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17.05.

2017 AssstedSucdeandEuthanasaHollandFreCancerMedcneNCBIBookshelf

NCBIBookshelf.AserviceoftheNationalLibraryofMedicine,NationalInstitutesofHealth.

KufeDW,PollockRE,WeichselbaumRR,etal.,editors.HollandFreiCancerMedicine.6thedition.
Hamilton(ON):BCDecker2003.

AssistedSuicideandEuthanasia
EzekielJ.Emanuel,MD,PhDandStevenJoffe,MD,MPH.

HistoricalPerspective
Theethicsofeuthanasiahavebeenacontentiousissuesincethebeginningofmedicine.118The
HippocraticOathtakesastrongstandagainsteuthanasia,requiringdoctorstopledgenevertogive
adeadlydrugtoanybodyifaskedforit,normakeasuggestiontothiseffect.6InancientGreece
andRome,thispositionwastheminorityviewasitwascommonforphysicianstoparticipatein
euthanasiaandphysicianassistedsuicide(PAS).Themoderndebateabouteuthanasiacanbedated
from1870,whenanonphysician,SamuelWilliams,arguedforeuthanasiainfrontofthe
BirminghamSpeculativeClub.118Thisspeechsparkeddebateaboutlegalizingeuthanasiaamong
AmericanandBritishphysiciansinthelatenineteenthcentury.118In1905,abillwasintroduced
intotheOhiostatelegislaturetolegalizeeuthanasia,butwasdefeated.118Thecontemporary
debatebecamemoreintenseandpublicwiththegrowingacceptanceofterminatinglifesustaining
care,thepermissibilityofeuthanasiaintheNetherlands,theKevorkiansuicidemachine,andthe
publicationin1988ofthearticleIt'sover,Debbie.119Toclarifythedebate,we(1)reviewthe
definitionsofkeyterms,(2)delineatetheargumentsforandagainsteuthanasiaandPAS,(3)
reviewtheUSSupremeCourt'sruling,(4)reviewthedataoneuthanasiaandPASinthe
Netherlands,and(5)reviewwhatweknowaboutthepracticesinothercountries.

Definitions
MuchconfusionsurroundsthedebatesabouteuthanasiaandPASbecauseofimprecise
terminology.Table794summarizestheessentialdefinitions.Importantly,socalledpassive
euthanasiaisactuallythewithdrawalorwithholdingoflifesustainingmedicalinterventionsandis
widelyacceptedasbothethicalandlegal.Inaddition,socalledindirecteuthanasia,increasing
narcoticstoeaseapatient'spainevenifthishastheconsequenceofhasteningthepatient'sdeath,
hasgenerallybeendeemedbothethicalandlegal.120Almostallcommentatorsagreethat
involuntary,andnonvoluntaryactiveeuthanasiaareunethicalbecausetheyendthelifeofapatient
withoutconsent.Consequently,thefocusofdebateintheUnitedStatesisonPASandvoluntary,
activeeuthanasia.Toavoidconfusion,useofthetermeuthanasiashouldberestrictedtovoluntary,
activeeuthanasia.

Table794

DefinitionsofAssistedSuicideandEuthanasia.

EthicalStandardsRegardingEuthanasiaandAssistedSuicide
ProponentstypicallycitefourreasonstojustifyPASoreuthanasia.121123First,itisclaimedthat
euthanasiaensurespatients'autonomy.122,123Individualshavedifferentvaluesandgoalsinlife
weprotectpatientautonomybypermittingpatientstopursuetheirgoals.Aproperdeathisas
essentialtoaperson'sgoalsandvaluesasanyotherchoice.Hence,torespectpatients'autonomy,
wemustrespectpatients'wishesregardingthemannerandtimingoftheirdeaththrougheuthanasia
andPAS.122,123Second,itisarguedthatforsomepatientsthedyingprocessinflictssignificant
painandsufferingandthateuthanasiaorPASmayrelievethemoftheseburdens.Hence,
euthanasiaorPASfurthersbeneficenceorthewellbeingofsickpatients.123Indeed,forsome
peoplejustknowingthereisthepossibilityofhavingeuthanasiaorPASmaybepsychologically
beneficial,eveniftheyultimatelyneverusetheseinterventions.Third,proponentsarguethat
euthanasiaismorallyindistinguishablefromtheacceptedpracticesofwithholdingand
122,123
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withdrawinglifesustainingcare.122,123Thisisbecausethefinalresult,thedeathofapatient,isthe
sameineitherscenarioandbecausethereisnomoraldifferencebetweenactsofomissionandacts
ofcommission.Fromamoralstandpoint,thereisnodifferencebetweenmerelylettingnaturetake
itscourseandactivelykillingapatientifthepatientconsciouslyandknowinglyrequestshisorher
lifebeterminated.Finally,itisarguedthattheadversepracticalconsequencesoflegalizing
euthanasiaorPASaretoospeculativeandhypotheticaltodeterminewhethertopermiteuthanasia
orPAS.Indeed,permittingeuthanasiaorPASshouldenhancethephysicianpatientrelationship,
becauseitmeansphysicianswillprovidewhatevercare,includingeuthanasiaorPAS,thatis
necessaryfordyingpatients.

OpponentsofeuthanasiaandPASofferfourparallelarguments.124,125First,opponentsclaimthat
autonomydoesnotjustifyeuthanasiaorPAS.124126Autonomydoesnotmeanapersonshould
bepermittedtodoanythingheorshewishes,especiallythoseactionsthatendtheabilitytoact
autonomously.126Onthisbasis,wedonotpermitvoluntaryduelingorvoluntaryenslavement.In
addition,evenifapersonwantstocommitsuicide,itisanotherissueentirelytopermitothersto
help.Second,beneficencemaynotjustifyeuthanasiaorPAS.Manyterminallyillpatients
experienceinadequatelytreatedpain,fatigue,anddepression.Ifwetreatedthesesymptoms
adequately,fewpeoplewouldhaveextremepainandsufferingthatwouldjustifyeuthanasiaor
PAS.124,125Third,itisarguedthatthereisanethicaldistinctionbetweenactsofomissionandacts
ofcommission.Evaluatingtheethicsofanactdoesnotonlydependonitsfinalresult,butwealso
mustevaluatehowthatresultwasproducedandtheintentionoftheactors.124Thereareethical
andlegaldifferencesbetweencasesinwhichapersonwaskilledbymistakeandcasesinwhich
thekillingwaspremeditated.Similarly,thereisadifferencebetweenstoppingamedicaltreatment
andlettingapatientdieandintentionallyandactivelyinjectingthepatientwithamedicationto
causehisorherdeath.Finally,opponentsnoteavarietyofadverseconsequencesthatmightresult
fromlegalizingeuthanasiaorPAS,includingdisruptionofthephysicianpatientrelationship,
intrusionofthecourtsintoterminatingcaredecisions,coercionofterminallyillpatientstocommit
euthanasiaorPAS,andextensionofeuthanasiatochildren,mentallyincompetentpatients,and
others.125

USSupremeCourtRulingonEuthanasiaandPAS
InJune1997,theUSSupremeCourtruledunanimouslythatthereisnoconstitutionalrightto
euthanasiaorPAS.89Manyofthejusticeswroteseparateopinionsandmanyseemedsympathetic
tothenotionofPASandeuthanasia,eveniftheydidnotdeemitaconstitutionalright.The
majorityviewwrittenbyChiefJusticeRehnquistdrewadistinctionbetweentherightto
withdraworwithholdlifesustainingtreatmentsasalibertyinterestinbeingfreeofunwanted
bodilyinvasionversustherighttoPAS,whichdoesnotcontainalibertyinterest.89Othersinquired
whetherarighttoPASmightbeviewedasarighttodeathwithdignitybut,nevertheless,rejected
thenotionofaconstitutionalrighttoPAS.89Theunanimityoftherulingsuggeststhatitisunlikely
tobeoverturnedinthefuture.Importantly,theSupremeCourtdidnotviewPASoreuthanasiaas
inherentlyunconstitutional,andthus,itpermittedindividualstates,suchasOregon,tolegalize
theseinterventions.

WithinweeksoftheSupremeCourtruling,Florida'sstatesupremecourtruledalsothatthereisno
stateconstitutionalrighttoPAS.127Similarly,otherstatesupremecourtshaveruledthatPASisnot
afundamentalright.128Also,MichiganandMainerejectedstatereferendatolegalizePAS.
OregonhasenacteditsDeathwithDignityActandasof2001hashad91casesofPAS.129,130

EuthanasiaandPASintheNetherlands
Recently,theNetherlandslegalizedeuthanasiaandPAS.Severalsafeguardsmustbeadheredto,
includingthat(1)thepatienthasunbearablepainandsufferingthatcannotbemedicallyrelieved
(2)thepatientiscompetentandrepeatedlymakesarequesttohavehisorherlifeendedand(3)
thephysicianconsultsasecondphysician.131,132

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TheDutchgovernmentcommissioneddetailedstudiesofthepracticesofeuthanasiaandPASin
1990andagainin1995,andindividualresearchershaveconductedmanyotherstudies.133135
Thesestudiesshowthatjustover50%ofDutchphysicianshaveparticipatedineuthanasiaorPAS
atsomepointintheircareersand29%withintheprevious2years.133,134Indeed,only
approximately12%ofDutchphysiciansindicatedthattheywouldneverperformeuthanasiaor
PAS.133,134Accordingtothelatestdata,approximately9,700patientsexplicitlyrequest
euthanasiaorPASeachyear.Andapproximately2.3%ofalldeathsintheNetherlandsareby
euthanasia,0.4%arebyPAS,and0.7%aredeathsinwhichactivemeasuresaretakentoendthe
patient'slifewithoutthepatient'sexplicitrequest.134Thus,approximately,3.4%ofalldeathsinthe
Netherlands,or4,600deathsannually,arebyeuthanasiaorPAS.134Importantly,80%ofthese
casesinvolvepatientswithcancer,3%involvepatientswithcardiovasculardisease,and4%
involvepatientswithneurologicdiseases.134Between1990and1995,thefrequencyofeuthanasia
andPAScasesincreasedfrom2.2%to2.7%ofalldeaths,althoughthefrequencyofintentional
deathswithoutthepatient'sexplicitrequestremainedconstantat0.7%to0.8%ofalldeaths.133,134

EmpiricalDataRegardingEuthanasiaandPAS
WhiletheDutchstudiesofeuthanasiaandPASarethemostvalidandreliable,dataare
accumulatingontheattitudesandpracticesofeuthanasiaandPASintheUnitedStatesandother
countries.136SurveysindicatethatamajorityoftheAmericanpubliciswillingtosupport
euthanasiaandPASinhypotheticalcasesandforterminallyillpatientswithpain.110,121Supportis
lowerwhenthequestioninvolveseuthanasiaorPASforreasonsotherthanpain.110Interestingly,
thishighlevelofsupportforeuthanasiaandPAShasbeenconstantsincethemid1970sandhas
notincreasedwiththedebatesoverthelast15years.136,137Similardifferenceshavebeenreported
amongCanadians.Inaddition,whilethereareconceptualdistinctionsbetweeneuthanasiaand
PAS,theAmericanpublicmakesnodistinctionbetweeneuthanasiaandPASthesameproportion
supportbothinterventionsforthesamesituation.110Importantly,peoplewhoarereligious,
Catholics,thoseolderthan65yearsofage,andAfricanAmericansaremuchlesslikelytosupport
euthanasiaorPAS.SupportamongAmericanphysiciansissignificantlylessthanamongthe
public.110Inalmostallsurveys,lessthanhalfofAmericanphysicianssupporteuthanasiaorPAS
andsignificantlyfewersupporteuthanasiathansupportPAS.Furthermore,thereisevidencethatat
leastamongAmericanoncologistssupportforbotheuthanasiaandPAShasdeclinedsignificantly,
byasmuchas75%,overthelastfewyears.138

SurveysinanumberofcountriesinwhicheuthanasiaandPASareillegalindicatethatphysicians
receiverequestsfortheseinterventionsanddoperformthem.InBritain,ithasbeenreportedthat
45%ofphysicianshavebeenaskedtohastendeath.139InAlberta,Canada,20%ofphysicians
reportedreceivingrequestsforactiveeuthanasia.IntheUnitedStates,manyphysicianshave
receivedrequestsforeuthanasiaandPAS,butdifferentstudiesprovidevastlydifferentestimatesof
thefrequency.110,121,138,140142AmongnononcologistsintheUnitedStates,itisreportedthat
between18.3%and26%havereceivedrequestsforeuthanasiaorPAS.140,141Reportsamong
oncologistsindicatethatbetween43%and62.9%ofoncologistshavereceivedrequestsfor
euthanasiaorPAS.110,136,142

InBritain,32%ofphysiciansindicatedthattheyhavetakenactivestepstobringaboutthedeath
ofapatient,althoughthismayincludeterminatinglifesustaininginterventions.139Again,inthe
UnitedStates,thereisalargedifferencebetweenoncologistsandotherphysicians.Amongnon
oncologists,itisreportedthatapproximately1.7%to4.7%hadperformedeuthanasiaand3.3%to
4.6%hadperformedPASintheircareer.140,141Amongoncologists,itisreportedthat3.7%to4%
hadperformedeuthanasia,while10.8%to18%hadperformedPASintheircareer.110,142Inthe
last12months,4%ofoncologistsperformedeithereuthanasiaorPAS.Importantly,iftheydo
performtheseinterventions,theydosorarely.Themediannumberofeuthanasiacasesistwoina
careerasisthemediannumberofPAScases.140Ifthesedataontheproportionofphysicianswho
haveperformedeuthanasiaandPASandthefrequencywithwhichtheyperformtheseeventsare

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accurate,theysuggestaverylownumberofcasesofeuthanasiaandPASintheUnitedStates.If
4%ofAmericanoncologists(400oncologists)perform1to2casesofeuthanasiaorPASperyear,
thentherearefewerthan1,000casesperyear,atinyfractionofthe2.4millionAmericanswhodie
annually.

AllavailabledataindicatethatthevastmajorityofcasesofPASandeuthanasiainvolveoncology
patients.Forinstance,inOregon,77%ofallpatientswhousedPASbetween1998and2001
sufferedfromcancer.129,130,143Importantly,contrarytoexpectations,thedatafromthese
countries,aswellassurveysofpatientswhomightbeeligibleforeuthanasiaorPASpatients
withcancer,110humanimmunodeficiencyvirus(HIV)/acquiredimmunodeficiencysyndrome
(AIDS),144andamyotrophiclateralsclerosis145indicatethatpainisnotthemainmotivating
factorbehindthedesireforeuthanasiaorPAS.Forinstance,amongtheOregonpatientswhodied
inthefirstyearofthelaw,only1of15(6.7%)haduncontrolledpain,whichislessthanthe35%
ofthecontrolpatients(dataonpainhavenotbeenpublishedforsubsequentyears).143Data
suggestthatshortnessofbreathisthephysicalsymptommostconsistentlyassociatedwithrequests
foreuthanasiaorPAS.Moreimportantly,depression,psychologicaldistress,andhopelessness
appeartobethemainsymptomsmotivatingpatients'desiresforeuthanasiaorPAS.110,144,145

Finally,theexistingdatasuggestcertainproblems.OneisthefailureofcasesofPAS.Inthe
Netherlands,approximately20%ofPAScasesdonotresultinthepatient'sdeath.134Andinthe
UnitedStates,onereportindicatesthat15%ofPAScasesresultinfailure.136,146Howthesecases
arehandledisunknown.In2001,Oregonreportedthatin2of21casestherewereproblems
becauseonepatientvomitedupthemedicine,andintheothercase,thepatientlived37hoursafter
takingthedrug,suggestingthatthepatientdiedofnaturalcausesratherthanthemedication.129In
addition,whilethemajorityofphysicianswhoparticipateineuthanasiaandPASreportsatisfaction
withtheiraction,between10%and20%ofphysiciansreportregretathavingparticipatedinthese
interventions.141Thelongtermsequelaeforthesephysiciansandtheconsequencesforthe
familiesofpatientswhodiebyeuthanasiaorPASarenotknown.

RespondingtoPatient'sRequestforEuthanasiaorPhysicianAssisted
Suicide
WhenaphysicianreceivesarequestforeuthanasiaorPAS,theinitialresponseshouldbeto
reassessthepatient'scircumstances,includingphysicalsymptoms,psychologicalsymptoms,social
supports,spiritualfulfillment,andcaregivingneeds(seeFigure791).114,115Specialattention
shouldbedevotedtoassessingdepressionandtheextentofcaregivingneeds,asdatasuggestthat
thesearestronglyassociatedwithpatients'interestineuthanasiaandPAS.Thephysicianshould
alsoreassesswhetheradditionalinterventions,includingpalliativecareconsultations,psychiatric
evaluations,skilledorunskilledhomehealthcareservices,andpastoralservices,arerequired.A
psychiatricevaluationcanbeobtainedwithoutnecessarilyrevealingthatarequestforeuthanasiaor
PASpromptedconcern.Obviously,thepatientandfamilyshouldalsobereassuredthatthe
physicianwillnotabandonthepatientandwillprovidecareandattendtothepatient'ssymptoms
andneeds.

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