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Doctors' opinions on euthanasia, end of life care, and doctor-patient communication: telephone survey in France

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• P Peretti-Watel , researcher ( peretti{at}marseille.inserm.fr ) 1 ,
• M K Bendiane , researcher 2 ,
• H Pegliasco , chairman 3 ,
• J M Lapiana , director of palliative care centre 4 ,
• R Favre , professor 5 ,
• A Galinier , consultant 6 ,
• J P Moatti , professor 7
• 1 Regional Center for Disease Control of South-Eastern France, 13006 Marseille, France
• 2 Health and Medical Research National Institute, Research Unit 379, Social Sciences Applied to Medical Innovation, Institut Paoli Calmettes, Marseille,
• 3 Departmental Center of Private Health Professionals, Marseille
• 4 La Maison, Gardanne, France
• 5 Assistance Publique Hôpitaux de Marseille, Service of Medical Oncology, Marseille
• 6 Assistance Publique-Hôpitaux de Marseille, Department of Penitentiary Care, Marseille, France
• 7 Department of Economics, University of Aix-Marseille II, France
• Correspondence to: P Peretti-Watel
• Accepted 28 July 2003

Introduction

During the past decade, the debate about legalising euthanasia has grown in many developed countries, including France. Medical journals have reflected this: surveys have assessed doctors' attitudes toward euthanasia and bioethics articles have discussed the pros and cons. Supporters of legalisation argue that euthanasia is a continuation of palliative care and that doctors must respect patients' autonomy, including a wish to die. 1 The latter argument suggests that cultural differences shape opinions about euthanasia, because the emphasis on autonomy is greater in English speaking countries than in other developed countries. 2 3

We assessed French doctors' opinions toward euthanasia and collected data about their attitudes and practices. We compared medical specialties which demand different amounts of palliative care and different amounts of empathy toward and communication with terminally ill patients.

Participants, methods, and results

In 2002, the Regional Center for Disease Control of South-Eastern France and the Health and Medical Research National Institute did a telephone survey of a sample of doctors, stratified by specialty. We selected general practitioners, oncologists, and neurologists randomly from all French doctors, kept on file by the National Health Insurance Fund.

We investigated respondents' involvement in end of life care and palliative care, their attitude toward terminally ill patients, and whether “euthanasia should be legalised, as in the Netherlands.” We compared medical specialties with Pearson's χ 2 .

We contacted 1552 doctors, and 917 (59%) agreed to participate. Response rate was greater for oncologists (217/261; 83%) and neurologists (198/287; 69%) than for general practitioners (502/1004; 50%). Doctors who did not respond were generally too busy; they did not differ in sex, age, or size of town from respondents.

Only a minority of respondents were trained in palliative care, especially neurologists (24/198; 12.1%). Oncologists treated more terminally ill patients during the past year (mean 26.3 patients v 9.4 for neurologists and 7.0 for general practitioners; P < 0.05), and general practitioners practised less often in palliative care units ( table ). Oncologists were less likely to feel uncomfortable with terminally ill patients (7.8% v 16.7% among general practitioners and 27.8% among neurologists; P < 0.001) and more prone to systematically communicate the objectives of treatment (65.9% v 57.2% among general practitioners and 47.0% among neurologists; P < 0.01) and the diagnosis to competent terminally ill patients. Oncologists were also less in favour of legalising euthanasia (35.5% v 44.8% of general practitioners and 46.5% of neurologists; P < 0.05).

French doctors' involvement in end of life care and palliative care, their attitude to and communication with patients, and their opinion on legalising euthanasia, 2002. Values are numbers (percentages) unless otherwise stated

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Many French doctors want euthanasia to be legalised. This opinion is more common among general practitioners and neurologists than among oncologists, who are more experienced in end of life care, more frequently trained in palliative care, and show greater comfort and better communication with terminally ill patients. Because most proponents of legalisation argue that euthanasia is a continuation of end of life care and that doctors should respect patients' autonomy, including a wish to die, we expected to find the reverse.

Our study has several limitations. Answering questions about a sensitive topic on the telephone can be difficult, a questionnaire with a fixed choice of answers prevented doctors from qualifying or justifying their responses, and we lacked detailed information about doctors who did not respond.

Previous studies found similar patterns, but the French counterparts to Italian general practitioners and US oncologists were more in favour of legalising euthanasia. 3 4 Our findings contradict the argument that opinions on euthanasia are related to cultural differences in English speaking countries; comparative studies are needed. 2 In France, the support shown for euthanasia may be due to a lack of professional knowledge on palliative care. 5 Improving such knowledge would improve end of life care and may also clarify the debate over euthanasia.

Acknowledgments

We thank H Granier, Y Obadia, B Planchet-Barraud, F Ravallec, M Rotily, and O Priolo.

Contributors MKB, HP, JML, RF, and AG designed the survey and reviewed and improved the paper. JPM and PP-W did the statistical analysis and wrote the paper. PP-W is guarantor.

Funding Departmental Centre of Private Health Professionals (grant from the fund for improving ambulatory care), Assistance Publique-Hôpitaux de Marseilles (within the hospital programme for clinical research), and Cancer Research Foundation (ARC).

Competing interests None declared.

Ethical approval Not needed.

• Hermsen MA ,
• ten Have HA
• Magnani K ,
• Emanuel EJ ,
• Fairclough D ,
• Clarridge BC ,
• Penley WC ,
• Ben Diane MK ,
• Pegliasco H ,
• Galinier A ,
• Lapiana JM ,
• Peretti-Watel P ,

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Euthanasia and the Law: The Rise of Euthanasia and Relationship With Palliative Healthcare

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• Published: 19 February 2019

Factors associated with requesting and receiving euthanasia: a nationwide mortality follow-back study with a focus on patients with psychiatric disorders, dementia, or an accumulation of health problems related to old age

• Kirsten Evenblij   ORCID: orcid.org/0000-0002-5984-4959 1 ,
• H. Roeline W. Pasman 1 ,
• Agnes van der Heide 2 ,
• Trynke Hoekstra 3 &
• Bregje D. Onwuteaka-Philipsen 1  

BMC Medicine volume  17 , Article number:  39 ( 2019 ) Cite this article

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Recently, euthanasia and assisted suicide (EAS) in patients with psychiatric disorders, dementia, or an accumulation of health problems has taken a prominent place in the public debate. However, limited is known about this practice. The purpose of this study was threefold: to estimate the frequency of requesting and receiving EAS among people with (also) a psychiatric disorder, dementia, or an accumulation of health problems; to explore reasons for physicians to grant or refuse a request; and to describe differences in characteristics, including the presence of psychiatric disorders, dementia, and accumulation of health problems, between patients who did and did not request EAS and between patients whose request was or was not granted.

A nationwide cross-sectional survey study was performed. A stratified sample of death certificates of patients who died between 1 August and 1 December 2015 was drawn from the central death registry of Statistics Netherlands. Questionnaires were sent to the certifying physician ( n  = 9351, response 78%). Only deceased patients aged ≥ 17 years and who died a non-sudden death were included in the analyses ( n  = 5361).

The frequency of euthanasia requests among deceased people who died non-suddenly and with (also) a psychiatric disorder (11.4%), dementia (2.1%), or an accumulation of health problems (8.0%) varied. Factors positively associated with requesting euthanasia were age (< 80 years), ethnicity (Dutch/Western), cause of death (cancer), attending physician (general practitioner), and involvement of a pain specialist or psychiatrist. Cause of death (neurological disorders, another cause) and attending physician (general practitioner) were also positively associated with receiving euthanasia. Psychiatric disorders, dementia, and/or an accumulation of health problems were negatively associated with both requesting and receiving euthanasia.

Conclusions

EAS in deceased patients with psychiatric disorders, dementia, and/or an accumulation of health problems is relatively rare. Partly, this can be explained by the belief that the due care criteria cannot be met. Another explanation is that patients with these conditions are less likely to request EAS.

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Patients suffering unbearably may wish to hasten their death. Since 2002, the Netherlands has been one of the few countries where euthanasia and assisted suicide (EAS) is allowed under strict conditions [ 1 ]. The practice of EAS is restricted to physicians who must adhere to the “statutory due care criteria,” i.e., they must (1) be satisfied that the patient’s request is voluntary and well-considered; (2) be satisfied that the patient’s suffering is unbearable and without prospect of improvement; (3) have informed the patient about his situation and prognosis; (4) have come to the conclusion, together with the patient, that there is no reasonable alternative; (5) consult at least one other, independent physician; and (6) exercise EAS with due medical care and attention. Furthermore, the cause of suffering underlying the request must have a medical dimension, either somatic or psychiatric [ 1 , 2 ], and physicians must report each case to the Regional Euthanasia Review Committees which review all EAS cases regarding whether the due care criteria were met.

In the past decade, the percentage of all deceased patients in the Netherlands who requested EAS prior to their death increased, from 5.2% in 2005, to 6.7% in 2011, and to 8.4% in 2015 [ 3 ]. Also, the percentage of requests that were carried out increased, from 37% in 2005, to 45% in 2010 and to 55% in 2015 [ 4 ]. Hence, not only is there a growing demand for EAS, requests are also more likely to result in EAS. Some evidence, however, suggests that requesting and receiving euthanasia depends, at least to some extent, on the cause of suffering. For instance patients who have cancer are more likely to request EAS compared to those with cardiovascular diseases [ 5 ]. Patients with physical symptoms, cancer, and a short life expectancy are more likely to receive EAS than others, while patients with depressive symptoms are less likely [ 6 , 7 , 8 ]. Also, demographic and care factors have been reported to influence requesting and receiving EAS [ 5 , 6 , 7 , 8 ].

Recently, EAS in patients with psychiatric disorders, dementia, or an accumulation of health problems related to old age (from now, accumulation of health problems) has taken a prominent place in the public debate [ 9 , 10 , 11 , 12 , 13 ]. In the Dutch Euthanasia Code, this last category, an accumulation of health problems, is referred to as a range of, mostly degenerative, disorders such as visual impairment, hearing impairment, osteoporosis, arthrosis, balance disorders, and cognitive decline [ 14 ]. Though the numbers are small, reports of the Euthanasia Review Committees have shown that the absolute number of EAS cases in people whose primary cause of suffering was a psychiatric disorder, dementia, or an accumulation of health problems has increased over the past 5 years [ 15 , 16 , 17 ].

Using a nationwide sample of deceased people, we studied requests for EAS in people with and without these conditions focusing on the following questions: How many deaths among people with psychiatric disorders, dementia, and accumulation of health problems were preceded by a request for EAS and how many of these requests were granted? What are the reasons to grant or refuse a request for EAS? Which patient and care characteristics, including the presence of psychiatric disorders, dementia, and an accumulation of health problems, are associated with a patient requesting EAS and with a patient receiving EAS?

Design and population

In 2015, a nationwide mortality follow-back study was performed to estimate the frequency of requesting and receiving EAS among people with (also) a psychiatric disorder, dementia, or an accumulation of health problems; to explore reasons for physicians to grant or refuse a request; and to describe differences in characteristics, including the presence of psychiatric disorders, dementia, and accumulation of health problems, between patients who did and did not request EAS and between patients whose request was or was not granted. The study was largely similar to previous mortality follow-back studies done in 1990, 1995, 2001, 2005, and 2010 [ 3 , 4 , 18 , 19 , 20 , 21 ]. A stratified sample of death certificates of persons who died between 1 of August and 1 of December 2015 was obtained from the central death registry of Statistics Netherlands. Death certificates were stratified into 10 strata based on the likelihood of the patient having made an end-of-life decision. The certifying physicians of the sampled cases received a questionnaire focusing on end-of-life decisions that might have preceded the death of the patient involved. A reminder was sent to those who had not returned the questionnaire. Of the 9351 questionnaires sent, 7277 were returned (response 78%). In this study, only those who died a non-sudden death and who were aged 17 years or older were included ( n  = 5361). Ethical approval was not required for the posthumous collection of anonymous patient data [ 22 ]. Further details of the study design are described elsewhere [ 3 ].

Questionnaire

A four-page written questionnaire was sent to the physicians who signed the death certificates. The questionnaire was largely similar to the previous mortality follow-back studies [ 3 , 4 , 18 , 19 , 20 , 21 ]. It contained questions about the medical decision-making that had preceded death, whether the patient had requested for euthanasia, the reasons for granting or refusing the request, and questions about the medical care during the last month before death such as the involvement of caregivers for palliative consultation and psychosocial and spiritual issues. To obtain insight into EAS requests from people with a psychiatric disorder, dementia, and/or an accumulation of health problems (related to old age), a new question was added to the questionnaire about whether the patient had a psychiatric disorder, dementia, and/or an accumulation of health problems (yes/no). No description of these groups was provided to the physicians to classify patients; thus, physicians will most likely have interpreted these categories in the context of the Dutch euthanasia act and the current debate. The cause of death and specialty of the certifying physician were derived from the death certificate.

Statistical analyses were carried out using IBM SPSS version 22 (IBM Analytics). For presenting the frequencies of (requests for) EAS as well as the reasons for granting or refusing the requests, the results were made representative of all deaths during 2015 by weighting the data for stratification and response by patient’s sex, age, ethnic origin, and place and cause of death. This weighting procedure was similar to previous mortality follow-back studies [ 3 , 4 , 18 , 19 , 20 , 21 ]. Due to this procedure, the percentages that are reported cannot be derived from the absolute unweighted numbers.

Two multivariable logistic regression models were developed: one to identify factors associated with patients requesting EAS and one to identify factors associated with receiving EAS. The latter model was developed on a subset of the sample: patients who made an EAS request. First, the univariable association between each independent variable and the dependent variables (requesting EAS and receiving EAS) was analyzed. Next, all variables associated with requesting and receiving EAS ( p value < 0.10) were entered in a multivariable model. Subsequently, a manual backward selection procedure was applied until only variables with p  < 0.10 remained. In both models, the eligible independent variables were age (17–64, 65–79, > 80 years); sex (female/male); marital status (married/unmarried); ethnicity (Dutch and Western immigrants/non-Western immigrants); cause of death (cancer, cardiovascular disorder, pulmonary disorder, neurological disorder, or other); the presence of a psychiatric disorder (yes/no), dementia (yes/no), or an accumulation of health problems (yes/no); specialty of the certifying physician (general practitioner, medical specialist, or elderly care physician); involvement (yes/no) of the following caregivers in the last month of life, namely palliative care consultant/team, specialist pain control, psychiatrist/psychologist, and pastor [ 5 , 6 , 7 , 8 ]. Results are presented as frequencies, ORs, and 95% CIs.

Extra analyses

In the multivariable model identifying factors associated with requesting EAS, the ORs and 95% CIs of cause of death changed drastically compared to the univariable model. Sensitivity analyses showed this was mainly driven by (i) collinearity between two variables, dementia and attending physicians; (ii) strong associations between cause of death, requesting EAS, and dementia and between cause of death, requesting EAS, and attending physician; and (iii) empty cells demonstrating the likelihood of unstable models. Therefore, we also performed the multivariable analyses for both requesting EAS and receiving EAS without dementia and attending physician. In these models, there was no indication for the issues described; the ORs and 95% CI of the variables did not change substantially compared to the univariable analyses. The results of the multivariable regression analyses including all independent variables (including dementia and attending physician) are reported as main outcomes.

Description of the study sample

Of the 5361 deceased patients aged ≥ 17 years and whose death was non-sudden, 183 (3.4%) had a psychiatric disorder, 803 (15.0%) dementia, and 918 (17.1%) an accumulation of health problems, possibly next to the illness that caused their death. In people with a psychiatric disorder, dementia, or an accumulation of health problems, the most frequently reported cause of death was “other.” Of the people with dementia, 25.3% died of a neurological disorder (including dementia), and of the people with an accumulation of health problems, 22.1% died of a cardiovascular disorder. Among all deceased patients who died non-suddenly, 37% died due to cancer. The characteristics of the study sample are provided in Table  1 .

Frequency of EAS requests

Figure  1 shows that 11.2% of all patients who were aged ≥ 17 years had requested EAS preceding their death. Of the people with a psychiatric disorder, 11.4% requested EAS. The prevalence of EAS requests was lower among people with an accumulation of health problems (8.0%) and people with dementia requests (2.1%). Six percent of all deceased patients had received euthanasia; this percentage was lower among people who had a psychiatric disorder (4.8%), an accumulation of health problems (3.7%), and/or dementia (0.9%).

Frequency of deceased patients who did or did not receive euthanasia. Percentage of requests carried out among all deceased patients who died non-suddenly, 56% (6.3/11.2); people with psychiatric disorders, 42% (4.8/11.4); people with dementia 43% (0.9/2.1); and people with an accumulation of health problems, 46% (3.7/8.0)

Factors associated with requesting EAS

In univariable analyses, all variables showed associations ( p  < 0.10) with requesting EAS, except for the presence of a psychiatric disorder (Table  2 ). In the multivariable analysis, sex, marital status, and the involvement of a palliative care consultant were no longer associated ( p  < 0.10) with requesting EAS. Compared with people aged 80 years or older whose death was non-sudden, people aged between 17 and 64 years (OR 1.65 [1.33–2.04]) and between 65 and 79 (OR 1.38 [1.15–1.66]) were more likely to request EAS. Dutch and Western immigrants were 8.49 (95% CI 5.37–13.42) times more likely to request EAS compared with non-Western immigrants. Compared with people who died of cancer, people who died of cardiovascular disorders were less likely to request EAS while people who died of pulmonary disorders, neurological disorders, or another cause were more likely. People with an accumulation of health problems (OR 0.69 [0.53–0.90]) or dementia (OR (0.18 [0.12–0.28]) had lower odds of requesting EAS compared with those without these conditions. People whose attending physician was a medical specialist or an elderly care specialist had lower odds of requesting EAS (OR 0.07 [0.05–0.11] and OR 0.17 [0.13–0.23]) compared with people whose attending physician was a general practitioner. People who were supported by pain specialists (OR 2.08 [1.47–2.93]) and psychiatrists (OR 4.50 [3.15–6.41]) in the last month of life were more likely to request EAS while those supported by pastors were less likely (OR 0.77 [0.59–1.00]).

The results of the extra analysis without the variables dementia and attending physician (see the “ Methods ” section) were largely similar to the original multivariable model. However, people who died of cancer were now more likely to request EAS compared to people who died of any other cause. An accumulation of health problems dropped from the model.

Reasons to grant or refuse the request

Table  3 shows that across the full sample, the two most important reasons for the attending physician to grant the request were the lack of prospect of improvement (81.9–94.6%) and the autonomy of the patient (72.4–85.8%). In case of a psychiatric disorder, the presence of (severe) symptoms other than pain (75.4%) and expected suffering (53.5%) were also important reasons. In case of dementia, the loss of dignity (73.7%) and expected suffering of the patient (49.1%) were important. Finally, in case of an accumulation of health problems, the presence of symptoms other than pain (48.7%) and loss of dignity (54.8%) were both important reasons to grant the request. Among those with a psychiatric disorder, dementia, or an accumulation of health problems, the most important reason to refuse the request was that the due care criteria were not met, especially regarding the well-considered nature of the request. Among all deceased patients, the most important reason was that the patient died before the request was granted.

Factors associated with receiving EAS

Table  4 shows associations between receiving EAS and patient and care characteristics. In univariable analyses, age, cause of death, the presence of a psychiatric disorder and an accumulation of health problems, attending physician, and the involvement of a palliative care consultant/team and pastor showed associations ( p  < 0.10) with receiving EAS. In multivariable analysis, most associations remained significant. People who died of neurological disorders or another cause had 4.70 [95% CI 2.09–10.58] and 2.38 [95% CI 1.34–4.26] times higher odds of receiving EAS compared with people who died of cancer. People with a psychiatric disorder and an accumulation of health problems had lower odds of receiving EAS compared with people without these conditions (OR 0.38 [0.18–0.82] and OR 0.62 [0.36–1.05]). People whose attending physician was a medical specialist or an elderly care specialist were less likely to receive EAS (OR 0.13 [0.06–0.27] and OR 0.16 [0.09–0.28]) compared with people whose attending physician was a general practitioner. Those who were supported by a palliative care consultant in the last month of life were also less likely to receive EAS (OR 0.70 [0.50–0.98]).

The results of the extra analysis without the variables dementia and attending physician (see the “ Methods ” section) were largely similar to the original multivariable model except for the negative association found between pastor and receiving EAS.

The frequency of EAS requests among deceased people who died non-suddenly and who had psychiatric disorders (11.4%), dementia (2.1%), and/or an accumulation of health problems (8.0%) varied. Less than half of these requests led to EAS. Factors positively associated with requesting EAS were age (< 80 years), ethnicity (Dutch/Western), cause of death (cancer), attending physician (general practitioner), and involvement of pain specialist and psychiatrist. Cause of death (neurological disorders or another cause) and attending physician (general practitioner) were also positively associated with receiving euthanasia. Psychiatric disorders, dementia, and accumulation of health problems were negatively associated with requesting and receiving EAS.

EAS in people with psychiatric disorders, dementia, and an accumulation of health problems

EAS in people with psychiatric disorders, dementia, and an accumulation of health problems is a highly debated subject, but this practice rarely occurs. Partially, this can be explained by reluctance of physicians to perform EAS in these patients [ 23 ]. Our results showed that the proportion of euthanasia requests that was carried out was lower among people with psychiatric conditions (42%), dementia (43%), and an accumulation of health problems (46%) compared to all non-sudden deceased people (56%). Moreover, having a psychiatric disorder or an accumulation of health problems was statistically significantly associated with a lower likelihood of having a request being carried out. Previous research has also shown that physicians consider it less likely to perform EAS in patients with a psychiatric disorder, dementia, and/or an accumulation of health problems compared to patients with a severe and life-limiting somatic illness such as cancer [ 23 , 24 , 25 ]. Our results suggest that the presence of a psychiatric disorder, dementia, and/or an accumulation of health problems may complicate the decision to grant a request, even if the patient also suffers from a severe and life-limiting somatic illness, such as cancer. The main reasons to refuse a request are doubts about whether the request was well-considered and about the unbearableness of the suffering. These findings corroborate previous studies [ 26 , 27 ].

This study is the first to show that people with dementia or an accumulation of health problems are less likely to request EAS compared to people without these conditions which may explain part of the lower frequency of EAS in people with these conditions. Possibly, the lower frequency of requests among people with dementia and an accumulation of health problems can be explained by the slow and gradual decline characterizing both dementia and an accumulation of health problems leading to the gradual acceptance of a declining health condition [ 28 , 29 , 30 ]. In addition, in case of advanced dementia, patients lose the ability to make a well-considered request for EAS.

Due to the aging society, associated with an increasing number of older people suffering from multimorbidity, it is likely that the number of EAS requests from patients suffering from dementia and/or an accumulation of health problems related to old age will continue to grow [ 31 , 32 ]. The question of how policy makers and care providers should respond to these requests is, therefore, highly relevant.

Characteristics associated with requesting and receiving EAS

Patient characteristics.

This study showed that younger people are more likely to request EAS which is consistent with previous studies in the Netherlands and Belgium [ 5 , 6 , 33 ]. Younger people tend to have more permissive and liberal attitudes compared to older people and are more likely to support EAS [ 34 , 35 ]. Also, a strong positive association between ethnicity and requesting EAS was found, with Dutch or Western migrants being 8.5 times more likely to request EAS compared to non-Western migrants. Cultural and religious values and beliefs have frequently been reported to profoundly influence the perceptions of death and end-of-life decision-making [ 36 , 37 , 38 , 39 , 40 ].

People who died due to a neurological disorder were almost four times more likely to receive EAS compared to people with cancer which corresponds with previous findings [ 5 , 33 , 41 ]. ALS disease, which is known for its progressive, severe physical symptoms and lack of effective treatments, probably contributes the most to this finding.

Care characteristics

The involvement of a pain specialist and the involvement of a psychiatrist/psychologist in the last month of life were associated with higher likelihood of requesting EAS. This confirms previous research in Belgium and the Netherlands [ 5 , 42 ]. Possibly, pain specialists and psychiatrists/psychologists stimulate patients to think and talk about their end-of-life wishes, including EAS, as autonomy and informed decision-making are key principles of palliative care [ 43 ]. Finally, prior to granting a request, a physician must be certain that there is no other reasonable solution; optimizing end-of-life care is one of them.

Multivariable regression analyses also showed that deceased patients who were attended by a general practitioner were more likely to request and receive EAS, supporting previous evidence [ 5 ]. The attendance of a general practitioner possibly provides more opportunity for discussing end-of-life wishes, including euthanasia, due to the long-term care relationship with the patient and the non-acute care setting.

Strengths and limitations

Major strengths of this study are the large nationwide sample which is the representative of all deaths in the Netherlands in 2015, the high response rate and few missing data. When interpreting the results, some limitations need to be considered. Physicians were asked whether the patient had either one or more of the following conditions: a psychiatric disorder, dementia, and an accumulation of health problems. Since this was a general, closed question, i.e., yes/no, it is unknown to what extent these conditions contributed to the suffering underlying the EAS request. Also, psychiatric disorders and an accumulation of health problems are very broad categories which one has to take into account when interpreting the results. Another limitation is that our sample included patients who were seriously ill after all our sample included deceased patients; patients without a life-threatening illness were not included unless their life was ended. On the one hand, this may have led to an underestimation of the number of requests since among those who request EAS are also people who are not seriously ill. On the other hand, it may have led to an overestimation of the number of requests granted among people with a psychiatric disorder, dementia, and/or an accumulation of health problems since physicians are more likely to grant requests of people with (also) a severe and life-limiting somatic condition.

A relatively small group of people who died non-suddenly received EAS but even fewer of those with (also) psychiatric disorders, dementia, or an accumulation of health problems. Partly, this can be explained by the belief that the due care criteria cannot be met. Another explanation is that patients with these conditions are less likely to request for it. Given the aging society and the related rising of the number of EAS requests from people suffering from dementia and/or an accumulation of health problems, the question of how policy makers and care providers should respond to these requests is highly relevant.

Abbreviations

Accumulation of health problems related to old age

Confidence interval

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KE, HP, AH, TH, and BO designed the study. The sample was drawn from the central death registry of Statistics Netherlands. KE performed the data management and statistical analysis. KE, HP, AH, TH, and BO interpreted the data. KE prepared the initial draft of this manuscript. HP, AH, TH, and BO critically revised the manuscript for intellectual content and commented on subsequent drafts of the manuscript. KE, HP, AH, TH, and BO contributed to the final draft of the manuscript and gave the final approval for submission.

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Evenblij, K., Pasman, H.R.W., van der Heide, A. et al. Factors associated with requesting and receiving euthanasia: a nationwide mortality follow-back study with a focus on patients with psychiatric disorders, dementia, or an accumulation of health problems related to old age. BMC Med 17 , 39 (2019). https://doi.org/10.1186/s12916-019-1276-y

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Euthanasia and physician-assisted suicide: a systematic review of medical students’ attitudes in the last 10 years

Alejandro gutierrez-castillo.

1 Researcher, School of Medicine, Monterrey Institute of Technology and Higher Education, Nuevo León México, Mexico.

Javier Gutierrez-Castillo

Francisco guadarrama-conzuelo, amado jimenez-ruiz.

2 Neurology Resident, Department of Neurology, National Institute of Medical Science and Nutrition Salvador Zubirán, Ciudad de México, México.

Jose Luis Ruiz-Sandoval

3 Professor, Department of Neurology, Civil Hospital of Guadalajara “Fray Antonio Alcalde”, Jalisco, México.

This study aimed at examining the approval rate of the medical students’ regarding active euthanasia, passive euthanasia, and physician-assisted-suicide over the last ten years. To do so, the arguments and variables affecting students’ choices were examined and a systematic review was conducted, using PubMed and Web of Science databases, including articles from January 2009 to December 2018.

From 135 identified articles, 13 met the inclusion criteria. The highest acceptance rates for euthanasia and physician-assisted suicide were from European countries. The most common arguments supporting euthanasia and physician-assisted suicide were the followings: ( i ) patient’s autonomy (n = 6), ( ii ) relief of suffering (n = 4), and ( ii ) the thought that terminally-ill patients are additional burden (n = 2). The most common arguments against euthanasia were as follows: ( i ) religious and personal beliefs (n = 4), ( ii ) the “slippery slope” argument and the risk of abuse (n = 4), and ( iii ) the physician’s role in preserving life (n = 2). Religion (n = 7), religiosity (n = 5), and the attributes of the medical school of origin (n = 3) were the most significant variables to influence the students’ attitude. However, age, previous academic experience, family income, and place of residence had no significant impact.

Medical students' opinions on euthanasia and physician-assisted suicide should be appropriately addressed and evaluated because their moral compass, under the influence of such opinions, will guide them in solving future ethical and therapeutic dilemmas in the medical field.

Introduction

Death by itself is not part of an ethical dilemma, as all lives are bound to end since the moment of conception, and human beings confront death through their personal beliefs, religion, and cultural context. Regardless of the natural and unavoidable causes of death, debate over death focuses on how to control it as well as on who and how should perform the death-related practices in medical field. The important role of physicians in this debate is that they are often both the judge and the executor of such practices ( 1 ). Several physicians believe that the idea of promoting death is against Hippocratic Oath and their primary role as healer, while others may reject the idea based on their moral or religious values ( 1 ).

The issues on control over death can be divided into two broad categories: euthanasia and physician-assisted suicide (PAS). Euthanasia is further divided into active euthanasia (AE) or passive euthanasia (PE), according to the role that the physician plays in the process. The term PE is no longer used in some countries, and the term Therapy Withdrawal (TW) is replaced as the physician’s role is limited to suspending treatment or stopping additional measures that artificially prolong life. In TW, the physician acts as a mere observer while the disease advances and ends the patient’s life. However, in AE, the physician operatively engages in ending patient's life by administering a toxic substance that accelerates death ( 2 ). In PAS, the physician intentionally helps the patient to commit suicide by providing drugs for their self-administration at the patient’s competent and voluntary request ( 3 ). The differences among aforementioned approaches have implications that surpass their moral approval, as the medical actions involved in these approaches are regulated by law. According to the American Medical Association (AMA), AE and PAS are in conflict with physicians’ healing role. Furthermore, their management are quite challenging, if not completely impossible, and they entail grave risks to the society ( 4 ). However, PE, described as withdrawal or withholding life-sustaining treatment, is ethically acceptable for a patient capable of decision-making, and if an intervention is not expected to achieve the patients’ goals for care or desired quality of life ( 4 ).

The contributions of this study are as follows: ( i ) quantitative assessment of medical students’ approval rate for AE, PE and PAS over the last ten years, ( ii ) analysis of the most common arguments validating such practices, and ( iii ) evaluation of the variables that can influence a personal position on the topic. This study aimed at answering the following questions: What is the percentage of euthanasia or PAE approval among medical students? What are the most common arguments associated with the approval or rejection of euthanasia or PAE? What are the variables affecting the approval or rejection of euthanasia and PAE?

This study was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) ( 5 ) ( Figure 1 ).

PRISMA flowchart

The literature searches in April 2019, included articles published between January 2009 and December 2018, and focused on PubMed and Web of Science as the primary electronic databases. The databases were searched using the following search strings: (medical students) AND (euthanasia OR Physician-assisted suicide).

Our review focused on original cross-sectional descriptive studies in English whose main population, or part of it, was composed of medical students and quantified their personal views regarding the legalization or practice of PAS or euthanasia.

Only original descriptive articles that quantitatively addressed the first focused question in the last ten years were included. The excluded cases were the followings: ( i ) Review articles, book chapters, conference papers, and letters to the editor; ( ii ) Non-neutral reports, where the authors expressed their views or stated an opinion on the topic; ( iii ) Articles whose main population consisted of physicians, nurses, or any group other than undergraduate medical students; ( iv ) Articles for which the complete text could not be found online; and, ( v ) Articles written in languages other than English.

Records were initially screened according to the titles and abstracts. Relevant abstracts and articles without an abstract were selected for full-text review. Articles selected in the first screening were carefully read and analyzed to determine whether they addressed the first focused question and whether they fulfilled the inclusion criteria. Further analyses were made to determine if they described any argument or variable that could persuade medical students to take a positive or negative side.

A total of 135 articles were identified after the database search (63 in PubMed and 72 in Web of Science); 97 non-duplicate documents were screened by the title and abstract. From the 25 articles eligible for full-text review, 13 fulfilled the inclusion criteria and were selected for further analysis ( 6 - 18 ). Reasons for exclusion of 12 remaining articles were as follows: ( i ) use of a language other than English (n = 2); ( ii ) absence of a full-text version online (n = 3); ( iii ) inclusion of a study population different than undergraduate medical students (n =3); and, ( iv ) failure to address the first focused question (n = 4).

From the 13 selected articles, seven ( 6 - 12 ) were published between 2014 and 2018 and six ( 13 - 18 ) were published between 2009 and 2013. Two studies were from Africa ( 7 , 9 ), four were from America ( 6 , 8 , 12 , 14 ), one was from Asia ( 15 ), and six were from Europe ( 10 , 11 , 13 , 16 - 18 ). The countries involved included Austria (n = 1) ( 18 ), Belgium (n = 1) ( 11 ), Brazil (n = 1) ( 12 ), Canada (n = 1) ( 14 ), Germany (n = 1) ( 10 ), Greece (n = 1) ( 18 ), Mexico (n = 2) ( 6 , 14 ), Pakistan (n = 1) ( 15 ), Poland (n = 2) ( 13 , 16 ), and South Africa (n = 2) ( 7 , 9 ).

Eight articles addressed the approval rate of medical students regarding legalization of AE, PE or PAS ( 7 - 9 , 11 , 13 , 15 - 17 ); ten stated a positive attitude toward AE exclusively ( 6 - 12 , 15 , 17 , 18 ); six addressed acceptance of PE ( 6 , 9 , 10 , 12 , 14 , 18 ); and, six addressed acceptance of PAS ( 7 , 8 , 10 , 14 , 15 , 18 ). Two articles addressed the students’ personal views on AE, PE or PAS, whether exclusively or conjunctively ( 13 , 16 ). The results are summarized in Table 1 .

Percentage of approval for AE, PE, and PAS, as well as the legalization of euthanasia or PAS.

Out of eight articles that addressed the positive views on legalization of the procedures, the lowest acceptance rate was 26% ( 13 ) and the highest 97% ( 11 ). The lowest and highest acceptance rates were as follows: ( i ) 14.2% ( 15 ) and 52% ( 18 ) for AE, ( ii ) 45.7% ( 12 ) and 83.3% ( 10 ) for PE, and ( iii ) 32.8% ( 15 ) and 69.7% ( 18 ) for PAS. The highest acceptance rates in the four scenarios were observed among students in European countries ( 10 - 12 , 15 ), while the lowest acceptance rates were related to Pakistan ( 15 ) and Brazil ( 12 ).

Eight articles ( 6 - 8 , 11 , 15 - 18 ) were related to second main question addressing students’ arguments for or against the practice of AE, PE or PAS. The most common arguments supporting AE, PE or PAS practice were as follows: ( i ) patients’ autonomy (n = 6) ( 6 - 8 , 11 , 16 , 17 ); ( ii ) relief of suffering or beneficence (n = 4) ( 7 , 11 , 16 , 17 ); and, ( iii ) the thought that terminally-ill patients are additional burden (n = 2) ( 11 , 18 ). Less relevant arguments included the followings: ( i ) legality of the procedure ( 6 ); ( ii ) educational or clinical experience ( 8 ); and, ( iii ) quality of life or life expectancy ( 18 ). The most common arguments against AE, PE or PAS were the followings: ( i ) religious or personal beliefs (n = 4) ( 7 , 8 , 15 , 18 ); and, ( ii ) “slippery slope” argument or risk of abuse (n = 4) ( 7 , 8 , 16 , 18 ); and, ( iii ) physicians’ responsibility to preserve life ( 7 , 18 ). The results are summarized in Table 2 .

Students’ arguments in favor or against the practice of euthanasia or PAS

Regarding the third focused question, 11 articles ( 6 - 9 , 11 , 12 , 14 - 18 ) highlighted variables that could cause the medical students to approve or disapprove AE, PE or PAS practices. Religion was the most significant variable that had a negative impact (n = 7) ( 6 - 8 , 11 , 12 , 14 , 16 ), followed by religiosity (n = 5) ( 6 , 12 , 14 , 15 , 18 ) as the second most significant variable. Moreover, university of origin for the medical students (n = 3) ( 12 , 14 , 16 ) and previous experience with euthanasia or palliative sedation in a relative (n = 1) ( 11 ) were other named variables. Non-significant variables included the followings: ( i ) age (n = 3) ( 6 , 12 , 17 ); ( ii ) previous academic experience regarding end-of-life decisions (n = 2) ( 11 , 16 ); ( iii ) family income (n = 1) ( 12 ); and, ( iv ) size or place of residence (n = 1) ( 16 ). Variable of gender in influencing the students’ opinions showed mixed results: significant ( 6 , 16 ) and non-significant ( 11 , 12 , 14 , 17 , 18 ). Similarly, for variable of medical students’ current academic year, three studies considered it to be significant ( 9 , 15 , 17 ) and one study reported it as irrelevant ( 6 ). The summarized results are shown in Table 3 .

Significant variables that affect the posture of medical students towards euthanasia or PAS

Despite the great diversity of opinions regarding AE, PE and PAS, the percentage of approval for AE was lower than those of PE or PAS in all analyzed scenarios ( 6 - 18 ). Regarding AE approval, the study of Kontaxakis et al. was the only one that reported an acceptance percentage higher than 50%, under special circumstances ( 18 ). If these results are compared to those of other groups, such as general population ( 19 ) or post-graduate students ( 11 ), the approval rate is usually higher than 50%. In contrast, physicians tend to show a negative attitude toward the topic ( 19 , 20 ). The relevance of clinical experience, as a variable that could influence the acceptance of euthanasia or PAS, was discussed by Marais et al. ( 9 ) and Hassan et al. ( 15 ), who reported different results depending on whether the students were at preclinical level (without active experience with patients) or on clinical rotations. Marais et al. stated that higher clinical-level correlated to medical students’ greater empathy towards patients and respect for their autonomy. This correlation was demonstrated by a 20% difference in acceptance rate for AE between preclinical and clinical students, which dropped to 10% when they were asked if they will perform an assisted-dying procedure ( 9 ). Hassan et al. found lower acceptance rate for euthanasia or PAS among senior medical students; the attitude toward euthanasia, however, split to 50% against and 50% undecided, highlighting a higher percentage of indecision among seniors than freshmen ( 15 ). Seniors stated that through clinical exposure, medical students become more aware that some diseases are incurable ( 15 ). However, a 2018 study by the authors of article ( 6 ) did not identify academic rank as a variable that could influence medical students’ attitude toward this topic. That study focused only on preclinical students in the first three years of medical school, justifying the uniformity of opinions and highlighting that exposure to patients affected medical students’ views regardless of their academic school year.

Until now, AE has been legalized in Belgium ( 11 ), the Netherlands ( 19 ), Luxemburg ( 19 ), Colombia ( 21 ), Uruguay ( 21 ), and Canada ( 8 ); Three countries where AE is legal are European ( 11 , 19 ), which justify that why the majority of the papers that met the present study’s inclusion criteria were published in this continent where the debate is open. In Belgium, the only country included in this study where AE is currently legalized, Roelans et al. reported that the approval percentage of the legalization of euthanasia to be 97% ( 11 ); a real legal environment, along with personal or professional experience in scenarios of assisted death, can create more favorable attitude among medical students ( 11 ). In Canada, another country where these practices are legalized, the study by Bator et al. was performed a year before the Canadian laws’ modification to abolish the penalization of euthanasia ( 8 ). These political discussions may affect medical students’ attitude toward acceptance.

Religion is defined as a moral institution with a unified system of values, beliefs and practices related to what is considered sacred ( 22 - 23 ). Religion is one of the most common variables mentioned by researchers to influence medical students’ views on euthanasia ( 6 - 8 , 11 , 12 , 14 - 16 , 18 ). Moreover, religion affects several other areas of medicine, such as adherence to treatment or the decision-making process in high-risk procedures ( 22 ). In seven studies that described religion as a relevant variable, five found Catholicism to be the most frequently self-reported religion ( 6 , 11 , 12 , 14 , 16 ), and less frequently ones were Christianity ( 7 ) and Islam ( 15 ). Conversely, the medical students who considered themselves atheists or those who did not actively practice any religion tended to have a more positive view towards AE, PE, and PAS for both patients and themselves ( 8 , 11 , 12 , 14 - 16 , 18 ). Different, sometimes conflicting views can be observed among various religions. In 2007, Sprung et al. studied the attitude of physicians towards PE; Catholics, Protestants and those with no religious affiliation compared to Jews, Greek Orthodoxies or Muslims had higher acceptance rate for therapy withdrawal ( 23 ). According to the Roman Catholic religion, practitioners are not obligated to ward off death at all costs, but they should not deliberately intervene to accelerate this process ( 24 ). The principle of “sanctity of life” categorizes life as a basic value as it establishes a direct relationship with God, and condemns any intervention that seeks to end this relationship ( 24 ). This principle could explain a more negative attitude toward AE and a mildly open posture toward PE. Studies that described a majority of the Catholic population and addressed the attitude of PE had acceptance rate higher than 50%, except one study from Poland ( 16 ). Leppert et al. did not separate the opinions in favor of or against AE, PE, or PAS, and considered that the students’ view could be influenced by the statements of the last Polish Pope, John Paul II ( 16 ). Regarding Islam, negative attitude is generally stated toward the topic ( 7 , 15 , 23 ). The Quran forbids self-harm and consenting to end life, which can be related to terminally-ill patients consenting to euthanasia ( 25 ). In Islam, death is not the final destination, and therefore a believer should keep facing difficulties despite suffering to stay alive ( 25 ). However, the concept of religion has to be differentiated from religiosity or religiousness, referring to the influence of religion on daily life and intrinsic values. A positive experience with religion, mainly described as a growing spirituality or closeness to God, empowers patients to undertake greater risks in their treatments ( 22 ). Regarding euthanasia, the greater the religiosity, the more opposition towards euthanasia ( 6 , 15 ). This association is in line with our previous study’s findings, where the participants who were described as strong believers showed a predominant negative view towards AE and PAS as well as inflexibility to change their original position in different scenarios ( 6 ). Similarly, Hassan et al. reported the lowest acceptance rate for AE, in a study involving predominately Muslim participants, which 17% of them identified themselves as very religious ( 15 ).

The main arguments on euthanasia are related to the bioethical principles. Autonomy, the most common argument stated by the medical students to support this practice ( 6 - 8 , 11 , 16 , 17 ), derives from the Greek auto (self) and nomos (rule) and refers to the individuals’ ability to make independent choices about their treatment ( 7 ). However, the state of autonomy in relation to euthanasia varies depending on whether autonomy is considered an intrinsic or moral value. In the former, patients would have free will in decision-making about their life or death ( 26 ), and in the latter —according to the Kantian perspective—death threatens autonomy by eliminating the individual who would otherwise exercise autonomy ( 27 ). Another argument to support euthanasia is relief from suffering, based on the principle of beneficence, as it considers the induction of death as a better alternative to avoid unnecessary suffering ( 28 ). The opponents of euthanasia argue that the elimination of suffering by death may not be the best alternative considering the followings: ( i ) increasing interest and research on palliative care and ( ii ) management of patients’ psychiatric conditions (e.g., depression), which may adequately relieve their suffering ( 28 , 29 ). The most common arguments against these practices were as follows: ( i ) personal and religious beliefs ( 7 , 8 , 15 , 18 ); ( ii ) risk of abuse, sometimes referred to as the “slippery slope” argument ( 7 , 8 , 16 , 18 ); and, ( iii ) the physicians’ role in preserving life ( 7 , 18 ). According to the argument of the “slippery slope”, if specific types of actions receive permission, then society will be coerced in permitting further morally wrong actions ( 30 , 31 ). As a classic example of this argument, in the Netherlands, where initially euthanasia was only approved for terminally-patients, the criteria were later expanded to allow euthanasia for chronically-ill patients and those suffering from severe psychiatric conditions. Subsequently, euthanasia was legally allowed for incompetent patients, including children ( 31 ). Opponents of the “slippery slope” argument state that for euthanasia to be considered as part of the risk of abuse argument, it must initially be condemned as morally wrong, an argument that in their opinion is dependent merely on personal experience ( 31 ). The final argument against euthanasia is the Hippocratic Oath’s view of the physicians’ role as healers. The Hippocratic Oath was first proclaimed in 400 BC and established one of the earliest codes of ethics for the medical profession ( 32 ). Because of its tradition and relevance, it is still frequently taken by medical students during their training or upon its completion. One of its lines states that physicians will not give poison to anyone though asked to do so, nor they would suggest such a plan ( 6 ), a line that contradicts modern-day views of euthanasia. This presumptive allegiance to the Hippocratic Oath may explain why students from newer, urban, public, and bigger universities usually have a more positive attitude towards euthanasia and PAS than students from older schools with more traditional values ( 12 , 14 , 16 ).

The relevance of understanding the medical students’ attitudes towards euthanasia and PAS lies not only in their values as present-time insights, but also as input data to generate strategies that optimize their education and address future medical dilemmas. Even though medical students usually have sufficient knowledge about euthanasia ( 15 ), they lack understanding of end-of-life care. Eyigör stated that most medical students believe that they have not received a complete education on palliative care or training on communication skills regarding palliative-care patients ( 33 ). A better understanding of end-of-life care, including euthanasia and PAS, for medical students, is essential, even if these practices are not currently legalized in their countries as related debates on the topic are not expected to end shortly.

A major limitation of this study was the use of non-standardized questionnaires to research the main focused questions, as they provide varied responses that are difficult to categorize and analyze adequately. Even if a students’ view on euthanasia or PAS is markedly positive or negative, the format of the questionnaire may not accurately address the real answer. Moreover, questions asked directly may obtain different answers than those asked indirectly; questions with clinical case scenarios or with only binary true or false answers could further alter the results. Another limitation was the use of only two electronic databases, which could narrow results. This limitation could also limit the number of countries included in the study, which may prevent the global perspective from being reflected.

Seeking a global perspective from medical students over a particular course and then describing that perspective is complex. This complexity is not only due to the great diversity of opinions, but also due to the geographical, social, cultural, and temporal context influencing their decisions. This study aimed to objectively describe the medical students’ attitude towards AE, PE, and PAS practices as well as to analyze the variables and arguments surrounding these practices. To summarize, PE and PAS are more accepted than AE, and the most critical arguments in favor of these practices are the respect for autonomy and the relief of suffering. Personal beliefs and the social role of the physician as a healer are the most common arguments against these practices. Even though a consensus may not be reached easily or soon, continuing the discussion about end-of-life decisions is essential because the debates over these practices and the necessity for such decisions will unavoidably linger. Medical students must be aware of different perspectives on the topic to make an informed decision in related circumstances.

Citation to this article:

Gutierrez-Castillo A, Gutierrez-Castillo J, Guadarrama-Conzuelo F, Jimenez-Ruiz A, Ruiz-Sandoval JL. Euthanasia and physician-assisted suicide: a systematic review of medical students’ attitudes in the last 10 years. J Med Ethics Hist Med. 2020; 13: 22

Conflict of Interests

The authors declare that they have no conflict of interests.

Euthanasia and Assisted Suicide: A Guide to the Evidence

Introduction

This evidence guide has been written to inform the debate about whether to legalise physician assisted suicide or euthanasia in the United Kingdom.  Most of the sources cited here are also relevant to the debates on assisted suicide or euthanasia in other countries.

You can skim to get a sense of the different issues at stake and where to find further information, especially the most reliable information that is freely available online.  

This guide aims to be useful for:

• students (especially of the medical professions, law, philosophy, and bioethics)
• research assistants to officials or parliamentarians.  

More than this, it is offered to anyone who is concerned about these issues and wishes to assess the evidence. 

It is important to remember, as has recently been pointed out , ‘that the medical literature is, in general, favourably disposed toward the empirical and the new [… resultantly] articles defending the ethical status quo (i.e., against PAS) tend to be shut out of the medical literature because they are not reporting anything new and, therefore, cannot have any data. The result is an impression of growing acceptance of PAS, but it really represents an artefact of a scientific bias’. It is hoped that this guide contributes to redressing this scientific bias.

Along with references for the source-data and official reports on assisted suicide and euthanasia in various countries, it identifies some useful articles that have been published in Peer Review Journals (PRJ). Publishing in a PRJ is no guarantee of the truth of an article’s conclusions, for especially in law, ethics and public policy academics frequently argue for opposite conclusions. However, being published in a PRJ is a sign that other academics have considered the argument to be well-structured and the sources of evidence to be clearly identified. This provides a good starting point for debate. Unfortunately, most PRJ material is not free to the general reader but is available only through universities or by subscription. Nevertheless, some PRJ articles are free online and sometimes there are freely available discussions based on the article. At a minimum the abstract of the article will generally be available free online. In this bibliography, all PRJ articles will be identified with an asterisk * . Where the full text of a PRJ is freely available this will be indicated by * (full text available) . Where the published version is not freely available, a pre- or post-print draft occasionally will be. This means that the full text can be read, but the article has none of the publisher’s formatting.

Many articles on euthanasia and assisted suicide have been published since the original version of this evidence guide in 2015. We have updated the guide to include new literature and the changes to legislation regarding euthanasia and assisted suicide throughout the world since that time. The guide is intended to be indicative rather than fully comprehensive, and we intend to update the resources periodically in the future.

DA Jones, R Gay and CM Wojtulewicz

Oxford, April 2022

Abbreviations

EAS = euthanasia and/or assisted suicide.

PAS / AS = physician-assisted suicide / assisted suicide

1. Parliamentary Reports

Since 1990 within the United Kingdom there have been three parliamentary reports on assisted euthanasia or suicide, each of which has been critical of such proposals. The most recent, and the most relevant to the Bills before the House of Lords and the House of Commons, is the 2015 Report of the Health and Sport Committee of the Scottish Parliament.

House of Lords Select Committee on Medical Ethics (HL Paper 21-I of 1993-4). There is no copy of the report available online, but a summary was provided by Lord Walton of Detchant (its chair) in a statement to the House of Lords recorded in Hansard.

House of Lords Assisted Dying for the Terminally Ill Committee 5 April 2005 (Mackay Committee ) On this committee’s findings see also I Finlay, VJ Wheatley, and C Izdebski. ‘The House of Lords Select Committee on the Assisted Dying for the Terminally Ill Bill: implications for specialist palliative care.’ Palliative medicine 19.6 (2005): 444-453 . *

Scottish Parliament Health and Sport Committee 6th Report, 2015 (Session 4): Stage 1 Report on Assisted Suicide (Scotland) Bill . This Committee was ‘not persuaded by the argument that the lack of certainty in the existing law on assisted suicide makes it desirable to legislate to permit assisted suicide... there are ways of responding to suffering (such as increased focus on palliative care and on supporting those with disabilities), which do not raise the kind of concerns about crossing a legal and ethical “Rubicon” that are raised by assisted suicide’. [292, 294]

The House of Lords introduced the Assisted Dying Bill 2021 [HL] , proposed by Baroness Meacher, which was given a second reading on 22 October 2021 . 

House of Commons Library Debate Pack 22 January 2020, ‘The Law on Assisted Dying’ , by Elizabeth Rough and Nikki Sutherland.

Current challenges in the culture of healthcare in the UK 

If legalised, assisted suicide or euthanasia would be implemented in the context of the NHS. In this regard it is important to be realistic about the current state of healthcare in the UK and failures that can occur and that have occurred, for example, in Mid Staffordshire and in the implementation of the Liverpool Care Pathway for the Dying Patient. These problems were not confined to one Trust or one Pathway but reflect cultural challenges within the NHS. How might assisted suicide or euthanasia be implemented in an environment of targets and ‘tick-boxes’ that sometimes operate to the detriment of patient care? 

Mid Staffordshire NHS Foundation Trust Public Inquiry (Francis Report)

Independent Review of the Liverpool Care Pathway: More Care, Less Pathway (Neuberger Report)

2. Official Statistics from Jurisdictions with Assisted Suicide or Euthanasia

Statistics for rates and characteristics of death by assisted suicide or euthanasia are available for fifteen jurisdictions: Canada, the Netherlands, Belgium, Luxembourg, Switzerland, Victoria (Australia) , and, in the USA, the District of Columbia , and the states of California, Colorado, Hawaii, Oregon, Maine, New Jersey, Vermont and Washington . Assisted suicide is legal in Montana and New Mexico, but there are no official reports on the practice. 

Such statistics are only as reliable as the questions asked and the means of data collection and in all cases rely on self-reporting. In Flanders (Belgium) it has been shown that official figures underestimate rates by approximately 50% (see section 5.4 below). Official reports tend to gloss the figures and readers should beware of ‘spin.’ Nevertheless, with these caveats, official figures remain an important source of evidence for the impact of legalising assisted suicide or euthanasia.

In Belgium euthanasia was legalised in 2002 and reports have been produced every two years. These are available (in French) here.  

In Luxembourg euthanasia was legalised in 2009 and reports are produced every two years. Luxembourg has a small population (less than 1% of the UK population) and thus the number of cases is small. Nevertheless, over 6 years it is possible to see some patterns (a general increase in cases, an increase in non-cancer cases, more cases of women than men). The fifth report (for 2017-2018) is available here. The sixth report (for 2019-2020) was completed in March 2021, but is not available for download.

In the Netherlands euthanasia was effectively decriminalised by a court decision in 1984. This was the basis of a legal statute in 2001 legalising euthanasia and physician assisted suicide. Since 2002 the Netherlands has produced an annual report on the cases notified to the five regional euthanasia committees. These are available (in English once the year is selected).  

In Switzerland , since 1942, inciting or assisting suicide has been illegal when it is for selfish motives (such as financial gain). Since 1982 this law has provided legal space for the organisation EXIT to promote assisted suicide for those ‘with unbearable symptoms or with unacceptable disabilities’. There are two government reports from the Federal Statistical Office, one in 2012 and latest, for 2014, published in 2016 and revised in 2017 . There are also statistics for assisted suicide by sex and age for 2003-2019 , published by the Federal Statistical Office. Dignitas has released statistics from 1998-2021 .

North America

Canada passed euthanasia and assisted suicide into law in 2016 (termed ‘medical assistance in dying’ or MAID). Further changes in the law, widening eligibility criteria, were introduced in March 2021 (though not effective until March 2023). The Second Annual Report on Medical Assistance in Dying (2020) shows that ‘MAID’ deaths increased by 34.2% from 2019.

The District of Columbia legalised assisted suicide in 2016 and has produced one statistics report in 2018.

California legalised assisted suicide in 2015 and has produced reports each year since. They can be found here.

Colorado legalised assisted suicide in 2016, and has produced reports each year since. They can be found here.

Hawaii passed assisted suicide into law in 2018, which came into effect in January 2019. The 2019 and 2020 legislative reports can be found here.  

Oregon legalised physician assisted suicide in 1997 and produces annual reports. Helpfully the latest report (2021) includes data from previous years. Note that the figure for the number of deaths in the most recent year covered by the report will generally be inaccurate as deaths are recorded against the year of the lethal prescription. For example, if a lethal prescription given in 2012 were used in 2013 the death would be recorded as due to assisted suicide in the 2012 figures. Reports from all individual years can be accessed here.

Maine introduced assisted suicide in 2019 and its reports can be found here.

New Jersey also passed assisted suicide into law in 2019 and its 2019 and 2020 data summaries can be found here.

Vermont legalised physician assisted suicide in 2013 for terminally ill patients. The latest report can be seen here (issued Jan 15 2022).

Washington legalised physician assisted suicide in 2009 following the Oregon model (Washington borders Oregon and to a great extent shares a common culture and history). Washington also produces annual reports.  

Victoria (Australia) legalised euthanasia and assisted suicide (under the umbrella term ‘voluntary assisted dying’ or VAD) in 2017, which came into effect in June 2019. Statistics are issued approximately every 6 months, and the data can be found here.

There are common patterns which emerge in each of these jurisdictions: in every jurisdiction numbers have increased over time and continue to do so; there has also been a shift from permitting assisted suicide for cancer victims to include other diseases. In Europe this includes non-terminal conditions such as neuro-psychiatric conditions and multiple co-morbidities (for example, those associated with old age). Supposed safeguards such as psychiatric referral have also declined in frequency (see below for further details). Essentially, the practice has become more widespread and more routine.

3. Public Opinion on Euthanasia and Assisted Suicide

Within the political debate on assisted suicide and euthanasia, both sides, but especially advocates of a change in the law, frequently appeal to surveys of public opinion. In polls, there is a consistent majority of public opinion that expresses support for legalising assisted suicide or euthanasia.

In the UK polls typically show between 70-80% support for legalising assisted suicide. Support drops to around 60% for euthanasia. See for example:

Ipsos-Mori Poll for The Economist (June 2015)

80% believe those accompanying a family member or friend abroad to receive assisted suicide should not be prosecuted. This drops to 74% when informed that current law in England and Wales is that assistance is punishable by up to 14 years in prison. 65% think the law should be changed to permit assistance in travelling abroad, see:

Ipsos-Mori Poll for Dignity in Dying (June 2009)

A 2019 poll commissioned by Dignity in Dying shows net support for assisted suicide law at 84%; but it must be noted that the procedure is referred to as ‘assisted dying’ rather than ‘assisted suicide’ (see the section below on wording of polls):

Populus Poll for Dignity in Dying (March 2019)

Gallup Poll (USA, 2013)

It should be noted that 73% think there ‘ is a difference between a terminally ill adult seeking assistance to end their life and suicide ’, see YouGov / Dignity in Dying (August 2021) . However, the proposed legislation (Assisted Dying Bill [HL] 2021) has the effect of amending the Suicide Act 1961 (as amended by the Coroners and Justice Act 2009) so that it is no longer and offence to ‘encourage or assist’ suicide.

On the issue of correct terminology and the use of euphemism, see:

David Albert Jones, ‘Defining the Terms of the Debate: Euthanasia and Euphemism’, Briefing Papers: Euthanasia and Assisted Suicide (Anscombe Bioethics Centre, Oxford: 2021)

In the UK, 78% are concerned that, as a society, as much as possible ought to be done to reduce suicide rates. 51% are concerned that people would see themselves as a burden and feel pressured into taking their own life if assisted suicide were legal, see:

ComRes Care Not Killing Assisted Suicide Poll (February 2019)

In a 2018 poll, although 75% were in favour of a change in the law, 60% did not know anyone close to them who had died who would have considered assisted suicide had it been available to them, see:

ComRes Daily Mirror Assisted Dying Poll (June 2018)

When participants are exposed to counter arguments to legislation, support wavers. In one poll from 73% to 43%:

Care Not Killing, “‘Assisted Dying’ and Public Opinion” (2014)

ComRes CARE Assisted Suicide Poll (2014)

The Mackay committee produced a very useful critical review on the state of evidence at that time (2005) in relation to public opinion on assisted suicide and euthanasia ( Chapter 6 and Appendix 7 ).

‘ The key conclusion of this report is that, although some idea of the basic attitude of the general public is available through research sources, this does not amount to an authentic picture of public opinion which is in any way comprehensive. Deliberative research techniques, unused so far for this subject, which can produce an account of informed public opinion, are recommended if a proper understanding of public opinion is to be achieved .’ ( Appendix 7 , para 17) 

In 2022, it remains the case that ‘ Research sponsors frequently appear to have been more concerned to achieve statistics for media consumption than to work towards achieving a comprehensive understanding of public and health sector attitudes’ (Appendix 7, para 2).

The flaws in most yes/no polls are methodological and are not corrected merely by conducting more polls of a similar kind. Qualitative research is needed to uncover the complexities of the issue and/or the complexities of people’s attitudes to the issue. For example, a study in the Journal of Medical Ethics showed that, if people were given a range of choices (and not just one), more individuals were in favour of legal sanctions against euthanasia than were in support of it.

Hagelin, J, T Nilstun, J Hau, and H-E Carlsson. ‘Surveys on Attitudes towards Legalisation of Euthanasia: Importance of Question Phrasing’. Journal of Medical Ethics 30, no. 6 (1 December 2004): 521–23. https://doi.org/10.1136/jme.2002.002543. * (full text available).

This complexity is also shown in qualitative research with nurses and with dying cancer patients. See here:

Berghs, M, B. Dierckx de Casterlé, and C. Gastmans, ‘The Complexity of Nurses’ Attitudes toward Euthanasia: A Review of the Literature’. Journal of Medical Ethics 31, no. 8 (August 2005): 441–46. https://doi.org/10.1136/jme.2004.009092. * (full text available).

Jaklin, A., N. Olver, and I. Eliott, ‘Dying Cancer Patients Talk about Physician and Patient Roles in DNR Decision Making’. Health Expectations 14, no. 2 (2011): 147–58. https://doi.org/10.1111/j.1369-7625.2010.00630.x * (full text available).

It is worth highlighting the following conclusion from the latter study: ‘ Survey studies showing majority support for euthanasia have typically required individuals to make judgements about hypothetical and abstracted scenarios. Under such conditions, individuals are likely to draw upon the readily available and socially approved discourses of autonomy and compassion, and voice approval. To conclude that this legitimises euthanasia as social policy is to deny the import of other factors that feature when individuals have opportunity to do more than endorse or reject euthanasia ’.

These complexities are by no means peculiar to the issues of assisted suicide and euthanasia, they apply more generally to use of public opinion in ethical debates around public policy. For such reasons government engagement with the public typically employs mixed methods: public events, open online consultations, stakeholder events, and representative opinion polls. The UK government’s Code of Practice on Consultation makes it clear that consideration of public opinion should give particular weight to the views of ‘any groups or sectors... that may be disproportionately affected by the proposals ’ (3.4). [In the case of assisted suicide and euthanasia this would be people who are dying, those who are living with disabilities, their carers, and healthcare professionals, especially doctors who care for the dying.] Consultations should not just ask for conclusions but ‘ the evidence given by consultees to back up their arguments. Analysing consultation responses is primarily a qualitative rather than a quantitative exercise ’ (6.1). 

These principles of good practice should apply also when judging the competing claims to how ‘the public’ thinks of assisted suicide and euthanasia.

Wording of polls

Support for euthanasia and assisted suicide in public opinion polls is subject to ‘ over 20% variation in mean support ’ where there are ‘ increasing levels of favourable wording’, and that ‘[a]llusions to hopelessness had an especially strong effect on increasing support for EPAS [euthanasia and physician-assisted suicide] ’:

Grove, Graham, Ian Hughes, Melanie Lovell, and Megan Best. ‘Content Analysis of Euthanasia Polls in Australia and New Zealand: Words Do Matter’. Internal Medicine Journal 51, no. 10 (2021): 1629–35. https://doi.org/10.1111/imj.15377. * (full text available after embargo ).

See also: L. Parkinson et al. ‘Cancer patients’ attitudes towards euthanasia and physician-assisted suicide: The influence of question wording and patients’ own definitions on responses’, Journal of Bioethical Enquiry , 2(2) (2005): 82-89 * (full text available).

Aghababaei, Naser, Hojjatollah Farahani, and Javad Hatami. ‘Euthanasia Attitude; A Comparison of Two Scales’. Journal of Medical Ethics and History of Medicine 4 (12 October 2011): 9 . * (full text available).

Another reason to be cautious of such polling (and opinion polls more generally) is that they do not necessarily reflect how people actually vote when given the opportunity. Most ballot initiatives in the USA on this issue have in fact failed , despite opinion polls seeming to show strong support. Those which have passed (Oregon, Washington, and Colorado) only secured modest majorities (51%, 58%, and 65% respectively).

4. Medical Opinion on Euthanasia and Assisted Suicide

Whereas simple yes / no public opinion polls typically find a significant majority in favour of legalising assisted suicide or euthanasia, opinion among the medical profession is generally opposed.

In March 2019, the Royal College of Physicians (RCP) adopted a position of neutrality , based on a survey of fellows’ and members’ views . 43.4% thought the RCP should be opposed to a change in the law, 31.6% thought the RCP should support such a change, and 25% thought the RCP should be neutral. While this shift was interpreted by some in the media as a move in favour of legalisation, they stated that, ‘ So that there can be no doubt, the RCP clarifies that it does not support a change in the law to permit assisted dying at the present time ’.

Although the Royal College of Radiographers (RCR) does not hold a position on ‘assisted dying’, in 2019 they polled their fellows and members , asking what they thought the RCR Faculty of Clinical Oncology’s position should be on whether or not there should be a change in the law on ‘assisted dying’. The response rate was only 34% (540 complete responses), but 42.9% thought the RCR position should be ‘opposed’, 26.9% thought ‘in favour’, and 30.3% thought ‘neutral’.

The 70th General Assembly of the World Medical Association (October 2019) stated that ‘ the WMA is firmly opposed to euthanasia and physician-assisted suicide ’.

In 2020, the Royal College of General Practitioners (RCGP) decided not to change its position of opposition to ‘assisted dying’, and would not review this for five years ‘ unless there are significant developments ’. 

The decision was based on a 2019 Savanta ComRes consultation of RCGP members . Only 41% of respondents thought the RCGP should support a change in the law if ‘ there is a regulatory framework and appropriate safeguarding processes in place ’. Only 7% thought ‘ GPs should be responsible for prescribing drugs for assisted dying (provided that a formal verification process is in place) ’. There was also reluctance to the idea of referring a patient (only 46% support) or supporting/counselling whilst a decision is being made (only 42% support).

The British Medical Association (BMA) changed its position on 14th September 2021 from opposition to a position of neutrality on the subject of ‘physician-assisted dying’. This was preceded by a survey of BMA members’ views on the subject (Kantar, February 2020). The response rate was 19.35% (28,986 members out of 152,004).

50% of respondents were personally supportive of ‘physician-assisted dying’ as a practice. But the percentage of those willing to participate in some way in ‘physician-assisted dying’ was only 36%. There is stronger opposition in general to euthanasia than there is for assisted suicide.

The Association for Palliative Medicine of Great Britain and Ireland (APM) urged parliamentarians to reject the Assisted Dying Bill [HL] 2021 in a briefing statement in October 2021 . A 2021 APM member survey found that 67% of respondents thought that ‘ patients and families think they are definitely or probably practicing covert euthanasia ’, showing a prevalence of misconceptions about palliative care among the public. 87% ‘ felt there has not been good enough press coverage of good deaths ’.

A study in New Zealand showed that medical students were less likely to support euthanasia / assisted suicide towards the end of their studies compared with the beginning, which is ‘ most likely due to their time in medical education ’, see:

Nie, Luke, Kelby Smith-Han, Ella Iosua, and Simon Walker. ‘New Zealand Medical Students’ Views of Euthanasia/Assisted Dying across Different Year Levels’. BMC Medical Education 21, no. 1 (23 February 2021): 125. * (full text available).

Research in Norway in 2014 and 2016 shows that only 9.1% of doctors in the Institute for Studies of the Medical Profession ‘strongly agree’ or ‘partially agree’ with PAS:

Gaasø, Ole Marius, Karin Isaksson Rø, Berit Bringedal, and Morten Magelssen. ‘Doctors’ Attitudes to Assisted Dying’. Tidsskrift for Den Norske Laegeforening: Tidsskrift for Praktisk Medicin, Ny Raekke 139, no. 1 (15 January 2019). * (full text available).

Disparity between support and willingness to be involved

Evidence from Canada and Australia show high levels of disparity between those who support euthanasia/assisted suicide in principle, and those who are willing to participate in the procedure.

Sellars, Marcus, Mark Tacey, Rosalind McDougall, Barbara Hayes, Bridget Pratt, Courtney Hempton, Karen Detering, et al. ‘Support for and Willingness to Be Involved in Voluntary Assisted Dying: A Multisite, Cross-Sectional Survey Study of Clinicians in Victoria, Australia’. Internal Medicine Journal 51, no. 10 (2021): 1619-1628 . * ( embargoed until 01/10/2022)

Bouthillier, Marie-Eve, and Lucie Opatrny. ‘A Qualitative Study of Physicians’ Conscientious Objections to Medical Aid in Dying’. Palliative Medicine 33, no. 9 (October 2019): 1212–20. * (full text available).

The RCR poll of fellows and members in 2019 (see above) showed that 37.3% supported a change in the law to permit ‘assisted dying’, with 46.9% opposed. But when asked, regardless of support or opposition, if they would ‘participate directly’ should the law change, 56.1% said ‘no’ and 23.2% said ‘yes’.

Religious views on End-of-Life Issues

Pew Research Center, ‘Religious Groups’ Views on End-of-Life Issues’, November 21 2013.

In the UK, a study of the influence of religious beliefs on medical students’ attitudes to EAS showed that among those surveyed (with 68.5% professing belief in God), ‘ the majority of students did not agree with euthanasia and physician-assisted suicide in the study scenario. Those who had a belief in god were more likely to disagree with actions that hasten death. The findings show that this was particularly the case with students from a Muslim background ’. See:

Pomfret, Suzie, Shaya Mufti, and Clive Seale. ‘Medical Students and End-of-Life Decisions: The Influence of Religion’. Future Healthc J 5, no. 1 (1 February 2018): 25–29. https://doi.org/10.7861/futurehosp.5-1-25 . * (full text available)

5. Causes of Concern where Euthanasia and / or Assisted Suicide (EAS) is Legal (Part 1)

Euthanasia and / or assisted suicide is legal in a number of places in the world. In some cases, legalisation happened nearly 30 years ago, although there has been a rapid growth in the last 10 years in the number of jurisdictions where, in particular, assisted suicide is permitted under certain conditions.

The British Medical Association have produced a map which shows at a glance where euthanasia and / or assisted suicide is legal.

Commonly there is a requirement for reporting data and monitoring of practice in places where EAS is permitted (see section 2 above). Such reports, along with other data and analysis provides a body of evidence which highlights several aspects of the practice, including reasons for concern. This section provides information from such data which highlight problematic aspects of euthanasia and assisted.

Ever increasing number of people dying by EAS following legalisation

Belgium and the Netherlands provide data over a long period of time, and therefore are amongst the most studied jurisdictions. An obvious cause of concern from both places is that EAS have shown large incremental increases over time. 

Figures 1 and 2 below show the number of deaths attributed to EAS since the early 2000s in Belgium and the Netherlands, showing the increasing numbers over time. Looking more closely, comparing the number of deaths in each country over the ten-year period between 2008 and 2018, we see significant increases, with EAS making up:

• 0.78% of deaths in Belgium in 2008, rising to 2.4% of deaths by 2018 
• 1.7% of deaths in 2008 and 3.9% of deaths in 2018 in the Netherlands (4.1% in 2020)

In other jurisdictions, similar increases are seen. In Canada, for example, the increase in deaths since legalisation of PAS was very steep, rising from 1,018 in 2016 to 7,595 in 2020, a 7.5-fold increase in just four years , representing 0.38% of all deaths in 2016, increasing to 2.5% of all deaths in 2020. In Switzerland, between 2009 and 2019, the number of AS deaths increased more than 4-fold from 297 to 1,196 (see Figure 3 below).

The number of deaths due to AS in Canada in 2020 is the highest total number of deaths due to EAS reported in any country in the world at 7,595, with the Netherlands the next highest number, recording its highest ever number at 6,938 in 2020 . It should be a cause for concern that in places where EAS is legal to practice, increasing numbers of people choose to end their own lives, or to ask for others to end them for them.

5. Causes of Concern where Euthanasia and / or Assisted Suicide (EAS) is Legal (Part 2)

Terminology of the Legislation

In many places where EAS is legally practised, the language surrounding the legislation could be argued to minimise the reality of the practices employed and the nature of the acts involved; namely a direct act by a medical practitioner with the intention of ending the life of a person (euthanasia), and the writing of a prescription for drugs knowing that they will be used by a person to bring about the end of their own life (physician-assisted suicide).

To accurately assess the ethics and effects of a particular law or practice it is important that terminology is clear and unequivocal in what it describes. ‘Assisted dying’ for example may mean PAS, or EAS. On this point see:

Jones, David Albert. ‘Defining the Terms of the Debate – Euthanasia and Euphemism’. Briefing Papers: Euthanasia and Assisted Suicide. Oxford: The Anscombe Bioethics Centre, 2021.

For an ‘ overview of the terminology, evolution and current legislative picture of assisted dying practices around the globe ’ see:

Mroz, Sarah, Sigrid Dierickx, Luc Deliens, Joachim Cohen, and Kenneth Chambaere. ‘Assisted Dying around the World: A Status Quaestionis’. Annals of Palliative Medicine 10, no. 3 (March 2021): 3540553–553. https://doi.org/10.21037/apm-20-637. * (full text available)

Figure 3 below gives the name for the legislation allowing EAS in various jurisdictions. 

Extension of eligibility criteria for EAS

Following legalisation, legislation can extend eligibility from those terminally ill to other non-terminal conditions (children, mentally ill, etc.), see:

Patton, Michaela, and Keith Dobson. ‘Proposal for the Extension of Rights to Medical Assistance in Dying (MAiD) to Mature Minors in Canada’. Canadian Psychology/Psychologie Canadienne 62, no. 3 (2021): 318–25. https://doi.org/10.1037/cap0000219 * (full text available).

The logic of EAS eligibility for the terminally ill can be applied in the same way both to the chronically ill, and to justify non-voluntary euthanasia ( i.e. for those incapable of requesting euthanasia). This is referred to as the ‘slippery slope’. See:

Keown, John. ‘Voluntary Euthanasia & Physician-Assisted Suicide – The Two “Slippery Slope” Arguments’. Briefing Papers: Euthanasia and Assisted Suicide. Oxford: The Anscombe Bioethics Centre, 2021.

Keown, John. ‘Euthanasia in the Netherlands: Sliding down the Slippery Slope’. Notre Dame J.L. Ethics & Pub. Pol’y 9, no. 2 (1995): 407–48. * (full text available).

These concerns, including (among others) the EAS for psychiatric indications and evidence in practice of non-voluntary euthanasia are best considered by examining evidence from the four jurisdictions which the longest history of EAS: Switzerland (1982); The Netherlands (1984); Oregon (1997); and Belgium (2002).

5.1 Switzerland

Assisted suicide in Switzerland is performed almost entirely through organisations such as EXIT and Dignitas. Since 1982 (when EXIT was founded) there have been only two official government reports, one in 2012 and another in 2014, and these are dependent on data provided by assisted suicide organisations. Media reporting of UK citizens dying in Switzerland plays a significant role in the UK debate, but it should be noted that most of those individuals would not qualify under current proposals for ‘Assisted Dying’, as they were not expected to die within six months. If the law changed in the UK either people would continue to go to Switzerland (which would have fewer restrictions) or the option of assisted suicide in Switzerland would place pressure on the UK to extend its practice to those who are not terminally ill. Research on the experience of assisted suicide in Switzerland is not reassuring.

In Switzerland, since 1942, inciting or assisting suicide has been illegal when it is for selfish motives (such as financial gain). Since 1982 this law has provided legal space for the organisation EXIT to promote assisted suicide for those ‘with unbearable symptoms or with unacceptable disabilities.’ There are two government reports from the Federal Statistical Office, one in 2012 and latest, for 2014, published in 2016 and revised in 2017 . There are also statistics for assisted suicide by sex and age for 2003-2019 , published by the Federal Statistical Office. Dignitas has released statistics from 1998-2021 .

A systematic study of 43 consecutive cases of assisted suicide in Switzerland from 1992 to 1997 found that in 10 cases (23%), the time between first contact with EXIT and the completed assisted suicide was less than a week and in 4 cases (9%) it was less than a day. In 6 cases (14%) the person had previously been treated in a psychiatric institution. In 11 cases (26%) there was no serious medical condition recorded on file, and in 5 cases (12%) the stated reason for seeking assisted suicide was bereavement. The authors of the study conclude that in the 1990s assisted suicide was ‘performed by lay-people who act without outside control and violate their own rules’.

Frei, Andreas, et al. ‘Assisted suicide as conducted by a “Right-to-Die”-society in Switzerland: a descriptive analysis of 43 consecutive cases.’ Swiss Medical Weekly 131.25-26 (2001): 375-380. * (full text available).

A later study found that between the 1990s and 2001-2004 the rate of assisted suicide for non-fatal diseases increased from 22% to 34% and concluded that ‘ weariness of life rather than a fatal or hopeless medical condition may be a more common reason for older members of Exit Deutsche Schweiz to commit suicide ’.

Fischer, S., Huber, C.A., Imhof, L., Imhof, R.M., Furter, M., Ziegler, S.J., Bosshard, G. ‘Suicide assisted by two Swiss right-to-die organisations’. Journal of Medical Ethics 34, no. 11 (2008): 810-814. * (full text available).

A study in 2014 found that assisted suicide in Switzerland was associated with living alone and divorce and was significantly more frequent among women. In 16% of deaths by assisted suicide no medical condition was listed. 

Steck, Nicole, Christoph Junker, Maud Maessen, Thomas Reisch, Marcel Zwahlen, and Matthias Egger. ‘Suicide Assisted by Right-to-Die Associations: A Population Based Cohort Study’. International Journal of Epidemiology 43, no. 2 (April 2014): 614–22.  * (full text available).

Research on trends from 1991 to 2008 showed ‘ a tripling of assisted suicide rates in older women, and the doubling of rates in older men ’.

Steck, Nicole, Marcel Zwahlen, and Matthias Egger. ‘Time-Trends in Assisted and Unassisted Suicides Completed with Different Methods: Swiss National Cohort’. Swiss Medical Weekly , no. 25 (14 June 2015). https://doi.org/10.4414/smw.2015.14153 . * (full text available).

Between 2009 and 2019 , the number of assisted suicide deaths increased from 297 to 1196 (an increase of over 400%).

Research showed that requests for assisted suicide were not based on symptom burden but on fear of loss of control. Moreover, those seeking assisted suicide had misconceptions about palliative care.

Gamondi, C., M. Pott, and S. Payne. ‘Families’ Experiences with Patients Who Died after Assisted Suicide: A Retrospective Interview Study in Southern Switzerland’. Annals of Oncology 24, no. 6 (1 June 2013): 1639–44. https://doi.org/10.1093/annonc/mdt033. * (full text available).

Until 2006 assisted suicide had not occurred in Switzerland in a hospital setting. The difficulties of introducing it into hospital and the concerns of the palliative care team are set out below.

Pereira, J, P Laurent, B Cantin, D Petremand, and T Currat. ‘The Response of a Swiss University Hospital’s Palliative Care Consult Team to Assisted Suicide within the Institution’. Palliative Medicine 22, no. 5 (1 July 2008): 659–67. https://doi.org/10.11 . * (full text available).

There is also research from Switzerland on the negative impact on family members of witnessing assisted suicide.

Wagner, B., J. Müller, and A. Maercker. ‘Death by Request in Switzerland: Posttraumatic Stress Disorder and Complicated Grief after Witnessing Assisted Suicide’. European Psychiatry 27, no. 7 (October 2012): 542–46. https://doi.org/10.1016/j.eurpsy.2010.1 *

Assisted suicide in Switzerland is most well known in the UK because of people travelling from the UK to die by assisted suicide. A detailed study of ‘suicide tourism’ shows numbers are increasing, the proportion of cancer is decreasing and the proportion of mental illness and multiple co-morbidities is increasing. Among reasons for assisted suicide the largest single cause, with 223 cases, was cancer, but 37 cited Parkinson’s disease, 37 gave arthritis as a reason, 14 cases were for mental illness, and 40 gave as a reason impairment of eyesight and/or hearing. 

Gauthier, Saskia, Julian Mausbach, Thomas Reisch, and Christine Bartsch. ‘Suicide Tourism: A Pilot Study on the Swiss Phenomenon’. Journal of Medical Ethics 41, no. 8 (1 August 2015): 611–17. https://doi.org/10.1136/medethics-2014-102091. * (full text available).

A study from 2016 shows that there has been an increase in the practices of voluntary and non-voluntary euthanasia in Switzerland, which are both illegal. Additionally, there has been a ‘ substantial increase in the use of continuous deep sedation until death, from 4.7% of all deaths in 2001 to 17.5% in 2013 [...] this practice was therefore more common in Switzerland than in either Belgium (12.0% in 2013) or the Netherlands (12.3% in 2010) ’.

Bosshard, Georg, Ueli Zellweger, Matthias Bopp, Margareta Schmid, Samia A. Hurst, Milo A. Puhan, and Karin Faisst. ‘Medical End-of-Life Practices in Switzerland: A Comparison of 2001 and 2013’. JAMA Internal Medicine 176, no. 4 (April 2016): 555–56. * (full text available).

5.2 The Netherlands

In addition to annual reports, based on notified cases of euthanasia there have been a series of studies of end-of-life practices at 5-year intervals since 1990. These were nationwide studies of a stratified sample from the national death registry. Questionnaires were sent to physicians attending these deaths and were returned anonymously. The first is commonly termed the Remmelink Report and subsequent reports followed the same pattern. Both the annual reports and the five yearly studies show incremental increases in deaths by euthanasia over time. Deaths by assisted suicide are less frequent, in part because they are associated with complications.

In the Netherlands euthanasia was effectively decriminalised by a court decision in 1984. This was the basis of a legal statute in 2001 legalising euthanasia and physician assisted suicide. Since 2002 the Netherlands has produced an annual report on the cases notified to the five regional euthanasia committees. These are available (in English once the year is selected) .

The first two reports showed evidence of a number of deaths without explicit patient request (in other words non-voluntary euthanasia). The rates were 0.8% and 0.7% being equivalent to 1,000 and 900 deaths in per year. The reaction of supporters was generally to dismiss the significance of these figures, rather than to see them as a possible cause for concern. 

Maas, Paul J. van der, Gerrit van der Wal, Ilinka Haverkate, Carmen L.M. de Graaff, John G.C. Kester, Bregje D. Onwuteaka-Philipsen, Agnes van der Heide, Jacqueline M. Bosma, and Dick L. Willems. ‘Euthanasia, Physician-Assisted Suicide, and Other Medical Practices Involving the End of Life in the Netherlands, 1990-1995’. New England Journal of Medicine 335, no. 22 (28 November 1996): 1699-1705. * (full text available).

Keown, John. ‘Euthanasia in the Netherlands: Sliding down the Slippery Slope’. Notre Dame Journal of Law, Ethics & Public Policy 9, no. 2 (1 January 2012): 407-448. * (full text available).

Van Delden, Johannes J. M., Loes Pijnenborg, and Paul J. Van Der Maas. ‘Reports from The Netherlands. DANCES WITH DATA’. Bioethics 7, no. 4 (1993): 323–29. https://doi.org/10.1111/j.1467-8519.1993.tb00222.x. *

Cohen-Almagor, Raphael. ‘Non-Voluntary and Involuntary Euthanasia in the Netherlands: Dutch Perspectives’. Issues in Law & Medicine 18 (2003): 239-257. * (full text available).

For such reasons the law and practice of euthanasia and assisted suicide in the Netherlands has been criticised several times by the United Nations Human Rights Committee.

UN Human Rights Committee (HRC), UN Human Rights Committee: Concluding Observations: Netherlands, 27 August 2001, CCPR/CO/72/NET  

UN Human Rights Committee (HRC), Concluding observations of the Human Rights Committee: Netherlands, 25 August 2009, CCPR/C/NLD/CO/4  

The 2019 report expresses its concern by stating ‘ The Committee is concerned, however, at the limited ex ante review of decisions to terminate life, including the legal and ethical implications of such decisions (art. 6) ’. (para. 28). See:

UN Human Rights Committee (HRC), UN Human Rights Committee: ‘Concluding Observations on the 5th Periodic Report of the Netherlands’, 126th session, 22 August 2019. CCPR/C/NLD/CO/5

Results from the most recent 5-yearly study (published in 2017 and providing data from 1990, 1995, 2001, 2005, 2010 and 2015) show that deaths classified as ‘ ending life without explicit patient request ’ have declined from 0.8% in 1990 0.3% in 2015. However, overall numbers of deaths by euthanasia have almost tripled (from 1.7% to 4.5%) Another matter of concern is the steep rise in cases of continuous deep sedation (from 8.2% in 2005to 18.3% in 2015), which is in addition to the rise in deaths by ‘ intensified alleviation of symptoms ’ (from 18.8% of deaths in 1990 to 35.8% of deaths in 2015). The presence of so many deaths with, or by, continuous deep sedation or drugs for intensified alleviations of symptoms confounds the data as either may be used as equivalent to (voluntary) euthanasia or to life ending without request. See:

Van der Heide, Agnes, Johannes JM Van Delden, and Bregje D. Onwuteaka-Philipsen. ‘End-of-life decisions in the Netherlands over 25 years.’ New England Journal of Medicine 377.5 (2017): 492-494. *

The latest annual report (for 2020) shows that the total number of deaths by euthanasia continues to increase. There were 6,938 deaths by euthanasia or assisted suicide notified in 2020, up 9.1% on the previous year, and constituting 4.1% of all deaths in the Netherlands for 2020 (which must be taken in conjunction with the fact that there was an excess of around 15,000 deaths in the Netherlands in 2020). In 2 cases, coronavirus infection was the grounds for euthanasia, and coronavirus infection plus other medical conditions in a further 4 cases. 

There are no data on euthanasia for either mental illness or dementia prior to 2012 (before this they are presumably considered under ‘other conditions’). In the 2013 report the category is changed from ‘mental illness’ to ‘mental disorders’, and from 2014 on is referred to as ‘psychiatric disorders’. Figure 1 ( data source ) below shows the figures for these conditions.

5.2 The Netherlands (cont’d)

From 2012-2020 euthanasia for psychiatric disorders has increased by over 600% and for dementia by over 400%.

This increase in euthanasia or assisted suicide for non-terminal conditions reflects opinion among professionals, with a significant number (between 24% and 39%) in favour of euthanasia or assisted suicide for individuals who experience mental suffering due to loss of control, chronic depression or early dementia. A third of doctors and 58% of nurses were in favour of euthanasia in the case of severe dementia, given the presence of an advance directive. 

Kouwenhoven, Pauline SC, Natasja JH Raijmakers, Johannes JM van Delden, Judith AC Rietjens, Maartje HN Schermer, Ghislaine JMW van Thiel, Margo J Trappenburg, et al. ‘Opinions of Health Care Professionals and the Public after Eight Years of Euthanasia Leg i slation in the Netherlands: A Mixed Methods Approach’. Palliative Medicine 27, no. 3 (1 March 2013): 273-80. * (post print text available).

Other research shows a wide variation among general practitioners, consultants and members of the euthanasia committees in their judgement of whether the patient’s suffering is sufficient for euthanasia.

Rietjens, J. a. C., D. G. van Tol, M. Schermer, and A. van der Heide. ‘Judgement of Suffering in the Case of a Euthanasia Request in The Netherlands’. Journal of Medical Ethics 35, no. 8 (1 August 2009): 502–7. https://doi.org/10.1136/jme.2008.028779. *

While euthanasia is defined as ending life on request, the Netherlands has extended life ending without request to newborn infants with disabilities. A description of the protocol (known as the Groningen protocol) is given by two authors who helped develop this practice.

Verhagen, A. A. E., and P. J. J. Sauer. ‘End-of-Life Decisions in Newborns: An Approach From the Netherlands’. Pediatrics 116, no. 3 (1 September 2005): 736–39. https://doi.org/10.1542/peds.2005-0014. * (full text available).

While euthanasia and assisted suicide are requested to secure an easeful death, complications are well documented, especially in assisted suicide. A study in 2000 found that ‘ complications [such as spasm, gasping for breath, cyanosis, nausea or vomiting] occurred in 7% of cases of assisted suicide, and problems with completion [a longer-than-expected time to death, failure to induce coma, or re-awakening of the patient] occurred in 16% ’ because of which ‘ physicians who intend to provide assistance with suicide sometimes end up administering a lethal medication themselves. ’ This is not only a problem of the past; in the 2020 report there were 6,705 cases of euthanasia (‘termination of life on request’), 216 cases of assisted suicide and 17 cases involving a combination of the two ( i.e. , cases which began as assisted suicide, but had to be completed by euthanasia). 

Groenewoud, Johanna H., Agnes van der Heide, Bregje D. Onwuteaka-Philipsen, Dick L. Willems, Paul J. van der Maas, and Gerrit van der Wal. ‘Clinical Problems with the Performance of Euthanasia and Physician-Assisted Suicide in the Netherlands’. New England Journal of Medicine 342, no. 8 (24 February 2000): 551–56. 

https://doi.org/10.1056/NEJM200002243420805. * (full text available).

Lastly, euthanasia is possible above the age of 12 and below the age of 1. But in 2020, the Netherlands Paediatric Association (Nederlandse Vereinging voor Kindergeneeskunde) expressed the position that the law be extended to allow the termination of life of children between the ages of 1 and 12 under certain conditions. See also the letter to parliament by Hugo de Jonge, the former Minister of Health, Welfare and Sport.

The most important evidence for practice in Oregon is provided by annual reports on the Death with Dignity Act. This section also highlights some aspects that been raised in relation to Oregon practice but are not based on the reports. See also research on the impact of assisted suicide on suicide prevention (section 7, below).

According to the latest official Oregon report, the most frequent end-of-life concern cited by people requesting assisted suicide is not pain but ‘loss of autonomy’ (90.9%), followed by decreased ability ‘to engage in activities making life enjoyable’ (90.2%), ‘loss of dignity’ (73%), ‘burden on family, friends/caregivers’ (48.3%), and ‘losing control of bodily functions’ (43.7%) and only then ‘inadequate pain control or concern about it’ (27.5%), (in each case citing accumulated data for 1998-2021). Evidently, most of these concerns relate to disability and increased dependence. The concern about feeling one is a ‘burden’ on others is significant, much more so than fear of pain (which, also, should not be conflated with actual pain).

From the same report it is clear that in only 14.6% of cases was the prescribing physician present at the time of death (only 11.6% in 2020), that only 3.3% were referred for psychiatric evaluation (only 0.8% in 2021), and that in 56.7% of cases the person was dependent on Medicare/Medicaid insurance or other governmental insurance (up to 78.9% in 2021).

According to Oregon’s Prioritized List of Health Services 2022 cancer treatment is limited according to relative life expectancy, for example, ‘[t]reatment with intent to prolong survival is not a covered service for patients who have progressive metastatic cancer [...]’(Guidance Note 12, GN-5). In contrast ‘It is the intent of the Commission that services under ORS 127.800-127.897 (Oregon Death with Dignity Act) be covered for those that wish to avail themselves to those services’ (Statements of Intent, SI-1). 

[N.B. The Statements of Intent and Guidance Notes come after the 160 pages of the prioritised list.] 

Health Evidence Review Commission, Prioritized List of Health Services (1 January 2022) . 

It should be noted that the drugs that are used for assisted suicide are also used in execution by lethal injection in the United States. This dual use is causing availability problems with supply of the drugs.

Jaquiss, Nigel. ‘Penalized By The Death Penalty’ Willamette Week 21 May 2014.

A good overview of practice in Oregon, including some case studies as well as statistical evidence, shows problems with doctor shopping, suspect coercion and lack of sufficient psychiatric evaluation.

Hendin, Herbert, and Kathleen Foley. ‘Physician-Assisted Suicide in Oregon: A Medical Perspective’. Michigan Law Review 106, no. 8 (2008): 1613–39 . * (full text available).

Kenneth Stevens has shown that from 2001 to 2007 a majority (61%, 165 out of 271) of the lethal prescriptions were written by a minority (18%, 20 out of 109) of the participating physicians. More striking still, just 3 physicians were responsible for 23% of lethal prescriptions (62 out of 271).

Stevens Jr., Kenneth R. ‘Concentration of Oregon’s Assisted Suicide Prescriptions & Deaths from a Small Number of Prescribing Physicians’. Physicians for Compassionate Care Education Foundation, 18 March 2015.

See also ‘Five Oregonians to Remember’ PCCEF, 27 December 2007.

5.4 Belgium

Though Belgium legalised euthanasia in 2002, eighteen years after the Netherlands (in 1984), its number of deaths are near that of the Netherlands. There were 5,015 reported cases in 2019 (more than six times the 822 reported cases in 2009). According to research conducted by Chambaere (see below) these official figures underreport euthanasia by around 50%. What is more worrying is that research indicates that more than 1,000 patients a year (1.7% of all deaths) have their lives ended deliberately without having requested it. This figure has not declined with time. Since legalisation in 2002, reports have been produced every two years. These are available (in French) here.

For a critical analysis of euthanasia in Belgium, see:

Jones, David Albert, Chris Gastmans, and C. MacKellar, eds. Euthanasia and Assisted Suicide: Lessons from Belgium . Cambridge Bioethics and Law. Cambridge, UK and New York, NY: Cambridge University Press, 2017. (This book can be ordered here ).

Devos, Timothy (ed.). Euthanasia: Searching for the Full Story: Experiences and Insights of Belgian Doctors and Nurses , Cham: Springer International Publishing, 2021. https://link.springer.com/book/10.1007/978-3-030-56795-8. (free e-book)

Belgian law came to prominence with the decision in February 2014 to extend euthanasia to children. This caused concern among clinicians and bioethicists in other countries.

Siegel, Andrew M., Dominic A. Sisti, and Arthur L. Caplan. ‘Pediatric Euthanasia in Belgium: Disturbing Developments’. JAMA 311, no. 19 (21 May 2014): 1963–64. https://doi.org/10.1001/jama.2014.4257. *

Carter, Brian S. ‘Why Palliative Care for Children Is Preferable to Euthanasia’. American Journal of Hospice and Palliative Medicine® 33, no. 1 (1 February 2016): 5–7. https://doi.org/10.1177/1049909114542648. * (full text available).

For background to the original 2002 law and its initial implementation see:

Cohen-Almagor, Raphael. ‘Euthanasia Policy and Practice in Belgium: Critical Observations and Suggestions for Improvement’. Issues in Law & Medicine 24, no. 3 (2009): 187–218. * (full text available) 

See also a report analysing ten years of euthanasia practice in Belgium. 

E de Diesbach, M de Loze, C Brochier and E Monterol. Euthanasia in Belgium: 10 years on European Institute of Bioethics (April 2012).

Research shows that the cases that are not reported are also less likely to involve a written request, less likely to involve specialist palliative care, and more likely to be performed by a nurse.

Smets, T., J. Bilsen, J. Cohen, M. L. Rurup, F. Mortier, and L. Deliens. ‘Reporting of Euthanasia in Medical Practice in Flanders, Belgium: Cross Sectional Analysis of Reported and Unreported Cases’. BMJ 341, no. oct05 2 (5 October 2010): c5174–c5174. * (full text available).

Research on nurses in Belgium in 2007 showed that cases of life-ending without request were almost as common as cases of euthanasia, and that in 12% of euthanasia cases and 45% of life-ending without request it was a nurse who administered the lethal dose, actions which went ‘beyond the legal margins of their profession’.

Inghelbrecht, E., J. Bilsen, F. Mortier, and L. Deliens. ‘The Role of Nurses in Physician-Assisted Deaths in Belgium’. Canadian Medical Association Journal 182, no. 9 (15 June 2010): 905–10. https://doi.org/10.1503/cmaj.091881. * (full text available).

On the ongoing issue of high levels of intentional life-ending without consent in Belgium see: 

Cohen-Almagor, Raphael. ‘First Do No Harm: Intentionally Shortening Lives of Patients Without Their Explicit Request in Belgium’. Journal of Medical Ethics , 4 June 2015. https://papers.ssrn.com/abstract=2614587. * (full text available).

Research has also shown that, in Belgium, continuous deep sedation is used with the intention or co-intention to shorten life in 17% of cases, but that it is rarely instituted at the request of the patient (only in 12.7% of cases).

Papavasiliou, Evangelia, Kenneth Chambaere, Luc Deliens, Sarah Brearley, Sheila Payne, Judith Rietjens, Robert Vander Stichele, and Lieve Van den Block. ‘Physician-Reported Practices on Continuous Deep Sedation until Death: A Descriptive and Comparative Study’. Palliative Medicine 28, no. 6 (1 June 2014): 491-500. https://doi.org/10.1177/0269216314530768 * (full text available).

Recent research (published in 2015) shows that while rates of euthanasia increase there has been no improvement in reporting and no reduction in cases of life-ending without request.

Chambaere, Kenneth, Robert Vander Stichele, Freddy Mortier, Joachim Cohen, and Luc Deliens. ‘Recent Trends in Euthanasia and Other End-of-Life Practices in Belgium’. The New England Journal of Medicine 372, no. 12 (19 March 2015): 1179–81 . * (full text available).

In the face of evidence of widespread ending of life without request some researchers have sought to excuse these actions because a third of such patients had, ‘at some point’ in the past, either explicitly or ‘implicitly’ expressed a wish that their lives be ended. However, the very attempt to downplay concerns about deaths deliberately brought about without an explicit request itself illustrates the degree to which non-voluntary euthanasia in Belgium is tolerated and is not regarded as shocking or as a practice in urgent need of correction. 

Chambaere, K., J. L. Bernheim, J. Downar, and L. Deliens. ‘Characteristics of Belgian “Life-Ending Acts without Explicit Patient Request”: A Large-Scale Death Certificate Survey Revisited’. CMAJ Open 2, no. 4 (2 December 2014): E262–67. * (full text available).

On the distinction between expressing a wish to die, a wish to hasten death, and a request, see:

Monforte-Royo, Cristina, Christian Villavicencio-Chávez, Joaquín Tomás-Sábado, and Albert Balaguer. ‘The Wish to Hasten Death: A Review of Clinical Studies’. Psycho-Oncology 20, no. 8 (2011): 795–804. https://doi.org/10.1002/pon.1839. * (full text available).

Data from the annual reports shows that an increasing percentage of those dying by euthanasia mention a combination of physical and psychical suffering (78.8% in 2018 and 82.8% in 2019), with figures for solely physical pain reducing (17.7% in 2018 and 12.8% in 2019) and suffering for solely psychic reasons increasing (3.5% in 2018 and 4.3% in 2019).

Stories of individual cases are no substitute for quantitative research, but they help show the possible human meaning behind these statistics. Some illustrative examples are given below.

‘Marc and Eddy Verbessem, Deaf Belgian Twins, Euthanized’ The World Post 15 January 2013 . 

Waterfield, ‘Belgian killed by euthanasia after a botched sex change operation’ Telegraph 01 Oct 2013.

E O’Gara ‘Physically healthy 24-year-old granted right to die in Belgium’ Newsweek 29 June 2015.

Associated Press, ‘Belgian Court Acquits 3 Doctors in Landmark Euthanasia Case’ Courthouse News Service 31 January 2020.

Further example cases from Belgium are described here:

Beuselinck, Benoit. ‘Euthanasia Case Studies from Belgium: Concerns about Legislation and Hope for Palliative Care’. Briefing Papers: Euthanasia and Assisted Suicide. Oxford: The Anscombe Bioethics Centre, 2021.

6. Disability and the Impact of Assisted Suicide and Euthanasia

Groups representing people with disabilities have been at the forefront of opposition to the legalisation of assisted suicide and euthanasia. Arguments from this perspective, especially in popular publications and comment pieces, have been criticised as reflecting and/or feeding on fears without showing that these fears are reasonable. However, there is also more critical reflection from this perspective, including discussion of empirical evidence relevant to assessing these concerns.

Some opinion polls among disabled people find considerable support for legalising ‘assisted dying’ .

These results are similar to opinion polls in the general population and should be treated with the same caution (see above on the wording of polls).  It is important also to take into account polls that identify concerns among disabled people that legal changes could put pressure on disabled people to end their lives prematurely .

An interesting exchange on this issue by two people with disabilities was conducted by Carol Gill and Andrew Batavia.  Batavia argues that empirical data is irrelevant to the issue which, in his view, is about values, and centrally the value of autonomy.  He is in favour of legalising assisted suicide.

Batavia, A. I. ‘The Relevance of Data on Physicians and Disability on the Right to Assisted Suicide: Can Empirical Studies Resolve the Issue?’ Psychology, Public Policy, and Law: An Official Law Review of the University of Arizona College of Law and the University of Miami School of Law 6, no. 2 (June 2000): 546-58. *

In response Gill presents data, which is relevant to the perception of disability and its role (implicitly or explicitly) in decisions to grant requests for assistance in suicide.  For example, she cites research that shows that among 153 emergency care providers, only 18% of physicians, nurses, and technicians imagined they would be glad to be alive with a severe spinal cord injury.  In contrast, 92% of a group of 128 persons with high-level spinal cord injuries said they were glad to be alive.

Gill, CJ. ‘Health professionals, disability, and assisted suicide: An examination of relevant empirical evidence and reply to Batavia (2000).’ Psychology, Public Policy, and Law 6.2 (2000): 526-45. *

Unfortunately, neither of these papers is freely available online.  However, another very interesting paper by Gill provides a good sense of what a critical and empirically informed disability perspective looks like.  More generally, the Disability and Health Journal (in which this paper appears) is a useful source for articles on disability and assisted suicide.

Gill, CJ. ‘No, we don't think our doctors are out to get us: Responding to the straw man distortions of disability rights arguments against assisted suicide’. Disability and Health Journal 3.1 (2010): 31-38 . * (full text available)

Probably the most influential article arguing that the evidence shows no negative impact of assisted suicide or euthanasia on vulnerable groups (including people with disabilities) is by Margaret Battin.

Battin, Margaret P, Agnes van der Heide, Linda Ganzini, and Gerrit van der Wal. ‘Legal Physician‐assisted Dying in Oregon and the Netherlands: Evidence Concerning the Impact on Patients in “Vulnerable” Groups’. Journal of Medical Ethics 33, no. 10 (October 2007):591-597. * (full text available)

The methodology and conclusions of this paper have been criticised by Ilora Finlay and Rob George.

Finlay, I. G., and R. George. ‘Legal Physician-Assisted Suicide in Oregon and The Netherlands: Evidence Concerning the Impact on Patients in Vulnerable Groups--Another Perspective on Oregon’s Data’. Journal of Medical Ethics 37, no. 3 (March 2011): 171–74 . https://doi.org/10.1136/jme.2010.037044 . *

A detailed discussion of Battin’s evidence and counter-evidence from other expert witnesses is found in the Irish Divisional Court case Fleming v Ireland [2013] IEHC 2 (especially para 67) .

‘ [T]he the expert evidence offered by Dr. O’Brien and Professor George to the effect that relaxing the ban on assisted suicide would bring about a paradigm shift with unforeseeable (and perhaps uncontrollable) changes in attitude and behaviour to assisted suicide struck the Court as compelling and deeply worrying… The Court finds the evidence of these witnesses, whether taken together or separately, more convincing than that tendered by Professor Battin, not least because of the somewhat limited nature of the studies and categories of person studied by Professor Battin… ’

Battin’s argument is also criticised by Pereira on the basis that “safeguards” are largely illusory.

Pereira, J. ‘Legalizing Euthanasia or Assisted Suicide: The Illusion of Safeguards and Controls’. Current Oncology 18, no. 2 (April 2011): e38. https://doi.org/10.3747/co.v18i2.883. * (full text available).

Similarly, a detailed discussion of the evidence from Oregon from a disability perspective concludes that ‘ Battin et al.’s interpretation that people with physical disabilities or chronic illnesses are not at increased risk for DWD does not seem to be supportable given available data’ .

CE Drum, G White, G Taitano and W Horner-Johnson, ‘The Oregon Death with Dignity Act: results of a literature review and naturalistic inquiry’. Disability and health journal , 2010, 3(1): 3-15 . * (full text available).

If disability includes mental illness, then there is clearly a group of patients who are prima facie endangered by assisted suicide. In Oregon there has been a decline in the “safeguard” of referral for psychiatric evaluation whereas in Belgium and Switzerland mental illness can itself be a basis for euthanasia or assisted suicide. A study published in the BMJ shows how far the euthanising of psychiatric patients has progressed in Belgium: of 100 patients who requested euthanasia for psychiatric reasons, 73 ‘ were medically unfit for work (they were either receiving disability living allowances or had taken early retirement) ’, i.e. most were categorised as having a disability. Of the 100, 38 were referred for further psychiatric evaluation, after which 17 were approved for euthanasia and 10 died by euthanasia during the study period. Of the 62 people not referred, 31 were approved for euthanasia and 25 died by euthanasia during the study period. These patients suffered from a variety of conditions including mood disorders (58 including 10 who were bipolar), borderline personality disorder (27), schizophrenia and other psychotic disorders (14), post-traumatic stress disorder (13), eating disorders (10), autism spectrum disorder (7), attention deficit hyperactivity (1) as well as other diagnoses, often combining diagnoses ( e.g. , a mood disorder and personality disorder). During the period of the study 6 participants died by (non-assisted) suicide, one from anorexia nervosa and one from palliative sedation. None were terminally ill.

Thienpont L, Verhofstadt M, Van Loon T, et al. ‘Euthanasia requests, procedures and outcomes for 100 Belgian patients suffering from psychiatric disorders: a retrospective, descriptive study’. BMJ Open 2015;5: e007454. doi:10.1136/bmjopen-2014-007454 * (full text available).

Disability makes assessment of ‘ decisional capacity ’ difficult. A study of cases in the Netherlands shows that the ‘ Dutch EAS due care criteria are not easily applied to people with intellectual disabilities and/or autism spectrum disorder, and do not appear to act as adequate safeguards. ’ See:

Tuffrey-Wijne, Irene et al. “Euthanasia and assisted suicide for people with an intellectual disability and/or autism spectrum disorder: an examination of nine relevant euthanasia cases in the Netherlands (2012-2016).”  BMC medical ethics  vol. 19,1 17. 5 Mar. 2018, doi:10.1186/s12910-018-0257-6 * (full text available).

Tuffrey-Wijne, Irene et al. “‘Because of His Intellectual Disability, He Couldn’t Cope.’ Is Euthanasia the Answer?”. Journal of Policy and Practice in Intellectual Disabilities , vol. 16, no. 2 (June 2019):113-116, https://doi.org/10.1111/jppi.12307 * (post-print draft version available).

EAS in the Netherlands for psychiatric disorders shows that patients are ‘ mostly women, of diverse ages, with complex and chronic psychiatric, medical, and psychosocial histories ’. See:

Kim, Scott Y H et al. “Euthanasia and Assisted Suicide of Patients With Psychiatric Disorders in the Netherlands 2011 to 2014.”  JAMA Psychiatry vol. 73,4 (2016): 362-8. doi:10.1001/jamapsychiatry.2015.2887 * (full text available).

Concern is also expressed over safeguards for the disabled, stemming from the myriad of problems the disabled face, such as ‘ subtle pressure, despair at living in a world where their daily existence is seen as one of inevitable suffering or, exhaustion from fighting for the accommodations required to live a life of dignity and pursue their chosen lifestyle and purposes ’. See:

Stainton, Tim. “Disability, vulnerability and assisted death: commentary on Tuffrey-Wijne, Curfs, Finlay and Hollins.”  BMC Medical Ethics vol. 20,1 89. 27 (Nov. 2019), doi:10.1186/s12910-019-0426-2 * (full text available).

With respect to more recent developments in Canada regarding EAS for mentally ill patients, see:

Komrad, Mark S. ‘First, Do No Harm: How Canadian Law Allows for Euthanasia and Assisted Suicide for Patients with Psychiatric Disorders’. Briefing Papers: Euthanasia and Assisted Suicide (Anscombe Bioethics Centre, Oxford: 2021).

On the changing social attitude to those living with dementia and how euthanasia poses a threat to living and dying well with dementia, see:

Matthews, Pia. ‘Dignity in Living: Addressing Euthanasia by Affirming Patient Personhood in Dementia’. Briefing Papers: Euthanasia and Assisted Suicide. Oxford: The Anscombe Bioethics Centre, 2021.

7. Suicide Prevention and the Impact of Assisted Suicide

Sometimes advocates of assisted suicide are happy to use this terminology, as for example in the ‘Assisted Suicide (Scotland) Bill’ (introduced in 2011), which was rejected by the Scottish Parliament in 2015. Other proponents avoid this language and prefer ‘dying / death with dignity’, ‘assisted dying/death’ or ‘medical aid in dying’. However, evidence indicates no sharp distinction between assisted suicide and non-assisted suicide. Evidence also suggests legalising assisted suicide ‘normalises’ suicide and is associated with increases in suicide. 

Evidence from the USA shows that the legalisation of ‘ assisted suicide is associated with a significant increase in total suicide (inclusive of assisted suicide) and no reduction in non-assisted suicide .’ 

Jones, David Albert and David Paton ‘How does legalization of physician-assisted suicide affect rates of suicide?, Southern Medical Journal , 108.10 (2015): 599-604. * (pre-print draft available).

The association of legalising assisted suicide and a ‘ significant increase in total suicides ’ is also supported by more recent research on data from the USA. Paton and Sourafel also conclude that ‘ [i]t is possible that there is some substitution from unassisted suicide to assisted suicide but that this is balanced out by an increase in unassisted suicide arising from, for example, a reduction in societal taboos associated with suicide ’. See:

Sourafel, Girma, and David Paton. ‘Is Assisted Suicide a Substitute for Unassisted Suicide?’ European Economic Review , 9 April 2022, 104113. https://doi.org/10.1016/j.euroecorev.2022.104113. * (pre-proof text available).

In Europe, the introduction of euthanasia and assisted suicide has resulted in ‘ considerable increases in suicide (inclusive of assisted suicide) and in intentional self-initiated death ’. See:

 Jones, David Albert. ‘Euthanasia, Assisted Suicide, and Suicide Rates in Europe’, Journal of the Ethics of Mental Health 11 (2022):1-35. * (full text available).

Restricting access to means of suicide appear to be ‘ particularly effective in contexts where the method is popular, highly lethal, widely available, and/or not easily substituted by other similar methods ’. See:

Sarchiapone, Marco, Laura Mandelli, Miriam Iosue, Costanza Andrisano, and Alec Roy. ‘Controlling access to suicide means.’ International journal of environmental research and public health 8, no. 12 (2011): 4550-4562, doi: 10.3390/ijerph8124550 * (full text available).

It is argued that ‘assisted death’ of a kind legalised in Oregon, is not assisted suicide because (1) with ‘assisted death’ the person is terminally ill and (2) (non-assisted) suicide is typically the result of depression. However, according to one UK study, ‘at least 10 percent of [non-assisted] suicides nationally involve[ed] some form of serious physical illness (either chronic or terminal)’. See:

Bazalgette, L., W Bradley, J Ousbey. The Truth about Suicide (London: Demos, 2011)  

Similarly in Switzerland ‘ In 53% of cases, causes of death registrations for [non-assisted] suicide do not contain any information about concomitant diseases. If no information is available, this may mean various things: either no disease was present or it was unknown. If information is available, 56% of entries cite depression. In the remaining 44% of entries, a physical disease is mentioned. Physical diseases include a range similar to that of assisted suicide (G11). ’ (emphasis added)

Similarly, a report on suicide in Oregon found that 25% of men and 26% of women who died by suicide had had physical health problems, and in the over-65 cohort, 66% of men and 56% of women had physical health problems, including conditions such as cancer, heart disease, and chronic pain.

Shen, X., L Millet. Suicide in Oregon: Trends and Risk Factors 2012 Report . Oregon Health Authority, Portland, Oregon.

The vulnerability of older people, those living alone and those with physical illness was highlighted in a report by the New York Task Force in 1994. The Task Force also found that depression was prevalent in this population, but largely undiagnosed and untreated (see especially chapter 2 of the report).

New York State Task Force on Life and the Law, ‘When Death is Sought: Assisted Suicide and Euthanasia in the Medical Context’ (1994).  

Similarly, in a study of 178 Compassion & Choices clients, of those who, in the study period, obtained lethal medication 3 out of 18 (17%) fulfilled the criteria for depression and of those who died by assisted suicide by the end of the study 3 out of 9 (33%) met the criteria for depression.

Ganzini, L., E. R Goy, and S. K Dobscha. ‘Prevalence of Depression and Anxiety in Patients Requesting Physicians’ Aid in Dying: Cross Sectional Survey’. BMJ 337, no. 2 (7 October 2008): a1682–a1682. https://doi.org/10.1136/bmj.a1682. * (full text available).  

It has been argued that legalising assisted suicide could, paradoxically, delay or inhibit suicide. This has been argued by Lord Falconer and others, but a particularly clear statement is provided by EXIT.  

However, in Oregon between 1999 (two years after PAS was introduced) and 2010 the suicide rate among those aged 35-64 increased by almost 50% (compared to 28% nationally).

See also the report on high rates of suicide in Portland, Oregon. This increase is without counting assisted suicides, which rose in Oregon by 44% in 2013 alone .

According to the Swiss government report , ‘ From 1995 to 2003, the absolute number of suicides fell considerably. Since then, it has more or less remained stable while cases of assisted suicide have increased considerably since 2008 in particular. In 2014, for 7 cases of suicide observed, 5 cases of assisted suicide were seen (G7) ’. 

Determination of eligibility for EAS may also have an effect on vulnerability. Looking at the situation in Canada, Isenberg-Grzeda et al conclude that ‘ Clinicians must be vigilant and prepared for the possibility of heightened risk, including risk of self-harm, after a finding of ineligibility for assisted death ’. See:

Isenberg-Grzeda, E., S. Bean, C. Cohen, and D. Selby, ‘Suicide attempt after determination of ineligibility for assisted death: A case series’ Journal of pain and symptom management 60, no. 1 (2020): 158-163 *

It must be noted that if suicide follows on from a determination of ineligibility for EAS, that person’s death would be considered suicide. However, it would not be considered ‘suicide’ if he or she had been eligible and died as a result of the provision of EAS. This highlights the broader point that euphemistic expressions such a ‘assisted dying’ or ‘medical aid in dying’ simply rename what is correctly termed ‘suicide’.

Suicide Contagion

A Swiss study indicates evidence for suicide contagion following media reports of assisted suicide: 

Frei, Andreas, Tanja Schenker, Asmus Finzen, Volker Dittmann, Kurt Kraeuchi, and Ulrike Hoffmann-Richter. ‘The Werther Effect and Assisted Suicide’. Suicide and Life-Threatening Behavior 33, no. 2 (June 2003): 192–200. https://doi.org/10.1521/suli.33.2.19 *

Research on the impact of reporting assisted suicide in Oregon has also suggested such an effect.

Stark, Paul. ‘Assisted suicide and contagion’ MCCL White Paper, May 2015 .

This evidence coheres with what is known about suicide, that it increases if the means are more widely available and if it is normalised, see for example, Euregenas (European Regions Enforcing Actions Against Suicide) Suicide Prevention Toolkit for Media Professionals .

See also Preventing Suicide: A Resource for Media Professionals, Update 2017 . Geneva: World Health Organization; 2017 (WHO/MSD/MER/17.5). Licence: CC BY-NC-SA 3.0 IGO.

Evidence of suicide rates among veterinarians (which are significantly higher than the average among the population) is generally understood to be due to access to lethal drugs.

Witte, T.K., E.G. Spitzer, N. Edwards, K.A. Fowler, and R. J. Nett. ‘Suicides and Deaths of Undetermined Intent among Veterinary Professionals from 2003 through 2014’. Journal of the American Veterinary Medical Association 255, no. 5 (2019):595-608. * (full text available).

Research also shows that positive ‘suicide role models’ reinforce high rates of suicide in a population:

Stack, Steven, and Augustine J. Kposowa. ‘The Association of Suicide Rates with Individual-Level Suicide Attitudes: A Cross-National Analysis*’. Social Science Quarterly 89, no. 1 (2008): 39–59. https://doi.org/10.1111/j.1540-6237.2008.00520.x . * (full text available).

Werther and Papageno Effects

Suicides are also associated with the way that suicide is presented in the media. The ‘Werther effect’ refers to media presentations of suicides (fictional and real) and their effect on an increase in suicide rates. The ‘Papageno effect’ refers instead to the preventative effect of media portrayals which depict people coping despite difficult life circumstances and suicidal ideation.

A survey of studies on the two effects shows that ‘ suicide contagion is more likely to occur after extensive media coverage with a content rich in positive definitions of suicide ’. Factors that increase the likelihood of imitation are, for example, ‘ the celebrity status of the suicide victim, similar demographic characteristics and the media audience, and media reports on a new suicide method’ . At the same time, different media portrayals can ‘ have an educative or preventative effect and can reduce the risk of contagion ’. See:

Domaradzki, J. ‘The Werther Effect, the Papageno Effect or No Effect? A Literature Review’. International Journal of Environmental Research and Public Health 18, no. 5 (1 March 2021): 2396. https://doi.org/10.3390/ijerph18052396 . * (full text available).

Studies of the Werther and Papageno effects focus on media portrayals of suicide, but ‘ [g]uidance is needed for media reporting of assisted suicide ’ as well. See:

Jones, David Albert. ‘Assisted dying and suicide prevention’ Journal of Disability & Religion , 22.3 (2018): 298-316 . * (pre print text available online).

A 2021 survey of members of the Association for Palliative Medicine of Great Britain and Ireland showed that ‘ There is also a significant degree of frustration at the media narrative regarding end of life care, which clinicians view as being driven by assisted suicide lobbying. There is concern that poor portrayal of palliative care in the media has led patients and families to have a skewed understanding of palliative care, and there is fear that patients are in a position of ignorance at a vulnerable moment in their lives ’.

8. Gender and the Impact of Assisted Suicide and Euthanasia

Proponents of a change in the law frequently invoke choice (for example the US organisation ‘Compassion & Choices’ or the Scottish organisation ‘My Life, My Death, My Choice’).  This language is very similar to ‘pro-choice’ language in relation to abortion, and so it might seem that feminists who are in favour of increased access to legal abortion would also support legalisation of EAS.  This argument is indeed accepted by some feminists; however, it has been challenged by a number of feminists who argue that EAS would have a disproportionately negative impact on women.

Wolf, SM. ‘Gender, Feminism, and Death: Physician-Assisted Suicide and Euthanasia’ in Feminism & Bioethics: Beyond Reproduction . New York: Oxford University Press, 1996, pp. 282-317.

Wolf argues that a legal right to abortion (which she supports) does not imply a legal right to assisted suicide.

Wolf, SM. ‘Physician-assisted suicide, abortion, and treatment refusal: Using gender to analyze the difference’ in R Weir, ed. Physician-Assisted Suicide . Indiana University Press, 1997, pp. 167-201 .

On this point see also:

Spindelman, Marc. ‘Are the Similarities between a Woman’s Right to Choose an Abortion and the Alleged Right to Assisted Suicide Really Compelling?’ U. Mich. J. L. Reform 29, no. 775 (1996): 775-856. * (full text available).

Whereas, in the West, the rate of suicide is much higher among men than women (roughly four times), PAS (in Oregon and Washington) is roughly equal between men and women, and rates of assisted suicide in Switzerland reveal a higher proportion of women; this is also true of the suicides assisted by Kervorkian.

Canetto, Silvia Sara, and Janet D. Hollenshead. ‘Gender and Physician-Assisted Suicide: An Analysis of the Kevorkian Cases, 1990–1997’. OMEGA - Journal of Death and Dying 40, no. 1 (2000): 165–208. *

Kohm, Lynne Marie, and Britney N. Brigner. ‘Women and Assisted Suicide: Exposing the Gender Vulnerability to Acquiescent Death’. Cardozo Women’s Law Journal 4 (1997): 241. * (full text available).

Canetto, Silvia Sara, and Janet D. Hollenshead. ‘Older Women and Mercy Killing’. OMEGA - Journal of Death and Dying 42, no. 1 (1 February 2001): 83–99. https://doi.org/10.2190/NRB4-JH8B-VBCW-WM7J. *

Canetto, Silvia Sara, and John L. McIntosh. ‘A Comparison of Physician-Assisted/Death-With-Dignity-Act Death and Suicide Patterns in Older Adult Women and Men’. The American Journal of Geriatric Psychiatry , June 2021, S1064748121003559. https://doi.org/10.1016/j.jagp.2021.06.003   *

George, Katrina. ‘A Woman’s Choice? The Gendered Risks of Voluntary Euthanasia and Physican-Assisted Suicide’. Medical Law Review 15, no. 1 (1 March 2007): 1–33. https://doi.org/10.1093/medlaw/fwl017. *

It has also been argued that a feminist account of relational autonomy gives more ground to be cautious about permitting assisted suicide.

Donchin, Anne. ‘Autonomy, Interdependence, and Assisted Suicide: Respecting Boundaries/Crossing Lines’. Bioethics 14, no. 3 (2000): 187–204. https://doi.org/10.1111/1467-8519.00190. *

Canetto, Sylvia Sara. ‘If Physician-Assisted Suicide Is the Modern Woman’s Last Powerful Choice, Why Are White Women Its Leading Advocates and Main Users?’ Professional Psychology: Research and Practice 50, no. 1 (2019): 39–50. *

For a study of the larger number of women who receive EAS for a psychiatric condition in Belgium and the Netherlands, and its relation to questions of suicide prevention, see:

Nicolini, Marie E., Chris Gastmans, and Scott Y. H. Kim. ‘Psychiatric Euthanasia, Suicide and the Role of Gender’. The British Journal of Psychiatry 220, no. 1 (January 2022): 10–13. https://doi.org/10.1192/bjp.2021.95. *

Data from Switzerland demonstrates not only an increase in total assisted suicides year on year, but also the disproportionately large number of women dying by assisted suicide.

9. Links to Some Campaign Organisations and Further Resources

Whichever side of the argument you find more cogent, it is useful to look at the opposite view and the counter-arguments and evidence they produce, such as it is. Campaign organisations are, by their nature, one sided, but at the very least they raise questions and identify some relevant evidence.

Organisations in favour of legalising assisted suicide or euthanasia

In 2005 the Voluntary Euthanasia Society (founded 1935) changed its name to ‘Dignity in Dying.’  Its immediate aim is legalising physician assisted suicide for the terminally ill not, currently, euthanasia.

http://www.dignityindying.org.uk/

In 2009 Michael Irwin left the Dignity in Dying to found the Society for Old Age Rational Suicide which campaigns for assisted suicide for people who are not dying, but are tired of living. In 2015, the organisation changed its name to ‘My Death, My Decision’.

https://www.mydeath-mydecision.org.uk/

The largest organisation in the USA to campaign in favour of assisted suicide is Compassion & Choices (successor to the Hemlock Society which was founded in 1980).

http://www.compassionandchoices.org/

Also founded in 1980, The World Federation of Right to Die Societies no longer counts Dignity in Dying or Compassion & Choices as ‘members,’ but has links to them as ‘other right to die societies’.

https://wfrtds.org

EXIT founded in 1982 is the main organisation that arranges assisted suicide for Swiss citizens. 

http://www.exit.ch/en/

Organisations opposed to legalising assisted suicide and euthanasia

Founded in 2005, Care Not Killing is a UK-based alliance of individuals, disability and human rights groups, healthcare providers, and faith-based bodies opposed to assisted suicide and euthanasia.

http://www.carenotkilling.org.uk/

In 2021 the Better Way campaign was founded to oppose assisted suicide and to set out a positive, alternative vision for the UK.  Its website contains information about the Canadian experience of euthanasia and assisted suicide.

https://www.betterwaycampaign.co.uk/canada/

The Euthanasia Prevention Coalition (EPC) has an international scope.  There is also a European arm.

https://www.epcc.ca/

https://www.epce.eu/

For a disability perspective see Not Dead Yet and the rather more British (and understated) Not Dead Yet UK.

http://www.notdeadyet.org/

http://notdeadyetuk.org/

For an American perspective critical of assisted suicide see the websites of Physicians for Compassionate Care Education Foundation, the Patients’ Rights Council and ‘Choice’ is an Illusion.

https://www.pccef.org/

https://www.patientsrightscouncil.org/site/

https://www.choiceillusion.org/

News and comment

The excellent and free bioethics news service Bioedge frequently includes stories on these issues.

https://bioedge.org/end-of-life-issues/euthanasia/

Alex Schadenberg (chair of EPC) has a blog, which is also very useful for news stories.

https://alexschadenberg.blogspot.co.uk/

Living and dying well is not a campaign organisation, but presents research and analysis of evidence relevant to (and critical of) assisted suicide and euthanasia.

https://www.livinganddyingwell.org.uk/

Further academic resources

This guide is intended only as an introduction to some of the resources for assessing the evidence and arguments for and against assisted suicide and euthanasia.  It is, of necessity, selective as there are many hundreds of official reports, legal cases and journal articles on these topics. Students should research independently making use of academic indices and databases such as EBSCO, Lexis Nexis, Philosophers’ Index, PhilPapers and MEDLINE. You should also ‘follow the footnotes’ reading the sources invoked by or criticised by the article you are reading.

The search engine Pubmed gives access to the MEDLINE database, which includes very many medical journals and also journals of medical ethics, and medically related humanities and social sciences.  Unlike other indices it is freely accessible and is a good place for the non-specialist to begin more serious research.

https://www.ncbi.nlm.nih.gov/pubmed

Anscombe Bioethics Centre Briefing Papers

Beuselinck, Benoit. ‘Euthanasia Case Studies from Belgium: Concerns About Legislation and Hope for Palliative Care’. Briefing Papers: Euthanasia and Assisted Suicide. Oxford: The Anscombe Bioethics Centre, 2021.

Jones, David Albert. ‘Defining the Terms of the Debate: Euthanasia and Euphemism’. Briefing Papers: Euthanasia and Assisted Suicide. Oxford: The Anscombe Bioethics Centre, 2021.

Keown, John. ‘Voluntary Euthanasia & Physician-assisted Suicide: The Two “Slippery Slope” Arguments’. Briefing Papers: Euthanasia and Assisted Suicide. Oxford: The Anscombe Bioethics Centre, 2022.

Komrad, Mark. ‘First, Do No Harm: How Canadian Law Allows for Euthanasia and Assisted Suicide for Patients with Psychiatric Disorders’. Briefing Papers: Euthanasia and Assisted Suicide. Oxford: The Anscombe Bioethics Centre, 2021.

Pontifical Academy for Life. ‘Position Paper of the Abrahamic Monotheistic Religions on Matters Concerning the End of Life (28 October 2019)’.

Symons, Xavier. ‘The Principle of Autonomy – Does it Support the Legalisation of Euthanasia and Assisted Suicide?’. Briefing Papers: Euthanasia and Assisted Suicide. Oxford: The Anscombe Bioethics Centre, 2022.

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Euthanasia in India: A Review on Its Constitutional Validity

LEX HUMANITARIAE: JOURNAL FOR A CHANGE 2021, ISSN:2582-5216 I www.lexhumanitariae.co.in I IF: 5.042, 1-10

13 Pages Posted: 29 Jun 2021 Last revised: 30 Jun 2021

Jayanta Boruah

North-Eastern Hill University (NEHU)

Date Written: May 16, 2021

Euthanasia has been made legal in India fully in March 2018 by the Supreme Court of India while deciding the Common Cause Case. It has also allowed living wills and has even formulated guidelines on this behalf. But this journey of the Indian Judiciary for making euthanasia legal in India was marked with several controversies and even now also there are opinions for and against this legality. There has been much debate on the issue that whether the Right to Life includes the Right to Die or not. In such a situation it becomes very necessary to review the opinions of various scholars to determine the validity of the Supreme Court’s action especially due to the unique system of Rule of Law in India. In the absence of a clear law on this behalf in the country, it may become very difficult to enforce this rule adequately. Further, in India, it is alleged to have a weak Rule of Law. As such euthanasia which deals with the life of human beings may exploit the vulnerable section of the society, for which an understanding of the concept of euthanasia in the Indian context attains much prominence. This Article, therefore, attempts to study the concept of euthanasia with its different legal parameters in different countries across the world and will also try to understand the Indian legal standpoint on this matter. The article will further focus on the various arguments for and against euthanasia in India to understand the validity of euthanasia laws in India.

Keywords: Constitutional Validity, Euthanasia, Indian Jurisprudence, Living Wills, Right to Die, and Right to Life

Suggested Citation: Suggested Citation

Jayanta Boruah (Contact Author)

North-eastern hill university (nehu) ( email ).

Meghalaya India

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