Health & Medical Question - Nursing Essays

ReviewPhysician-assisted suicide and
physician-assisted euthanasia:
evidence from abroad and
implications for UK neurologists
Uma Nath,1 Claud Regnard,2 Mark Lee,3 Kiran Alexander Lloyd,4
Louise Wiblin5
1
Neurology, South Tyneside and
Sunderland NHS Foundation
Trust, Sunderland, UK
2
Palliative Medicine, St Oswald’s
Hospice, Newcastle upon Tyne,
UK
3
Palliative Medicine, St
Benedict’s Hospice, South
Tyneside and Sunderland NHS
Trust, Sunderland, UK
4
Department of Philosophy,
Oxford University, Oxford, UK
5
Neurology, South Tees
Hospitals NHS Foundation Trust,
Middlesbrough, UK
Correspondence to
Dr Uma Nath, Neurology, South
Tyneside and Sunderland NHS
Foundation Trust, Sunderland
SR47TP, UK; uma.nath@chsft.
nhs.uk
Accepted 15 February 2021
Published Online First
13 April 2021
© Author(s) (or their
employer(s)) 2021. No
commercial re-use. See rights
and permissions. Published
by BMJ.
To cite: Nath U, Regnard C,
Lee M, et al. Pract Neurol
2021;21:205–213.
ABSTRACT
In this article, we consider the arguments for
and against physician-assisted suicide (AS) and
physician-assisted euthanasia (Eu). We assess
the evidence around law and practice in three
jurisdictions where one or both are legal, with
emphasis on data from Oregon. We compare
the eligibility criteria in these different regions
and review the range of approved disorders.
Cancer is the most common cause for which
requests are granted, with neurodegenerative
diseases, mostly motor neurone disease, ranking
second. We review the issues that may drive
requests for a physician-assisted death, such
as concerns around loss of autonomy and the
possible role of depression. We also review the
effectiveness and tolerability of some of the
life-ending medications used. We highlight
significant variation in regulatory oversight across
the different models. A large amount of data are
missing or unavailable. We explore physician-
AS and physician-assisted Eu within the wider
context of end-of-life practice.
DEFINITION OF TERMS
Assisted suicide (AS) is the act of deliberately assisting another person to kill
themselves.1 Physician-
AS occurs when
a physician facilitates a patient’s death
by providing the necessary means and/
or information to enable the patient to
perform the life-ending act.2
Euthanasia (Eu) is the act of deliberately
ending a person’s life to relieve suffering.1
There is no consensus on terminology.
We use the following terms for clarity and
readability: Physician-AS is when a doctor
provides the means, usually a prescription, to end their patient’s life. Physician-
assisted Eu, by contrast, is where a doctor
directly administers a drug, usually by
lethal injection, to the patient. Physician-
assisted death/dying is used here when
referring to both AS and Eu.
INTRODUCTION
Assisting or encouraging another person
to commit suicide is illegal in the UK and
those who do so could potentially face
up to 14 years in prison. Furthermore,
under UK law, Eu is considered either as
murder or manslaughter.1 The General
Medical Council has issued guidance for
doctors that highlights the need for them
to follow UK law.3
The issue of physician-
AS has been
considered at parliamentary level on
several occasions but has not passed into
UK law.4 5 AS and Eu or just AS are now
legal in 16 jurisdictions across the world
(figure 1) with others currently considering legalisation.6
Figure 1 shows that the pace of legalisation is increasing. Approximately 150
million people across the world (around
2% of the world’s population) are said
to have access to a physician-
assisted
death.6 7 The majority of people in the UK
now favour legalisation of physician-AS
patients with a terminal illness.8 Moving
personal testimony, some of which comes
from people suffering from neurological
disorders, has also highlighted the issue
in recent years. It is therefore timely
that doctors, particularly neurologists,
consider what this might mean for them
and for their patients.
The moral imperative for physicians
to relieve suffering and to support their
patient’s personal autonomy are among
the ethical arguments cited by those who
support AS or Eu.6 Those who oppose
this view contend that it is fundamentally
Nath U, et al. Pract Neurol 2021;21:205–213. doi:10.1136/practneurol-2020-002811
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Review
Summary Reports from the Oregon Health Authority.9
We also review and compare the models for AS and
Eu in the Netherlands, which has the most physician-
assisted deaths and in Canada, which has the largest
population.10 11 We have also included information
from a wide-
ranging British Medical Association
(BMA) survey on end-
of-
life care and physician-
assisted dying.12
AIMS OF THIS ARTICLE
Each author of this article holds differing views on
AS and Eu, which has led us to search for unbiased
sources of information around which we could form
a consensus. We hope that the article will provide an
overview for physicians, particularly neurologists, of
the main issues around this challenging topic.
Table 1 shows that the proportion of deaths from
AS in Oregon is comparatively low. The number of
deaths from AS and Eu across Canada rose by 26.1%
in 2019 compared with the previous year.11 AS and Eu
are also rising in many jurisdictions (see figure 2 for
data from the Netherlands).9–11 13 The percentage of
reported deaths from AS or Eu in the Netherlands in
2019 was 4.2%.
Eligibility criteria for AS or Eu
Figure 1 Jurisdictions where either AS alone or both AS and
Eu are legal, showing year of legalisation.6 AS, assisted suicide;
Eu, euthanasia.
incompatible with a doctor’s role as a healer who does
not harm their patient, and they also raise concern
about the possible adverse impact on society.6 It has
proved difficult to debate this issue constructively, by
means of ethical arguments alone.
A review of available data from areas of the world
where AS or AS/Eu are legal could inform this debate
and help clinicians better understand the issues
involved. It could begin to address some key questions
about how it works in practice. For example, has the
range of conditions for which requests are granted
broadened over time? Where should the line be
drawn? What makes people choose an assisted death?
Could these be remedied by other (non-life-ending)
measures? Does depression drive some requests? Are
physician-assisted deaths more peaceful and painless
than non-assisted deaths? Are life-ending medications
effective? Are patients’ requests truly voluntary? Is the
process effectively monitored to ensure the vulnerable
are protected?
Although there are few well-designed observational
research studies on this topic, there are some useful
official sources of information from areas where AS
alone or AS and Eu are legal that shed some light on
the above questions. Previous draft legislation in the
UK for AS followed relatively restricted criteria that
resemble those used in Oregon. We therefore focus
on Oregon, drawing information largely from Annual
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These criteria vary greatly across different parts of
the world. In Oregon, only AS (not Eu) is legal and is
restricted to adults with capacity who are terminally ill
and expected to die within 6 months. The legislation,
essentially unchanged since 1994, has been recently
broadened to allow patients to self-administer AS drugs
by non-oral means (eg, intravenous injection).14 Canada’s government has recently proposed a change in the
law to include non-terminal illnesses and is considering
the inclusion of mature minors (table 1).15 16
In the Netherlands, the criteria are more inclusive. AS or Eu may be approved for either medical
or psychological conditions, provided that the criterion of ‘intolerability’ is met. They do not require the
condition to be ‘terminal’. AS or Eu may be granted to
patients with dementia who lack capacity—provided
they have a prior valid advance directive.10
Range of conditions for which AS or Eu are granted
Data from Oregon
In 2019, cancer accounted for 68% and neurological
disease for 13.8% of cases. Motor neurone disease
accounted for most (10.1%) of all the neurological disorders. Eight people approved for AS were
reported to have either diabetes, arthritis, musculoskeletal system disorders, ‘stenosis’ or ‘sclerosis’. Some
of these terms are non-specific. There is not enough
information to determine which aspect of these conditions made them terminal.
Data from other jurisdictions
Cancer remains the most commonly approved condition worldwide.6 In the Netherlands, 20% of deaths in
Nath U, et al. Pract Neurol 2021;21:205–213. doi:10.1136/practneurol-2020-002811
Review
Table 1 Overview of three jurisdictions where either AS alone or both AS and Eu are legal9–11
Jurisdiction (name and year of
legislation)
Oregon
(Death with Dignity Act, 1994)
Canada
(medical assistance in dying, 2015)
The Netherlands
(Termination of Life upon Request
Act, 2001)
Physician-assisted suicide (AS)
Physician-assisted Euthanasia (Eu)
Must be a voluntary, well
considered request
Age
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
18 years and over
18 years and over
Summary of eligibility criteria (key
sections highlighted)
Adult with capacity who has a
terminal illness that will lead to
death within 6 months
Nature of underlying illness
Advance directive considered
Mandatory psychiatric evaluation
Foreign nationals accepted
Number of AS/Eu deaths per year
in 2019
Per cent of AS/Eu deaths as a
proportion of all deaths
Population (estimated) in 2019
Physical illness
No
No
No
188
Adults with capacity who have a grievous
and irreversible medical condition that is
serious, in an advanced irreversible state
and causing unbearable physical or mental
suffering that cannot be relieved under
conditions the person finds acceptable,
and be at the point where natural death is
reasonably foreseeable
Physical illness
No
No
No
5631
Age 12 and over (parental consent
required for those aged 12–16)
Individuals must be ‘decisionally
competent’ (at time of request) and have
unbearable suffering with no prospect
of improvement for which there is no
reasonable alternative in the patient’s
situation
0.4% in 201956
2% in 2019
4.2% in 201957
4.2 million
37.5 million
17.2 million
people with motor neurone disease from 1994 to 1998
were due to AS or Eu.17 The range of conditions that
can be approved for AS or Eu across the world is broad
and now includes multiple sclerosis, Parkinson’s disease,
dementia, ‘multiple geriatric syndromes’, musculoskeletal disorders, depression and chronic pain syndromes.10
There is some support in the Netherlands for a proposal
to allow healthy people aged over 75 years to have AS or
Eu if they are ‘tired of living’.18
Q. Has the range of approved conditions expanded over time; if so,
where should the line be drawn?
Both the range of approved conditions and eligibility criteria have broadened in most areas over time
and there are divergent opinions as to whether this
Either physical or mental illness
Yes
No
No
6361
represents a positive step forward for patients. It might
be considered, for example, that a child suffering with a
terminal illness deserves the option of an assisted death
just as much as an adult or that a person with a mental
illness deserves equal access to AS or Eu as someone
with a physical disorder. Others may take the view
that these developments increase the risk to vulnerable
groups.
The original criteria requiring that a patient carries a
terminal diagnosis have now been set aside in the Netherlands and Belgium. A recent Canadian bill argues
for the same change by proposing the removal of the
necessity for a ‘reasonably foreseeable’ death.16 Such a
development would considerably broaden the range of
neurological conditions that might be approved for a
physician-assisted death.
Reasons for choosing AS or Eu
Figure 2 Reported annual deaths from assisted suicide or
euthanasia in the Netherlands since legalisation.10
Nath U, et al. Pract Neurol 2021;21:205–213. doi:10.1136/practneurol-2020-002811
Data collection methods are not directly comparable
between Oregon and Canada; however, figures 3 and
4 show some common themes that emerged. The most
common category in both jurisdictions is the loss of
ability to engage in enjoyable or meaningful activities.
In Canada, 13.7% of people cited isolation or loneliness as a significant factor; there are no comparable
data for Oregon. In Oregon, one person was referred
for psychological or psychiatric evaluation. In Canada,
6.2% of people being considered for AS or Eu were
referred to a psychiatrist.19
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Figure 3 End-of-life concerns in people undergoing assisted suicide in Oregon (2019) (‘don’t know’ included as a negative answer.
Answers not mutually exclusive).9
Q. Can the reasons people choose AS or Eu be remedied by other
means?
It is important to ensure that people are not choosing
AS or Eu because of inadequate access to palliative
care, undiagnosed depression or financial pressures.
Non-life-ending interventions such as palliative care
have been shown to be effective, even where there is
complex physical and emotional distress.20 21 In 2019,
263 Canadian patients requested AS or Eu, but then
later withdrew their requests—26% did so because
they found that palliative care met their needs.11 A
survey found that across care settings, most people who
received palliative care did so only in the last month
of life. It also found that in some parts of Canada,
fewer than 15% of Canadians who died received
publicly funded palliative care in their own homes.22
Although research has not established a definitive link
between palliative care needs and requests for AS or
Eu,23 this field is further complicated by varying definitions of what is meant by specialist palliative care.
Training also varies widely between jurisdictions and
few provide mandatory or standardised training in
the decision-
making and practice of AS/Eu.24 25 A
2017 Canadian survey suggested that further training
might help healthcare providers to identify people
whose concerns of being a burden on their family or
whose mental health issues might push them toward
an assisted death.26 A survey of 3299 US oncologists
in 2000 found that those who could not obtain all the
care that their dying patient needed were more likely
to have performed Eu.27 Those who reported receiving
Figure 4
4 of 9
better training in end-of-life care seemed to be less
likely to perform Eu or physician-AS.
The financial implications of treatment were cited
in 14 cases in Oregon, which is of potential concern.
It is not possible to determine from the available data
whether these people considered such pressures to be
the decisive factor in their choice.
Depression is a potentially treatable condition. It
is common at the end of life, easily missed by non-
psychiatrists and is more difficult to detect in the
terminally ill.28 Studies have not found a consistent
link between depression in patients with advanced
illnesses (such as motor neurone disease) and a desire
for AS or Eu.23 29–31 Such studies are complex to interpret. For example, it is not always easy to distinguish
existential despair from clinical depression.32 Furthermore, perhaps counter-intuitively, a stated wish to die
does not necessarily imply a wish to hasten death.33
Mandatory psychiatric or psychological evaluation
before AS or Eu approval did not appear to be part of
any of the three legislations that we studied.
Q. Do people prescribed AS medications have a better end-of-life
experience?
Good comparative studies between physician-assisted
and non-assisted deaths are rare. One retrospective
study in Oregon based on responses from family
members found that people receiving AS prescriptions were perceived to have more control over their
surroundings and to have better preparedness for
death, but there were no differences in quality of death
Nature of suffering of those who received assisted suicide or euthanasia in Canada, 2019.11
Nath U, et al. Pract Neurol 2021;21:205–213. doi:10.1136/practneurol-2020-002811
Review
Data from other jurisdictions
There are few published studies of AS drug effectiveness
and tolerability and some of the largest studies of this
kind are now several decades old.39 The results suggest
that Eu has fewer side effects and a lower failure rate
than AS. In Canada, most people opt for Eu rather than
AS and while complications are said to be rare, such data
are not routinely systematically recorded.40
Q. What should be done if AS or Eu drugs fail to work?
Figure 5 Reported deaths from AS in Oregon over time versus
number of prescriptions issued for AS drugs.9 AS, assisted
suicide.
compared with people dying without AS.34 In Oregon,
35% of people who were prescribed AS medication in
2019 never used their prescription (figure 5).9 Keeping
the drug to hand might lead to its inappropriate use
for a transient or treatable depression. However, one
could equally surmise that some of them found a
measure of control and autonomy in having the life-
ending option to hand.
People who request AS from their doctors open
the way for palliative care conversations and advance
care planning. Doctors may find it harder to initiate
such conversations with other patients who have not
specifically asked about their care at end of life.35 36
The first Annual Summary Report from Oregon stated
that ‘physicians prescribing lethal medications may
have spent more time exploring end of life concerns
and care options’ with patients who requested lethal
medications’.9
Thorough assessment is key to effective symptom
control. For physicians to elicit the distress associated
with serious illness, their assessment must include
effective communication, irrespective of whether or
not the patient has requested an assisted death.37 38
Effectiveness and tolerability of life-ending medications
Data from Oregon
A mixture of AS medications such as DDMP2 (diazepam, digoxin, morphine sulfate and propranolol)
has now largely replaced single barbiturate agents. In
2019, there were no publicly available data on complications in 68% (127/188) of cases in people taking AS
drugs. Complications such as difficulty in swallowing
or regurgitation were reported in 3% of people (6/188
cases). The median time from drug ingestion to death
was 51 min (range 1 min–47 hours), but in 32.4%
(61/188) of cases, there was no available information
on time from ingestion to death.
No patient regained consciousness after drug ingestion in 2019; however, eight patients did so between
1998 and 2018.
Nath U, et al. Pract Neurol 2021;21:205–213. doi:10.1136/practneurol-2020-002811
AS drugs (like any other drugs) can fail to work as
intended. This would be of concern if the patient were
distressed or in pain and would also cause distress to
any family in attendance. There are insufficient clinical data provided for further meaningful assessment
in Oregon, where the option of Eu is not available.
In Canada, doctors are advised to be present at
the time of lethal oral drug ingestion so that if problems arise, they can relieve any distress and complete
the procedure, by euthanising the patient.40 Studies
suggest that this is what happens in practice in similar
situations in the Netherlands.39
Safeguarding of vulnerable individuals
The law in all jurisdictions emphasises the importance of safeguarding to avoid coercion of vulnerable
people. Regulatory oversight varies widely and is often
reactive rather than proactive. The Oregon Health
Authority states that, for AS, the law ‘does not include
any oversight or regulation that is distinct from what
is done for other medical care’.41 In the Netherlands,
regional review committees retrospectively monitor
each reported physician-
assisted death.10 The time
from a request for AS to death in Oregon in 2019
ranged from 15 days to 4 years, which falls outside the
stipulated 6 months’ expected survival.9 However, the
reality of many disorders is that it is difficult to make
accurate estimates of survival, particularly in neurodegenerative diseases with complex and varying disease
trajectories. Arguably, a longer than expected survival
could be due to an incorrect diagnosis. The possibility
that the introduction of AS could reduce the overall
suicide rate is not supported by data from Oregon.42
Data from Oregon
The vast majority (94%) of the 188 people who underwent AS in 2019 died at home. Their median age was
74 years (33–98 years). Figure 6A shows that in 8% of
cases, no healthcare provider or volunteer was present
at the time the person took the AS drug. In 43% of
cases, no provider or volunteer was present at the time
the patient died (figure 6B).
Q. Are requests for AS or Eu truly voluntary? Do existing safeguards
protect the vulnerable?
If at the time of taking the AS drug there is no healthcare provider or volunteer present, it is not possible to
be sure that the request was truly voluntary. If there is
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Figure 6
2019.9
Healthcare provider/volunteer present at time of drug ingestion (A) and death (B) from assisted suicide in Oregon in
no provider or volunteer present at the time the patient
dies, this could be concerning if the drug fails to work
as intended. The extent of missing data is a concern.
Restricted approval criteria should not be automatically conflated with higher levels of safeguarding.
In Canada, 571 people were deemed ineligible for
AS or Eu in 2019. A third of these rejections related to
concerns around their capacity.11 In the Netherlands
and Oregon, people who are refused AS or Eu by their
own physicians can approach other providers.9 43
There are specific challenges in relation to the
assessment of those who may have limited mental
capacity. Evidence from the UK suggests that health
professionals do not always follow or fully understand
all the guidelines laid down in existing mental capacity
legislation.44–46 This has safeguarding implications if
further complex new laws are introduced.
Death certification in patients who undergo AS
Data from Oregon
The Oregon Health Authority advises doctors ‘to
record the patient’s underlying terminal disease as the
cause of death and to mark the manner of death as
natural’. It states that ‘Approximately 1 year from the
publication of the Annual Report, all source documentation is destroyed’.41
These practices, which on the face of it lack openness,
are often done to protect confidentiality, but do render
effective audit and research much more difficult.47
need. There are now more neurology trainees with an
interest in palliative care. Together with colleagues in
palliative and primary care, they can help to ensure
that their patient’s end of life is managed with sensitivity and dignity. Getting end-of-life care right for
patients would allow any conversations around AS,
was it to be legalised in the UK, to be placed appropriately in that wider context.
In Canada, the rollout of AS and Eu has proved
challenging, which in part may be due to the previously observed inequalities in access to palliative care
services.22 In the UK population (which is larger), the
NHS (National Health Service) is free at the point of
care so access to palliative care should be universal.
The BMA survey on end-of-life care in the UK notes
that ‘there is still significant variability in quality of …
services provided’ and refer to the ‘current shortfall
in end-of-life care provisions’.50 It would be wise to
ensure that end-of-life services are well integrated and
optimised before considering new legislation with life-
ending consequences.
Interpreting surveys and opinion polls
Patients with neurodegenerative diseases can have a
similar symptom burden to patients with metastatic
cancer.48 There is a growing recognition of the benefit
of the palliative approach in such cases.49 Open and
early discussion around death with patients and their
families allows time for reflection and planning, can
reduce unwanted interventions and alleviate fear.36
Listening to those who suffer from neurological disorders and finding out what a good death really means
to them will put neurologists in a much better position
to provide the support and reassurance their patients
As noted earlier, there is popular support for AS in the
UK. However, framing the choice for the public (or
doctors) as simply either in favour of AS or against it may
obscure the complexity of the decisions involved.
A study from Quebec found that following legalisation, physicians refused to participate in AS or Eu
much more frequently than had been anticipated
from a pre-legislative survey.51 Around 1% of Canadian doctors provide AS or Eu. In Canada, nurse
practitioners act as both assessors and providers of an
assisted death.52 Overall, 7% of all Canadians’ assisted
deaths are carried out by nurse practitioners.11 Of
the 6191 practising physicians in Oregon in 2019,
112 wrote prescriptions for AS drugs. Most (80%) of
prescribing physicians wrote only one or two prescriptions. The range was between 1 and 33 prescriptions
per physician.9
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The UK landscape: what makes a ‘good’ death?
Review
The merely conceptual assent of a clinician in a
survey may not always translate into a willingness to
participate in practice.
Population surveys can give very different results
depending on how their questions are worded.53 54
Surveys of the views of disabled adults may include
a heterogenous group of diseases and severities and
could be biased against those with a greater level of
disability.55
CONCLUSION
A small number of people in the UK continue to
request a physician-assisted death. Review of law and
practice across the world suggests that trying to embed
it safely into clinical practice might pose unforeseen
problems. The current variability of access to palliative
care services in the UK would represent a particular
challenge.
A quarter of a century ago, a UK Select Committee
on Euthanasia concluded the following: ‘…it was
virtually impossible to ensure that all acts of euthanasia were truly voluntary and that any liberalisation
of the law in the United Kingdom could not be abused.
We were also concerned that vulnerable people—the
elderly, lonely, sick or distressed—would feel pressure,
whether real or imagined, to request early death’.5
There still seems to be insufficient data to address
these concerns conclusively. Gaps in systematic data
collection and the paucity of large-scale prospective
studies represent a significant barrier to meaningful
debate. Opinions about physician-assisted death vary
widely among doctors and can sometimes be sharply
polarised. Arguments well supported by robust
Key points
►► This is a complex issue with wide variations in law and
practice.
►► There are large gaps in systematic data collection.
►► There is a need to balance safeguarding with patient’s
autonomy.
►► Neurologists should foster early and open discussion
with their patients about the end of life and be trained
and supported to do so.
►► Neurologists should continue to work with other
specialities to optimise patient care at the end of life.
Further reading
1. BMA. British Medical Association Physician Assisted
Dying Information Pack. https://www.bma.org.uk/
media/2353/bma-physician-assisted-dying-info-packapril-2020.pdf. Accessed 27 Sep 2020.
2. With the End In Mind: Dying, Death and Wisdom in an
Age of Denial. Kathryn Mannix author, published by
William Collins (London) 2017.
Nath U, et al. Pract Neurol 2021;21:205–213. doi:10.1136/practneurol-2020-002811
evidence are more likely to lead to a degree of medical
consensus on this issue, which will help both patients
and their families.
Acknowledgements UN is indebted to Mr and Mrs Barry
and Margaret Martin and the patients and committee of the
Sunderland branch of Parkinson’s UK for early discussions
around this topic. The authors would like to thank the
following contributors who provided assistance with language
editing and proofreading: K Anderson, D Bates, S Fenwick,
GA Ford, S Junejo, S Louw and A Schaefer. The authors would
also like to thank Dr C Morris for allowing UN to access
her PhD ‘Palliative and end of life care provision for people
with Parkinson’s disease, progressive supranuclear palsy and
multiple system atrophy’.
Contributors UN drafted the manuscript and subsequent
revisions and conceived and designed the review. CR sourced
information and provided the figures. KAL provided advice
relating to ethics and logical argumentation. All authors
critically appraised and revised the manuscript for important
intellectual content and approved the final version of the
article.
Funding The authors have not declared a specific grant for this
research from any funding agency in the public, commercial or
not-for-profit sectors.
Competing interests CR and ML are the members of the
Association of Palliative Medicine. CR manages the KADOH
website (www.kadoh.uk).
Patient consent for publication Not required.
Provenance and peer review Commissioned; externally
reviewed by Martin Turner, Oxford, UK.
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physician-assisted-dying-volume-one-report.pdf
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15 Laupacis A. Canada’s federal government should continue
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18 Florijn BW. Extending’ euthanasia to those ‘tired of living’ in
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19 Downar J, Fowler RA, Halko R, et al. Early experience with
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20 Mateo-Ortega D, Gómez-Batiste X, Maté J, et al. Effectiveness
of psychosocial interventions in complex palliative care
patients: a quasi-experimental, prospective, multicenter study.
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21 Gomes B, Calanzani N, Curiale V, et al. Effectiveness and cost-
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22 Canada. Access to palliative care in Canada. Ottowa: Canadian
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sites/default/files/document/access-palliative-care-2018-en-web.
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23 Maessen M, Veldink JH, Onwuteaka-Philipsen BD,
et al. Euthanasia and physician-assisted suicide in
amyotrophic lateral sclerosis: a prospective study. J Neurol
2014;261:1894–901.
24 White BP, Willmott L, Close E, et al. Development
of voluntary assisted dying training in Victoria,
Australia: a model for consideration. J Palliat Care
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25 Jansen-van der Weide MC, Onwuteaka-Philipsen BD, van
der Wal G. Implementation of the project ‘Support and
Consultation on Euthanasia in The Netherlands’ (SCEN).
Health Policy 2004;69:365–73.
26 Antonacci R, Baxter S, Henderson JD, et al. Hospice
palliative care (HPC) and medical assistance in dying
(MAID): results from a Canada-wide survey. J Palliat Care
2019:082585971986554.
27 Emanuel EJ, Fairclough D, Clarridge BC, et al. Attitudes
and practices of U.S. oncologists regarding euthanasia and
physician-assisted suicide. Ann Intern Med 2000;133:527–32.
28 Thompson C, Kinmonth AL, Stevens L, et al. Effects of
a clinical-practice guideline and practice-based education
on detection and outcome of depression in primary care:
Hampshire depression project randomised controlled trial.
Lancet 2000;355:185–91.
29 van der Lee ML, van der Bom JG, Swarte NB, et al. Euthanasia
and depression: a prospective cohort study among terminally
ill cancer patients. J Clin Oncol 2005;23:6607–12.
30 Achille MA, Ogloff JRP. Attitudes toward and desire for
assisted suicide among persons with amyotrophic lateral
sclerosis. Omega 2004;48:1–21.
31 Marrie RA, Salter A, Tyry T, et al. High hypothetical interest
in physician-assisted death in multiple sclerosis. Neurology
2017;88:1528–34.
32 Albert SM, Rabkin JG, Del Bene ML, et al. Wish to die in end-
stage ALS. Neurology 2005;65:68–74.
33 Ohnsorge K, Gudat H, Rehmann-Sutter C. What a wish to
die can mean: reasons, meanings and functions of wishes to
die, reported from 30 qualitative case studies of terminally
ill cancer patients in palliative care. BMC Palliat Care
2014;13:38.
34 Smith KA, Goy ER, Harvath TA, et al. Quality of death and
dying in patients who Request physician-assisted death.
J Palliat Med 2011;14:445–50.
35 Walker RW. Palliative care and end-of-life planning in
Parkinson’s disease. J Neural Transm 2013;120:635–8.
36 Connolly S, Galvin M, Hardiman O. End-of-life management
in patients with amyotrophic lateral sclerosis. Lancet Neurol
2015;14:435–42.
37 Virdun C, Luckett T, Davidson PM, et al. Dying in the
hospital setting: a systematic review of quantitative studies
identifying the elements of end-of-life care that patients and
their families RANK as being most important. Palliat Med
2015;29:774–96.
38 Schram AW, Hougham GW, Meltzer DO, et al. Palliative care
in critical care settings: a systematic review of communication-
based competencies essential for patient and family
satisfaction. Am J Hosp Palliat Care 2017;34:887–95.
39 Groenewoud JH, van der Heide A, Onwuteaka-Philipsen BD,
et al. Clinical problems with the performance of euthanasia
and physician-assisted suicide in the Netherlands. N Engl J Med
2000;342:551–6.
40 Bakewell F, Naik V. CAMAP: complications with medical aid
in dying (MAID) in the community in Canada; review and
recommendations white paper Canadian association of medical
assistance in dying (MAiD) assessors and providers, 2019.
Available: https://camapcanada.ca/wp-content/uploads/2019/
05/Failed-MAID-in-Community-FINAL-CAMAP-Revised.pdf
[Accessed 8 Jan 21].
41 Oregon Health Authority. Death with dignity: frequently
asked questions, 2019. Available: https://www.oregon.
gov/oha/PH/PROVIDERPARTNERRESOURCES/
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EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/
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42 Jones DA, Paton D. How does Legalization of physician-
assisted suicide affect rates of suicide? South Med J
2015;108:599–604.
43 Snijdewind MC, Willems DL, Deliens L, et al. A study of the
first year of the end-of-life clinic for physician-assisted dying in
the Netherlands. JAMA Intern Med 2015;175:1633–40.
44 Heslop P, Blair P, Fleming P. Confidential enquiry into the
premature deaths of people with learning disabilities (CIPOLD).
Bristol: Norah Fry Research Centre, University of Bristol,
2013. http://www.bristol.ac.uk/cipold/
45 Marshall H, Sprung S. The Mental Capacity Act: 10 years on
– the key learning areas for healthcare professionals. Nursing
Research Review 2018;8:29–38.
46 House of Lords. Mental capacity act 2005: post-legislative
scrutiny. House of Lords select Committee on the mental
capacity act 2005. London: The Stationery Office, 2014.
https://publications.parliament.uk/pa/ld201314/ldselect/
ldmentalcap/139/139.pdf
47 Dierickx S, Cohen J. Medical assistance in dying:
research directions. BMJ Support Palliat Care
2019;9:bmjspcare-2018-001727.
48 Miyasaki JM, Long J, Mancini D, et al. Palliative care for
advanced Parkinson disease: an interdisciplinary clinic and new
scale, the ESAS-PD. Parkinsonism Relat Disord 2012;18(Suppl
3):S6–9.
49 Wiblin L, Lee M, Burn D. Palliative care and its emerging role
in multiple system atrophy and progressive supranuclear palsy.
Parkinsonism Relat Disord 2017;34:7–14.
50 British Medical Association. End of life care and physician
assisted dying: 3- reflections and recommendations, 2016.
Available: https://www.bma.org.uk/media/1418/bma-end-of-
life-care-and-physician-assisted-dying-volume-three-report.pdf
[Accessed 8 Jan 21].
51 Bouthillier M-E, Opatrny L. A qualitative study of physicians’
conscientious objections to medical aid in dying. Palliat Med
2019;33:1212–20.
52 Pesut B, Thorne S, Schiller C, et al. Constructing good
nursing practice for medical assistance in dying in Canada:
an interpretive descriptive study. Glob Qual Nurs Res
2020;7:233339362093868.
53 Magelssen M, Supphellen M, Nortvedt P, et al. Attitudes towards
assisted dying are influenced by question wording and order: a
survey experiment. BMC Med Ethics 2016;17:24.
54 Hagelin J, Nilstun T, Hau J, et al. Surveys on attitudes towards
legalisation of euthanasia: importance of question phrasing.
J Med Ethics 2004;30:521–3.
55 Michell S, Ciemnecki A, CyBulski K. Removing the barriers to
survey participation for people with disabilities. Washington:
Cornell University, 2006. http://citeseerx.ist.psu.edu/viewdoc/
download?doi=10.1.1.155.4144&rep=rep1&type=pdf
56 Borasio GD, Jox RJ, Gamondi C. Regulation of assisted
suicide limits the number of assisted deaths. Lancet
2019;393:982–3.
57 RTE regional euthanasia review committees: annual report (in
Dutch), 2019. Available: https://www.rijksoverheid.nl/binaries/
rijkoverheid/documenten/jaarverslagen/2020/03/31/jaarverslag-
2019-rte/jaarverslag-2019-rte.pdf
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Submit a detailed outline of your term paper. Your submission must include sections
corresponding to the following subheadings:
•
•
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Technical Aspects
Provides necessary medical and scientific information to understand the issue.
Public Policy
Describes current and proposed changes in public policy/law.
Arguments For and Against
Include a summary of the arguments in favor of and opposed to specific
interventions, techniques, or products and a discussion of underlying ethical
principles. Discuss the public policy with two additional argumentative
paragraphs- one discussing the in favor of and one paragraph discussing the
opposing argument.
Conclusion
Expresses your personal opinion regarding the importance of the topic and the
strength of the pro and con arguments.
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Each section of your outline should include topic sentences and paragraph
transitions that tie your significant points together.
Detail Sufficient to Evaluate your Thinking
Write complete thoughts.
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Medical Assistance in Dying
The Goals of Medicine and Compassion in the
Ethical Assessment of Euthanasia and PhysicianAssisted Suicide: Relieving Pain and Suffering by
Protecting, Promoting, and Maintaining the
Person’s Well-Being
Journal of Palliative Care
2022, Vol. 37(3) 366‐371
© The Author(s) 2022
Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/08258597221078371
journals.sagepub.com/home/pal
Ercan Avci1
Abstract
Arguments regarding the goals of medicine in end-of-life occupy a prominent place in the debate on life-ending medical interventions. The discussions in favor of euthanasia and physician-assisted suicide focus on relieving patients’ intractable pain and suffering
to justify the physician’s active engagement in killing. Furthermore, the arguments that claim the existence of intractable suffering
vindicates euthanasia and physician-assisted suicide are predicated upon compassion in the ﬁrst instance. The present article concisely studies the goals of medicine and compassion to evaluate their utilization in the ethical justiﬁcation of life-ending interventions to draw normative conclusions on that basis. The article concludes that relieving a person’s unbearable pain and suffering is a
crucial goal of medicine, but this goal should be accomplished through morally acceptable means, not euthanasia or physicianassisted suicide. Medicine intends to protect, promote, and maintain the person’s physical and psychological wellbeing.
Considering euthanasia or physician-assisted suicide an appropriate means to achieve these goals may dramatically impair the therapeutic relationship for patients who regard the physician as a healer. In respect of compassion, the article deduces that even
though playing an important role in the patient-physician relationship, compassion does not produce an objective, reliable, and
applicable standard to appraise the ethical assessment of euthanasia and physician-assisted suicide because compassion derives
from feelings that vary from person to person according to their social, cultural, religious, or political stances and values. The
article proposes interpreting the goals of medicine and the concept of compassion in line with giving suffering people adequate
and appropriate medical, palliative, spiritual, and emotional care in light of the dedication of medicine to people’s health and welfare and the requirement of compassion to help suffering individuals in a constructive course of action.
Keywords
goals of medicine, compassion, euthanasia, physician-assisted suicide, life-ending interventions
Introduction
The impact of medical and technological developments on the
death and dying process necessitates reevaluating the goals of
medicine. The advances have made a longer life possible,
which leads to an aging population, expands chronic illnessbased treatment periods, and escalates long-term disease-related
pain and suffering.1 Furthermore, growing attention to individual liberty and respect for autonomy, as well as some interpretations of compassion have brought about questions regarding
whether medicine should meet the demand for actively terminating one’s life in light of the person’s free choice.2
However, the traditional insight of the two classic principles
of medical ethics – beneﬁcence and non-maleﬁcence – precludes healthcare professionals from engaging in ending a life.3
Vitalism and subjectivism are two opposite approaches in the
evaluation of the value of human life. Vitalism’s attention is on
the existence of life, while subjectivism focuses on a person’s
perception regarding the value of his/her own life. Namely,
vitalism requires prolonging a person’s life as much as possible
because life is the greatest value, while subjectivism asserts that
a person’s life has value so long as the individual attributes
value to her/his life.4 The views on end-of-life interventions –
euthanasia, physician-assisted suicide (PAS), and palliative
sedation – explicitly or implicitly, are grounded in one of
these approaches or particular religious aspects. For instance,
the Catholic tradition considers human life a gift from God
and regards any direct intervention in life or the intention of
shortening life or hastening death as evil.5 In this context, the
article aims to examine whether euthanasia and PAS may be
1
Duquesne University, USA
Corresponding Author:
Ercan Avci, Carl G. Grefenstette Center for Ethics in Science, Technology, and
Law, Duquesne University, United States.
Email: avcie@duq.edu
Avci
utilized as means to achieve one of the primary goals of medicine – relieving pain and suffering – and justiﬁes that approach
through the notion of compassion. Without getting involved in
the relevant philosophical discussions on the difference between
killing and letting die, the term killing in this paper refers to a
death resulting from any direct medical intervention, such as
PAS and euthanasia.6–8 Therefore, withdrawing and withholding life-sustaining treatment, like in well-known legal cases,
such as Karen Ann Quinlan, Nancy Beth Cruzan, and Theresa
Marie Schiavo, is regarded as letting die, which is out of the
scope of this article.9
Goals of Medicine in End-of-Life
To explain the fundamental function of medicine, Eric J. Cassell
states that “medicine has a tradition in which a hierarchy of
values—the patient comes ﬁrst, doctors must above all do no
harm, the good of the patient is intended—is ﬁrmly established”
and considers medicine the science and art of healing built on a
trust-based relationship between the patient and the physician.10
The physician’s knowledge and medical facilities are the scientiﬁc aspect, which aims to deal with disease, while the connection and interaction between the physician and patient are the
artistic dimensions of medicine. According to Cassell, in the
therapeutic relationship, the physician’s focus should be on
the patient, as a unique individual, rather than the disease
because it is the patient who is treated, not the disease.10
However, advances in medical technology have led to overlooking the patient and excessively concentrating on the disease and
its treatment-related mechanical components.11 These changes
have not only provided physicians more power to engage in
diagnosis and treatment processes but also provoked a paradigm
shift in the end-of-life issues and the perception of death and
dying.12 Daniel Callahan describes this situation as “[t]he transformation of death from a biological evil to a moral evil”
because increasing possibilities of medical interventions have
brought about a moral debate regarding the boundaries and
goals of medicine (p. 60).11
Technological advances, medical developments, and public
health improvements have generated a higher life expectancy
with many chronic diseases, long-term treatments, and a prolonged dying process.11 These undesirable consequences of a
longer life can induce longer suffering for some people. Li
Yiting et al. emphasize that “[a]dvances in medicine have the
capacity to extend a life that is often burdened with poor emotional and social quality”(p. 34).13 Furthermore, as Gawande
recalls Erving Goffman’s analogy between prisons and
nursing homes, the perception of living in an end-of-life institution gives some clues about the quality of life at the end of life.14
Thanks to available medical, technological, and pharmaceutical
opportunities, death or dying is no longer considered a natural
end, but “a technical phenomenon”(p. 88).15 However, despite
all these advances, physicians have limited power in dealing
with human biology, and missing that point causes physical,
psychological, and ﬁnancial harm. Gawande states “I have
seen the damage we in medicine do when we fail to
367
acknowledge that such power is ﬁnite and always will be”
(p. 259).14 Nevertheless, the overuse of aggressive treatment
is not only a problem resulting from physicians’ perception
about the limitations of medicine but also a predicted matter
intentionally overlooked by some healthcare professionals.
According to Gawande, almost half of oncologists confess
that they provided patients with certain treatments from which
they know the patient will most likely not beneﬁt.14
Additionally, the study conducted by Thanh N. Huynh et al.
shows that based on the critical care specialists’ perception,
19.6% of patients in intensive care units in the United States
receive futile or probably futile treatment.16
From this perspective, the goals of medicine, particularly in
the end-of-life-related areas, need to be reassessed and elaborated in order to determine the ethical limits of medical interventions in death and dying. The Hastings Center’s report, The
Goals of Medicine: Setting New Priorities, prepared by an international group from 14 countries, speciﬁes the goals of medicine as:
The prevention of disease and injury and promotion and maintenance of health.
The relief of pain and suffering caused by maladies.
The care and cure of those with a malady, and the care of those who
cannot be cured.
The avoidance of premature death and the pursuit of a peaceful
death (executive summary).1
Although it is possible to associate all four goals with
end-of-life care, the goals whose purposes are to relieve pain
and suffering, take care of patients with incurable maladies,
and avoid premature death and fulﬁll a peaceful death are
essential ones dictating speciﬁc actions in the end-of-life
issues. Nevertheless, the primary challenge is how to interpret
these goals and how to set their limits. Furthermore, the
matter of whether there is a need for prioritizing goals and determining an ultimate goal is another important discussion.
Especially in regard to end-of-life care, whether to prolong
life at all costs or to relieve pain and suffering through any available means are fundamental questions. As Callahan emphasizes,
whether to “aggressively work to prolong life until it becomes
futile, or harmful, to continue doing so; then, just as boldly,
halt life-extending treatment” or to consider the inevitability
of human mortality and place greater attention on the quality
of life and the relief of pain and suffering are the key dilemmas
(p. 41).11
The Hastings Center’s report does not identify any priority
for the goals of medicine but recommends “a temperate [and]
prudent medicine,” which “respects human choice and
dignity” (p. 24, 10).1 The temperate and prudent medicine
requires acknowledging the indispensability of death and the
existence of a certain amount of pain and suffering despite all
medical possibilities. In terms of the goal of medicine in
end-of-life care, Callahan underscores the signiﬁcance of relieving pain and suffering in order to achieve a peaceful death.11
Similarly, Cassell concludes that “the relief of suffering is the
368
fundamental goal of medicine” (p. 291).10 In light of all these
approaches, it is possible to make a deduction that the goal of
medicine in end-of-life care is to relieve pain and suffering to
accomplish a peaceful death.
Role of Compassion in End-of-Life
Alleviating patients’ pain and suffering is a primary goal of
medicine and essential duty of healthcare professionals.17
Cassell distinguishes pain from suffering and claims that it is
a main obligation of physicians to assuage the suffering of
patients even when it is impossible to mitigate the pain.10
Cassell explains suffering “as the state of severe distress associated with events that threaten intactness of person” (p. 32).10
According to Cassell, suffering may derive from an external
source, such as an injury or illness or the person’s self as internal
distress. He also highlights that although relieving suffering is a
crucial duty of healthcare professionals, they fail to achieve that
duty because of focusing only on external sources of suffering,
rather than also taking into consideration internal sources of suffering, like emotional, psychological, and spiritual disturbances.10 Callahan demonstrates a similar approach by
relating pain to the physical body and suffering to “a person’s
psychological or spiritual state” (p. 95).11 Therefore, even
though there is a cause-and-effect relationship between pain
and suffering, the two terms are not interchangeable.
Suffering may stem from many sources, merely one of which
is pain. Moreover, pain does not always cause suffering, and
suffering does not always require pain; suffering can exist
without pain, and pain can exist without leading to suffering.
Similar to the difference between pain and suffering, it is
possible to draw a distinction between curing and healing to
address the role of medicine and compassion in pain and suffering. According to David C. Thomasma, medicine can cure, but
not heal; curing is related to the patient’s pain, while healing is
associated with the person’s suffering; curing can be accomplished through medical means and interventions, but healing
needs compassion.18 Based on his view, curing the patient’s
pain demands medicine, whereas healing the person’s suffering
requires compassion.
In regard to the relationship between suffering and compassion, Petra Gelhaus considers compassion a combination of “the
recognition of a situation of suffering with benevolence and the
motivation to help” (p. 408) and Charles J. Dougherty and Ruth
Purtilo regard compassion as a necessary part of the patientphysician relationship.19,20 According to Laura W. Ekstrom,
the failure of compassion in the therapeutic relationship
exposes vulnerabilities in both human dignity and psychological health and people’s physical well-being.21 These statements
reveal that compassion and suffering are inversely proportional;
showing compassion mitigates or reduces suffering, and the
lack of compassion causes or increases suffering.
Even though “philosophical deﬁnitions of compassion” do
not stipulate a connection between compassion and helping,
lexical deﬁnitions and scholarly works indicate a tendency to
help the sufferer (p. 22).22 The Cambridge Online Dictionary
Journal of Palliative Care 37(3)
describes compassion as “a strong feeling of sympathy and
sadness for the suffering or bad luck of others and a wish to
help them.”23 This deﬁnition contains three components: it is
a feeling of sympathy; it is about the suffering of others; and
it encompasses the wish to help. Andre Comte-Sponville analyzes compassion with a viewpoint similar to the lexical description. He stresses some characteristics of compassion as follows:
it carries a solely positive connotation; it is universal because it
focuses directly on suffering without morally judging the causes
of the suffering; and it does not merely value the suffering of
human beings, but the suffering of all beings.24
Thomasma considers compassion a virtue that “urges us
forward from the feelings, prompting toward explicit activities
of care, from kissing the child’s cut to providing hospice care
for the dying” (p. 416).18 Even though Thomasma accepts the
interconnection between compassion and feelings, he says that
compassion transcends the existence of certain feelings by
turning them into a readiness to help the sufferer.18
Comte-Sponville reaches a parallel conclusion by evaluating
the interaction between compassion and feelings. He articulates
that “[c]ompassion allows us to pass from one realm to the
other, from the emotional realm to the ethical realm, from
what we feel to what we want, from what we are to what we
must do” (p. 116).24 From this perspective, compassion is not
only a feeling that leads human beings to sympathize with the
suffering of others, but also creates an impulse to relieve that
suffering.
Ethics of Euthanasia and PAS
The previous section demonstrates that suffering is a fundamental phenomenon requiring and urging medicine and human
beings to alleviate it as much as possible. As Callahan states,
“our highest moral duty to one another is the relief of suffering”
(p. 97).11 However, the central debate is whether euthanasia and
PAS can be morally justiﬁable methods when relieving pain and
suffering. It is doubtless that current medical options do not
have the capacity to eliminate all types of suffering without
killing or hastening death. Therefore, one of the major arguments embracing the demand for euthanasia and PAS is the
idea of relieving pain and suffering. Nevertheless, the following
subsections will expound on why medicine should not utilize
euthanasia and PAS as means to achieve one of the primary
goals of medicine – relieving pain and suffering.
Principle of Non-Maleﬁcence
As a traditional principle of medical ethics, non-maleﬁcence
encompasses a negative moral obligation to do no harm.3
According to Bernard Lo, do no harm has different meanings:
not providing ineffective interventions; not acting maliciously;
acting “with due care and diligence”; and not worsening the
patient’s situation if it is not possible to beneﬁt the patient
(p. 33).2 Killing is commonly deemed serious harm or evil.
For instance, Gert, Culver, and Clouser introduce do not kill
as a moral rule, accepting killing as harm.25 Bert Gordijn and
Avci
his colleagues emphasize how “[t]he ban on killing innocent
human life is one of the most widely accepted ethical norms
of humanity” (p. 191).26 The immorality of killing and its connection with harm goes back to the time of Hippocrates, as highlighted in the Hippocratic Oath “I will do no harm … I will not
give a lethal drug to anyone if I am asked, nor will I advise such
a plan.”27 In this view, it is possible to assert that nonmaleﬁcence is a fundamental principle rejecting undue harm
including killing.
Nevertheless, neither do no harm nor do not kill is an absolute moral rule. For example, killing is considered legitimate in
the case of self-defense or during a war. In this context, in the
event of the presence and persistence of unbearable pain and
suffering, why should killing not be acceptable on the
grounds of relieving the suffering? If relieving suffering and
pursuing a peaceful death are two primary goals of medicine,
and some types of killing are morally justiﬁable, why are
medical facilities not utilized to terminate a person’s life in
order “to achieve a compassionate and painless death”
(p. 801)?28 In such a case, the intention of terminating a
patient’s life is not to harm him/her; on the contrary, the
purpose is to relieve the patient’s intolerable suffering.
Furthermore, euthanasia and PAS are used as means to end
the patient’s/person’s suffering through medical instruments.
However, euthanasia and PAS require a positive action to do
something, like injecting or preparing a fatal medication. This
means that irreversible harm emerges as the result of a healthcare professional’s action. Even though there is a strong
reason (uncontrollable pain and suffering) for inducing that
harm, the action is morally illegitimate. Firstly, it is difﬁcult
to prove whether unbearable suffering stems from medical incapability or derives from the healthcare professionals’ insufﬁcient and inaccurate approach. Secondly, the action is
immoral by itself because the direct and foreseen consequence
is killing, which represents a moral violation. As Jonsen and
his colleagues point out, “[p]rohibition of direct taking of
human life has been a central tenet of many religious traditions”
that attracts the attention of the secular ethics as well (p. 157).17
Thirdly, although it may be claimed that the patient autonomously desires the outcome, it is questionable whether the
patient is capable of making such a substantial decision under
the conditions of intolerable pain. Cassell asserts that
the patient’s request for dying does not mean that the patients
want to die; the requests chieﬂy result from depression,
mental illness, desperation, or suffering that the patients
have.10 Finally, as Callahan elaborates, killing a person even
based on relieving suffering is evil; justifying this evil under
any condition will transform it into a duty to kill over time;
once it is legitimized in a society, then no one can guess
where and when it will stop.11
Unreliability of Compassion
Relieving pain and suffering is the central goal of medicine and
the traditional duty of healthcare professionals. Nevertheless,
this does not imply that medicine and healthcare professionals
369
can always carry out the relief successfully. Despite all
medical endeavors, some patients still go through severe pain
and suffering. The idea of terminating a person’s life comes
from that failure. Severe pain and suffering in end-of-life
covers all dimensions of human life and prevents the person
from almost all human functions. In such cases, in general,
healthcare professionals are medically impotent to assuage
pain and suffering and ethically prohibited to end the patient’s
life (based on do not kill). However, as a feeling and virtue,
compassion exhorts caregivers to explore appropriate methods
to help the person with oppressive pain and suffering, as a
duty for healthcare professionals to heal their patients.18,20
In regard to the principle of non-maleﬁcence, as noted above,
killing is deemed evil and harm, and in the case of euthanasia
and PAS, there is no sufﬁcient evidence that the relief of suffering morally outweighs the evil of killing. Based on do no harm,
medicine should not conduct any practice that causes a direct,
intended, and predicted harm without generating a greater
beneﬁt, which means that harm may be induced if a proportionally larger beneﬁt is possible. Since non-maleﬁcence is a prima
facie principle, euthanasia and PAS could be justiﬁed if it is
believed that ending pain and suffering carries a greater
beneﬁt than terminating a life. Nevertheless, apart from selfdefense and in war, killing a person is chieﬂy considered
morally unjustiﬁable because of its serious and irreversible
harm.11 On the other hand, compassion may be deemed an absolute value or necessity for healthcare professionals in the therapeutic relationship.29,30 Such an assumption entails showing
compassion to every patient who suffers and needs help.24
For this reason, it might be reasonable to defend that if available
medical interventions are incapable of relieving pain and suffering, euthanasia and PAS may be used as means to help the
person on the grounds of compassion and based on the following interpretations of compassion:
– Compassion is an absolute virtue/value,
– Compassion is a duty for healthcare professionals,
– Compassion is a solid feeling to help,
– Compassion does not have a limitation because it is a purely
positive concept.
Mahatma Gandhi, a prominent human rights activist and spiritual leader, is one of the pioneers justifying killing through
the notion of compassion. According to Gandhi, the idea of
compassion legitimizes killing a person under three circumstances: the impossibility of cure, the failure of relieving suffering, and the absence of motivations of self-interest.31,32
Nevertheless, due to the following reasons, compassion
should not be interpreted as a morally respectable foundation
for euthanasia and PAS. Firstly, regardless of whether it is a
virtue or not, compassion denotes feelings, which may vary
from person to person in light of cultural, religious, political,
and individual stances; it may be utopian to expect compassion
or the same level of compassion from everyone toward a speciﬁc case. In other words, compassion is not an objective phenomenon that can be understood, shown, or applied by
370
everyone in the same way. As Hans Jones states, establishing a
morality or “an ethics based on compassion alone is something
very questionable” (p. 48).33 Secondly, compassion urges
people to help, but killing is not an act of help; terminating a
life is a reﬂection of desperation; help encompasses promising
outcomes or a high probability of them. If euthanasia and
PAS are acknowledged as morally acceptable ways to help,
then terminating the life of any miserably suffering individual
would be justiﬁable and may even turn into a duty. Thirdly,
even though compassion is mostly accepted as an essential component of healthcare services, measuring and teaching/learning
compassion are problematic matters.34,35 In this view, objectivity, measurability, and teachability are crucial issues in the reliability of compassion. Finally, compassion is not an unlimited
feeling of help; it should be limited to alleviating suffering
without engaging in any direct action that terminates the sufferer’s life; compassion should be shown as long as there is chance
and room to help. In other words, as Roger Crisp highlights,
compassion is an essential component of human beings to
take care of and help others, but it should be limited to a constructive form of help.36
Conclusion
Relieving pain and suffering is a traditional and indispensable
goal of medicine. However, current medicine is impotent to
completely alleviate all forms of pain and suffering with available medical options. The present article inquired into whether
euthanasia and PAS may be utilized as means to fulﬁll one of
the primary goals of medicine – relieving pain and suffering
– based on the notion of compassion. The article concluded
that neither euthanasia and/or PAS should be used as means
to achieve any medical goal, nor compassion to justify these
life-ending interventions. Terminating the life of a person
with intolerable pain and suffering means actively employing
medicine to induce undue harm. Of course, do no harm – or
do not kill – is not an absolute moral rule, but utilizing
medical knowledge, experience, and tools for terminating a
life would transform the curing role of medicine into a destroying function. Medicine should protect, promote, and maintain
people’s wellbeing, not terminate their life. Additionally, interpreting compassion as the moral reasoning to terminating the
suffering person’s life is complicated; compassion requires
helping the sufferer, but euthanasia and PAS are life-ending
interventions. Furthermore, compassion refers to feelings,
which could vary from person to person. In this sense, compassion is not an objective, reliable, and applicable standard in the
ethical evaluation of euthanasia and PAS. Therefore, medical
options and compassion should be construed as providing
patients with adequate and accurate medical, palliative, spiritual, and emotional care.
Declaration of Conﬂicting Interests
The author(s) declared no potential conﬂicts of interest with respect to
the research, authorship, and/or publication of this article.
Journal of Palliative Care 37(3)
Funding
The author(s) received no ﬁnancial support for the research, authorship,
and/or publication of this article.
Ethical Approval
Not applicable, because this article does not contain any studies with
human or animal subjects.
Informed Consent
Not applicable, because this article does not contain any studies with
human or animal subjects.
Trial Registration
Not applicable, because this article does not contain any clinical trials.
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Medicine, Health Care and Philosophy (2019) 22:239–244
https://doi.org/10.1007/s11019-018-9864-8
SCIENTIFIC CONTRIBUTION
The psychological slippery slope from physician-assisted death
to active euthanasia: a paragon of fallacious reasoning
Jordan Potter1
Published online: 25 August 2018
© Springer Nature B.V. 2018
Abstract
In the debate surrounding the morality and legality of the practices of physician-assisted death and euthanasia, a common
logical argument regularly employed against these practices is the “slippery slope argument.” One formulation of this argument claims that acceptance of physician-assisted death will eventually lead down a “slippery slope” into acceptance of active
euthanasia, including its voluntary, non-voluntary, and/or involuntary forms, through psychological and social processes that
warp a society’s values and moral perspective of a practice over an extended period of time. This formulation is known as
the psychological slippery slope argument. This paper analyzes the psychological slippery slope argument as it is applied to
the practice of physician-assisted death, and utilizing recent empirical evidence from various nations around the world that
practice physician-assisted death and/or euthanasia, the paper argues that (1) employing the psychological slippery slope
argument against physician-assisted death is logically fallacious, (2) this kind of slippery slope is unfounded in practice,
and thus (3) the psychological slippery slope argument is insufficient on its own to justify continued legal prohibition of
physician-assisted death.
Keywords Physician-assisted death · Euthanasia · Physician-assisted suicide · Physician aid-in-dying · Slippery slope ·
End-of-life
The New England Journal of Medicine recently published
several studies demonstrating significantly increased rates of
euthanasia in both the Netherlands and Belgium. In August
of 2017, one study was published that found that euthanasia
rates in the Netherlands jumped from 1.7% of all deaths
in 1990 to 4.5% of all deaths (a 265% increase) in 2015,
and a jump from 2.8% to 4.5% occurred from 2010 to 2015
alone. This is in addition to an overall increase in end-oflife decisions preceding patient deaths, increasing to 58%
of all deaths in 2015 from 39% of all deaths in 1990 (van
der Heide, van Delden, and Onwuteaka-Philipsen 2017).
In 2015, a study from Belgium reported an eerily similar
increase in euthanasia rates from 1.9% in 2007 to 4.6% in
Disclaimer: The views expressed in this article are those of the
author and do not represent the position or policy of Cleveland
Clinic.
* Jordan Potter
potterj3@ccf.org; jordangabrielpotter@gmail.com
1
Cleveland Clinic, Center for Bioethics, 9500 Euclid Avenue,
Cleveland, OH 44195, USA
2013, representing an increase in both requests (3.5%–6.0%
of deaths) and requests granted (56.3%–76.8%). The authors
of this paper opined that “after 11 years of experience,
euthanasia is increasingly considered as a valid option at the
end of life in Belgium” (Chambaere et al. 2015: 1179–1180).
Inevitably, opponents of physician-assisted death (PAD)
in the U.S. will extrapolate this evidence from the Netherlands and Belgium as part of a “slippery slope” justification
for the continued prohibition of PAD in most U.S. states.
This is a common type of argumentation in both ethics and
law known as a slippery slope argument, and these arguments have long been central to the debate surrounding the
legalization of PAD and euthanasia. However, while slippery
slope arguments regarding euthanasia are well-addressed in
the professional literature, there is little recent literature analyzing slippery slope arguments in the context of PAD—
specifically the psychological slippery slope argument that
PAD legalization is a slippery slope to euthanasia legalization—even though these types of arguments are common
in the media and other venues of bioethics and health law
discussion (for example, see Beckford 2010; Kamisar 1997;
and Hurst 2015). This paper then aims to address that hole
13
Vol.:(0123456789)
240
in the literature. By analyzing the logic of the psychological
slippery slope argument and applying that logic to the most
recent empirical data available from nations worldwide that
practice PAD and/or euthanasia, this author argues that the
psychological slippery slope argument against PAD legalization is logically fallacious and insufficient on its own to
justify continued prohibition of PAD.
PAD versus euthanasia
Though many use the concepts of PAD and euthanasia interchangeably, there are significant practical, and many also
believe moral, distinctions between the two concepts and
their subcategories, and understanding these distinctions is
critical to any discussion regarding a potential slippery slope
between these practices. Euthanasia is a larger, overarching
concept that can be broken down into several subcategories,
including passive euthanasia and active euthanasia. Where
passive euthanasia refers to the withdrawal or withholding
of life-sustaining treatment at the end of life,1 Active Euthanasia (AE) refers to the active and intentional termination
of life via medical means by a medical professional. AE
can then be further broken down into three other subcategories depending upon the act’s voluntariness. Voluntary AE
is when a conscious patient with decision-making capacity
explicitly requests a physician to end their life, which usually
occurs in terminal patients or patients with unbearable suffering. This is contrasted with both non-voluntary (without
an explicit patient request or consent—usually in incapacitated patients and/or those in persistent vegetative states)
and involuntary (against an explicit wish to not undergo
euthanasia—essentially murder) forms of AE (Potter 2015).
Differently, PAD is when a physician merely provides a
patient with the means to end one’s life, such as prescribing
the patient a lethal dose of a barbiturate, rather than actively
administering the lethal drugs and terminating the patient’s
life themselves. While most slippery slope arguments focus
on AE and its various subcategories, this paper primarily
focuses on the less commonly utilized variant of the slippery slope argument from PAD to AE, including the various
subcategories of AE and other similar formulations of the
slippery slope argument that begin with PAD.
1
In practice, especially in the clinical setting, it is best to avoid the
language of “passive euthanasia” when referring to withdrawing or
withholding life-sustaining treatment, because since these distinctions
between PAD and euthanasia, let alone the various subcategories of
euthanasia, are not well known and understood, confusions may arise
that conflate withdrawing or withholding life-sustaining treatment
with more active and controversial forms of active euthanasia.
13
J. Potter
What is a slippery slope argument?
In the realms of ethics and law, a slippery slope argument
utilizes a conditional proposition and argues that acceptance of a relatively minor practice A will eventually lead to
acceptance of a much more substantial and less favorable
practice Z, which in turn provides sufficient justification for
denying the possibility of practice A altogether. Essentially,
slippery slope arguments posit a conditional proposition in
the traditional format of “if P, then Q” and argue that avoidance of “Q” then justifies the prohibition of “P,” even if “P”
is viewed as acceptable in itself.2 Describing these types of
arguments, Walter Wright states:
Typically, “slippery slope” arguments claim that
endorsing some premise, doing some action or adopting some policy will lead to some definite outcome
that is generally judged to be wrong or bad. The
“slope” is “slippery” because there are claimed to be
no plausible halting points between the initial commitment to a premise, action, or policy and the resultant
bad outcome. The desire to avoid such projected future
consequences provides adequate reasons for not taking
the first step (Wright 2000:177).
These arguments then come in two main forms with differing explanations for the causal nature of the slippery
slope. The first form is known as the “logical” slippery
slope argument. This argument claims that acceptance of
some practice A (PAD) then logically entails acceptance of
some immoral or less desirable practice Z (AE in its various forms) due to the two practices’ conceptual similarities
(Shariff 2012:147–148). Prohibiting PAD is then justified
by disallowing this logical entailment leading to further
acceptance and legalization of AE in its various forms. This
2
This is an interesting and important point to highlight, because
these types of slippery slope arguments have been utilized by both
those fundamentally opposed to PAD and those sympathetic to PAD
as a morally licit practice in itself. One’s perspective on the antecedent of the conditional (i.e. “P”) is ultimately irrelevant so long as one
perceives the consequent of the conditional (i.e. “Q”) to be immoral,
unacceptable, and/or not proper for legalization. For example, Tom
might find PAD to be a perfectly moral and acceptable practice in
itself, but due to the belief that it will eventually lead to acceptance
and legalization of practices that Tom finds immoral and unacceptable (e.g. AE in its various forms), Tom does not believe that PAD
should be accepted by society and legalized in order to avoid this
potential slippery slope. Thus, as long as the result of the slippery
slope is seen as sufficiently immoral, unacceptable, and/or unfit for
legalization, the perspective on PAD is ultimately irrelevant, as the
main motivating factor is avoiding the result of the slippery slope,
not one’s perspective on PAD, which means this type of argumentation is not limited simply to those who already oppose PAD on moral
grounds.
241
The psychological slippery slope from physician-assisted death to active euthanasia: a paragon…
is essentially the perspective of David Jones from the Anscombe Bioethics Centre:
…Prof Jones argued that the legalization of assisted
suicide logically leads to the tolerance of non-voluntary euthanasia. He said that anyone who wants to
legalize assisted suicide must believe that it is better
for some people, such as the terminally ill, to end their
lives. They must therefore agree that it is also right to
help physically disabled people to die if they cannot
administer the fatal dose themselves. Prof Jones said
the logical conclusion of this “slippery slope” is that
society must permit doctors to kill mentally ill people,
who are unable to give consent, if their life is deemed
not worth living (Beckford 2010).
While logical slippery slope arguments are interesting,
this form of the slippery slope argument is viewed as less
credible than other forms of the slippery slope argument,
and it is less often utilized by opponents of the legalization of PAD or AE (Lewis 2007: 197). Thus, it will not be
the primary focus of this paper, but rather a secondary and
more widely-discussed form of the slippery slope argument
known as the “psychological” or “empirical” slippery slope
argument will be the primary focus of this paper. Rather than
relying on logical entailment, this form of the slippery slope
argument claims that over time, through psychological and
social processes, acceptance of some practice A ultimately
warps and changes a society’s values and moral perspective on a differing, less desirable practice Z, which leads
into the society eventually accepting the latter practice as
just as morally and legally acceptable as the former practice
(Shariff 2012: 147–148). In the context of PAD, the psychological slippery slope argument claims that acceptance
and legalization of PAD will eventually lead to acceptance
and legalization of AE based on psychological and social
processes that change society’s values and moral perspective over time, which justifies the prohibition of PAD. This
is the perspective of the renowned American constitutional
lawyer Yale Kamisar:
What we cannot do in one step- perhaps even think about
doing- we can often do in two or three or four. The modern history of our activities and beliefs about the law
and ethics of death and dying is a good illustration- it
is ‘a history of lost distinctions of former significance’
(e.g. ‘extraordinary means’ versus ‘ordinary means,’ the
respirator versus the feeding tube). My colleague Carl
Schneider has called this step-by-step process ‘a psychological aspect of slippery slopes’: They work partly by
‘domesticating one idea’ (say, disconnecting the respirator) and thus making its nearest neighbor (terminating
‘artificial’ feeding) ‘seem less extreme and unthinkable.’
What many used to call ‘negative’ or ‘passive’ eutha-
nasia has become a fait accompli in modern medicine.
The next sequence of events is likely to be physicianassisted suicide for (a) the terminally ill, (b) those with
an ‘objective medical condition’ that significantly diminishes the quality of life, and (c) those whose wish to
die is ‘objectively reasonable.’ If so, as this progression
unfolds, active voluntary euthanasia will become more
thinkable, more tenable and more supportable (Kamisar
1997: 244–245).
Psychological slippery slope arguments can also focus on
the frequency of the practice or the demographics of those
that utilize the practice. For example, one alternate formulation of the psychological slippery slope argument claims that
acceptance of PAD eventually leads to its “routinization” and/
or overutilization into inappropriate usages of PAD. Another
alternate formulation of this argument claims that acceptance of PAD eventually slides down the slippery slope into an
exploitative practice that preys upon traditionally marginalized
groups, e.g. the poor, minority populations, the disabled, etc.,
due to their particular vulnerabilities. An example would be
poorer minority populations being unduly influenced or pressured into utilizing PAD for a loved one due to the cheaper cost
of PAD drugs compared to end-of-life palliative care.
While not necessarily always true, in informal logic slippery slope arguments are generally considered weak forms
of logical reasoning, and many times they are even classified
as logical fallacies that are not consistent with sound logical
reasoning. For moral and legal slippery slope arguments, a
slippery slope fallacy occurs when one argues for the prohibition of practice A due to the belief that it will eventually lead
to some immoral or less desirable practice or state of affairs Z
without either: (1) showing evidence that allowance of A will
probably lead into Z, or (2) arguing that A is immoral or should
be prohibited itself. This is logically fallacious, because without sufficient evidence supporting a probable slippery slope
from A to Z, this argument becomes a “red herring” argument
(another logical fallacy) that diverts attention away from the
issue at hand (the allowance of A) to argue some irrelevant
position (the immorality of Z) that is not causally or empirically connected to the issue at hand in the first place. To avoid
the status of a logical fallacy, then, the psychological slippery
slope argument must demonstrate and provide empirical evidence highlighting a substantial probability that acceptance
and legalization of PAD will ultimately devolve into an acceptance and legalization of AE.
The psychological slippery slope and PAD
The problem with the psychological slippery slope argument
against PAD is that the empirical evidence suggests that
there simply is no observable slippery slope from legislation
13
242
of PAD to acceptance and legalization of AE in any of its
forms. For example, there is zero empirical evidence supporting such a legislative slippery slope from legislation of
PAD to legislation of AE, because there has literally been
no occurrence of this slippery slope in nations, states, or
territories where PAD is legally practiced but AE is illegal.
While AE is legally practiced in some form in the Netherlands, Belgium, Colombia, Luxembourg, and Canada, all of
these nations either legislated PAD and AE simultaneously
or legislated AE without PAD, meaning AE legislation has
never evolved from PAD legislation. Further, there are several territories where PAD is legal but AE is not, including
Switzerland and the U.S. states and territories of Oregon,
Washington, Montana, Vermont, California,3 Colorado,
and the District of Columbia (Emanuel et al. 2016; Nirappil
2017). None of these territories that allow PAD have ultimately transitioned to allow AE, too, which defies the claims
of the psychological slippery slope argument from PAD to
AE. One of the better examples of this evidence is the nation
of Switzerland, which has legally practiced PAD for over
three decades with no move toward also legislating AE.
Another salient example is the U.S. state of Oregon, which
just celebrated the 20th anniversary of the implementation
of their Death with Dignity Act with no move toward AE
(“Oregon Death with Dignity Act: Data Summary 2016”).
In law and health policy, then, this psychological slippery
slope simply does not seem to obtain.
But even barring the lack of AE legislation arising out of
previous PAD legislation, there is also a paucity of empirical evidence suggesting any change in public attitudes and
perceptions toward AE after PAD legislation. While admittedly there seems to be no concrete empirical evidence that
has studied and compared public attitudes and perceptions
toward PAD and AE both before and after legislation in
particular contexts, e.g. in Oregon or Switzerland, there is
other related evidence that suggests that this type of psychological slippery slope in public attitudes and perceptions
does not exist. For example, in Switzerland, where PAD has
been legally practiced for decades, recent national surveys
suggest that there has been no surge in favorable attitudes
toward AE, and PAD is regularly perceived as (slightly)
more favorable than AE (both morally and legally) by
Swiss nationals (Schwarzenegger et al. 2013). Similarly,
though it was a national survey that was not specifically
limited to Oregon citizens, in a recent Gallup poll it was
found that Americans’ positive attitudes toward AE have
been relatively stable, if not even decreasing, ever since the
3
There have been recent legal challenges to the legitimacy of California’s End of Life Option Act; however, at the time of writing (June
21, 2018) a California state appeals court has temporarily reinstated
the law pending further litigation. For more information, refer to the
CBS News article in the references.
13
J. Potter
introduction of PAD in Oregon in the mid 1990s. Interestingly, though, while attitudes toward AE have been relatively
stable during this timeframe, positive attitudes toward PAD
have significantly increased since Gallup started inquiring
about this practice in the late 1990s. From 1997 to 2017,
support for the legalization of PAD has jumped from 52% to
67%, and a jump from 49% to 57% was noted from 2002 to
2017 regarding the moral acceptability of PAD (Wood and
McCarthy 2017). Thus, the little evidence that is available
suggests that the psychological slippery slope from PAD to
AE is simply not a factor in this context, which is consistent
with the fact that there have been no actual occurrences of
this legislative slippery slope in nations that legally practice
PAD but not AE.
With regard to the alternate formulations of the psychological slippery slope argument against PAD, evidence
from Oregon highlights that there is also no slippery slope
into exploitation of vulnerable, marginalized groups. In
2017, 143 people died in Oregon from PAD, and they were
largely white (94.4%), well-educated (48.9% having Bachelor’s Degrees), and well-insured with some form of health
insurance (99.1%) (“Oregon Death with Dignity Act: Data
Summary 2017”). These demographics have been fairly consistent through the years in Oregon and the other states that
have legalized PAD, as a recent article from JAMA details:
“The demographic profile of patients in the United States
[with a majority being from Oregon] who have received
these interventions [PAD] is white, well-educated, and
well-insured” (Emanuel et al. 2016: 87). The statistics are
virtually identical in Washington State, too (“Washington
State 2016 Death with Dignity Act Report”). And even in
the much more diverse state of California, results from the
first 6 months after the End of Life Option Act was enacted
highlight a very similar picture: the vast majority of those
who utilize PAD are white (89.5%), well-insured (96.4% had
some sort of medical insurance), and well-educated (72.1%
had some level of college education; 57.6% had an Associate’s Degree or higher) (“California End of Life Option Act:
2016 Data Report”). Thus, at least in the U.S., this concern
of PAD “slipping” into an exploitative practice that preys
on vulnerable, marginalized populations is simply not supported by the statistical empirical evidence.
However, when it comes to “routinization” and increased
usage of these practices, there is substantial evidence that
this does occur in some fashion in most contexts, including
AE in Belgium and the Netherlands and PAD in Oregon
and Washington State. In virtually every context considered,
there is an eventual uptick in the rates of either AE or PAD,
most likely due to greater public acceptance of the practice
after longer exposure and comfort with the practice, which
The psychological slippery slope from physician-assisted death to active euthanasia: a paragon…
is consistent with the evidence from the Gallup poll above.4
So the question is this—is the “routinization” and increased
usage of PAD sufficient to justify continued prohibition of
PAD in most U.S. states? No, it is not, because making this
type of argument is ultimately utilizing the slippery slope
fallacy that was described above. Remember, for moral
and legal slippery slope arguments a slippery slope fallacy
occurs when one argues for the prohibition of practice A due
to the belief that it will eventually lead to some immoral or
less desirable practice or state of affairs Z without either: (1)
showing evidence that allowance of A will probably lead into
Z, or (2) arguing that A is immoral or should be prohibited
itself. This is logically fallacious, because without sufficient
evidence supporting a probable slippery slope from A to Z,
this argument essentially becomes a fallacious “red herring”
argument that diverts attention away from the issue at hand
(the allowance of A) to argue some irrelevant position (the
immorality of Z) that is not causally or empirically connected to the original issue at hand.
But this is exactly what the psychological slippery slope
argument against PAD employs in its logical analysis. Since
the empirical evidence clearly does not support any substantial probability that acceptance and legalization of PAD
will eventually devolve into acceptance and legalization of
AE, this argument is employing a “red herring” fallacy by
arguing that avoidance of AE justifies the continued prohibition of PAD, even though the two practices are not causally
or empirically connected. Thus, rather than arguing for the
immorality and justifiable prohibition of PAD itself, this
type of logical argument relies on the perceived slippery
slope and undesirable consequences of the acceptance of
PAD in order to logically function. But if there is neither a
slippery slope into AE nor overutilization of PAD into cases
where it is not medically indicated or appropriate, which
the evidence from Oregon, Washington State, and California presented above demonstrates, then “routinization” and
increased usage of PAD is not a sufficient, or even rational,
logical justification for the continued prohibition of PAD,
because it does not establish the immorality or jus…

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