euthanasia should be banned or not essay

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Why euthanasia should not be legalised

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Why active euthanasia and physician assisted suicide should be legalised

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In response to the editorial regarding the legalisation of active euthanasia and physician-assisted suicide,1 I present the following arguments against the legalisation of active euthanasia.

Active euthanasia is unnecessary because alternative treatments exist

It is widely believed that there are only two options for patients with terminal illness: either they die suffering or receive euthanasia. Recent research in palliative medicine has shown that virtually all unpleasant symptoms experienced in terminal illness can be relieved or alleviated by existing techniques.

Requests for active euthanasia are rarely free and active.

A person with terminal illness is vulnerable, lacking the skills and knowledge to alleviate their symptoms. It is very difficult for him to be entirely objective about his own situation. Their capacity for decision-making may equally be affected by confusion, dementia or symptoms, which could be relieved with appropriate treatment. Patients who on admission say "let me die" usually after effective treatment are grateful that their request was not acceded to.

Active euthanasia gives too much power to doctors

Ironically, active euthanasia legislation makes doctors less accountable and gives them more power. Patients generally decide in favour of euthanasia on the basis of information given to them by doctors. If a doctor confidently suggests a certain course of action, it can be difficult for a patient to resist. However, diagnoses may be mistaken and prognoses may be widely misjudged. Active euthanasia gives the medical practitioner power, which in turn can be abused.

Active euthanasia leads inevitably to involuntary euthanasia

When active euthanasia has been previously accepted and legalised, it has led inevitably to inactive euthanasia.

Holland is moving rapidly down the slippery slope with the public conscience changing quickly to accept such action as acceptable. The Royal Dutch Medical Association has recommended that the termination of the lives of patients suffering from dementia is acceptable under certain conditions. Case reports include a woman killed at her own request for reasons of "mental suffering".[2]

Such a progression requires only four accelerating factors: favourable public opinion, willing doctors, economic pressure and a law allowing it. In most Western countries the first three ingredients are present already. When legislation comes into effect and political and economic interests are brought to bear, the generated momentum inevitably follows.

Dr Liz Croton SHO A&E City Hospital NHS Trust, Dudley Rd,Birmingham B18 7QH [email protected]

1. Doyle L, Doyle L. Why active euthanasia and physician assisted suicide should be legalised. BMJ 2001:323;1079-80.

Competing interests: No competing interests

The Right to Life and Active Euthanasia Essay

Introduction.

Bibliography

Euthanasia is a Greek word meaning “good death”. Euthanasia refers to the deliberate action that is taken with the intention of ending life due to a pressing suffering. The suffering may be for instance incurable diseases, injuries, or irreversible coma.

Death is only euthanasia if there is intention of death occurring by whatever was done or not done. As it concerns euthanasia, three different terms are necessary in bringing out the exact meaning of the word.

The first word is action. This is what is done to cause death. The action must be from one’s wish and no force or conditions should be met for taking of life. The other term is suffering. This necessary condition is the key to the action.

This leads to accepting the action of taking life to get relieved from the pain. The last term is intention. The death should be intended and not accidental. The intention should be positive as the good of the victim of the matter is concerned.

The means of the action taken to bring death should be made painless as possible and it should prove it as a merciful killing. In this argumentative essay, different forms of euthanasia shall be discussed in depth for the argument to be brought out.

This has been legalized in some countries. However, it is not morally right to kill. One should be left to die as per our religious ethics and no one should be killed even when it is intentional. With different reasons, the issue shall be examined at to determine if it should be banned or not.

Euthanasia is classified into three different categories depending on whether the individual facing death had given informed consent or not. These three categories are voluntary, non-voluntary and involuntary.

Voluntary euthanasia is death done to a person with his/her consent. The person should be ready to be killed from his/her own wish and there should be no external forces compelling the victim to accept death.

Non-voluntary euthanasia is the one in which the person killed had not made the request of the action taken and he/she had not made any consent. This type of euthanasia is not accepted in all countries around the world.

Involuntary euthanasia is the situation in which an individual is killed and the action taken was contrary to his/her wish. This kind of death exhibits ignorance as the victim’s wishes are given a deaf ear.

These three categories of euthanasia can be further divided into passive euthanasia and active euthanasia. Passive euthanasia is done by inhibiting some necessities to the individual, for instance food and antibiotics, which are necessary for continuity of life.

Active euthanasia involves use of lethal substances or use of force to cause death. Active euthanasia has been debated for long on whether it should be banned or not.

Active euthanasia should be banned as all individuals have the rights to live. Each individual should be given a chance to determine his/her own fate. Every individual should enjoy the right to life.

Although sometimes it becomes difficult, to continue living with a person, for instance a person who has used massive wealth of a family in treatment and yet there are no improvements in the individual’s condition.

No matter how the situation is, the right to life should remain. No one should have the authority or desire to take another persons life even incase of many expenses on the individual.

Many believe that in conditions like the latter, active euthanasia should be accepted but it should not. An individual should live with his/her pain and suffering and his/her destiny should not be affected by anything but he/she should remain alive until the last gasp of air on earth without any factor coming in.

Many people try to show tenders of mercy to the victim but it would be better if they extend their mercy in giving aid to the victim for instance giving out money to cater for operations and other treatments.

Active euthanasia has recently resulted into many cases that become difficult to solve. For instance, in a situation where an individual was killed without all the parties desiring the action coming to the point of accepting the actions to be taken.

In such a case, individuals who had not yet accepted the actions taken may go to court and accuse those who accepted the action. In other cases, an individual may be forced to die but the individual refuses to give out his/her will.

After the person’s death, the greatest possibilities are that the members alive will have many miss-understandings and quarrels. In some cases like the latter, the individuals inheriting property may even end up killing one another.

To avoid all these situations, an individual should be left to live and die in peace and leave others peaceful. Active euthanasia should therefore be banned to avoid occurrence of the situations that result after the individual is dead.

Legalizing active euthanasia will place the whole society in a slippery slope that will lead to unacceptable actions and consequences. For instance, members of a family who are against one of them may find it worthy to kill the person.

This may lead to the people doing much harm to the person they are against. They may do this secretly without the individual noticing and this will mostly end in active euthanasia where the individuals accept merciful death.

This is a clear example showing the negative impacts of legalizing active euthanasia. To avoid such pathetic actions from happening, active euthanasia should be banned. This will aid in promoting the right to life and all people will have equal chances of living with no threatening factors or action that may determine their destiny.

Illegalizing active euthanasia will therefore give each person assurance of determining their fate. This as seen may also act to promote peace, as individuals will have to negotiate peacefully over a matter since they have no chance bringing harm to any one of them so that active euthanasia may be the last option.

In the world, it is also very clear that not almost all the religions accept active euthanasia. The governments should not go contrary to the rules and regulations of majority of the religions. No individual who is in a religion that does not support active euthanasia should take part in the actions.

The god of every individual should be the only one to bring death to a person and no person should have the authority to accept dying no matter the situation he/she is in. In addition, physicians should not accept taking any action leading to death, as they would be held responsible for their actions.

In addition, a physician may kill a person and other issues against the action arise. Although many people do not accept people in severe suffering and term them as liabilities, no one should have the permission to take any action leading to the death of the individual. Active euthanasia should therefore be banned completely and no physician should be involved in taking any actions that may result to loss of life.

It would be very inhumane and cruel to kill someone because of suffering. No party should advocate for killing of another person and yet his/her own life is not affected.

It becomes unfair to do to others what cannot be done to you. It becomes difficult to ignore the interests of the majority in killing an individual but no matter what they say, an individual’s right to life should not be violated.

Most countries allow active euthanasia in such conditions to promote the interests of the majority but it is not worthwhile since they will have rendered the right to life useless and will have violated it.

It would be senseless to say that promoting the interests of the majority will mean no violation of rights and yet we know that the right to life is enjoyed individually and therefore the person’s right will have been violated. All the governments should therefore ban active euthanasia in whatever conditions.

Active euthanasia is not intended to be painful. However, with modern medicine there are only few cases where pain can be alleviated. The physicians carrying out the medication to bring death will therefore have caused another kind of death and not active euthanasia, which is supposed to be painless.

Instead of giving medication to cause death, the physicians should better their medications to save life and help the individual recover. Also, if a doctor is in a position to give painless medicine to cause death, then the same doctor should also be able to give medicines to stop the pain felt by an individual hence death will not take place.

This kind of assisted death should be banned, as it will also give pharmacists enough time to research on life-saving medicine and not life-ending medicines.

When physicians are in training, the aim of the training is to help people recover life and not to help people lose life. A lengthy period is spent educating them on medications until they become qualified personnel to work in the field. If active euthanasia is legalized then it will render the medical profession a body performing wrong duties.

The duties they were taught to carry out should be the only ones done. Patients are brought to health centers so that they can receive treatment that should help them in recovering from a suffering.

The physicians should therefore play their role effectively. It becomes a great fault to take another person’s life, which was not part of their long training. Active euthanasia should therefore be banned, as it will also make the medical body worthy.

If a person accepts to be killed mercifully, many say it is morally upright. I however do not accept this because life is personal and no one should be involved in taking of another person’s life.

Life is not communal neither is it group-oriented like land, where the owners can decide on what to do. The personality of life should be maintained and this can only happen by banning active euthanasia.

The person wishing to be killed should be morally counseled and be helped to change his/her life perspective from needing death to needing recovery. Active euthanasia should not be used as a means to end life of an individual.

Each individual should do what he/she would like done to him/her. One cannot be ready to kill another person and yet he/she cannot accept the same to be done to him or her. This becomes unfair and so the act should be banned to enhance fairness.

The right to life is a right to every one in this world. This right should not be violated in any way and people’s lives should be respected. To promote this, active euthanasia should be banned completely no matter the situation.

Physicians should make their profession realistic by saving people’s lives. They should not be involved in any act of killing patients since their training does not consist or promote losing of life but saving of life.

Life is a gift from God and since we were made in the likeness of God, the when one kills he/she has killed God. Though they say that the interests of the majority should be put into consideration, the government would be contradicting itself in accepting the majority’s desire and yet they are the ones singing on right to life.

Death should not be on mercy grounds but by God’s own plan. Majority accepts the action to be taken on others and yet they themselves cannot accept it. This is unfair and therefore active euthanasia should be banned to promote fairness.

Cavan, Seamus and Dolan, Shean. Euthanasia: The debate over the right to die . New York: The Rosen Publishing Group, 2000.

Cohen, Carl and Regan, Tom. The animal rights debate . New York: Rowman & Littlefield, 2001.

Howell, James and Sale, Williams. Life choices: A Hastings Center introduction to bioethics. London: Georgetown University Press, 2000.

Keown, John. Euthanasia, ethics, and public policy: An argument against legalization . Cambridge: Cambridge University Press, 2002.

Manning, Michael. Euthanasia and physician-assisted suicide: Killing or caring ? New York: Paulist Press, 1998.

McDougall, Gorman, Martha and Roberts, Carolyn. Euthanasia: a reference handbook Washington, DC: ABC-CLIO, 2008.

Mitchell, Stephen. Understanding assisted suicide: Nine issues to conside r. United Kingdom: University of Michigan Press, 2007.

Moreland, James and Geisler, Norman. The life and death debate: moral issues of our time . Washington, DC: ABC-CLIO, 1990.

Otlowski, Margaret. Voluntary Euthanasia and the Common Law . London: Oxford University Press, 2000.

Schaler, Jeffrey. Szasz under fire: A psychiatric abolitionist faces his critics . Washington, DC: Open Court Publishing, 2004.

1 Margaret, Otlowski. Voluntary Euthanasia and the Common Law . London: Oxford University Press, 2000.

2 John, Keown. Euthanasia, ethics, and public policy: An argument against legalization . Cambridge: Cambridge University Press, 2002.

3 Jeffrey, Schaler. Szasz under fire: A psychiatric abolitionist faces his critics . Washington, DC: Open Court Publishing, 2004.

4 Seamus, Cavan and Shean, Dolan. Euthanasia: The debate over the right to die . New York: The Rosen Publishing Group, 2000.

5 James, Howell,and Sale, Williams. Life choices: A Hastings Center introduction to bioethics. London: Georgetown University Press, 2000.

6 Michael, Manning. Euthanasia and physician-assisted suicide: Killing or caring ? New York: Paulist Press, 1998.

7 Carl, Cohen and Tom, Regan. The animal rights debate. New York: Rowman & Littlefield, 2001.

8 James, Moreland and Geisler, Norman. The life and death debate: moral issues of our time . Washington, DC: ABC-CLIO, 1990.

9 Stephen, Mitchell. Understanding assisted suicide: Nine issues to conside r. United Kingdom: University of Michigan Press, 2007.

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IvyPanda. (2022, April 6). The Right to Life and Active Euthanasia. https://ivypanda.com/essays/active-euthanasia/

"The Right to Life and Active Euthanasia." IvyPanda , 6 Apr. 2022, ivypanda.com/essays/active-euthanasia/.

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IvyPanda . 2022. "The Right to Life and Active Euthanasia." April 6, 2022. https://ivypanda.com/essays/active-euthanasia/.

1. IvyPanda . "The Right to Life and Active Euthanasia." April 6, 2022. https://ivypanda.com/essays/active-euthanasia/.

IvyPanda . "The Right to Life and Active Euthanasia." April 6, 2022. https://ivypanda.com/essays/active-euthanasia/.

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• Euthanasia and Assisted Suicide
• Tuskegee Experiment: The Infamous Syphilis Study
• Ethical Issues in the Health Sector

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Euthanasia – Arguments in Favour and Against

Last updated on April 7, 2024 by ClearIAS Team

Euthanasia is the deliberate act of ending a person’s life to relieve them of suffering. It is a complex and ethically sensitive topic that has sparked debates and discussions worldwide. There are different forms of euthanasia, and it is regulated differently in various countries.

Euthanasia (“good death”) is the practice of intentionally ending a life to relieve pain and suffering. It is also known as ‘mercy killing’.

In many countries, there is a divisive public controversy over the moral, ethical, and legal issues of euthanasia. Euthanasia is categorized in different ways, which include voluntary, non-voluntary, or involuntary. Euthanasia is also classified into active and passive Euthanasia.

Table of Contents

Voluntary, Non-Voluntary, and Involuntary Euthanasia

• Voluntary euthanasia: It is conducted with the consent of the patient and is termed voluntary euthanasia. Voluntary euthanasia is legal in some countries. Jurisdictions, where euthanasia is legal, include the Netherlands, Colombia, Belgium, and Luxembourg.
• Non-Voluntary euthanasia: It is conducted where the consent of the patient is unavailable and is termed non-voluntary euthanasia. Non-voluntary euthanasia is illegal in all countries. Examples include child euthanasia, which is illegal worldwide but decriminalized under certain specific circumstances in the Netherlands under the Groningen Protocol.
• Involuntary euthanasia: It is conducted against the will of the patient and is termed involuntary euthanasia. Involuntary euthanasia is usually considered murder.

Passive vs Active euthanasia

Voluntary, non-voluntary, and involuntary euthanasia can all be further divided into passive or active variants.

• Passive euthanasia entails the withholding of common treatments, such as antibiotics, necessary for the continuance of life.
• Active euthanasia entails the use of lethal substances or forces, such as administering a lethal injection, to kill and is the most controversial means.

Euthanasia debate

Euthanasia raises profound ethical and moral questions. Supporters argue that it can be a compassionate and dignified way to end suffering, particularly in cases of terminal illness.

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Opponents argue that it raises significant ethical concerns, including the potential for abuse, coercion, and mistakes in diagnosing terminal conditions.

Arguments in Favor

Historically, the euthanasia debate has tended to focus on several key concerns. According to euthanasia opponent Ezekiel Emanuel, proponents of euthanasia have presented four main arguments:

• that people have a right to self-determination, and thus should be allowed to choose their fate
• assisting a subject to die might be a better choice than requiring that they continue to suffer
• the distinction between passive euthanasia, which is often permitted, and active euthanasia, which is not substantive (or that the underlying principle–the doctrine of double effect–is unreasonable or unsound);
• permitting euthanasia will not necessarily lead to unacceptable consequences. Pro-euthanasia activists often point to countries like the Netherlands and Belgium, and states like Oregon, where euthanasia has been legalized, to argue that it is mostly unproblematic.
• Constitution of India: ‘Right to life’ is a natural right embodied in Article 21 but euthanasia/suicide is an unnatural termination or extinction of life and, therefore, incompatible and inconsistent with the concept of ‘right to life’. The State must protect life and the physician’s duty to provide care and not to harm patients. Supreme Court in Gian Kaur Case 1996 has held that the right to life under Article 21 does not include the right to die.
• Caregiver’s burden: Right-to-die supporters argue that people who have an incurable, degenerative, disabling, or debilitating condition should be allowed to die in dignity. This argument is further defended by those, who have chronic debilitating illness even though it is not terminal such as severe mental illness. The majority of such petitions are filed by the sufferers or family members or their caretakers. The caregiver’s burden is huge and cuts across various financial, emotional, time, physical, mental, and social domains.
• Refusing care: The right to refuse medical treatment is well recognized in law, including medical treatment that sustains or prolongs life. For example, a patient suffering from blood cancer can refuse treatment or deny feeds through a nasogastric tube. Recognition of the right to refuse treatment gives way to passive euthanasia.
• Encouraging organ transplantation: Mercy killing in terminally ill patients provides an opportunity to advocate for organ donation. This, in turn, will help many patients with organ failure waiting for transplantation. Not only does euthanasia give the ‘Right to die‘ for the terminally ill, but also the ‘Right to life‘ for the organ needy patients.

Arguments against

Emanuel argues that there are four major arguments presented by opponents of euthanasia:

• not all deaths are painful;
• alternatives, such as cessation of active treatment, combined with the use of effective pain relief, are available;
• the distinction between active and passive euthanasia is morally significant; and
• legalizing euthanasia will place society on a slippery slope, which will lead to unacceptable consequences
• Euthanasia weakens society’s respect for the sanctity of life.
• Euthanasia might not be in a person’s best interests, for example, getting old-aged parents killed for property will.
• Belief in God’s miracle of curing the terminally ill.
• The prospect of a discovery of a possible cure for the disease shortly.
• Proper palliative care makes euthanasia unnecessary.
• There is no way of properly regulating euthanasia.
• Allowing euthanasia will lead to less good care for the terminally ill.
• Allowing euthanasia undermines the commitment of doctors and nurses to save lives.
• Euthanasia may become a cost-effective way to treat the terminally ill.
• Allowing euthanasia will discourage the search for new cures and treatments for the terminally ill.
• Euthanasia gives too much power to doctors.

Euthanasia in India

Passive euthanasia is legal in India. On 7 March 2011, the Supreme Court of India legalized passive euthanasia using the withdrawal of life support to patients in a permanent vegetative state. The decision was made as part of the verdict in a case involving Aruna Shanbaug, who had been in a Persistent Vegetative State (PVS) for 42 years until she died in 2015.

The Aruna Shanbaug Case

In March 2011, the Supreme Court of India passed a historic judgment permitting Passive Euthanasia in the country. This judgment was passed after Pinki Virani’s plea to the highest court in December 2009 under the Constitutional provision of “Next Friend”. It’s a landmark law which places the power of choice in the hands of the individual, over government, medical or religious control which sees all suffering as “destiny”. The Supreme Court specified two irreversible conditions to permit Passive Euthanasia Law in its 2011 Law:

• The brain-dead for whom the ventilator can be switched off.
• Those in a Persistent Vegetative State (PVS) for whom the feed can be tapered out and pain-managing palliatives be added, according to laid-down international specifications.

The same judgment law also asked for the scrapping of 309 , the code that penalizes those who survive suicide attempts. In December 2014, the Government of India declared its intention.

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PIL filed by Common Cause

However, on 25 February 2014, a three-judge bench of the Supreme Court of India termed the judgment in the Aruna Shanbaug case to be ‘inconsistent in itself’ and referred the issue of euthanasia to its five-judge Constitution bench on a PIL filed by Common Cause , which case is the basis of the current debate.

Then, the CJI referred to an earlier Constitution Bench judgment which, in the Gian Kaur case , “did not express any binding view on the subject of euthanasia; rather it reiterated that the legislature would be the appropriate authority to bring change.” Though that judgment said the right to live with dignity under Article 21 was inclusive of the right to die with dignity, it did not conclude the validity of euthanasia, be it active or passive.

“So, the only judgment that holds the field about euthanasia in India is the ruling in the Aruna Shanbaug case, which upholds the validity of passive euthanasia and lays down an elaborate procedure for executing the same on the wrong premise that the Constitution Bench in Gian Kaur had upheld the same,” the CJI said.

Common Cause Case: In 2018, the Supreme Court issued a significant judgment in the Common Cause case. The court recognized the right to die with dignity as a fundamental right and permitted passive euthanasia. It provided guidelines for the process and conditions under which passive euthanasia could be allowed.

Government’s endorsement of Passive Euthanasia

On December 23, 2014, the Government of India endorsed and re-validated the Passive Euthanasia judgment law in a Press Release, after stating in the Rajya Sabha as follows: The Hon’ble Supreme Court of India, while dismissing the plea for mercy killing in a particular case, laid down comprehensive guidelines to process cases relating to passive euthanasia.

Thereafter, the matter of mercy killing was examined in consultation with the Ministry of Law and Justice and it has been decided that since the Hon’ble Supreme Court has already laid down the guidelines, these should be followed and treated as law in such cases. At present, there is no legislation on this subject and the judgment of the Hon’ble Supreme Court is binding on all.

The court rejected active euthanasia using lethal injection. In the absence of a law regulating euthanasia in India, the court stated that its decision becomes the law of the land until the Indian parliament enacts a suitable law. Active euthanasia, including the administration of lethal compounds to end life, is still illegal in India, and in most countries.

As India had no law about euthanasia, the Supreme Court’s guidelines are law until and unless Parliament passes legislation. The following guidelines were laid down:

• A decision has to be taken to discontinue life support either by the parents the spouse or other close relatives, or in the absence of any of them, such a decision can be taken even by a person or a body of persons acting as a next friend. It can also be taken by the doctors attending the patient. However, the decision should be taken bona fide in the best interest of the patient.
• Even if a decision is taken by the near relatives or doctors or next friend to withdraw life support, such a decision requires approval from the High Court concerned.
• When such an application is filled, the Chief Justice of the High Court should forthwith constitute a Bench of at least two Judges who should decide whether to approve or not. A committee of three reputed doctors to be nominated by the Bench, will report the condition of the patient. Before giving the verdict, a notice regarding the report should be given to the close relatives and the State. After hearing the parties, the High Court can give its verdict.

A law commission had proposed legislation on “passive euthanasia”, it said. According to the Centre, the decision to come out with a bill was taken after considering the directives of the apex court, the law commission’s 241st report, and a private member bill introduced in Parliament in 2014.

The Centre said that initially, a meeting was held under the chairmanship of B.P. Sharma, secretary in the Health and Family Welfare Ministry, on May 22, 2015, to examine the draft of The Medical Treatment of Terminally Ill Patients (Protection of Patients and Medical Practitioners) Bill and the draft of The Euthanasia (Regulation) Bill.

This move to introduce a bill is a welcome step to clear the grey areas in the Euthanasia debate. Students can also link to this issue while answering questions on:

• Judicial activism: SC framing laws when the parliament hasn’t. Just like the Visaka case.
• Ethical dilemma in Paper 4 .

In India,  euthanasia has no legal aspect , and there is no penal law yet introduced in the IPC that specifically deals with euthanasia.

• However, the Supreme Court of India legalized passive euthanasia in 2018 with some conditions, allowing patients to withdraw medical support if they go into an irreversible coma.
• Passive euthanasia is a matter of ‘living will’, and an adult in their conscious mind is permitted to refuse medical treatment or voluntarily decide not to take medical treatment to embrace death naturally, under certain conditions.
• Individuals are only allowed to draft a living will while in a normal state of health and mind.
• Active euthanasia remains illegal in India.

Read:  Living wills

Article by: Jishnu J Raju

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Reader Interactions

February 11, 2016 at 3:48 pm

excellent one..

February 24, 2016 at 8:34 pm

Giving passive euthanasia to a patient who is already dead (not literally) is a right choice.Its better than making them as well as others to suffer.

July 20, 2017 at 4:28 pm

so very true.

July 1, 2016 at 10:58 pm

If the patient does not wants to suffer and himself asking for euthanasia then voluntary euthanasia should be made legal because it will be difficult for him to live than to die. But in case of involuntary euthanasia, there should be some specific time limit upto which the patient’s relatives must wait for him to recover but if there is no improvement like in case of coma , after 7-10 years , there is less chances of the patient to recover. In such cases , involuntary euthanasia should be made legal.

March 16, 2017 at 12:37 pm

no it is not possible If the patient tends to recover over a period of time or suddenly he becomes normal then the involuntary euthanasia will become very dangerous

March 16, 2017 at 12:35 pm

Very Very Useful

June 26, 2018 at 8:12 am

Helpful source I can use to rely on research. Thank you so much, clear IAS.

May 17, 2019 at 9:58 pm

Thanku for quality content

May 23, 2020 at 10:27 pm

“Mercy Killing ” is a responsible debate . It mainly depends on persons will on his /her life.

July 2, 2020 at 2:26 pm

Euthanasia should not be accepted as there is always some hope for better.

May 24, 2021 at 11:57 am

If under Article 21 of the constitution, right to live with dignity is inclusive of right to die with dignity, then why should the provisions under the Euthanasia act be restricted to the old and dying patients. There are a lot of people in their 60s and 70s with limited financial resources, who feel neglected / unwanted by the family who would like to die with dignity rather than be dependent on their children or the other members of family. They may be in good health but would still like to self determine to end their life with dignity. In such cases the law should allow for such people to adopt active Euthanasia. Such people could be persuaded to donate their organs which will help save other lives.

August 25, 2021 at 9:40 am

euthanasia cannot be legalised because of its higher probability of misuse. whether it is for property, money or because of any family problem

August 4, 2022 at 12:11 pm

A thought for all: If you do not have a choice to life, i.e. choose to be born then how can choosing your own means of death, be fair or valid? Something you cannot create or re-created is not yours to manage. My say: God is the giver of life and He alone should take it. Our sufferings are a means of learning, loving, understanding and above all our closeness to Almighty God.

June 28, 2023 at 6:36 pm

ur death is already written whether you take it or god does so doesnt matter

September 19, 2022 at 12:47 pm

I can’t put my dog to sleep for I am as old as he; and despite our handicaps he also wants to live like me.

Boghos L. Artinian

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Article Contents

The implication of a medicalized dying process, the historical case against physicians assisting suicide, the medical cloak, collaborators in euthanasia, healing and euthanasia, recent developments, is euthanasia medical treatment, acknowledgements.

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Euthanasia is not medical treatment

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J. Donald Boudreau, Margaret A. Somerville, Euthanasia is not medical treatment, British Medical Bulletin , Volume 106, Issue 1, June 2013, Pages 45–66, https://doi.org/10.1093/bmb/ldt010

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The public assumes that if euthanasia and assisted suicide were to be legalized they would be carried out by physicians.

In furthering critical analysis, we supplement the discourse in the ethics and palliative care literature with that from medical education and evolving jurisprudence.

Both proponents and opponents agree that the values of respect for human life and for individuals' autonomy are relevant to the debate.

Advocates of euthanasia and assisted suicide give priority to the right to personal autonomy and avoid discussions of harmful impacts of these practices on medicine, law and society. Opponents give priority to respect for life and identify such harmful effects. These both require euthanasia to remain legally prohibited.

Proposals are emerging that if society legalizes euthanasia it should not be mandated to physicians.

The impact of characterizing euthanasia as ‘medical treatment’ on physicians' professional identity and on the institutions of medicine and law should be examined in jurisdictions where assisted suicide and euthanasia have been de-criminalized.

….tha'll nivver feel it, tha'll be out of existence i' two minutes

James Billington

Physician-assisted suicide (PAS) and euthanasia are among the most contentious issues faced by the medical profession. Numerous scholars have argued in favor of 1 or against 2 ‘assisted death’, as these interventions are euphemistically called. These debates generally take it for granted that the person carrying out euthanasia will be a physician. That assumption has been questioned, most recently, by two ethicists from the Harvard Medical School who propose a limited role for physicians in assisted dying. 3 We discuss their proposal shortly. The possibility of deleting the physician from the equation has certainly not been salient in professional discourse.

In this article we will examine factors, highlighting historical contexts and the influence of language, which have helped campaigners who aim to sanitize ‘assisted dying’ by associating it with medicine. We broach the issue of whether euthanasia can be considered medical treatment by focusing on the irreconcilability of euthanasia with medicine's mandate to heal.

In the remainder of this text, we use the word euthanasia to include PAS, unless the contrary is indicated. We do so in accordance with the fact that both procedures raise the same ethical and legal considerations with respect to many of the issues discussed in this article. In PAS and euthanasia, physicians and society are complicit in helping persons to commit suicide or giving them a lethal injection, respectively. Moreover, whether or not a society will alter its laws to allow ‘medically induced death’ is a binary decision.

Are medical doctors, by being responsible for the prolongation of the dying process, blameworthy for the existence of conditions that elicit a desire for hastened death? The profession has indeed created circumstances, through overly aggressive technical interventions, whereby persons' illness narratives have included chapters with alienating, depersonalizing and dehumanizing plots and characters. The following trajectory of a hypothetical patient with amyotrophic lateral sclerosis is all too common: first, non-invasive nocturnal ventilation enters the scenario; next, a wheelchair; then a Dobhof feeding tube, promptly replaced by a jejunostomy; innumerable venous punctures and catheterizations; intervening urinary tract infections; recurrent aspiration pneumonias, followed by invasive ventilation, eventually necessitating a tracheostomy; accompanied by unremitting despondency; and finally, progressive somnolence and terminal sepsis. Too many patients find themselves in a sickroom in such a state, one of spent physical resources and suspended hope or even total despair. Some would add that this metaphoric dwelling is also inhabited by a crushed spirituality.

Pro-euthanasia advocates sometimes present such scenarios to support their views that the profession is, in some measure, responsible for the condition in which a patient may conceive of no escape or redress other than self-willed death. A comment such as, ‘I'd rather die than slog on with deformity, disfigurement and disability', is not infrequently heard and, when expressed, often denounces a sequence of medical interventions rather than the original illness. In dire situations, one of the few avenues that can seem to offer a sense of comfort is that of personal control. Control, usually packaged in a discursive frame of politico-judicial personal autonomy, can be manifest as a desire to manage the ultimate mode of exit from life, that is, for patients to select the method, place and hour of their death. Moreover, some may want this stance to be legitimized by societal approval and even see it as a heroic act and as furthering a common cause, by promoting shared values and ideologies. 4

It would, however, be an overstatement to attribute all changes in the nature of death to the health professions. Improvements in general socioeconomic conditions have decreased the incidence of death from catastrophic accidents, trauma and obstetrical mishaps and have lessened the impact of previously deadly infectious diseases. Undeniably, the shift in prevalence from acute and preventable conditions to chronic degenerative diseases, as well as many cancers, is a consequence of a prolongation of life resulting from improvements in public health, universal literacy and preventive interventions. Nonetheless, there is a kernel of truth in the notion, expressed in commentaries dating from Hellenistic to modern times, that physicians have invented ‘lingering’ death. 5 We believe that some of the profession's approaches in responding to illness in modern society may have fueled the clamour for radical solutions such as euthanasia.

The process has been abetted by those who espouse so-called ‘progressive values’, in what are often referred to as the ‘culture wars’, and who often manifest a pervasive questioning of authority. 6 A desire for unfettered individual decision-making powers—seeing ‘radical autonomy’ as always being the overriding value—and the demotion of established religions as influential voices in the public square are also important factors in the rise in demands to legalize euthanasia. We consider euthanasia a misguided solution to a complex socio-cultural transformation. It is reasonable that the medical profession not deny its contributions to the situation; but, it would be perverse if it allows itself to be co-opted by a perceived need for atonement. It must be vigilant to avoid over-compensating by endorsing society-sanctioned euthanasia.

The profession must not disown its ethical tradition or abandon its basic precepts. The potential harm is not only to individuals, but also to the institutions of medicine and law and the roles they play in society, especially in secular societies, where they are the primary carriers of the value of respect for human life, at the level of both the individual person and society. Ironically, they are more important in this regard now than when religion was the main carrier of the value of respect for life. 4 Therefore, the degrees of freedom, in terms of legitimate actions and behaviours available to physicians confronted with a dying patient are, and must remain, clearly and strictly limited.

The injunction against physician involvement in hastening death has recurred throughout recorded history, the Hippocratic Oath providing the following emblematic statement: ‘I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect’. 7 This unambiguous prohibition has oriented medical practice towards specific ends and means and away from certain others for over 2400 years. Its enduring impact was apparent in early-modern Western society. Euthanasia was discussed by the lawyer Casper Questel in a book entitled ‘De pulvinari morientibus non subtrahendo’. 8 Translated as ‘On the pillow of which the dying should not be deprived’, it described common practices that were thought to hasten death. These popular practices included removing pillows from dying persons so that, with their bodies completely supine, ventilatory capacity would be constricted and death accelerated. Another strategy was to transfer dying persons from their beds to the ground. Perhaps the latter operated through a tacit understanding that the bodily cold thereby induced would bring dying persons closer to their natural demise. Regardless of the underlying pathophysiologic mechanism, it is highly probable that symbolism (for example, facilitating passage of the soul from the shell of the dying body to life eternal) was at play. We note that it was natural death that was sought, not terminating the life of the person.

An intriguing and noteworthy feature of this ancient text is that such practices were popular amongst the general public. They were not acts delegated by society to a particular group and certainly not restricted to medical doctors. Questel was aware of undesirable ramifications if they were practiced by physicians. Physicians risked losing trust should they be discovered to have intentionally shortened the lives of dying patients. Trust is of paramount importance to a successful doctor–patient encounter and is indispensable to the implicit moral contract between the profession and society. 9 Maintaining the trust of individual patients and of society is a sine qua non for the maintenance of professional status. Participating in euthanasia carries the risk of vitiating trustworthiness.

Constraints on physician complicity in euthanasia are to be found throughout history. An 1826 Latin manuscript by a physician, Carl Friedrich Marx, referred to medical euthanasia as the skillful alleviation of suffering. 10 He absolutely forbade physicians from engaging in any attempt at accelerating death, stating : ‘ … and least of all should he be permitted, prompted either by other people's request or his own sense of mercy, to end the patient's pitiful condition by purposefully and deliberately hastening death’. Examples of more recent statements of such prohibitions include the defeat in the House of Lords in 1932 of the ‘Voluntary Euthanasia Bill’ 11 and the Canadian parliament's clear rejection in 2010, by a vote of 228 to 59, of Bill C-384, a private member's bill that would have permitted PAS and euthanasia. 12

Certain jurisdictions, notably the Netherlands and Belgium, have legalized euthanasia. In America, Oregon's ‘Death with Dignity Act’, which permits PAS, came into force in 1997 and Washington state followed suit in 2008. However, on 6 November 2012, Massachusetts voters defeated a ballot that would have allowed assisted suicide, 51–49%. There have been discussions, debates and proposed legislation in many other American states and other countries in the recent past. Generally, these have reaffirmed the ban on medical assistance in killing (whether in the context of end-of-life or, in the USA, physicians' involvement in carrying out capital punishment through lethal injections). The Benelux and a few American states represent the exception to the rule. ‘Do not kill’ has been considered a moral absolute for most physicians for millennia, and remains so for physicians even in jurisdictions where the public has looked favorably on legislative change. That medicine has all to do with healing, and nothing to do with the purposeful ending of life, has been a reverberating imperative throughout history.

The pro-euthanasia lobby derives advantages by aligning itself tightly with medicine and physicians. The history of physician involvement in capital punishment is illustrative of this strategy. Juries in the USA, who had seen horrific footage of convicted murderers being executed in the ‘electric chair’, became reluctant to convict persons accused of capital offences or to vote for a death sentence for felons convicted of a capital offence. Most physicians and the American Medical Association adamantly opposed medicine's involvement in administering capital punishment by lethal injections. Nevertheless, some physicians participated. By virtue of their involvement and in concocting a method of execution that makes a convicted criminal appear serene during final moments, enhanced acceptability was conferred on the procedure. It has been suggested that ‘the law turned to medicine to rescue the death penalty’. 13

It is germane to point out that the word ‘doctor’ is linked etymologically to ‘teacher’. The Oxford English dictionary's definition is: ‘one who gives instruction in some branch of knowledge, or inculcates opinions or principles’. 14 Medical doctors can influence public opinion, much as teachers contribute to the socialization of their pupils. The recruitment of doctors, both as a collectivity and as individuals, to undertake a procedure, can greatly modify the public's view of that procedure.

Language is critically important in not only reflecting, but also creating reality. For example, the field testing conducted prior to the passage of the Oregon Death with Dignity Act demonstrated that when the intervention was described as ‘suicide’ or ‘euthanasia’, popular support declined by 10–12%. 15 The phrase ‘death with dignity’, by avoiding the negative connotations of suicide, was perceived as less alarming. It was able to create a halo of benignity and to generate greater support for and muted opposition to the proposed law. For similar reasons, the euphemism ‘physician assistance in a dignified death’ is reassuring. It would be rare indeed for an individual to wish explicitly for a gruesome death or want to banish a benevolent healer from the sickroom. Research shows that emotions, 16 which we would qualify as ‘examined emotions’, and we would add, moral intuition, are important in making good ethical decisions. Choice of language affects both these human ways of knowing what is morally right and morally wrong. 17

Jill Dierterle, a member of the Department of History and Philosophy at Eastern Michigan University, denigrates the validity and power of words in order to claim that none of the anti-PAS arguments hold merit and concludes that ‘we have no reason not to legalize it’. 18 She turns a blind eye to any potential harm and conveniently overlooks the lacuna in current data-gathering procedures or impact assessments. This stance flies in the face of the golden rule of medicine: primum non nocere. Hence, it is anathema to the vast majority of practicing physicians. Few of us, presented with a new and relatively untested therapeutic instrument, would conclude, ‘we have no reason to doubt its safety; let's forge ahead’. Her nonchalant dismissal borders on the offensive. Note how she handles an important deontological argument against PAS: ‘ … if PAS is wrong, its wrongness cannot be constituted by its conflict with the Hippocratic Oath. After all, the Hippocratic Oath itself is just a bunch of words’. 18 With the phrase ‘just a bunch of words’ Diertele implies that the oath is hollow and meaningless. But ethical precepts and laws are also just a ‘bunch of words’, yet they establish our metaphysical reality—what can be called our metaphysical ecosystem—which, depending on its nature, determines whether or not we have a society in which reasonable people would want to live.

It is critical to the euthanasia debate to consider what role, if any, physicians may, should or must not play. It is not a ‘given’ that, were euthanasia to be legalized, it would be inextricable from the medical mandate. We propose that it is in the best interests of individuals and society to remove the medical cloak from euthanasia in order to lay bare fundamental arguments against it. The stakes are too high to have the veneer of doctoring obscure the essential core of what is involved and its potential harms and risks.

The commentary previously mentioned, ‘Redefining Physicians’ Role in Assisted Dying’, suggests that a non-physician group could be made responsible for the ‘active’ role in euthanasia. 3 The label ‘thanatologist’ has been suggested for such a group. 11 The possibility that a new discipline might emerge raises a set of intriguing questions: What would be the scope of practice of thanatologists? Where would one draw the line between ‘active’ and ‘passive’ roles? Of what might their education consist? We want to make it clear that we believe euthanasia is inherently wrong and, therefore, should never be undertaken, but, it is important to consider what such a proposal could involve if it were put into practice.

It is reasonable to speculate that the training could be offered in a program at a technical level and that the duration of training period would be modest. The act of terminating someone's life is thought to be fairly straightforward—at least, the execution of it is not overly complicated. The experience in the UK of recruiting and training hangmen can provide useful clues. 19 Executioners were trained in the late 19th to mid-20th century with a 5-day course that included lectures, a practical component—‘applicants to pass pinioning in the presence of the Governor’—and ended with a written examination that included simple algebra—the applicant was required to calculate the length of drop (i.e. stretch of the rope) for men of varying weights. Given the complexity of drug-based protocols used in euthanasia, 5 days of instruction would likely be insufficient. A program in the order of 24 weeks, as is the case for cadet training in many police academies, might allow for core objectives to be adequately covered and relevant abilities to be tested and credentialed.

A provocative essay on the topic suggests that lawyers could be trained in euthanasia, practicing a new specialty called legistrothanatry. 20 Although admittedly implausible, the proposal serves to foreground pragmatic issues relevant to the debate. It rests on two fundamental assumptions: (i) that lawyers are trained to interpret laws and regulations accurately, to apply them strictly and to act on the basis of implementing patients' values and (ii) that carrying out the required tasks does not require sophisticated technical expertise. The authors state, ‘Attorneys who wish to provide this service would require only a small amount of additional training’. 20 An appropriate educational blueprint could include the following cognitive base: the physiology of dying, basic pharmacology and an overview of the historical, ethical and legal aspects of natural and requested/assisted death. The toolkit of required skills would likely include: communication, verification of decision-making capacity and informed consent, securing of intravenous access, supplying and/or administering of lethal drugs, management of complications, accurate recognition of death and completion of death certificates. The desired attitudinal substrate would include: personal resolve (that is, stick-with-it-ness), respect for individuals' rights to autonomy and self-determination, and, ideally, a calm demeanour.

Although the tone of the previous discussion may be—and should be—rather ‘chilling’, the substance it addresses has clearly gained a foothold in the current medical literature. A description of procedures for successful euthanasia has been published; one is entitled ‘Euthanasia: medications and medical procedures’. 21 It includes protocols for dealing with terminal dyspnea or agitation in the terminal phase, euthanasia, and the induction of ‘controlled sedation’. Controlled sedation is placed in inverted commas by the author, presumably because he feels that it needs qualification; in his opinion, it represent a hypocritical response to suffering and is undertaken with the aim of muzzling the patient while he dies. We note, but will not discuss here, the ethical issues raised by ‘palliative sedation’, sometimes called ‘terminal sedation’, in which the dying patient is sedated in order to relieve otherwise unrelievable suffering. We suggest that the former term should be used when sedation is the only reasonable, medically indicated, way to relieve the patient's suffering (when it is not euthanasia); the latter term is appropriate when those conditions are not fulfilled and the doctor's intention is to hasten the patient's death (when it is euthanasia).

The epigram to the euthanasia guidelines cited above is fascinating. It states: ‘One summer evening, Mr J-M L, suffering from Charcot's Disease, passed away peacefully after having asked for and obtained the assistance of a physician. Upon leaving the home, the latter did not ponder: ‘What did I do?’ but rather, ‘Did I do it well?’ (Translation by author JDB) 21 This formulation reveals a unique mindset. The affective and moral stance expressed in that quote is closely aligned to a technical perspective, one where the emphasis is on accomplishing tasks with self-efficacy as opposed to one embellished with critical reflection. Meta-reflection is an important aspect of doctoring. What we do and the conversations we routinely engage in forge who we become; they become a habitus. Even the clothing we wear can influence our thought processes. For example, a recent article documents the impacts on cognition of donning a lab coat. 22 If the simple habitual act of wearing a white lab coat can affect thinking and action, one can easily imagine the harmful impacts of regular discussions of euthanasia as they insinuate themselves into the ethos of medical care.

‘The Executioner's Bible’, a story of England's executioners in the 20th century, describes the work of the hangman as a ‘cold, clinical operation’. 19 The epigram we have chosen for our essay, extracted from that textbook, is a quote from James Billington, the UK's Chief Executioner from 1891 to 1901. It is intended to evoke calculated efficiency. The author of ‘Euthanasia: medications and medical procedures’ is similarly categorical, prescriptive and unrestrained by self-doubt. For example, he advises the physician not to propose suicide without medical assistance; to do so is considered incompatible with the role of the physician. He warns the physician against using ‘violent options’ (such as injecting potassium chloride) as this is considered contrary to medical ethics. Leaving aside a disregard for the value of respect for life, the punctilious euthanizer can be seen as behaving with professional dignity and serenity, within a priori defined limits. As the Home Office stated in 1926, when describing the work of hangman William Willis, ‘ … .even an executioner can remain humane and decorous’. 19 Our purpose in making this historical link is not to denigrate advocates of euthanasia. Rather, through this analogy we are endeavoring to focus on the act itself and not just the actor. The latter is often well meaning.

Thanatologists, given the narrow focus of their field of expertise would, over time, almost certainly develop clinical practice guidelines; these might be tailored to different illness categories, for instance, neurodegenerative diseases and the various cancers with poor prognosis. This process seems to be well underway. For example, a recent paper explores euthanasia requests and practices in a highly particularized context, namely, patients in Belgium dying of lung cancer. 23 If euthanasia is accepted as integral to ‘medical care’, this sort of disease-specific focus will surely expand. One can envisage the emergence of guidelines delineating the complementary roles of physicians and thanatologists. Most physicians (we hope) would eschew any involvement in euthanasia and confine themselves to traditional roles such as diagnosing, estimating prognosis and providing supportive care and symptom control, that is, excellent palliative care—which does not include euthanasia, as some advocates argue it should.

The extent to which principled opponents of euthanasia would be legally ‘excused’ from participating in the steps leading up to fulfilling a patient's request for assisted death is a contentious aspect of the debate. How would the profession balance the requirement for individual physicians to fulfill specific social roles and the need to respect the freedom of conscience of those who, on moral grounds, reject certain options? Physician–philosopher Edmund Pellegrino argues that physicians can refrain from entering into professional relationships that have the potential to erode their moral integrity; he offers strategies to assist the physician in navigating potential conflicts. 24

Psychiatrists and medical ethicists who do not reject euthanasia would be expected to focus on soliciting patient perspectives, exploring options and assessing comprehension, competence and voluntariness—that in making her decision, the patient is free from coercion, duress or undue influence, assuming this is possible. The profession has begun to equip itself with tools to deal with this incipient new clinical reality in jurisdictions which allow euthanasia. Physicians in the USA have been provided with an eight-step algorithm to assist them in discussing assisted suicide with patients who request it. 25 These guidelines were developed immediately after the legalization of PAS in Oregon. It is reasonable to expect that additional decision-making tools will emerge should the practice gain wider societal acceptance. Also, the possible consequences on undergraduate medical education, should it have to include protocols for ending patients' lives, have been explored. 26

Again, we note that the above discussion is included for the sake of comprehensive coverage of the issue of physicians' involvement in euthanasia, were it to be legalized, and whether it could be ethically acceptable ‘medical treatment’ or even ‘therapy’. It is not meant to signal that we see euthanasia as ethically acceptable.

It has been repeatedly found that of all separately identified groups in Western societies, physicians are among the most opposed to involvement in euthanasia. There is substantial indirect evidence to support this claim, even in jurisdictions in which doctor-assisted death is legal. For example, in Oregon, there is a suggestion that some patients have to resort to ‘doctor shopping’ to obtain their lethal medications. The Oregon Public Health Division's annual report for 2011 shows that one physician was responsible for 14 of the requisite prescriptions out of a total of 114 that year. 27 Also, the Netherlands recently approved the launching of mobile euthanasia clinics. A stated reason for this development was that patients' goals in self-determination were being thwarted by physician resistance to providing euthanasia. Not all physicians, including many Dutch colleagues, are on-side with having euthanasia become a medical act.

A questionnaire-based study comparing the opinions of the Dutch general public with that of physicians revealed some marked differences. With respect to the active ending of life for patients with dementia, the level of acceptance was 63% for the public and 6% for physicians. 28 With respect to terminally ill cancer patients, the figures were much higher and less divergent; this may be a consequence of the prolonged experience of euthanasia in cases of terminal illness in the Netherlands. Or, it might be that often survey questions are phrased as, ‘If a person is in terrible pain, should they be given access to euthanasia?’ The respondent must choose between leaving the person in pain and euthanizing them. But this choice is wrongly constructed. The person should be able to choose fully adequate pain management—that is, the ‘death’ of the pain—without having to endorse the intentional infliction of death on the patient. 29 Despite high levels of acceptance by physicians of euthanasia for cancer patients in the Netherlands, recent reports reveal persistent ethical concerns. 30 It is also noteworthy that physicians involved in palliative care, including in Britain, appear to be particularly concerned about legalizing euthanasia. 31

What underlies the medical profession's reluctance to accept euthanasia? There are multiple explanations. Aside from ethical, moral and religious beliefs, one of the most salient and compelling has to do with one's conception of the medical mandate, especially as it relates to healing. Healing is a challenging term to define. Many in our institution (the Faculty of Medicine, McGill University) consider it to be ‘a relational process involving movement towards an experience of integrity and wholeness’. 32 It has been operationally defined as ‘the personal experience of the transcendence of suffering’. 33 A feature of healing important to our thesis is the notion that healing does not require biological integrity. Although it may seem counter intuitive at first glance, it has been pointed out that if a sick person is able to construct new meaning and is able to achieve a greater sense of wholeness, that individual may ‘die healed’. 32 It is undeniably a vastly different concept than curing, although they are not in opposition one to the other. Most physicians accept the healer role as a fundamental and enduring characteristic of the profession. 34 In our undergraduate medical program, this concept is taught using the term ‘physicianship’; it refers to the dual and complementary roles of the physician—the physician as healer and professional. 35 It could be argued that one can remain ‘professional’ even while serving as a collaborator in requested death. On the contrary, many commentators—the American Medical Association is a prime example 36 —believe that it is impossible to do so as a ‘healer’, one who is focused on accompanying the patient on a transformational journey towards personal integrity that transcends the embodied self.

The process of healing in the doctor–patient relationship is poorly understood. We do not have a complete picture of how it is initiated or which clinical skills or abilities are essential in fostering a healing relationship. The literature suggests that healing resides in the quality of interpersonal connections and that it requires a deep respect for the agency of the physician in the therapeutic process. 37 An appreciation of the placebo effect, or in more poetic terms, the ‘doctor as the medicine’, is required. 38 , 39 It is almost certainly linked to the phenomena of transference and counter-transference and it may utilize the power differential for salutary purposes, even if these phenomena operate largely at a covert level.

The patient–doctor relationship is marked by intense ambivalence. Any physician who has initiated a discussion with a patient on the issue of resuscitation or desired level of technical intervention will realize how easily it can be misinterpreted, how quickly it can catalyze existential angst and how thoroughly it can overwhelm hopeful sentiments. Affective turmoil and cognitive dissonance can rapidly ensue. These sorts of cross-purpose exchanges would surely be magnified in the context of discussions regarding euthanasia. Although there may be a productive ‘meeting of the minds’ in any specific doctor–patient dyad, the risks of emotional derailment, self-effacing dependency and irremediable miscommunication should not be minimized. It is inconceivable to us that deep layers of existential suffering would not be activated and exposed by such a discussion. A healing space that can support patients would be unnecessarily deflated. Admittedly, this belief is based on incomplete understandings of the clinical encounter, yet the axiomatic foundation of that encounter is anchored in a 2400-year old tradition. We must consider why we have so jealously guarded that tradition. We could always have abandoned it by accepting euthanasia. Unlike many other current medical–ethical dilemmas, neither death nor euthanasia is a novel issue presented by new technoscience.

Many proponents of euthanasia like to claim that opponents rely on two types of unsound arguments: one based on empirical data and the other anchored in axiology. In the first instance, they allege that the outcomes data available from jurisdictions where euthanasia or assisted suicide has been legalized, suggest that our fears of potential abuse are groundless. They deny that there is a ‘logical’ slippery slope—that the situations in which euthanasia will be available will expand over time—or a ‘practical’ slippery slope—that euthanasia will be used abusively. Pro-euthanasia advocates claim that evolving legislation does not pose a threat to persons with a disability, does not lead to euthanasia without consent, does not invite extension of the practice to vulnerable populations—in short, that it has not become a ‘run-away train’. They usually express satisfaction with individual clinicians' professional restraint and integrity as well as with administrative safe guards. Some suggest that the acceptance of euthanasia results in improvements in traditional palliative care. This belief that it represents a positive force for changing prevailing clinical practices is not based on robust evidence. Moreover, the evidence for the existence of a practical slippery slope is very convincing. This was very recently affirmed by the High Court of Ireland, in a judgment we discuss shortly, in deciding whether prohibiting assisted suicide contravened the Irish Constitution, which it held it did not. 40

A recent dramatic example of the logical slope's gravitational pull is the euthanizing, in December 2012, of 45-year-old twins in Belgium. Deaf since childhood, Marc and Eddy Verbessem were facing the additional disability of blindness. Accepting that they were irremediably suffering, their physician euthanized them. 41 Euthanizing patients with non-terminal conditions, even though it can be legal in Belgium, will surely meet with the disapproval of most physicians. Even within the pro-euthanasia movement, this development may be considered an aberration. Nonetheless, there are increasing numbers of commentators who subscribe to the following philosophy: ‘If a patient is mentally competent and wants to die, his body itself constitutes unwarranted life-support unfairly prolonging his or her mental life’. 42

There are two arguments, both warranting careful scrutiny, frequently advanced in support of physician involvement in euthanasia. The first is that physicians have privileged access to information about their patients' unique perspectives and circumstances, including personal resources and frailties, as well as complex family dynamics. That argument has been undermined by evolving practices. The ‘Oregon Public Health Divisions’ report for 2011 reveals that the median length of the doctor–patient relationship for those who died by PAS was merely 12 weeks (with a range of 1–1379 weeks). 27 It is highly unlikely that a physician would have acquired a sophisticated understanding of a person's values, hopes and fears in the matter of a few weeks. It is even less plausible in the case of the mobile euthanasia units currently being deployed in the Netherlands. The second argument is that physicians are inclined, by temperament and experience, to accompany their patients throughout the illness trajectory, including death. That too is not defensible on the known facts. For example, in Oregon, in the first 3 years of the administration of Oregon's ‘Death with Dignity Act’, physicians were present at approximately half of assisted deaths. By 2005, it was 23%. In 2011, it was a mere 9%. 27 The behaviour of these prescribing physicians is not congruent with the image of physicians represented in that iconic painting by Sir Luke Fildes, bearing the title ‘The Doctor’, and often used to portray empathic witnessing. Pro-euthanasia advocates can come across as rather intrepid in their defense of personal autonomy. Autonomy is the overriding principle that is used to buttress arguments in favor of euthanasia; indeed, it generally runs roughshod over all other considerations. Many pro-euthanasia commentators are disposed to brush off concerns about the impact of accepting ‘radical autonomy’ as always being the overriding value—especially concerns about the risks and harms to vulnerable people and to important shared values, in particular, respect for life at the societal level. A 2012 case in British Columbia manifests all these issues; it involved vulnerable persons, values conflicts and shows the preferencing by the court of the value of individual autonomy in relation to euthanasia. The case originates in a challenge to the Canadian Criminal Code's current prohibition of assisted suicide. 43

Gloria Taylor, a plaintiff in the case, Carter v Canada (Attorney General) 44 , was a person with ALS who requested assisted suicide arguing that as her illness progressed she would be incapable of committing suicide, unaided, due to her physical disability. The judge, Justice Lynn Smith, ruled in the plaintiff's favour on the basis that the prohibition was unconstitutional on the grounds that it contravened both Ms Taylor's constitutional ‘right to life, liberty and security of the person’ (under section 7 of the Canadian Charter of Rights and Freedoms) 45 and her right not to be discriminated against as a physically disabled person (under section 15 of the Charter ); and that the prohibition could not be saved (under section 1 of the Charter ), as a reasonable limit on constitutionally protected rights. Consequently, the judge held that the law prohibiting assistance in suicide was not applicable with respect to preventing Ms Taylor and other people in similar circumstances from having such assistance. The judgment is very long and legally complex and is now on appeal. Read as a whole, it strongly supports legalizing PAS and euthanasia.

In that case, the Canadian court reviewed the available evidence from other jurisdictions with liberalised legislation and concluded that there was no evidence of abuse. This Court also reviewed the same evidence and has drawn exactly the opposite conclusions. The medical literature documents specific examples of abuse which, even if exceptional, are nonetheless deeply disturbing. Moreover, contrary to the views of the Canadian court, there is evidence from this literature that certain groups (such as disabled neonates and disabled or demented elderly persons) are vulnerable to abuse. Above all, the fact that the number of LAWER (‘life-ending acts without explicit request’) cases remains strikingly high in jurisdictions which have liberalised their law on assisted suicide (Switzerland, Netherlands and Belgium) – ranging from 0.4% to over 1% of all deaths in these jurisdictions according to the latest figures – without any obvious official response speaks for itself as to the risks involved’. 40

One can also question Justice Smith's conclusions that PAS is not inherently unethical; that individuals' right to autonomy takes priority over the value of respect for life; that sanctity of life is only a religious value; that there is no relevant ethical or moral difference between refusals of life-support treatment that result in the death of the patient and euthanasia; and, that the availability of legalized PAS is necessary ‘medical treatment’ for some.

Justice Smith's justification for allowing euthanasia is largely based on a selective application of Canadian Charter of Rights and Freedoms jurisprudence 45 and depends upon her being able to distinguish the binding precedent set by the Supreme Court of Canada in the Rodriguez case. 46 The latter held, in a four to three split among the judges, that the Canadian Criminal Code's prohibition on assisted suicide 43 was constitutionally valid.

Invoking the Canadian Charter of Rights and Freedoms , Justice Smith ruled that Ms Taylor's right to life was infringed by the prohibition of assisted suicide because she might conclude that ‘she needs to take her own life while physically able to do so, at an earlier date than she would find necessary if she could be assisted’. 44 We believe that this would strike many as a straw man argument. It is to convert a right to life to a right to assisted suicide, by accepting as a breach of a right to life that a person will commit suicide sooner, if not given access to assisted suicide. But validating assistance in committing suicide hardly upholds a right to life.

Like everybody else, Ms Taylor has a right to refuse treatment even if that means she will die sooner than she otherwise would. Justice Smith accepts the plaintiffs' argument that there is no ethical or moral difference between euthanasia and refusals of life-support treatment that result in death and, therefore, both should be legal. But a right to refuse treatment is based in a right to inviolability—a right not to be touched, including by treatment, without one's informed consent. It is not a right to die or a right to be killed. At most, people have a negative content right to be allowed to die, not any right to positive assistance to achieve that outcome. A person with Ms Taylor's illness trajectory will surely die—even more precipitously if they decline many of the interventions described in the hypothetical patient with ALS we introduced earlier on. (Subsequent to the judgment, Ms Taylor died a natural death from an infection). It is also important to underline that current medical practices enable physicians to attenuate much of the suffering that may accompany the progressive loss of function and well-being in advanced ALS.

The judge appears also to accept the argument that legalizing euthanasia enhances palliative care. This goes some way towards treating euthanasia, as some have termed it, ‘the last act of good palliative care’. 47 It is also consistent with the ‘no-difference-between-them approach’ to a spectrum of end-of-life medical interventions. Euthanasia is confused with interventions, such as pain management and rights to refuse treatment, which are ethically and legally acceptable, and an argument is thus set up that, if we are to act consistently, euthanasia must also be ethically and legally acceptable. It is tantamount to legalizing euthanasia through confusion. 48

In the policy, ‘palliative care’ is defined as ‘a qualified medical practitioner, or a person acting under the general supervision of a qualified medical practitioner, administering medication or other treatment to a terminally ill patient with the intention of relieving pain or suffering, even though this may hasten death’. The policy states that that conduct, ‘when provided or administered according to accepted ethical medical standards, is not subject to criminal prosecution’. 44

In other words, the policy's definition of palliative care can be expansively interpreted to place euthanasia in same category as other end-of-life interventions which may hasten death.

For the sake of exploration of the issue, let us assume momentarily that euthanasia is medical treatment. What might flow from this?

Classifying euthanasia as medical treatment would affect the scope of disclosure of information necessary to obtain informed consent. A physician must disclose to the patient all reasonably indicated medical treatments as well as their risks and benefits. It would now have to include euthanasia. Even most pro-euthanasia advocates regard it as unethical for a physician to introduce the possibility of euthanasia. Currently, it is generally accepted that any discussion of it must be initiated by the patient.

It would also mean that to obtain informed consent to euthanasia, all reasonably indicated treatments would need to be offered and they would certainly include all necessary palliative care, in particular, fully adequate pain management. Many of those advocating for euthanasia posit euthanasia and palliative care as alternatives, but informed consent to euthanasia could not be obtained unless good palliative care was available. This is not available to a majority of people who die in Canada; it has been estimated that less than 30% have access to even the most minimal form of palliative care. 49

As well, Canadian psychiatrist Dr Harvey Max Chochinov, who specializes in psychiatric treatment for dying people, has shown that there are significant fluctuations in the will to live, even as death is imminent. 50 The impact of these findings, as well as conditions such as depression, on the possibility of obtaining valid informed consent to euthanasia would need to be fully addressed.

Another crucially important issue is that, if PAS and euthanasia are ‘medical treatment’, then surrogate decision-makers have the authority to consent to them for the patient. Their decisions must be based on either their knowledge of what the patient would have wanted or, if those wishes are unknown, their belief that these interventions are in the ‘best interests’ of the patient. Would mentally incompetent people and those with dementia or disabled newborn babies, as is now the case in the Netherlands under the Groningen protocol, be eligible for ‘therapeutic homicide’? 51

Yet another issue is what would be the indications for euthanasia as medical treatment and who could access it if were legalized? Justice Smith, citing an expert witness for the plaintiffs, refers to ‘the end-of-life population’. 44 This is a term used in the Royal Society of Canada Expert Panel Report on End of Life Decision - Making. 52 In the report, this population is defined as those persons on a continuum beginning with any serious diagnosis or injury. This represents an expansion of a term, ‘end-of-life’, traditionally used for those inevitably in the last days of life, to all people with serious chronic conditions, resulting from illness or injury, that may be fatal in the course of time. And, of course, it is notoriously difficult to predict with any certainty the timing of even obviously terminal illnesses. It is precisely the type of ‘slippery slope’ that we fear emerging from the ‘limited’ exception, as defined by Justice Smith. It will likely culminate in more decisions similar to that taken in the case of the Verbessem brothers in Belgium.

It is also pertinent to point out that Canada continues to fund and promote programs that aim to prevent suicide. If suicide is conferred the status of a right or is held to be acceptable medical treatment it would be difficult to reconcile this situation with the presence of programs that aim to actively thwart it. Some resolve this dilemma by trying to banish the word ‘suicide’ from the debate, in favor of the phrase ‘assisted dying’. Marcia Angell, erstwhile editor of the NEJM and a fervent proponent of PAS, endorses the notion that ‘assisted dying’ can be distinguished from ‘typical suicide’. The latter is described as being undertaken by someone with a normal life expectancy, whereas the former is carried out in someone ‘who is near death from natural causes anyway’. 53 They are going to die anyway, so what does it matter?! We believe that this reasoning is rather disingenuous and that it can result in a dishonouring of that segment remaining in someone's life, whether this is measured in minutes or months, and could deprive them of something as ephemeral as dreams and hopes. It certainly negates the idea of dying as our last great act of living. 54

Finally, a decision classifying euthanasia as medical treatment could have impact far outside the context of issues directly related to death and dying. For example, in Canada, the federal and provincial governments' respective powers are allocated under the Canadian Constitution. The criminal law power belongs to the federal parliament and the power to govern health and social services to the provincial legislatures. If euthanasia was defined as medical treatment, the federal parliament's prohibition of it in the Criminal Code could be invalid by reason of its trespassing on the provincial jurisdiction to govern health and social services. That is one reason that the Quebec College of Physicians and Surgeons, which supports legalizing euthanasia, argues that it is medical treatment. Likewise, the Quebec Legislative Assembly committee, which issued a report, ‘Dying with Dignity’, 55 adopts the same argument. From past experience, we expect that Quebec might challenge the constitutional validity of the Criminal Code prohibition on this basis. However, a legal committee, set up by the Quebec government, has proposed another approach. It has just reported on how Quebec could operationalize giving doctors legal immunity for carrying out euthanasia, including by the Attorney General of Quebec instructing Crown Prosecutors not to prosecute them under the Criminal Code for doing so, provided they comply with certain guidelines. 56 In either case we could see Quebec becoming ‘separate’ from the rest of Canada on this critically important issue.

In pondering medicine's possible involvement in euthanasia, we must foreground those aspects of the medical mandate that are immutable and eternally relevant. We believe these to be the constant nature of ‘illness’, changeless across time, place and culture, and the resultant obligations of the healer. It is important to appreciate how illness affects persons in all spheres of their lives. Patients become intensely vulnerable, impressionable and open to abuse. Pellegrino has summarized the nature of the clinical encounter eloquently as ‘a peculiar constellation of urgency, intimacy, unavoidability, unpredictability and extraordinary vulnerability within which trust must be given’. 57 This vulnerability sets up an intense and enduring obligation of physicians; they must respond to the wounded person with authenticity, compassion and moral agency. The latter demands that physicians harness and deploy their unique influences and persuasive powers in a particular manner. The essential nature of physicianship has evolved over time in a direction that recognizes the extraordinary vulnerability of patients and guards ferociously against their exploitation. In part, this has been achieved by imposing inviolable limits on the physician's terrain of action. Moreover, we believe that, even if one accepted that euthanasia was ethically acceptable—which we do not—it opens up too many doors for abuse.

The medical profession has arrived at a crossroad; it must choose whether to embrace euthanasia as medical treatment, as a logical extension of end-of-life care, or it can reject the redefinition of its healing mandate that this would entail. We believe, that looking back in the future, the euthanasia events of the present time will be seen as a turning point, not only for the profession of medicine, but also for societies. Crossing the line in the sand articulated by Hippocrates, that as a physician ‘I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect’, would result in the ‘doctor as healer’ becoming the ‘doctor as executioner’. In short, healing and euthanizing are simply not miscible and euthanasia can never be considered ‘medical treatment’.

Donald Boudreau was an Arnold P. Gold Foundation Associate Professor of Medicine when this manuscript was written and submitted. He is grateful for the financial support the foundation has provided in the past and requests that readers appreciate the opinions expressed herein are his personal views and not necessarily reflective of the perspectives of the Foundation, its staff, affiliates or benefactors.

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Disability Rights Education & Defense Fund

Why Assisted Suicide Must Not Be Legalized

Table of contents, introduction.

• Legal Alternatives Avoid A Great Harm
• Fear, Bias, and Prejudice against Disability
• An Ailing System Made Worse
• Deteriorating Health Care in Oregon
• The Broad Indirect Impacts on Health Care
• The Myth of Free Choice and Self-Determination
• The Fundamental Loophole of Terminal Illness Prognosis
• Doctor Shopping: All Roads Lead to Rome
• Alternatives: Presented But Not Provided
• Good Faith: A Safeguard for Doctors, Not Patients
• Depression and the Wish to Die
• Ignoring What Lies Beneath: The Abandonment of the Patient
• One Visit, Rarely: The Impact on the Individual
• Minimal Data and Fatally Flawed Oversight
• The Questionable Circumstances of Oregon Deaths
• The Netherlands: Pandora’s Box
• Other Factors Driving Toward Expansion

While many people know that Oregon, Washington State, and California have legalized assisted suicide, it is less well known that approximately half the states in the U.S. have either defeated bills to legalize it, or have passed laws explicitly banning it. [1]

In many cases, the bills or referenda were defeated due to the efforts of an opposition coalition spanning the political spectrum from left to right. These coalitions typically represent disability rights organizations, physicians and other health care workers, hospice organizations, and Catholics and other right-to-life organizations. In some cases, they also include organizations representing the Latino community, poor people, and workers.

The opposition to the legalization of assisted suicide is often mischaracterized as driven exclusively by religious conservatives, but most current opposition coalitions include many persons and organizations whose opposition is based on their progressive politics. Among those are disability rights groups; many nationally prominent disability rights organizations oppose the legalization of assisted suicide. [2]

Other key opponents include the World Health Organization, the American Medical Association and its state affiliates, the American College of Physicians, the National Hospice and Palliative Care Organization, the American Cancer Society, many other medical organizations, and the League of United Latin American Citizens (LULAC). Many prominent Democrats and liberals also oppose legalization, including Bill Clinton, Ralph Nader, and noted civil liberties journalist Nat Hentoff.

Assisted suicide strikes many people, when they first hear about it, as a cause to support. But upon closer inspection, there are many reasons why legalization is a serious mistake. Supporters focus on superficial issues of choice and self-determination. It is crucial to look deeper. Legalizing assisted suicide would not increase choice and self-determination, despite the assertions of its proponents. It would actually augment real dangers that negate genuine choice and control.

The disability community’s opposition is based on the dangers to people with disabilities and the devaluation of disabled peoples’ lives that result from assisted suicide. Further, this opposition stems from factors that directly impact the disability community as well as all of society. These factors include the secrecy in which assisted suicide operates today, even where it is legal; the lack of robust oversight and the absence of investigation of abuse; the reality of who uses it; the dangers of legalization to further erode the quality of the U.S. health care system; and its potential for other significant harms.

In view of this reality, we address many of the disability-related effects of assisted suicide, while also encompassing the larger social context that inseparably impacts people with disabilities as well as the broader public. First, after addressing common misunderstandings, we examine fear and bias toward disability, and the deadly interaction of assisted suicide and our profit-driven health care system. Second, we review the practice of assisted suicide in Oregon, the first U.S. state to legalize it, and debunk the merits of the so-called Oregon model. By detailing significant problems with Oregon’s supposed safeguards, we raise some of its real dangers, particularly for people with depression and other psychiatric disabilities. Third and finally, we explore the ways that so-called “narrow” assisted suicide proposals can easily expand. This article focuses primarily on conditions in the United States, though much of our discussion also applies in other countries.

In short, we must separate our private wishes for what we each may hope to have available for ourselves some day—a hope that often fails to understand how assisted suicide actually operates—and, rather, focus on the significant dangers of legalizing assisted suicide as public policy in our society today. Assisted suicide would have many unintended consequences.

A note about terminology: The words used in this policy debate are controversial. We use the term “assisted suicide” because it is understood by the public and is used in the legal and medical literature. A clear, specific term is needed. “Aid in dying” could mean anything done to help a dying person, while “death with dignity” has many meanings. The politicization of this terminology is discussed below.

I. Few Helped, Many Harmed: Disability Prejudice and the Damage to Society

A. legal alternatives available today.

The movement for the legalization of assisted suicide is driven by anecdotes of people who suffer greatly in the period before they die. But the overwhelming majority of these anecdotes describe either situations for which legal alternatives exist today, or situations in which the individual would not be legally eligible for assisted suicide.

It is legal in every U.S. state for an individual to create an advance directive that requires the withdrawal of treatment under any conditions the person wishes and for a patient to refuse any treatment or to require any treatment to be withdrawn. It is legal to receive sufficient painkillers to be comfortable, and we now know this will not hasten death. [3] And perhaps least understood, for anyone who is dying in discomfort, it is currently legal in any U.S. state to receive palliative sedation, wherein the dying person is sedated so discomfort is relieved during the dying process. Thus, there is already a legal recourse for painful deaths. These alternatives do not raise the serious difficulties of legalizing assisted suicide.

Moreover, anyone with a chronic but non-terminal illness is not eligible for assisted suicide in either Oregon or Washington State. Anyone with depression that affects his or her judgment is also ineligible. Consequently, the number of people whose situations would actually be eligible for assisted suicide is extremely low, yet its harmful consequences would be significant.

Even assisted suicide’s proponents acknowledge that a very small number of people would utilize it. They will tend to be affluent, white, and in possession of good health insurance coverage. At the same time, large numbers of people, particularly among those less privileged in society, would be at significant risk of harm.

Perhaps for these reasons, the World Health Organization (WHO) has recommended that governments not consider assisted suicide and euthanasia until they have demonstrated the availability and practice of palliative care for all their citizens. As Herbert Hendin, noted international expert on suicide prevention, explained, “All U.S. states and all countries have a long way to go to achieve this goal.” [4]

B. Fear, Bias, and Prejudice against Disability

Fear, bias, and prejudice against disability play a significant role in assisted suicide. Who ends up using assisted suicide? Supporters advocate its legalization by suggesting that it is needed for unrelievable pain and discomfort at the end of life. But the overwhelming majority of the people in Oregon who have reportedly used that state’s assisted suicide law wanted to die not because of pain, but for reasons associated with disability, including the loss of autonomy (89.9 percent), the loss of the ability to engage in activities that make life enjoyable (87.4 percent), the loss of dignity (83.8 percent), and the loss of control of bodily functions (58.7 percent). [5] Furthermore, in the Netherlands, more than half the physicians surveyed say the main reason given by patients for seeking death is “loss of dignity.” [6]

This fear of disability typically underlies assisted suicide. Janet Good, an assisted suicide advocate who worked with Jack Kevorkian in bringing about the deaths of several people with disabilities, said:

Pain is not the main reason we want to die. It’s the indignity. It’s the inability to get out of bed or get onto the toilet … [People] … say, ‘I can’t stand my mother – my husband – wiping my butt.’ [It’s] about … dignity. [7]

But as many thousands of people with disabilities who rely on personal assistance have learned, needing help is not undignified, and death is not better than reliance on assistance. Have we gotten to the point that we will abet suicides because people need help using the toilet? [8]

Diane Coleman, president and founder of Not Dead Yet, a grassroots disability organization opposed to legalizing assisted suicide, has written that the “public image of severe disability as a fate worse than death … become[s] grounds for carving out a deadly exception to longstanding laws and public policies about suicide intervention services … Legalizing assisted suicide means that some people who say they want to die will receive suicide intervention, while others will receive suicide assistance. The difference between these two groups of people will be their health or disability status, leading to a two-tiered system that results in death to the socially devalued group.” [9]

And as Paul Longmore, Professor of History at San Francisco State University and a foremost disability advocate on this subject, explained that the legalization of assisted suicide would “take place within the context of a health care system and a society pervaded with prejudice and discrimination against people with disabilities.” [10] This prejudice and discrimination often plays out in deadly ways, including pressure by hospital staff members on people with disabilities to sign “Do Not Resuscitate” forms:

“Yvonne Duffy had hospital personnel constantly urging and demanding that she sign the order,” while Robert Powell, a wheelchair rider, was denied admittance to a hospital when he refused to sign a DNR. The disability rights magazine Mouth related that a New Mexico subscriber went to a hospital emergency room during a severe asthma attack. While she struggled to breathe, a social worker carefully took the time to explain that she had a right to reject medical treatment. At last, the disabled woman demanded that the staffer summon a doctor. As she departed, the social worker insistently informed her: “It’s not too late. The Right to Die is on the hospital channel 6 twenty-four hours a day. You can watch it in your room!” Mouth writer Joe Ehman entered a Rochester, New York, hospital for back surgery. Both before and after the operation, a squad of hospital, county, and home-health social workers pressured him to sign a Do Not Resuscitate order. Ehman shot back at them, “I’m only 30 years old! I don’t want to die!” [11]

Additional linkages between assisted suicide and the danger it poses to people with disabilities are made below, particularly in The Danger to People With Depression and Psychiatric Disabilities, and The Questionable Circumstances of Oregon Deaths.

C. A Deadly Mix: Managed Health Care and Assisted Suicide

1. an ailing system made worse.

A significant problem with legalization is the deadly interaction between assisted suicide and profit-driven managed health care. Again and again, health maintenance organizations (HMOs) and managed care bureaucracies have overruled physicians’ treatment decisions because of the cost of care. These actions have sometimes hastened patients’ deaths. [12] Financial considerations can have similar results in non-profit health plans and government-sponsored health programs such as Medicare and Medicaid, which are often under-funded.

The cost of the lethal medication generally used for assisted suicide is about $300, far cheaper than the cost of treatment for most long-term medical conditions. The incentive to save money by denying treatment already poses a significant danger. This danger is far greater where assisted suicide is legal. Direct coercion is not necessary. If patients are denied necessary life-sustaining health care treatment, or even if the treatment they need is delayed, many will, in effect, be steered toward assisted suicide.

A 1998 study from Georgetown University’s Center for Clinical Bioethics underscores the link between profit-driven managed health care and assisted suicide. The research found a strong link between cost-cutting pressure on physicians and their willingness to prescribe lethal drugs to patients, were it legal to do so. [13]

The deadly impact of legalizing assisted suicide would fall hardest, whether directly or indirectly, on socially and economically disadvantaged people who have less access to medical resources and who already find themselves discriminated against by the health care system. As the New York State Task Force on Life and the Law notes, assisted suicide:

… will be practiced through the prism of social inequality and prejudice that characterizes the delivery of services in all segments of society, including health care. Those who will be most vulnerable to abuse, error, or indifference are the poor, minorities, and those who are least educated and least empowered … [T]here [is no] reason to believe that the practices, whatever safeguards are erected, will be unaffected by the broader social and medical context in which they will be operating. This assumption is naïve and unsupportable. [14]

Longmore underscored this point, stating, “Poor people, people of color, elderly people, people with chronic or progressive conditions or disabilities, and anyone who is, in fact, terminally ill will find themselves at serious risk.” [15]

2. Deteriorating Health Care in Oregon

Longmore and other disability rights activists have long made the point that Oregon’s adoption of assisted suicide must be critically examined in relation to its curtailment of Medicaid spending. As Longmore explained, Oregon instituted “health care rationing for the poor” in the same year that the State’s assisted suicide initiative became law in 1994. [16] That year, the Oregon Medical Assistance Program (OMAP) ranked over 700 health services and terminated funding for 167 of these services. Four years later, when the assisted suicide law went into effect, OMAP directors put lethal prescriptions on the list of “treatments,” categorized as “comfort care.” At the same time, OMAP slashed Medicaid funding for more than 150 services crucial for people with disabilities, people with terminal illnesses, and older adults, while further trimming already limited funding for in-home support. In the same year, OMAP attempted, but failed, to limit the funded doses of a powerful pain medication and successfully put barriers in the way of funding for a path-breaking anti-depressant.

Longmore demonstrates, moreover, that the chronological link between assisted suicide and the attacks on health care services for Oregon’s most vulnerable residents are neither accidental nor well disguised:

A newspaper profile revealed that Barbara Coombs Lee [author of Measure 16, Oregon’s assisted suicide initiative] was “closely involved in passage” of Oregon’s health plan. Oregon’s governor John Kitzhaber, a former emergency room physician and the chief architect of this health care rationing system, admitted—or perhaps he was boasting—that “only three states spend less per person on health care for the poor.” The British magazine The Economist praised Kitzhaber “for rationing health care in the face of limited resources” and observed that “Oregon no longer pays for such treatments as ‘efforts to fight the final stages of AIDS.'” Politicians’ and bureaucrats’ implementation of these cost-cutting measures while they willingly fund assisted suicide amounted to a declaration of class warfare against the poor, many of whom are sick or disabled. [17]

The impact of the Oregon Health Plan’s drastic limitations became very real to Oregon Medicaid recipients Barbara Wagner and Randy Stroup. Wagner, a 64-year-old great-grandmother, had recurring lung cancer. Her physician prescribed Tarceva to extend her life. Studies show the drug provides a 30 percent increased survival rate for patients with advanced lung cancer, and patients’ one-year survival rate increased by more than 45 percent. But the Oregon Health Plan sent Wagner a letter saying the Plan would not cover the beneficial chemotherapy treatment “but … it would cover … doctor-assisted suicide.” Stroup was prescribed mitoxantrone as chemotherapy for his prostate cancer. His oncologist said the medication’s benefit has been shown to be “not huge, but measurable”; while the drug may not extend a patient’s life by very long, it helps make those last months more bearable by decreasing pain. [18] Yet Stroup also received a letter saying that the state would not cover his treatment, but would pay for the cost of physician-assisted suicide. [19]

These treatment denials were based on an Oregon Medicaid rule that denies surgery, radiotherapy, and chemotherapy for patients with a less than a five-percent expectation of five-year survival. H. Rex Greene, M.D., former Medical Director of the Dorothy E. Schneider Cancer Center at Mills Health Center and currently a member of the AMA Ethics Council, called this rule “an extreme measure that would exclude most treatments for cancers such as lung, stomach, esophagus, and pancreas. Many important non-curative treatments would fail the five-percent/five-year criteria.” [20]

It is also often alleged that legalized assisted suicide has improved end-of-life care in Oregon. While it is true that Oregon has shown some improvements, similar improvements have occurred in other states that have not legalized assisted suicide. [21] And research strongly suggests that Oregon has seen a reduction in the quality of end-of-life palliative care during the years since the Oregon law went into effect. A 2004 Journal of Palliative Care Medicine study showed that dying patients in Oregon are nearly twice as likely to experience moderate or severe pain during the last week of life, as reported by surviving relatives, compared with patients before the Oregon law took effect. [22] An article in The Oregonian about the study stated, “The findings call into question the widespread view that pain control at the end of life has improved markedly in Oregon.” [23] And in 2008, authorities on end-of-life care and suicide prevention Herbert Hendin, M.D., and Kathleen Foley, M.D., discussed a number of studies that show inadequate palliative and end-of-life care in that state. [24]

3. The Broad Indirect Impacts on Health Care

Addressing the negative impact of the legalization of assisted suicide on the practice of medicine, the two professional associations representing oncologists in California wrote in 2007 that legalization “strikes at the heart of what we do as physicians and adds ambiguity to the physician-patient relationship.” Legalization, they concluded, undermines the “physician’s primary directive … to first, do no harm “; “destroys the trust between the patient and doctor”; and, “[u]nder the pretense of providing compassion,” relieves a physician “of his or her primary responsibility … to safeguard [patients’ lives] and to provide comfort to the suffering. It is the ultimate patient abandonment.” [25]

It has been argued that concerns about health care inequalities and assisted suicide are belied by the fact that the reported assisted suicide deaths in Oregon have largely occurred to white educated individuals who are not poor. However, these concerns are not strictly about the handful of official reported assisted suicides, but the wider indirect impact of legalization on medical and legal practice.

The death of Wendy Melcher in August 2005 illustrates this impact. Two nurses, Rebecca Cain and Diana Corson, gave Melcher large overdoses of morphine and phenobarbital. They claimed that she had requested assisted suicide, but they administered the drugs without her doctor’s knowledge, in clear violation of the law. Yet no criminal charges have been filed against the two nurses. Proponents of assisted suicide argue that this case has no connection to it. But it is a strong indication of the legal erosion of public protections associated with assisted suicide. The case prompted one newspaper to write, “If nurses—or anyone else—are willing to go outside the law, then all the protections built into [Oregon’s] Death with Dignity Act are for naught.” [26]

Supporters of assisted suicide frequently make the claim that where it is legal, there is no longer any underground practice of assisted suicide. No documentation is ever offered to support this claim. But Melcher’s death suggests the exact opposite. It appears that underground assisted suicide is thriving in Oregon, due to the breakdown in legal rules and codes of conduct that elsewhere protect health care patients, a breakdown that may be an inevitable by-product of assisted suicide’s legalization.

Other indirect harms of assisted suicide are discussed below, especially in the section, One Visit, Rarely: The Impact on the Individual.

II. The Failure of Safeguards and the Case of Oregon

Oregon’s Death with Dignity Act initiative, known as Measure 16, narrowly passed in November 1994, but court proceedings delayed its implementation. After the court dismissed the challenge, the Oregon legislature, concerned that Measure 16 might soon be enacted, and knowing it to be dangerously flawed, referred it back to the voters for reconsideration in a November 1997 special election. After a campaign in which assisted suicide’s proponents succeeded in keeping the public’s attention away from the proposal’s actual problems, Oregon voters legalized assisted suicide. [27]

Washington State’s Initiative 1000, nearly identical to the Oregon law, passed in November 2008, and went into effect as the Death with Dignity Act in March 2009.

One of the myths about assisted suicide in Oregon is that it is highly regulated and has strong safeguards. Those alleged safeguards include limiting assisted suicide to people who are terminally ill, requiring doctors to present patients with the option for palliative care, ensuring that each request is voluntary, requiring that a second opinion be obtained, ensuring that patients are competent to make the decision to end their lives, requiring a fifteen-day waiting period, and requiring doctors to inform the state of any lethal prescriptions they write. [28] However, each and every one of these reportedly strong rules is either fundamentally flawed or has been rendered an empty ritual.

The discussion that follows focuses largely on Oregon because assisted suicide has been legal in that state for over a decade. Exploring Oregon and Washington is a means to examine many significant problems with the legalization of assisted suicide. These problems include the myth of free choice and self-determination; the fundamental loophole of terminal illness prognosis; the safeguards in name only; the danger to people with depression and psychiatric disabilities; Oregon’s minimal data and fatally flawed oversight; and the questionable circumstances of Oregon deaths.

A. The Myth of Free Choice and Self-Determination

Assisted suicide proponents frequently appeal to free choice and self-determination. But in reality, legalized assisted suicide actually diminishes individual choice, control, and self-determination.

Margaret Dore, a specialist in elder law, has extensively documented how the Oregon and Washington State assisted suicide laws, contrary to the rhetoric, dramatically undermine patient control. In a May 2009 article on the website of the King County (Seattle) Bar Association, she pointed out:

During the election, proponents touted [assisted suicide] as providing “choice” for end-of-life decisions. A glossy brochure declared, “Only the patient—and no one else—may administer the [lethal dose].” The Act, however, does not say this—anywhere. The Act also contains coercive provisions. For example, it allows an heir who will benefit from the patient’s death to help the patient sign up for the lethal dose. … The Act also allows someone else to talk for the patient during the lethal-dose request process, for example, the patient’s heir. This does not promote patient choice; it invites coercion. By comparison, when a will is signed, having an heir as one of the witnesses creates a presumption of undue influence. The probate statute provides that when one of the two required witnesses is a taker under the will, there is a rebuttable presumption that the taker/witness “procured the gift by duress, menace, fraud, or undue influence.” Once the lethal dose is issued by the pharmacy, there is no oversight. The death is not required to be witnessed by disinterested persons. Indeed, no one is required to be present. The Act does not state that “only” the patient may administer the lethal dose; it provides that the patient “self-administer” the dose. … Someone else putting the lethal dose in the patient’s mouth qualifies as “self-administration.” Someone else putting the lethal dose in a feeding tube or IV nutrition bag also would qualify. “Self-administer” means that someone else can administer the lethal dose to the patient. … Indeed, someone could use an alternate method, such as suffocation. Even if the patient struggled, who would know? The lethal dose request would provide an alibi. This situation is especially significant for patients with money. A California case states, “Financial reasons [are] an all too common motivation for killing someone.” Without disinterested witnesses, the patient’s control over the “time, place and manner” of his death, is not guaranteed. If one of your clients is considering a “Death with Dignity” decision, it is prudent to be sure that they are aware of the Act’s gaps. By signing the form, the client is taking an official position that if he dies suddenly, no questions should be asked. The client will be unprotected against others in the event he changes his mind after the lethal prescription is filled and decides that he wants to live. [29]

As Dore also stated, “Involuntary killing is not an ‘abuse.’ It is allowed by the statute.” [30] And Dore pointed out that assisted would actually restrict choice and self-determination by giving insurers a supposedly humane and dignified alternative to covering a patient’s health care and by making people with disabilities and chronic illness vulnerable to predators by removing the protection of illegality for assisted suicide. [31]

These concerns are developed further below in The Questionable Circumstances of Oregon Deaths.

Moreover, there is a significant danger that many people would choose assisted suicide due to external pressure. Elderly individuals who don’t want to be a financial or caretaking burden on their families might take this escape. In fact, the percentage of reported Oregon cases attributed to patients’ reluctance to burden their families has risen alarmingly. It totaled 12 percent in 1998, but increased to 26 percent in 1999, then 42 percent in 2005, and 45 percent in 2007. [32] Nothing in the Oregon law will protect patients when there are family pressures, whether financial or emotional, which distort patient choice.

The impact of pressures to choose assisted suicide was illustrated when Rob Miller, Director of the pro-assisted suicide group Compassion & Choices of Washington, commented on the death of Linda Fleming, the first reported death under Washington State’s assisted suicide law. When asked if he knew that Fleming, who was divorced, had had financial problems, had been unable to work due to a disability, and was forced to declare bankruptcy in 2007, Miller said he was unaware of all that, but that her case presented “none of the red flags” that would cause his organization to reconsider supporting her suicide request. [33]

Also troubling is that research has documented widespread elder abuse in the United States. The perpetrators are often family members. [34] Such abuse could easily lead to pressures on elders to “choose” assisted suicide.

Still others may undergo assisted suicide because they lack good health care, or in-home support, and are terrified about going to a nursing home. A case in point, Oregon resident Kate Cheney (discussed below) appears to have been strongly motivated to take her life by fear of the nursing home where she had just spent an unhappy week. As Diane Coleman noted regarding Oregon’s law, “Nor is there any requirement that sufficient home and community-based long-term care services be provided to relieve the demands on family members and ease the individual’s feelings of being a ‘burden’ … The inadequacy of the in-home long-term care system is central to the assisted suicide and euthanasia debate.” [35]

While the proponents of legalization argue that it would guarantee choice, assisted suicide would actually result in deaths due to a lack of choice. Real choice would require adequate home and community-based long-term care; universal health insurance; housing that is available, accessible, and affordable—a full range of social supports currently unavailable to many, if not most people. In a perverse twist, widespread acceptance of assisted suicide is likely to reduce pressure on society to provide these very kinds of support services, thus reducing genuine options even further. [36]

B. The Fundamental Loophole of Terminal Illness Prognosis

The Oregon and Washington laws are based on the faulty assumption that it is possible to make a clear distinction between those who are terminally ill with six months to live, and everyone else. Everyone else is supposedly protected and not eligible for assisted suicide.

But it is extremely common for medical prognoses of a short life expectancy to be wrong. Studies indicate that only cancer patients show a predictable decline, and even then, it’s only in the last few weeks of life. With every disease other than cancer, prediction is unreliable. [37] Prognoses are based on statistical averages, which are nearly useless in determining what will happen to an individual patient. Thus, the potential reach of assisted suicide is extremely broad, far beyond the supposedly narrow group its proponents claim. The affected group could include many people who may be mistakenly diagnosed as terminal but who have many meaningful years of life ahead of them.

This poses considerable danger to people with new or progressive disabilities or diseases, who may often be misdiagnosed as terminally ill but who in many cases outlive these prognoses by years or even decades. Research overwhelmingly shows that people with new disabilities frequently go through initial despondency and suicidal feelings, but later adapt well and find great satisfaction in our lives. [38] However, the adaptation usually takes considerably longer than the mere fifteen-day waiting period required by assisted suicide proposals and the Oregon and Washington laws. People with new diagnoses of terminal illness appear to go through similar stages. [39] In that early period before one learns the truth about how good one’s quality of life can be, it would be all too easy, if assisted suicide is legal, to make the final choice, one that is irrevocable.

Dr. Richard Radtke, a well-known retired academic oceanographer in Hawaii, provides one such example. Dr. Radtke has had a very disabling form of muscular sclerosis for over 25 years. In the period after his diagnosis, doctors often classified him as terminally ill. He experienced severe depression for two years. Had assisted suicide been legal, he acknowledges that he would have chosen it and died long ago. Today, still with an extremely limiting disability, he has retired from a successful academic career, is a happily married father, remains the president of a charitable foundation, and is grateful for the length and varied experiences of his life. [40] How many such individuals is our society prepared to sacrifice as the collateral damage from the legalization of assisted suicide?

C. Safeguards in Name Only

1. doctor shopping: all roads lead to rome.

There are many other significant weaknesses in Oregon’s safeguards. For example, physicians are not permitted to write a lethal prescription under a set of inappropriate conditions defined in the law, such as when a patient is incompetent or when a request is involuntary. But in many instances, patients have engaged in “doctor shopping,” which can circumvent any of these supposed protections. When the first physician a patient approached refused to comply with the request for lethal drugs, possibly because the patient didn’t meet the conditions of the law, the patient sought out a second physician, and in some cases, a third and a fourth, until someone eventually agreed to write the prescription.

As the International Task Force on Euthanasia and Assisted Suicide stated to the Montana Supreme Court in April 2009,

Many other patients seeking assisted suicide have … had to ask more than one physician for the lethal prescription. There is no way to know if physicians declined due to personal convictions, because they believed the patients were not terminally ill or because they determined that the patients had impaired judgment. During the first three years of legal assisted suicide in Oregon, reports indicated that, in 59 percent of cases, patients had to ask two or more physicians before receiving the lethal drugs. After the third year, official reports stopped including this category. Patients or their families can doctor shop until a willing physician is found. And, since non-prescribing physicians are not interviewed for official state reports, there is no way to know why they refused to lethally prescribe. [41]

To understand how easily the approval-by-two-doctors “safeguard” can be circumvented as well, it is important to know that the lead organization advocating for assisted suicide, Compassion & Choices, also facilitates most of Oregon’s reported assisted suicides, often by referring individuals to assisted-suicide-friendly doctors. (In addition, the organization’s officers “are the authors [of the law] … and [are its] self-proclaim[ed] … stewards … .” [42] ) Dr. Peter Goodwin, the group’s former Medical Director, said that about 75 percent of those who died using Oregon’s assisted suicide law through the end of 2002 did so with the organization’s assistance. [43] In one example year, during 2003, the organization was involved in 79 percent of reported assisted suicide deaths. [44] According to Dr. Elizabeth Goy of Oregon Health and Science University, Compassion in Dying (since renamed Compassion & Choices) sees “almost 90 percent of requesting Oregonians…” [45] And “in 2008 the proportion of C&C PAS deaths significantly increased to 88 percent (53/60) of all [OPHD] reported deaths.” [46] (More information about the role of Compassion & Choices in the Oregon law is discussed in the section below on Minimal Data and Fatally Flawed Oversight.)

H. Rex Greene, M.D., also noted that:

This law [referring to a California bill patterned on the Oregon law] would allow marginal physicians, say two Botox dermatologists, to diversify into end-of-life prescribing. This is a real concern as a study done a few years ago indicated that the more experience physicians have in end-of-life care the more they disapprove of PAS. Conversely, it is those that rarely care for the dying that tend to support it. Thus, this law will necessarily put vulnerable patients in the hands of physicians who either lack experience or hold philosophical beliefs that an approach to end-of-life care includes lethal overdoses to relieve “suffering.” [47]

The first person reported to die under Oregon law, whose name was not revealed, represents an example of doctor shopping. Her doctor and a second physician refused her a lethal prescription. The latter diagnosed her as “depressed.” Nonetheless, a doctor affiliated with Compassion in Dying wrote the prescription after knowing her for only a short time. [48]

Another example is Kate Cheney, an 85-year-old woman. [49] Cheney saw two physicians. Her daughter thought the first doctor was “dismissive” and requested another opinion. The second physician ordered a psychiatric evaluation, which found that Cheney lacked “the very high level of capacity required to weigh options about assisted suicide.” Cheney’s request was then denied, and her daughter “became angry.” Another evaluation took place, this time with a psychologist who insisted on meeting Cheney alone. Disturbingly, the psychologist deemed Cheney competent while still noting that her “choices may be influenced by her family’s wishes and her daughter, Erika, may be somewhat coercive.” Cheney soon took the drugs and died, but only after spending a week in a nursing home.

2. Alternatives: Presented But Not Provided

In the Oregon law, physicians are required to discuss alternatives to assisted suicide as another safeguard. However, there is no requirement that these alternatives actually be made available to patients, or even that the professional who discusses them fully understands them. Kate Cheney’s case exemplifies this. Further, her case demonstrates the shocking laxness with which safeguards in Oregon are being followed. Cheney decided to take the lethal medication immediately after spending a week in a nursing home in order to give her family a break from caregiving. The chronology shows that Cheney felt she had only three choices: burdening her family, the hell of a nursing home, or death.

As Herbert Hendin, M.D., and Kathleen Foley, M.D., suicide prevention and end-of-life care experts, wrote about Kate Cheney, “one can readily see how in the best of circumstances frail, elderly patients can feel coerced to die. … How can any physician be sure there is no coercion unless the physician has met the family and seen the interaction among them and with the patient? … This particular case raises the question of what real meaning or value Oregon’s prohibition of coercion has if it can be circumvented so easily.” [50]

After reading about Kate Cheney, Diane Coleman of Not Dead Yet sent a letter via the Internet to Dr. Robert Richardson, who authorized Cheney’s request for lethal drugs. It stated, in part:

In my role as a long-term care advocate, I have heard for years of Oregon’s claim to operate the most progressive long-term care programs in the country, model programs that emphasize in-home and community-based services, even for the most frail elderly. What in-home services was Ms. Cheney receiving? How is it that Ms. Cheney had to spend a week in a nursing home to give her family respite from caregiving? Did Ms. Cheney and her family know of other respite options? If not, who failed to tell them? How can their actions have been based on the informed consent promised in Oregon’s law? Or did the family choose the nursing home respite option with the knowledge of other alternatives (an even more disturbing possibility)? … There are many ways to resolve the feeling of being a burden on family, and the family’s feelings of being burdened. In what depth were these issues explored? In this context, family relationships are complex, and the emotional dynamics could not realistically be uncovered in a brief consultation. It appears from the newspaper account, as well as your response to Dr. Hamilton, that these issues were not meaningfully addressed. Ms. Cheney appears to have been given the message that she had three choices—to be a burden on family, to go to a nursing home, or to die. After a week in a nursing home, an experience I wouldn’t wish on my opponents except perhaps to educate them, it appears that Ms. Cheney felt she had only one option. How is this a voluntary and uncoerced decision based on informed consent? [51]

Dr. Richardson did not reply.

3. Good Faith: A Safeguard for Doctors, Not Patients

There is one foolproof safeguard in the Oregon and Washington laws. Unfortunately, it is for physicians and other health care providers rather than for patients—the good faith standard. This provision holds that no person will be subject to any form of legal liability, whether civil or criminal, if they act in good faith. [52] However, a claim of a good faith effort to meet the requirements of the law is virtually impossible to disprove. Moreover, this particular provision renders all other alleged safeguards effectively unenforceable.

Even more alarming, for all other medical procedures, doctors are liable under a much stronger legal standard, that of negligence. Yet even if negligent, practitioners of assisted suicide will not be found to have violated the law as long as they practice in good faith. In an ironic twist, assisted suicide doctors and other practitioners are safer from liability if they cause a patient’s death than if they provide his or her medical treatment.

As Diane Coleman asked, “…is society really ready to ignore the risks, tolerate the abuse, marginalize or cover up the mistakes, and implicitly agree that some lives—many lives—are expendable, in order to enact a law that immunizes health care providers and other participants in assisted suicide?” [53]

Hendin and Foley offered this analysis:

A concern with physician protection, rather than patient protection, pervades the Oregon experience. … Oregon physicians assisting in a suicide are exempt from the ordinary standards of care, skill, and diligence required of Oregon physicians in other circumstances (e.g., a physician’s conduct when withdrawing life support). Instead, the physician is immunized from civil and criminal liability for actions taken in “good faith” in assisting a suicide irrespective of community standards in other matters and even when the physician acts negligently. Good faith is a troublesome, subjective standard. … In professional practices a negligence standard based on objective, established medical guidelines is customary. If the intent of the assisted suicide law is to protect physicians from accountability for violating the statute’s provision, the good faith standard is ideal. But if the intent of the law is to provide protection for patients, a negligence standard would be more appropriate. [54]

D. The Danger to People with Depression and Psychiatric Disabilities

1. depression and the wish to die.

The drive to legalize assisted suicide comes from anecdotes of painful, uncomfortable deaths. Yet available data shows that when assisted suicide is legal, those who use it are not typically acting based on current pain or other discomfort. As H. Rex Greene, M.D., stated in 2006:

… the psychosomatic literature [describes] … Demoralization Syndrome, which is very common in chronic, … life threatening illness, the features of which (hopelessness, helplessness, and despair) fit the profile of the victims of Oregon’s law, who are consistently reported NOT to be in pain or disabled by their allegedly terminal illness but request [assisted suicide] because of fears of what might come in the future: helplessness, dependency, becoming a burden. Oregon in fact has proven that the only symptom driving requests for [assisted suicide] is psychological distress. Clearly the standard of care for depression and demoralization is not a lethal overdose of barbiturates.

Greene also stated:

The wish for death is a “cry for help,” a reliable sign of depression. How absurd that it would be met with a lethal prescription. Such an act violates professional standards of palliative care as much as if I were presented with a suicidal patient and handed her a gun or drove her to the Golden Gate Bridge. … What this legislation neglects is the fact that advances in palliative medicine have made it possible to relieve … symptoms in virtually all dying patients. The argument that five to ten percent of dying patients experience intractable symptoms relies on outdated data. (Of course, the victims of the Oregon law were not imminently dying or suffering intractable pain; they were suffering from depression and despair.) Those patients who are truly at the end-of-life need access to excellent palliative and hospice care, not a lethal overdose. [55]

Other research supports Greene’s conclusion that most patients requesting death do so not based on physical symptoms such as pain or nausea, but rather based on depression and other forms of psychological distress. [56]

2. Ignoring What Lies Beneath: The Abandonment of the Patient

Addressing the situation of the individual patient, Hendin stated in Congressional testimony:

a request for assisted suicide is … usually made with as much ambivalence as are most suicide attempts. If the doctor does not recognize that ambivalence as well as the anxiety and depression that underlie the patient’s request for death, the patient may become trapped by that request and die in a state of unrecognized terror. [57]

As Hendin and Foley wrote in 2008, when patients requesting a doctor’s assistance to die “are treated by a physician who can hear their desperation, understand the ambivalence that most feel about their request, treat their depression, and relieve their suffering, their wish to die usually disappears.” [58] Yet primary care physicians are generally not experts in diagnosing depression. Where assisted suicide is legal, the depression remains undiagnosed, and the only treatment consists of a lethal prescription.

The danger assisted suicide raises for people with depression and psychiatric disabilities has been very real in Oregon, and this is a key way that assisted suicide harms people with disabilities. N. Gregory Hamilton, M.D., Distinguished Fellow of the American Psychiatric Association and co-founder of Physicians for Compassionate Care, has demonstrated how Oregon’s flimsy safeguards do not protect people with psychiatric and other mental health disabilities. In his 2004 testimony to a British delegation considering a law similar to Oregon’s, Hamilton documented the case of Michael Freeland, a man with “a long history of serious depression and previous suicide attempts” who nonetheless received lethal drugs under the Oregon law. [59] A recent study in the British Medical Journal confirmed that that some of the reported Oregon cases were patients who were, in fact, depressed. [60]

People with depression can receive lethal drugs in Oregon and Washington legally, because they are still technically eligible as long as they are deemed legally competent, that is,  “competent and not suffering from a psychiatric or psychological disorder or depression causing impaired judgment. “ [61] [emphasis added] Yet the notion that patients with depression may be considered legally competent to decide to end their lives merely because the depression doesn’t impair their legal competency—Orwellian at best—is also at variance with the majority of clinical and forensic psychiatrists who believe “that the presence of major depressive disorder should result in an automatic finding of incompetence” to make decisions about assisted suicide. [62] And as Hendin and Foley pointed out, “Reducing the psychiatric consultation to the issue of competency ignores all the other psychological factors that go into the request for assisted suicide.” [63]

3. One Visit, Rarely: The Impact on the Individual

Over time, serious abuses of the Oregon law exemplified by the cases of Michael Freeland and Kate Cheney, discussed above, have come to light. But this has occurred only sporadically, in the media and by word of mouth, because neither the Oregon nor the Washington law requires any investigation of abuse (the laws’ weak enforcement is examined below in Minimal Data and Fatally Flawed Oversight). The example of Michael Freeland, as well as those that follow, offer an indication of the serious problems that have beset people with depression and psychiatric disabilities since the Oregon law went into effect.

In discussing Joan Lucas, an Oregon woman whose evaluating psychologist did not “take the trouble to see,” and “on the basis of a single questionnaire administered by her family, … was willing to give an opinion that would facilitate ending [her] life,” Hendin and Foley pointed out that when a psychiatric evaluation is employed in Oregon, it has a tendency to be used to protect clinicians rather than patients:

[The Oregon Public Health Division’s] monitoring procedures do not make it possible for OPHD to evaluate the care Joan Lucas received. To do so OPHD would have to interview Joan’s primary care physician who had refused to assist in her suicide and to assess the quality of her psychological evaluation. Using psychologists or psychiatrists as gatekeepers only to establish a patient’s capacity to make a decision for assisted suicide contributes to pro forma , meaningless consultations. In the Lucas case, we have no way of knowing if Joan Lucas was seriously depressed or if the doctor or psychologist was disposed to proceed even if she were. Even more troubling is that OPHD does not seem to want to know about the psychiatric status of patients requesting assisted suicide. Under the current monitoring system, OPHD collects no information from psychiatrists who did not find patients to be competent and has no direct communication with psychiatrists or psychologists who did. Its monitoring reflects a lack of concern with the welfare of depressed patients. [64]

And as N. Gregory Hamilton, M.D., pointed out,

The Oregon law does not require … a psychiatric evaluation. Only if the doctor intending to write the prescription, or the consultant, believes that the patient has seriously impaired judgment due to a mental disorder is there any requirement for referral to a psychiatrist. In actual practice, few patients requesting assisted suicide are ever referred for such an evaluation—it has dropped to only 5%. When made, it’s to a psychiatrist or psychologist chosen by the assisted suicide doctor and the evaluations tend to be pro forma, so they provide no protective function … even if an opinion disallows assisted suicide … seeking alternative opinions until one that favors assisted suicide can be found, is permitted. Thus, the law provides no effective protection for the mentally ill. [65]

Only six percent of Oregon psychiatrists are confident they can diagnose depression after one visit, [66] yet the Oregon and Washington State definitions of a psychiatric consultation permit one visit only. [67]

Psychiatric evaluation of individuals who die from assisted suicide dropped from 31 percent in 1998 to a mere five percent in 2003 – 2004. [68] In the 2007 Oregon report, no Oregon patients underwent a psychiatric evaluation. [69] And “over the [following] two years in Oregon, less than 2% of patients committing assisted suicide were referred for psychiatric evaluation.” [70]

Yet Hendin and Foley described an Oregon example of what can happen when psychiatric consultation is not provided:

[A] woman in her mid-fifties with severe heart disease … requested assisted suicide from her cardiologist, despite having little discomfort and good mobility. She was referred to another doctor, who in turn referred her to a physician willing to provide assisted suicide. That doctor determined that the woman had more than six months to live, according to his best estimate. Therefore, she was eventually dismissed as ineligible. Rather than inquire further into possible causes of [her] suicidal despair [or refer her for psychiatric treatment], the physician apparently considered … his responsibility ended. … [H]e told her to go back and make yet another appointment with her original physician and dismissed her. She killed herself the next day. [71]

Proponents of assisted suicide may argue that this event does not constitute an assisted suicide abuse, because the woman did not die from lethal drugs provided under the Oregon law. But her depression may well have been treatable by a medical provider seeking to help her. That her practitioners narrowed their consideration to her eligibility for assisted suicide surely demonstrates another of assisted suicide’s significant indirect harms.

As the two associations of California oncologists stated, considering all the Oregon assisted suicides to date, “What percentage of these cases might have been helped by aggressive psychiatric intervention or spiritual counseling?” [72]

E. Minimal Data and Fatally Flawed Oversight

The State of Oregon’s minimal data collection and gross lack of strong oversight of assisted suicide undermines any pretense of rigorous monitoring or strict regulation. A series of problems renders any conclusions based on the data to be critically flawed. Washington State’s law, which is much newer, contains similarly limited, deeply flawed oversight provisions.

Oregon’s annual reports tell us very little. In reality, we don’t know what is happening under the Oregon law due to the following oversight problems:

• The reporting requirement lacks teeth. On paper, the law requires doctors to report all lethal drug prescriptions, but sets no penalties for physicians who fail to report. As a result, there is no enforcement of this requirement. [73]
• Non-compliance is not monitored. The law requires annual statistical reports from the Oregon Public Health Division (OPHD), but OPHD does not monitor underreporting, noncompliance, or violations. Many of Oregon’s reports acknowledge that the State cannot confirm compliance with the Oregon law. OPHD announced in its first year that the state cannot determine if assisted suicide is practiced outside the law’s framework, stating “[W]e cannot detect or collect data on issues of noncompliance with any accuracy.” [74] And every annual report through Oregon’s seventh year came with disclaimer similar to this one from the fifth year: “[O]ur numbers are based on a reporting system for terminally-ill patients who legally receive prescriptions for lethal medications, and do not include patients and physicians who may act outside the law.” [75]

The Oregon Department of Human Services has no authority to investigate individual Death with Dignity cases … . The state law authorizing physician-assisted suicide neither requires nor authorizes investigations by DHS, said Barry S. Kast, DHS Assistant Director for Health Services. [81]

According to Dr. Kenneth Stevens,Oregon DHS has limited funding and they do not have the time, financial resources, authorization, or desire to investigate what is happening with assisted suicide in Oregon. He pointed out that, as the years have progressed, there is less and less information in the OPHD annual reports, adding:

But in contrast, Compassion & Choices of Oregon has much more information. … C&C wrote the law; they control the data; and when they say that everything is under control with “death with dignity” (assisted suicide) in Oregon, they are correct in that they control it. [82]

OPHD has focused more on patient-doctor confidentiality than on monitoring compliance or abuse. The agency has developed confidentiality measures unique to physician-assisted suicide which appear to be unnecessarily secretive and limit the potential for thorough research … The Oregon law specifically states that although OPHD will issue a report each year based on a selected sample of cases, “the information collected shall not be a public record and may not be made available for inspection by the public.”There is no provision for an independent researcher or evaluator to study whatever data are available. Medical standards require openness about facts, research data, and records to assess the appropriateness of treatment. The anonymity and secrecy about physician practice of assisted suicide makes such an assessment impossible. If physician-assisted suicide is to be part of the medical treatment for terminal illness, why are existing patient-doctor confidentiality rules not sufficient to protect physicians in this setting? Restricting access to information about the indications for assisted suicide, patient data, radiologic documentation, and specific drug therapy limits the opportunity to establish an objective standard of care, provides excessive protection to the physician and, in the name of confidentiality, leaves the patient vulnerable. [83]

And regarding Washington, an article by John Ruhl and William Watts, M.D., on the King County (Seattle) Bar Association website discussed the Washington law’s extraordinary requirement that on the death certificate, a patient’s underlying disease must be listed as the cause of death—even if he or she died from lethal drugs at a time when that disease manifested no symptoms: [84]

Ferreting out victims of abuse would be even more difficult because the patient’s death certificate would be required to “list the underlying terminal disease as the cause of death” rather than suicide. Nor would the press or public be able to verify the accuracy of the State’s summary statistical reports, because I-1000 provides specifically that “[e]xcept as otherwise required by law, the information collected [regarding compliance with I-1000] is not a public record … .” [85]

Assisted suicide is practiced in Oregon in secret and without oversight. In this lax context, without any systematic investigation of abuse, or even a way to report it, the examples that come to light in the media and through other means are likely to be only the tip of the iceberg. An editorial in The Oregonian pointed out that the law established “a system that seems rigged to avoid finding” the answers. [87] These problems, in aggregate, belie the allegation by assisted suicide’s proponents and backers that it is safely regulated.

In discussion of Kate Cheney, Hendin and Foley wrote, “This case makes a compelling argument for the need for openness and transparency—and perhaps even judicial review of competency determinations … .” [88] Certainly, judicial review is required on other matters no less significant than what is at stake here.

As Daniel Callahan, Senior Research Scholar and President Emeritus of the Hastings Center, wrote:

[The Oregon law] is a laboratory lacking all transparency and accountability, with no information other than of a statistical kind made available to the public. The proposed Washington law is no less blunt in its denial of public information: “the department of health shall adopt rules to facilitate the collection of information. … Except as otherwise required by law, the information … may not be made available for inspection by the public.” In the case of Oregon, we have been assured that all is well, that no abuses are occurring. In their confidence and firmness, those assurances are the equal of those expressed in the Netherlands prior to its confidential surveys. But Oregon has never sponsored a confidential survey, and probably never will. If you know, just know , there are no abuses, why bother? The flavor of the proposed law in Washington does not suggest a survey will ever be carried out there either. Regulations of that kind, protected from public scrutiny, but with the ring of authority and oversight, are a Potemkin village form of regulatory obfuscation. They look good, sound good, feel good, but have nothing behind them.” [89]

F. The Questionable Circumstances of Oregon Deaths

There are additional troubling aspects of how assisted suicide is practiced in Oregon. One is that there are no monitoring mechanisms or, indeed, controls of any kind once the prescription for lethal drugs has been written. No one knows what may happen to the lethal agents that are not taken by the patients who originally request them, and the Oregon reports have made it clear that some patients have died of other causes. [90] The drugs could be stored over time in private homes or workplaces, with no oversight to protect public safety.

As if to underscore this point, Dr. Katrina Hedberg, a lead author of most of Oregon’s official reports, testified in 2004:

Our job is to make sure that all the steps happened up to the point the prescription was written. … In fact, after they write the prescription the physician may not keep track of that patient. … The law itself only provides for writing the prescription, not what happens afterwards. … We do not have a way to track if there was a big bottle [of lethal drugs] sitting in somebody’s medicine cabinet and they died whether or not somebody else chose to use it. [91]

Concern about the fate of unused lethal barbiturates is compounded by the fact that the Oregon law does not necessarily require that the drugs be ingested by mouth. Barbara Glidewell, Patient Advocate at Oregon Health & Science University, said that patients who cannot swallow would “need to have an NG tube or G tube placement … [Then, they could] express the medication through a large bore syringe that would go into their G tube.” [92] Dr. David Jeffrey wrote, “The question of administration is a delicate one, a patient even had a PEG feeding tube inserted solely to allow him to have PAS.” [93] Moreover, Oregon’s 2008 The Oregon Death with Dignity Act: A Guidebook for Health Care Professionals states, “The Oregon [law] does not provide guidance on the degree of assistance with self-administration that may be given by another person.” The Guidebook also notes, “Under the Oregon Act, physicians are not legally permitted to provide a lethal injection if the patient’s self-administered medication does not result in death.” [94] But it does not state that a patient cannot end his or her own life by lethal injection. And according to Sue Davidson of the Oregon Nurses Association, a 2002 survey found that nurses are very actively involved in the process and that “some indicated that they had assisted [patients] in the taking of [the lethal dose].” [95]

There is at least one documented example in Oregon in which assistance by others in the dying process has been acknowledged. Discussing a case in which a man said he helped his brother-in-law take the prescribed drugs, Dr. Katrina Hedberg said, “[W]e do not know exactly how he helped this person swallow, whether it was putting a feed tube down or whatever, but he was not prosecuted. …” [96] Supporters of the Oregon law allege that assisted suicide is totally voluntary by virtue of the fact that the individual alone must actually ingest the lethal agents, and do so very quickly, before the drugs’ effects stall the process. But if a patient or someone assisting uses a feeding tube or an injection, intravenous or intramuscular, abuse is far more difficult to detect and prove.

The ambiguity about what happens after the prescription is written—the actual manner of death—is highly problematic. Again contrary to the impressions created by assisted suicide supporters, the lethal drugs are not at all simple to take quickly. According to Kenneth R. Stevens, Jr., M.D., former Chairman of Radiation Oncology at Oregon Health & Science University and Vice-president of the Physicians for Compassionate Care Education Foundation, assisted suicides in Oregon have generally used one of two agents, secobarbital or pentobarbital (Nembutal). Use of secobarbital, a powder, requires a person to take the contents of 90 to 100 large capsules. These capsules cannot feasibly be swallowed, because the individual would fall asleep before ingesting enough to achieve the intended purpose. So the capsules must be emptied into applesauce or pudding, which cannot disguise the very strong and exceptionally bitter, distasteful flavor. Taking a substance to numb the mouth is not necessarily a good way to make the drug more palatable, because it could interfere with swallowing. The other agent, pentobarbital, is only available as an injectable liquid. Four bottles, or approximately seven ounces of liquid, must be taken to reach the needed dose of ten grams, and this potion is also exceptionally distasteful.

Dr. Stevens commented on how bitter a death oral ingestion provides, and he pointed out that in at least one known Oregon case, a feeding tube was used. [97] He observed that since the lethal agent can be administered to a willing person through a feeding tube, it is equally possible to administer it to an unwilling person by the same means. Moreover, once the injectable pentobarbital leaves the pharmacy, there is nothing to prevent it from being used through an intravenous (IV) line, or as a lethal injection. If a patient or someone assisting appears to have used a feeding tube or an injection, abuse is far more difficult to detect and prove. [98]

This slide away from self-administration is a cause of considerable concern to the disability community, which has known a long history of involuntary euthanasia at the hands of others, whether governments, medical establishments, or families that did not necessarily value their presence. [99] With no controls on the drug after the prescription is filled, and with the possibility of administration through a nasogastric tube or gastrostomy feeding tube, or even through injection by third parties—how does this scheme protect vulnerable people from abuse, particularly at home?

The two professional associations of California oncologists wrote:

Despite the reporting requirements, death by physician-assisted suicide in Oregon largely occurs in the dark. There is little accurate information about what actually happens at the time of death, as physicians are not required to be present at the time …. In 2005, physicians were in attendance in only 23% of cases… Between 1998 and 2005, the time between ingestion and death ranged from four minutes to 48 hours.  It is hard not to imagine that those patients who required 48 hours to die might have experienced suffering over and above that brought on by the terminal illness. Indeed, this has been the experience in the Netherlands, with a report from 2000 showing that so-called “problems with completion” (a longer-than-expected time to death, failure to induce coma, or induction of coma followed by awakening of the patient) occurred in 16% of cases, prompting physician intervention 18% of the time, which of course blurs the line considerably between suicide and euthanasia. [100]

Other physicians specializing in end-of-life care have also questioned the circumstances of Oregon deaths. Doctors at Physicians for Compassionate Care wrote, “The range of time between ingestion and death ranged from 2 minutes to 25 hours. Both of those times are problematic. It is very unlikely that someone would die within 2 minutes of taking an overdose of sleeping medication. Likewise, the major effect of the short-acting sleeping medication would have worn off by 25 hours. So what was the cause of death in these circumstances?” [101]

H. Rex Greene, M.D. responded to these observations by pointing out that prior reports from Oregon consistently reported five-minute deaths—and only one victim has survived. He agreed that nobody dies five minutes—or even twenty minutes—following oral ingestion of a lethal dose of barbiturates. “About 15 percent of the Dutch overdoses survive and need to be euthanized,” Greene concluded. “If true, the Oregon numbers suggest they are asphyxiating the patients … in violation of the Oregon law.” [102]

III. So-called “Narrow” Proposals Can Easily Expand

Most assisted suicide supporters claim that assisted suicide will be narrowly limited to people who are terminally ill, but these so-called “narrow” proposals, if enacted, can easily expand. As the New York State Task Force on Life and the Law wrote,

Once society authorizes assisted suicide for … terminally ill patients experiencing unrelievable suffering, it will be difficult if not impossible to contain the option to such a limited group. Individuals who are not [able to make the choice for themselves], who are not terminally ill, or who cannot self-administer lethal drugs will also seek the option of assisted suicide, and no principled basis will exist to deny [it]. [103]

A. The Netherlands: Pandora’s Box

The example of the Netherlands demonstrates clearly that assisted suicide cannot be limited to a small, targeted group once Pandora’s box is opened. The Dutch example provides the longest experience with assisted suicide in any country. Although it remained technically illegal until 2002, the Netherlands first began to legally tolerate assisted suicide in the early 70s. [104] Today, active euthanasia—doctors giving lethal injections—has almost completely replaced assisted suicide. [105]

The Netherlands has become a frightening laboratory experiment because of how far assisted suicide and lethal injections have spread. Herbert Hendin documented how assisted suicide and lethal injections have become not the rare exception, but the rule for people with terminal illness in the Netherlands. Hendin was one of only three foreign observers given the opportunity to study these medical practices in the Netherlands in depth, to discuss specific cases with leading practitioners, and to interview Dutch government-sponsored euthanasia researchers.

Hendin stated in Congressional testimony, “Over the past two decades, the Netherlands has moved from assisted suicide to euthanasia, from euthanasia for the terminally ill to euthanasia for the chronically ill, from euthanasia for physical illness to euthanasia for psychological distress and from voluntary euthanasia to nonvoluntary and involuntary euthanasia. Once the Dutch accepted assisted suicide it was not possible legally or morally to deny more active medical [assistance to die], i.e. euthanasia, to those who could not effect their own deaths. Nor could they deny assisted suicide or euthanasia to the chronically ill who have longer to suffer than the terminally ill or to those who have psychological pain not associated with physical disease. To do so would be a form of discrimination. Involuntary euthanasia has been justified as necessitated by the need to make decisions for patients not [medically] competent to choose for themselves.” [106]

Hendin has also described how the government-sanctioned studies suggest an erosion of medical standards in the care of terminally ill patients in the Netherlands: 50 percent of Dutch cases of assisted suicide and euthanasia  are not reported, more than 50 percent of Dutch doctors feel free to suggest euthanasia to their patients, and 25 percent of these doctors admit to ending patients’ lives without their consent. [107] Further, he reported that, for a thousand people each year in the Netherlands, physicians have ended their patients’ lives without consulting the patients. [108]

U.S. assisted suicide advocates, attempting to distinguish the Oregon experience from that of the Netherlands, argue that the numbers of reported users of assisted suicide in Oregon are low. But in fact, the number of people requesting lethal drugs has steadily increased. [109] In the beginning, the numbers were low in the Netherlands as well, but usage grew along with social acceptance of the practice. There is no reason to believe that legalization in the U.S. would not be followed, in 20 years or more, with the kind of extraordinary growth that has taken place in the Netherlands.

B. Other Factors Driving Toward Expansion

Assisted suicide proponents and medical personnel alike have established that taking lethal drugs by mouth is often ineffective in causing a quick and simple death. The body sometimes expels the drugs through vomiting, or the person falls into a lengthy state of unconsciousness rather than dying promptly, as assisted suicide advocates wish. Such ineffective suicide attempts happen in a substantial percentage of cases—estimates range from 15 percent to 25 percent. [110] The way to prevent these “problems,” in the view of euthanasia advocates, is by legalizing lethal injections by physicians—that is, legalizing active euthanasia. This is the likely next step if society first accepts assisted suicide as a legitimate legal option.

Assisted suicide proponents tell us that none of these things will happen in the United States. But once assisted suicide is legalized, no significant barriers remain to prevent them. The very existence of assisted suicide as a legal option is likely to gradually erode social resistance, as it has in the Netherlands. In fact, the leading public champion for assisted suicide in Washington State, former Governor Booth Gardner, openly articulated a vision of its expansion as his dream. According to the New York Times Magazine in December 2007:

Gardner wants a law that would permit lethal prescriptions for people whose suffering is unbearable, a standard that can seem no standard at all; a standard that prevails in the Netherlands, the Western nation that has been boldest about legalizing aid in dying; a standard that elevates subjective experience over objective appraisal and that could engage the government and the medical profession in the administration of widespread suicide. … Gardner’s campaign is a compromise; he sees it as a first step. If he can sway Washington to embrace a restrictive law, then other states will follow. And gradually, he says, the nation’s resistance will subside, the culture will shift and laws with more latitude will be passed … [111]

Thus, the danger of expansion is another reason why it is important to maintain the legal barriers prohibiting assisted suicide.

The movement to legalize assisted suicide would do far better to advocate for high quality end-of-life care. Within the context of prevailing negative attitudes about disability and a profit-driven health care system, people with disabilities pay a high price for legalizing assisted suicide. But we are not alone in doing so, because the negative consequences of legalization affect many dimensions of society, extending well beyond the disability community and the health care system.

Leading disability rights organizations and advocates in the U.S. and in many countries, as well as most health care providers and many others, will continue to oppose the legalization of assisted suicide and euthanasia. In place of legalization, we will call for adequate home and community-based long-term care, universal health coverage, and a range of social supports that provide true self-determination for everyone. As Paul Longmore wrote, “Given the absence of any real choice, death by assisted suicide becomes not an act of personal autonomy, but an act of desperation. It is fictional freedom; it is phony autonomy.” [112]

[1] International Task Force on Euthanasia and Assisted Suicide, Failed Attempts to Legalize Euthanasia/Assisted Suicide in the United States , available at http://www.internationaltaskforce.org/usa.htm (accessed July 13, 2009).

[2] Currently, these twelve nationally prominent disability organizations have stated their opposition to the legalization of assisted suicide: American Disabled for Attendant Programs Today (ADAPT); American Association of People with Disabilities (AAPD); Association of Programs for Rural Independent Living (APRIL); Disability Rights Education and Defense Fund (DREDF); Justice For All (JFA); National Council on Disability (NCD); National Council on Independent Living (NCIL); National Spinal Cord Injury Association; Not Dead Yet (NDY); TASH; the World Association of Persons with Disabilities (WAPD); and the World Institute on Disability (WID). Many state and local disability community leaders and organizations have declared their opposition in states where assisted suicide proposals have been introduced, and the Disability Section of the American Public Health Association has also declare opposition.

[3] According to Herbert Hendin and Kathleen Foley, “We now know that that proper use of pain medications in patients with chronic pain, as well as patients at the end of life, does not hasten death. Studies have demonstrated that dying patients who received morphine lived longer than those who did not receive morphine.” See Herbert Hendin and Kathleen Foley, “Physician Assisted Suicide: A Medical Perspective,” Michigan Law Review , June 2008, pp. 1634 – 1635. Herbert Hendin is Chief Executive Officer and Medical Director, Suicide Prevention International, and Professor of Psychiatry, New York Medical College. Kathleen Foley is Attending Neurologist, Memorial Sloan-Kettering Cancer Center; Professor of Neurology, Neuroscience, and Clinical Pharmacology, Weill Medical College of Cornell University; and Medical Director, International Palliative Care Initiative of the Open Society Institute. For the first sentence, Hendin and Foley cite Frank J. Brescia et al., “Pain, Opioid Use, and Survival in Hospitalized Patients With Advanced Cancer,” Journal of Clinical Oncology , Vol. 10, p. 149, 1992 (“reporting that increased use of painmedication for cancer patients does not affect the relative risk of survival significantly more thanother variables do”). For the second sentence, they cite William C. Wilson et al., “Ordering and Administration of Sedatives and Analgesics During the Withholding and Withdrawal of Life Support From Critically Ill Patients,” Journal of the American Medical Association , Vol. 267, pp. 949, 952 – 53, 1992. Also see Andrew Thorns and Nigel Sykes, “Opioid use in the last week of life and implications for end-of-life decision-making,” The Lancet , July 29, 2000, pp. 398 – 399; Gina Kolata, “When Morphine Fails to Kill,” New York Times , July 23, 1997; and Joanna Lynn, Letter to the Editor, New England Journal of Medicine , April 23, 1998, p. 1230.

[4] Herbert Hendin, M.D., “Commentary: The Case Against Physician-Assisted Suicide: For the Right to End-of-Life Care,” Psychiatric Times , Vol. 21, Num. 2, February 1, 2004, available at http://www.psychiatrictimes.com/display/article/10168/54071 (accessed July 8, 2009).

[5] Based on Oregon Public Health Division, Death with Dignity Act Annual Reports, Table 1, available at http://oregon.gov/DHS/ph/pas/docs/yr11-tbl-1.pdf (accessed July 13, 2009).

[6] Karen Birchard, “Dutch MD’s Quietly Overstepping Euthanasia Guidelines: Studies.” Medical Post , Vol. 35, Num. 11, March 16, 1999.

[7] Richard Leiby, “Whose Death Is It Anyway? The Kevorkian Debate. It’s a Matter of Faith, In the End,” Washington Post , August 11, 1996, sec. Style, p. F1.

[8] Paraphrased from Diane Coleman, Stephen Drake, and Paul Longmore, The Real Hemlock Society , available at http://www.broadreachcentre.ca/advocacy/arhemloc.htm (accessed July 13, 2009).

[9] Diane Coleman, J.D., “Not Dead Yet,” The Case Against Assisted Suicide – For the Right to End-of-Life Care , Kathleen Foley and Herbert Hendin, eds. (Baltimore: The Johns Hopkins University Press, 2002), p. 221.

[10] Paul Longmore, “The Resistance: The Disability Rights Movement and Assisted Suicide,” Why I Burned My Book and Other Essays on Disability (Philadelphia: Temple University Press, 2003), p. 178.

[11] Ibid. Longmore is quoting “Joint Statement from Evan Kemp and Justin Dart,” November 15, 1996; Carl Weiser, “Protesting Assisted Suicide Disabled People Shout, ‘We’re Not Dead Yet!’,” Louisville Courier-Journal , January 9, 1997, 4A; and Joe Ehman, “The Politics of D.N.R. (Do Not Resuscitate),” Mouth Magazine 6:6 March – April 1996, pp. 14 – 16. These near-fatal encounters with anti-disability prejudice in the health care system are not limited to the U.S. See, e.g., Olga Craig, “Baroness Campbell: Believe me, I absolutely love my life,” Telegraph , July 12, 2009, available at http://www.telegraph.co.uk/news/5803716/Baroness-Campbell-Believe-me-I-absolutely-love-my-life.html (accessed July 14, 2009).

[12] See, e.g., the story of Dr. Linda Peeno. In 1996, before the U.S. House of Representatives Commerce Committee, she testified, “In the spring of 1987, as a physician [and managed-care executive for the HMO Humana], I caused the death of a man [by denying coverage of a heart transplant] … I have not been taken before any court of law or called to account for this in any professional or public forum. In fact, just the opposite occurred: I was ‘rewarded’ for this. It brought me an improved reputation in my job, and contributed to my advancement afterwards.” See also HMO Whisteblower Dr. Linda Peeno on the Subordination of Healthcare to a For-Profit System , June 21, 2007, available at http://www.democracynow.org/2007/6/21/hmo_whisteblower_dr_linda_peeno_on (accessed July 13, 2009); and “Doctor to Confess Role in Man’s Death,” San
Francisco Chronicle , April 15, 1997, p. A13.

[13] Daniel P. Sulmasy, M.D.; Benjamin P. Linas, B.A.; Karen F. Gold, Ph.D., and Kevin A. Schulman, M.D., “Physician Resource Use and Willingness to Participate in Assisted Suicide,” Archives of Internal Medicine , Vol. 158, May 11, 1998, p. 978.

[14] New York State Task Force on Life and the Law, When Death Is Sought: Assisted Suicide and Euthanasia in the Medical Context (New York: New York State Task Force on Life and the Law, 1994) pp. xiii, xv.

[15] Longmore, “The Resistance: The Disability Rights Movement and Assisted Suicide,” p. 195.

[16] Longmore, “The Resistance: The Disability Rights Movement and Assisted Suicide,” pp. 193 – 194. For his analysis, Longmore draws on Peter Steinfels, “Beliefs: Oregon Medicaid’s Doctor-Assisted Suicide,” New York Times , March 7, 1998; Erin Hoover, “Coverage of Assisted Suicide Looks Certain,” The Oregonian , November 24, 1998; Patrick O’Neill, “Kitzhaber Proposes New Programs, No New Taxes; The Oregon Health Plan Would Face Some Cuts, Tougher Screening under the Governor’s Proposal,” The Oregonian , December 2, 1998; Associated Press, “Oregon Health Plan Will Cover Assisted Suicide Costs,” December 2, 1998; Physicians for Compassionate Care, “Assisted Suicide Report Plagued by Shortcomings,” Press Release, February 23, 2000;  Nat Hentoff, “Free Ticket to Eternity,” Washington Post ; February 6, 1999, A21; and Tom Bates, “Chief petitioner answers questions on Measure 16,” Sunday Oregonian , November 26, 1994.

[18] Kenneth R. Stevens, Jr., M.D., Oregon Rationing Cancer Treatment But Offering Assisted Suicide to Cancer Patients—Paying to Die But Not to Live , Physicians for Compassionate Care Educational Foundation, June 6, 2008, available at http://www.pccef.org/articles/art67.htm (accessed July 9, 2009). Stevens is Professor Emeritus and former Chairman of Radiation Oncology at Oregon Health & Science University and Vice-president, Physicians for Compassionate Care Education Foundation.

[19] Dan Springer, “Oregon Offers Terminal Patients Doctor-Assisted Suicide Instead of Medical Care,” Fox News , July 28, 2009, available at http://www.foxnews.com/story/0,2933,392962,00.html (accessed July 9, 2009).

[20] H. Rex Greene, M.D., personal communication, July 5, 2009.

[21] Kenneth R. Stevens, Jr., M.D., and William L. Toffler, M.D., noted in 2008 in The Oregonian that many states do better than Oregon. For example, the latest data ranks Oregon ninth (not first) in Medicare-age use of hospice; four out of the top five are states that have criminalized assisted suicide. See Kenneth R. Stevens, Jr., M.D., and William L. Toffler, M.D., “Assisted suicide: Conspiracy and Control,” The Oregonian , September 24, 2008. See Steven’s qualifications above. Toffler is Professor of Family Medicine at Oregon Health and Science University (OHSU) and the National Director of Physicians for Compassionate Care Educational Foundation.

[22] Erik K. Fromme, M.D., Virginia P. Tilden, D.N.Sc., R.N., Linda L. Drach, M.P.H., and Susan W. Tolle, M.D., “Increased Family Reports of Pain or Distress in Dying Oregonians: 1996 to 2002,” Journal of Palliative Care Medicine , Vol. 7, Num. 3, 2004.

[23] Don Colburn, “An OHSU Study Finds That Pain Management Has Not Kept Up With Expectations of the 1997 Law,” The Oregonian , July 23, 2004.

[24] Hendin and Foley, “Physician Assisted Suicide: A Medical Perspective,” Michigan Law Review , pp. 1619 – 1620 and 1636 – 1637. Hendin and Foley, “Physician Assisted Suicide: A Medical Perspective,” Michigan Law Review , pp. 1619 – 1620 and 1636 – 1637. Hendin and Foley are drawing on Erik K. Fromme et al., “Increased Family Reports of Pain or Distress in Dying Oregonians: 1996 to 2002,” Journal of Palliative Medicine , Vol. 7, Num. 3, 2004; Linda Ganzini et al., “Physicians’ Experiences with the Oregon Death with Dignity Act,” New England Journal of Medicine , Vol. 342, Num. 8, 2000; Susan Tolle and Kathleen Haley, “Pain Management in the Dying … Successes and Concerns,” BME Report (Oregon Board of Medical Examiners), Fall 1998, pp. 1, 4; Susan W. Tolle and Susan E. Hickman, “Don’t prescribe less—chart better,” BME Report (Oregon Board of Medical Examiners), Winter – Spring 2002, pp. 1, 4; Last Acts Program, Robert Wood Johnson Foundation, Means to a Better End , 2002, pp. 10 – 43; Linda Ganzini et al., “Nurses’ Experiences with Hospice Patients Who Refuse Food and Fluids to Hasten Death,” New England Journal of Medicine , Vol. 349, Num. 4 (2003); Helene Starks et al., “Family Member Involvement in Hastened Death,” Death Studies , Vol. 31, Num. 2, 2007; and Dr. David Jeffrey, Winston Churchill Fellow, 2006, “Physician-assisted suicide v Palliative Care: a Tale of Two Cities,” available at http://www.pccef.org/articles/PCCEF_June07_posting.pdf (accessed July 13, 2009).

[25] Association of Northern California Oncologists and Medical Oncology Association of Southern California, Position Statement on Physician-Assisted Suicide and Opposition to AB 37 4, April 16, 2007, available at /issues/assisted-suicide/position-statement-on-assisted-suicide/ (accessed July 8, 2009).

[26] Editorial, “Another case for nursing reform,” Portland Tribune , July 10, 2007.

[27] Oregon’s Death Wish: The Vote and the Aftermath , International Task Force on Euthanasia and Assisted Suicide, available at http://www.internationaltaskforce.org/iua11.htm (accessed July 9, 2009).

[28] Hendin and Foley, “Physician Assisted Suicide: A Medical Perspective,” Michigan Law Review , p. 1614.

[29] Dore, Margaret, “Death with Dignity”: What Do We Advise Our Clients?,” King County Bar Association , May 2009 Bar Bulletin , available at What Do We Advise Our Clients? (accessed July 13, 2009).

[30] Margaret Dore, personal communication, May 8, 2009.

[31] Margaret Dore, personal communication, June 16, 2009.

[32] Trend noted by Licia Corbella, “If Doctors Who Won’t Kill Are Wicked, the World Is Sick: In Jurisdictions Where Euthanasia Is Allowed, A Loss of Choice Has Followed,” Vancouver Sun , January 14, 2009. See also Oregon Public Health Division, Oregon’s Death with Dignity Act: The First Year’s Experience , 1999, available at http://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Documents/year1.pdf (accessed July 13, 2009); Oregon’s Public Health Division, Oregon’s Death with Dignity Act: The Second Year’s Experiences , 2000, available at http://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Documents/year2.pdf (accessed July 13, 2009); and Oregon Public Health Division, Eighth Annual Report on Oregon’s Death with Dignity Act , 2006, available at http://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Documents/year8.pdf (accessed July 13, 2009).

[33] William Yardley, First Death for Washington Assisted-Suicide Law , New York Times, May 22, 2009, available at http://www.nytimes.com/2009/05/23/us/23suicide.html .

[34] The National Elder Abuse Incidence Study (NEAIS) was conducted by the National Center on Elder Abuse at the American Public Human Services Association. It showed that, in 1996, 450,000 elders age 60 and over were abused, according to a study of observed cases. In almost 90 percent of the elder abuse and neglect incidents with a known perpetrator, the perpetrator was a family member, and two-thirds of the perpetrators were adult children or spouses. See National Center on Elder Abuse, National Elder Abuse Incidence Study (NEAIS ), American Public Human Services Association, 1998, p. 4–28.

[35] Coleman, “Not Dead Yet,” The Case Against Assisted Suicide , p. 224.

[36] Laura Remson Mitchell, a public policy analyst, consultant, and writer who specializes in disability and health-care issues, has explored this concept in articles and other writings. Personal correspondence, March 13, 2003.

[37] E.B. Lamont et al., “Some elements of prognosis in terminal cancer,” Oncology (Huntington ), Vol. 9, August 13, 1999, pp. 1165-70; M. Maltoni, et al., “Clinical prediction of survival is more accurate than the Karnofsky performance status in estimating lifespan of terminally-ill cancer patients,” European Journal of Cancer , Vol. 30A, Num. 6, 1994, pp. 764-6; N.A. Christakis and T.J. Iwashyna , “Attitude and Self-Reported Practice Regarding Prognostication in a National Sample of Internists,” Archives of Internal Medicine , Vol. 158, Num. 21 November 23, 1998, pp. 2389-95; J. Lynn et al., “Prognoses of seriously ill hospitalized patients on the days before death: implications for patient care and public policy,” New Horizons , Vol. 5, Num. 1, February 1997, pp. 56-61. Also: “17 percent of patients [outlived their prognosis] in the Christakis study. This roughly coincides with data collected by the National Hospice and Palliative Care Organization, which in 2007 showed that 13 percent of hospice patients around the country outlived their six-month prognoses. … When a group of researchers looked specifically at patients with three chronic conditions—pulmonary disease, heart failure, and severe liver disease—they found that many more people outlived their prognosis than in the Christakis study. Fully 70 percent of the 900 patients eligible for hospice care lived longer than six months, according to a 1999 paper published in the Journal of the American Medical Association .” See Nina Shapiro, “Terminal Uncertainty,” Seattle Weekly , January 14, 2009, available at http://www.seattleweekly.com/content/printVersion/553991/ (accessed July 13, 2009).

[38] Harris, Louis & Associates, The ICD Survey of Disabled Americans: Bringing Disabled Americans into the Mainstream , 1986, p. 55; Gerhart, K.A. et al., “Quality of life following spinal cord injury: knowledge and attitudes of emergency care providers,” Annals of Emergency Medicine , Vol. 23, 1994, pp. 807 – 812; P. Cameron et al., “The Life Satisfaction of Nonnormal Persons,” Journal of Consulting and Clinical Psychology , Vol. 41, 1973, pp. 207 – 214; C. Ray and J. West, “Social, sexual and personal implications of paraplegia,” Paraplegia , Vol. 22, 1984, pp. 75 – 86; R. Stensman, “Severely mobility-disabled people assess the quality of their lives,” Scandinavian Journal of Rehabilitation Medicine , Vol. 17, 1985, pp. 87 – 99; Whiteneck, G.G. et al., “ Rocky Mountain Spinal Cord Injury System Report,” National Institute of Handicapped Research , 1985, pp. 29 – 33; and M.G. Eisenberg and C.C. Saltz, “Quality of life among aging spinal cord injured persons: long term rehabilitation outcomes,” Paraplegia , Vol. 29, 1991.

[39] New York State Task Force on Life and the Law, When Death Is Sought .

[40] Richard Radtke, “A Case Against Physician-Assisted Suicide,” Journal of Disability Policy Studies , Vol. 16, Num. 1, Summer 2005, pp. 58 – 61.

[41] Brief of Amicus Curiae Int’l Task Force on Euthanasia & Assisted Suicide et al . at13 – 14, Baxter v. State of Montana , No. DA 09-0051(Mont.)( case pending, brief filed Apr. 24, 2009).

[42] Kenneth R. Stevens, Jr., M.D., The Proportion of Oregon Assisted Suicides by Compassion & Choices Organization , Physicians for Compassionate Care Educational Foundation, March 4, 2009, available at http://www.pccef.org/DOWNLOADS/AssistedSuicidesbyCC2009report.pdf (accessed July 13, 2009).

[43] Transcript of tape of Peter Goodwin, Oregon , January 11, 2003, Presentation at 13 th National Hemlock Society Biennial Conference, “Charting a New Course, Building on a Solid Foundation, Imagining a Brighter Future for America’s Terminally Ill,” January 9 – 12, 2003, Bahia Resort Hotel, San Diego, California.

[44] Compassion in Dying of Oregon , Summary of Hastened Deaths , data attached to Compassion in Dying (now called Compassion and Choices) of Oregon’s IRS Form 990 for 2003.

[45] Dr. Elizabeth Goy of Oregon Health and Science University (OHSU) is an Assistant Professor in the Department of Psychiatry, School of Medicine, OHSU and has worked with Dr. Linda Ganzini in surveys dealing with Oregon’s law. In 2004, members of the British House of Lords traveled to Oregon seeking information regarding Oregon’s assisted-suicide law for use in their deliberations about a similar proposal that was under consideration in Parliament. They held closed-door hearings on December 9 and 10, 2004 and published the proceedings on April 4, 2005.House of Lords Select Committee on the Assisted Dying for the Terminally Ill Bill, Assisted Dying for the Terminally Ill Bill [HL ] Vol. II: Evidence (London: The Stationery Office Limited, 2005), p. 291, Question 768, available at: http://www.publications.parliament.uk/pa/ld200405/ldselect/ldasdy/86/86ii.pdf (accessed July 13, 2009).

[46] Stevens, The Proportion of Oregon Assisted Suicides by Compassion & Choices Organization .

[47] H. Rex Greene, M.D., Letter to the Council on Ethical Affairs , California Medical Association, February 22, 2006, available at /issues/assisted-suicide/opposition-to-neutrality-on-ab-651/ . H. Rex Greene, M.D., is the former Medical Director of the Dorothy E. Schneider Cancer Center at Mills Health Center in San Mateo, California, currently a member of the AMA Ethics Council, and a leader in bioethics, health policy and oncology.

[48] Kathleen Foley and Herbert Hendin, “The Oregon Report:  Don’t Ask, Don’t Tell,” Hastings Center Report (May-June 1999): 37-42.

[49] Erin Hoover Barnett, “A Family Struggle: Is Mom Capable of Choosing to Die,” The Oregonian , October 17, 1999, p. G–01.

[50] Hendin and Foley, “Physician Assisted Suicide: A Medical Perspective,” Michigan Law Review , p. 1625. Authors’ qualifications are listed in note 3 above.

[51] Coleman, “Not Dead Yet,” The Case Against Assisted Suicide , p. 226.

[52] Or. Rev. Stat. § 127.885(1)–(3).

[53] Coleman, “Not Dead Yet,” The Case Against Assisted Suicide , p. 227.

[54] Hendin and Foley, “Physician Assisted Suicide: A Medical Perspective,” Michigan Law Review , pp. 1626-1627.

[55] Greene, Letter to the Council on Ethical Affairs .

[56] The two professional associations representing oncologists in California wrote:

“In this debate, it is critical to recognize that, contrary to belief, most patients requesting physician-assisted suicide or euthanasia do not do so because of physical symptoms such as pain or nausea. Rather, depression, psychological distress, and fear of loss of control are identified as the key end of life issues.

This has been borne out in numerous studies and reports. For example, … a survey of 100 terminally ill cancer patients in a palliative care program in Edmonton, Canada … showed no correlation between physical symptoms of pain, nausea, or loss of appetite and the patient’s expressed desire or support for euthanasia/PAS. Moreover, in the same study, patients demonstrating suicidal ideation were much more likely to be suffering from depression or anxiety, but not somatic symptoms such as pain.

An important study from the Netherlands of a cohort of 138 cancer patients with a life expectancy of three months or less demonstrated similar findings. In this study, the authors had hypothesized that patients requesting euthanasia would be unlikely to have depressed mood or affect, since it would be expected that such a request would be a well-thought out decision, particularly since euthanasia has been legal in the Netherlands since 2002. The authors expected that these patients would be more accepting of their terminal diagnosis and therefore better adjusted.  What they found surprised them—depressed patients were more than four times as likely to request euthanasia as patients who were not depressed. Over 40% of depressed patients requested euthanasia. Of those who requested euthanasia, about half were depressed.”

See Association of Northern California Oncologists and Medical Oncology Association of Southern California, Position Statement on Physician-Assisted Suicide and Opposition to AB 37 4, April 16, 2007, available at /issues/assisted-suicide/position-statement-on-assisted-suicide/ (accessed July 8, 2009). The statement cites ME Suarez-Almazor et al., “Attitudes of Terminally Ill Cancer Patients About Euthanasia and Assisted Suicide: Predominance of Psychosocial Determinants and Beliefs Over Symptom Distress and Subsequent Survival,” Journal of Clinical Oncology , Vol. 20, 2002, pp. 2134 – 41 and E.J. Emanuel, “Depression, Euthanasia, and Improving End-of-Life Care,” Journal of Clinical Oncology , Vol. 23, 2005, pp. 6456 – 8.

[57] Herbert Hendin, M.D., Suicide, Assisted Suicide and Euthanasia: Lessons From the Dutch Experience , Testimony Summary, U.S House of Representatives, Subcommittee on the Constitution, April 29, 1996.

[58] Hendin and Foley, “Physician Assisted Suicide: A Medical Perspective,” Michigan Law Review , p. 1623. Also: “Contrary to much popular and professional opinion, depression is a treatable condition, even in patients who are terminally ill.” Susan D. Block, “Psychological Issues in End-of-Life Care,” Journal of Palliative Medicine 9(3), 2006: p. 762.

[59] N. Gregory Hamilton, M.D., Physicians for Compassionate Care Educational Foundation, Testimony to the Select Committee on the Assisted Dying for the Terminally Ill Bill , House of Lords, Portland, Oregon, December 10, 2004, available at http://www.pccef.org/articles/art32HouseOfLords.htm (accessed July 13, 2009). Also see House of Lords Select Committee on the Assisted Dying for the Terminally Ill Bill,  Assisted Dying for the Terminally Ill Bill [HL ] Vol. II, pp. 329 ­– 343, available at  http://www.publications.parliament.uk/pa/ld200405/ldselect/ldasdy/86/86ii.pdf (accessed July 13, 2009). Also see N. Gregory Hamilton, M.D. and Catherine Hamilton, M.A., Competing Paradigms of Responding to Assisted-Suicide Requests in Oregon: Case Report , presented at American Psychiatric Association Annual Meeting, Symposium on Ethics and End-of-Life Care: New Insights and Challenges, New York City, May 6, 2004.

[60] Linda Ganzini, Elizabeth R. Goy, and Steven K. Doscha, “Prevalence of Depression and Anxiety in Patients Requesting Physicians’ Aid in Dying: Cross Sectional Survey,” British Medical Journal , Vol.337, a1682.

[61] Revised Code of Washington 70.245.010; Oregon Legislative Statue 127.800 §1.01.

[62] Linda Ganzini, M.D., Gregory B. Leong, M.D., Darien S. Fenn, Ph.D., J. Arturo Silva, M.D., and Robert Weinstock, M.D., “Evaluation of Competence to Consent to Assisted Suicide:  Views of Forensic Psychiatrists,” American Journal of Psychiatry , Vol. 157, April 2000, pp. 595 and 598.

[63] Hendin and Foley, “Physician Assisted Suicide: A Medical Perspective,” Michigan Law Review , p. 1631.

[64] Ibid., p. 1623.

[65] N. Gregory Hamilton, M.D., Physicians for Compassionate Care Educational Foundation, Testimony to the Select Committee on the Assisted Dying for the Terminally Ill Bill , House of Lords, Portland, Oregon, December 10, 2004, available at http://www.pccef.org/articles/art32HouseOfLords.htm .

[66] L. Ganzini, et al., “Attitudes of Oregon Psychiatrists Towards Assisted Suicide,” American Journal of Psychiatry , Vol. 153, 1996, pp. 1469 – 75.

[67] Revised Code of Washington 70.245.010; Oregon Legislative Statue 127.800 §1.01.

[68] Oregon Public Health Division, Fourth Annual Report on Oregon’s Death with Dignity Act , 2002, p. 16, available at http://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Documents/year4.pdf (accessed July 13, 2009); Oregon Public Health Division, Sixth Annual Report on Oregon’s Death with Dignity Act , 2004, p. 11, available at http://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Documents/year6.pdf (accessed July 13, 2009); and Oregon Public Health Division, Seventh Annual Report on Oregon’s Death with Dignity Act , 2005, p. 13, available at http://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Documents/year7.pdf (accessed July 13, 2009).

[69] Data taken from Oregon Public Health Division, Death with Dignity Act Annual Reports, available at http://oregon.gov/DHS/ph/pas/ar-index.shtml (accessed July 13, 2009); and Oregon Death With Dignity Act: A Guidebook for Health Care Professionals , 2008, developed by The Task Force to Improve the Care of Terminally-Ill Oregonians, convened by The Center for Ethics in Health Care, Oregon Health & Science University, available at http://www.ohsu.edu/xd/education/continuing-education/center-for-ethics/ethics-outreach/upload/Oregon-Death-with-Dignity-Act-Guidebook.pdf (accessed July 17, 2009).

[70] Physicians for Compassionate Care Educational Foundation, 2008 Annual PAS Report Press Release , March 4, 2009, available at http://www.pccef.org/pressreleases/press34.htm (accessed July 13, 2009).

[71] Hendin and Foley, “Physician Assisted Suicide: A Medical Perspective,” Michigan Law Review , p. 1621.

[72] Association of Northern California Oncologists and Medical Oncology Association of Southern California, Position Statement on Physician-Assisted Suicide and Opposition to AB 37 4.

[73] Hendin and Foley, “Physician Assisted Suicide: A Medical Perspective,” Michigan Law Review , p. 1627.

[74] See Oregon Public Health Division, Oregon’s Death With Dignity Act: The First Year’s Experience ; and also A. E. Chin, et al., “Legalized Physician‑Assisted Suicide in Oregon—The First Year’s Experience,” The New England Journal of Medicine , Vol. 340, Num. 7, February 18, 1999, pp. 577 – 83.

[75] Oregon Public Health Division, Fifth Annual Report on Oregon’s Death with Dignity Act , 2003, available al http://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Documents/year5.pdf (accessed July 7, 2009).

[76] Joseph P. Shapiro, “Casting a Cold Eye on ‘Death With Dignity,'” U.S. News & World Report , March 1, 1999.

[77] Oregon Public Health Division, “Methods,” Death with Dignity Annual Reports, available at http://www.oregon.gov/DHS/ph/pas/ar-index.shtml (accessed July 13, 2009).

[79] Hendin and Foley, “Physician Assisted Suicide: A Medical Perspective,” Michigan Law Review , p. 1637.

[80] Though OPHD has no investigative authority, assisted suicide’s defenders have occasionally responded to this critique by pointing out that the annual reports detail 20 referrals made to the Oregon Board of Medicine and one referral to the Board of Pharmacy. But no reports suggest that any disciplinary action was ever taken. Such referrals are made when physician-completed questionnaires or interviews involve minor paperwork irregularities such as “incorrectly completed report forms” or “an incomplete written consent.” Yet these referrals do not constitute a meaningful investigation or a true safeguard, as they depend entirely on self-reporting; they address very minor irregularities, and there has not been disciplinary action. Oregon’s second report acknowledges this problem, noting, “Under reporting and non-compliance is thus difficult to assess because of possible repercussions for noncompliant physicians reporting to the division.” Oregon Public Health Division,  Oregon’s Death with Dignity Act: The Second Year’s Experiences .

[81] Oregon Department of Health Services News Release, No Authority to Investigate Death with Dignity Case, DHS Says , March 4, 2005, available at http://www.oregon.gov/dhs/pages/news/2005news/2005-0304a.aspx (accessed July 7, 2009).

[82] Kenneth R. Stevens Jr., M.D., personal communication, July 10, 2009.

[83] Hendin and Foley, “Physician Assisted Suicide: A Medical Perspective,” Michigan Law Review , pp. 1627-1628.

[84] Revised Code of Washington 70.245.020 (2).

[85] John Ruhl and William Watts, MD, “I-1000: Prescription for Coercion, Not Freedom,” King County (Seattle, Washington) Bar Association website. John Ruhl was the president of the King County Bar Association in 2006 – 2007. William Watts, M.D., was the president of the King County Medical Society in 2007.

[86] Testimony of Dr. Katrina Hedberg, December 9, 2004, in House of Lords Select Committee on the Assisted Dying for the Terminally Ill Bill, Assisted Dying for the Terminally Ill Bill [HL] , Vol. II, p. 262, question 592.

[87] Editorial, “Living With the Dying Experiment,” The Oregonian , March 8, 2005.

[88] Hendin and Foley, “Physician Assisted Suicide: A Medical Perspective,” Michigan Law Review , June 2008, p. 1625.

[89] Daniel Callahan, “Organized Obfuscation: Advocacy for Physician-Assisted Suicide,” Hastings Center Reports , September-October 2008, p. 32.

[90] Based on data taken from Oregon Public Health Division, Death with Dignity Act Annual Reports, Years 1 – 11, available at http://oregon.gov/DHS/ph/pas/ar-index.shtml (accessed July 13, 2009).

[91] Testimony of Hedberg in House of Lords Select Committee on the Assisted Dying for the Terminally Ill Bill, Assisted Dying for the Terminally Ill Bill [HL ] Vol. II, p. 256, questions 566-567, and p. 262, question 591.

[92] Letter from Barbara Glidewell, included in testimony transcript, House of Lords Select Committee on the Assisted Dying for the Terminally Ill Bill, Assisted Dying for the Terminally Ill Bill [HL ] Vol. II, p. 268, number 3; p. 270, question 623; p. 275, question 653.

[93] Dr. David Jeffrey, Winston Churchill Fellow, 2006, “Physician-assisted suicide v Palliative Care: a Tale of Two Cities,” available at http://www.pccef.org/articles/PCCEF_June07_posting.pdf (accessed July 13, 2009).

[94] “ Oregon Death With Dignity Act: A Guidebook for Health Care Professionals . See Chapter 8, “The Role of Other Health Care Professionals,” p. 4; and Chapter 7, “Attending Physician and Consulting Physician,” p. 10.

[95] Witnesses’ testimony was published in House of Lords Select Committee on the Assisted Dying for the Terminally Ill Bill, Assisted Dying for the Terminally Ill Bill [HL ] Vol. II, pp. 352-353, Question 1058.

[96] Testimony of Hedberg, House of Lords Select Committee on the Assisted Dying for the Terminally Ill Bill, Assisted Dying for the Terminally Ill Bill [HL ] Vol. II, p. 267, question 621.

[97] On March 11, 2007, a Los Angeles Times story described David Bradley, a man with esophageal cancer, who moved to Oregon from New Mexico, and reportedly underwent assisted suicide in summer 2005. The lethal substance was poured into his feeding tube. Lauren Kessler, “The End in Two Acts,” Los Angeles Times , March 11, 2007.

[98] Kenneth R. Stevens, Jr., M.D., personal communication, July 8, 2009; information on lethal drugs based on data taken from Oregon Public Health Division, Death with Dignity Act Annual Reports.

[99] See, for example, Hugh Gallagher, By Trust Betrayed: Patients, Physicians and the License to Kill in the Third Reich (St. Petersburg, FL: Vandamere Press, 1995) andthe work of Richard (Dick) Sobsey on maltreatment and killing of children with disabilities, including “Exceptionality, Education, and Maltreatment,” Lawrence Earlbaum Associates, Inc., 2002, available at http://www.childinfo.org/files/childdisability_Sobsey2002.pdf (accessed July 7, 2009) and “Murder and Social Endorsement, Part II,” International Coalition on Abuse & Disability, available at http://icad.wordpress.com/2008/12/03/murder-and-social-endorsement-part-ii/ (accessed July 8, 2009).

[100] Association of Northern California Oncologists and Medical Oncology Association of Southern California, Position Statement on Physician-Assisted Suicide and Opposition to AB 37 4. The position statement is in part discussing JH Groenewoud et al., “Clinical Problems With the Performance of Euthanasia and Physician-Assisted Suicide in the Netherlands ,” New England Journal of Medicine , Vol. 342, 2000, pp. 551 ­– 556.

[101] Physicians for Compassionate Care Educational Foundation, 2008 Annual PAS Report Press Release .

[102] H. Rex Greene, M.D., personal communication, March 11, 2009.

[103] New York State Task Force on Life and the Law, When Death Is Sought: Assisted Suicide and Euthanasia in the Medical Context , 1997 Supplement.

[104] Both euthanasia and assisted suicide have been widely practiced in the Netherlands since 1973, although they were against the law until 2002. The Dutch situation between 1973 and 2002 was an outgrowth of a series of court decisions and medical association guidelines, beginning with a 1973 District Court case in which Geertruida Postma, a Dutch physician, was convicted of the crime of euthanasia after she ended the life of her seriously ill mother. See Nederlandse Jurisprudentie 1973, no. 183, District Court of Leeuwarden, 21, February 21, 1973; translation in Walter Lagerway, Issues in Law and Medicine ,Vol. 3, pp.  429, 439 – 42, 1988. Her admission that she had given her mother a lethal injection seemed calculated to force public and legal reconsideration of the laws against assisted suicide (Penal Code of the Netherlands, §294) and euthanasia (Penal Code of the Netherlands, §293). While finding Dr. Postma guilty of the crime of mercy killing that was punishable by imprisonment for a maximum of 12 years, the court imposed a one-week suspended sentence and a week’s probation. The Dutch court relied heavily on expert testimony by the District’s medical inspector who set forth certain conditions “under which the average physician thought euthanasia should be considered acceptable.” Inclusion of those conditions formed the basis for subsequent acceptance of euthanasia and assisted suicide in the Netherlands. The guidelines required that the patient must be considered incurable and experiencing subjectively unbearable suffering; the request for termination of life should be in writing; and there should be adequate consultation with other physicians before death could be induced. See Carlos Gomez, Regulating Death: Euthanasia and the Case of the Netherlands (Old Tappan, NJ: Free Press , 1991), p. 30. Other cases followed, each widening the boundaries and further liberalizing the conditions under which euthanasia and assisted suicide, although remaining illegal, would not be punished. Among the cases was the Alkmaar case ( Nederlandse Jurisprudentie 1985, no. 106) in which a woman died after requesting death because “her advancing age and physical condition caused her to be dependent on others, thus leading to psychological suffering.” The case gave rise to the 1986 decision by the Hague Court of Appeals that recognized “psychic suffering” and “potential disfigurement of personality” as grounds for induced death. The courts have also exonerated physicians who assisted in the suicides of a young woman with anorexia nervosa (Amelo, Tijdschrift voor Gezondheidsrecht , 1992, No. 19) and a woman who was depressed over the death of her two children and the failure of her marriage (Assen, Nederlandse Jurisprudentie 1994, No. 656). This discussion is drawn from the International Task Force on Euthanasia and Assisted Suicide, Assisted Suicide & Death with Dignity: Past, Present & Future—Part III, International Perspective , available at http://www.internationaltaskforce.org/rpt2005_3.htm (accessed July 13, 2009). For additional discussion of these and other cases, see Gomez, Regulating Death ; I .J. Keown, “The Law and Practice of Euthanasia in the Netherlands,” Law Quarterly Review , Vol. 108, 1992, pp. 51 – 52; Herbert Hendin, Seduced by Death: Doctors, Patients, and Assisted Suicide (New York: W.W. Norton & Co., 1997); and Jonathan T. Smies, “The Legalization of Euthanasia in the Netherlands,” Across Borders International Law Journal , Vol. 7, 2004.

[105] “Doctors had reported that a total of 2,146 people were euthanised and 152 died in assisted suicides in 2008, while in 33 cases there was a combination of the two practices.” See “Dutch Court Jails Euthanasia Group Chairman For Aiding Suicide,” Expatica.com , May 30, 2009, available at http://www.expatica.com/nl/news/dutch-news/Dutch-court-jails-euthanasia-group-chairman-for-aiding-suicide_53107.html# (accessed July 13, 2009).

[106] Hendin, Suicide, Assisted Suicide and Euthanasia: Lessons From the Dutch Experience , Testimony Summary.

[107] Hendin, “Commentary: The Case Against Physician-Assisted Suicide: For the Right to End-of-Life Care,” Psychiatric Times .

[108] “The most alarming concern has been the documentation of several thousand cases a year in which patients who have not given their consent have their lives ended by physicians. A quarter of physicians stated that they ‘terminated the lives of patients without an explicit request’ from the patient. Another third of the physicians could conceive of doing so.” Ibid.

[109] The following table demonstrates the steadily increasing numbers of reported lethal prescriptions and deaths under Oregon’s assisted suicide law.

Eleven-year Breakdown of Reported Oregon Requests for Lethal Prescriptions and Reported Assisted Suicide Deaths from Oregon’s Annual Reports

Total Reported Lethal Prescription Recipients: 627

Total Reported Deaths After Lethal Drug Administration: 401

Total Reported Deaths from Terminal Illness Within One Year of Receiving Prescription: 162

Total Reported Alive Within Year of Receiving Prescription: 101

• Annual reports note that death total includes patients who received prescriptions in previous years.

[110] Ezekiel J. Emanuel, Elisabeth R. Daniels, Diane L. Fairclough, et. al, “The Practice of Euthanasia and Physician-Assisted Suicide in the United States: Adherence to Proposed Safeguards and Effects on Physicians,” Journal of the American Medical Association , Vol. 280, No. 6, August 12,1998, p. 512; andDerek Humphrey, Letter to the Editor, New York Times , December 3, 1994.

[111] Daniel Bergner, “Death in the Family,” New York Times Magazine , December 2, 2007, available at 02suicide-t.html?_r=2&adxnnl=1&oref=slogin&adxnnlx=1197327386-QFZ8VR5Wz/XiMRmZOcX3zA (accessed July 13, 2009).

[112] Paul Longmore, “The Resistance: The Disability Rights Movement and Assisted Suicide,” p. 195.

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Why assisted dying should remain illegal

Michael Wenham was grateful that the option of assisted dying wasn’t available to him when he had a frightening diagnosis. Plus letters from Charles Harris and Alison Watson

Dame Esther Rantzen has done the country yet another service in raising the issue of assisted dying again ( Esther Rantzen ‘considering assisted dying’ if cancer treatment fails, 19 December ). As someone who experiences the “intolerable suffering” of a prolonged incurable disease, I believe we should be far less scared of talking about the taboo subject of dying.

I well remember the day when, after a year of tests, the consultant confirmed that I had “a motor neurone disorder”. I knew what that meant, as it was the year that Diane Pretty’s case to allow her husband to help her take her own life, because she had motor neurone disease, was hitting the headlines. I asked the doctor how long he thought I had left. “Everyone’s different. Let’s wait and see.” The prospects seemed bleak. I anticipated one last Christmas with my family.

In the event, my worst fears weren’t realised; my diagnosis was refined to primary lateral sclerosis, a slowly developing form of MND. Twenty-two years later, I’m still alive and able to find hope and fulfilment in my very restricted life. Day to day, I’m totally dependent on my wife and carer from dressing to bedtime. I occasionally have falls, choke when swallowing, and my speech is barely intelligible. However, my quality of life is enhanced by a team of health professionals who are excellent in this area.

Looking ahead, I don’t wish to hasten my death, and I am grateful that, thanks to the law, I couldn’t be tempted to choose an early death on my first frightening diagnosis. As it should, the law provides a vital safeguarding function. So I have real reservations about any proposals that seek to legalise assisted suicide in the future. Michael Wenham Wantage, Oxfordshire

It’s certainly true that there is a danger of abuse with assisted dying, as Katia Lom says ( ‘When life becomes intolerable, I want out’: Britons’ views on assisted dying. 22 December ), as well as putting pressure on already overworked doctors, but there are potential solutions.

One strong contender is to add a new division to the Office of the Public Guardian, which oversees power of attorney. My wife and I have taken out lasting power of attorney in case of future need, to cover both finance and health.

It would not be difficult to devise a similar legal document, to be drawn up in advance, to cover assisted dying: a “lasting power of extinction”. If enacted, it would need the approval of a third party, perhaps delegated by the Office of the Public Guardian, whose job would be to ensure that no pressure was being put on the subject for financial or other reasons. Charles Harris London

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Why Euthanasia Should not be Legalized

A Reflection on the Dutch Experiment

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Part of the book series: International Library of Ethics, Law, and the New Medicine ((LIME,volume 12))

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The experience of the Netherlands continues to be cited as illustrative of the euthanasia debate that is going on in many countries. The parliamentary debates on the legalization of euthanasia (November 2000 in the Second Chamber and April 2001 First Chamber) have drawn a lot of international attention. But, before this legalization in the Penal Code this country had adopted a legal regulation of euthanasia and, before and after that, extensive surveys into the practice of euthanasia had been carried out. The fact that the Dutch example is cited both by those who favor the legislation of euthanasia and those who reject it demonstrates that empirical data in themselves do not settle an ethical or juridical issue.

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Jochemsen, H. (2001). Why Euthanasia Should not be Legalized. In: Weisstub, D.N., Thomasma, D.C., Gauthier, S., Tomossy, G.F. (eds) Aging: Decisions at the End of Life. International Library of Ethics, Law, and the New Medicine, vol 12. Springer, Dordrecht. https://doi.org/10.1007/978-94-015-9682-4_5

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• Why We Should Not Legalize Euthanasia

The Foundational Ethical Principle Obliging Us To Protect Life Must Be Translated Into a Concrete Norm

Fr. Place is research theologian for the Curia and counsel for policy development, Archdiocese of Chicago. This article is based on his talk at the 1992 Frank M. Norfleet Forum for the Advancement of Health, Memphis.

The euthanasia debate is really the backdrop for a discussion within our society about the very nature of human life and meaning. Because the origin of life is in God, human beings do not have dominion over life but are stewards of life.

The powerful combination of sanctity and stewardship is expressed in the foundational ethical principle. This principle says that no person has the right to directly take innocent human life and in fact there is a positive obligation to nurture and protect life.

In our secular society there is a need to develop a "natural" metaphysic of sacredness. Such a metaphysic can serve as bedrock from which a foundational principle can be developed and then applied in concrete moral norms. It can show that life contributes to the full dignity of the human person. For this perspective to be effective in countering the movement to legalize euthanasia, this sense of integral wholeness of human personhood must be demonstrated in a convincing manner. It can be because a dualistic philosophical bias has been found wanting by Western culture.

We must arrive at what ethicists would call concrete norms that guide individual choices. At issue is how we translate our foundational principle—Do not directly attack innocent human life—into a concrete norm when confronted with the possibility of death.

Some persons question whether the concrete norm opposing euthanasia should be a matter of public morality. To answer this question, we must turn to our foundational principle. As a society, we must ask ourselves, How "sacred" is life? Will that natural sense of awe about life, that natural desire not to be vulnerable, be enhanced or threatened by making euthanasia legal?

Euthanasia has become the ethical issue of the 1990s and the focus of some of our most controversial public policy questions. I oppose the legalization of euthanasia. But we must do more than simply disagree with its proponents. It is possible, using the belief structures of the Judeo-Christian tradition and other reflections, to develop a persuasive understanding of human life that can serve as the foundation for an ethic that would oppose the legalization of euthanasia.

Although voters in California and Washington State have rejected assisted-suicide initiatives, the euthanasia debate will continue. Religion serves a vital role in this public policy discussion. But I see the euthanasia debate as symptomatic of a much more profound cultural discussion on the nature and meaning of human life. Certain foundational principles, which can be formulated in both religious and secular terms, can guide the opposition to euthanasia.

Religion and Public Policy Persons involved in the euthanasia debate are often concerned about the role of religion. Many people are concerned that participation by religious leaders is an inappropriate attempt to impose a particular religion's morality on society. But the constitution protects our nation's religious pluralism and ensures that a person who practices a religion or a person who practices no religion will not be excluded from participating in public policy development. Such participation, however, is based on two distinctions:

• The distinction between civil law and morality. Although our legal tradition is rooted in moral principles, "the scope of law is more limited and its purpose is not the moralization of society." 1 Everything that people of good will consider to be morally wrong need not be made illegal. This should only happen when the mutually agreed-on demands of the public good or the public order require it.
• The distinction between public moral questions and private moral questions. Something is a matter of public morality if it affects the public order of society. Catholic thinker John Courtney Murray defined public order as encompassing three goods: public peace, essential protection of human rights, and commonly accepted standards of moral behavior in a community. As a general principle, the domain of law and public policy is public morality, not private morality.

Thus religious leaders must be circumspect when they speak outside their congregations. Some areas of religious belief and practice are not appropriate matter for legislation. Religious leaders should speak out, however, on matters pertaining to public morality. In a pluralistic society religious leaders are as free as other citizens to participate in the public discussion that seeks to build consensus on what constitutes public morality. Card. Joseph Bernardin of Chicago has suggested that when religious leaders do participate in such public dialogue, they must translate their religious beliefs or philosophical assumptions "into commonly agreed upon language, arguments and categories before they can become the moral or ethical foundations for key public policy choices." 2 He adds:

A rationally persuasive case must be made that an action violates the rights of another or that the consequences of actions on a given issue are so important to society that the authority of the state ought to be invoked through public policy or civil statute, to govern personal and group behavior. Obviously, in a pluralistic society, arriving at a consensus on what pertains to public policy is never easy. But we have been able to achieve such consensus in the past by a process of dialogue, decision making and review of our decisions.

In accepting Card. Bernardin's challenge, I will explain why the legalization of euthanasia would violate the public order of our society and therefore should not be allowed. Persons who propose the legalization of euthanasia must be held to the same standard: They must demonstrate how such a change of public policy would not adversely affect public order.

The Cultural Context Although euthanasia is not new in Western culture, it is evident that euthanasia has not been acceptable practice within U.S. culture or our civil laws. Only in the past few years has euthanasia become a matter of public discussion and concern. The reasons for this growing openness to euthanasia are many, including the advancements of medical technology that have made it possible to maintain and extend human life as never before. Clearly, the sense of powerlessness and the fear of needless pain often associated with such advanced forms of treatment have been practical reasons for the advancement of the euthanasia movement. However, deeper reasons exist for this euthanasia phenomenon—reasons that are cultural or philosophical.

Underlying Assumptions Harvard's Arthur J. Dyck has identified what he considers to be the underlying presuppositions of an ethic of euthanasia. They are as follows:

• That an individual's life belongs to the individual to dispose of entirely as he or she wishes;
• That the dignity that attaches to personhood by reason of the freedom to make moral choices demands also the freedom to take one's life;
• That there is such a thing as a life not worth living, whether by reason of distress, illness, physical or mental handicaps, or even sheer despair for whatever reason;
• That what is sacred or supreme in value is the "human dignity" that resides in man's own rational capacity to choose and control life and death. 3

Obviously, one might disagree with some of Dyck's characterizations, but I suggest that he has captured, in a general sense , the presuppositions of the euthanasia movement. And there is much to be said for these presuppositions. For example, they make us aware that values exist beyond those of physical survival. Similarly, they force us to realize that death is not the greatest harm which can befall a person.

Assumptions' Weaknesses Nevertheless, weaknesses are inherent in these assumptions. Rev. Richard M. Gula, SS, identifies three:

• They are arbitrary in that they identify a few values to define the significance of human life and fail to put them in the context of a full spectrum of human values and their consequences.
• Taken as a freestanding composite, they are too risky. It is not self-evident why their application could not be extended to the most vulnerable members of society such as the elderly and the handicapped.
• They erode the "character of a helping community of trust and care." 4

Disagreements regarding the end of life choices open to dying persons reflect non-moral assumptions about the source of meaning and good in human life; the significance of suffering and death in human experience; the relation between dependency, dignity and control; the moral character of caring relationships; and the nature of the human self. 5

The euthanasia debate is really the backdrop for a discussion within American society about the very nature of human life and meaning. Although societies seldom choose to engage such fundamental questions in their abstract form, we must not lose sight of the fact that we are discussing more than whether euthanasia should be legalized.

Argument Against Euthanasia For Catholics (indeed for many Christians), at the center of such a discussion on the nature of human life and meaning is the question of the sanctity of human life. For the believer, God is the origin of all life and the sustainer of all life. For that reason human life has a dignity greater than the sum of life's parts. In a sense this dignity is not intrinsic to the human person. Human dignity is not conferred by one's actions, by the judgments of others, or by the fiat of law. Rather, it is conferred by God. Intimately associated with the concept of sanctity is an awareness that, because the origin of life is in God, human beings do not have dominion over life but are the stewards of life, which is a gift from another.

The Foundational Ethical Principle The powerful combination of sanctity and stewardship is expressed in the foundational ethical principle. This principle says that no person has the right to directly take innocent human life and, in fact, we have a positive obligation to nurture and protect life. This same ethical principle inspired religious leaders and the faithful to participate in the civil rights movement of the 1950s and 1960s, raised citizens' concern about the morality of nuclear warfare, enlightened the discussions on the manner in which the war against Iraq was conducted, and now motivates the drive against the legalization of euthanasia. This foundational ethical principle is the keystone, if you will, of a consistent ethic of life.

Many persons might suggest that this perspective on the sacredness of life is no longer valid for a large number of Americans. They argue that traditional Judeo-Christian symbols and values are no longer adequate to serve as a substratum for the development of a consensus or vision to guide the evaluation of the needs of public order. Some Americans believe we should replace that substratum with one similar to Dyck's presuppositions. If this were to happen, the legalization of euthanasia would be easily justified.

As a committed Christian, I disagree with such a contention. But it is not enough to simply disagree. As Card. Bernardin has proposed, we must offer a positive vision that opposes euthanasia, one secular America will heed.

A Positive Vision Several persons have attempted to develop such a vision. One of the more persuasive contributions is that of Edward Shils. Shils proposes a natural metaphysic that supports the sacredness of life. Sacredness for him is not rooted in a transcendent creator but "in the primordial experience of being alive, in the fear of extinction, in the spontaneous revulsion to contrived interventions and unnatural destruction of human life, and in the sense of awe one feels before one's own vitality and that of the species." 6

For Shils, sanctity of life does not come from outside life but from the experience of life itself. On a pragmatic level, Shils and others argue that unless sacredness of life is acknowledged, the entire structure of human values and rights will collapse. This natural metaphysic of sacredness, much as the Christian understanding, serves as bedrock from which a foundational principle must be developed and then applied in concrete moral norms. The process of developing such a principle is complex, and there is room for disagreement. For example, one could hold to a natural understanding of the sacredness of life and still support euthanasia.

Developing a Foundational Principle Instrumental Good To develop a foundational principle, it is necessary to discuss the question, Is human life and its natural sacredness only an instrumental good necessary for personal fulfillment? Or is it something more? Many euthanasia supporters view life as an instrumental good. In other words, the living body is a means to achieve the true end or purpose of being, which is personal activity. Bodily life provides the wherewithal for personal fulfillment. And when the personal component (the ability to control life through rational choice) is missing, the person has no obligation to continue living. Bodily living has lost its purpose.

The Body-Person Distinction In response to this dualistic distinction between body and person, Fr. Gula proposes an anthropology that "regards the human being as one. . . . Bodily life participates in the integrity of the human person as a substantive good of human life, and human life is the life of a personal being." 7 In other words, life is not only a condition necessary for a person to achieve other values, it is intrinsic to being human, and it contributes to the full dignity of the human person. This sense of an integral wholeness to personhood must be demonstrated in a convincing manner. And I believe it can be, because a dualistic philosophical bias has been found wanting by Western culture.

A Community of Trust and Care Another area that must be addressed is the nature of the community in which human life is situated. As Fr. Gula notes, "If we focused our attention solely on the dying patient and extended our vision no further, then perhaps we might be able to make a case for euthanasia. But if we are socially conscious so that our vision encompasses the caring community as well, then we can make a better case against euthanasia." 8

In this context Stanley Hauerwas has argued that an essential aspect of human experience is the need and the desire to trust the community in which one lives. If life is sacred, then that community of necessity will be a community of trust and care. Euthanasia would be unacceptable because it means the community has abandoned its responsibility to care and comfort. Euthanasia fails to show to dying persons what Hauerwas calls "the continuing trustworthiness of their existence." 9

In a similar fashion one must evaluate euthanasia's effect on the life of the community. Because we are social by nature, we are connected to others. Our individual choices have an impact on others. We must keep in mind that:

Actions reflect and give expression to certain values and beliefs. The more people perform a certain action and the more frequently they perform it, the more those values and beliefs are expressed. The effect is cumulative and eventually influences the moral tone and character of a society. . . . [And] as a result, we need to be concerned not only with individual welfare but also with societal welfare. 10

Clearly, as Robert Bellah and others have demonstrated, the relationship between individual and community is an issue of fundamental importance to our society. 11 An increased sense of isolation and alienation affects many in our midst because we have allowed the individual to be separated from community. In a sense euthanasia can be seen as the logical conclusion of the existential angst of the person alienated from self and community.

Setting Concrete Ethical Norms If we are able as human beings and as a society to agree on this foundational principle, it is then necessary to apply it to concrete ethical issues. We must arrive at what ethicists would call concrete, or material, norms that guide individual choices.

Historically, we have done this. For example, we believe it is wrong to take the life of another person except in self-defense. In simple, straightforward terms we say it is wrong to murder. As a society, we accept this concrete norm as true whether its source is the decalogue or a secular ethic of human sacredness. And we affirm this concrete norm with such conviction that we teach it to our young and expect them to make it part of their code of personal or private morality. We are offended or frightened when we see it violated, especially in senseless or wanton killing.

We also have come to the conclusion that the consequences of the violation of this concrete norm are so great that they threaten the well-being of society. In other words, murder threatens the good of the public order. The public peace is shattered, and the protection of human rights compromised. For these reasons the concrete norm "Do not murder" has been translated into public law. It is understood to be part of the public morality.

At issue, then, is how we translate our foundational principle—Do not directly attack innocent human life—into a concrete norm when confronted with the possibility of death. I could argue that the earlier discussion about the natural "sacredness" of life, the integrity of personhood, and the trustworthiness necessary to sustain human community can be drawn together to support a concrete moral norm saying that it would be wrong to directly take or assist in the taking of human life to relieve pain or suffering. Although originally grounded in a Christian foundational principle, this concrete norm opposing euthanasia now has a nonsectarian basis, like the concrete norm regarding murder. It can, if you will, be called a human or a natural norm.

Although many persons might agree this is a worthy concrete norm to guide the development of personal morality, they would question whether it is so exceptionless, or the consequences of its violation so significant, as to also make it a matter of public morality. For this reason, some are questioning the validity of the existing societal presumption—namely, they question whether the concrete norm opposing euthanasia should be a matter of public morality.

To answer this question, we must return to the grounding for our foundational principle. As a society, we must ask ourselves, How "sacred" is life? Will that natural sense of awe about life, that natural desire not to be vulnerable or at risk, be enhanced or threatened by making euthanasia legal? Are enough protections available in the human community, in light of human foibles and limitations, to ensure that this practice will not make individuals more vulnerable to outside attack? In other words, will the "safe harbor" that laws against murder and euthanasia have created for human existence be enhanced or diminished? We must consider whether, as a society, we want to say that human life is but another "thing" to be used and discarded at will, like a broken toy. Is this the understanding of life we wish to celebrate as a civil society? We must ask whether we are happy living as lone rangers on the frontier of life or whether community is essential to our well-being. And if it is, what are the mutual commitments of trust necessary to support and sustain such community? Will the legalization of euthanasia enhance these commitments or detract?

Meeting the Challenge All too often the euthanasia discussion has not addressed these more fundamental issues. The image of persons dying needlessly painful deaths controlled by insensitive medical technology dominates the discussion. And I suspect many persons who might vote to legalize euthanasia are doing so out of desperation. Ironically, they view their votes as the only way to preserve the sacredness of life and community. What they fail to see is how in fact euthanasia compromises what they most deeply believe.

Card. Bernardin addressed this reality in the following terms:

It is important for us to address the sense of powerlessness which many people experience in regard to the contemporary practice of medicine. While the catch phrase "patient as person" is a helpful guide in this matter, we have to extend this concept more aggressively into the world of critical and terminal illness where the patient is the frailest and most vulnerable. We must also face our own fear of death and learn to provide for those who are dying or critically ill in a way that preserves their dignity and ennobles them. . . . In this way we can eliminate many of the legitimate concerns that may motivate people to consider euthanasia—which otherwise would be unacceptable to them and to society. 12

I agree with the cardinal. The reasoned and sophisticated arguments against the legalization of euthanasia will never be heard and the real discussion will not take place unless, as individuals and providers of healthcare, we first meet this critical challenge.

• Joseph Bernardin, "Address: Consistent Ethic of Life Conference," Consistent Ethic of Life , Sheed & Ward, Kansas City, MO, 1988, pp. 86-95.
• Joseph Bernardin, "Euthanasia: Ethical and Legal Challenges," Origins , June 9, 1988, p. 52.
• Arthur J. Dyck, "An Alternative to the Ethics of Euthanasia," as cited in Richard M. Gula, What Are They Saying about Euthanasia? Paulist Press, Mahwah, NJ, 1986, p. 169. These reflections are deeply indebted to Fr. Gula's masterful analysis of this important subject.
• Gula, p. 70.
• Courtney S. Campbell, "Religious Ethics and Active Euthanasia in a Pluralistic Society," Kennedy Institute of Ethics Journal , vol. 2, 1992, pp. 253-284.
• Edward Shils, "The Sanctity of Life," in Daniel H. Labby, ed., Life or Death: Ethics and Options , University of Washington Press, Seattle, 1968, p. 12.
• Gula, p. 97.
• Gula, p. 71.
• Ron Hamel and Edwin DuBose, "Views of Major Faith Traditions," in Ron Hamel, ed., Active Euthanasia, Religion and the Public Debate , Park Ridge Center, Chicago, 1991.
• Robert N. Bellah, Habits of the Heart: Individualism and Commitment in American Life , HarperCollins, New York City, 1986.
• Bernardin, "Euthanasia," p. 56.

HOW THE CATHOLIC TRADITION VIEWS EUTHANASIA

In the Catholic tradition euthanasia is understood "as an action or omission which of itself or by intention causes death in order that all suffering may in this way be eliminated" (Congregation for the Doctrine of the Faith, "Declaration on Euthanasia," Origins , vol. 10, 1980, pp. 154-157). Euthanasia may be voluntary or involuntary. The difference is found in the patient's intention. Voluntary euthanasia is when a patient ends his or her own life with the assistance of a care giver, or when a care giver does it at a patient's request. Involuntary euthanasia occurs when a care giver ends a patient's life without the patient's consent.

Also, euthanasia may be either active or passive. Active euthanasia occurs when death is induced through an external method, such as Dr. Jack Kevorkian's machine. Passive euthanasia occurs "if the cause of death is present within one's body, but is not resisted when there is a moral obligation to do so" (Kevin O'Rourke, "Assisted Suicide: An Evaluation," Journal of Pain and Symptom Management , vol. 6, 1991, p. 2).

Within the Catholic theological tradition, no moral distinction is made between active and passive euthanasia. Both are described as causing the death of a person who is ill when there is a moral obligation to prolong that person's life.

Key to this ethical analysis is the assumption that there is a moral obligation to preserve and protect human life. The existence of such an obligation is relevant because, according to the Catholic theological tradition, there are times when no moral obligation exists to prolong life—namely, when the care or treatment would be futile or disproportionately burdensome. Consequently, when there is no such obligation and a person is allowed to die from a fatal pathological condition, "then the act by which one is allowed to die is not euthanasia" (O'Rourke).

This is an important point. Catholic tradition does not require that persons who are dying be kept alive needlessly. Rather, it opposes reversing a centuries-old tradition enshrined in our civil law saying that no one should directly take the life of another innocent person or assist in the taking of that life even if that person is dying or is seriously ill.

Copyright © 1993 by the Catholic Health Association of the United States For reprint permission, contact Betty Crosby or call (314) 253-3477.

Copyright © 1993 by the Catholic Health Association of the United States

For reprint permission, contact Betty Crosby or call (314) 253-3490.

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Home — Essay Samples — Social Issues — Euthanasia — Why Euthanasia Should Not Be Allowed

Why Euthanasia Should not Be Allowed

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Published: Jan 29, 2024

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Body paragraph 1: ethical concerns, body paragraph 2: slippery slope argument, body paragraph 3: palliative care alternatives, body paragraph 4: psychological and societal impact, counterargument.

• BBC News. "Euthanasia and Assisted Suicide: What Are They and What Do They Mean?" BBC, 18 September 2019, www.bbc.com/news/world-51332355.
• DePergola, Orona, et al. "Euthanasia and Assisted Suicide in the Netherlands." BMC Medical Ethics, vol. 21, no. 71, 2020, doi: 10.1186/s12910-020-00504-w.
• Gallup. "Euthanasia." Gallup, Inc., 2021, news.gallup.com/poll/4703/euthanasia.aspx.
• Pereira, João. "Legalizing Euthanasia or Assisted Suicide: The Illusion of Safeguards and Controls." Current Oncology, vol. 17, no.2, 2010, pp. 38-45.

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Why Euthanasia Should Not Be Legal: Pros and Cons

• Category: Life , Health
• Topic: Ethical Dilemma , Euthanasia , Moral

Pages: 2 (944 words)

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