Assisted Suicide: Overview

Introduction

Assisted suicide is a controversial medical and ethical issue based on the question of whether, in certain situations, medical practitioners should be allowed to help patients actively determine the time and circumstances of their death. Although the taking of another human's life is almost universally condemned as murder, assisted suicide and other forms of euthanasia are sometimes seen as benevolent acts because they allow a person who is suffering or terminally ill to choose how and when to die and to do so with less pain than they otherwise would experience.

Assisted suicide differs from euthanasia in that euthanasia involves a physician who administers a fatal dose of medication or withholds life-saving medical treatment. With an assisted suicide, however, the physician merely prescribes lethal drugs that the patient then self-administers. Assisted suicide can take a variety of forms. In voluntary passive euthanasia, a physician may instruct an individual on the best method for dying by suicide, while the activity is actually undertaken by the individual. In voluntary active euthanasia, the physician, at the request of the patient, administers a substance that causes death. A related practice is that of passive euthanasia, in which a physician removes life-support or does not take all possible measures to prolong life.

US law makes a general distinction between physician-assisted suicide and passive euthanasia. In many states, it is acceptable upon the request of the patient, their representative, or family members, to withhold extraordinary measures or some forms of treatment even if by doing so the patient stands a greater chance of dying. Most states guarantee a patient’s right to refuse treatment, especially in cases of terminal illness. Assisted suicide and euthanasia are prohibited in most states and carries felony charges akin to manslaughter or murder. In many states, it is illegal for a physician to give any advice that might help a patient die by suicide.

Physicians and ethicists debate whether assisted suicide is a legitimate medical practice. The Hippocratic oath, one of the earliest examples of codified medical ethics, contains a provision stating that physicians should not, through the course of their work, cause any harm to a patient. Some believe that this ancient principle should still apply and that assisted suicide constitutes a violation of ethical principles. Most modern ethical codes, such as those adopted by the American Medical Association, require physicians to swear to follow all national and local laws in performing their jobs. The issue of physician-assisted suicide has therefore become both an ethical and a legal debate.

With the advent of drugs that can both prolong and terminate life, as well as medical technology that can keep patients technically alive even in comatose or vegetative states, many questions have been raised about the quality of life each person deserves and identifying the fine line that demarcates the end of life. In addition, in the United States—a country marked from its inception by the hallmarks of individuality and personal responsibility—citizens and lawmakers alike are wrestling with issues regarding the degree to which an individual or family member should be empowered to make personal, private decisions about whether to continue medical care for a loved one or choose the time, place, and manner of the loved one's death.

Activists on both sides of the euthanasia and assisted suicide debate have lobbied lawmakers to enact legislation in support of their views. The right-to-die movement is gaining support as a humane alternative to a poor quality of life maintained solely through continuous medical intervention.

Understanding the Discussion

Euthanasia: The practice of ending a person's life either through an intentional act or by withholding medical care. The action is performed without malice but with the intention of alleviating suffering or ending the pain of a terminal illness or poor quality of life.

Hippocratic Oath: An oath (or promise) all physicians must swear to uphold, regarding the ethical practices of the medical profession. Its central premise is "to cause no harm" and work for the "good of the patient." A second clause states that a doctor will not administer lethal drugs.

Hospice: An alternative program of care for patients in the final stages of life in which efforts are not designed to treat the patient's underlying illness but rather to provide pain management, symptom control, and family support.

Informed consent: A patient's expression of knowledge and acceptance of the risks, benefits, and alternative treatment options of a medical procedure and subsequent permission to a physician to perform the procedure.

Physician-assisted suicide: A procedure in which a physician deliberately and knowingly prescribes lethal drugs at the individual's request for the purpose of self-administration, allowing them to die by suicide.

Refusal of Treatment: When medical professionals agree not to give a patient certain treatments, even though they might be needed in order to prolong the patient’s life.

Right to Die: A belief that individuals should have the authority to choose the time, place, and manner of their death.

Terminal Illness: A medical condition that has no effective treatment options or that is so advanced that treatment options are no longer available.

History

Although modern medical advancements and increased patient autonomy have renewed public interest in the right to die, the practice of euthanasia has been in existence for centuries. Numerous Greek and Roman writings have revealed a belief that death, even if initiated by self or another person, was preferable to prolonged suffering. However, this belief was not universal. The Hippocratic oath, which medical practitioners in the United States have traditionally recited or agreed to uphold as a basic tenet of their practice, is believed to have been penned about 400 BCE by the Greek physician Hippocrates, known as the Father of Medicine. The oath not only includes the promise to never cause a patient harm, but it also includes promises to never knowingly provide deadly medicine to a patient if asked or to ever suggest such a course of action.

In the United States, prohibitions against intentionally aiding in the death of another date back to the country's formation. Early American statutes outlawed suicide and assisted suicide. In the early 1900s, a physician's grim decision brought euthanasia to the forefront of public debate. On November 12, 1915, a badly deformed child was born to Anna Bollinger. Her doctor conferred with the hospital's chief of staff, Dr. Harry J. Haiselden, who advised against performing surgery to save the child. Five days later, the baby girl died, and the case and Dr. Haiselden's decision were widely debated.

During the 1930s, widespread distress caused by the Great Depression and its accompanying economic turbulence led to a spike in suicide rates and discussions of euthanasia and a right to self-determination over end-of-life matters. Public opinion polls revealed a growing belief that euthanasia was acceptable under certain circumstances. While it seemed that public support for legalizing euthanasia was coalescing, World War II broke out and the world recoiled in horror as news of Nazi death camps and the calculated mass extermination of vulnerable members of society, including tens of thousands of people with disabilities, made international headlines. Such atrocities dampened support for any form of legalized assistance in initiating another's death.

For several decades, discussions of euthanasia simmered largely in the background. In 1976, the tragic case of twenty-one-year-old Karen Ann Quinlan once again moved the euthanasia debate to national headlines. After consuming alcohol and prescription drugs at a party, Quinlan lost consciousness and ceased breathing. She was rushed to the hospital where doctors declared that she was in a "persistent vegetative state," with full recovery unlikely. Her adoptive parents fought a year-long legal battle for rights to make the final decision to remove her respirator, thereby likely ensuring the end of her life. Although the New Jersey Supreme Court ultimately ruled in favor of the Quinlan family, Karen continued breathing naturally after her respirator was removed for nearly a decade, until she finally succumbed to complications from pneumonia. The Quinlan case also led to the advent of formal ethics committees in hospitals, nursing homes, and hospices that provide support in complying with a patient's advanced health care directives, or written instructions to family members and health care professionals about end-of-life care.

In 1980, right-to-die advocate Derek Humphry formed the Hemlock Society, a grassroots organization that worked to advance euthanasia legislation. In addition, growing consensus for patients' rights, including the right to refuse medical care—and even life-sustaining care—refocused attention on the right-to-die movement. Over the next several decades, public support for autonomy in end-of-life decision making has increased, with several states enacting legislation that recognizes living wills, or a legal document in which a person expresses his or her wishes regarding life prolonging medical treatments, including the withdrawal or refusal of life-sustaining medical treatment.

In 1990, the US Supreme Court first ruled on the right to die movement in Cruzan v. Director, Missouri Department of Health. A car accident left Nancy Cruzan permanently unconscious, and her parents requested that her feeding tube be withdrawn. After years of continuous care, most of the costs for Cruzan's hospitalization were being paid by the state of Missouri. Although a Missouri district court granted the Cruzan family's request to remove the tube, the director of the Missouri Department of Health took the case on appeal to the Missouri Supreme Court, arguing for clear proof of Nancy Cruzan's end-of-life wishes. The case went before the US Supreme Court, which ruled that a competent person has a constitutionally protected right to refuse any medical treatment, although states have a right to insist on clear and convincing evidence as to a patient's wishes. In this case, there was no clear and convincing evidence that Cruzan would have wanted to have life-sustaining treatment withdrawn.

In the US Supreme Court cases of Washington v. Glucksberg (1997) and Vacco v. Quill (1997), physicians in Washington and New York challenged state prohibitions on assisted suicide. The Supreme Court determined that the “right to die” by one’s own hands or assisted by another is not a fundamental right protected by the Constitution, thereby upholding state bans prohibiting assisted suicide. However, the Supreme Court’s rulings did not actually prohibit assisted suicide as a constitutional matter, thus leaving room for states to prohibit or legalize suicide at their own discretion.

In 1998, Dr. Jack Kevorkian appeared on the television program 60 Minutes, which aired a videotape of him administering a lethal injection to Thomas Youk, who was suffering from amyotrophic lateral sclerosis (ALS, or Lou Gehrig’s disease). Although several juries had acquitted Dr. Kevorkian for assisting in patients' suicides, in 1999 a Michigan judge sentenced Kevorkian to ten to twenty-five years in prison for the second-degree murder of Youk. Kevorkian served eight years and was released on parole on June 1, 2007.

In another landmark case, Terri Schiavo's family waged a legal battle for seven years to determine rights to her end-of-life care. Terri experienced brain damage resulting from the loss of oxygen in 1990 and lapsed into a persistent vegetative state. In 1998, her husband, Michael Schiavo, petitioned the Pinellas County Circuit Court to have her feeding tube removed, but her parents objected, arguing that Terri remained conscious. After complex legal proceedings, the Florida Supreme Court overturned Terri's Law, emergency legislation that was enacted to give Governor Jeb Bush the power to order the reinsertion of Terri's feeding tube, and the US Supreme Court refused to intervene in the case. Terri Schiavo died thirteen days later on March 31, 2005.

Between the 1990s and 2010s, several state legislatures considered right-to-die legislation. In 1994, Oregon became the first state to legalize assisted suicide, giving physicians the right to prescribe chemicals that facilitate death only once specific conditions have been met, including residency in Oregon, two oral and one written requests each two weeks apart, a medical prognosis of six months or less left to live and confirmation of the diagnosis by a second physician. Oregon’s Death with Dignity Act was approved by popular vote but was delayed by strong resistance from lobbyist groups. After the Supreme Court’s rulings in 1997, Oregon’s bill became law and received a second vote of popular approval from Oregon citizens.

In 2001, Attorney General John Ashcroft issued an Interpretive Rule threatening sanctions under the federal Controlled Substances Act against doctors who assisted patients in ending their lives in accordance with Oregon’s Death With Dignity Act. The State of Oregon challenged the attorney general’s rule in court and the Ninth Circuit decided in the state’s favor, issuing a permanent injunction against the rule’s enforcement. In 2005, Attorney General Roberto Gonzales brought the case to the Supreme Court. The Ninth Circuit’s decision was ultimately upheld by the US Supreme Court in 2006 in Gonzales v. Oregon.

Washington and Vermont passed legislation similar to Oregon's in 2008 and 2013, respectively, and the Montana First Judicial District Court ruled in 2008 that a terminally ill, mentally competent patient has a legal right to die using the assistance of his or her physician to obtain a prescription for a lethal dose of medication. In 2012, a Massachusetts ballot initiative, the Death with Dignity Initiative, was narrowly defeated in the state's general election. Two years later, in January 2014, New Mexico Second Judicial District Judge Nan Nash ruled that terminally ill, mentally competent patients have a right to physician-assisted death; that ruling was appealed to the New Mexico Supreme Court, which overturned Nash's decision in June 2016. In November 2014, the New Jersey Assembly passed the Aid in Dying for the Terminally Ill Act, which the state senate referred to committee and which the state governor vowed to veto; the measure was reintroduced again in 2015 and in 2016. With legislation passed in October 2015, California began permitting physician-assisted death for terminally ill patients in June 2016. In November 2016, 65 percent of Colorado voters supported Proposition 106, which made it legal in the state for individuals who are over the age of eighteen and who have a terminal illness that leaves them with less than six months to live to receive a life-ending prescription from a licensed physician. Washington, DC, passed its Death with Dignity Act in December 2016, which went into effect in February 2017.

Outside of the United States, Euthanasia became legal in certain countries and territories in the late twentieth century and early twenty-first century. In Australia, euthanasia was legalized in the Northern Territory in 1995 and then overturned in 1997. In 2002, both the Netherlands and Belgium officially sanctioned euthanasia. In 2008, Luxembourg legalized euthanasia for terminally ill patients and those with incurable diseases or conditions, provided there is documented and witnessed evidence of a patient's multiple requests to die and the consent of two doctors. In 2015, euthanasia was made legal by the government of Colombia. By 2017, assisted suicide was legal in Switzerland, Japan, Canada (led by Quebec's decision to allow it in 2014), and Germany, as well.

Assisted Suicide Today

State legislatures continued to pass physician-assisted suicide laws in the late 2010s and early 2020s. By May 2024, physician-assisted suicide was a legal option for terminally ill patients in ten states and the District of Columbia, although euthanasia, in which fatal drugs are administered to a patient by a physician, remained illegal at the federal level. Hawaii passed the Our Care, Our Choice Act into law in April 2018. The law took effect the following January. New Jersey's Aid in Dying for the Terminally Ill Act became law in April 2019, and took effect that August, while Maine's governor, Janet Mills, signed its Death with Dignity Act into law in June 2019. In April 2021, New Mexico's Elizabeth Whitefield End-of-Life Options Act was signed by Governor Michelle Lujan Grisham and went into effect in June 2021.

Even as several states passed laws allowing assisted suicide, some existing state laws faced legal challenges. In May 2018, Superior Court Judge Daniel Ottolia overturned California's End of Life Option Act (2015), ruling that it was unconstitutional because the state legislature had passed it during a special session. The state's appellate court stayed Ottolia's judgment the following month and the California Supreme Court affirmed the appellate court's stay in February 2019, thus keeping physician-assisted suicide a legal option for terminally ill Californians who qualified.

In October 2021, an Oregon family practice physician challenged Oregon's assisted-suicide law's residency requirements in federal district court. Dr. Nick Gideonse and the advocacy group Compassion and Choices sued to allow Oregon physicians to provide patients from other states with end-of-life care, including assisted suicide, without criminal liability or loss of their medical licenses. The plaintiffs argued that Oregon's residency requirement violated clauses in Articles I and IV of the US Constitution. In March 2022, the case was settled for the plaintiffs, with the Oregon Health Authority and state medical board both agreeing to end enforcement of the requirement and request that the legislature strike the requirement from the law.

While some states allowed the practice of assisted suicide by 2024, at that time some individuals faced criminal charges in US states where the practice remained illegal, even when patients allegedly consented to the procedure. For example, in February 2024, state authorities in New York, which at that time had not passed legislation legalizing assisted suicide, charged a former doctor with manslaughter after the former physician, who was based in Arizona, allegedly provided a woman with drugs that allowed her to die by suicide. This case also reignited debate over whether assisted suicide should be legal for people who have chronic but not terminal conditions, as the woman who died was not confirmed as having a terminal illness.

These essays and any opinions, information or representations contained therein are the creation of the particular author and do not necessarily reflect the opinion of EBSCO Information Services.

About the Author

Heather Newton earned her JD, cum laude, from Georgetown University Law Center, where she served as articles editor for The Georgetown Journal of Legal Ethics. She has worked in the legal industry in various capacities for five years, including working as an associate attorney at Jones Day in Washington, DC, and as an editor for Juriscape, a legal recruiting and publishing company. Prior to law school, she was a high school English teacher and has worked consistently as a freelance writer for over fifteen years, with her works appearing in numerous print and online publications.

Bibliography

Barbuzzi, Miranda. "Who Owns the Right to Die? An Argument about the Legal Status of Euthanasia and Assisted Suicide in Canada." Penn Bioethics Journal, vol. 10, no. 1, 2014, pp. 16–20.

Brown, Jennifer. "Colorado Passes Medical Aid in Dying, Joining Five Other States." The Denver Post, 8 Nov. 2016, www.denverpost.com/2016/11/08/colorado-aid-in-dying-proposition-106-election-results. Accessed 30 Jan. 2017.

Campbell, Lorne. "In a Way, I Am Grateful I Have Got MS." New Statesman, vol. 139, no. 5017, 2010, pp. 32–33.

Dembosky, April. "California Governor Signs Landmark Right-to-Die Law." Shots: Health News from NPR, National Public Radio, 5 Oct. 2015, www.npr.org/sections/health-shots/2015/10/05/446107800/california-governor-signs-landmark-right-to-die-law. Accessed 19 Oct. 2015.

Dowbiggin, Ian. A Merciful End: The Euthanasia Movement in Modern America. Oxford UP, 2003.

Gummere, Peter J. "Opposing Assisted Suicide in Vermont." Ethics and Medics, vol. 39, no. 7, 2014, pp. 1–4.

Hosseini, Hengame. "Ethics, the Illegality of Physician Assisted Suicide in the United States, and the Role and Ordeal of Dr. Jack Kevorkian before His Death." Review of European Studies, vol. 4, no. 5, 2012, pp. 203–9.

Johnson, Gene. "Oregon Ends Its Residency Rule for Medically Assisted Suicide." Los Angeles Times, 29 Mar. 2022, www.latimes.com/world-nation/story/2022-03-29/oregon-ends-residency-rule-medically-assisted-suicide. Accessed 29 Mar. 2022.

Karlamangla, Soumya. "Will California’s End-of-Life Law Push Lethal Drugs over Costlier Care?" Los Angeles Times, 18 Oct. 2015, www.latimes.com/local/politics/la-me-end-of-life-medical-20151019-story.html. Accessed 19 Oct. 2015.

Lauritzen, Paul. "Intellectual Street Fighter." Commonweal, vol. 137, no. 10, 2010, pp. 13–17.

Levy, Tal, et al. "Attitudes towards Euthanasia and Assisted Suicide: A Comparison between Psychiatrists and Other Physicians." Bioethics, vol. 27, no. 7, 2013, pp. 402–8.

Lewis, Browne. "A Graceful Exit: Redefining Terminal to Expand the Availability of Physician-Facilitated Suicide." Oregon Law Review, vol. 91, no. 2, 2012, pp. 457–94.

Lewis, Penney. "Assisted Dying: What Does the Law in Different Countries Say?" BBC News, 6 Oct. 2015, www.bbc.com/news/world-34445715. Assisted 29 Sept. 2016.

Physician Assisted Suicide: Expanding the Debate, edited by Margaret P. Battin, et al., Routledge, 1998.

"Physician-Assisted Suicide Fast Facts." CNN, 1 June 2021, www.cnn.com/2014/11/26/us/physician-assisted-suicide-fast-facts/index.html. Accessed 29 Mar. 2022.

Shanahan, Ed. "Ex-Doctor Charged With Manslaughter in New York Woman’s Suicide." The New York Times, 5 Feb. 2024, www.nytimes.com/2024/02/05/nyregion/former-doctor-manslaughter-aided-suicide.html?searchResultPosition=1. Accessed 8 May 2024.

"States Where Medical Aid in Dying is Authorized." Compassion & Choices, 2024, www.compassionandchoices.org/resource/states-or-territories-where-medical-aid-in-dying-is-authorized. Accessed 8 May 2024.

The Case against Assisted Suicide: For the Right to End-of-Life Care, edited by Kathleen M. Foley and Herbert Hendin, Johns Hopkins UP, 2002.

"The Right to Die." Economist, 27 June 2015, www.economist.com/leaders/2015/06/27/the-right-to-die. Accessed 19 Oct. 2015.

Trianni, Francesca, and Josh Sanburn. "Why One Doctor Is Fighting for the Right to Die." Time, 29 Sept. 2015, time.com/4054178/right-die-doctor-california/. Accessed 19 Oct. 2015.