Physician-Assisted Suicide: The Legal Slippery Slope

, Division of Medical Ethics and Humanities at the University of South Florida College of Medicine, Tampa, Florida.

Cancer Control. 2001;8(1) 

In This Article

Euthanasia and PAS

The debate involving euthanasia and physician-assisted suicide (PAS) has been plagued by imprecise and euphemistic language. Thus, it is important to clarify the terms associated with euthanasia and PAS. Euthanasia is an act whereby a physician intentionally causes the death of a terminally ill patient. For example, a physician performs euthanasia when he or she deliberately injects a lethal amount of potassium chloride into a patient for the express purpose of terminating the patient's life. Euthanasia is a form of homicide and is illegal in the United States. It differs from murder in that the motive is seen as merciful rather than malevolent. The physician's intent is to help the terminally ill patient avoid the suffering that often accompanies the process of dying.

When euthanasia is performed with the consent of the patient, it is called voluntary euthanasia. When euthanasia is performed absent patient choice, such as may be the case with incapacitated patients, it is called nonvoluntary euthanasia. [5] It could also be called non-choice euthanasia. A third form of euthanasia, involuntary euthanasia, refers to performing euthanasia against the patient's wishes.

Euthanasia differs fundamentally from the act of withholding or withdrawing life-sustaining medical treatment. When physicians forego life-sustaining treatments at the end of life for their terminally ill patients, the patients die of their disease process. With euthanasia, death is caused not by the disease but by the physician. Even though death may occur in close conjunction with a decision to withhold or withdraw treatment, it does so only because there is no longer active resistance to an inexorable dying process. With euthanasia, however, death is immediate because it is directly caused by the physician. Patients who request euthanasia are asking that their life be taken by a physician before the disease causes their death.

Euthanasia also differs from PAS in that patients requesting PAS are actively involved in causing their own death. PAS can be defined as an act of self-destruction committed by a patient with the assistance of a physician. The most common example is that of a physician giving a patient a prescription for a lethal amount of medication that the patient later ingests to bring about death. PAS is called suicide because the patient deliberately ends his or her own life. It is physician-assisted because the physician not only agrees to participate in the patient's plan, but also assists by prescribing a lethal amount of medication. PAS and voluntary euthanasia are similar in that both involve patient choice. However, in voluntary euthanasia, the physician alone is the cause of the patient's death, whereas in PAS, the patient and the physician work together to bring about death, with the patient taking the final action to end life.

These distinctions have been borne out in case law through a series of court decisions, beginning with the 1976 case of In re Quinlan[6] in New Jersey. In this case, which involved a young woman in a permanent vegetative state, the issue was whether her guardian could authorize doctors to discontinue Quinlan's mechanical ventilator. The court wrote, "There is a real and in this case determinative distinction between the unlawful taking of the life of another and the ending of artificial life-support systems as a matter of self-determination." This distinction was echoed in most of the cases that followed in various states. In 1990, when the US Supreme Court ruled on the Cruzan[7] case, which involved disconnecting a feeding tube from a young woman in a persistent vegetative state, it too distinguished homicide and assisted suicide from the constitutional right to refuse unwanted medical treatment. Later, in Washington v Glucksberg[8] and Vacco v Quill, [9] the US Supreme Court made this distinction explicit by stating that "when a patient refuses life-sustaining medical treatment, he dies from an underlying fatal disease or pathology; but if a patient ingests lethal medication prescribed by a physician, he is killed by that medication."

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