from the University of Washington, School of Medicine, List of Bioethics Topics
suicide (PAS) generally refers to a practice in which the physician provides
a patient with a lethal dose of medication, upon the patient's request,
which the patient intends to use to end his or her own life.
physician-assisted suicide the same as euthanasia?
Physician-assisted suicide refers to the physician providing the means for
death, most often with a presciption. The patient, not the physician, will
ultimately administer the lethal medication. Euthanasia generally means
that the physician would act directly, for instance by giving a lethal injection,
to end the patient's life. Some other practices that should be distinguished
from PAS are:
sedation: This refers to the practice of sedating a terminally
ill competent patient to the point of unconsciousness, then allowing
the patient to die of her disease, starvation, or dehydration.
life-sustaining treatments: When a competent patient makes
an informed decision to refuse life-sustaining treatment, there is virtual
unanimity in state law and in the medical profession that this wish
should be respected.
medication that may hasten death: Often a terminally ill, suffering
patient may require dosages of pain medication that impair respiration
or have other effects that may hasten death. It is generally held by most
professional societies, and supported in court decisions, that this is
justifiable so long as the primary intent is to relieve suffering.
physician-assisted suicide ethical?
ethics of PAS continue to be debated. Some argue that PAS is ethical (see
arguments in favor). Often this is argued on the grounds
that PAS may be a rational choice for a person who is choosing to die to
escape unbearable suffering. Furthermore, the physician's duty to alleviate
suffering may, at times, justify the act of providing assistance with suicide.
These arguments rely a great deal on the notion of individual autonomy,
recognizing the right of competent people to chose for themselves the course
of their life, including how it will end.
Others have argued that PAS is unethical (see arguments
against). Often these opponents argue that PAS runs directly counter
to the traditional duty of the physician to preserve life. Furthermore,
many argue if PAS were legal, abuses would take place. For instance, the
poor or elderly might be covertly pressured to chose PAS over more complex
and expensive palliative care options.
are the arguments in favor of PAS?
who argue that PAS is ethically justifiable offer the following sorts of
for autonomy: Decisions about time and circumstances death
are very personal. Competent person should have right to choose death.
Justice requires that we "treat like cases alike." Competent, terminally
ill patients are allowed to hasten death by treatment refusal. For some
patients, treatment refusal will not suffice to hasten death; only option
is suicide. Justice requires that we should allow assisted death for
Suffering means more than pain; there are other physical and psychological
burdens. It is not always possible to relieve suffering. Thus PAS may
be a compassionate response to unbearable suffering.
liberty vs. state interest: Though society has strong interest
in preserving life, that interest lessens when person is terminally
ill and has strong desire to end life. A complete prohibition on assisted
death excessively limits personal liberty. Therefore PAS should be allowed
in certain cases.
of discussion: Some would argue that assisted death already occurs,
albeit in secret. For example, morphine drips ostensibly used for pain
relief may be a covert form of assisted death or euthanasia. That PAS
is illegal prevents open discussion, in which patients and physicians
could engage. Legalization of PAS would promote open discussion.
are the arguments against PAS?
that argue that PAS should remain illegal often offer arguments such as
of life: This argument points out strong religious and secular
traditions against taking human life. It is argued that assisted suicide
is morally wrong because it contradicts these beliefs.
vs. Active distinction: The argument here holds that there
is an important difference between passively "letting die" and actively
"killing." It is argued that treatment refusal or withholding treatment
equates to letting die (passive) and is justifiable, whereas PAS equates
to killing (active) and is not justifiable.
for abuse: Here the argument is that certain groups of people,
lacking access to care and support, may be pushed into assisted death.
Furthermore, assisted death may become a cost-containment strategy.
Burdened family members and health care providers may encourage option
of assisted death. To protect against these abuses, it is argued, PAS
should remain illegal.
integrity: Here opponents point to the historical ethical traditions
of medicine, strongly opposed to taking life. For instance, the Hippocratic
oath states, "I will not administer poison to anyone where asked," and
"Be of benefit, or at least do no harm." Furthermore, major professional
groups (AMA, AGS) oppose assisted death. The overall concern is that
linking PAS to the practice of medicine could harm the public's image
of the profession.
of the profession: The concern raised here is that physicians
will make mistakes. For instance there may be uncertainty in diagnosis
and prognosis. There may be errors in diagnosis and treatment of depression,
or inadequate treatment of pain. Thus the State has an obligation to protect
lives from these inevitable mistakes.
most nations and in most states in the US, aiding in a suicide is a crime.
However, suicide or attempted suicide itself is not illegal, although an
attempted suicide will often result in a short term involuntary psychiatric
commitment for a psychiatric assessment and evaluation. The state of Oregon
is the only state within the United Statres that currently has legalized
PAS. A constitutional challenge to the Washington State law was dismissed
by the US Supreme Court in 1997, with the court refusing to recognize PAS
as a constitutional right. The Supreme Court left it to individual states
to address the legality of PAS through legislation, but encouraged efforts
to improve care of the dying.
Despite the apparent illegality of PAS in most states, no physician has
ever been convicted for PAS. Dr. Timothy Quill was investigated but not
indicted for his participation in the suicide of a patient after he published
his account of the incident. Jack Kevorkian was convicted for second degree
murder for an act that more closely approximated active euthanasia.
does the medical profession think of PAS?
of individual physicians show that half believe that PAS is ethically justifiable
in certain cases. However, professional organizations such as the American
Medical Association have generally argued against PAS on the grounds that
it undermines the integrity of the profession.
Surveys of physicians in practice show that about 1 in 5 will receive a
request for PAS sometime in their career. Somewhere between 5-20% of those
requests are eventually honored.
do patients and the general public think of PAS?
of patients and members of the general public find that the vast majority
think that PAS is ethically justifiable in certain cases, most often those
cases involving unrelenting suffering.
should a physician do if a patient asks him or her for assistance in suicide?
of the most important aspects of responding to a request for PAS is to be
respectful and caring. Virtually every request represents a profound event
for the patient, who may have agonized over his situation and the possible
ways out. The patient's request should be explored, to better understand
its origin, and to determine if there are other interventions that may help
ameliorate the motive for the request. In particular, one should address:
and degree of suffering: are there physical or emotional symptoms that
can be treated?
support: does the patient have a system of psychosocial support, and
has she discussed the plan with them? accuracy of prognosis: every consideration
should be given to acquiring a second opinion to verify the diagnosis
of patient understanding: the patient must understand the disease state
and expected course of the disease. This is critical since patient may
misunderstand clinical information. For instance, it is common for patients
to confuse "incurable" cancer with "terminal" cancer.
if the request persists?
a patient's request for aid-in-dying persists, each individual clinician
must decide his or her own position and choose a course of action that is
ethically justifiable. Careful reflection ahead of time can prepare one
to openly discuss your position with the patient, acknowledging and respecting
difference of opinion when it occurs. Organizations exist which can provide
counseling and guidance for terminally ill patients. No physician, however,
should feel forced to supply assistance if he or she is morally opposed