Death with Dignity: The patient’s right to chose - The case for euthanasia and assisted suicide in terminally ill patients.



1.      Introduction

2.      Origin of desires for assisted suicide and euthanasia

3.      Defining the vehicles of assisted death

4.      Legal framework of assisted suicide and euthanasia and the state of Oregon example

5.      Other safe guard and legal guideline for assisting the terminally ill with death

6.      Arguments and examples for endorsing assisted suicide for terminally ill patients: end of life options for AIDS and HIV+ patients

7.      Arguments and examples of cases against physician-assisted suicide

8.      Other associated health care issues

9.      Discussion and potential future directions

10.  Conclusion

11.  Other resource


Death with Dignity: The patient’s right to chose - The case for euthanasia and assisted suicide in terminally ill patients.



Tzuyung Doug Kou, MA.

Laura Leone.


1.      Introduction


The burgeoning world of medicine creates a hailstorm of medical, legal and ethical dilemmas.  Advances in medical technology enable individuals to counter-act and delay the inevitable fate of death, overcoming cancer, diabetes, and traumatic injury. As of 2001, the U.S. Center for Disease Control and Prevention, reports the average life expectancy for men and women within the United States to be 77.2[1] years.  In the face of such promise and medical ability lies a bitter and contentious battle over the right to die. There still exists a population of patients within this country for whom technology does not offer salvation in the form of cure. The terminal nature and the duration of certain diseases relegate patients to state of painful and greatly reduced physical capacity. Despites our advance in medical technologies, for some, the phrase “terminally ill” is applicable.  Merely labeling a patient as “terminally ill” creates problems because advocates on either side of the right to die debate differ as to the acceptable definition of terminally ill.  Two popular medical definitions of a “terminally ill” state the condition as  having an incurable or irreversible condition that has a high probability of causing death within a relatively short time with or without treatment (one year) and an incurable and irreversible disease that has been medically confirmed and will, within reasonable medical judgment, produce death within six months.[2] A wide range of degenerative diseases can fall into either category, ranging from, HIV/AIDS, Alzheimer’s disease and many forms of cancer.


For some terminally ill patients, the desire to exercise control over one’s passing is a hallmark for enabling them to die with dignity. Central to this control, however, lays assistance, whether direct or indirect, from a physician. This debate is about a patient’s right to choose death versus the state’s right to preserve life in the U.S.


This chapter seeks to develop an overview of some current ethical and legal debates.  Beginning with defining the various vehicles of assisted death, this article will present an overview of the origin of desire and the current legal framework for assisted suicide and euthanasia.  The balance of this chapter will analyze the popular arguments endorsing and rejecting the topic as well as examining existing international models for assisting terminally ill patients’ death. The act of committing suicide will not be covered in this particular chapter. It is the goal of this chapter to further the conversations and debates among public health practitioners within this country as well as in other developed and developing countries.


2.      Origin of desires for assisted suicide and euthanasia


Since the 1970s the concepts of euthanasia and physician assisted suicide are gaining more attention because of advances in modern medical technologies and increasing interest in protecting human rights. These two concepts fundamentally challenge both the medical profession and the community. From the medical prospective, these two acts could alter and harm the existing patient-physician relationship. The balance between a physician’s duty of benevolence or do no harm often conflicts with his equally important duty to respect patients’ autonomy. Within the context of this debate, those duties are further balanced against patients’ right for self-determination in healthcare decision-making. Should a patient have the right to terminate his or her life when medical conditions and suffering become unbearable and irreversible? This debate fundamentally challenges the duty of a physician to do no harm and to protect the patients’ best interests.


From a broader prospective, can physicians consider alleviation of pain and suffering through  physician-assisted suicide as the best way to perform their duty as physicians to protect the patient’s best interests at the end stage of disease? If so, how would different cultural and religious groups view such medical option? On the other hand, the decision for physician-assisted suicide could also be considered a private matter just between the physician and the patient, or a matter for society-at-large given the argument that it is the duty of a society to protect vulnerable populations. From the legal prospective, will physician –assisted suicide have any legal protection while all other forms of euthanasia are considered murder? All these are complicated and interrelated issues in any discussion of euthanasia and physician assisted suicide.


The desire for assisted suicide and euthanasia will never disappear in a small portion of the population. The question to us becomes, “how does a society consisted of various medical, legal, religious, and other backgrounds reach an acceptable guideline to address these desires?”


3.      Defining the Vehicles of Assisted Death


The debate about Physician-assisted suicide involves the use of many terms and it is therefore important to clarify the meaning of each term so as to reduce confusion. One can think of the terms as moving along a continuum beginning with suicide and ending with euthanasia.  Black’s Law Dictionary defines suicide as the act of taking one’s own life and assisted suicide as “the intentional act of providing a person with the medical means or the medical knowledge to commit suicide[3].” This definition fails to distinguish between intentional acts of assistance provided by a layperson from acts by a physician.  For purposes of this article such distinction is recognized and thus intentional acts of providing medical means by a physician are deemed physician-assisted suicide.  When a patient is in the advanced stages of terminal illness and thus unable to affirmatively act in ending their own life, assistance received by another is deemed euthanasia.  Euthanasia can be either active or passive. In contrast to passive euthanasia, where an individual fails to act to stop the suicide attempt, active euthanasia encompasses affirmative conduct such as helping a patient swallow pills or syringe injection of medicine to induce overdose. 


Within the context of physician assisted suicide or euthanasia the role of a physician as healer conflicts with his equally important role of promoting the best interests of his patient.   Certainly under the Doctrine of Double Effect one can easily imagine a slippery slope wherein pain management merely serves as a conduit for assisted suicide. As stated earlier, the Doctrine of Double Effect[4] essentially states that death, as a secondary result of managing pain is permissible and legal conduct of the physician. Put another way when a physician prescribes high doses of pain medication to a patient for purposes of managing that individual’s pain, the physician is free from any potential criminal liability if the individual then dies as a result of the high dose.  One can imagine a scenario involving a patient with pancreatic, late-stage prostate or ovarian cancer, where death is all but inevitable and the patient is experiencing excruciating pain as the disease progresses.  In this situation, the physician would be within his professional rights to prescribe extremely high doses of painkillers, even if the dose proves lethal to the patient. 


Surprisingly, the Doctrine of Double Effect finds support within Euthanasia’s staunchest opposition:  Catholic Church.  The Catholic Church’s position on death secondary to medicating for pain is one of limited acceptability.  Specifically, Catechism #2279 reads “[t]he use of painkillers to alleviate the sufferings of the dying, even at the risk of shortening their days, can be morally in conformity with human dignity if death is not willed either as an end or a means, but only foreseen and tolerated as inevitable[5].” It provides some religious backings and justifications in the debate.


4.      Legal Framework of Assisted Suicide and Euthanasia and the state of Oregon example


As terminally ill patients navigate the murky waters of their declining health and increasing dependence on others, the small happenstance of “comfort care” provides a glimmer of hope for ending the suffering and disgrace. Pain management is a universally recognized goal for terminally ill patients by their physicians, even though statistics reveal certain populations of patients to be routinely under treated for pain.  In fact, statistics reveal that 56% of outpatients with cancer and 82% of outpatients with AIDS pain are under-treated.[6]  The law accordingly recognizes the pursuit of pain management for deteriorating and painful illnesses does require increasing amounts of pain medication. Generally speaking no criminal liability attaches to a physician who provides a patient with medication sufficient to alleviate their pain even if doing so may result in death as a secondary risk. This phenomenon, termed the Doctrine of Double Effect acknowledges that a patient’s death may be hastened as a result of treating pain. 


The distinctions between acceptable and unacceptable conduct in the view of the courts turn on the intention of the physician’s prescription. A physician’s goal in prescribing high levels of medication for pain management is for the express relief of pain and suffering, not to cause the patient’s death. However in circumstances of physician-assisted suicide, the medication is in fact prescribed to facilitate the patient’s controlled death and not merely to relieve their pain.  It is this splitting of hairs that leaves both physicians and prosecutors walking the fine line between culpability and duty. Perhaps one solution lies within educating physicians about appropriate pain management as an effort to decrease the frequency and desire of physician-assisted suicide.  Better pain management during end of life care may decrease specific desires of patients to prematurely end their lives.


One physician’s story highlights these tensions. In his quest for advocacy, Dr. Timothy Quill recounts one patient’s plight, clearly highlighting the distinction between the Doctrine of Double-Effect and Physician-assisted suicide.[7]

The patient, a fifty-year old woman named Diane, is newly diagnosed with acute myelomonocytic leukemia.  After discussing the treatment options with Dr. Quill, Diane chooses to forgo treatment, instead opting to live out the remaining days of her life with her family free of therapy’s burden.  Shortly after deciding to withhold treatment, Diane expresses to Dr. Quill her desire to control the time of her own death.  As he writes, “[i]t was extraordinarily important to Diane to maintain control of herself and her own dignity during the time remaining to her.  When this was no longer possible, she clearly wanted to die.” Id.  As a physician, Dr. Quill was placed in the intractable position of choosing between providing information or direct assistance in the form of prescription’s and upholding medicine’s ethical foundation of do no harm as stated in The Hypocratic Oath.  In the end, Dr. Quill reveals his decision to tell Diane of the Hemlock Society, an organization dedicated to providing information on ending one’s life, to then have Diane return to him and request a prescription of barbiturates.  It is at this point, a prosecutor would argue, the line between Doctrine of Double Effect and physician-assisted suicide becomes hazy and unclear.  To spare her physician potential criminal culpability and professional discipline, Diane was fully willing to engage in superficial discussions about insomnia as a “medical reason” justifying the barbiturate prescription.  Dr. Quill knew how Diane planned to use the medication; moreover, he went on to inform Diane the exact ingestion quantity to commit suicide.  Diane used the medication as planned; choosing the time and place of her final hour. When she was gone, the medical examiner was notified by Dr. Quill that the cause of death was Acute Leukemia. 



Most would argue Dr. Quill’s conduct amounted to Physician-assisted suicide because he consciously and actively relayed to his patient the specific amount of pain medication necessary to induce death. This, they argue, constitutes providing “medical knowledge.”  If Diane had merely overdosed on barbiturates without the information from her physician, her death would have amounted to suicide; however, given the information imparted by Dr. Quill regarding specific dosage for specific outcomes, her death was physician-assisted suicide. Alternatively, one might argue his goal in prescribing the barbiturates was, at least facially, to assist Diane with her insomnia from which she genuinely suffered.  Had he not informed Diane how much medication she needed to induce her death, such would be an accurate statement.  However, in light of the full factual situation, such interpretation is superficial.


Currently, an individual’s liberty interests do not include a right to assistance committing suicide.  The United State Supreme Court’s decision in Washington v. Glucksberg[8] continues as the leading legal precedent for physician-assisted suicide.  Although the Court was moved by the respondents’ arguments about quality of life and autonomy, they were ultimately unwilling to alter long-standing legal traditions against suicide and assisted suicide. Concerned about abuse by such a decision, the Court cited three key State interests’ compelling a ban on physician-assisted suicide: protecting the integrity and ethics of the medical profession; protecting vulnerable groups; protecting disabled and terminally ill people from prejudice.  Id.  The Court’s decision in Washington v. Glucksberg came on the heels of an interesting and cataclysmic year in the courts for the physician-assisted suicide debate. 


Two 1996 decisions resulted in what legal analysts call a “2nd/9th split.” In 1996 the Second Circuit of the United States Court of Appeals rendered its decision in Quill v. Vacco[9] and the Ninth Circuit decided Compassion In Dying v. Washington[10] (later appealed as Washington v. Glucksberg to the United States Supreme Court). 


Although based on differing rationales, both Circuits ruled that physicians could provide assistance in death to terminally ill patients free from potential criminal liability. The Second Circuit couched its decision in Equal Protection and the Ninth Circuit in Substantive Due Process. The Supreme Court overturned both Circuit decisions.  With the exception of Oregon’s Death With Dignity Act, the right to end one’s life with the assistance of a physician remains prohibited conduct in this country. This leaves those affected individuals with two options: do nothing or commit suicide.


In the United States, the state of Oregon is the only state government that attempted to address the issues associated with physician assisted suicide. , During 1994, Oregonian’s voted to make physician-assisted suicide a legal option for the terminally ill[11].  In light of the Supreme Court’s ban on physician-assisted suicide, one may wonder how Oregon’s Death With Dignity Act (DWDA) remains on the books and in force.  Unfortunately, DWDA’s affirmative vote in 1994 was stalled that same year by a legal injunction, an order by the court preventing physician-assisted suicide from taking place, until the legal debate was resolved.  Ultimately the Supreme Court denied petition for review, leaving the decision in the hands of the Ninth Circuit Court of Appeals. On October 27, 1997 the Ninth Circuit Court of Appeals lifted the injunction, permitting physician-assisted suicide as an exercisable option for terminally ill Oregonians. The DWDA permits physicians to prescribe lethal medications for self-administration. This point is very important because the act expressly prohibits euthanasia. A physician is not allowed to administer the medications for his patient; he can only provide them with a prescription, a means of obtaining the medication. This permissive conduct is exactly what Dr. Quill did for his patient, Diane. Dr. Quill wrote the prescription for Diane’s barbiturates but it was Diane who administered the barbiturates to herself, without the aide or presence of her physician. 


After five years of implementation of the Oregon law, only 171 individuals have exercised the right under DWDA.[12] Of these 171 individuals, 97% were Caucasian, 71% were over the age of 65 and 79% had cancer. Id.  Moreover, 61% of individuals had at least some college education. These statistics appear to indicate the fallacy of society’s concerns about potential abuse of process and possible manipulation of vulnerable populations.  The demographics reveal an educated elderly Caucasians with devastating illness choosing to end their life. To further understand the possible explanation of their choice, one need also examine the type of health insurance of these 171 individuals utilize. Certainly, concern arises for patients, elderly or otherwise, who may feel pressured to end their lives because they perceive themselves as economically burdensome to their children and family. 86% of patients were enrolled in Hospice.[13] Only 1% of those utilizes DWDA did not have insurance while 61% had private insurance and the remaining 38% were covered either by Medicare or Medicaid.  Based on physician interviews, 145 patients (87%) indicated the primary concern was loss of autonomy.  Id. Within this population the financial implication accounted for only 2% of individuals.  There seems to an existing connection between the burden of care on family members and DWDA in 36% of the patients. 


Oregon has gone to great lengths to create a framework for assisting terminally ill residents with death while protecting against abuse of process and misuse.  The five-year statistics appear to indicate success in this endeavor.  For some, however, even such a well-designed system is unacceptable.  Those against PAS point to the potential physiological complications associated with barbiturate overdose, including spasms and regurgitation along with prolonged delay of death.[14]  These are legitimate concerns.  Oregon’s five-year rates indicate that 7 of 171 patients experienced regurgitation after medication ingestion and range of death after ingestion went from 4 minutes to 48 hours.  Proponents of PAS would counter that 4% regurgitation is a nominal risk of adverse event when taken on balance. 


Although the U.S. legal system is currently unwilling to sanction physician assisted suicide across board, one sees from stories such as Dr. Quill’s and state programs such as Oregon’s DWDA that perhaps a subtle shift in ideology is occurring.  The five-year data from Oregon supports strong inferences that physician-assisted suicide has a role to play in end of life care for certain populations while seemingly protecting against the abuses its adversaries so loudly protest will occur. In addition, many interactions between patient and physician may go largely unnoticed by law enforcement.  Had it not been for his brave account of Diane’s life, Dr. Quill’s actions and knowledge would have gone completely unknown to everyone.  Operating within the statutes as they currently exist does not completely prohibit physicians from in manners similar to Dr. Quill, but rather, it makes their actions significantly more risk intensive.  Criminal sanctions for assisting a patient’s suicide rest entirely with local prosecutors, known as prosecutorial discretion.  It is the unknown variable of prosecutorial discretion which makes conduct like Dr. Quill’s prohibitive and undesirable to physicians.  The bottom line, therefore, is that this nation has not progressed to point where policy will condone this behavior, nor is it on the warpath to challenge and inquire into the conduct of each physician whose patient dies from a terminal illness.


5.      Other  International Models for Assisting the Terminally Ill with Death


In many countries, assisted suicide or any act of counseling, aiding, or abetting suicide are prosecutable under the criminal laws and qualify as murder (25). As more groups and organizations advocate decriminalization of physician-assisted suicide or medical euthanasia for terminally ill and mentally competent adults the controversies of this issue will gain more attention (25).


The Netherlands presents a unique cultural and social framework for the debates on euthanasia and physician assisted suicide related issues.  Dutch society is described as progressive and generally compassionate, with significant religious and cultural diversities among their population of 16 million.  Physicians are also family friends of their long-standing patients who make frequent house calls and are generally more familiar with specific circumstances that may provide further insights when a request for euthanasia is made. The patient and physician relationship is unique compared to the physician and patient relationship in other developed countries (23, 25).


The majority opinion among physicians and health lawyers in the Netherlands is that euthanasia is not a normal medical procedure even though it could be administered by a doctor. Perhaps it is a decision for the society instead of resting the responsibility on the medical professionals (23, 25, 28, 30).


Any case of euthanasia or physician assisted suicide has to be reported according to the Burial Act of Dutch Law. A request for either option can also be made in a living will and has to meet all the legal requirements.  A living will, or health care power of attorney, is a comprehensive statement of desired medical treatment that may be administered after the patient is no longer legally competent to make their own medical decisions.  These documents may be drawn up at any time after an individual reaches legal adulthood. Each act of euthanasia is evaluated by regional committees (25, 30, 31). If the committees do not find any abnormality or deviation from the regulations, the physician who administers the act of euthanasia will not be prosecuted by the penal code. So how does the law apply to incompetent individuals or minors? These are the two special conditions and problems debated in the Dutch Parliament. Under the current law, euthanasia for patients between ages 12 and 16 are not allowed against the will of their parents, even when the doctor is convinced that the suffering of the patient could no longer be tolerated. So far, there has not been any reported case where euthanasia was done against the will of the patient or a minor’s parents (25, 30). There were disagreements between doctors and parents, but were generally resolved after extensive discussions between the doctor, the parents, and the patient. Currently, euthanasia for patients who are minors could be done only with parental consent. In the case of incompetent patients, the Dutch law allows the living will to represent patient autonomy. It is also under the assumption that the living will was written after long consideration by the patient.


The Netherlands, the Northern Territory in Australia, and Switzerland are a few other countries or states with legalized systems of euthanasia and/or physician assisted suicide. A similar trend is emerging and in progress in many other countries (29, 31, 35). In Belgium, 81.8% of the general public is in favor of euthanasia. Currently, the Belgium government has a law of euthanasia in the making. Physician assisted suicide is also now permitted in Switzerland. 79% of France’s citizenry, 64% of whom are Roman Catholic, now support euthanasia and are arguing that euthanasia should be allowed under exceptional circumstances when certain conditions are met (29). In Germany, around 70% of the public is in favor for euthanasia when an incurably ill patient makes such request. In Spain 67% of the public is in favor (29). The increasing acceptance of euthanasia and physician assisted suicide will continue to bring such end-of-life issues out in the open and will only encourage more open discussions between various medical professionals and the general public. 


Since the law was implemented in the Netherlands, the number of requests for physician assisted suicide and euthanasia have stabilized. Euthanasia and assisted suicide occur in 2.7% of all deaths which is higher than the data from the state of Oregon and Australia (41). The new focus in the Netherlands is on how to improve the decision-making process associated with these requests (39).


6.      Examples and discussion on assisted suicide within the context of HIV/AIDS


In the Netherlands, Switzerland, the northern territory of Australia, and the state of Oregon in the United States have laws allowing for medical euthanasia and/or physician assisted suicide (23, 27, 30). In these particular states and countries, euthanasia or physician assisted suicide is a valid medical option when the patient and the health conditions meet a strict set of criteria. Perhaps HIV and AIDS patients are the best group of people to benefit from such availability. Despite all the treatment options and drug regimens, the patient’s end stage outcome is almost universal. There are also the financial problems associated with cost of treatment and care and the availability of the expensive drug treatments (37). Given the knowledge that the infections will eventually overwhelm the patients’ compromised immune system and lead to death, perhaps HIV and AIDS patients should have the right to utilize euthanasia or physician assisted suicide as the last option to maintain some degrees of control over themselves and their health conditions? What are the ramifications for such decisions and reasoning? All these are complicated end-of-life decisions that physicians and patients will have to eventually come to an agreement.


Currently, there is draft legislation in South Africa to allow physician’s active participation to end the life of terminally ill and mentally competent patients (40). With the increasing number of HIV+ and AIDS patients, one can argue for the validity and necessity of such legislation as a possible outcome for those patients.


With the availability of HIV antiviral treatment, HAART, the morbidity and mortality data as in the occurrence of specific opportunistic infections has gone down among HIV and AIDS patients. Some studies proposed that HAART significantly improved the quality of life and maintenance of functioning and well being for the HIV positive and advance AIDS patients. The effectiveness of HAART could also impact the need and availability of palliative care, and the discussion on desire for euthanasia and physician assisted suicide for end stage AIDS patients (33).


So what is the financially burden for such AIDS treatment options? In a published French study, it documented that the mean cost of HAART and other related cares was estimated at 3,370 euros per person-month during the initial months around the occurrence of an AIDS-defining event; at 1,750 euros per person-month during the period spanning from 2 months after the diagnosis of specific AIDS-defining event to 1 month prior to death; and at 13,010 euros per person-month in the final month prior to death (22). If clinical management of HIV infection began at a CD4 cell count of 378/microl, the discounted lifetime cost of treating an HIV-infected French patient was estimated at 214,000 euros. The undiscounted costs were 309,000 euros over a projected life expectancy of 16.4 years (37).


Currently, there are emerging possibilities that can totally discredit using financial burden as a legitimate line of reasoning for euthanasia request. If AIDS and HIV+ are considered as a crisis on a national and international level, it is possible for countries legally producing generic version of expensive patented drug can greatly reduce the cost for AIDS or HIV+ treatment and prevention. The availability of cheaper version of AIDS and HIV treatment can reduce the possibility of financial burden heavily influencing the decision making process. Despites such possibility, there will always patients who can’t overcome the other barriers to obtain adequate health care. The financial burden will continue to be a factor influencing the decision making process. 


Within the context of physician and patient relationship, the amount of data is minimal when it comes to physician assisted suicide and euthanasia specifically for the end stage AIDS patients as a therapeutic option. Despite the success of various AIDS treatment regimens in prolonging the life of HIV and AIDS patients, it remains an incurable and irreversible illness that will eventually become unbearable (32). In a European survey on HIV/AIDS patient attitudes and opinions on end-of-life decisions, more than half of the respondents in most countries had, at one time or another discussed the possibility of purposely terminating their own life with someone. As for the question of with whom they would have had those end-of-life discussions, only in the Netherlands the patients are more likely to discuss such topic with their physician. Some of the benefits of such openness and willingness for discussion are related to the anxiety issues. A legalized euthanasia law would reduce their anxiety over the disease and the burdens imposed on their families (29).


Needless the say the financial burden will continue to play a role when selecting therapeutic options and subsequently the end-of-life decision.  With the irreversible and universal outcome of AIDS infection along with the high cost of treatment regimens at the disease’s end stage, only open discussion between the physician, the patient and the family can ensure all aspects of the decision are discussed and understood. Doing so in this manner is necessary to minimize the bias from other motivations.


7.      The case against physician-assisted suicide


Despite the economic and philosophical arguments in favor of physician-assisted suicide, poignant and powerful arguments against legalization also exist.  Strong, long-standing religious and secular traditions against the taking of human life resonate throughout this country.  These organizations argue assisted suicide is wrong and immoral because it contradicts this primary edict regarding sanctity of life.  Others who are less religiously inclined draw distinctions between active and passive conduct.  Refusing treatment or withholding treatment is therefore classified as passive conduct.  Interestingly, this argument finds support in the courts.[15]  Physicians are permitted to withdraw life-sustaining treatment, such as hydration and respiration, from legally competent adults desiring to refuse such treatment, even though doing so will result in their death.  The distinction to note here is that without hydration or respiration, these individuals would die a natural death because the machines are seen as prolonging their life artificially.  Alternatively, terminally ill patients who induce medication to cause death are prematurely causing their life to end.  Therefore, a doctor giving a prescriptive is argued as “acting” versus withdrawing life-support seen as “passive.”  A third argument involves potential for abuse.  As noted earlier in Washington v. Glucksberg, the court and society-at-large are particularly concerned with legalizing behavior that may coerce and abuse vulnerable populations.  These vulnerable populations can include people lacking access to care, money for prolonged care, minorities, disabled and handicapped individuals, elderly, etc.  This argument expressly derives from physician-assisted suicide proponent arguments about cost-containment and economic efficiency. 


Two final concerns relate to the profession of medicine, including its integrity and the inherent fallibility of doctors. It is axiomatic that to err is human. One can imagine scenarios of uncertainty in diagnosis or prognosis, misdiagnosis of depression or inadequate treatment of pain.  This argument is somewhat similar to anti-capital punishment advocates who caution against executing wrongly convicted persons.  The stakes of mistakes in this context are high for death is irreversible.  Although death is inevitable, that it may come sooner for some than necessary is a legitimate concern. The existing safe guards may never reduce the possibility of abuse to zero, hence the legalization of physician assisted suicide and euthanasia will continue to be hot topics of any debate.   


8.      Other associated end-of-life health care issues


Along with discussion on physician assisted suicide and euthanasia, we should not ignore the role of palliative care, utilization of hospice care, and better pain management. These are areas that can greatly impact the decision process on physician assisted suicide.


The practice of palliative care is considered a very new development in the Netherlands. The Dutch government is now making palliative care a part of the official national health care policy. Even thought the policy regarding euthanasia went through extensive public debate, but now they are convinced that a well-considered policy on euthanasia can only be developed on the basis of a well-developed system of palliative care. It is to rule out the possibility that future requests of euthanasia might perhaps be brought about because of insufficient and inadequate palliative care and other resources (23, 30, 33). 


With the improvement and the efficacy of the retroviral treatment for AIDS patient’s and the emphasis on creating an effective palliative care system, the physicians and the patients have a wide range of options for a more meaningful discussion about  end-of-life care with regard to euthanasia and physician assisted suicide.


As a general overview, an article published by Bosshard, et al, examined the conceptual difference between the Netherlands and other countries. It emphasizes the importance of understanding the problematic and sometimes impossible balance between physicians’ duty to provide care and to minimize patient’s suffering. It also focus on a concept of patient’s right to die (41).


As the number of population susceptible to chronic degenerative and terminal diseases increases along with improvement in critical care medicine to prolong life, the difficulty in achieving an acceptable balance between physicians’ duty to provide care and minimize patient suffering will only increase. Unlike other countries, individuals do not have a universal right to health care in the United States. While there is a patient’s right to refuse medical treatment contingent upon a finding of the patient’s legal mental competency or a carefully articulated exception, there is no clearly defined patients’ right to health care or to die. Such ambiguity and lack of clarity only further increases the difficulty in reaching a generally acceptable view point or policy on physician assisted suicide and euthanasia.  


9.      Discussion and potential future directions


The arguments in support of euthanasia and physician assisted suicide focus, almost to the exclusion of other social interests and moral values, on the physicians’ duties to relieve patient suffering and respect patient autonomy especially their desire to die. It is also argued that the patient’s decision to end his or her own life should be interpreted as a private matter that does not harm others, therefore being free from State intervention or prohibition by medical professions. Opponents of euthanasia and physician-assisted suicide focus on the ambiguities in evaluating the patient’s ability to competently decide on health matters while experiencing all the sufferings at the end stage of terminal illnesses.  Additionally, opponents caution against creating a precedent where society begins viewing anything less than perfect health as undesirable quality of life.


Others also argue the issue of trust also comes into question when euthanasia or physician assisted suicide becomes an option of end-of-life discussions. It could also alter the physician-patient relationship. Perhaps assistance with suicide would compromise the patient and physician relationship and violate the trust factor of this relationship. Opponents vigorously assert euthanasia and physician-assisted suicide undermines the integrity and societal role of medical and allied health professions. This conduct, they argue, skews and alters the meaning of beneficence, the duty to do goods and to promote the best interests of the patients. Opponents do not deny the existence of suffering and pain during end-of-life stages, but rather, they claim the existences of other alternative medical solutions which have not been fully explored are available.  


Some have argued, including the U.S. legal system, that our society and the medical profession have a duty to safeguard the value of human life and protect vulnerable members of society. When a physician respects the patient’s autonomy, does the physician risk trumping this societal value and respect for human life? Patients might come to believe that they are becoming an unbearable burden and consider it is their duty to die. Others might argue that perhaps autonomy should be limited as in the slippery slope argument. So, when euthanasia or physician-assisted suicide is legalized, does that mean patients without terminal illness could also request for such option under certain circumstances?


Another commonly used example for this argument is Alzheimer’s disease. Alzheimer patients might fear for the future and desire euthanasia or physician-assisted suicide when the right moment comes. So if we only allow terminally ill patients for euthanasia and physician-assisted suicide, would such policy be considered a discriminatory? Also, can medical professions accurately predict how long a patient will live? All these questions further demonstrate the amount of ambiguities that can lead to abuse or misuse of euthanasia and physician assisted suicide.


Another important factor is how well and how long the patient has known their physician? Unlike the Netherlands, many patients in the United States do not have a long standing relationship with their physicians and therefore the foundation for knowing each other well is absent.. So perhaps the length of that relationship could also impact the quality of discussions regarding euthanasia and physician assisted suicide or any other end-of-life decision. Also in the United States, the patients do not have a “general” right to health care. So it can also be used to question the “general” right to euthanasia. But on the other hand the patients do have the right to refuse treatment. So perhaps the right to end ones’ life would be the next rational step.


If the right to medically end one’s life is legalized, will the patient appreciate the availability and the effectiveness of alternative options? We also have to assess whether there exists adequate availability of hospice and palliative care for any meaningful discussion on end-of-life decisions. These questions will invariably surface in any debate regarding euthanasia and physician assisted suicide.  


In developed countries like the United States and other European countries, there have been a long series of open debates on the philosophy, concepts and practices of euthanasia and physician assisted suicide. At least in the Netherlands and a few other countries, the general public and the medical professions came to an agreement how euthanasia or physician assisted suicide can be legalized and regulated. The Dutch example of emphasis on improving hospice and palliative care for patients suffering from terminal diseases will ensure that the decision for euthanasia or physician assisted suicide is not simply because there are not enough options available. In developing countries where the health care systems are less prepared to deal with all aspects of end-of-life patient cares, the practices of voluntary euthanasia and physician assisted suicide will only invite greater levels of ambiguities and opportunities for misuse for one motive or another. The practice of euthanasia and physician assisted should not be advocated with the same momentum compared to those in the developed countries. So until a society decides whether euthanasia is a therapeutic option or not for patients suffering from terminal diseases, further discussion should continue to explore all aspect of cares related to the end-of-life decisions.


With the improvement in modern medicine and diversed cultural and policitical environments, there is not a single group of individual who will create a generally acceptable policy on this issue. The desire for euthanasia and physician assisted suicide will always exist in subset of patients suffering from unbearable and terminal conditions. By prohibiting euthanasia and physician assisted suicide will not minimize the level of such desire. Instead, the number of successful and unsuccessful suicide attempt as an alternative to legalized euthanasia will only increase the burden on emergency medicine department and other public health related infrastructures. The medical professionals and different elements of the society should open up discussion on euthanasia and other end of life options. Euthanasia should only be advocated when all other options are explored to the fullest and when the only option left is still euthanasia.


10.  Conclusion


The physician-assisted suicide/euthanasia debate is far from resolution. There is room for the United States to look to existing international models, described above, as guides for future policy.  To understand where this debate is headed, one need only look through history at topics such as Abortion, Civil Rights and currently, same-sex marriage to appreciate the complexity. For this nation, we will find resolution in only one of two places: the Supreme Court or Congress. Regardless of geopolitical borders, the issues remain the same autonomy versus benevolence, freedom from undue pain and suffering versus misuse and abuse of vulnerable populations. Admittedly, the topics underlying this issue are too vast, broad and complex for complete and thorough analysis within this chapter, however, this chapter strived to provide a comprehensive overview of the major areas of this debate.


11.  Other resources


For those interested in further study of the Physician-Assisted Suicide/Euthanasia Debate, the following web sites may provide assistance:


Specific legal case report:

·        Dr. Timothy Quill’s case


Resources that are in support of physician-assisted suicide:

·        American Medical Student Association webpage on PAS.


·        Dedicated to education about PAS and death with dignity.


·        Oregon Health Department web site.



Resources that are in opposition of Physician-assisted suicide:

·        Oregon Right to Life website. Dedicated to debunking popularly held myths about Oregon’s DWDA.


·        Examines PAS within framework of Jewish law.


·        Comprehensive website in opposition to Euthanasia and Physician-assisted suicide.



General review article:

·        Bosshard G, Fischer S, Bar W. Open regulation and practice in assisted dying. Swiss Med Wkly. 2002 Oct 12;132(37-38):527-34.





1.      National Center for Health Statistics, online at

2.      Drickamer, Margaret A. et al. Practical Issues in Physician-Assisted Suicide. Annals of Internal Medicine. 1997; 126, Issue 2; 146-151.

3.      Black’s Law Dictionary, Second Edition page 6784 Washington v. Glucksberg, 521 US 702 (1997).

4.      Garrison, Marsha, The Law of Bioethics:  Individual Autonomy and Social Regulation. Pg 414. Thomson West  2003.

5.      Catechism on Euthanasia, online at:

6.      Foley Kathleen M, Competent Care for the Dying Instead of Physician-Assisted Suicide, New England Journal of Medicine 1997; 336: 54.

7.      Quill TE, I want to Die, Will You Help Me?  Journal of the American Medical Association 1993; 270:870-873.

8.      Washington v. Glucksberg, 521 US 702 (1997).

9.      Quill v. Vacco, 80 F.3d 716 (2d Cir 1996)

10.  Compassion In Dying v. Washington, 79 F.3d 790 (9th Cir 1996)(en banc).

11.  Oregon Health Department State Website, online at:

12.  Table 1:  Demographic Characteristics of 171 DWDA patients, by year, Oregon, 1998-2003.  Oregon Health Department State Website, online at:

13.  Table 4:  Death With Dignity Act participant end of life care and DWDA utilization, 1998-2003. Oregon Health Department State Website, online at:

14.  Problems Associated With Physician Assisted Suicide, online at:

15.  Cruzan v. Director, Missouri Department of Health, 497 US 261 (1990)

16.  Angela Komiti, et al. Suicidal behaviour in people with HIV/AIDS: a review. Australian and New Zealand Journal of Psychiatry 2001; 35:747-757.

17.  Charles S. Bryan. HIV/AIDS and Bioethics: Historical Perspective, Personal Retrospective. Health Care Analysis 10: 5-18, 2002.

18.  Ronit D. Leichtentritt, et al. Holocaust survivors’ perspectives on the euthanasia debate. Social Science & Medicine 48 (1999) 185-196.

19.  Michael G. Young, et al. Thje role of nurses in AIDS care regarding voluntary euthanasia and assisted suicide: a call for further dialogue. Journal of Advanced Nursing, 2000, 31(3), 513-519.

20.  Luigi Grassi, et al. Attitudes toward euthanasia and physician-assisted suicide among Italian primary care physicians. Journal of Pain and Symptom Management. Vol 17, No 3 March 1999.

21.  Bert Gordijn, et al. The prevention of euthanasia through palliative care: new developments in the Netherlands. Patient Education and Counseling 41 (2000) 35-46.

22.  Anna Mavroforous, et al. Euthanasia in Greece, Hippocrates’ birthplace. European Journal of Health Law 8: 157-162, 2001.

23.  Raphael Cohen-Almagor. Should doctors suggest euthanasia to their patients? Reflections on dutch perspectives. Theoretical Medicine 23: 287-303, 2002.

24.  Mirko Bagaric, et al. The Kuhse-Singer euthanasia survey: why it fails to undermine the slippery slope argument – comparing apples and apples. European Journal of Health Law 9: 229-241, 2002.

25.  Lois Snyder. Bioethics, assisted suicide, and the “right to die” Annals of Clinical Psychiatry, Vol 13, No 1, 2001.

26.  James V. Lavery, et al. Origins of the desire for euthanasia and assisted suicide in people with HIV-1 and AIDS: a qualitative study. The Lancet. Vol 358, August 4, 2001.

27.  Phillip M. Kleespies, et al. Suicide in the medically and terminally ill: psychological and ethical considerations. Journal of Clinical Psychology, Vol 56(9), 1153-1171 (2000)

28.  Judith C. Ahronheim, at al. Pursuit of assisted dying: a pilot study of inquiries made to a national consumer-based organization. Journal of Pain and Symptom Management, Vol 18, No 6, December 1999.

29.  R. Andraghetti, et al. Euthanasia: from the perspective of HIV infected persons in Europe. HIV medicine (2001) 2, 3-10.

30.  David C. Thomasma, et al. Asking to die: inside the Dutch debate about euthanasia. Journal of Health Politics, Policy and Law. Vol 25, No 2, April 2000.

31.  Bregje D. Onwuteaka-Philipsen, et al. Consultation with another physician on euthanasia and assisted suicide in the Netherlands. Social Science and Medicine, 51 (2000) 429-438.

32.  Ilinka Haverkate, et al. Guidelines on euthanasia and pain alleviation: compliance and opinions of physicians. Health Policy 44 (1998) 45-55.

33.  John R. Brechtl, et al. The Use Of Highly Active Antiretroviral Therapy (HAART) In Patients With Advanced HIV Infection: Impact On Medical, Palliative Care, And Quality Of Life Outcomes. Journal of Pain and Symptom Management. Vol 21. No 1, January 2001.

34.  Barry Rosenfeld, et al. The Schedule of Attitudes toward Hastened Death: measuring desire for death in terminally ill cancer patients. Cancer 2000;88:2868-75.

35.  Samia A Hurst. Assisted suicide and euthanasia in Switzerland: allowing a role for non-physicians. BMJ Vol 326. February 1, 2003.

36.  M.T. Harvey. What does a right to physician assisted suicide legally entail? Theoretical Medicine 23: 271-286, 2002.

37.  Yazdanpanah Y. Lifetime cost of HIV care in France during the era of highly active antiretroviral therapy. Antivir Ther 2002 Dec;7(4):257-66

38.  Marjolein Bannink. Psychiatric consultation and quality of decision making in euthanasia. The Lancet. Vol 356. December 16, 2000.

39.  Legemaate J. The Dutch Euthanasia Act and related issues. J Law Med. 2004 Feb;11(3):312-23.

40.  Oosthuizen H. Doctors can kill--active euthanasia in South Africa. Med Law. 2003;22(3):551-60.

41.  Bosshard G, Fischer S, Bar W. Open regulation and practice in assisted dying. Swiss Med Wkly. 2002 Oct 12;132(37-38):527-34.

[1] National Center for Health Statistics, online at

[2] Drickamer, Margaret A. et al. Practical Issues in Physician-Assisted Suicide. Annals of Internal Medicine. 1997; 126, Issue 2; 146-151.

[3] Black’s Law Dictionary, Second Edition page 678

[4] Garrison, Marsha, The Law of Bioethics:  Individual Autonomy and Social Regulation. Pg 414. Thomson West  2003.

[5] Catechism on Euthanasia, online at:

[6] Foley Kathleen M, Competent Care for the Dying Instead of Physician-Assisted Suicide, New England Journal of Medicine 1997; 336: 54.

[7] Quill TE, I want to Die, Will You Help Me?  Journal of the American Medical Association 1993; 270:870-873.

[8] Washington v. Glucksberg, 521 US 702 (1997).

[9] Quill v. Vacco, 80 F.3d 716 (2d Cir 1996)

[10] Compassion In Dying v. Washington, 79 F.3d 790 (9th Cir 1996)(en banc).

[11] Oregon Health Department State Website, online at:

[12] Table 1:  Demographic Characteristics of 171 DWDA patients, by year, Oregon, 1998-2003.  Oregon Health Department State Website, online at:

[13] Table 4:  Death With Dignity Act participant end of life care and DWDA utilization, 1998-2003. Oregon Health Department State Website, online at:

[14] Problems Associated With Physician Assisted Suicide, online at:

[15] Cruzan v. Director, Missouri Department of Health, 497 US 261 (1990)