguments in favor of legalizing AID are respect for patient autonomy and relief of suffering. A third, related, argument is that AID is a safe medical practice, requiring a health care professional.

Respect for Patient Autonomy

Bioethics as a discipline gained significant traction in the 1970s, at a time when the concept of patient rights was pushing back against physician paternalism. The philosophers Tom Beauchamp and James Childress, in their well-known textbook Principles of Biomedical Ethics, advanced four fundamental principles as a framework for addressing ethically-complex cases: autonomy, beneficence, non-maleficence, and justice. Of these principles, autonomy undeniably exerts the most influence on current US medical practice [ 7 ].

Autonomy refers to governance over one’s own actions. In the health care setting, this means a patient determines which medical interventions to elect or forgo. Patient autonomy serves as the justification for informed consent; only after a thorough explanation of risks and benefits can the patient have the agency to make a decision about treatments or participation in medical research. This logic, it is argued, naturally extends to AID; patients accustomed to making their own health care decisions throughout life should also be permitted to control the circumstances of their deaths.

Relief of Suffering

At its core, medicine has always aimed to relieve the suffering of patients from illness and disease. In the West, Hippocrates’s ancient oath pledged to use treatments to help the sick, but not “administer a poison to anybody when asked to do so [ 8 ].” In contrast, advocates of AID argue that relief of suffering through lethal ingestion is humane and compassionate – if the patient is dying and suffering is refractory. Indeed, some of the most compelling arguments made in favor of AID come from patients, such as Maynard, who suffer from life-threatening illnesses.

A Safe Medical Practice

Aid in dying is lauded by advocates for being a safe medical practice – that is, doctors can ensure death in a way that suicide by other means cannot. Aid in dying thus becomes one option among many possibilities for care of the dying. Although individual state laws vary, most propose a number of safeguards to prevent abuses and to provide structure for an act that some people will do anyway, albeit more haphazardly or even dangerously. Safeguards include requiring that a patient electing AID be informed of all end-of-life options; that two witnesses confirm that the patient is requesting AID autonomously; and that patients are free of coercion and able to ingest the lethal medication themselves [ 9 ].

Con Arguments

Although opponents of AID offer many arguments ranging from pragmatic to philosophical, we focus here on concerns that the expansion of AID might cause additional, unintended harm through suicide contagion, slippery slope, and the deaths of patients suffering from depression.

Suicide Contagion

The sociologist David Phillips first described suicide contagion in the 1970s. He showed that after high profile suicides, society would witness a broad spike in suicides [ 10 ]. This was particularly true for individuals whose demographic profiles were similar to those of the person who died by suicide [ 11 ]. Although Phillips’s work did not focus on AID, it has been corroborated recently by the spike in youth suicidality following the airing of Netflix’s 13 Reasons Why [ 12 ].

The publicly-available data from Oregon, however, reveal that in the months surrounding Maynard’s high-profile death in November 2014, the number of similarly situated individuals in Oregon who ended their lives by lethal ingestion more than doubled. Furthermore, from 1998 (when Oregon started recording data) to 2013, the number of lethal prescriptions written each year increased at an average of 12.1%. During 2014 and 2015, however, this increase doubled, suggesting that high-profile AID leads to more AID [ 13 ]. Although the data do not prove that an increase in AID causes more non-assisted suicide, a study by Jones and Paton found that the legalization of AID has been associated with “an increased rate of total suicides relative to other states and no decrease in non-assisted suicides [ 14 ].” They suggest that this means either AID does not inhibit non-assisted suicide or that AID makes non-assisted suicide more palatable for others.

Slippery Slope

Some opponents of AID express concern that once doctors are involved in the business of hastening patients’ deaths; they have already slid down the slippery slope [ 15 ]. Others suggest that the slope is best exemplified by an expanding list of reasons for electing AID. Refractory physical pain is no longer the most compelling reason for ending one’s life through lethal ingestion. Instead, cumulative Oregon data suggest that the vast majority of patients elect AID because they are concerned about “losing autonomy” (90.6%) or are “less able to engage in activities making life enjoyable” (89.1%). Some fear a “loss of dignity” (74.4%); being a “burden on family, friends/caregivers” (44.8%); or “losing control of bodily functions” (44.3%). Concern about inadequate pain control was the reason for pursuing a lethal ingestion in only 25.7% of cases [ 16 ].

Opponents also point to increasing calls in the US for euthanasia. In 2017, Senate Bill 893 was introduced to the Oregon State Legislature; it would have enabled patients to identify in a legal directive the person they wished to administer their lethal medications, effectively legalizing euthanasia [ 17 ]. Although this bill failed, the Oregon House passed HB2217 in 2019, which expanded the definition of “self-administer” to include options in addition to the oral ingestion of lethal drugs. The House also put forward HB2903, which seeks to expand the word “ingest” for lethal medication to “any means” and also proposes to expand the definition of “terminal disease” to include “a degenerative condition that at some point in the future” might cause death. It remains to be seen whether Oregon will become the first state to legalize euthanasia.

Although Belgium and The Netherlands permit both AID and euthanasia, the latter dominates. Over the years there has been a steady increase in acceptable criteria. Currently, patients who suffer from depression, dementia, or being “tired of life” may be euthanized. In some cases, minors may also be euthanized [ 18 ]. Published data from the Flanders region of Belgium highlights that vulnerable populations are especially likely to be euthanized. From 2007 to 2013, the largest increases in rates of granting euthanasia requests were among women, those 80 years or older, those with lower educational achievement, and those who died in nursing homes [ 19 ].

Depression in Advanced Illness

Up to half of patients with cancer suffer from symptoms of depression [ 20 ]. The elderly also suffer from high rates of depression and suicide [ 21 ]. Because depression often manifests somatically [ 22 ], if patients are not screened, clinicians miss half of all cases of clinical depression [ 23 - 25 ]. Opponents of AID are concerned that in Oregon, greater than 70 percent of patients who elect AID are elderly and have cancer, but fewer than five percent are referred to a psychiatrist or psychologist to rule out clinical depression.

Physician AID remains a controversial subject relevant to the care of patients. The Hippocratic model dominated medical practice for thousands of years. With the rise of euthanasia in Europe during the second half of the twentieth century, many began to rethink this stance, but hastening the death of patients still sits uncomfortably with many physicians. Although a number of medical societies have begun to reconsider their positions, the American Medical Association’s House of Delegates voted in June 2019 to maintain the organization’s long-held opposition to physician-assisted suicide and euthanasia [ 26 ]. Strong arguments remain both in favor and in opposition to the practice, and physicians have an ethical responsibility to remain informed on this timely issue.

aid in dying

medical assistance in dying

Additional Information

Co-author Daniel Callahan, PhD, died after the first submission of this article.

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18 Advantages and Disadvantages of Euthanasia

Euthanasia is a deliberate action that is taken by a physician or another party that knowingly results in the ending of a person’s life. This step is taken under most circumstances to end the persistent suffering that individuals experience because of a terminal illness, genetic disorder, or traumatic event. It is a process that, along with physician-assisted suicide, is against the law in most countries. These actions may even include a jail sentence if an individual is convicted of this practice.

Voters in Oregon approved the Death with Dignity Act in 1994, allowing a doctor to help a patient with a terminal illness find the peace they wanted. Part of this law required that the patient have only six months or fewer to live with their diagnosis. The Supreme Court ruled in 1990 that non-active euthanasia is permissible. Formal ethics committees in hospitals and nursing homes have existed since 1977 to encourage advanced health directives and living wills.

The Netherlands eliminated the criminalization of assisted suicide in 2002, loosening some of their restrictions at the same time euthanasia was approved for the first time in Belgium. Switzerland was one of the first nations to allow the practice, authorizing doctors in 1937 to help patients if ending their life did not provide them with a personal gain.

There are several advantages and disadvantages to consider with euthanasia, especially since it is such an emotive and sometimes controversial topic.

List of the Advantages of Euthanasia

1. We use euthanasia as the last resort when all other options are off the table. The average person or doctor is not going to support the proactive termination of a life when there is no suffering involved. Euthanasia is different than suicide, even though both actions end a life, because the former uses assistance and the latter does not. The goal with this help is to end the suffering of a lengthy death, especially if there is chronic and severe pain included with the process.

People often criticize pet owners for not taking them to the vet to end their suffering when something tragic occurs – even if it is only cancer or old age. When an individual wants to take the same action, then they receive criticism for it. How does that make sense?

2. The right to die should be a personal choice, not one that the government mandates. We have the right to choose numerous paths in life that can take us in a variety of different directions. Most of those actions receive very little, if any, governmental interference. When we start talking about euthanasia, the story becomes very different. There are some spiritual views of suicide that might influence this discussion, along with the personal difficulties that helping someone might cause, but someone with a terminal illness may wish to end their life on their own terms.

Incorporating Death with Dignity laws can help to make this a possibility. The decision remains in the hands of the patient at all times instead of going to a review panel. Then the patient is the one who takes the fatal prescription or starts the needed IV instead of the doctor so that it remains in a person’s control.

3. Doctors have a minimal role in the modern euthanasia process. One of the reasons why society might be against the idea of euthanasia is because of the actions of people like Dr. Jack Kevorkian in the past. Instead of allowing people with no threat of death to take their lives under supervision, the Death with Dignity Acts that have passed across the United States allow for voluntary physician inclusion. Even if you live in a place that allows this process, such as Washington State or Oregon, then you’re not required to perform this action.

Recent statistics show that less than 1% of doctors choose to participate in these programs. About 40% of those who wrote a legal lethal prescription had no knowledge as to whether or not the patient took the medication. That’s very different from Kevorkian, where 60% of his patients were not terminally ill.

4. There is more control over the final decisions in life. Like it or not, the end of a person’s life is the beginning of a financial journey for their loved ones. Debts are not wiped away at death. Your estate becomes responsible to pay off remaining obligations and handle other items of business. It can take years sometimes to settle complex financial issues. When euthanasia is part of the conversation for someone with a terminal illness, then there can be more planning involved to make this transition easier on everyone else.

By having more control over the final decision of life, the emotional and physical toll of an illness can be reduced for everyone involved. It’s not just relief for the person who is suffering. The rest of the family can find peace knowing that there is a planned time to create an end to this situation.

5. Patients can avoid the issue of caregiver guilt with euthanasia. One of the most significant challenges that occur with a terminal diagnosis is the emotions of guilt and shame that a patient has with regards to their caregivers. They begin to feel like a burden on the people they love, creating a reaction that can cause relationship challenges because it is only natural to push people away to help them to avoid pain. Legalizing euthanasia might not be a popular option in some circles, but it can create organization for the transitory time that everyone experiences in a situation such as this one.

By helping someone to find the physical peace they need, there can be a process of emotional healing that can help everyone push through their grief with greater consistency.

6. We use specific legal requirements to eliminate the threat of a mistaken identity. There are two primary concerns that the critics of euthanasia often express: helping an individual die without their permission or targeting an incorrect patient for this process. The states in the U.S. which have a Death with Dignity Act require that patients self-administer their lethal prescription. You must also be of sound mind when making this decision, and the law requires that you make it more than once after a waiting period.

If someone in an altered state or a patient with a mental disability issued a written request for euthanasia, it would be rejected for a lack of competency. Some jurisdictions require the presence of two witnesses as well, and they cannot be a relative or someone who would benefit from an estate inheritance.

7. Only a handful of people who are terminally ill take advantage of euthanasia laws. Whether you’re looking at data from Europe, the United States, or other countries which allow euthanasia in some way, the results are quite consistent. The people who qualify for this program is 0.3% or less of the general population. When you look at this specific group of people with a terminal illness who decide that this is the method they wish to use to end their life, the rate of adoption is typically less than 3%. Critics are often concerned about the idea that more people would choose suicide because of its accessibility, but the data doesn’t back up that idea.

These figures have been consistent since 2002 in the United States when the first Death with Dignity Act actions were taken. The results are similar to what Europe has experienced since the 1990s with their actions in this area as well.

8. Death is still going to happen, one way or the other. Is the way that a person dies really that important to the rest of society? The advantages and disadvantages of euthanasia should be rightfully debated, but it is not our place to dictate an outside sense of morality or ethics on a person who is trying to manage a terminal diagnosis. These people are already working toward an end-of-life scenario. If they decide not to take advantage of this legal process, there is an excellent chance that they will pass away in the near future anyway.

List of the Disadvantages of Euthanasia

1. The prediction of a terminal diagnosis is rarely accurate. During a 2005 study of terminal illness diagnoses by the Mayo Clinic, they found that only 1 in 5 patients received an accurate number. 17% of people who find themselves in this situation live for longer, sometimes much longer, than what the doctor initially recommends. That is why euthanasia encounters such resistance, even when there are legal definitions in place which allow for its use.

If about 1 in 5 people beat their diagnosis, then what else could be possible? It might be unrealistic to expect a medical miracle in every situation, but we should take an open and honest approach to these statistics.

2. There can be issues with consent when looking at euthanasia. The legalization of euthanasia works when a physician is willing to provide this option for their patient. There are times when a doctor is unwilling to provide a lethal prescription for their own ethical reasons, going back to the concept to “do no harm.” There are some in the medical field that believe the quality of death should be just as much a priority as the quality of life, but the idea of trying to recommend this option is something that critics find to b e a possibility in the future.

No one should ever go through a situation where they feel like their doctor is trying to talk them into the euthanasia process. Doctors need the option to get out of this program just as much as a patient deserves a second option.

3. Euthanasia medication doesn’t always deliver on its promised result. The State of Oregon tracked the results of patients who took lethal prescriptions as part of the Death with Dignity Act for two decades, starting in 1998. This data found that seven people regained consciousness after taking the medication, and one person was even alive after the study period still fighting their disease. Another 1,179 people out of 1,857 qualifying patients had a successful result from their encounter with the euthanasia program.

We must remember that the legalization of euthanasia is not a guaranteed outcome. When someone makes this decision and it doesn’t work as intended, it places them and their doctor into an almost impossible situation. Do you continue to treat the disease? Or do you attempt to help that person end their life once again.

4. Euthanasia could allow people to choose death for reasons that go beyond an illness. When surveying individuals who qualify for a euthanasia program, over 90% said that it was their “loss of autonomy” that was driving their decision – not the actual diagnosis of a terminal illness. The survey asked patients to choose any reason that applied, and 90% of people also chose a restriction in their usual activities as a primary factor in their choice.

Only 1 in 4 people who decide to pursue the idea of euthanasia say that pain is an influencing factor in their decision. If patients are using the Death with Dignity Act to have doctors help to end their life because they don’t like their “new normal,” then doesn’t that go against the purpose of this legislation in the first place?

5. Second opinions are not always necessary for euthanasia. The field of medicine is not an exact science, even if we know that there are certain outcomes that are likely in specific circumstances. If you have a bacterial infection, for example, then taking antibiotics should help to clear things up for you. Is that outcome guaranteed? No.

Medical interventions are based on the idea that the benefits which are possible outweigh the potential risks that you face. That is why a second opinion is often recommended when there is a serious diagnosis. Even if there is a consensus in a patient’s condition, there is an unpredictability to the way a person might respond to treatment. “You get surprises because diseases have their own personality, and every once in a while, a disease that’s usually bad behaves in a more indolent fashion,” Dr. David Steinberg, an oncologist at the Lahey Clinic Medical Center, told NBC News.

6. Euthanasia would require a change to the legal and medical statutes in most countries. Although the United States, the Netherlands, and other countries which offer euthanasia at some level would require little in the way of legislation to permit this practice, it would require a complete overhaul of the criminal justice system in others. Even in the U.S., the judicial system has found that an individual does not have a Constitutional right to ask for a prescription that could end their life.

What we do know from the countries which allow euthanasia is that more people are requesting this service without having a terminal illness. Almost 5% of the individuals who die in the Netherlands each year do so because of euthanasia, with over 30% of the requests coming from individuals above the age of 80 without a significant health diagnosis.

7. Some doctors may purposely give out false information. We already know that 1 in 5 people can survive a terminal diagnosis based on length. The University of Chicago also found that doctors sometimes refuse to even offer an estimate if a patient asks them how long they have to live. 2 out of 5 physicians said that they would give an optimistic time that was up to three times longer than what they thought was possible. If we cannot be honest about patient information even with the presence of death with dignity laws, then isn’t it possible that some people could qualify for a program when the reality of their health was a very different story?

8. Most patients do not go through with the process of euthanasia. Only a small group of people decide that ending their life is the right decision to make. About 15% of people who are given a terminal diagnosis even bring up the idea of taking their life through a lethal prescription in the first place. The patients who then follow through with their doctor about this choice is about 2%. When you get to the individuals who actually take the pills so that they can use their local euthanasia laws, that figure drops to less than 1%.

Because there are so few people who take advantage of this option, it could be more beneficial to direct the resources dedicated to euthanasia into other forms of medical research. Although there isn’t a realistic cure for old age, we might come up with a way to stop cancer reliably, manage Alzheimer’s disease with consistency, and find solutions for genetic conditions that can reduce the quality of life for a person.

9. Euthanasia avoids the benefits of palliative care. Instead of trying to improve the life of a patient who has a terminal diagnosis, euthanasia seeks to take what remains of a person’s life away from them. People who specialize in palliative care can benefit from the new social, spiritual, and physical problems they face with their health. It is a benefit that people with a non-fatal diagnosis can use to their advantage as well. Giving up on the hope of life because of a challenging circumstance isn’t the right message for doctors to send to their patients. Suicide is an action that someone can take on their own in most instances if they are of sound mind and body, which means a doctor doesn’t need to be involved in many of these situations.

10. It can result in accidental life termination. In 2018, Dutch doctor Bert Keizer was asked to come to the home of a man dying from lung cancer. When he arrived, there were over 30 people gathered around the man’s bed, all drinking, crying and grieving – but it was boisterous. Then the patient told everyone to calm down, the children were taken from the room, and Keizer gave the man his shot that would end his life.

It’s not a slippery slope argument. The first prosecution for medical malpractice while administering euthanasia occurred in 2018. When the Dutch passed their laws in 2002, there wasn’t a stipulation in place for the patient to be competent at the time of medication administration. There are even instances where parents call in doctors to euthanize their mentally ill children.

Verdict on the Advantages and Disadvantages of Euthanasia

The idea that people should have a way to control their suffering is one that touches each family and individual in some way. No one wants to see someone needlessly suffer. Even though the result likely ends in death, it may be better to find physical peace than to have a few more months on this planet.

Every person’s situation is unique. Trying to force a moral equivalency on someone when those who are taking such an action have no idea about what it means to live in that situation is unacceptable. We should allow people to have an opportunity to end their life if that’s what they want to do.

The advantages and disadvantages of euthanasia must also look at the doctor’s, the patient’s family, and the other people involved with the decision. If someone is mentally fit and wishes to proceed in this manner instead of hoping for a miracle, then this option can help them to make it a reality.