Euthanasia and assisted suicide: a physician’s and ethicist’s perspectives

Figures & data

Table 1 List of common reasons for requested death

Reason

Loss of autonomy and independence (eg, loss of control over decisions, inability to make decisions, loss of self-care abilities) Less able to engage in activities making life enjoyable Perceived loss of human dignity; this is often related to an impairment of physiological functions in basic body systems (eg, bowel functioning, swallowing, speech, reproduction) or preoccupations with bodily appearance A fear of becoming a burden on family, friends, and community Cognitive impairment or fear of cognitive impairment Depression, hopelessness (nothing to look forward to), or demoralization* Feeling useless, unwanted, or unloved; social isolation Inadequate pain control or concern about it Existentialist angst or terror, mortality salience, fear of the unknown Intractable symptoms other than pain (eg, pruritus, seizures, paresthesias, nausea, dyspnea) Financial implications of treatment

Notes: This list is not presented in the order of frequency.

* Some experts deny that demoralization actually exists as a mental disorder separate from clinical depression.

Table 2 Main arguments advanced by proponents and opponents of euthanasia

Arguments

Arguments in favor of euthanasia    Persons have an inalienable right to self-determination; that is, patients can decide how, where, and when they are going to die.    Euthanasia is a profoundly humane, merciful, and noble humanitarian gesture because it relieves suffering.    Assistance in dying is a logical and reasonable extension to end-of-life care and involves only an incremental expansion of practices that are legal and seen as ethical.    It bypasses physicians’ reluctance to accept patients’ advanced directives and their requests to limit interventions.    It can be carried out humanely and effectively, with negligible risk of slippery slopes. Arguments against euthanasia    Intentionally taking a human life, other than to save innocent human life, is inherently wrong and a violation of a universal moral code.    The value of respect for autonomy must be balanced by other values, particularly respect for individual human life and respect for human life in general.    It is different in kind from other palliative care interventions aimed at relieving suffering, such as pain management, and from respect for patients’ refusals of life support treatment.    Slippery slopes are unavoidable.    It introduces an unacceptable potential for miscommunication within the doctor-patient relationship.    It is incompatible with the role of the physician as healer and would erode the character of the hospital as a safe refuge.

Table 3 Slippery slopes

Slopes

The practical slippery slope    Performing euthanasia without informed consent or any consent    Persons administering euthanasia who are not legally authorized to do so    Failure of reporting euthanasia or physician assisted suicide as required    Misclassifying euthanasia as “palliative sedation”    Noncompliance with safeguard protocols (eg, not obtaining psychiatric evaluations of competence, circumventing policies for mandatory second opinions, functioning as “willing providers” without having had a previous clinical relationship with the patient) The logical slippery slope    Euthanasia offered to those with existentialist angst, mental illness, anorexia nervosa, depression    Euthanasia expanded to include patients with dementia    Euthanasia expanded to persons who are neither physically nor mentally ill: “over 70 and tired of life”    Extending legislation to include children    Euthanasia becomes accepted as medical care, as a sort of “therapeutic homicide”