Euthanasia and physician-assisted suicide: focus on the data

Ezekiel Emanuel
Med J Aust 2017; 206 (8): 339-340. || doi: 10.5694/mja16.00132

We should aim at improving the care of dying patients

Modern debates about legalising euthanasia and physician-assisted suicide (PAS) in Great Britain and the United States began in the late 19th century.1 Legislation was periodically proposed only to be defeated until, in 1942, Switzerland decriminalised assistance in suicide for cases when there were no “selfish motives”.2 In 2002, euthanasia was legalised in the Netherlands and Belgium, then in Luxembourg in 2009, and most recently, in 2015 in Colombia and in 2016 in Canada.3 PAS, but not euthanasia, has been legalised in five US states. In Oregon, PAS was legalised by popular referendum in 1997. In addition, in 2009, Washington State legalised PAS by referendum and Montana by court ruling; Vermont in 2013 and California in 2015 also legalised PAS by legislation.4

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  • Ezekiel Emanuel

  • University of Pennsylvania, Philadelphia, PA, USA


Competing interests:

No relevant disclosures.

  • 1. Emanuel EJ. The history of euthanasia debates in the United States and Britain. Ann Intern Med 1994; 121: 793-802.
  • 2. Hurst SA, Mauron A. Assisted suicide and euthanasia in Switzerland: allowing a role for non-physicians. BMJ 2003; 326: 271-273.
  • 3. Deliens L, van der Wal G. The euthanasia law in Belgium and the Netherlands. Lancet 2003; 362: 1239-1240.
  • 4. Emanuel EJ, Onwuteaka-Philipsen BD, Urwin JW, Cohen J. Attitudes and practices of euthanasia and physician-assisted suicide in the United States, Canada and Europe. JAMA 2016; 316: 79-90.
  • 5. Onwuteaka-Philipsen BD, Brinkman-Stoppelenburg A, Penning C, et al. Trends in end-of-life practices before and after the enactment of the euthanasia law in the Netherlands from 1990 to 2010: a repeated cross-sectional survey. Lancet 2012; 380: 908-915.
  • 6. Chambaere K, Vander Stichele R, Mortier F, et al. Recent trends in euthanasia and other end-of-life practices in Belgium. N Engl J Med 2015; 372: 1179-1181.
  • 7. Oregon Public Health Division. Oregon Death with Dignity Act annual reports, 1999–2016. Oregon Health Authority; 2016. (accessed Mar 2017).
  • 8. Washington State Department of Health. 2014 Death with Dignity Act report: executive summary. Washington, DC: DOH; 2015. (accessed Mar 2017).
  • 9. Emanuel EJ, Fairclough DL, Daniels ER, Clarridge BR. Euthanasia and physician-assisted suicide: attitudes and experiences of oncology patients, oncologists and the public. Lancet 1996; 347: 1805-1810.
  • 10. Kissane DW, Street A, Nitschke P. Seven deaths in Darwin: case studies under the Rights of the Terminally Ill Act, Northern Territory, Australia. Lancet 1998; 352: 1097-1102.
  • 11. van der Lee ML, van der Bom JG, Swarte NB, et al. Euthanasia and depression: a prospective cohort study among terminally ill cancer patients. J Clin Oncol 2005; 23: 6607-6612.
  • 12. Groenewoud JH, van der Heide A, Onwuteaka-Philipsen BD, et al. Clinical problems with the performance of euthanasia and physician-assisted suicide in the Netherlands. N Engl J Med 2000; 342: 551-556.


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access_time 09:12, 24 April 2017
Ann Bull

I completely agree that the reason many people seek euthanasia or PAS is not primarily physical pain. Many seek it because of intolerable psychological pain, or what I would term end of life existential angst. Ask people who know, or consult the data - this seems to be a normal part of the ageing process for many people; as well as physical decline and inability to participate in activities, there is a loss of interest in and loss of enjoyment in activities of living. This gets to the extent where it is unable to be managed by anti-depressants and other means of managing depression. I have seen it happen myself, more than once.
It is ridiculous to pretend you can make decisions about how individuals feel about their end of life; it must be left to the individual. This is not all about physical symptoms; psychological pain is no less real and much more difficult to "palliate". Many people are very frail, very old, have extremely limited lives and are just ready to die. Why should they not be allowed to? It is false to argue that euthanasia and PAS will not improve the care of many dying patients. That is nothing but an appeal to the fear that the great majority of people have of death. I can assure you it is not shared by all of us to that extent. I suspect the author of this article has not watched their 89 year old father decline to the point where he begged to be killed as he could no longer get out of bed. Was he in physical pain? No, not really. Was he on antidepressants? Yes. Had he seen every specialist in the book? Yes, multiple times. Had he had great medical treatment for years? Yes. Had he just had enough and was ready to die? Also Yes. Did he have the right to die after a great life? Also Yes. Finally, to talk about a "small minority of patients who are depressed, worried about losing autonomy and being tired of life" when thousands of older Australians are driven to suicide each year (in some cases using nail guns) is so insulting I can barely contain my anger. If you do not wish to take advantage of your right to a dignified death, you have that choice.

Competing Interests: No relevant disclosures

Dr Ann Bull
Personal response

access_time 10:46, 24 April 2017
Christopher James Ryan

Prof Emanuel provides a concise but comprehensive overview of assisted dying, including the often overlooked concern that some people who request it in jurisdictions where it is legalised may have impaired decision-making capacity that is being missed.

At the end of his paper though, Prof Emanuel appears to lose his way. His conclusion that consideration of the evidence makes the case for legalising assisted dying less compelling appears to depend upon an assumption that those advocating legalisation claim it will "help solve the problem of poor end-of-life care". If there are such advocates, and I note Prof Emanuel provides no citation to support this claim, then they are obviously wrong. (Though perhaps it ought be acknowledged that in some jurisdictions legalisation has often precipitated significant enhancements to the funding of end-of-life care).

Medically assisted dying will not solve the problems of end-of-life care, and like all interventions it is not without risk or side-effect. Nonetheless, we should legalise such interventions because of the small minority of patients who would benefit from them. These are those who are near the end of their lives, are distressed, are losing their autonomy and who feel that their remaining days offer only continued burden.

We should, of course, apply careful safeguards and acknowledge limitations, but these are arguments for carefully drafted legislation and policy, not for a continuation of the status quo.

Competing Interests: No relevant disclosures

Dr Christopher James Ryan
University of Sydney

access_time 12:48, 13 May 2017
Katherine Pettus

Thank you for this very important article, which reinforces the literature building over recent years about psychological and spiritual suffering being at the root of requests for hastened dying. I believe there is a typo in the following sentence that you might want to correct, though: "Despite the importance of psychological suffering as the main motivator, few physicians in the jurisdictions where euthanasia and PAS are legal receive psychiatric consultation." While this claim is no doubt true, I believe that the author meant to say "few patients," which is a critical point and displays the structural tension between the "clearance" biomedical doctors will provide if not informed by psychologists or psychiatrists in a request for hastened death.

Competing Interests: No relevant disclosures

Dr Katherine Pettus

access_time 06:44, 13 June 2017
David Olive

To the extent that the medical profession must engage in the debate about end-of-life choices, the article by Ezekiel Emanuel is welcome. In its dismissal of euthanasia and physician-assisted suicide (E/PAS), however, it repeatedly fails on grounds of logic.

Emanuel points out that E/PAS is only relevant to a minority of dying patients, with “only” 6-6.7% of European patients requesting E/PAS and “only” 3.8-4.6% dying this way. Many would consider these proportions significant. Regardless, these percentages are irrelevant to the discussion. Assisted dying laws will only be accessed by a small proportion of dying patients. It is illogical to suggest that this makes such laws not worthwhile. Are laws prohibiting discrimination against the disabled unnecessary because most of the population is not disabled?

Secondly, Emanuel rejects E/PAS as most requests for it are not due to pain. This non-sequitur is never explained. The corollary of Emanuel’s arguments seems to be that if a patient did have untreatable pain, then this would be cause enough to seek a doctor’s help to die. Why is pain considered a more death-worthy symptom than any other? He is dismissive of psychological suffering, due, for example, to loss of autonomy or loss of dignity, as valid reasons for requests for E/PAS.

The psychological suffering of dying patients requesting assisted dying is most likely secondary to somatic symptoms. Few supporters of medically assisted dying propose it for primary mental illness. Emanuel quotes the low numbers of North American patients requesting E/PAS that receive formal psychiatric evaluation. This is not a valid argument against medically-assisted dying per se, but simply a suggestion that psychiatric assessment be included.

Finally, Emanuel highlights that E/PAS is not flawless. What in medicine is flawless? That 3.7-9.8% of cases of E/PAS have (undefined) “complications” or “technical problems” is no reason to jettison the whole concept. (Remarkably, these percentages, considered so significant by Emanuel in this context, are very similar in magnitude to those earlier considered trivial when discussing the percentage of patients requesting medically assisted dying.)

Emanuel appears to assume that E/PAS is mutually exclusive to palliative care. This is far from the standpoint of most supporters of E/PAS, who simply want E/PAS to be an option alongside palliative care.

The issue of patient autonomy is not mentioned in this review, despite it being a cornerstone of medical ethics. Opponents of physician-assisted dying are free to live according to their principles, be they religious or otherwise. Many object, however, to those principles being imposed on society at large.

In closing, Emanuel beseeches us to stop focussing on E/PAS and instead focus on improving the care of patients who are dying and need optimal symptom management at home. No, we can and should be doing both.

Competing Interests: No relevant disclosures.

Dr David Olive
Monash University

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