Case example

Dr. Quill has recently given his patient Diane some very bad news; a bone marrow biopsy shows that she has acute myelomonocytic leukemia. Diane owns a successful business, is married, and has a college-aged son. An oncologist informs her that treatment for her leukemia involves two courses of chemotherapy followed by whole body irradiation and stem cell transplantation, with a projected five-year survival rate of about 25 percent. Without treatment, life expectancy is less than six months. The oncologist recommends that she begin the chemotherapy immediately. To the surprise and dismay of her physicians, Diane refuses aggressive therapy for her condition, saying that the one-in-four chance of five-year survival is not good enough for her to undergo so difficult a course of therapy. Despite their efforts to persuade her to begin chemotherapy, she persists in her decision to live the rest of her life outside the hospital and to accept only palliative and hospice care.

Shortly thereafter, Diane tells Dr. Quill, who has been her primary care physician for the past eight years, that she dreads the thought of a lingering and painful death and very much wants to maintain control and dignity in her final days. She says that, when her condition gets worse, she wants to take her own life in the least painful way possible. She adds that she has discussed this at length with her husband and son, and they believe that they should respect her choice. Diane then asks Dr. Quill if he will help her take her life when her discomfort, physical deterioration, and dependence become too great. She tells him that having the means to end her life will free her from the fear of a lingering death and enable her to enjoy the time she has left.

How should Dr. Quill respond?¹

Key concepts

For more than half a century, the potential role of physicians in aiding the death of their patients has been one of the most controversial issues of health care ethics. Because “aid in dying” includes several different practices, and because commentators do not always use the terms that describe these practices in the same way, it is important to begin with definitions of suicide, physician-assisted suicide, and euthanasia. I define these concepts as follows: Suicide is the act of taking one’s own life voluntarily and intentionally. Physician-assisted suicide is the act of taking one’s own life voluntarily and intentionally, using means provided or prescribed by a physician, or with the advice of a physician. Euthanasia is the act of killing a gravely ill or injured person (but not oneself) in a relatively painless or humane way, for reasons of mercy.

In early discussions of euthanasia, some commentators defined euthanasia in a broader sense that included both killing and allowing the death of a suffering person for beneficent reasons.² Relying on this broader definition, these commentators offered a distinction between active and passive euthanasia. In active euthanasia, a physician (or other person) directly kills a patient, as, for example, by injecting a lethal drug, while in passive euthanasia, a physician withholds or withdraws a life-sustaining treatment, allowing the patient to die. As decisions to allow a patient to die by withholding or withdrawing life-sustaining treatment became more and more common, the term ‘passive euthanasia’ fell into disuse, and most contemporary scholars use the term ‘euthanasia’ to refer exclusively to the active killing of a patient for that patient’s own good. Chapter 16, “Moral conflicts in end-of-life care,” examines decisions to limit life-sustaining treatment in more detail.

Another distinction is often made between voluntary and non-voluntary euthanasia. In voluntary euthanasia, a patient is killed for beneficent reasons at his or her own request, or with his or her consent. In non-voluntary euthanasia, a patient who lacks decision-making capacity, and therefore cannot give consent, is killed for beneficent reasons.

A brief recent history

‘Mercy killing’ (Gnadentod) and ‘euthanasia’ (Euthanasie) were the terms used to describe physician-administered programs that killed thousands of mentally and physically disabled patients in Nazi Germany between 1939 and 1945.³ These programs served as a training and proving ground for the Holocaust, the Nazi genocide of European Jews.⁴ Though the use of the term ‘euthanasia’ to describe these extermination programs is highly questionable, the moral outrage they evoked also cast grave doubt on the concept and practice of euthanasia in the years following World War II.

In a series of court decisions beginning the 1970s, the Netherlands became the first country in the world to permit physicians to practice euthanasia and physician-assisted suicide without significant risk of criminal prosecution.⁵ National legislation in the Netherlands enacted in 2002 formally legalized the practices of euthanasia and physician-assisted suicide, and a nationwide survey estimated that 1.7 percent (or about 2300) of all deaths in the Netherlands in 2005 were the result of euthanasia (defined as “medication that is administered by a physician with the explicit intention of hastening death at the explicit request of the patient”), and another 0.1 percent (or about 113) of deaths in 2005 were the result of physician-assisted suicide.⁶ Benelux neighbors Belgium, in 2002, and Luxembourg, in 2008, joined the Netherlands in legalizing euthanasia and assisted suicide.⁷ Swiss law has, for many decades, permitted assistance in suicide for altruistic reasons, by both physicians and non-physicians.⁸ In February 2015, the Supreme Court of Canada issued a decision legalizing physician-assisted suicide, following a year-long transition period for development of guidelines and procedures.⁹ Despite ongoing public debate and news reports featuring patient appeals for aid in dying, the United Kingdom has retained its legal prohibition of euthanasia and physician-assisted suicide.¹⁰

In the United States, Dr. Jack Kevorkian, a retired pathologist, captured wide public attention when he announced, in June 1990, that he had used a “suicide machine” to assist the death of Janet Adkins, an Alzheimer’s disease patient from Portland, Oregon.¹¹ Despite harsh criticism, Kevorkian assisted the suicides of more than one hundred patients over the next decade. In 1999, Kevorkian was convicted of murder after the popular US TV news program “60 Minutes” broadcast a videotape in which he administered a lethal injection to Thomas Youk, a patient with amyotrophic lateral sclerosis.¹²

Physician-assisted suicide was also a topic of major attention in US courts and at the ballot box during the 1990s. After failed voter initiatives in Washington in 1991 and in California in 1992, Oregon voters approved an initiative legalizing physician-assisted suicide in 1994, and reaffirmed their support for this practice in 1997.¹³ Seventeen years after enactment of the law, the Oregon Public Health Division reported that 859 patients had completed physician-assisted suicide under the law (about 0.3 percent of all deaths in that state).¹⁴ Voters in the state of Washington followed Oregon’s lead in approving an initiative legalizing physician-assisted suicide in 2008, and the Vermont legislature enacted a state statute legalizing physician-assisted suicide in 2013.¹⁵ A Montana Supreme Court decision legalized physician-assisted suicide in that state in 2009, and a 2014 New Mexico district court decision, now under appeal, legalized physician-assisted suicide in that court’s jurisdiction, Bernalillo County.¹⁶

In the mid-1990s, US federal courts addressed the question whether assistance in suicide is a basic right under the US Constitution. In the spring of 1996, two federal Circuit Courts of Appeals ruled that terminally ill patients have a constitutional right to physician-assisted suicide, striking down state statutes in Washington and New York that prohibited this practice.¹⁷ The US Supreme Court’s announcement later that year that it would hear appeals of these two decisions stimulated an intense national debate about the morality of this practice. In its 1997 opinions, the Supreme Court rejected the Circuit Courts’ assertions of a constitutional right to physician-assisted suicide.¹⁸ Instead, the High Court reaffirmed the legal distinction between forgoing life-sustaining treatment and receiving assistance in suicide, and the authority of states to enact legislation either permitting or prohibiting this practice. As of 2012, some thirty-seven US states had statutes that explicitly prohibit assistance in suicide, and other states prohibited this practice under the common law.¹⁹