analyzing publications

Physician-Assisted Suicide: Finding a Path Forward in a Changing
Legal Environment
Imagine yourself with a disease that has recently be-
come terminal. What kinds of treatments and options
would be most important to you? Almost everyone
would want to be sure their physicians had considered,
if not tried, all potentially effective disease-directed
therapy and best possible palliative treatments to max-
imize their quantity and quality of life. Many patients
would want to consider a timely transition to hospice
care if no acceptable disease-directed therapies ex-
isted, hoping to live as fully as possible for their remain-
ing time, and then to die peacefully. On these points
we are completely in sync with the American College of
Physicians (ACP) position paper (1).

We also know that most patients would want to
know that they could refuse burdensome treatments
that may keep them alive but with a low quality of life.
(In fact, most patients die having forgone some poten-
tially life-sustaining treatment.) A substantial minority of
terminally ill patients also would want some assurances
about their ability to access or potentially activate a
physician-assisted suicide if their suffering becomes un-
acceptable (2). For many of these patients, the motiva-
tion is to maintain control over the manner and timing
of their own death (many have been making a series of
very challenging decisions throughout their illness and
see no reason not to stay in charge of the last phase).
Others fear the potential of unacceptable physical suf-
fering in the last phase of their illness, perhaps on the
basis of experience. Still others might find that the pro-
longed debility and dependence that might occur dur-
ing the dying process are unacceptable (3).

Knowledge about what “last-resort” options are
available (4), as well as which options one’s own doctor
can support, would be reassuring to these patients. It
would free their emotional energy for other psychoso-
cial and spiritual matters potentially critical to this last
phase of life, and most patients ultimately will not need
a medically assisted death if they receive excellent end-

of-life care. However, even with the best possible palli-
ative and hospice care, a small percentage of patients
eventually will want direct assistance with dying now.
Carefully exploring the why now for such requests and
redoubling efforts to palliate suffering are the next
steps, followed by an exploration of legally available
options for responding (2).

The legal landscape for patients who want to end
their life now is rapidly changing in North America and
western Europe (5). Both physician-assisted suicide and
voluntary active euthanasia have been legal in the
Netherlands, Belgium, and Luxembourg for many
years, and both recently were legalized in Canada.
Physician-assisted suicide is now legal in 6 states and
the District of Columbia (affecting one sixth of t

The Slippery Slope of Legalization of Physician-Assisted Suicide

The American College of Physicians (ACP) positionpaper on the legalization of physician-assisted sui-
cide reaffirms the ACP’s opposition to this practice,
even though it is now legal in several countries and U.S.
jurisdictions (1). The ACP’s position deserves credit for
its clarity and courage.

Among other achievements, the ACP paper identi-
fies “euthanasia” and “medical assistance in dying” as
euphemisms. These terms do what euphemisms are
supposed to do: make a distasteful subject palatable,
or at least discussable. The social process of change
in ethical and moral standards makes bold use of
such euphemisms. At one time, “mercy killing” and
physician-assisted suicide were both illegal and un-
thinkable. However, times are changing, and the
changes have followed a recognizable pattern (2). First,
the unthinkable becomes discussable although highly
controversial. After a while, it is seen as acceptable un-
der certain circumstances. As it becomes more familiar,
it seems increasingly sensible and reasonable. Finally, it
is established as a legal right. In this way, what was
once unthinkable can eventually become policy, or
even a duty (3).

Space limitations permit only a brief consideration
here of arguments for and against medically assisted
suicide. The argument in favor that is based on “non-
abandonment” ignores a conscientious physician’s
commitment to relieve suffering and to accompany
sick and dying patients to the very end. We all should
provide “medical assistance in dying” and not abandon
our suffering patients. This argument also tends to stig-
matize those who object to suicide as a solution to

The “slippery-slope” objection to medical suicide
and euthanasia may be dismissed as alarmist, but it is
not easily refuted. Euthanasia was legalized in the Neth-
erlands in 2002, with multiple safeguards against
abuse. However, in 2015, the Dutch government re-
ported that hundreds of persons were put to death
without their express consent or because of psychiatric
illness, dementia, or just “old age” (4). In addition, the
Groningen protocol has legalized infanticide in the
Netherlands. In view of these developments, it is laud-
able that Oregon, Canada, and other jurisdictions have
built safeguards into their end-of-life legislation. How-
ever, a slope still exists, and it may be fairly steep.

The argument based on intractable suffering ap-
peals to a physician’s sense of empathy. However, if
hard cases make bad law, they also may produce un-
wise medical policies, and the argument surely greases
the slippery slope. If intractable physical suffering is a
justification for actively ending life, why should intracta-
ble existential angst, a severe sense of personal alien-
ation, or the helplessness and hopelessness of severe
depression not be as well?

The principle of patient au