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Physician-Assisted Suicide: Considering the Evidence, Existential Distress, and an Emerging Role for Psychiatry

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Physician-assisted suicide (PAS) is one of the most provocative topics facing society today. Given the great responsibility conferred on physicians by recent laws allowing PAS, a careful examination of this subject is warranted by psychiatrists and other specialists who may be consulted during a patient's request for PAS. In this article, recent evidence regarding the implementation of PAS in the United States and The Netherlands is reviewed. Support is found for some concerns about PAS, such as the possibility that mental illness occurs at higher rates in patients requesting PAS, but not for other concerns, such as the fear that PAS will be practiced more frequently on vulnerable populations (the slippery-slope argument). These data and common arguments for and against PAS are discussed with an emphasis on the tension between values, such as maximizing patient autonomy and adhering to professional obligations, as well as the need for additional research that focuses more directly on the patient-centered perspective. Implications of the available evidence are discussed and lead to a consideration of mental anguish in terminally ill patients including aspects of existential distress and an acknowledgment of the importance of tailoring end-of-life care to the distinct set of values and experiences that shape each patient's perspective. The article concludes with a discussion of an expanding role for psychiatrists in evaluating patients who request PAS.

Religious condemnation and moral disapproval of suicide by society were associated with its criminalization in most societies before modern times. 1 However, views toward suicide changed during the 19th and 20th centuries, coincident with the emergence of psychiatry as an autonomous discipline in which practitioners could diagnose and treat anxiety, depression, and other ailments contributing to suicide. In addition, modern sociological theory describing suicide as a social ill reflecting widespread alienation and anomie facilitated a growing cultural sensitivity to the plight of the mentally ill. Scientific advancements in our understanding of mental illness thus implied that suicide was caused by social or psychological forces often beyond the control of individuals and contributed to the decriminalization of suicide. 1 , 2

Modern laws in the United States allowing physician-assisted suicide (PAS), defined as the practice of a physician providing a competent patient with a prescription for medication for the patient to use with the primary intention of ending his life, are thought to have emerged from a growing dissatisfaction with the medical profession and the development of a national right-to-die movement. 3 The right-to-die sentiment developed in parallel with skepticism of medical authority, beginning in 1967 with the creation of the first living will that allowed patients to make decisions about their end-of-life care years in advance. 4

Currently, assisted suicide is legal in the United States in only four states: Oregon, Washington, Montana, and Vermont. However, it has been a source of controversy in many other states for some time, as voter initiatives for legalizing assisted suicide were introduced and defeated in California, Michigan, and Maine over a period from the early 1990s until 2000. In recent time, legislatures in Connecticut and New Jersey have proposed bills to legalize assisted suicide. These repeated recent efforts in support of assisted suicide and the strident opposition that typically results keep the question in the American public's mind as one of vital importance.

It should be noted that the phrase physician-assisted suicide is itself not without controversy. Proponents of the practice prefer the term aid in dying to describe doctor-provided assistance to patients who want to end their lives. Although I appreciate the sentiment behind such arguments, in this article, I will use PAS to describe the practice, as it is the term predominantly used in the medical context.

As PAS implies, modern attitudes toward death and dying consider the subject of assisted suicide to fall within the purview of medical practice, despite the American Medical Association's opposition to PAS on the grounds that it is antithetical to a doctor's role as healer. 5 U.S. physicians remain sharply divided on assisted suicide, with opposition to the practice associated with increased religiosity and certain moral and ethics-based principles. 6 , – , 8 Oregon's Death With Dignity Act clearly delineates the role of physicians as the primary gatekeepers of assisted suicide in enumerating responsibilities for the attending physician such as ensuring that each patient who requests aid in dying is capable, acts voluntarily, makes an informed decision, and is dying of a terminal disease (defined as an incurable and irreversible disease that will produce death within six months). The grave responsibility conferred by Oregon's Death With Dignity Act suggests that psychiatrists and other physicians who may be consulted to opine on the integrity of a patient's request for aid in dying must think deeply about their views on the subject.

The impassioned debate over PAS spans a wide range of disciplines and reflects the incendiary nature of the question. Arguments for and against PAS touch on many basic moral beliefs and illustrate the tension among values such as autonomy, paternalism, fairness, and the value of human life. Although the controversy can be described in political, social, and medical terms, an individual's feelings on the subject can often be reduced to a simple moral conviction about whether a person can aid another in ending his life. Debates that turn on such basic beliefs tend to divide people deeply, and the resultant conversation is often characterized by rhetoric and ideology. Over time and with the further polarization of views, common ground and compromise often seem unlikely.

However, although it is often overlooked or dismissed in these cases, scientific evidence has the opportunity to inform our thinking on matters that evoke moral and ethics-related questions. While not dispositive, evidence can characterize the conditions and consequences associated with different viewpoints. Some of the most contentious aspects of the debate over assisted suicide include fears or questions that can be illuminated with actual evidence.

In this article, I will review the recent evidence that pertains to the arguments for and against PAS and suggest avenues for future research. I will then discuss implications of the available evidence and consider mental suffering in terminally ill patients as comprising aspects of existential distress (i.e., concerns related to feelings of hopelessness, futility, and meaninglessness; anxiety about death; and disruption of personal identity), as well as acknowledge the importance of tailoring end-of-life care to the distinct set of values and experiences that shape each patient's perspective. Finally, I will explore an emerging role for psychiatrists in evaluating patients who request PAS.

In this section I will review some of the recent data that address some of the open questions and fears regarding PAS. An important caveat is that most of the evidence is taken from studies conducted in Oregon and The Netherlands, and moreover, many of the studies involve the work of Linda Ganzini, a professor of psychiatry and medicine at Oregon Health and Science University. This is not to imply a particular bias on the part of the studies mentioned in this article, but rather to characterize the current state of evidence as limited by region and principal investigator.

Psychiatric Illness in Patients Who Request PAS

One basic question that frames the debate on assisted suicide is the extent to which patients who request PAS have a treatable psychiatric illness. Ganzini et al . 9 interviewed a cross section of patients who requested a physician's aid in dying under Oregon's Death with Dignity Act and found that one in four had clinical depression. In another study, physicians in Oregon who received requests from patients for aid in dying reported that 20 percent of them were depressed. 10 The results of these studies imply that a significant minority of patients who request aid in dying have depression. However, of all patients who received a prescription for a lethal drug in Oregon since 1997, just under 7 percent were referred for a psychiatric evaluation. Ganzini and colleagues also studied health care providers and family members in Oregon and found that these groups thought that depression was rarely a factor influencing requests for PAS. 9 , 11 , 12 Together, these findings raise the concern that clinicians and family members may fail to detect signs and symptoms of depression in these patients.

For purposes of comparison, a recent systematic review found that, in The Netherlands, the rate of depression in patients whose requests for euthanasia were honored was similar to that in the surrounding population of seriously ill patients, but that the presence of depression was a significant factor in refusals of requests for euthanasia, suggesting that the Dutch system may be successful in screening out many requests motivated by depression. 13 Moreover, with regard to the overall prevalence of depressive symptoms in the terminally ill population, one study of terminally ill patients with cancer found that 59 percent of those with a serious and pervasive desire to die had significant symptoms of depression, versus only 8 percent of those without such a desire. 14 This result is consistent with other research that has found an increased association between an expressed desire for a hastened death and symptoms of depression, 15 implying a higher probability that patients who request PAS have depression. These findings suggest the importance of screening such parents carefully for evidence that mental illness may be interfering with their decision-making capacity.

Impact on Vulnerable Patients: the Slippery Slope

Another concern that can be illuminated by evidence is the question of the slippery slope that leads to abuse. Many have expressed apprehension that abusive pressures would disproportionately affect vulnerable patients, such as those whose capacities for decision-making are compromised by cognitive impairment or lack of education, those who are subject to social prejudice, or those who may have been socially conditioned to think of themselves as less deserving of care. 16 Ultimately, there is concern that these pressures would result in an increased risk of death by PAS among vulnerable persons compared with the risk in other populations.

Battin et al. 16 explored this question by examining data collected in jurisdictions where assisted dying is legal, such as Oregon and The Netherlands, and by looking for evidence that the lives of people in groups identified as vulnerable were more frequently ended with assistance from a physician than those of other populations. Their findings were limited by substantial differences in methodologies in source studies and difficulties in determining with certainty the actual incidence of assisted dying in several of the vulnerable groups studied. However, they found no evidence of heightened risk of death by physician assistance in the elderly, women, uninsured people, the poor, racial and ethnic minorities, people with low educational status, minors, patients with psychiatric illness, and patients with chronic nonterminal illness.

Although conclusive proof about the impact of legalized assisted suicide on vulnerable patients would entail studies of higher complexity, duration, and comprehensiveness, Battin et al. certainly provided a first-pass look at the slippery-slope question. At this stage, there appears to be no evidence to support the fear that assisted suicide disproportionately affects vulnerable populations. Instead, the available data indicate that people who die with a physician's assistance are more likely to be members of groups with higher social, economic, educational, and professional status.

Patients' Experience of PAS

Other aspects of the debate on assisted suicide that can be informed by evidence are those related to the tension between autonomy and paternalism. In essence, paternalism presupposes that doctors are better able to act in patients' best interests than the patients are themselves. One way to examine the question of whether patients are indeed capable of making decisions about dying is to compare the quality of death and dying in patients who request PAS with that of those who do not.

Smith et al. 17 sought to determine whether there was a difference in the quality of the dying experience, from the perspective of family members, among patients in Oregon who received lethal prescriptions, those who requested but did not receive lethal prescriptions, and those who did not pursue physician-assisted dying. Altogether, they noted few significant differences between the groups in items that measured domains such as connectedness, transcendence, and overall quality of death. However, they did observe that families reported that patients who received lethal prescriptions had higher quality ratings on items measuring symptom control (e.g., control over surroundings and control of toileting) and higher ratings on items related to preparedness for death (e.g., saying goodbye to loved ones) than those who did not pursue physician-assisted death. Their conclusion was that the quality of death experienced by those who received lethal prescriptions was no worse than that of those who did not pursue PAS, and in some areas, family members rated it as better. In another study, Georges et al. 18 used retrospective interviews with relatives to describe the experiences of patients who died by euthanasia (EAS) or PAS in The Netherlands and found that, according to relatives, EAS had a positive impact on the quality of the end of their loved one's life in 92 percent of cases, primarily by preventing or ending suffering.

One interpretation of the findings of these studies is that in those patients who opt for it, assisted suicide contributes favorably to the experience of their relatives. This inference is supported by evidence from other studies showing no differences in mental health outcomes in family members of patients in Oregon who had requested physician aid in dying compared with family members of patients in Oregon who died of terminal illness. 19 However, although information regarding the experience of family members of patients who opt for PAS may be important in influencing social norms regarding the acceptability of PAS, these data do not speak to the central question of patient autonomy. In fact, it is arguable that the aforementioned studies are irrelevant to the patient-centered perspective, in that they do not directly assess patients' experiences of PAS. In this sense, sufficient research into this and other questions regarding PAS seems to be lacking.

Current State of Research on PAS

As mentioned earlier, most of the clinical studies performed in the United States are associated with the work of one researcher (Ganzini). The relative paucity of research on PAS compared with other areas of medicine implies that there may be a reluctance to study it. Reasons for this reluctance include the taboo associated with PAS, the small number of states that have legalized it, a reliance on using rhetoric or ideology to argue points for or against it rather than actual evidence, and finally, a fear by doctors that research may lead to changes that would restrict, rather than inform, the care that they provide. The identification of the impediments to research in this realm may itself be a consideration for future study, as this may provide a clear path to encouraging more research on PAS.

Another important open question regarding PAS that has not been directly addressed by research to date is the quality of the dying experience of patients who opt to die in this way. Research that directly assessed the patient's experience leading up to death by PAS would clarify questions about the well-being of patients who died by this method and, in doing so, provide evidence potentially in support of PAS as a form of care. Such evidence would be vital for several reasons. For example, it could confirm the sense that physician supporters of PAS have that PAS is a valid form of health care that does indeed improve patients' well-being. Moreover, it would address fears that PAS is inconsistent with the medical dictum to “first, do no harm,” for if it could be shown more clearly that PAS improves the experience of dying for patients, it could be argued that the essence of PAS is to relieve suffering rather than to kill or cause harm. Finally, data taken directly from the patient-centered perspective would address concerns that may be raised about the ability of patients to predict their future mental state accurately, as depressed patients have been shown to have more negatively biased mood predictions, 20 which in turn could adversely affect their ability to make decisions about end-of-life care. 21 Evidence that patients who opt for PAS experience increased well-being up to the time of death would support the belief that, for selected patients, such end-of-life decisions could be consistent and authentic.

The evidence reviewed offers support for some fears with regard to assisted suicide and seems to refute others. One study found no evidence to support the slippery-slope fear that assisted suicide would eventually be used prejudicially on vulnerable populations. 16 Also, researchers found that families of persons who used assisted suicide felt more prepared for and accepting of their loved one's death and in other ways had mental health outcomes that were no worse than those in families of persons who died of other causes. 19

However, data from multiple sources indicate that the concern that depression is often missed or overlooked in patients seeking assisted suicide may be valid. For example, although only a small percentage of patients who request assisted suicide are actually referred to psychiatrists, around 20 percent of those who request assisted suicide have depression. Moreover, health care providers and family members underestimate the extent to which depression is a factor in requests for aid in dying. 9 , – , 12 , 22 From one perspective, this finding implies a need for mandating more frequent referrals to psychiatrists to evaluate patients for evidence that mental illness may have interfered with their decision-making capacity.

On the other hand, psychiatrists and physicians in general may be overly inclined to pathologize suicidal ideation and depression in patients who request aid in dying. Most people with major depression retain competence to make medical decisions, 23 and the legalization of PAS reflects an acceptance that active hastening of death can be a valid choice in terminal illness, implying that PAS can be a valid choice despite the presence of depression. 13 It follows that, although the expression of suicidal ideation may indeed be pathologic in most settings in which it is observed, the conditions that characterize terminal illness may truly be distinct, as patients can reasonably interpret such a diagnosis as a death sentence. One would anticipate that no matter how psychologically healthy a patient might be, it would be understandable for that person to experience feelings of despair, demoralization, and existential distress (i.e., concerns related to feelings of hopelessness, futility, or meaninglessness; anxiety about death; and a disruption of personal identity) in response to receiving a diagnosis of terminal illness.

The Evaluation and Treatment of Existential Distress

Researchers have explored the concept of existential distress in terminally ill patients and have found that their concerns are often related to themes such as loss of control, loss of continuity, and acceptance and preparation. 24 Some have resolved to address the plight expressed by these patients by emphasizing the importance of finding “meaning” at the end of life. Breitbart and colleagues 25 describe psychotherapeutic approaches intended to explore spiritual and existential themes through a meaning-oriented approach that encourages the dying patient to find meaning and purpose in living until death and promotes a patient's personal agency and responsibility.

Chochinov and colleagues 26 have studied the psychological experience of terminally ill patients and have proposed that a fractured sense of dignity can be diagnosed, quantified, associated with a decreased quality of life, and treated with dignity-conserving therapies, such as maintaining autonomy by participating in decisions about care or contributing to something that might serve as a lasting legacy.

Although these researchers have offered therapies that promote continued life, their findings also imply alternative solutions to the existential dilemma facing the terminally ill. For example, important values such as autonomy and dignity would appear to be served with the practice of assisted suicide as well. In fact, assisted suicide might plausibly be a choice that resolves the existential dilemma of terminal illness and its attendant helplessness and hopelessness. Choosing the time and manner of one's death could be a way of symbolically wresting back the reins of the course of one's life. After all, if the healthy among us face up to our finite lives by making choices about how to live, it may also be reasonable for those facing their imminent demise to determine the conditions of their death.

The use of assisted suicide to resolve the existential distress of the terminally ill gains additional support from the work of Chochinov et al. 26 on the concept of dignity in this population. They found that, although there were many common elements shared in different patients' definitions of dignity, there were also important distinctions. For example, some patients valued a “fighting spirit” and “railing against their illness,” whereas others valued acceptance. Some patients spoke of their distress at the thought of having to rely on others for their care, whereas others raised fears related to the anticipation that their death would cause their loved ones pain.

The findings of Chochinov et al . highlight the diverse set of values and manifold experiences within the terminally ill population and imply that treatments aiming to improve these patients' well-being would have to take into account their various desires and perspectives. After deep consideration and reflection on his goals and wishes, as well as careful evaluation to rule out the possibility that pathologic motivations (such as severe mental illness) may be playing a role in his decision, a patient may ultimately decide that assisted suicide is the best way to end his life.

A Role for Psychiatry

These findings imply a potential role for psychiatrists in evaluating patients who request PAS. However, this perspective, too, is not without its complications. Psychiatrists themselves are divided in their support for assisted suicide, with surveys indicating that about two-thirds of U.S. psychiatrists believe that it should be permitted in certain circumstances. 27 , 28 Moreover, most psychiatrists believe that a single independent psychiatric examination would be insufficient to determine a patient's capacity to decide on PAS, 28 especially given previously mentioned concerns about the general difficulty humans have in accurately forecasting their future mental state. 20 , 21

It must be acknowledged that mandated or multiple independent psychiatric examinations would have the effect of increasing the labor and time associated with ensuring the integrity of a patient's request for PAS, which in turn may serve as an impediment to the overall process. Moreover, terminally ill patients may feel stigmatized by being mandated to undergo a psychiatric examination. In Australia, Kissane et al. 29 found that mandated psychiatric assessments for patients requesting euthanasia or PAS sometimes leads them to withhold key information because they see the psychiatric assessment as a legal hurdle to be overcome, suggesting also that mandated psychiatric assessments may compromise the relationship between psychiatrist and patient.

Yet, the push for more extensive evaluations by psychiatrists in this context is understandable. Concerns about a patient's capacity to make reasoned decisions about treatment are likely to be raised in circumstances where a patient expresses a desire for an intervention with unfavorable outcomes and high risk. 30 In addition, some physicians may feel uncomfortable participating in PAS without a more comprehensive evaluation. 28 Thus, in instances where a patient's capacity is in serious question, multiple independent evaluations from consulting psychiatrists over time may be indicated.

For the purpose of guiding a psychiatrist's evaluation of a patient who has requested PAS, Muskin 31 emphasized a psychodynamic approach to exploring the complexity contained in a patient's request to die, which could be interpreted as a communication to the patient's doctor, a method of control over aspects of the patient's life or death, rage or revenge, an expression of hopelessness, or even an expression of guilt, self-punishment, or atonement. A psychiatrist's role as expert in exploration would also include evaluating the effect of psychiatric or medical disease on a patient's decision-making capacity, as well as clarifying communications among treatment team, family, and patient to minimize the possibility of undue influence on a patient's ultimate decision. Finally, a psychiatrist may simply bear witness to and acknowledge the validity of the patient's emotional experience, thereby offering relief by way of empathy. The expertise of psychiatrists in these important areas thus suggests that they would be well suited to provide careful guidance to a patient as he explores his feelings, desires, and values in the service of making authentic decisions about end-of-life care.

In the final analysis, however, a psychiatrist's impressions of the integrity of a patient's request for PAS may turn on the psychiatrist's conception of rational suicide. Thus, it seems critical for psychiatrists to ponder the psychological constituents of rational suicide. Muskin's article 31 is useful in summarizing the questions necessary for a sufficient exploration of a patient's request for PAS, but additional work is warranted to delineate the essential features of rational suicide. The conception set forth by Tomasini 32 of rational suicide as instrumentally rational, autonomous, born of stable goals, and not due to mental illness offers a potential starting point, but in its brevity, it also implies that patients who possess these basic qualities may differ greatly. The challenge will then be for consulting psychiatrists to immerse themselves in a patient's psychological experience with the goal of ensuring that the request is emotionally appropriate, purposive, free of undue influence, and consistent over time with the patient's stated goals, values, and preferences.

Although the arguments and evidence reviewed herein may influence some to change their views on assisted suicide, there are undoubtedly those who will remain steadfast in their beliefs. That strong arguments can be made on both sides of the debate and strident disagreement continues suggests that the question of assisted suicide may touch on something deeper than any single ideology.

In medicine, it may be especially difficult to feel comfortable with helping a patient commit suicide, given that some may equate PAS with killing rather than healing. For this and other reasons, which may be religiously or philosophically derived, certain physicians may feel that it is against their code of ethics to participate in assisted suicide. The question of assisted suicide can also raise feelings of personal failure, as if medicine has nothing left to offer patients, although as implied by the arguments outlined in this article, assisted suicide could instead function as a vital form of care for someone who is suffering.

Indeed, for our purposes in medicine, it is this latter perspective that forms the raison d ' etre of PAS. Rather than merely seeking to maximize patient autonomy in some abstract sense, physicians are experts in the service of patients' health and are therefore obligated to practice PAS only when it is deemed to be in the interest of patients' well-being and not solely in the service of patient autonomy or preference satisfaction. This approach obviates the absurd implication of prioritizing maximization of autonomy over our professional obligations and moreover serves as a useful framework with which to deny the practice of PAS in other conditions, such as chronic, nonterminal illness, in which physicians would feel that PAS would not constitute appropriate care.

In fact, the fear that assisted suicide could eventually be used in such cases is fundamentally unsettling to many. When the philosopher Albert Camus 33 said, “There is but one truly serious philosophical problem and that is suicide,” he was identifying one of the most basic fears that humans can have. Camus' statement highlights the fact that, at one point or another in our lives, we all must confront our mortality and the question of whether life is worth living. As fellow humans and in psychiatry in particular, we hope that each person is able to resolve this dilemma in a way that allows him to live life in a satisfying, meaningful way. Assisted suicide seems to flout that basically pro-life view, but on closer examination, its purpose is instead to relieve suffering in imminently terminal cases where it is thought that no other treatment could reasonably hope to do the same. Our charge as physicians is to encourage an honest, scientific inquiry into the questions raised by PAS that is commensurate with the ideological fervor that surrounds the debate and, as psychiatrists, to ensure that patients struggle valiantly and honestly before making a decision in that direction.

Disclosures of financial or other potential conflicts of interest: None.

© 2015 American Academy of Psychiatry and the Law
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Justin O'Brien

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Attitudes and Practices of Euthanasia and Physician-Assisted Suicide in the United States, Canada, and Europe

1 Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
2 Department of Public and Occupational Health, EMGO Institute for Health and Care Research and Cancer Center Amsterdam, VU University Medical Center, Amsterdam, the Netherlands
3 End-of-Life Care Research Group, Vrije Universiteit Brussels (VUB) and Ghent University, Brussels, Belgium
Correction Incorrect Label in Figure JAMA
Comment & Response Euthanasia and Physician-Assisted Suicide Kenneth R. Stevens Jr, MD; William L. Toffler, MD JAMA
Comment & Response Euthanasia and Physician-Assisted Suicide Daniel P. Sulmasy, MD, PhD; E. Wesley Ely, MD, MPH; Charles L. Sprung, MD, JD JAMA
Comment & Response Euthanasia and Physician-Assisted Suicide—In Reply Ezekiel J. Emanuel, MD, PhD; Bregje D. Onwuteaka-Philipsen, PhD; Joachim Cohen, PhD JAMA

Importance The increasing legalization of euthanasia and physician-assisted suicide worldwide makes it important to understand related attitudes and practices.

Objective To review the legal status of euthanasia and physician-assisted suicide and the available data on attitudes and practices.

Evidence Review Polling data and published surveys of the public and physicians, official state and country databases, interview studies with physicians, and death certificate studies (the Netherlands and Belgium) were reviewed for the period 1947 to 2016.

Findings Currently, euthanasia or physician-assisted suicide can be legally practiced in the Netherlands, Belgium, Luxembourg, Colombia, and Canada (Quebec since 2014, nationally as of June 2016). Physician-assisted suicide, excluding euthanasia, is legal in 5 US states (Oregon, Washington, Montana, Vermont, and California) and Switzerland. Public support for euthanasia and physician-assisted suicide in the United States has plateaued since the 1990s (range, 47%-69%). In Western Europe, an increasing and strong public support for euthanasia and physician-assisted suicide has been reported; in Central and Eastern Europe, support is decreasing. In the United States, less than 20% of physicians report having received requests for euthanasia or physician-assisted suicide, and 5% or less have complied. In Oregon and Washington state, less than 1% of licensed physicians write prescriptions for physician-assisted suicide per year. In the Netherlands and Belgium, about half or more of physicians reported ever having received a request; 60% of Dutch physicians have ever granted such requests. Between 0.3% to 4.6% of all deaths are reported as euthanasia or physician-assisted suicide in jurisdictions where they are legal. The frequency of these deaths increased after legalization. More than 70% of cases involved patients with cancer. Typical patients are older, white, and well-educated. Pain is mostly not reported as the primary motivation. A large portion of patients receiving physician-assisted suicide in Oregon and Washington reported being enrolled in hospice or palliative care, as did patients in Belgium. In no jurisdiction was there evidence that vulnerable patients have been receiving euthanasia or physician-assisted suicide at rates higher than those in the general population.

Conclusions and Relevance Euthanasia and physician-assisted suicide are increasingly being legalized, remain relatively rare, and primarily involve patients with cancer. Existing data do not indicate widespread abuse of these practices.

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Open access
Published: 30 July 2020

Euthanasia and assisted suicide in patients with personality disorders: a review of current practice and challenges

Lars Mehlum ORCID: orcid.org/0000-0003-2813-0045 1 ,
Christian Schmahl 2 ,
Ann Berens 3 ,
Stephan Doering 4 ,
Joost Hutsebaut 5 ,
Andres Kaera 6 ,
Ueli Kramer 7 ,
Paul Anthony Moran 8 ,
Babette Renneberg 9 ,
Joaquim Soler Ribaudi 10 , 11 ,
Sebastian Simonsen 12 ,
Michaela Swales 13 ,
Svenja Taubner 14 &
Ester di Giacomo 15 , 16

Borderline Personality Disorder and Emotion Dysregulation volume 7 , Article number: 15 ( 2020 ) Cite this article

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Over the last two decades an increasing number of countries have legalized euthanasia and physician-assisted suicide (EAS) leading to considerable debate over the inherent ethical dilemmas. Increasing numbers of people with personality disorders, faced with unbearable suffering, have requested and received assistance in terminating their lives. EAS in people with personality disorders has, however, received very sparse attention from clinicians and researchers. In this paper, we examine the literature on the practice and prevalence of EAS in people with personality disorders to date and discuss the associated challenges for research and practice.

Narrative review of the literature combined with the authors’ collective experience and knowledge of personality disorders.

In six of the eight countries where EAS is currently legal, mental disorders are accepted as disorders for which EAS may be granted. In four of these countries, EAS in minors with mental disorders is also accepted. Our literature search resulted in 9 papers on the subject of EAS in people with personality disorders. These studies suggest that most clinicians who grant EAS have indeed perceived their patients’ suffering as chronic, unbearable and untreatable without prospect of improvement. The majority of patients with personality disorders had tried some form of psychotherapy, but very few had received any of the relevant evidence-based treatments. The decision to grant EAS based on a perception of the patient’s illness as being untreatable with no prospect of improvement, could, thus, in many cases fail to meet the due care criteria listed in EAS laws. People with personality disorders more often wish for death for extended periods of time than people without these disorders. However, there is ample empirical data to show that suicidal tendencies and behaviour can be treated and that they fluctuate rapidly over time.

Conclusions

In light of our findings, we believe that the current legislation and practice of EAS for people with personality disorders is based on an inadequate understanding of underlying psychopathology and a lack of awareness about the contemporary treatment literature. Moreover, we assert that this practice neglects the individual’s potential for having a life worth living.

On February 20th 2020 Portugal’s parliament provisionally approved a bill to legalize euthanasia and physician-assisted suicide (in the following collectively labelled EAS), thus joining a burgeoning group of nations who have chosen to permit what has for many centuries, remained a prohibited and morally condemned practice. Similar legislative changes are currently taking place in other countries. Invariably, what motivates legislators to decriminalize EAS, is to end what is considered as unbearable, untreatable and unnecessary suffering in people with incurable illness and, thus, assisting a peaceful death. Although somatic suffering is almost always the main focus of law-makers attention, life-ending assistance for people with mental illness has become more common in recent years. Over the past decade, we have identified the fact that an increasing number of people with personality disorders (PD) have requested and received EAS. Nevertheless, EAS in this group has received very sparse attention. In this paper, we examine the literature on the practice and prevalence of EAS in people with PD to date, discuss associated challenges and provide recommendations for policy makers, clinicians and researchers.

A brief history of euthanasia

The Greek term euthanasia (εὐθανασία) denotes a good ( eu ) death ( thanatos ) and was from antiquity originally not associated with physician-assisted dying, but regarded as a natural and highly desirable course at the end of one’s life [ 1 ]. Indeed, under the Hippocratic oath, any kind of assisted dying is explicitly forbidden [ 2 ]. In the medieval period and early modern age, euthanasia was generally prohibited and it was only at the beginning of the sixteenth century that so-called “mercy killing” was openly discussed and supported by some philosophers and ethicists. Euthanasia was regarded as a facilitation of dying, assisted by physicians and potentially, but not necessarily, shortening life [ 1 ]. In the late 19th and early 20th centuries, on the background of Darwinism and the Eugenics Movement, euthanasia became more frequently discussed and practiced, culminating in the ideology and practices embraced by the Nazi regime in Germany, where so-called “Gnadentod” (German for “mercy death”) became a euphemistic term for the coordinated killing of mentally ill and physically or mentally disabled people who did not fit into the prevailing ideal of human beings. As a consequence, in German-speaking countries the term “euthanasia” is still negatively charged and has, thus, been banned from the societal discourse and replaced by the term “aktive Sterbehilfe”, which is close to the English term “assisted dying”. This linguistic situation is different in many other countries in the world, where euthanasia in the public eye seems to represent a more or less desirable facilitation of death without pain or other suffering.

A contemporary definition of euthanasia is proposed by Denys [ 3 ]: “Euthanasia means that the physician acts directly to end the patient’s life, e.g., by giving a lethal injection”. In contrast “Physician-assisted Suicide” (PAS) is the situation in which a physician provides the specific means and instructions to a patient with the intention of ending the patient’s life, but where the patient him/herself performs the act of ending his or her life [ 4 ]. In 1942, Switzerland was the first country to legalize PAS but not euthanasia. However, according to Swiss legal practice, the latter will not be punished, if it is delivered free of selfish motives [ 5 ]. After 2001, seven more countries have legalized PAS and/or euthanasia (for an overview see Table 1 ). The Netherlands, Belgium, Luxembourg as well as Colombia and Canada now all permit euthanasia, whereas Switzerland, parts of Australia (the state of Victoria), and ten states of the USA only legalized PAS. In addition, the legislature of New Zealand has just recently allowed euthanasia, but the final decision will be made in a referendum in 2020. In Germany the Federal Constitutional Court (Germany’s highest court) in February 2020 overturned a ban on organized assisted suicide, thus declaring that the right to die includes the freedom to rely on the voluntary help of another person. In all of the countries having legalized PAS and/or euthanasia, so far, more or less detailed procedures have been described as requirements for directly or indirectly helping people to die. Usually, an examination by a medical doctor has to take place, and the person has to be able to decide freely without being influenced by any relevant cognitive impairment or external pressure.

Although PAS or euthanasia were originally intended to facilitate death without pain or other suffering from physical illness, people with mental illness have gradually also been considered eligible.

This paper is based on a narrative review of the literature combined with the authors’ collective experience and knowledge of personality disorders from extensive clinical practice, clinical research and treatment development, and involvement in the formulation of national policy in relation to the management of personality disorder.

Literature search

We searched the Medline database (OVID) for peer reviewed articles and letters to the Editor published in English through October, 2019 with the following MeSH-terms: “Euthanasia”, “Euthanasia, Active”, “Euthanasia, Active, Voluntary”, “Suicide, Assisted”, “Personality Disorders” and “Borderline Personality Disorder”. No language or time filters were applied. The literature search resulted in 9 papers; 2 regular articles based on empirical studies, 4 literature reviews and 3 comments/letters to the editor. In the following, we summarise the main findings and conclusions from these publications.

Table 1 provides an overview of the legislation on euthanasia and physician-assisted suicide in the different countries where it is established. The majority of the countries allowing EAS restrict it to people above the age of 18 years, whereas the Netherlands offer both PAS and euthanasia from the age of 12 years, Colombia permits PAS in children after the age of 5 years, and Belgium has abolished any age limit (Table 1 ).

In the case of Belgium, the law requires a repeated wish from the child himself and permission from parents (except in the case of so-called ‘emancipated minors’ where a minor, through court order or other means, legally becomes an adult). Few cases of EAS in minors have so far been reported; all in cases of physical illness. Some countries allow EAS in mentally ill people, provided they are considered able to express their free will (this is not required by Colombia and Australia, but here EAS is not permitted for psychiatric reasons). To be granted euthanasia in Belgium, to date the country with the most liberal EAS legislation, a person must be “in a medically futile condition of unbearable and untreatable physical or psychological suffering, resulting from a serious and incurable disorder caused by accident or illness” [ 6 ]. The Federal Control and Evaluation Committee on Euthanasia in Belgium reports [ 7 ] that about of 3% of EAS-cases are mainly linked to mental disorders. Thienpont and colleagues [ 8 ] conducted a retrospective analysis of medical records of the first 100 consecutive patients (23 men and 77 women) who requested euthanasia for psychological suffering associated with mental disorders in the years between 2007 and 2011. The most common of these disorders were treatment resistant mood disorders ( n = 58) and personality disorders ( n = 50), whereas 29 patients had both types of disorder. Among the 50 patients with a PD, 27 had borderline PD (BPD), 3 had dependent PD, 2 had histrionic PD and 18 had some other PD or PD not otherwise specified. In all patients with PD suffering was reported to be chronic, constant and unbearable, “without prospects of improvement, due to treatment resistance” [ 8 ]. The study does not specify or operationalize the concept of “treatment resistance” or how it was measured. In total, 48 of all of the 100 euthanasia requests were accepted, of which 35 were carried out, but the authors do not specify how many of these had a PD diagnosis.

In 2018, 4% of all deaths in the Netherlands were due to EAS, and among all cases of EAS ( N = 6126) around 1% involved patients with a mental disorder according to the Dutch regional euthanasia review committees (RTE) [ 9 ]. Since 2013 the RTE has published all psychiatric cases of EAS on their website. Kim and co-workers reviewed the first 66 psychiatric cases of EAS published and found that 52% of these were patients with personality disorders or difficulties [ 10 ]. The prevalence of PD was higher in patients who were younger. Recently, a larger Dutch study based on content analysis was published by Nicolini et al. [ 11 ]. Among the 116 cases published by the RTE, a diagnosis of PD was likely, according to the authors’ clinical judgement, in just under two-thirds of cases ( n = 74), although a PD diagnosis had been explicitly made by the patients’ doctors in only 48 (41%) cases. The majority (72%) of patients with PD had received some form of psychotherapy, but mostly of unspecific nature, and only one patient (1%) had received any of the standard PD-specific evidence-based treatments currently in existence.

Most of the people who request EAS for mental illness appear to be experiencing multiple mental health problems. In the study by Kim et al. [ 10 ] depressive disorders (55%), posttraumatic stress disorder and other anxiety disorders (42%) were prominent whereas 52% of the patients had personality-related problems, sometimes without a formal PD diagnosis, more so in younger patients. Social isolation or loneliness were mentioned in 56% of the cases.

Our review of the literature suggests that a large proportion of people with mental disorders who request and receive EAS are people with personality disorders. It is difficult to reach firm conclusions about prevalence figures and proportions based on the limited number of studies and cases reported in each study. Yet, we think these findings make for disturbing reading, particularly in light of the time-sensitive changes that can occur in the psychopathology of personality disorder. We consider this issue further below.

Personality disorders and the wish for death

Suicidal and self-harming behaviours are frequently seen in people with personality disorders, in particular borderline personality disorder (BPD), where this is one of the diagnostic criteria [ 12 ]. Emotional and behavioural dysregulation is characteristic of BPD and is closely linked to suicidal behaviour [ 13 ]. In addition, suicidal behaviour in people with BPD is often linked to the wish to seek help, to communicate or to solve interpersonal problems. An important aspect of BPD individuals’ problems is their difficulty with regulating their relationships with other people maintaining nurturing close interpersonal relationships over time [ 14 ]. This extends to the clinical setting where patients with BPD all too often feel disappointed, rejected or invalidated by their therapists and thus terminate treatment at an early stage [ 15 ].

A wish for death and an increased risk of suicide may be prominent, although less well documented, among people with other personality disorders. In narcissistic personality disorder, there is frequently a hypersensitivity to the evaluations of others and a fluctuation in the self-esteem between grandiose and depleted states, depending on life circumstances [ 16 , 17 ]; these are personality features associated with an increased risk of both suicidal and non-suicidal self-injury [ 18 , 19 ]. Suicidal behaviour is frequently seen in people with antisocial personality disorder, where it is often associated with severe problems in interpersonal relations and with the justice system.

It follows from the above that people with personality disorders on average more often contemplate death and may have a stronger wish for death for more extended periods of time than is the case for people without these disorders. We have, however, no data to suggest that these tendencies of thinking about suicide or wishing for suicide are completely immutable to change. Rather they are very likely learnt dysfunctional behaviours, and they fluctuate rapidly. An individual who frequently experiences strong and painful feelings of helplessness, sadness and entrapment may find that thinking of death and suicide will offer some sense of control (“I can stop the pain”) and relief. Thus, it will be likely that this person will be more inclined to think about suicide next time the painful feelings become overwhelming. This reinforced pattern of frequently thinking of and/or wishing for death and suicide is very familiar to many people with BPD and other personality disorders [ 20 ], but it may seem difficult to accept or to understand for other people, including health-care personnel. In turn, this frequently leads to a host of dysfunctional transactions between people with severe PDs and their families and carers.

Under the principle of self-determination, it can be argued that only patients themselves can be the judge of what is best for them and that it should not be up to doctors to make interpretations of a patient’s wish for death. Whereas we respect this principle, it is still the duty of clinicians to provide due care and use their knowledge to act in accordance with what they believe is in the best interest of their patient. This is also emphasized in the due care criteria in several of the current laws and guidelines for EAS, for example in the Dutch guideline where it mentions explicitly that if the wish for death is a symptom of a mental disorder, it should be treated and not lead to EAS.

We believe that in contexts where EAS for people with PDs is available, particularly precarious circumstances are present, with the potential for adverse consequences. Frequent suicidal communications and requests for EAS may lead carers to underestimate the basic criterion for granting such requests; that the patient’s situation must entail unbearable suffering with no prospect of improvement and no alternative to end the suffering. However, in most cases even severe suicidal tendencies and self-harming behaviour can be treated and individuals can be helped to recover. We must emphasize that a range of psychosocial interventions, including cognitive-behavioural therapy, dialectical behaviour therapy and mentalization based therapy have all been shown to reduce suicidal and self-harming behaviour in randomized trials with both adolescents [ 21 ] and adults [ 22 ]. Admittedly, even though effects of specialized treatments are good for the average patient, some patients are non-responders or even deteriorate or drop out early. We would argue that, in cases of non-response, patients with PD should be offered an alternative evidence-based treatment before EAS is considered. Currently, we don’t know how large proportion of patients with PD requesting euthanasia could have been treated effectively, and how big the group is who would not respond to even the best of treatments. There is a great need for more studies to shed light over these important questions.

The transactional aspects of asking for and granting of EAS in patients with PD

A request for EAS from a severely ill patient, in reality, may be a request for communication about loneliness or mental suffering, or an attempt by the patient to find a reason to continue living through eliciting a dialogue with his/her doctor or mental health worker [ 23 ]. Studies have shown, however, that people with BPD have significant difficulties with correctly appraising other people’s emotions and intentions through observing their facial expressions [ 24 ]. They frequently associate neutral faces as expressions of sadness, aggression or disgust. Such difficulties could result in patients believing that their physicians agree with them that they would be better off dead. To our knowledge, there are no empirical studies of whether, and how frequently, such misperceptions occur in the context of requests for EAS and whether they have a significant influence on the outcome of these requests. In our experience, this is just one of several possible mechanisms through which patients and their carers might severely miscommunicate with respect to requests for and granting of EAS.

Authors writing about EAS from a psychodynamic perspective have highlighted that a request for EAS may be viewed as an expression of rage at the physician for a variety of reasons – for example, appearing to give up (or indeed giving up) on the patient, or not provide a cure [ 25 ]. Clinicians often find it hard to work with these clients because being close to someone who is in unbearable emotional pain is difficult. Furthermore, clinicians frequently experience their transaction with patients with BPD as more difficult and demanding than with other patients. This is very accurately described by the well-known American psychiatrist Allen Frances as follows: “Most of us have a much greater immediate empathy for a patient’s depression or anxiety, and even for violent impulses and psychotic thinking, than we do for the relief some patients feel when they hurt and scar themselves. The typical clinician (myself included) treating a patient who self-mutilates is often left feeling some combination of helpless, horrified, guilty, furious, betrayed, disgusted and sad” [ 26 ].

Again, it is important to remember that our knowledge on what influences physicians’ decisions when dealing with requests for EAS is very limited due to a severe lack of research in this field. However, in a Dutch study, a lower proportion of physicians found it conceivable that they would grant EAS in patients with mental illnesses (34%) than the proportion who found it conceivable that they would grant EAS in patients with physical illnesses, such as cancer (85%) [ 27 ]. Interestingly, general practitioners were 2.6 times more likely than clinical specialists to find it conceivable that they would grant EAS in patients with mental illnesses. This could mean that with higher level of clinical expertise may follow a reduced willingness to grant EAS for mental illnesses.

Patients with BPD and suicidal and self-harming behaviours are typically regarded as being hard to treat. This seems to have been the case with patients with PD in the study of Thienpont et al. [ 8 ] who were perceived as being “untreatable”. However, the question whether patients with PD are untreatable or “uncurable”, as demanded by Belgian law, is debatable. The most prevalent PD diagnosis in this particular study was Borderline PD, which although often a long-term condition, is not, contrary to popular belief, an incurable disorder. Over the past twenty years, treatment studies have flourished showing that a diverse range of manualized treatments for BPD such as dialectical behaviour therapy (DBT), transference-focused psychotherapy (TFP), mentalization based therapy (MBT), or schema therapy are effective with medium to large effect sizes and remission achievable in a high percentage of cases [ 28 , 29 ]. National guidelines (e.g. in Germany or the UK) recommend one of the evidence-based psychotherapies mentioned above as first-line treatment [ 30 ]. They also stress the importance of careful delivery and supervision of these treatments by trained therapists, and the potential benefit of adjunctive psychotropic medication for symptom relief. Currently, there is a scarcity of research into the question of whether patients with PD who requested EAS were offered evidence-based PD-specific treatment. We think, however, that it is doubtful whether these guidelines have been followed in the majority of individuals with BPD who have requested EAS. We strongly recommend that adherence to guidelines for state-of-the art treatment for PDs, and BPD in particular, are included in the decision-making process underpinning EAS applications.

Conclusions and recommendations

Based on the scant published literature, we have serious concerns about the practice emerging in an increasing number of countries of facilitating EAS for people with personality disorders. This appears to be based on faulty assumptions about the underlying psychopathology and a lack of awareness about the contemporary treatment literature, particularly on borderline personality disorder. First, we would argue that wishes for death or suicide, even when clearly articulated by the patient to doctors or next-of-kin, and even if it represents the true will at that very moment, this desire or wish for death will likely change in many of these cases. As we have pointed out above, such an articulated death wish, can be a symptom of the disorder and may in reality convey several other possible messages, that have more to do with the patient feeling abandoned, disappointed or angry. It may also convey a wish for help to live rather than a wish for help to die. Second, we would claim that the notion of personality disorders as “untreatable” conditions and “without prospects of improvement” are based on outdated knowledge about the state of PD treatment. Today, a range of effective psychotherapeutic interventions are available for people with personality disorders in most of the countries that have so far legalized EAS. That this has seemingly escaped the attention of both legislators and expert medical communities is deeply disturbing. It may be that the current lack of effective psychotropic medication to treat personality disorders could have made many physicians and psychiatrists not specializing in PD treatment less optimistic about the prognosis in people with PDs and the prospects of receiving effective treatment in general. We urgently call for a revision of the current legislation and practice of EAS for people with personality disorders which we believe, is currently based on an inadequate understanding of these peoples’ needs and their potentials for having a life worth living.

We recommend that professionals involved in making decisions regarding granting of EAS as a minimum should receive training covering a) insight in the fluctuating nature of suicidal thinking and its emotion regulation function, b) the evidence that PD – but especially BPD – is treatable, c) the risk of miscommunication around this issue given the impairments in identifying / reading emotions in others combined with a sense of being a burden to others and d) an examination of their own attitudes and beliefs towards suicidal and self-harm behaviour with particular attention to their own emotional responses. We further recommend that EAS Guidance should require that clients with BPD should have had a substantial period of treatment in at least two of the evidence-based approaches from an appropriately trained and supervised clinical team which has led to no noticeable improvement before EAS can be considered. Given the high likelihood of change in presentation of any mental disorder in minors, EAS should not be considered on the grounds of any established or emerging mental disorder for those under 18 years. Finally, we recommend legislators involved in EAS legislation and policy making should make provisions for funding of research into the current practice of EAS in people with mental disorders.

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Abbreviations

Euthanasia and physician-assisted suicide

Physician assisted suicide

Personality disorder

Borderline personality disorder

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National Centre for Suicide Research and Prevention, Institute of Clinical Medicine, University of Oslo, Oslo, Norway

Lars Mehlum

Department of Psychosomatic Medicine and Psychotherapy, Central Institute of Mental Health, Heidelberg University, Mannheim, Germany

Christian Schmahl

University Psychiatric Centre Duffel, CAPRI, faculty Medicine and Health Sciences, University Antwerp, Antwerp, Belgium

Department of Psychoanalysis and Psychotherapy, Medical University of Vienna, Vienna, Austria

Stephan Doering

De Viersprong Institute for Studies on Personality Disorders, Bergen op Zoom, The Netherlands

Joost Hutsebaut

Kanta-Häme Central Hospital, Hämeenlinna, Finland

Andres Kaera

Department of Psychiatry, University of Lausanne, Lausanne, Switzerland

Ueli Kramer

Centre for Academic Mental Health, Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK

Paul Anthony Moran

Freie Universität, Berlin, Germany

Babette Renneberg

Department of Psychiatry and Legal Medicine, Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, UAB, Barcelona, Spain

Joaquim Soler Ribaudi

Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, Madrid, Spain

Stolpegaard Psychotherapy Centre, Copenhagen, Denmark

Sebastian Simonsen

NWCPP, School of Psychology, Bangor University, Bangor, UK

Michaela Swales

Institute for Psychosocial Prevention, University-Hospital Heidelberg, Heidelberg, Germany

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School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy

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Psychiatric Department-ASST Monza, Monza, Italy

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Mehlum, L., Schmahl, C., Berens, A. et al. Euthanasia and assisted suicide in patients with personality disorders: a review of current practice and challenges. bord personal disord emot dysregul 7 , 15 (2020). https://doi.org/10.1186/s40479-020-00131-9

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Euthanasia and assisted suicide: An in-depth review of relevant historical aspects

Affiliations.

1 Medical and Surgical Research Center, Future Surgeons Chapter, Colombian Surgery Association, Bogotá, Colombia.
2 Grupo Prometheus y Biomedicina Aplicada a las Ciencias Clínicas, School of Medicine, Universidad de Cartagena, Cartagena, Colombia.
3 Department of Medicine, RedSalud, Santiago de Chile, Chile.
4 Department of Medicine, Keralty Salud, Bogotá, Colombia.
5 Colombian Clinical Research Group in Neurocritical Care, Latin American Council of Neurocritical Care, Bogotá, Colombia.
6 Department of Intensive Care, Regions Hospital, Minnesota, USA.
7 Independent University, Dhaka, Bangladesh.
PMID: 35242326
PMCID: PMC8857436
DOI: 10.1016/j.amsu.2022.103380

End-of-life care is an increasingly relevant topic due to advances in biomedical research and the establishment of new disciplines in evidence-based medicine and bioethics. Euthanasia and assisted suicide are two terms widely discussed in medicine, which cause displeasure on many occasions and cause relief on others. The evolution of these terms and the events associated with their study have allowed the evaluation of cases that have established useful definitions for the legal regulation of palliative care and public policies in the different health systems. However, there are still many aspects to be elucidated and defined. Based on the above, this review aimed to compile relevant historical aspects on the evolution of euthanasia and assisted suicide, which will allow understanding the use and research of these terms.

Keywords: Assisted suicide; Bioethical issues; Euthanasia; History of medicine; Terminal care.

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Published: 14 May 2019

A qualitative study on existential suffering and assisted suicide in Switzerland

Marie-Estelle Gaignard ORCID: orcid.org/0000-0001-8473-448X 1 , 2 &
Samia Hurst 1

BMC Medical Ethics volume 20 , Article number: 34 ( 2019 ) Cite this article

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In Switzerland, people can be granted access to assisted suicide (AS) on condition that the person whose wish is to die performs the fatal act, that he has his decisional capacity and that the assisting person’s conduct is not selfishly motivated. No restrictions relating to the ground of suffering are mentioned in the act. Existential suffering as a reason for wanting to die, however, gives raise to controversial issues. Moreover, existential suffering lacks definition and no consensus exists on how to evaluate and manage it. This study explores the perspectives of care professionals and volunteers from a “right-to-die organization” on existential suffering as a motive for assisted suicide requests.

A qualitative study based on face-to-face interviews was conducted with twenty-six participants: palliative care and primary care providers as well as EXIT right-to-die organization volunteers. Elements from the grounded theory approach were used.

The twenty-six participants described existential suffering in a multiplicity of individual ways. In total, sixty-three stories were recounted. Their representations were grouped into eight categories: physical decline and its consequences, loneliness, fear of the future, life is over, loss of social significance, loss of hope for a better future, being a financial burden and loss of pleasurable activities. According to all participants, suffering coming from the loss of self-identity was always linked to physical decline, as if one’s image completely defined someone’s identity. Society’s perception of old people and vulnerable people were also often questioned. Another interesting point was that only four stories referring to a “pure” existential suffering were found. This suffering was related to a feeling that life has come to an end, without identification of any other related restriction or suffering.

Conclusions

Existential suffering is multifaceted. Legislators and right-to-die organisations have to address the question of what make a AS acceptable. The plurality of existential suffering implies the need of a very personalized care. A better understanding of what it is made of could provide a “toolbox” to people concerned by these requests, helping them to explore it in order to offer suffering people a wider range of alternatives.

Peer Review reports

Existential suffering is frequent in seriously ill patients [ 1 ], an important factor affecting quality of life [ 2 ], one of the reasons why some patients request assisted suicide (AS). [ 3 ] The acceptability of requests for AS motivated by existential suffering are, however, controversial. [ 3 , 4 , 5 , 6 ] This controversy is rendered more difficult by vagueness regarding what people understand the definition of existential suffering to be. Indeed, it is often simply described as “being tired of life”, “distress” that arises when the meaning and value of one’s life is unclear » [ 7 ], and despite the increasing focus on existential concerns over the past decade, its definition still lacks consistency and there is no consistency on how to evaluate or treat it. A recent article reviewed the definition of existential suffering and suggested that it could be understood as an incapacitating state of despair resulting from an inner realization that life is futile and without meaning. [ 8 ] In 2011, a review identified 56 definitions of the term “existential suffering”. [ 9 ] The authors emphasized relevant themes such as: the loss of meaning or purpose in life, hopelessness, feeling of loneliness, fear of being a burden, fear of future, loss of social role functioning. They also pointed out the difficulty in distinguishing existential suffering from spiritual concerns or from psychological symptoms such as depression.

Switzerland has what may well be the most liberal legislation on AS in the world, making the question of where to set the limits in practice even more relevant. [ 10 ] Only three conditions are needed in this country to access AS: first, the person whose wish is to die has to perform the fatal act; second, this person has to have her/his decisional capacity; finally, the conduct of the assisting person must have no selfish motive. It should also be noted that the prescription of lethal drugs are subject to the Federal Narcotics Act. [ 11 ] This law leaves an important place to individual freedom and permits the “right-to-die organizations” in Switzerland to define the boundaries of their practice within the legal framework. In 2016, 928 people died from AS in Switzerland and a 2013 study showed that physician-assisted death counted for 1.1% of all death. [ 12 , 13 ] Although the legislation does not examine the reason for requesting AS, the motive “existential suffering” often gives raise to controversial issues. What, then, makes a case of AS morally acceptable? Suffering is surely not limited to disease status. If we consider relief from suffering to be one of the central considerations for AS, it is reasonable to think that the acceptability of a request should not exclusively depend on the diagnosis of an incurable or terminal disease. [ 14 , 15 ]

Professional definitions of existential suffering were examined in 2004 [ 16 ], but to our best knowledge no study has been performed about their perspectives when this existential pain or suffering is part of the request for AS in a country where it is legal. Moreover, no study has been conducted to see how those people confront it, how they actually manage this kind of suffering. This is why, in the context of this particular legislation, we asked care professionals and volunteers from a “right-to-die organization” (EXIT Suisse Romande) who are confronted to assisted suicide to tell us about their experiences regarding existential suffering as being the reason for the request. Asking them first about their representations of existential suffering then enabled us to progressively build the conversation around their attitudes when confronted to it. We hope that their responses can be used to inform the debates in Switzerland and elsewhere about assisted suicide and in particular about the controversy around the acceptability of existential suffering as being the reason for an AS request. In this paper, we present the first part of our study. Before discussing the acceptability of existential suffering as a motive for AS requests, it is essential to clearly understand what this kind of suffering is and who are the people who endure it and request AS. This study could also stimulate thoughts about preferable alternatives that could be offered to these suffering people.

Study design

We chose a qualitative design, face-to-face interviews, for this study because of the lack of insights on how to manage existential suffering when it’s part of the request for assisted suicide. Elements from the grounded theory approach were used to develop a conceptual model derived from the data.

We contacted a full spectrum of persons that we thought to be the most commonly involved in end-of-life care and assisted suicide and we included them into three groups (volunteers from a Swiss “right-to-die organization”, palliative care providers and primary care providers). A snowball sampling was used and each participant was contacted either by email or phone and explanations were provided regarding the goals and the modalities of our study. We also asked them if they felt concerned by this issue and if they consented to participate. No additional selection criteria was taken into account.

Data collection

After this first contact, we collected data through face-to-face interviews done by the main research at a location chosen by the participant (most of the time at their office). Concise information about the study was given before an informed consent was signed (written consent). At the beginning of each interview, the participants were asked their age, gender, job, and how many years of experience they had. We used a semi-structured interview guide (Additional file 1 : Table 1). Interviews ranged from twenty to fifty minutes depending on participants’ experiences with deliberating about assisted suicide and existential suffering. All interviews were tape-recorded and then transcribed verbatim.

Data analysis

We proceeded in three steps: open coding, axial coding and selective coding. As a first step, we used open coding which means breaking down data to examine and conceptualize it into codes. We therefore labelled phrases from the participants. In this example of open coding, a palliative care provider talks about a patient she used to see at home because of chronic pain and who one day shared with her her desire to request AS: “… and who had planned for a long long time to call EXIT with the explanation that she finally had very little company, that her existence didn’t serve anybody anymore and that it finally was her only option.” We labelled this phrase as an example of “loneliness”, “feeling useless” and “loss of hope for a better future”. Three codes were used here.

Axial coding was the second step of our analysis. It consisted of reassembling our codes into broader categories in order to better understand the facets and associations between them. We for example associated the codes “physical decline”, “dependency” and “hurt self” found in different testimonies as being part of the wider category “physical decline and its consequences”. Indeed, according to all participants dependency and hurt self were always a consequence of physical decline.

Selective coding was used only for the code “life is over” because it was found to be a core category and it was important to better clarify its relationship with the other codes.

Two full recordings were double coded and discussed together at different stages during the analysis, to ensure that codes well represented the testimonies of the participants and were suitably associated with others into wider categories. After coding 21 interviews, no newer codes appeared and thus we were satisfied that data saturation had been reached for the main results presented here. [ 17 , 18 ] All quotations were translated from the original French by the authors. People identification is mentioned as follows: Pn (Participant number) / PallCP (Palliative Care Providers) or PrimCP (Primary Care Providers) or EV (EXIT Volunteer).

Protection of human participants

This study was exempted from ethics review by the president of the CCER (Commission Cantonale d’Ethique de la Recherche, Swiss Cantonal Ethics Committee) because the study entailed no more than minimal risks and was outside the scope of the Swiss Federal Act (Human Research Act, HRA) on research with human participants.

The participation was voluntary and did not involve the collection of personally identifiable information.

Participants

Participant characteristics are described in Additional file 1 : Table 2. Between January and April 2016, twenty-seven professionals were contacted to participate in this study. Only one did not answer our request, therefore twenty-six people participated altogether. This included four physicians, one nurse, one physiotherapist, one nurse’s aid, two psychologists, one social worker and two hospital chaplains of a palliative care unit. In addition, we interviewed six volunteers from a Swiss “right-to-die organization” ( EXIT Suisse Romande ), one physician and three nurses from a palliative care mobile team, two general practitioners and a nurse, as well as the person responsible for recreation in a retirement home. The participants varied in gender, age and years of experience.

Professionals’ perspectives on existential suffering as a reason for requesting assisted suicide

Providers from palliative care and primary care, as well as volunteers from EXIT , described existential suffering in a multiplicity of very individual ways. In total, they recounted sixty-three stories. When referring to existential suffering, most of them described a life that wasn’t worth living any longer and/or a life that did not make sense anymore, for many different reasons. The coding of their statements resulted in eight categories that were ranked according to the frequency of their occurrence: physical decline and its consequences, loneliness, fear of the future, life is over, loss of social significance, loss of hope for a better future, being a financial burden, and loss of pleasurable activities (Additional file 1 : Table 3).

Physical decline and its consequences

A vast majority of the participants referred to experiences regarding physical decline and feelings that can result from this decline. The codes grouped in this category are thus: physical decline itself, dependency and hurt self. Each of those includes sub-codes that are listed in Additional file 1 : Table 3.

Physical decline itself and dependency were the two most represented codes in this category. Below is an example of how physical decline can lead to a request for AS:

“( … ) but finally the problem (for her) was the anal incontinence, she didn’t want to continue (living) so she asked us (to assist her) and told us: “Now it’s my limit. I am already blind, deaf, I can’t move anymore and now this (the incontinence). That’s enough!”” (P19/EV).

According to this participant, the reason why this person wanted to die was because of a too damaged physical condition. Actually, most of the participants considered physical decline as being a trigger for existential suffering, in that it induces dependency, pain, loss of pleasurable activities, hurt self or loss of hope. Moreover, we found that the idea of dependency was always linked to physical decline and this is why dependency was included in this category. A palliative care provider illustrates it:

“On the other hand, I had the feeling that for this woman, beyond a certain limit, it was no longer acceptable. She was too damaged, too dependent. You could see it. So, she preferred stepping down before becoming too dependent on nursing.” (P15/PallCP).

This quote shows that dependency was actually considered by this participant as unbearable. It was relevant in many other testimonies.

Participants also pointed out the fact that dependency can induce a diminished perception of someone’s own image and that suffering originates from this feeling. “Hurt self”, one of the codes in this category, is illustrated in the following example:

“The caregivers also play an important role because they frequently are the confidants of patients during the bathing, during their physical activities. It’s often here that patients talk about their suffering regarding their loss of autonomy, their physical decline. It’s often what we hear. One’s self-image also plays an important role in this kind of decision. Patients often tell us: « I don’t recognize myself ».” (P16/PallCP).

“I don’t recognize myself” puts into question the notion of self-identity and it was actually always mentioned this way. This statement signal the role of one’s image or physical appearance defining one’s identity. All participants spoke of deteriorating physical appearance as inducing a loss of one’s self identity. Another participant expresses it differently while talking about an illness that can be the turning point of a change in self-identity:

“There is a relevant element. It’s that often the illness, the severe illness, irrupted into these people’s life and this constituted a threshold . And rightly there often is a fracture between the “before of who I was once” and the “now” where people often take an « ill person » identity. And their identity is now limited to the issue of being ill.” (P8/PallCP).

When participants talked about physical decline, dependency or hurt self, there was another relevant idea to point out. The fact that all the sufferings induced by those conditions can be partly explained by how people perceive them. Here is an illustration by one palliative care provider:

“( … ) I’m convinced that the way society perceives those people who are not productive anymore, ( … ), with cognitive trouble, (those people) becoming a financial burden and the ones becoming diminished or incontinent, is a problem.” (P10/PallCP).

This notion that how people perceive old age or dependency is to some extent responsible for those multiple and different types existential sufferings was recurrent.

Loneliness was the second most mentioned component of existential suffering with nearly two-third of participants who talked about it. According to many participants, loneliness seems to be a significant cause for requesting AS. This is illustrated by a general practitioner talking about one of the last discussions she had with one of her patients:

“( … ) and I told her "I’d just like to know something honestly. If you were with children, grandchildren, would you do that? (request AS). She told me “Surely not”; and I told her “So, it is really (because of) loneliness?” And she told me “Yes”” (P24/PrimCP).

Loneliness was also often described as a loss of human contact. A hospital chaplain talked about solutions that could be proposed to people demanding AS due to existential suffering in these terms:

“So, I think of the possibilities, of activating a greater human proximity, because it’s actually often what is lacking. This lack of connection, this lack of contact. But it is also because this is what people often wanted. Because they arrived to this type of loneliness.” (P5/PallCP).

She actually referred to a kind of “chosen loneliness” contrary to the one induced by the loss of a loved one. Another participant illustrates it:

“She didn’t necessarily have pain, but it’s true that her treatment was quite heavy for her. And in addition, the fact that she was deeply mourning her husband. So, it’s true, I don’t know what exactly motivated her wish to commit suicide”. (P6/PallCP).

This palliative care provider did not exactly understand why his patient requested AS but suggested that loneliness might be partly responsible for it.

Fear of the future

The codes of this category are: fear of a terrible agony, fear of being placed into a retirement home, fear of the unknown, fear of the hospital and anxiety. The fear of an imagined agony was linked most of the times to past experiences, as a nurse put it:

“By digging a bit what was worrying him, it was the memory of his spouse who died from an oncologic illness. She was very young at the time and she was screaming out in pain. And he was leaving the house in order to not hear her screaming out of pain. This had a big impact on him. His fear was really linked to the fact that medicine couldn’t address many of the symptoms, pain in particular.” (P11/PallCP).

The fear of being placed into a retirement home was also expressed a few times and was often linked to the fear of physical decline and dependency as a general practitioner explained:

“( … ) and they had talked about a placement in a retirement home. And I’d say that for many elderly persons this is something, this placement in a retirement home is a “bête noire”. Because it means total decline for them.” (P25/PrimCP).

The other codes within this category were less salient but taken together they pointed to the fact that sufferings were emerging here from a kind of fear of going on living in a state of unbearable decay. Not only was there a fear of potential future suffering but this anticipation itself was a source of current suffering that would lead to a wish to die.

Life is over

This category was mentioned by more than one-third of the participants. It was often described as being tired of life. Although it was often linked to other sufferings, it needed to be differentiated because it really referred to a fully aware reasoning: “My life has come to an end”. Here an example:

“He tells me: “Do you understand? My world shrinks, you can do whatever you want. ( … ) I know that I will be soon coming to an end. I hope everything is going to be alright and that someone will help me if not.” This is an objective observation. He is 91 years old.” (P20/EV).

It is in this category that we found what we can call a kind of “pure” existential suffering. A suffering without identification of any other related ones. Only four of twenty-six participants talked about it and it was described in four out of sixty-three stories. An EXIT volunteer illustrated it:

“But it concerns more the people in the retirement homes. Except this woman who clearly said that she didn’t want to find a spouse again and that her life was finished. That she had a beautiful life, with her husband, that she had raised her children, that she had grandchildren who were going well. So she had done it all and said “so I can leave now””. (P19/EV ).

It sounds like this woman had accomplished what she had to and was ready to die. No physical decline, no dependency. A little bit of loneliness maybe.

Loss of social significance

Loss of social significance was mentioned by eight out of twenty-six participants and was especially described as a feeling of uselessness. Here is an illustration of how this feeling could be experienced as a deep suffering:

“I also think that there is something else we didn’t talk about: this feeling of uselessness. Everything that refers to « me feeling useful », or « me feeling useless », « not serving purpose », is a big suffering.” (P5/PallCP).

The loss of usefulness in family and society was described by participants as linked to the process of aging. And, as mentioned before for the code “Hurt self”, many participants pointed out the fact that society, our culture, might be partly responsible for these feelings such as expressed by a primary care provider:

“( … ) the big existential suffering for many people is this feeling of useless (ness). It doesn’t happen in the cultures where elderly remain integrated in the family, where they can even look after the grandchildren or participate in the activities. Those people (in Switzerland) are lonely.” (P25/PrimCP).

Loss of hope for a better future

Loss of hope for a better future being a cause of a life that is not worth living anymore had the same relevance as the loss of social significance. As one can imagine, the description of what a better future is, is highly personal and plural. This category refers to a feeling that the future will be worse than the present life. Here is an example of a conversation between an EXIT volunteer and someone he helped to die:

“Well, I have to (request AS).” And I told her: “How is that? Why do you have to?” And she told me: “Yes I have to because I don’t have remission anymore.” Yes, it’s true. “Her diagnosis was clear, her remission was finished, her disease reappeared and she did not want to live through that.” (P19/EV).

This woman wanted to requested AS because all she could expect from this point was suffering.

Being a financial burden

The fact that being a financial burden could be a cause of existential suffering and lead to a AS request was stated by six out of twenty-six participants. It was often described as one more form of suffering on top of an already distressful daily life. Like other categories and codes, being a financial burden was described as closely related to the way society perceives old age, dependency or physical decline such as explained by an EXIT volunteer:

“ what those people generally fear is loneliness, and the fact of becoming a burden and being a high cost to society, as we can hear it and read it in newspapers. They also talk about this, and I always tell them “It’s not a reason. You worked; you don’t have to worry because you are expensive. You’re no more expensive than anyone else.”” (P18/EV).

This participant highlights the fact that the concern of becoming a burden might be caused by media’s perception in these people.

Loss of pleasurable activities

The loss of pleasurable activities was the least mentioned category and was often linked to other categories. However, it was important to highlight it because the loss of pleasures and joys of life was directly described as leading to a life that isn’t worth living anymore. Here is an illustration:

“She found that it was not enough to be more or less fit again. And, above all, she gave up visiting Museums in Europe and she loved to do this in the past. So, she came back one day to terminate her life simply because her goals in life couldn’t be achieved any more. Because of physical or psychological problems.” (P12/PallCP) .

In the story of this patient, life wasn’t worth living any longer mainly because her condition prevented her from enjoying museum visits, which used to be the greatest pleasure in her daily life. Hence, life did not make sense anymore for her.

One of the purposes of this study was to deepen the understanding of existential suffering from the perspectives of professionals (palliative and primary care providers) and Right-to-die organization volunteers when it is part of the request for AS, especially in a country like Switzerland, where it is legal. Our study found that existential suffering included physical decline and its consequences, loneliness, fear of the future, life is over, loss of social significance, loss of hope for a better future, being a financial burden and loss of pleasurable activities, all of which were intertwined with the impression that life had lost its meaning and/or was not worth living anymore.

Suffering coming from a “diminished perception of one’s own image” or from a “loss of self-identity” was always linked to physical decline, which could be a decline in the physical ability to invest life, a profound alteration in physical appearance, or both. In a society that gives great importance to physical appearance, as aging represents a slow loss of a culturally self-identity because one stops to be a productive and contributing member of society, physical decline leads to an even deeper fracture of identity. The loss of vitality separates one from a past life in which one could enjoy the body and depend on it. It also shuts the door on desires and hopes for the future.

According to our participants, society was somehow responsible at least in part for existential suffering. Perceptions of old age or physical decline are influenced by social contexts, they shape the way we see ourselves, and this can lead to deep suffering. A form of internalised ageism could be at work in these situations. [ 19 ] More pragmatically, lack of the sort of social support required to maintain relationships, a sense of self, and well-being may have played a role as well. [ 20 ]

Finally, we found that in most cases existential suffering consisted of different, and sometimes compounded, losses of the dimensions of life. Requests for suicide assistance in such cases were described as emanating from persons who were as if shut out from components of their own existence; a finding similar to the description by Sjöberg and colleagues of older patients’ narratives of being “disconnected from life”. [ 21 ] Despite this, a minority of cases did seem to represent what might be termed “pure” existential suffering, or a feeling that life was meaningless or over, without identification of any specific restrictions in the components of it. This was present in just four of sixty-three stories. These findings are relevant to the status of existential suffering as a possible justification for AS. Cases where life is -sometimes severely- restricted are morally significantly different from those where this is not the case. Existential suffering as a motive for suicide assistance requests often leads to controversial issues. This is partly due to questions regarding whether existential suffering is sufficiently severe, rather than a name given to situations where a decision to ask for death may have been made too lightly. Our findings suggest that most suicide assistance requests for reasons of existential suffering are made by people who are indeed suffering in readily recognizable ways. This is also what the few data from EXIT right-to-die organization on motives for AS requests tend to demonstrate. Even though existential suffering might be present in all requests, and this is something current data does not capture, a serious illness is always present. [ 22 ] Suicide assistance requests motivated by “pure” existential reasons raises different issues. Such cases are of course controversial, and viewed alternately as irrational, as cases where the true causes of suffering remain unrecognized, or as instances of “existential maturity” in facing our own mortality. [ 23 ] Our findings suggest that these situations do exist but only count for a small number of AS requests motivated by existential suffering. In these rare cases, the only justification, recognized by the Swiss law, for offering such assistance is to not have selfish motive and to respect the Federal Narcotics Act. The law actually does not specify requirements in terms of suffering. However, this year, the SAMS (Swiss Academy of Medical Sciences), which provides healthcare professionals with recommendations on ethics issues, published new guidelines on the management of dying and death. They stated that the assisting person has to verify five requirements, including that the “symptoms of disease and/or functional impairments are a source of intolerable suffering” for the patient. [ 24 ] For the first time, the institution provided healthcare professionals with more specific requirements in terms of suffering for requesting AS.

By probably providing the first in-depth published account on this studied group in this particular legal framework, our study contributes to the literature in several ways. It adds content to the definition of existential suffering. Existential suffering is not solely related to being tired of living. It comprises different forms of suffering, and sometimes combines them. As the recent integrated literature review concludes: “Although ambiguity in these definitions may be justifiable given the broad range of similarity in terminology, clinical clarity may be necessary given the current challenges of treating this form of suffering, and a general consensus that it has not been well defined or treated is also required”. [ 9 ] Clinical clarity is essential. It could provide a kind of “toolkit” to people concerned by this question. Based on our findings, we could for example imagine a questionnaire investigating at least these eight categories of existential suffering. This would help care providers and volunteers from “right-to-die organizations” to better understand the suffering experienced by the persons they are taking care of and, in this way, help them to propose more personalized and more appropriate care. Recognizing existential suffering to be plural could help to identify the different actors needed to assist individual patients.

This study has several limitations. First, as in all qualitative research, some intrusion of the researcher’s biases is inevitable. To reduce this effect, some of the interviews were double-coded and all the codes and categories were discussed together. Furthermore, an on-going and reflective research journal recorded the first researcher’s impressions to make sure to stay as close possible to what the participants wanted to share. Our sample size was small, and our participants were recruited exclusively in the French-speaking part of Switzerland. Our results cannot be generalized. However, as our sample of participants is quite representative of the people concerned by the question, it would be interesting to see whether our findings are transferable to other palliative care units, to other primary care providers and to other “right-to-die organizations” in Switzerland. As such, it might help to build a consensus on evaluating and treating existential suffering. Finally, our study focused on the perspectives of care providers and EXIT volunteers, and not on those of people requesting AS. We found, however, that their perspectives were not so distant from the ones of people actually requesting AS, particularly regarding the aspects of loneliness, dependency, hopelessness, loss of life’s meaning and loss of self-identity. [ 5 , 6 , 25 ]

Representations by the palliative care and primary care providers and volunteers from EXIT on existential suffering are multiple. They include the notion of physical decline and its consequences, loneliness, fear of the future, life is over, loss of social significance, loss of hope for a better future, being a financial burden and loss of pleasurable activities. To our knowledge, no study had been conducted yet on the perspectives of these people in a country like Switzerland, where AS is legal and where different groups of people have to confront it and try to respond to it. Our study might be helpful in providing a better understanding of existential suffering to and help identify a wider range of alternatives to offer these suffering people, rather than simply thinking of limiting the conditions for an acceptable AS.

Abbreviations

assisted suicide

Commission Cantonale d’Ethique de la Recherche (Swiss Cantonal Ethics Committee)

EXIT Volunteer

name of a swiss right-to-die organization

Palliative Care Providers

Participant number

Primary Care Providers

Swiss Academy of Medical Sciences

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Acknowledgments

The authors wish to thank the participants in the study for their time and willingness to be interviewed. They would also like to show their gratitude to Paola Ricci for reviewing the initial manuscript and to their colleagues, Dr. Marinette Ummel and Prof. Alex Mauron, who provided insight and expertise that greatly improved the manuscript.

MEG conducted this work without funding as part of her Master Degree in Medicine. The Institute for Ethics, History, and the Humanities at the Geneva University Medical School provided access to library facilities and SH’s salary. The Institute had no role in designing the study, nor in its execution, analyses, interpretation and in writing the manuscript.

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Marie-Estelle Gaignard & Samia Hurst

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MEG collected, analyzed and interpreted the data and drafted the manuscript. SH contributed to project design, the development of the data collection instrument, and data analysis. Both authors read and approved the final manuscript.

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Additional file 1:.

Table 1. Interview guide. The semi-structured interview guide used to collect data. Table 2. Participant characteristics Number of participants and their demographics. Table 3. Results. Representations of existential suffering by the palliative care and primary care providers and volunteers from EXIT right-to-die organization. (DOCX 17 kb)

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Gaignard, ME., Hurst, S. A qualitative study on existential suffering and assisted suicide in Switzerland. BMC Med Ethics 20 , 34 (2019). https://doi.org/10.1186/s12910-019-0367-9

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Assisted dying: The motivations, benefits and pitfalls of hastening death

As physician-assisted dying becomes more available, psychologists are finding opportunities to study people’s motivations and the potential benefits and harms of aid in dying

By Kirsten Weir

December 2017, Vol 48, No. 11

Print version: page 26

13 min read

Older Adults and Aging

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Upon successful completion of the test — a score of 75 percent or higher — you can immediately print your CE certificate.

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Learning objectives: After reading this article, CE candidates will be able to:

Describe APA’s resolution on assisted dying.
Discuss the ways depression can complicate a patient’s wish for assisted dying.
Discuss research on how family and friends are affected when a loved one chooses assisted dying.

It's been two decades since Oregon enacted the nation's first Death with Dignity Act, allowing people with terminal illnesses to hasten their deaths by self-administering medications prescribed by a physician. Since then, California, Colorado, Vermont, Washington state and Washington, D.C., have passed similar statutes.

Yet the topic arouses strong feelings—and raises plenty of questions. Can a person with depression rationally choose to hasten death? Would the option be less appealing if people received better care for physical symptoms and emotional distress? Could aid in dying put marginalized groups at risk?

As physician-assisted dying becomes available in more places, research psychologists are finding opportunities to study people's motivations and the potential benefits and harms of aid in dying. On the clinical side, psychologists' skills are helpful as people sort through their feelings and desires at the end of life, says Elizabeth Goy, PhD, a psychologist at the Portland VA Medical Center and associate professor at Oregon Health and Science University, and chair of the APA Working Group on End-of-Life Issues and Care.

"The very best thing we can do as psychologists is to improve communication and make sure that we are attending to the needs and suffering of patients who are at the end of life," Goy says. "Dying is universal, and it behooves all of us to have some foundational knowledge about end-of-life issues."

A new language

Goy and her colleagues on the working group were charged with updating APA's previous resolution on assisted suicide, adopted in 2001. In August, APA's Council of Representatives voted to approve the updated resolution. Like the previous resolution, the 2017 update states that APA neither endorses nor opposes assisted dying at this time.

"It was the consensus of the working group that this is a matter between the psychologist and the person considering aid in dying," says group member and Jonesville, Virginia–based psychologist James L. Werth Jr., PhD. "Psychologists have to be aware of their own biases, and if they can't be a part of the discussion without those biases getting in the way, they should refer the person to someone else. But we determined that APA shouldn't be a limiter of that discussion."

The most notable update to the resolution was linguistic. When the 2001 resolution was passed, the topic was known as "assisted suicide." Today, providers prefer the term "assisted dying" to reflect the distinction between suicide and the process of hastening death to alleviate pain and suffering.

Still, the specter of depression and suicide hangs over public opinion of assisted dying. Since Oregon first raised the possibility of legalized dying in the 1990s, researchers have grappled with the question of whether it can ever be considered a rational choice, Rosenfeld says. "Some people felt that almost everyone who seeks this option is doing so out of a rational appraisal of their situation. Others argued this is just a form of suicide and we should protect them from themselves," he says.

But research in the intervening years has suggested the truth lies in the gray area between, he adds. "Of the people who pursue this option, a sizable portion are rationally appraising their situation. And a sizable proportion are appraising it through a lens of depression."

In a study of terminally ill patients, for instance, Rosenfeld and his colleagues found that desire for death was associated with depression, and that desire decreased in patients who responded to antidepressants ( Psychosomatics , Vol. 51, No. 2, 2010). Other research, however, suggests that depression is not a major driver for most people who request aid in dying. When Oregon's law was passed, Goy teamed up with psychiatrist Linda Ganzini, MD, MPH, at Oregon Health and Science University, to study the moods, values, needs, concerns and symptom burdens of 58 Oregon residents with terminal illnesses who pursued assisted death. They found that most of those people did not have depressive disorders.

However, they also concluded that the Death with Dignity Act, as written, might fail to protect some patients with depression from making the choice to hasten death ( BMJ , Vol. 337, 2008).

Still, some advocates note that depression shouldn't necessarily make a person ineligible for physician-assisted death. "In the normal world of decision-making, we wouldn't say people lose autonomy to make decisions because they're moderately depressed," Rosenfeld says. Indeed, he adds, there's too little research to indicate how a person should feel or act as they approach their final days. "How cheerful should you be when you have a terminal illness?" he asks.

Some proponents of legalized aid in dying suggest that the option may be unfairly singled out because of cultural beliefs about the morality of suicide. "Assisted dying gets a lot of attention because of the values and emotions that get brought into it," says Werth. Yet many more people with serious illness end their lives through some other negotiated means, he says, such as ceasing medications, withholding food or drink, refusing life-sustaining treatment or signing "do not resuscitate" orders. "Most people will die those ways," he says.

Regaining control

After two decades of evidence from Oregon, research is answer-ing many questions about aid in dying. That evidence suggests that the desire to hasten death often comes from wanting to maintain some power over one's own life, Goy says. "In our research, the main reason people voiced for wanting the option was that they really wanted to have control over the circumstances of dying."

The wish for control can be for a variety of reasons, they found, including loss of autonomy and function or worries about future pain ( JAMA Internal Medicine , Vol. 169, No. 5, 2009). But reassuringly, when Goy and her colleagues compared people who expressed a desire for aid in dying with others with terminal illness who did not seek that option, they found no indication that the former group was motivated by financial concerns or being a burden to their loved ones, Goy says.

More research is needed to fully understand why and when some people ultimately make that choice, Shead notes. But it may be that just having the option provides a sense of control over the circumstances of one's death, allowing the person to focus on the quality of life that remains rather than fear of future suffering.

Research also shows that the choice to hasten death doesn't negatively impact surviving family members. Months or years after the death of the patients in their study, Goy and Ganzini interviewed their family caregivers. When they compared family members of those who requested aid in dying with those who did not, the researchers found no differences in depression, grief or use of mental health services. In fact, families of people who chose aid in dying reported that they felt more prepared and accepting of their loved one's death ( Journal of Pain and Symptom Management , Vol. 38, No. 6, 2009).

That could be because family discussions of hastened death often force families to discuss difficult topics they might otherwise not have spoken about, suggests Judith Gordon, PhD, a Seattle-based psychologist and clinical professor of psychology at the University of Washington who has studied end-of-life decision-making since 1996. "In this culture, there's still a lot of resistance to talking about dying, even if someone is diagnosed with a terminal disease," she says. "When people want to use this option, they need the support of their doctors and typically also want the support of their families."

Most people who receive a prescription for lethal medication talk to their families about their decision. "One of the gifts when someone makes this choice is that it brings the discussion to the table. The whole family or support group talks not just about this particular way of dying, but about all the issues related to how they feel about the death and what they will do later. It's an enormous benefit," Gordon says.

End-of-life inequity

Despite those potential benefits, critics express concerns about the possible harms of assisted death.

One worry surrounds access. So far, most of the people who have requested aid in dying are white, middle-class and typically well-educated, notes Carol Gill, PhD, APA working group member and professor of disability and human development at the University of Illinois at Chicago. "This sector of the population generally has access to options and seeks control of their life circumstances up to the end of life," she points out. "In contrast, there are underrepresented communities who have very different views of assisted dying."

The biggest concern to Gill and others is that people from disadvantaged groups might consider hastened death because their health-care needs are not being met. There are well-documented disparities in access to health-care services, with people from lower socioeconomic backgrounds, those with lower health literacy, and members of ethnic or racial minorities being less likely to receive adequate care, including palliative care services.

"There are a number of marginalized populations that are legitimately concerned about whether they are getting all of the best options in care at the end of life," Goy says. "We want to be sure we are attentive to treating pain adequately and addressing emotional experiences such as hopelessness, depression and despair, so that assisted dying does not seem like the only option."

Gill says that many in the disability-rights community have expressed unease with aid in dying because of concerns that people won't receive the resources they need to live meaningful lives despite physical limitations. "There are no assisted-dying laws that guarantee those resources, and that feels discriminatory to a lot of people with disabilities," she says.

Indeed, the very idea of "death with dignity" is an affront to many people who have physical limitations that require daily assistance, Gill says. "Some right-to-die activists have written about assisted dying as an antidote for indignity that occurs at the end of life, such as needing help to dress or use the bathroom. If you're a person with functional limitations, that's a real slap in the face," she says.

For most people, including those with disabilities and those facing functional loss at the end of life, social connection is what makes life worth living, she adds. "Having a meaningful life doesn't necessarily mean that life needs to be pain-free or without physical impairment or functional limitations. What it means is to remain engaged humanly, and get enough support from others or technology to engage in the activities that matter, that make life meaningful."

Unanswered questions

Even advocates of physician-assisted death say it's crucial that researchers continue to explore the process to ensure it's used responsibly. More work is needed to understand how terminally ill people make treatment decisions, Rosenfeld says, including the decision to end one's life. "The fact that assisted-dying laws aren't used that often has made people more confident that the law isn't being misused. But could that number go down a notch further by having more services available? That's where more research could be really informative," he says.

Gill adds that too little is known about how people make the decision to take lethal medication after they request the prescription. "We don't follow these individuals and hear what they're thinking day to day in the period before they ingest the drugs, and we don't know what happens to people who express interest but don't end up going through with it," she says.

Gill also hopes that researchers will further explore how the availability of aid in dying will affect medical practice. "Will it seem more and more reasonable for people to want their death hastened? Will we remember that life, even when it includes suffering, can still be considered meaningful given adequate support and resources? What will happen to the balance of those resources when assisted dying becomes more common?"

There's an open opportunity for psychology researchers to answer such questions, Rosenfeld says. "I think we are uniquely poised to do the kind of research that would inform these issues."

Psychologists can also fill an important role by evaluating and counseling people who have expressed a wish to pursue aid in dying. Though it's not a topic taught in graduate school, some state psychological associations have prepared guidelines for mental health professionals who do such evaluations, Gordon says. (For example, the Washington State Psychological Association issued the Washington Death with Dignity Act WSPA Guidelines for Mental Health Professionals , and the California Psychological Association recently published its guidelines, California's End of Life Option Act: CPA Guidance for Psychologists .)

Although it's not an easy job to work with people facing their final days, it is often a gratifying one, says Goy. "All of psychology comes to bear when you are working with people at the end of life. It calls for skills in every area that psychologists are trained in," she says. "There are a lot of emotions around this topic and it's ethically sensitive. The best we can do is be open to the concerns, continually be looking for data and challenge our own biases as best we can."

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Assisted Suicide

Reviewed by Psychology Today Staff

Physician-assisted suicide, also known as aid-in-dying or simply “assisted suicide,” is a decision made in collaboration with a medical professional to deliberately end one’s life. Most cases of assisted suicide involve a serious terminal illness, in which an individual is suffering immensely and/or has only a short time to live.

The practice is legal in some countries (and some U.S. states) only under certain circumstances. In these locations and elsewhere, however, it remains the subject of intense debate. Helping a person die by suicide, outside of a medical setting, is generally considered a crime, and some opponents of physician-assisted suicide have argued that the same principles should apply and that helping someone end their life is an affront to our moral responsibilities to one another. On the other hand, proponents of assisted suicide argue that forcing an individual (and their loved ones) to suffer serious pain with no hope of recovery is cruel. They also argue that—as with any other serious decision—each person should be granted the autonomy to make their own choices and end their life on their own terms.

For immediate help in the U.S., 24/7: Call 988 or go to 988lifeline.org . Outside of the U.S., visit the International Resources page for suicide hotlines in your country. To find a therapist near you, see the Psychology Today Therapy Directory .

Whether someone has an ethical duty to speed the death of someone who is in terrible, incurable pain, or whether doing so would be morally objectionable, has been debated for centuries. But the modern assisted suicide debate, which questions whether doctors should be legally allowed to help terminally ill patients end their lives, dates approximately to the early 20th century. The debate, and legal action for or against assisted suicide, gained steam in the 1990s and early 2000s, and continues to this day.

Those who argue in favor of assisted suicide often base their arguments on the principles of autonomy and “death with dignity.” They argue that individuals who are suffering should have the right to choose how much pain they will endure—and for how long—and end their life on their own terms when the costs of staying alive outweigh the benefits. They argue that, when applied judiciously and empathetically, assisted suicide can be a relief both for the terminally ill individual and for their loved ones, who often bear a significant burden as they try to care for the terminally ill person in his or her final days.

On the other hand, opponents of assisted suicide often argue that the practice devalues human life and that no one should actively seek to die; some make this argument for religious reasons, though not all do. Those who are skeptical of the practice also argue that physician-assisted suicide may be a mistake in cases of human error or random luck. Someone who is told they have six months to live, for example, may have received an inaccurate prognosis and end up living several more years; in rare cases, the terminal illness in question enters an improbable remission.

Some opponents of assisted suicide suggest that patients might refuse potentially life-saving treatments and opt for assisted suicide out of fear of looking like a “burden,” not because they truly desire to die; others fear that many terminally ill individuals will be pressured into assisted suicide by caretakers or others, or may only wish to die due to depression or another mental illness that may respond to treatment.

Both arguments have merit, and experts and laypeople will likely continue to debate the ethical, legal, and moral implications of assisted suicide for years to come. In many cases, someone’s personal feelings about assisted suicide are informed by their own experiences with death and illness.

The words "assisted suicide" and "euthanasia" are often used interchangeably, though their definitions vary slightly.

"Assisted suicide" typically means that a doctor will assist a patient in obtaining the means of dying, but will not personally administer them. A doctor may, for example, prescribe a patient end-of-life medications, but would then leave it to the patient whether or not to take them; some patients who receive such medications ultimately decide not to follow through.

The term “euthanasia,” by contrast, most often refers to someone intentionally and directly ending someone’s life to spare them from pain and suffering—by, for example, personally injecting them with life-ending drugs. “Pulling the plug” on someone on life support, while technically a kind of euthanasia, is allowable in many countries—but “active” euthanasia, in which a deliberate intervention is undertaken to end someone’s life, is illegal in the vast majority of places, even many that allow physician-assisted suicide.

Assisted suicide remains relatively rare even in places where it’s legal. In Switzerland, for example—a country whose assisted dying laws are relatively liberal—there were less than 1,000 assisted suicide deaths reported in 2015, accounting for approximately 1.5 percent of the total deaths in the country that year. While some evidence suggests that absolute numbers of assisted suicides do increase each year, they typically represent a very small percentage of total deaths—in most places far less than 1 percent.

Its legality, on the other hand, is slowly becoming more common. The practice is currently legal in a small number of countries—including the Netherlands, Belgium, and Canada; other nations, such as Spain and New Zealand, are in the process of approving and implementing assisted suicide laws. Several U.S. states, such as Oregon and Washington, have allowed assisted dying for a decade or more. More recent additions include California, Colorado, Vermont, and Washington, D.C.; Maine, Hawaii, and New Jersey all enacted assisted suicide laws in 2019.

But legal progress of the practice has been slow, and many countries and U.S. states explicitly forbid assisted suicide. Some U.S. states, in recent years, have strengthened their laws against the practice—in Utah, for example, assisted suicide is now considered manslaughter after the passage of a 2018 law.

Some evidence suggests that support for assisted suicide is generally strong in the U.S. and some other Western nations; some recent surveys, for example, suggest that as many as 7 in 10 Americans are in favor of some form of assisted suicide.

But how the question is worded appears to play a role—in one Gallup poll, for example, 70 percent of respondents responded “yes” to the question, “When a person has a disease that cannot be cured, do you think doctors should be allowed by law to end the patient's life by some painless means if the patient and his family request it?” Only 51 percent, however, agreed when the question asked whether doctors should be allowed to help patients “commit suicide.” Since the former phrasing is actually contrary to how most U.S. assisted suicide laws work in practice (in that the doctor does not themself end the patient's life, but rather helps them do it themselves if they choose), the results suggest that support for assisted suicide may not be as clearcut as some polls make it appear.

Most assisted suicide laws stipulate that the patient must be at least 18 (in certain jurisdictions, like the Netherlands, children over the age of 12 can request assisted suicide with a parent’s permission). Patients must be deemed mentally competent and capable of making health decisions, and (with rare exceptions) must be diagnosed with a terminal illness that doctors believe will lead to death. In some places, this death must be forecasted to occur within a certain definable period—in the U.S., many states stipulate that it be less than six months—while in others, including many European countries, the exact prognosis is less relevant. Most jurisdictions require the patient undergo some form of psychological counseling, as well as receive a second medical opinion to confirm the terminal prognosis.

In most places, including the U.S., only those with terminal physical illnesses are able to pursue assisted suicide. In a small number of countries, however—including Belgium and the Netherlands—patients with severe, treatment-resistant psychiatric illnesses can apply for physician-assisted death . Though the number of these deaths remains small even in places where they are legal, they tend to prompt fierce debate and fears of “suicide tourism,” in which mentally ill individuals travel to a specific place for the sole purpose of taking their own life.

Proponents argue that severe mental illness can significantly detract from the quality of life and cause psychic pain comparable to that of a physical illness. What’s more, advocates often emphasize that the severely mentally ill have a right to autonomy like everyone else. On the other hand, opponents argue that psychiatric illnesses do not have the same terminal prognosis that something like cancer might have, and recovery is, in many cases, more possible than patients believe. Evidence suggests that many patients who pursue physician-assisted suicide suffered from depression—a condition that, while distressing, is capable of remitting. And many patients who died by assisted suicide reportedly refused treatment beforehand, suggesting that they had not exhausted their options before making the decision to take their own life.

Some countries, like the Netherlands, do allow assisted suicide in cases of dementia if certain strict conditions are met (including the patient filing an advance written request before their disease progresses too severely). But the vast majority of aid-in-dying laws do not cover individuals with dementia or Alzheimer’s disease because they prioritize mental competence at the time of the request. In other words, the person who wishes to die must have the cognitive capacity to make an informed decision immediately before the death, something that severe dementia, by its very nature, precludes. To some with dementia and their caregivers, this is a grave oversight because of the immense suffering that dementia can cause and the near-assured physical and emotional decline of those who live with it.

But even those who argue in favor of assisted suicide for dementia patients acknowledge that the question is fraught. Someone with dementia may still find pleasure and purpose in their life in spite of their condition, and if they are unable to articulate (or even make sense of) their own wishes, it would be much harder for physicians to determine if it was their preferred course of action or if they were being pressured into it by others.

No. Some people request assisted suicide, have their request approved, and procure the means to end their life before ultimately deciding not to go through with it. Estimates place this number between ⅓ and ½ of those who have an assisted suicide request approved. While someone's motivations for not going through with it vary, many report that just having the option granted them a sense of control that made it easier to cope with their illness or with natural death.

No one considers assisted suicide lightly. Anyone who even entertains the idea is likely facing an incurable illness, unbearable pain, or a looming loss of functioning that they find unlivable. Still, even then, deciding whether or not to formally pursue assisted suicide can be a difficult choice, and it's imperative that significant thought be given before any choice is made—often with the help of a therapist, other medical professionals, and close loved ones. Deciding to pursue assisted suicide is not without its challenges, but because of the legal and psychological safeguards in place, someone who is seeking physician-assisted death will hopefully feel confident that they are making the best choice for themselves and their family.

The vast majority of individuals who consider assisted suicide often report that despite the hand they were dealt, they wish to retain at least some degree of control over their life. By controlling the manner and timing of their death, they assert, they are better able to make peace with their own mortality and mentally prepare for the end of their life. Many are in serious, near-constant physical pain or have burdensome medical needs; in most cases, the individual feels that their quality of life has deteriorated to such a degree that hastening death would be preferable to prolonging life.

Though evidence suggests that few who pursue assisted suicide are directly motivated by financial concerns or of feeling like a “burden” to their families, many cite their loved ones’ emotional well-being as a prime motivator for their pursuit of aid in dying. Ending their life on their own terms and with advanced notice, they reason, would help their loved ones prepare for and make sense of the death; research suggests that this prediction is often correct.

In order to qualify for assisted suicide, most localities require that an individual be over 18 (in some places, 16), mentally competent, and diagnosed with a terminal illness that is strongly predicted to take their life in a short period of time. Anyone who lives in a country or state in which assisted suicide is legal should reach out to their doctor to discuss their options and get more information.

Someone considering assisted suicide should do their research—both to find out what the process entails (as it varies from place to place) and what factors they should take into account while making their decision. Most people factor in both physical symptoms—Is the pain they’re in unbearable? Is it likely to get worse? Will it become increasingly more difficult to care for their physical needs?—and their own feelings about morality, autonomy, and the sanctity of life. Some people, for example, will ultimately conclude that deliberately ending one’s life is not in accordance with their personal religious or moral beliefs; others will decide that their desire to maintain control over their life and death is their first priority, and/or that pursuing assisted suicide would be the best way to retain their dignity in their final days. Both stances are equally valid.

Only you can decide whether assisted suicide is in accordance with your values and the specificities of your illness. Though it’s always helpful to discuss options with family and other loved ones, it’s important not to feel pressured into pursuing aid-in-dying. If you suspect that others in your life are significantly more invested in assisted suicide than you are, it is highly possible that it is not the right choice for you or your family.

Most countries and states that allow assisted suicide require that the patient consult with a psychologist before the decision is approved. The therapist will typically assess the patient for depression or other potentially confounding mental health disorders. They will also ask questions to determine their mental competence, whether they are fully informed about what the decision entails, and whether they are making the choice of their own free will or are being pressured into it by others. Beyond assessing the patient’s mental state, most therapists will make an effort to understand any additional psychological factors that could inform a patient’s decision—their morals and values, for example, or their own assessment of the quality and meaning of their life.

It can be frustrating and hurtful to feel as if a decision to die by assisted suicide is not supported by family members, partners, or other loved ones. But it’s important to remember that they may have different views about morality, the meaning of life, and how death “should” occur. These views are not wrong, necessarily; they are simply different from yours. Your loved ones likely want what’s best for you, even if you disagree on what “best” means.

You don’t need to acquiesce to your loved one’s dissent and shouldn’t feel pressured to rescind your decision. But it’s best to respond to their pushback with empathy, rather than antagonism. Experts recommend telling loved ones who object that you respect their view and that while they do not have to approve of your decision, you would appreciate it if they could respect your autonomy and not interfere. Keep in mind that they may just need time—some opposing family members eventually come around to their loved one’s point of view or come to feel that it was the best decision for the family as a whole. Others may never change their minds; as long as they are respectful of your decision, despite disagreeing, you will likely be able to maintain a close relationship.

In general, experts recommend that families share their thoughts on death and dying with one another long before a terminal illness even occurs, to both destigmatize the topic (making it easier to talk about when the time comes) and to get a sense of how someone might feel if they are faced with the choice to end their own life later on. Such conversations shouldn’t be considered binding, of course—but knowing in advance that someone is generally supportive of assisted suicide may help their loved ones feel less blindsided by their decision later on.

There is no way to definitively determine beforehand how loved ones will respond to someone’s choice to pursue assisted suicide. But some research suggests that deciding to die in this manner won’t necessarily have a negative impact on surviving family members—and may even make them more accepting of the death.

One study , for example, found little difference in mental health outcomes between individuals whose family member died by assisted suicide and those who died by cancer; the rate of depression and prolonged grief was the same for both groups, and they received post-death mental healthcare at the same rate. However, those whose loved ones had died by assisted suicide were less likely to have regrets about the manner of death; they were also more likely to believe that their loved one’s choices were honored, and reported feeling more prepared for the death.

Someone who is considering or has chosen assisted suicide will benefit greatly from the support of their loved ones, both emotional and practical. Even if they are ultimately confident in their decision, it can still come with some strong and confusing emotions; they may find it helpful to talk through them with the people closest to them as they come to terms with the end of their life. On the other hand, once the decision has been made, they may prefer to talk about it as little as possible. Ask your loved one how they want to proceed, and follow their lead as much as possible.

Your loved one may need logistical support—finding a doctor who is willing to assist, planning the necessary appointments, and putting their affairs in order. If you’re able, helping them manage these necessary but at times tedious tasks can allow them to focus on what they’d like to do with their remaining time. Asking how they would like their death itself to unfold and helping them make the arrangements can be beneficial, too—some individuals ask, for example, that their loved ones visit in the days or weeks beforehand to share a few words before they go.

It’s important, too, to spend joyful time with your loved one whenever possible. They may have a sort of “bucket list” of things that they hope to do before they pass; joining them in these endeavors, if it’s OK with them, can bring you closer together and can spur the creation of fond memories that will linger long after your loved one’s death.

Despite a surging youth mental health crisis, a new study finds that psychiatric hospital beds are in short supply for much of the country and not increasing in number.

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Euthanasia and assisted suicide: An in-depth review of relevant historical aspects

Picón-Jaimes, Yelson Alejandro a ; Lozada-Martinez, Ivan David a,b ; Orozco-Chinome, Javier Esteban c ; Montaña-Gómez, Lina María d ; Bolaño-Romero, María Paz a,b ; Moscote-Salazar, Luis Rafael e ; Janjua, Tariq f ; Rahman, Sabrina g,*

a Medical and Surgical Research Center, Future Surgeons Chapter, Colombian Surgery Association, Bogotá, Colombia

b Grupo Prometheus y Biomedicina Aplicada a las Ciencias Clínicas, School of Medicine, Universidad de Cartagena, Cartagena, Colombia

c Department of Medicine, RedSalud, Santiago de Chile, Chile

d Department of Medicine, Keralty Salud, Bogotá, Colombia

e Colombian Clinical Research Group in Neurocritical Care, Latin American Council of Neurocritical Care, Bogotá, Colombia

f Department of Intensive Care, Regions Hospital, Minnesota, USA

g Independent University, Dhaka, Bangladesh

* Corresponding author.

E-mail: [email protected]

Submitted January 3, 2022; revised February 4, 2022; accepted February 10, 2022.

HIGHLIGHTS

The history of euthanasia and assisted suicide has been traumatic.
The church and research have been decisive in the definition of euthanasia.
The legal framework on the use of euthanasia and assisted suicide has been strengthened.

1. Introduction

Euthanasia and assisted suicide are two topics discussed throughout history, mainly because they fall within the scope of life as a human right, which has been universally defended for many years [ 1 ]. However, the mean of the word euthanasia as good death generates conflicts at social, moral, and ethical levels. Mainly because death is a loss, it is difficult to understand it as something positive and; additionally, several historical events such as the Nazi experiments related the term euthanasia more to murder than to a kind and compassionate act [ 1 ]. More current texts mention that euthanasia is the process in which, through the use or abstention of clinical measures, the death of a patient in an incurable or terminal condition can be hastened to avoid excessive suffering [ 2 ].

The difference between euthanasia and assisted suicide is that in the latter, the patient takes the final action; however, both practices can be combined in the term assisted death [ 2 ]. At present, several countries authorize assisted death, including Holland, Luxembourg, and Canada [ 3 ]. Belgium and Colombia have regulations that decriminalize only euthanasia; other places where assisted suicide is legal are Switzerland and five states of the United America states, specifically Oregon, Vermont, Washington, California, and Montana [ 2,3 ]. Spain recently joined the list of countries that have legislated on euthanasia through the organic law March 2021 of March 24 that regulates euthanasia in that state in both public and private institutions [ 4 ]. The fact that more and more countries were joining the legislation on euthanasia and assisted suicide has brought to light the opinion of thinkers, politicians, philosophers, and physicians. Several nations have initiated discussions on the matter in their governmental systems. Latin America is trying to advance powerfully in this medical-philosophical field. Currently, in Chile, the “Muerte digna y cuidados paliativos” law, which seeks to regulate the issue of euthanasia and assisted suicide in the country, is being debated in Congress [ 5 ].

It is essential to know the point of view of physicians on euthanasia and assisted suicide, especially taking into account that these professionals who provide care and accompany patients during this moment, which, if approved, would involve the medical community in both public and private health systems. Although it seems easy to think that physicians have a position in favor of the act of euthanasia because they are in direct and continuous contact with end-of-life situations, such as palliative care, terminally ill, and critically ill patients. It is important to remember that the Hippocratic medical oaths taken at the time of graduation of professionals are mostly categorical in mentioning the rejection of euthanasia and assisted suicide [ 6 ]. Furthermore, it is also important to note that many of the oldest universities in the Western world originated through the Catholic Church; and just this creed condemns the practice of euthanasia and continues to condemn it to this day. This situation generates that many medical students in these schools have behaviors based on humanist principles under the protection of faith and religion and therefore reject the possibility of euthanasia [ 7,8 ].

The relevance of the topic and the extensive discussion that it has had in recent months due to the COVID-19 pandemic added to the particular interest of bioethics in this topic and the need to know the point of view of doctors and other health professionals on euthanasia and assisted suicide.

2. Origin and meaning of the term euthanasia

The word euthanasia derives from the Greek word “eu” which means good, and the word “thanatos” which means death; therefore, the etymological meaning of this word is “good death”. Over time the evolution of the meaning has varied; even as we will see below was considered a form of eradication of people categorized under the designation of leading a less dignified life. Assisted suicide is a condition in which the patient is the one who carries out the action that ends his life through the ingestion of a lethal drug but has been dispensed in the context of health care and therefore called assisted. This care is provided by a physician trained in the area. However, it requires the prior coordination of a multidisciplinary team and even the assessment by an ethics committee to determine that the patient is exercising full autonomy, free from coercion by the situation he/she is living and free from the fatalistic desires of a psychiatric illness [ 9 ]. In a more literary sense, the word euthanasia meaning of “giving death to a person who freely requests it in order to free himself from suffering that is irreversible and that the person himself considers intolerable” [ 9 ].

Some authors go deeper into the definition and consider that for the meaning of euthanasia, are necessary to consider elements that are essential in the word itself; such as the fact that it is an act that seeks to provoke death and that carried out to eliminate the suffering in the person who is dying. Other elements with a secondary character in the definition are the patient's consent (which must be granted respecting autonomy and freedom in the positive and negative sense; that means the fact must be not be coerced in any way). Another element is the terminal nature of the disease, with an irreversible outcome that generates precariousness and a loss of dignity. The third secondary element is the absence of pain of the death through the use of drugs such as high-potency analgesics, including opioids, high-potency muscle relaxants, and even anesthetic drugs. Finally, the last element is the health context in which the action is performed (essential in some legislations to be considered euthanasia) [ 10 ]. According to the World Health Organization, the union of these two components is the current definition of euthanasia, which describes as “the action performed by a person to cause the painless death of another subject, or not preventing death in case of terminal illness or irreversible coma. Furthermore, with the explicit condition that the patient must be suffering physical, emotional, or spiritual and that affliction is uncontrollable with conventional measures such as medical treatments, analgesics, among others; then the objective of euthanasia is to alleviate this suffering” [ 11 ]. Unfortunately, the term euthanasia has been misused over the years, and other practices have been named with this word. An example of this situation occurred during the Nazi tyranny when the word euthanasia concerned the murder of people with disabilities, mental disorders, low social status, or gay people. At that time, euthanasia was even a simultaneous practice to the Jewish genocide [ 11 ].

Not only has the term been misused; also exists an enormous variability of terms to refer to euthanasia. For example, the laws created to regulate euthanasia have different names around the world; in the Netherlands (Holland), the law that regulates this practice is known as the law of termination of life; in Belgium, it is called euthanasia law, in France, it is called euthanasia law too. In Oregon (USA), it is called the death with dignity act; in California, it is the end of life option act. In Canada is called the medical assistance in dying act. Victoria (Australia) is the voluntary assisted dying bill, but all these denominations refer to the already well-known term euthanasia [ 11 ].

3. Evolution of euthanasia and assisted suicide: digging into historical events

To understand the evolution and relevance of these concepts should analyze the history of euthanasia and assisted suicide; from the emergence of the term, going through its first manifestations in antiquity; mentioning the conceptions of great thinkers such as Plato and Hippocrates; going through the role of the Catholic Church; mainly in the Middle Age, where following the thought of St. Thomas Aquinas, self-induced death or death contemplated by own will, was condemned. Later, with the renaissance age and the resurgence of science, technology, and the arts, the term euthanasia made a transition to a form similar to what we know today from thinkers such as Thomas More and Francis Bacon. Finally, the first signs of eugenics were known in London, Sweden, Germany, and the United States in the twentieth century. There was a relationship with the term euthanasia that was later used interchangeably, especially in the Nazi regime, to denote a form of systemic murder that sought to eradicate those who were not worthy of living a life.

Since the sixties, with emblematic cases, the path towards the decriminalization of euthanasia began in some countries, especially concerning the cessation of extreme support measures in cases of irreversible illness or a terminal condition. The practice has progressed to the appearance of laws on euthanasia in several countries.

4. Euthanasia and assisted suicide in ancient times

In book III of Plato's “The Republic”, the author stated that those who live their lives amidst illnesses and medicines or who were not physically healthy should be left to die; implying that it was thought that people in these conditions suffered so much that their quality of life diminished, which seemed understandable to these thinkers. However, other authors such as Hippocrates and his famous Hippocratic oath sought the protection of the patient's life through medicine, especially in vulnerable health conditions prone to fatal outcomes. This Hippocratic oath is the same oath that permeates our times and constitutes an argument among those who mark their position against euthanasia and assisted suicide [ 12,13 ].

Other texts that collect thoughts of Socrates and his disciple Plato point out that it was possible and well understood to think of ceasing to live in the face of a severe illness; to consider death to avoid a long and torturous agony. This fact is compatible with the conception of current euthanasia since this is the end of this health care procedure [ 13 ].

In The Republic, the text by Plato, the physician Heroditus is also condemned for inventing a way to prolong death and over manage the symptoms of serious illnesses, which is currently known as distanasia or excessive treatment prolongs life. This kind of excessive treatment prolongs the sick person's suffering, even leading him to maintain biological signs present but in a state of alienation and absolute dependence on medical equipment such as ventilators and artificial feeding [ 13 ]. However, the strongest indication that Euthanasic suicide was encouraged in Greece lies in other thinkers such as the Pythagoreans, Aristotelians, and Epicureans who strongly condemned this practice, which suggests that it was carried out repeatedly as a method and was therefore condemned by these thinkers [ 12,13 ]. According to stoicism, the pain that exceeded the limits of what was humanly bearable was one of the causes for which the wise man separates himself from life. Referring to one of the nuances that euthanasia touches today, that is, at a point of elevated suffering, the dignity and essence of the person are lost, persisting only the biological part but in the absence of the person's well-being as a being. In this sense, Lucius Seneca said that a person should not love life too much or hate it; but that person should have a middle ground and end their life when they ceased to perceive life as a good, worthy, and longed-for event [ 1,12 ].

During the Roman Empire and in the territories under its rule, it was believed that the terminally ill who commit suicide had sufficient reasons to do so; so since suicide caused by impatience and lack of resolution to pain or illness was accepted, when there was no access to medicines. In addition, there was little development in medicine during that time, and many of the sick died without treatment [ 12 ]. This situation changed later with the emergence of the Catholic church; in this age, who attempted against own life, was deprived of burial in the ground. Saint Augustine said that the suicide was an abominable and detestable act; from 693 AD, anyone who attempted against his physical integrity was excommunicated. Rejecting to the individuals and their lineage, depriving them of the possibility of attending the funeral and even expelled from cities and stripped of the properties they owned [ 12,13 ].

4.1. Euthanasia and assisted suicide in the Middle Age

During the Middle Age, Catholicism governed the sciences, arts, and medicine; the sciences fell asleep. Due to this solid religious tendency and the persistence of Augustinian thought, suicide was not well seen. It was not allowed to administer a lethal substance to a person to end the suffering of a severe or terminal illness [ 9,12 ]. People who took their own lives at this time could not be buried “Christianly”; therefore, they did not have access to a funeral, nor to the accompaniment of their family in a religious rite. Physical suffering and pain were then seen as a path to glorification. Suffering was extolled as the form that god purified the sin, similar to the suffering that Jesus endured during his Calvary days. However, a contrary situation was experienced in battles; a sort of short dagger-like weapon was often used to finish off badly wounded enemies and thus reduce their suffering, thus depriving them of the possibility of healing and was called “mercy killing” [ 12 ].

5. Euthanasia in renaissance

With the awakening of science and philosophy, ancient philosophers’ thoughts took up again, giving priority to man, the world, and nature, thus promoting medical and scientific development. In their discourse, Thomas More and Francis Bacon refer to euthanasia; however, they give a eugenic sense to the concept of euthanasia, similar to that professed in the book of Plato's Republic. It is precise with these phylosophers that the term euthanasia got its current focus, referring to the acceleration of the death of a seriously ill person who has no possibility of recovery [ 12 ]. In other words, it was during this period that euthanasia acquired its current meaning, and death began to be considered the last act of life. Therefore, it was necessary to help the dying person with all available resources to achieve a dignified death without suffering, closing the cycle of life that ends with death [ 13,14 ].

In his work titled “Utopia”, Thomas More affirmed that in the ideal nation should be given the necessary and supportive care to the dying. Furthermore, in case of extraordinary suffering, it can be recommended to end the suffering, but only if the patient agrees, through deprivation of food or with the administration of a lethal drug; this procedure must be known to the affected person and with the due permission of authorities and priests [ 12,13 ]. Later, in the 17th century, the theologian Johann Andreae, in his utopia “Christianopolis”, contradicts the arguments of Bacon and Moro, defending the right of the seriously ill and incurably ill to continue living, even if they are disturbed and alienated, advocating for the care based on support and indulgence [ 15,16 ]. Similarly, many physicians rejected the concepts of Plato, Moro, and Bacon. Instead, they focused on opposing euthanasia, most notably in the nineteenth century. For example, the physician Christoph Hufeland mentioned that the doctor's job was only to preserve life, whether it was a fate or a misfortune, or whether it was worth living [ 16 ].

5.1. Euthanasia in the 20th century

Before considering the relevant aspects of euthanasia in the 20th century, it is vital to highlight the manuscript by Licata et al. [ 17 ], which narrates two episodes of euthanasia in the 19th century. The first one happened in Sicily (Italy) in 1860, during the battle of Calatafimi, where two soldiers were in constant suffering, one because he had a serious leg fracture with gangrene, and the other with a gunshot wound. The two soldiers begged to be allowed to die, and how they were in a precarious place without medical supplies, they gave them an opium pill, which calmed them until they died [ 17 ]. The second episode reported by Licata et al. [ 17 ] was witnessed by a Swedish doctor named Alex Munthe; who evidenced the pain of many patients in a Parisian hospital. So he decided to start administering morphine to help people who had been seriously injured by wolves and had a poor prognosis; therefore, the purpose of opioid use was analgesia while death was occurring.

It is also important to highlight the manuscript entitled “Euthanasia” by S. Williams published in 1873 in “Popular Science Monthly”, a journal that published texts by Darwin, Edison, Pasteur, and Beecher. This text included the report for the active euthanasia of seriously ill patients without a cure, in which the physicians were advised to administer chloroform to these patients or another anesthetic agent to reduce the level of consciousness of the subject and speed up their death in a painless manner [ 16 ].

Understanding that euthanasia was already reported in the nineteenth century, years after, specifically in 1900, the influence of eugenics, utilitarianism, social Darwinism, and the new currents of thought in England and Germany; it began in various parts around the world, projects that considered the active termination of life, thus giving rise to euthanasia societies in which there were discussions between philosophers, theologians, lawyers, and medical doctors. Those societies discussed diverse cases, such as the tuberculous patient Roland Gerkan, who was considered unfit and therefore a candidate to be released from the world [ 16 ]. The scarcity of resources, famine, and wars were reasons to promote euthanasia as a form of elimination of subjects considered weak or unfit, as argued in texts such as Ernst Haeckel's. However, opponents to the practice, such as Binding and Hoche, defended the principle of free will in 1920 [ 16 ].

5.2. Euthanasia in the time of the Nazis

As mentioned above, the term euthanasia was misused during this period; approximately 275,000 subjects (as reported at the Nuremberg International Military Tribunal 1945–1946), who had some degree of physical or mental disability, were killed during Adolf Hitler's Euthanasia program [ 13 ]. However, the Nazis were not the first to practice a form of eugenics under the name of euthanasia, since the early 1900s in London had already begun the sterilization of the rejected, such as the blind, deaf, mentally retarded, people with epilepsy, criminals, and rapists. This practice spread to different countries like Sweden and the United States [ 13,16 ].

For the Nazis, euthanasia represented the systematic murder of those whose lives were unworthy of living [ 13 ]. The name given to this doctrine was “Aktion T4”. At first and by law, from 1939, the hospitals were obliged to account for all disabled newborns, which led to the execution of more than 5000 newborns utilizing food deprivation or lethal injection [ 12,18 ].

A year before that law, in 1938, one of the first known cases of euthanasia in children arose in Germany. That history called the story of child K, in which it was the father of the minor who asked Hitler in writing for euthanasia for his son because the child had a severe mental disability and critical morphic disorders. Hitler gave his consent to carry out the procedure on child K, and thus the program began to spread throughout the Aleman territory. Since then, physicians and nurses had been in charge of reporting the newborns with alterations, arising the “Kinderfachabteilugen” for the internment of children who would be sentenced to death after a committee's decision [ 12,18,19 ]. A list of diseases and conditions that were considered undesirable to be transmitted to Hitler's superior Aryan race was determined; thus, any child with idiocy, mongolism, blindness, deafness, hydrocephalus, paralysis, and spinal, head, and hip malformations were eligible for euthanasia [ 19 ].

Subsequently, the program was extended to adults with chronic illness, so those people were selected and transported by T4 personnel to psychiatric sanatoriums strategically located far away. There, the ill patients received the injection of barbiturate overdoses, and carbon monoxide poisoning was tested as a method of elimination, surging the widely known gas chamber of the concentration camp extermination; this situation occurred before 1940 [ 12,19 ]. Again, physicians and nurses were the ones who designated to the patients to receive those procedures; in this case, these health professionals supported Nazi exterminations. They took the patients to the sanatoriums, where psychiatrists evaluated them and designated with red color if they should die and with a blue color if they were allowed to live (this form of selection was similar in children) [ 12,13,19 ]. In this case, the pathologies considered as criteria for death were those generating disability such as schizophrenia, paralysis, syphilis with sequelae, epilepsy, chorea, patients with chronic diseases with many recent treatments, subjects of non-German origin and individuals of mixed blood [ 19 ]. Once in the sanatoriums, they were informed that they would undergo a physical evaluation and take a shower to disinfect themselves; instead, they were killed in gas chambers [ 12,13 ]. Despite the church's action in 1941 against Nazis and after achieving suspension of the Aktion T4 project; the Nazi supporters kept the practices secretly, resuming them in 1942, with the difference that the victims were killed by lethal injection, by an overdose of drugs, or left to starve to death, instead of the use of gas chambers. This new modified form of euthanasia, which did not include gas chambers, became known as “savage euthanasia” [ 12,13,19 ].

5.3. Euthanasia since the 1960s

In September 1945, trials began for crimes perpetrated by Nazi supporters; the victorious Allied forces conducted these trials at the end of the war. During these tribunals, cases of human experimentation were identified and the public exposure of the Nazi euthanasia program. After the Nuremberg trials and the abolition of Nazi experiments, a series of seven documents emerged, among which the Nuremberg code containing the ten basic principles for human research stood out [ 20,21 ].

After these judgments, biotechnology was accelerated, with the apparition of new techniques to intervene in the health-disease process. Additionally, the increase in life expectancy and the appearance of diseases that chronically compromise the state of health of people generated a change in the conception of the critically ill patient and the terminal state of life [ 20,21 ]. Cases such as Karen Ann Quinlan brought to the forefront the issue of euthanasia and precisely the control of extreme treatment measures. Karen, a young American woman, was left in a vegetative state due to severe neurological damage following alcohol and barbiturate intoxication. After six months in that state and under the guardianship of a Catholic priest, Karen's parents requested the removal of the artificial respirator, arguing that in her state of consciousness prior to the incident, she had stated that she disagreed with artificially maintaining life in comatose patients. The hospital refused to remove the ventilator, arguing the legal issues for the date, and the parents went to court, which in the first instance granted the hospital the right. Nevertheless, the New Jersey Supreme Court granted Karen Ann's right to die in peace and dignity. Despite the withdrawal of the artificial respirator, he continued to live until 1985, when he finally died [ 21–23 ].

Another important case was Paul Brophy, which also occurred in the United States. Paul was a firefighter in Massachusetts and went into a deep coma due to the rupture of a basilar artery aneurysm; initially, his family advocated for support measures but later requested the hospital to disconnect these means to allow death, as Paul had indicated when he was still conscious. The hospital refused to carry out this procedure, so the family went to court, where the removal of the support measures (gastrostomy) was initially denied. Hence, the family went to the state supreme court, achieving the transfer of Paul to another medical center where the gastrostomy was removed, leading to his death within a few days [ 23 ].

The case of Arthur Koestler, an influential English writer and activist diagnosed with Parkinson's disease and later with leukemia, who served as vice-president of the voluntary euthanasia society (Exit) and wrote a manual book with practical advice for euthanasia called “Guide to Self-Liberation”. He stood out because he applied one of his advice and ingested an overdose of barbiturates, causing his self-death. According to his writings, Koestler was not afraid of death but of the painful process of dying [ 23 ]. In this sense, it was a relevant case because it involved someone who held an important position in an association that advocated euthanasia, in addition to being the author of several works, which made him a recognized public figure [ 23 ].

Baby Doe was a case that also occurred in the United States; it was a small child with Down syndrome who had a tracheoesophageal fistula and esophageal atresia; in this case, surgery was necessary. On the advice of the obstetrician, the parents did not allow surgery, so the hospital managers took the case before a judge who ruled that parents could decide to perform or not the surgery. The case was appealed before a county judge who upheld the parents’ power to make the decision, in the course of which the case became public and many families offered to take care of the child; however, before the case reached the supreme court, the child died at six days of age [ 23 ].

In the case of Ingrid Frank, a German woman who was in a quadriplegic state by a traffic accident, who initially sought rehabilitation but later insisted on being allowed to die; it was provided with a drink containing a cyanide solution that she drank. At the same time, she was filmed, which shows a kind of assisted suicide. For that reason, this is another case that deals with this issue and is important to know as background in the development of euthanasia and assisted suicide [ 22,23 ].

6. Current and future perspectives

The definition of brain death, the rational use of the concept of euthanasia and assisted suicide, and scientific literacy are the objectives of global bioethics to regulate euthanasia and assisted suicide, which can be accessible in all health systems [ 24–30 ]. End-of-life care will continue to be a subject of debate due to the struggle between biomedical principles, the different existing legal frameworks, and the general population's beliefs. Medical education and preparation in the perception of death, especially of a dignified death, seems to be the pillar of the understanding of the need to develop medical-legal tools that guarantee the integrity of humans until the end of their existence [ 31,32 ]. This is the reason why the new generations of physicians must be trained in bioethics to face these ethical conflicts during the development of their professional careers.

In addition, although the conception of bioethics belongs to the Western world, it is crucial to take into account the point of view of other cultures and creeds, for example, a study carried out in Turkey, where nursing students were questioned, found that many of them understood the reasons for performing euthanasia; however, they know that Islam prohibits it, as well as its legislation, and therefore they would not participate in this type of procedure [ 33 ]. Furthermore, Christianism and Islam prohibit euthanasia, but Judaism also prohibits it; in general, the so-called Abrahamic religions are contrary to any form of assisted death, whether it is active euthanasia, passive, or assisted suicide [ 34 ].

7. Conclusiones

The history and evolution of euthanasia and assisted suicide have been traumatic throughout human history. The church, politics, and biomedical research have been decisive in defining these concepts. Over the years, the legal framework and bioethical concepts on euthanasia have been strengthened. However, there is still much work to educate the general population and health professionals about end-of-life care and dignified death.

It is also important to remember that life is a concept that goes beyond biology. Currently, bioethics seeks to prioritize the concept of dignity, which must be linked to the very definition of life. Although the phrase is often heard that it is not necessary to move to be alive, what is important is that person feels worthy even if they have limited movement. The person's treatment must be individualized in bioethics since each individual is a unique unit. Therefore, medical paternalism must be abandoned. Instead, the subject must be more involved to understand their context and perception of life and dignity.

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All authors equally contributed to the analysis and writing of the manuscript.

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Not commissioned, externally peer reviewed.

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Sabrina Rahman. Independent University, Dhaka, Bangladesh. [email protected] .

Declaration of interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Euthanasia; Assisted suicide; Terminal care; Bioethical issues; History of medicine

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Iran J Public Health
v.46(2); 2017 Feb

An Ethical Review of Euthanasia and Physician-assisted Suicide

Božidar banoviĆ.

1. Faculty of Security Studies, University at Belgrade, Belgrade, Serbia

Veljko TURANJANIN

2. Faculty of Law, University at Kragujevac, Kragujevac, Serbia

Anđela MILORADOVIĆ

3. Seniorenzentrum Röweland, Hamburg, Germany

Background:

In the majority of countries, active direct euthanasia is a forbidden way of the deprivation of the patients’ life, while its passive form is commonly accepted. This distinction between active and passive euthanasia has no justification, viewed through the prism of morality and ethics. Therefore, we focused on attention on the moral and ethical implications of the aforementioned medical procedures.

Data were obtained from the Clinical Hospital Center in Kragujevac, collected during the first half of the 2015. The research included 88 physicians: 57 male physicians (representing 77% of the sample) and 31 female physicians (23% of the sample). Due to the nature, subject and hypothesis of the research, the authors used descriptive method and the method of the theoretical content analysis.

A slight majority of the physicians (56, 8%) believe that active euthanasia is ethically unacceptable, while 43, 2% is for another solution (35, 2% took a viewpoint that it is completely ethically acceptable, while the remaining 8% considered it ethically acceptable in certain cases). From the other side, 56, 8% of respondents answered negatively on the ethical acceptability of the physician-assisted suicide, while 33% of them opted for a completely ethic viewpoint of this procedure. Out of the remaining 10, 2% opted for the ethical acceptability in certain cases.

Conclusion:

Physicians in Serbia are divided on this issue, but a group that considers active euthanasia and physician-assisted suicide as ethically unacceptable is a bit more numerous.

Introduction

Does a man, in addition to the right to live, have a right to die? More specifically, does he have a right to a dignified death? Is a deprivation of life from the mercy reasons a crime or unpunishable act? The answer to these questions varies from country to country. On the one hand, if a state decides to legalize this form of the deprivation of life, the key question is what are the reasons for it? On the other hand, in a case when legislator takes an opposite view, we have the same question ( 1 ). Therefore, euthanasia, and in recent time physician-assisted suicide, are inexhaustible topics for reflection and observation of the different aspects of medicine, law, sociology, philosophy, religion and morality (according to some authors, this debate is one of the ten hotly moral issues ( 2 ), but also one of the major problems in the national and international health limits. By bypassing defining these two very famous terms at this point in time, we will just point out that the direct active euthanasia is a medical act directed to the deprivation of life (hereinafter: ADE), while a physician-assisted suicide is an act of the physician where he provides to the patient a medicament for taking life (hereinafter: PAS).

It is not clear when the man for the first time came to the idea of euthanasia ( 3 ). There have been many discussions in the United States and United Kingdom, culminated in 1906, when Ohio attempted to pass a law to legalize euthanasia ( 4 ). Movements to the legalization of the ADE and PAS have marked the last few decades, but we can notice that legislators across the world more easily decriminalize PAS, as a milder form of the deprivation of life. This is primarily evident on the American continent, where a few states decriminalized PAS, although the Supreme Court held that there is no constitutional right to ADE and PAS, nor the ban on the mentioned acts. Parallel to this process, there are strict criticisms of such actions, which have the ultimate aim of eliminating criminal penalties for persons who assist in the deprivation of the life of the patient, who is terminally ill at his request ( 5 ). If we take the example of England, the constant change of the attitudes of the British Medical Association and Royal College of Physicians, that varies from the strict opposition to the neutral position and vice versa, shows that is hard for them to accept any attitude regarding taking one’s life and to take any constant attitude whatsoever ( 6 ).

Different viewpoints in some countries caused a different approach to the legislative treatment of these two issues ( 7 , 8 ), but their solutions are, due to the many activities in this area, constantly reviewed ( 9 ). For example, Belgium in 2014 went far ahead when approved ADE for children, considering them as competent for such decision ( 10 , 11 ). Both procedures are in the majority of countries in the world illegal, but they exist everywhere ( 12 ).

However, in this paper, we will mainly deal with the observation of the ADE and PAS from ethical point of view, where we devote due attention to the criticism of a different regulation of ADE and passive euthanasia (hereinafter: PE), which is inexhaustible field for everyone who seriously takes this matter. In order to contribute to existed theoretical and practical considerations, we conducted a survey among physicians in Serbia on this topic.

Materials and Methods

The data for the current analysis have been derived from the broader research project whose aim was to identify occurrence, distribution, and opinions of the physicians about euthanasia and physician-assisted suicide. In this paper, we analyzed part of the obtained data. Research is primarily based on quantitative research approach, and data were collected using a short survey, created specifically for the purpose of this study. In the civilized countries, physicians are increasingly faced with demands to assist patients in committing suicide or to apply euthanasia ( 13 , 14 ). Therefore, we conducted a survey among the physicians from Clinical Hospital Center in Kragujevac (Serbia) in 2015. Data were collected during the first half of the mentioned year. We analyzed the segments of dataset which concern to two questions: Which of them is acceptable: ADE ethically or PAS ethically? To both questions, we offered three answers: yes , no , and yes, in some cases .

The scope of the tested population, gender structure of the respondents, as well as the diversity of the health departments in participants employed, gives us possibility of a wider generalization of the findings to the physicians’ populations across the whole country. The initial sample plan was to try to conduct a survey of all employees in this medical institution. Of 100 physicians, 88 expressed their willingness to be participants. The final sample included 88 physicians: 57 male physicians (representing 64, 77% of the sample) and 31 female physicians (35, 23% of the sample). The study was divided into three parts: in the Ambulance, in the Emergency Room, while the third, the most numerous sample, and included physicians from the departments of Surgery, Transfusion, and Cardiology. The initial hypothesis was that the physicians who work in the Emergency Room are prone to saving lives, and will be exclusively against ADE and PAS. The same situation is expected in the Ambulance, while in the remaining sample, physicians will be divided by their opinions. We analyzed total data as well as data by departments.

The sample included 88 physicians, who declared on ethical acceptability of ADE and PAS. In Table 1 are total data for the ADE, while in the Table 2 are results located by departments; in the Table 3 are total data for the ethical acceptability for the PAS, and in the Table 4 are located data by departments for this question.

Is ADE ethically acceptable?


Valid	Yes	31	35.2	35.2	35.2
	No	50	56.8	56.8	92.0
	Yes, in some cases	7	8.0	8.0	100.0
	Total	88	100.0	100.0




	Yes	6 (31.5%)	25 (50%)	0	31
	No	12 (63.15%)	20 (40%)	18 (94.73%)	50
	Yes, in some cases	1 (5.35%)	5 (10%)	1 (5.27%)	7
Total		19	50	19	88

Is PAS ethically acceptable?


Valid	Yes	29	33.0	33.0	33.0
	No	50	56.8	56.8	89.8
	Yes, in some cases	9	10.2	10.2	100.0
	Total	88	100.0	100.0




Yes	6 (31.5%)	23 (46%)	0	29
No	12 (63.15%)	20 (40%)	18 (94.73%)	50
Yes, in some cases	1 (5.35%)	7 (14%)	1 (5.27%)	9
Total	19	50	19	88

The issue of the right to death with dignity is inevitably linked with ethics and morals. The law and moral in some cases does not stand in the necessary pervasive connection, due to the brutal features of some legal systems, although such phenomena should be as rare as possible ( 15 ).

In the literature, we can find another significant question: could the moral and ethical conduct be illegal, but the act to be in accordance with the law to be immoral ( 16 )? If we start from the basic rule that the law is only a minimum of morality, thus the moral rules are at the higher level then legal. Based on this, when a legislator regulates ADE and PE, he should not make distinction between them, because they are equal in weight. In the numerous issues raised in the area of euthanasia, the existence or non-existence of moral differences between killing and letting to die a patient from the effects of the disease, and between ADE and PAS stands out ( 17 ).

The supporters of this attitude (most commonly in the sphere of philosophy and religion ( 18 )) found one of the main reasons for the immorality of ADE in the assertion that human life is sacred (although this term usually belongs to the religion -“traditional ethical principle” ( 19 , 20 ) that one cannot and must not take. They bypass a debate about the reasons that led to killing by using ADE. They do not put an accent on the quality and content of life. At the same time, these authors are divided into two fractions: radical and moderate. The supporters of moderate direction reject possibility of the moral justification and legal regulation of ADE, while the authors who hold the radical position are absolutely against any form of euthanasia and taking of human life. Human life is sacred and it is the work of the God ( 21 – 23 ). However, human life has a meaning only in a case when the brain is operational ( 24 ), and from the times of Confucius, we have had philosophical thought that biological life has not more value of the man ( 25 ). The supporters of ADE and PAS do not believe that these actions are immoral per se , especially in the situations where the patient is suffering from great pain ( 26 ). In the medical practice, we have such conditions of the patient in which their pain cannot be controlled or reduced. According to the specific research, in the best scenario, 97% of all pain can be brought under control, but 3% of pains remain and that can be unbearable and cannot be controlled ( 27 ). We have noted just one of the many examples of unreasonableness of the observation of euthanasia as an immoral procedure ( 28 ). Simply, the interests and the will of the patient should be above the wishes of doctors, and even legislators. According to some authors, respect for human being involves four dimensions: concern for his well-being, respect for his wishes, respect of the core values of his life and respect of his interests ( 29 ).

When a physician determines that the patient suffers from an incurable disease, death becomes the inevitable outcome, and therefore, we cannot seek the cause of death in the medical treatment, but in the natural reasons. Regardless of the fact that determines the patient’s life by his active engagement, his act cannot be considered as a direct cause of the patient’s death. This removes the doctor’s responsibility, legal and moral ( 30 ). The fact that lies in the basic of the ADE and PE is the intention to terminate a patient’s life, elaborated in the acting/omission doctrine. Some authors assert this view, stating that a big difference exists between deprivations of life and letting someone to die, citing the example of the hunger in the poor regions of the world. If we accept a view that there are no differences between ADE and PE, and arguing that persons who die from the hunger did not die from poverty and shortages of the food, and in that case, we are all killers ( 31 ). This attitude is unacceptable for the obvious reasons. It is very important difference between occurrence of a death as an effect of the direct physicians’ act and its occurrence as a side effect of the drug given with the aim of relieving pain ( 32 ). Obviously, it gives moral justifications primarily to the active indirect euthanasia, while ADE remains in every sense morally prohibited, which is the unsustainable structure. Here, it is also unacceptable to set up possibility of comparing these two modes of death, especially from the patient’s point of view. After the occurrence of death, the patient is indifferent about this issue ( 33 ).

The authors who argue about admissibility of legalization ADE and on its complete immorality and deny the possibility of the deletion of legal and moral dividing line, when presenting counter-arguments do not take into account, or they mention it only cursory, without deeper analysis, a crucial fact without no treatment applied – the will of the patient ( 31 ). Here, we bypass theories about autonomy of the will from the John Stuart Mill and Immanuel Kant, although some authors believe that the right to self-determination derives only from the teaching of Kant ( 2 ). Autonomy of the will is the basis of dignity of human nature and the every mind nature ( 34 ). However, the authors who are deeply involved in the studying of the individual autonomy of the will bring into the question the ability of the patient to express his will to ADE, because they are under the pressure to agree with such act ( 35 ). As a counter-argument, there is a possibility of abuse, but this is a case with every procedure in the world.

The main argument for the removal of the status of immorality from the ADE lies in the patient’s autonomy of the will, and not bypassed. Therefore, we ought once again to remind Dworkin’s thesis that the grossest form of the tyranny is allowing the death of the person in a manner that another people justify ( 27 ). At the same time, we have to bear in mind the best interest of the patient, not limited only to the perception of his physician ( 36 ). Based on that, we can assess the patient’s best interest, because, there are situations in life in which a patient wants shortening of his life despite the real possibilities of his healing, where one should restrict his autonomy of the will. In addition, a patient wants to continue his medical treatment, even though the doctor diagnosed that death is inevitable. In such cases, the autonomy of patient’s will have a dominant character. The application of the euthanasia on that patient would mean a violation of the all ethical principles that exist. The men who simply do not want to accelerate his death despite serious medical condition, either for religious or from nonreligious reasons, thus expressing their will that must be respected and their life must not be shortened by applying ADE. Nobody has a moral right to decide for another person whether his life is worth living or not, because, for one person his pain can be unbearable to the point that his life is of no value, while for others pain cannot be compared with the values of life. Any decision that patiently brings is morally acceptable for him. It must be the same for everyone else. Overall, from the Table 1 , we can see that physicians were divided regarding the issue of the ethical acceptability of ADE. A slight majority, 56.8% believe that this method is ethically unacceptable, while 43.2% opted for another solution. In addition, 35.2% took a viewpoint that it is completely ethically acceptable, while the remaining 8% considered it ethically acceptable in certain cases. Respondents who viewed ADE ethically acceptable in certain situations could not deny its acceptability because they are aware of the fact that patient’s condition could be extremely difficult. This confirms initial hypothesis and we got expected results, not only here but also almost through the remaining results. Namely, in the region of Kragujevac, and also in the most part of Serbia, physicians did not yet meet with the ADE in practice, and therefore, their basic view on it and its ethical acceptability is mostly negative. Orthodox Church in the region contributes to such a view because it regards ADE and PAS as murders.

Our starting hypothesis is proved through the next, Table 2 . The highest percentage of the respondents who declared themselves in favor of ethics ADE is among respondents in the third, the largest part of the sample. Of the 19 physicians in the Ambulance, six consider that this practice is ethically acceptable, while just one considered that it is ethically acceptable in some cases. Twelve physicians opted for the opposite response. In the Emergency Room, on the other hand, almost no one of the respondents did vote in favor of ethics, except one, who sees ADE as ethically acceptable in some cases. The results show the correctness of the assumption that the physicians who are in the first place turned to saving lives will be against ADE, and that physicians in the Ambulance with majority will be against ADE. Another part of the sample with the mild majority voted in favor of ADE - we expected that because this part of the sample is not on the front line of the struggle for the life of the patients. Precisely because of this group of respondents, the percentage of the physicians who are against the ethical acceptability of ADE does not deviate much from the supporters.

The following question tried to establish ethical acceptability of the PAS and results are shown in Table 3 . What surprised us a bit is a greater support, even in a minuscule percentage, to the ADE in the relation to the PAS. As we can see, 56.8% of respondents answered negatively on the ethical acceptability of the PAS, while 33% of them opted for a completely ethic viewpoint of this procedure. Out of the remaining 10.2% opted for the ethical acceptability in certain cases. Although there are no excessive variations in relation to ADE, we assumed that a greater percentage of respondents would consider PAS more acceptable than ADE, since in this procedure physicians do not represent the main cause of the patient’s death. In PAS, they represent just accomplices, who will provide a necessary aid to the patients. In addition, physicians in some cases consider that they should not abandon their patients and that they should take responsibility for their death.

Results almost identically to the ADE are with PAS when we have a look at the distribution by departments in Table 4 . The only difference is reflected in the fact that the number of respondents who believe that these procedures are ethical to have fallen from 25 to 23, while two respondents increased the number of those who believe that PAS is ethically acceptable in some cases. Moreover, we can assume that these are two same respondents. Therefore, if we compare the percentage of the subjects in the ADE and PAS tables in the relation to the Emergency Room, we have identical data. Simply, respondents are absolutely against these procedures, except for the one, who believes that in some cases PAS would be ethically acceptable. Absolute orientation to saving lives contributes their denial of the justification of any form of the deprivation of life.

Euthanasia, regarded as deprivation of life with compassion, as well as PAS, is complex issues that cause and raise numerous questions. A particular problem is breaking euthanasia on ADE and PE, and then their different regulation. Morally and ethically, they are equal. In any case, autonomy of the will of the patient should be an essential moment. Physicians in Serbia are divided on this issue, but a group that considers ADE and PAS as ethically unacceptable is a bit more numerous. However, for the better view of their attitudes we should research on a much wider area.

Ethical considerations

Ethical issues (Including plagiarism, Informed Consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc) have been completely observed by the authors.

Acknowledgments

This work was supported by Faculty of Law, University of Kragujevac. The authors declare that there is no conflict of interest.

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