Physician-assisted Suicide and Euthanasia from a Policy Perspective

It is no doubt that with the decline of the baby boomer population and the increase in the

number of people who are suffering from life threatening diseases, subjects such as euthanasia

and physician-assisted suicide (PAS) will resurface and become the focus of the medical world

as many hospitals and nursing homes especially, are increasingly being confronted with this

ethically sensitive societal issue (Lemiengre et al., 2014). With many different factors to take

into consideration, a decision on such a subject cannot be reached overnight and requires an

extensive amount of research and evidence. Both euthanasia and PAS are in fact a controversial

topic because of the many sides that encompass it and the various groups of people that are

affected by any course of action taken in developing policies regarding this issue. These terms

have been divided into separate categories and are often mistaken for one another, it would then

be appropriate to define each term as well as the subcategories that may be underlying them,

which will therefore become of importance regarding the policy realm.

Physician-assisted suicide refers to a situation in which a physician knowingly and

intentionally provides a person with the knowledge and/or “means required to end their own

lives, including counselling about lethal doses of drugs, prescribing such lethal doses or

supplying the drugs” (Landry et al., 2015), in cases such as this, the physician is not the one who

is administering any form of drug, but has only validated their request, therefore this becomes

the task of the patient to take his/her own life. In the case of PAS, the use of the word suicide

gives the term an overall negative meaning and in the eyes of the public might be misleading to

what that form of treatment may offer for the patient. When compared to suicide, PAS has been

authorized by a team of medical professionals and it ensures that the death will be painless for
the patient. PAS is also discussed with the family of the patient in order to ensure that there is

support and closure regarding the death, but suicide conducted outside of the medical context

causes an extensive amount of grief to the family and friends of the victim and sometimes with

no explanation, unlike PAS which is driven purely by physical and mental illness. In the case of

euthanasia, there are two different categories, voluntary and involuntary. Voluntary euthanasia

encompasses all those patients who have, based on their own volition, agreed to euthanasia and

are characterized as “those in which the patient is mentally competent” (Emanuel et al., 2016),

this term is interchangeable with active euthanasia which is defined as the infliction of painless

death as an act of commission (Zachariah, 2015). On the other hand, involuntary euthanasia

occurs when the patient is not aware and did not request euthanasia, examples of such cases are

patients in long term comas, those who are mentally deficient or have severe brain damage

(Emanuel et al., 2016), with a secondary term of passive euthanasia, which is defined as the

infliction of painless death as an act of omission (Zachariah, 2015). These definitions raise many

questions when a policy is needed to be put into place for example, who is considered mentally

competent? Who is eligible to receive euthanasia or PAS? As well as many other layers that

make up the policy making steps for reaching a solution.

Specific to North America, neither PAS nor euthanasia is legal everywhere. In Canada,

Quebec legalized both in 2014 and as of June 2016 it became legal nationwide and for the United

States of America, only 5 states have legalized euthanasia and PAS (Oregon, Washington,

Montana, Vermont, and California) (Emanuel et al., 2016). All US states require patients

receiving PAS/euthanasia to have a prognosis for survival of less than 6 months. As well, all US

states permitting PAS/euthanasia require a 15-day period between 2 oral requests and a 48-hour

waiting period between a final written request and dispensing of the prescription. In contrast,
Canada only requires a 10-day waiting period between a written request and provision of

PAS/euthanasia (Emanuel et al., 2016). In cases without death in the foreseeable future,

consultation of a second independent physician and of a third physician is required, as well as a

one-month waiting period between the written request and the performance of PAS/euthanasia

(Dierickx, 2017)

There are many individuals who are currently suffering from some sort of physical or

mental illness and in a poor medical condition. These individuals would rather receive PAS or

euthanasia as opposed to living another day in excruciating pain, yet this cannot happen for them

since neither practice may be legal in their location. Not only is the location of the individual a

barrier, but there are also other restrictions that may make a patient ineligible to receiving this

form of medical attention, such as age, mental state, physical state, accessibility and even the

willingness of the physician to comply with the request of the patient. In order to regulate the

number of people that receive this form of care, in every country there is a checklist of things

that the patient must qualify for. For example in North America, the patient must be at least 18

years of age in order to provide verbal and written consent, the individual must be suffering from

a serious and incurable disease to the point where their symptoms have now become irreversible,

and are experience some sort of physical or psychological pain that cannot be alleviated in a way

that he or she deems tolerable (Mishara and Weisstub, 2015).

Question arise when these restrictions are being implemented such as, the mental state of

a patient, what it truly means for an individual to be categorized as having a poor mental state

and whether more medical precautions are required in such cases. Individuals who experience
some form of mental distress will more likely than not will be receiving some sort of psychiatric

help to aid them through the process of their illness, hopefully towards recovery. Unfortunately,

there are cases when the patient does not feel as though there is any possible cure to their ill

besides death, in which case the patient will request PAS or euthanasia. Regarding this form of

medical assistance, The Canadian Psychiatric Association, has no official position and cannot

weigh in on the decision of a physician to approve the request for death. They have argued that,

because the patient will be experience cognitive distortions, found in mentally ill patients, they

will be unable to make the proper decision and might not be aware of the irreversible effects of

this (Benrimoh et al., 2017). Patients that are affected by “a severe mental disorder with repeated

suicide attempts” (Benrimoh et al., 2017) could be choosing this medical route as a way of

fulfilling what they have been attempting to do multiple times, but have not succeeded. In

addition to this, it is very possible that death might be the symptom of their psychiatric disorder,

which would therefore mean that their capacity to make a proper decisions is impaired (Dierickx

et al., 2017). Despite the fact that there are many with these disorders that do request for PAS or

euthanasia, a section within the law has not yet been made to include such special cases and only

“recognizes those that death is foreseeable and that prognosis to survival can be made”

(Benrimoh et al., 2017). Such individuals who are not included within this ‘check-list’ of

qualification, but sincerely want to go through with their own death will now be faced with two

options, one of which is to take his/her own life, often through violent means, and the other

would be to suffer until death occurs through natural causes (Guichon et al., 2017).

Another restriction in the PAS/ euthanasia debate is the age in which patients can make

an independent decision whether they would like to receive this form of medical attention. As

previously stated, Canada requires the patient to be a minimum of 18 years old to make a verbal
and written decisions as to whether they would like to receive PAS or euthanasia. This restriction

does not entirely cover special cases such as severe illness at a young age, at it is the goal of

most individuals to see children thrive so that they can live long and healthy lives and when

faced with the decision to take away this opportunity, most physicians and key contributors to

the decision will hesitate and look extensively for alternative options in order to preserve the life

of a minor, even when they might have the desire to go forth with PAS/euthanasia (Guichon et

al., 2017). Even though it is of utter distress to take the life of a minor, only in special cases

where the minor is mature, competent, well-informed and acting voluntarily, will they be

allowed to request PAS/euthanasia, and they must have permission from a legal guardian to go

forward with this form of medical assistance granted they meet all other requirements in terms of

pain level and lifespan (Guichon et al., 2017).

As this process is taking the life of an individual it is required that the steps being taken

are each approached with evidence and have data and study to support the findings. Evidence

based decision making can eliminate many errors, as it considers the various areas and

individuals within those sectors that will be affected by whatever policy is being made.

Therefore, for the case of PAS/euthanasia, the written institutional ethics policy is a written

agreement which covers all the protocols, restrictions, procedures, guidelines etc., that has been

authorized at an institutional level to ensure that the care providers are approaching this the

clinical-ethical problems from the proper angles and their decisions are made with caution to

eliminate the chances for accidents (Lemiengre et al., 2014).

Physician-assisted suicide and euthanasia requires a permissive regime with properly

designed and administered safeguards to protect vulnerable people from abuse and error (Landry

et al., 2015). This regime contains five policies that should be met: ‘‘(1) the parties that must
comply with the policy must be represented; (2) there must be a deliberative process that is based

on facts and that covers the scope of the healthcare organization’s obligations; (3) the rationales

for the policy must be publicly known and accessible; (4) there must be mechanisms for

conscientious objection and for revising the policy; (5) there must be specific procedures for

ongoing evaluation of the practice” (Lemiengre et al., 2014). It is of utter importance for there to

be rigorous academic literature accessible to the public so that they can be informed by facts and

properly integrate themselves within this public policy and not be misshapen by smoke and

mirrors (Downie et al., 2012). Those that are educated regarding the topic will be able to make

more appropriate decisions when faced with the policy issue and will have the ability to tackle

the problem from all areas, as they have the proper background information to do so (Downie et

al., 2012).

Even with restriction in place and studies that have been conducted, there remains a large

group of individuals that do not agree with any form of PAS or euthanasia, believing that by

taking the life of another human being irrespective of their physical or mental state is playing

God (Huntoon, 2016). It was found in a study, an individual’s religious faith or religiosity is

widely recognized as one of the strongest indicators of euthanasia acceptance, correlating

negatively with support for euthanasia (terkamo-moisio et al., 2017). Therefore most of the

individuals who belong to this opposition group have made their decisions based off of their

religious backgrounds and have not, for the most part, looked at research or evidence to make

their claims against PAS/euthanasia. These individuals strongly believe that this form of medical

assistance is driving society towards normalizing and promoting a culture of death, and would

rather life take its course no matter the amount of pain the patient may feel (Huntoon, 2016).

And as society takes its course towards this form of normalization, “society would slide down a
slippery slope to the killing of patients who did not make a free and informed request and

palliative care would be disregarded as the number one resource for the patients (keown, 2002).

Individuals in the opposition could develop the fear that, “the practice of PAS and euthanasia

would irrevocably destabilize the trust that society confers upon them as healers” (wright et al.,

2015). Other arguments that have been made against PAS/euthanasia are that temporary pain

relief should be repeatedly administered to the patient until death and that the difference between

active and passive euthanasia are insignificant and can all be classified under assisted suicide, as

the life of a human being is taken (Zachariah, 2015).

Aside from those who do not wish to have PAS/euthanasia as an option to illness, there is

also a category of people that are not willing to comply with the administering of

PAS/euthanasia, these are the physicians themselves. A study was conducted which disproved

that physicians were abusing these medical technics, as the results found that 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 (Emanuel et al., 2016). This is primarily due to

the guilt that these individuals feel in regarding to taking a life, even though it is the life of a

patient that is dying from a painful illness, and this statement is supported by a study that

presented data, stating that 86% of physicians dread the emotional burden of performing any

form of assisted-suicide as it creates a feeling of guilt, therefore they would rather refuse the task

instead of living with the thought that they took a life (Emanuel et al., 2016). The downside to

the refusal on behalf of the physicians could be that they may feel pressure on behalf of the

legislature as well as the feeling that they have abandoned their patient and therefore broken that

patient-physician bond that was established (Huntoon, 2016). Many have stated that they had
taken an oath to save lives and that “medicine’s basic mission as healing and protecting life” and

they may “see euthanasia as fundamentally conflicting with this mission” (Wright 2015).

With the rise of diseases, natural disasters, elderly deaths and accidents placing

individuals in poor mental and physical states, PAS/ euthanasia is a policy issue that will never

go to rest as it is also one of the most controversial topics. With a group of individuals for

PAS/euthanasia and one group against, it is the job of policy-makers and stakeholders to

implement a course of action which will create a compromise for the majority. They must

abolish the worry that the legalization of euthanasia and PAS may eventually progress into

becoming a routine practice (keown, 2002), while complying with those who would like to die

with dignity and receive such medical assistance to do so. To eliminate this worry, more rigorous

steps should be taken in order to label a patient as qualifying to receive PAS/euthanasia,

therefore “only when palliative care fails to address the patient’s wishes and is unable to

adequately mitigate the patient’s physical and mental suffering should physicians offer

euthanasia” (Cohen-Almagor, 2009). As a part of the policy, yearly assessment should be

conducted to monitor the number of patients that are requesting this medical treatment and the

number of cases which the physicians are complying with the wishes of the patient. The

government has recognized that even with the physicians not wanting to comply with

PAS/euthanasia and a small group of individuals opposing it, euthanasia is what the people want

and now politicians are studying the situation before they would opt to introduce further changes.

The government does not think there is a problem with the euthanasia practice (Cohen-Almagor,

2009), which indicates that in terms of the policy, PAS/euthanasia practices will not terminate in

the mean time, but might experience changes to satisfy the needs of the public receiving this

care.
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Nureen Bahraini (300125446)

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