What Is the Debate Over Physician-Assisted Suicide?

The debate over the ethics and legality of physician-assisted suicide (PAS) is a long-standing and highly charged one. Notable legal challenges in the United States include Washington v. Glucksberg and Vacco v. Quill, both in 1997 and both of which upheld bans on PAS in Washington State and New York.

On the opposite side of the debate, Oregon enacted the first law legalizing PAS with the passing of the Oregon Death with Dignity Act in 1994. Since then, California, Colorado, Hawaii, Maine, Montana, New Jersey, New Mexico, Vermont, Washington, and Washington D.C. joined Oregon in enacting similar legislation.

Abroad, PAS in various forms (and with various restrictions) is currently legal in Australia, Austria, Belgium, Canada, Colombia, Ecuador, Germany, Jersey, the Netherlands, New Zealand, Portugal, Scotland, and Spain. Though attempts were made to lift assisted suicide bans, it is still illegal in Denmark, England, France, Ireland, South Africa, Switzerland, and Wales, among others.

This article takes a look at both sides of the debate over physician-assisted suicide, including the "morality" of PAS and whether it violates or supports the Hippocratic Oath ("first, do no harm").

What Is Physician-Assisted Suicide?

Physician-assisted suicide (PAS) is defined as the voluntary termination of one's own life by the administration of a lethal substance with the direct or indirect assistance of a physician. In the United States, a physician is a licensed practitioner with a doctor of medicine (MD) or doctor of osteopathic medicine (DO) degree.

PAS is not the same thing as euthanasia. Euthanasia takes place when a physician performs the intervention; with PAS, the physician provides the necessary means and the patient performs the act.

There are arguments for and against PAS based on ethics (the designated code of conduct for professions like medicine), mortality (the subjective designation of right or wrong), and legality (the interpretation of law).

Legal Challenges to Consent Laws

Many who opposed PAS are concerned that if assisted suicide is allowed, euthanasia won't be far behind and may lead to "mercy killings" in which people are euthanized without consent. These include people who are on life support, have serious mental illness, or are otherwise unable to grant informed consent for such actions.

Those who endorse PAS consider such conjecture inflammatory, arguing that the enactment of such laws goes against every constitutional law in place to ensure patient autonomy and self-determination. This includes the right to refuse or accept any medical procedure protected by the Due Process Clause of the Fourteenth Amendment.

Proponents of PAS further argue that a ban on assisted suicide restricts a patient's right of self-determination, namely by denying the choice to "die with dignity."

Moreover, physicians are not required by law to assist in the ending of a patient's life. They can conscientiously refuse and are protected by law to do so.

Violation of the Hippocratic Oath

The Hippocratic Oath is an oath of ethics historically taken by physicians that was written between the fifth and third centuries BC. Central to the oath is the phrase primum non nocere (meaning “first, do no harm”).

Opponents of PAS believe that the participation of a physician in a patient's suicide is the definition of harm and directly contradicts the oath. Doing so, they argue, is equivalent to "killing" or "murder."

Proponents of PAS argue that "death" and "harm" are not synonymous and neither are "suicide" and "murder." Many of these terms are legally defined and, as such, are not seen to be equivalent in the eyes of the law.

Countering this argument is the word "harm," which is legally defined as the "loss or damage of a person's physical well-being." While this may suggest the loss of life is "harm," the Hippocratic Oath is ultimately a principle rather than and law and the use of the term in the context is subject to debate.

Limit of Patient Autonomy

It was determined in the case of Bouvia v. Superior Court in 1986 that “the right to die is an integral part of our right to control our own destinies so long as the rights of others are not affected.”

The lawyers for Elizabeth Bouvia, a young quadriplegic woman who suffered from cerebral palsy, successfully argued that a person could not be forced to stay alive (in this case, through forced feeding) if their quality of life is severely and irreparably in decline. Doing so essentially deprives a patient of autonomy, including the right to die.

Opponents of PAS, many of whom would oppose forced feeding, nevertheless regard the Bouvia case and PAS as non-equivalent. Central to the argument is that PAS is not a completely autonomous act; it requires the assistance of another person.

Proponents of PAS counter that there is equivalence and that forcing a person to live with extreme, intractable suffering is unethical. By denying PAS, these same individuals may be forced to take extreme and violent actions to end their lives (and possibly fail).

Alternatives Make PAS Unnecessary

Palliative care is the practice of increasing comfort and easing pain and physical and emotional suffering in people with severe illness. Hospice care is a form of palliative care where comfort and pain control are provided when life-extending treatment is no longer desired.

Proponents of PAS argue that palliative and hospice care are humane and provide people the means to die with dignity if they are terminally ill.

Opponents of PAS counter that this excludes many with severe illnesses who will not improve and are exposed to needless suffering. They argue that PAS is an entirely different issue unrelated to palliative or hospice care.

Under the law, only people with six months or less to live are afforded coverage under Medicare and most other insurance. Palliative care can last for years. PAS, on the other hand, is the legal means to end a person's suffering whose life may or may not end soon.

Moreover, some people in hospice care choose to stop life-extending treatment because of the financial burden it places on their families. Supporters of PAS contend that the same choice should be afforded to people with severe, intractable illnesses who may also want to protect their families from financial harm.

Risk of 'Suicide Contagion'

Suicide contagion is an increase in suicide and suicidal behaviors as a result of exposure to suicide or suicidal behaviors within one’s family, from peers, or through media reports.

Opponents of PAS argue that providing a person with the legal means to end their life may promote suicide as a "solution" and encourage others to do the same.

Proponents of PAS point out that suicide contagion is not associated with a desire to end one's life for long-standing medical reasons but rather a response to emotional trauma, such as the suicide of someone the person was close to.

Studies investigating suicide rates after the passing of PAS laws have thus far found no association. A multi-center review of studies published in 2022 concluded that "no study has found a negative association between assisted suicide and non-assisted suicide."

In fact, one study from Oregon found a reduction in suicide rates among other males following the passage of that state's law.

In addition, there is no evidence that people "rush" to get PAS once laws are enacted. While the number of assisted suicides in Oregon has increased from 16 in 1998 to 278 in 2023, the rate of increase has been slow and gradual. Over 25 years, only 2,454 assisted suicides have been performed in the state.

PAS May Benefit Insurers and Others

There are some who argue that PAS will benefit insurers who can "save money" by avoiding the cost of life-extending treatments that could last for years. Over time, insurers may not only promote PAS to their patients but encourage it.

To date, there is no evidence of that occurring. While it is true that the cost of treating an illness like cancer can cost tens of thousands of dollars (and sometimes more), there is little evidence that insurers are "eager" to fund PAS.

A study published in the American Journal of Public Health found that many insurers will not cover the cost of a lethal dose of Seconal (secobarbital), a barbiturate drug most commonly used in PAS. As such, people are more often denied access to PAS due to the cost, particularly poor people.

Federal law currently prohibits Medicare, Medicaid, or any other government insurance from paying for or covering any expense associated with assisted suicide even in states where PAS is allowed.

Moreover, given the relatively modest number of patient-assisted suicides to date—as of 2022, 2,422 in California, 2,454 in Oregon, 291 in Washingon, 246 in Colorado, and 17 in Vermont—there is currently no indication that insurance practices have shifted from life-extending treatments to PAS.

Patient's Judgement May be Clouded by Depression

A concern frequently shared among people whose loved ones chose to stop life-saving treatment is that they are "just depressed" and will eventually change their minds.

The same concerns are shared among many opponents of PAS who express fears that not enough may be done to screen people for depression and other psychiatric illnesses who might otherwise avoid PAS if they are properly treated.

While it is true that a person with severe, intractable illness is almost certain to have a certain degree of anxiety or depression, proponents of PAS argue that the medical workup prior to the approval of PAS is extensive and intended to take that into account.

In California, for example, a person wanting to pursue PAS must be evaluated by a psychiatrist or licensed psychologist in addition to obtaining a confirmed diagnosis of a terminal illness with a life expectancy of less than months. Some states require multiple diagnoses from multiple providers.

To date, less than 1% of people who underwent PAS in Oregon were diagnosed with a mental illness. However, all were diagnosed with a terminal illness in which they were expected to live for less than six months.

Summary

Physician-assisted suicide remains a hotly contested topic despite laws allowing for it in 10 U.S. states and the District of Columbia. Arguments for and against assisted suicide include limits on patient autonomy, interpretation of the Hippocratic Oath, insurance coercion, whether current regulations are sufficient or lacking, and how current laws may affect future ones.