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Physician-Assisted Suicide and Euthanasia: The Issues

By: Romayne Gallagher MD, CCFP

Physician-assisted suicide or euthanasia seem like reasonable options for people who are suffering because of an incurable condition and cannot get relief.  And so they attract intense interest and discussion.

See also: Physician-Assisted Suicide and Euthanasia: Introduction

Doing whatever it takes to relieve suffering seems humane.  Yet the right to legally end life must be balanced by the responsibility to ensure the right is not abused.

The challenge of finding adequate safeguards against abuse is one of the major debates in physician-assisted suicide and euthanasia. Safeguards must ensure that the decision to seek death is made only by people who can understand such decisions, and who choose of their own free will. Vulnerable people must be protected from influence by others to choose death.

Other debates centre on questions of the "slippery slope" and how to balance physician-assisted dying with expanding quality palliative care. It is important to debate these fundamental issues, as the way we treat the most vulnerable among us says a lot about what our society values.
 

Why some people ask to die

Many people with a life-limiting illness talk about wanting to die. It is part of coming to terms with the illness. It does not mean they are asking for death sooner than later. People who suffer from uncontrolled symptoms such as pain, shortness of breath, nausea and anxiety may also say they want to die. This usually means they don’t want to live the way they do and are not aware of options other than death. Yet evidence shows that when symptoms are controlled with quality palliative care, the wish to die usually goes away.

People who ask to die may not have all the information they need to make a fully informed decision. They may not be aware of palliative care that can alleviate symptoms and remove the wish to die, or those options may not be offered or available where they live. Much work needs to be done to ensure quality palliative care is widely available for all people with a serious illness.

See also: What Is Palliative Care?
 

Ability to make decisions and the request to die

A major concern about assisted death is that person asking to die may not be mentally capable of making such a complex decision. He or she must be able to:

  • remember and understand information;
  • understand the consequences of the options being considered;
  • judge what is best for his or her circumstances;
  • give reasons for the request that are consistent with his or her known beliefs and values.

Effects of illness

Illness can have several effects on the ability to make a medical decision:

  • Dementia, stroke or trauma may damage brain function.
  • Medication may affect the ability to think and reason.
  • Failing organs such as kidney, liver, lung or heart may increase toxins or decrease oxygen in the body, which will make the brain foggy.

Older patients are more likely to develop problems with brain function. Their brains are more fragile than those of younger people, which makes them less resistant to toxins, and more likely to be injured by illnesses such as stroke or dementia.

A sudden change in brain function caused by illness is called delirium. A person’s ability to think and make decisions may change within hours or days. It is easy to spot delirium when a person is agitated, doesn't make sense, or doesn't respond to reason. It is hard to spot delirium when a person is quiet and withdrawn, or when there are no family or friends to report a change in behaviour.

See also: Confusion

Delirium or problems with thinking are common in the last months or weeks of life. When this happens, people may not be capable of making complex medical decisions. Research has shown that health care providers often can't identify those patients. In one study (1), more than 150 hospital patients who appeared normal were given a decision-making test. Of those patients, 50 could not make standard medical decisions. Of the 50 patients, the medical team identified only 12 as unable to make decisions.

Other studies (2) show that memory and judgment problems can last long after the causes of delirium have been treated and the delirium reversed. Often, health care providers don’t detect these difficulties, especially if patients have good social skills and are not asked questions to test their judgment.

Effects of depression

Depression can affect decisions. Up to 25% of people with serious chronic illness are depressed, but often it is not identified and not treated because of the assumption that it is normal to feel depressed with a life-limiting illness. Many people feel down when they get bad news or their health gets worse. But feeling depressed enough to want to die is not normal even with a life-limiting illness. Neither is feeling hopeless, helpless or worthless. These are signs of depression.

In one study (3), 200 terminally ill patients were asked about their desire to die. Researchers found that of those who had a strong desire to die, 59% were depressed. Studies have also shown that anxiety can make people want to die. Treatment of mood and anxiety disorders can often help people feel much better and change their minds about hastening death.

See also: Depression

Effects of external factors

People who ask for death may do it because of the influence of other people.  It may be that they have trouble adjusting to being dependent on others. They may feel they are placing too big a burden on their family and that their death would relieve that burden. They may not have told their family about these concerns.  In most situations the family doesn’t consider caregiving a burden and really wants to help. Some people find the experience of caring for someone enriches their lives.

Patients who have no close family or friends may worry that they will have no help as their illness progresses. They may see death as a way to escape their fear and loneliness.

Concerns about money may make some people ask  to die. While fees for health care are mostly covered in Canada, there are still costs to being ill, which can be a hardship.
 

Safeguards

Safeguards are intended to make sure that people make free, informed decisions, and that they consider all possible options.

In most places where physician-assisted death is legal, two physicians are involved in each request. One physician makes the initial assessment and recommendation, the second physician reviews the recommendation. To safeguard against decisions driven by depression, people with signs and symptoms of depression must be referred to a psychiatrist. Yet some have concerns these safeguards are not always followed. Often only one physician assesses a request for death, and depressed patients are not always referred to a psychiatrist.

All doctors would like to think that they recommend treatment in an unbiased way, with the patient’s best interests in mind. Yet studies (4) show that doctors’ decisions are shaped by a variety of values and concerns that have less to do with the patient than with the doctor. These findings emphasize the need for independent safeguards.
 

“Slippery slope”

Physician-assisted suicide and euthanasia are considered a rare exception and last resort after all other options are exhausted. Yet there are worries that the criteria used to approve assisted death will broaden over time. This could make physician-assisted suicide and euthanasia a first choice rather than last resort in some situations. Another worry is that opening the door to physician-assisted suicide and euthanasia may lead to acceptance of forms of death currently not acceptable. This is the issue of the “slippery slope.”

In the Netherlands and Belgium, physician-assisted suicide initially applied only to patients with a terminal illness. Now the rule is that a person must be “suffering hopelessly and unbearably,” and that the suffering may be physical or psychological. The revised rules have opened the way for people with depression or chronic conditions to ask for death. It is very difficult to define hopeless and unbearable suffering, as studies (5) have shown these can vary over time. This is especially true when there are symptoms such as anxiety, depression or pain.
 

Health care providers' concerns

Studies (6) show that attitudes of health care providers to physician-assisted suicide and euthanasia vary greatly. In general, the health care providers with the most experience in palliative care are the least likely to support physician-assisted suicide and euthanasia, and generally do not provide these services. This may be because doctors have the right to refuse to provide a service they are ethically opposed to, or it may be because they are aware of the many ways to alleviate suffering.

Many health care providers are concerned that allowing physicians to prescribe or administer drugs to end a patient’s life will change the nature of the doctor-patient relationship. Some believe it will lead to a lack of trust in physicians and the medical profession, especially of those working in palliative care.
 

Alternatives to physician-assisted suicide or euthanasia

Palliative care does not try to prolong life or hasten death. The goal of palliative care is to give comfort - to control the patient’s symptoms and support the patient's family. While the goal is to relieve suffering, palliative care professionals recognize that not all suffering can be controlled.  Yet it does not follow that the only response to uncontrolled suffering is to end the person's life. We need to understand more about the nature of suffering. We need research to help us understand what makes suffering tolerable for some people and unbearable for others. We need to understand how we can help to maintain dignity and control to the end of life.

See also: Dignity in Care

We need to ensure that palliative care continues to give patients and their families the best possible quality of life and support. The goal must continue to be respect people's desire to control their lives and maintain their dignity during the dying process. This includes respect for their questions about physician-assisted suicide and euthanasia. It is important that we continue to explore these questions in the context of all options for care at the end of life.

Physician-assisted suicide and euthanasia in Canada

Physician assisted suicide and euthanasia in Canada has been termed medical assistance in dying (MAID). Medical assistance in dying in Canada applies only to people who are fully able to make an informed decision, who have a serious illness, are in an advanced state of decline, are suffering unbearably from their illness, and are at a point where their natural death has become reasonably foreseeable.

A Supreme Court of Canada decision has made medical assistance in dying legal in Canada starting in February 2016.  Bill C-14, legislation on medical assistance in dying in Canada, received royal assent on June 17, 2016.

Decision-making about MAID and provision of medical assistance in dying lies outside the palliative care focus of CVH. 

Information about medical assistance in dying can be found on the Government of Canada’s website. 

The Canadian Virtual Hospice (CVH) provides information and support to manage illness through a palliative approach to care. This website has many valuable articles and videos about serious illness as well as grief and loss. Please search our website for information and supportive ways to cope.
 

References

(1) Raymont V, Bingley W, Buchanan A, David A, Hayward P, Wessely S et al. Lancet 2004; 364:1421-27.

(2) Cole M. Persistent delirium in older hospital patients. Current Opinion Psychiatry 2010: 250-54.

(3) Wilson KG, Chochinov HM, McPherson CJ, et al. Desire for euthanasia or physician-assisted suicide in palliative cancer care. Health Psychol. 2007;26(3):314-323.

(4) Teriman J, Berry D, Cochrane B, Doorenbos A, Schepp K. Physician, patient, and contextual factors affecting treatment decisions in older adults with cancer and models of decision making: a literature review. Oncol Nurs Forum. 2012 Jan;39(1):E70-83.

(5) Chochinov H, Tartaryn D , Clinch J, Dudgeon D. Will to live in the terminally ill. Lancet 1999; 354: 816-19.

(6) Portenoy R, Coyle N, Kash K, et al. Determinants of the willingness to endorse assisted suicide: a survey of physicians, nurses and social workers. Psychosomatics. 1997;38:277-287.

Content Reviewed August 31, 2016