-align:justify;line-height:200%'>Two 1996 decisions resulted in what legal analysts call a “2nd/9th split.” In 1996 the Second Circuit of the United States Court of Appeals rendered its decision in Quill v. Vacco and the Ninth Circuit decided Compassion In Dying v. Washington (later appealed as Washington v. Glucksberg to the United States Supreme Court).
on differing rationales, both Circuits ruled that physicians could provide
assistance in death to terminally ill patients free from potential criminal
liability. The Second Circuit couched its decision in Equal Protection and the
Ninth Circuit in Substantive Due Process. The Supreme Court overturned both
Circuit decisions. With the exception of
After five years
of implementation of the
5. Other International Models for Assisting the Terminally Ill with Death
In many countries, assisted suicide or any act of counseling, aiding, or abetting suicide are prosecutable under the criminal laws and qualify as murder (25). As more groups and organizations advocate decriminalization of physician-assisted suicide or medical euthanasia for terminally ill and mentally competent adults the controversies of this issue will gain more attention (25).
opinion among physicians and health lawyers in the
Any case of euthanasia or physician assisted suicide has to be reported according to the Burial Act of Dutch Law. A request for either option can also be made in a living will and has to meet all the legal requirements. A living will, or health care power of attorney, is a comprehensive statement of desired medical treatment that may be administered after the patient is no longer legally competent to make their own medical decisions. These documents may be drawn up at any time after an individual reaches legal adulthood. Each act of euthanasia is evaluated by regional committees (25, 30, 31). If the committees do not find any abnormality or deviation from the regulations, the physician who administers the act of euthanasia will not be prosecuted by the penal code. So how does the law apply to incompetent individuals or minors? These are the two special conditions and problems debated in the Dutch Parliament. Under the current law, euthanasia for patients between ages 12 and 16 are not allowed against the will of their parents, even when the doctor is convinced that the suffering of the patient could no longer be tolerated. So far, there has not been any reported case where euthanasia was done against the will of the patient or a minor’s parents (25, 30). There were disagreements between doctors and parents, but were generally resolved after extensive discussions between the doctor, the parents, and the patient. Currently, euthanasia for patients who are minors could be done only with parental consent. In the case of incompetent patients, the Dutch law allows the living will to represent patient autonomy. It is also under the assumption that the living will was written after long consideration by the patient.
Since the law was
implemented in the
6. Examples and discussion on assisted suicide within the context of HIV/AIDS
is draft legislation in
With the availability of HIV antiviral treatment, HAART, the morbidity and mortality data as in the occurrence of specific opportunistic infections has gone down among HIV and AIDS patients. Some studies proposed that HAART significantly improved the quality of life and maintenance of functioning and well being for the HIV positive and advance AIDS patients. The effectiveness of HAART could also impact the need and availability of palliative care, and the discussion on desire for euthanasia and physician assisted suicide for end stage AIDS patients (33).
So what is the financially burden for such AIDS treatment options? In a published French study, it documented that the mean cost of HAART and other related cares was estimated at 3,370 euros per person-month during the initial months around the occurrence of an AIDS-defining event; at 1,750 euros per person-month during the period spanning from 2 months after the diagnosis of specific AIDS-defining event to 1 month prior to death; and at 13,010 euros per person-month in the final month prior to death (22). If clinical management of HIV infection began at a CD4 cell count of 378/microl, the discounted lifetime cost of treating an HIV-infected French patient was estimated at 214,000 euros. The undiscounted costs were 309,000 euros over a projected life expectancy of 16.4 years (37).
Currently, there are emerging possibilities that can totally discredit using financial burden as a legitimate line of reasoning for euthanasia request. If AIDS and HIV+ are considered as a crisis on a national and international level, it is possible for countries legally producing generic version of expensive patented drug can greatly reduce the cost for AIDS or HIV+ treatment and prevention. The availability of cheaper version of AIDS and HIV treatment can reduce the possibility of financial burden heavily influencing the decision making process. Despites such possibility, there will always patients who can’t overcome the other barriers to obtain adequate health care. The financial burden will continue to be a factor influencing the decision making process.
context of physician and patient relationship, the amount of data is minimal when
it comes to physician assisted suicide and euthanasia specifically for the end
stage AIDS patients as a therapeutic option. Despite the success of various
AIDS treatment regimens in prolonging the life of HIV and AIDS patients, it remains
an incurable and irreversible illness that will eventually become unbearable
(32). In a European survey on HIV/AIDS patient attitudes and opinions on
end-of-life decisions, more than half of the respondents in most countries had,
at one time or another discussed the possibility of purposely terminating their
own life with someone. As for the question of with whom they would have had
those end-of-life discussions, only in the
Needless the say the financial burden will continue to play a role when selecting therapeutic options and subsequently the end-of-life decision. With the irreversible and universal outcome of AIDS infection along with the high cost of treatment regimens at the disease’s end stage, only open discussion between the physician, the patient and the family can ensure all aspects of the decision are discussed and understood. Doing so in this manner is necessary to minimize the bias from other motivations.
7. The case against physician-assisted suicide
Despite the economic and philosophical arguments in favor of physician-assisted suicide, poignant and powerful arguments against legalization also exist. Strong, long-standing religious and secular traditions against the taking of human life resonate throughout this country. These organizations argue assisted suicide is wrong and immoral because it contradicts this primary edict regarding sanctity of life. Others who are less religiously inclined draw distinctions between active and passive conduct. Refusing treatment or withholding treatment is therefore classified as passive conduct. Interestingly, this argument finds support in the courts. Physicians are permitted to withdraw life-sustaining treatment, such as hydration and respiration, from legally competent adults desiring to refuse such treatment, even though doing so will result in their death. The distinction to note here is that without hydration or respiration, these individuals would die a natural death because the machines are seen as prolonging their life artificially. Alternatively, terminally ill patients who induce medication to cause death are prematurely causing their life to end. Therefore, a doctor giving a prescriptive is argued as “acting” versus withdrawing life-support seen as “passive.” A third argument involves potential for abuse. As noted earlier in Washington v. Glucksberg, the court and society-at-large are particularly concerned with legalizing behavior that may coerce and abuse vulnerable populations. These vulnerable populations can include people lacking access to care, money for prolonged care, minorities, disabled and handicapped individuals, elderly, etc. This argument expressly derives from physician-assisted suicide proponent arguments about cost-containment and economic efficiency.
Two final concerns relate to the profession of medicine, including its integrity and the inherent fallibility of doctors. It is axiomatic that to err is human. One can imagine scenarios of uncertainty in diagnosis or prognosis, misdiagnosis of depression or inadequate treatment of pain. This argument is somewhat similar to anti-capital punishment advocates who caution against executing wrongly convicted persons. The stakes of mistakes in this context are high for death is irreversible. Although death is inevitable, that it may come sooner for some than necessary is a legitimate concern. The existing safe guards may never reduce the possibility of abuse to zero, hence the legalization of physician assisted suicide and euthanasia will continue to be hot topics of any debate.
8. Other associated end-of-life health care issues
Along with discussion on physician assisted suicide and euthanasia, we should not ignore the role of palliative care, utilization of hospice care, and better pain management. These are areas that can greatly impact the decision process on physician assisted suicide.
The practice of
palliative care is considered a very new development in the
With the improvement and the efficacy of the retroviral treatment for AIDS patient’s and the emphasis on creating an effective palliative care system, the physicians and the patients have a wide range of options for a more meaningful discussion about end-of-life care with regard to euthanasia and physician assisted suicide.
As a general
overview, an article published by Bosshard,
et al, examined the conceptual difference between the
As the number of population susceptible to
chronic degenerative and terminal diseases increases along with improvement in
critical care medicine to prolong life, the difficulty in achieving an acceptable
balance between physicians’ duty to provide care and minimize patient suffering
will only increase. Unlike other countries, individuals do not have a universal
right to health care in the
9. Discussion and potential future directions
The arguments in support of euthanasia and physician assisted suicide focus, almost to the exclusion of other social interests and moral values, on the physicians’ duties to relieve patient suffering and respect patient autonomy especially their desire to die. It is also argued that the patient’s decision to end his or her own life should be interpreted as a private matter that does not harm others, therefore being free from State intervention or prohibition by medical professions. Opponents of euthanasia and physician-assisted suicide focus on the ambiguities in evaluating the patient’s ability to competently decide on health matters while experiencing all the sufferings at the end stage of terminal illnesses. Additionally, opponents caution against creating a precedent where society begins viewing anything less than perfect health as undesirable quality of life.
Others also argue the issue of trust also comes into question when euthanasia or physician assisted suicide becomes an option of end-of-life discussions. It could also alter the physician-patient relationship. Perhaps assistance with suicide would compromise the patient and physician relationship and violate the trust factor of this relationship. Opponents vigorously assert euthanasia and physician-assisted suicide undermines the integrity and societal role of medical and allied health professions. This conduct, they argue, skews and alters the meaning of beneficence, the duty to do goods and to promote the best interests of the patients. Opponents do not deny the existence of suffering and pain during end-of-life stages, but rather, they claim the existences of other alternative medical solutions which have not been fully explored are available.
Some have argued,
Another commonly used example for this argument is Alzheimer’s disease. Alzheimer patients might fear for the future and desire euthanasia or physician-assisted suicide when the right moment comes. So if we only allow terminally ill patients for euthanasia and physician-assisted suicide, would such policy be considered a discriminatory? Also, can medical professions accurately predict how long a patient will live? All these questions further demonstrate the amount of ambiguities that can lead to abuse or misuse of euthanasia and physician assisted suicide.
important factor is how well and how long the patient has known their
physician? Unlike the
If the right to medically end one’s life is legalized, will the patient appreciate the availability and the effectiveness of alternative options? We also have to assess whether there exists adequate availability of hospice and palliative care for any meaningful discussion on end-of-life decisions. These questions will invariably surface in any debate regarding euthanasia and physician assisted suicide.
countries like the
With the improvement in modern medicine and diversed cultural and policitical environments, there is not a single group of individual who will create a generally acceptable policy on this issue. The desire for euthanasia and physician assisted suicide will always exist in subset of patients suffering from unbearable and terminal conditions. By prohibiting euthanasia and physician assisted suicide will not minimize the level of such desire. Instead, the number of successful and unsuccessful suicide attempt as an alternative to legalized euthanasia will only increase the burden on emergency medicine department and other public health related infrastructures. The medical professionals and different elements of the society should open up discussion on euthanasia and other end of life options. Euthanasia should only be advocated when all other options are explored to the fullest and when the only option left is still euthanasia.
physician-assisted suicide/euthanasia debate is far from resolution. There is
room for the
11. Other resources
For those interested in further study of the Physician-Assisted Suicide/Euthanasia Debate, the following web sites may provide assistance:
Specific legal case report:
· Dr. Timothy Quill’s case
Resources that are in support of physician-assisted suicide:
· American Medical Student Association webpage on PAS.
· Dedicated to education about PAS and death with dignity.
· Oregon Health Department web site.
Resources that are in opposition of Physician-assisted suicide:
· Examines PAS within framework of Jewish law.
· Comprehensive website in opposition to Euthanasia and Physician-assisted suicide.
General review article:
· Bosshard G, Fischer S, Bar W. Open regulation and practice in assisted dying. Swiss Med Wkly. 2002 Oct 12;132(37-38):527-34.
2. Drickamer, Margaret A. et al. Practical Issues in Physician-Assisted Suicide. Annals of Internal Medicine. 1997; 126, Issue 2; 146-151.
Law Dictionary, Second Edition page 6784
4. Garrison, Marsha, The Law of Bioethics: Individual Autonomy and Social Regulation. Pg 414. Thomson West 2003.
5. Catechism on Euthanasia, online at:
Foley Kathleen M, Competent Care for the Dying Instead
of Physician-Assisted Suicide,
7. Quill TE, I want to Die, Will You Help Me? Journal of the American Medical Association 1993; 270:870-873.
9. Quill v. Vacco, 80 F.3d 716 (2d Cir 1996)
10. Compassion In Dying v. Washington, 79 F.3d 790 (9th Cir 1996)(en banc).
11. Oregon Health Department State Website, online at: http://www.ohd.hr.state.or.us/chs/pas.
1: Demographic Characteristics of 171
DWDA patients, by year,
13. Table 4: Death With Dignity Act participant end of life care and DWDA utilization, 1998-2003. Oregon Health Department State Website, online at: http://www.ohd.hr.state.or.us/chs/pas.
14. Problems Associated With Physician Assisted Suicide, online at: http://www.internationaltaskforce.org/prob1.htm
v. Director, Missouri Department of Health, 497
Komiti, et al. Suicidal behaviour in people with HIV/AIDS: a review. Australian
17. Charles S. Bryan. HIV/AIDS and Bioethics: Historical Perspective, Personal Retrospective. Health Care Analysis 10: 5-18, 2002.
18. Ronit D. Leichtentritt, et al. Holocaust survivors’ perspectives on the euthanasia debate. Social Science & Medicine 48 (1999) 185-196.
19. Michael G. Young, et al. Thje role of nurses in AIDS care regarding voluntary euthanasia and assisted suicide: a call for further dialogue. Journal of Advanced Nursing, 2000, 31(3), 513-519.
20. Luigi Grassi, et al. Attitudes toward euthanasia and physician-assisted suicide among Italian primary care physicians. Journal of Pain and Symptom Management. Vol 17, No 3 March 1999.
Gordijn, et al. The prevention of euthanasia through palliative care: new
developments in the
Mavroforous, et al. Euthanasia in
23. Raphael Cohen-Almagor. Should doctors suggest euthanasia to their patients? Reflections on dutch perspectives. Theoretical Medicine 23: 287-303, 2002.
24. Mirko Bagaric, et al. The Kuhse-Singer euthanasia survey: why it fails to undermine the slippery slope argument – comparing apples and apples. European Journal of Health Law 9: 229-241, 2002.
25. Lois Snyder. Bioethics, assisted suicide, and the “right to die” Annals of Clinical Psychiatry, Vol 13, No 1, 2001.
26. James V. Lavery, et al. Origins of the desire for euthanasia and assisted suicide in people with HIV-1 and AIDS: a qualitative study. The Lancet. Vol 358, August 4, 2001.
27. Phillip M. Kleespies, et al. Suicide in the medically and terminally ill: psychological and ethical considerations. Journal of Clinical Psychology, Vol 56(9), 1153-1171 (2000)
28. Judith C. Ahronheim, at al. Pursuit of assisted dying: a pilot study of inquiries made to a national consumer-based organization. Journal of Pain and Symptom Management, Vol 18, No 6, December 1999.
Andraghetti, et al. Euthanasia: from the perspective of HIV infected persons in
30. David C. Thomasma, et al. Asking to die: inside the Dutch debate about euthanasia. Journal of Health Politics, Policy and Law. Vol 25, No 2, April 2000.
31. Bregje D. Onwuteaka-Philipsen, et al. Consultation
with another physician on euthanasia and assisted suicide in the
32. Ilinka Haverkate, et al. Guidelines on euthanasia and pain alleviation: compliance and opinions of physicians. Health Policy 44 (1998) 45-55.
33. John R. Brechtl, et al. The Use Of Highly Active Antiretroviral Therapy (HAART) In Patients With Advanced HIV Infection: Impact On Medical, Palliative Care, And Quality Of Life Outcomes. Journal of Pain and Symptom Management. Vol 21. No 1, January 2001.
34. Barry Rosenfeld, et al. The Schedule of Attitudes toward Hastened Death: measuring desire for death in terminally ill cancer patients. Cancer 2000;88:2868-75.
A Hurst. Assisted suicide and euthanasia in
36. M.T. Harvey. What does a right to physician assisted suicide legally entail? Theoretical Medicine 23: 271-286, 2002.
37. Yazdanpanah Y. Lifetime cost of HIV care in
38. Marjolein Bannink. Psychiatric consultation and quality of decision making in euthanasia. The Lancet. Vol 356. December 16, 2000.
39. Legemaate J. The Dutch Euthanasia Act and related issues. J Law Med. 2004 Feb;11(3):312-23.
40. Oosthuizen H. Doctors can kill--active
41. Bosshard G, Fischer S, Bar W. Open regulation and practice in assisted dying. Swiss Med Wkly. 2002 Oct 12;132(37-38):527-34.
 Drickamer, Margaret A. et al. Practical Issues in Physician-Assisted Suicide. Annals of Internal Medicine. 1997; 126, Issue 2; 146-151.
 Black’s Law Dictionary, Second Edition page 678
 Garrison, Marsha, The Law of Bioethics: Individual Autonomy and Social Regulation. Pg 414. Thomson West 2003.
 Catechism on Euthanasia, online at: http://www.flacathconf.org/Issuesinfo/Endoflife/Catechism.htm
Kathleen M, Competent Care for the Dying Instead of Physician-Assisted Suicide,
 Quill TE, I want to Die, Will You Help Me? Journal of the American Medical Association 1993; 270:870-873.
 Quill v. Vacco, 80 F.3d 716 (2d Cir 1996)
 Compassion In Dying v. Washington, 79 F.3d 790 (9th Cir 1996)(en banc).
 Oregon Health Department State Website, online at: http://www.ohd.hr.state.or.us/chs/pas.
1: Demographic Characteristics of 171
DWDA patients, by year,
 Table 4: Death With Dignity Act participant end of life care and DWDA utilization, 1998-2003. Oregon Health Department State Website, online at: http://www.ohd.hr.state.or.us/chs/pas.
 Problems Associated With Physician Assisted Suicide, online at: http://www.internationaltaskforce.org/prob1.htm
v. Director, Missouri Department of Health, 497