In the context of health care, physician-assisted suicide (PAS) is the process by which a terminally ill patient may legally request and receive a lethal dose of medication to end their own life. More generally, assisted suicide refers to any circumstance in which one person intentionally provides another with the means to end their life, while euthanasia refers to the active administration of a life-ending intervention. While PAS is permitted in some US jurisdictions, euthanasia is considered a form of homicide and remains uniformly illegal in the United States. In states that allow PAS, patients must meet eligibility requirements and undertake a process that includes submitting multiple requests to health-care providers. In addition to receiving approval from a physician, patients must have received a diagnosis that they will die within six months and be deemed competent to make their own health-care decisions.
Debates regarding terminology continue among lawmakers, activists, and health-care professionals. The aid-in-dying advocacy group Death with Dignity, for instance, argues that the term "suicide" is inaccurate for describing aid-in-dying for terminal patients because it suggests that the end of life is not already imminent. Terms such as dying with dignity, right-to-die, end-of-life options, and aid-in-dying are often used as alternatives to "assisted suicide" because, according to advocates, they emphasize control over death rather than rejection of life.
Legislation and Regulation
In the United States, the legality of assisted suicide is determined at the state level. Though the US Supreme Court ruled that there is no constitutional right to die in Washington v. Glucksberg (1997) and Vacco v. Quill (1997), it also ruled in Gonzales v. Oregon (2006) that federal authorities cannot block doctors from prescribing assisted-suicide drugs in states where the practice is legal. As of 2020, aid-in-dying is permitted through legislation in the District of Columbia, California, Colorado, Hawaii, Maine, New Jersey, Oregon, Vermont, and Washington. The practice is also decriminalized in Montana due to a 2009 state supreme court ruling that protects doctors from charges of homicide for providing life-ending medication to a consenting, competent, terminally ill patient.
Oregon's Death with Dignity Act, approved by voters in 1994 and enacted as law in 1997, was the first US statute to cover a terminally ill patient's right to die and set the legislative precedent on which subsequent laws have been based. Though there is some variation among the different state laws, the legal assisted-dying process generally occurs over several steps. First, the patient must submit an oral request to his or her physician, who must then confirm that the patient meets all eligibility requirements. If necessary, the patient may be referred for a psychiatric evaluation to ensure he or she is legally capable of making such a decision. At this time, the patient must be advised by the physician of all other treatment options and asked to notify his or her next of kin of the request. A second physician must confirm the terminal diagnosis and agree that the patient is of sound mind. Once this initial request is completed and authorized, the patient must wait at least fifteen days, at which point he or she can make the required second oral request.
A written request must also be submitted, which typically takes place between the first and second oral requests. To be considered valid, the written request requires two witnesses. At least one of the witnesses cannot be related to the patient, be due to inherit part of the patient's estate, or be providing care or treatment for the patient. In some jurisdictions, a waiting period of forty-eight hours follows the second oral request, after which the patient's prescription for life-ending substances is filled. Patients are free to rescind their request at any time during this process, and doctors are encouraged to communicate regularly with patients to ensure their ongoing consent.
Medical Ethics, End-of-Life Care, and Right-to-Die Advocacy
While some countries have adopted national right-to-die laws, the issue of assisted suicide continues to be controversial in the United States. According to Gallup, while 72 percent of US adults supported legal doctor-assisted suicide for terminally ill patients in 2018, 42 percent indicated a belief that the practice is morally wrong. A similar ambivalence is found among physicians, with a 2019 study published in the Yale Journal of Biology and Medicine reporting that 60 percent of surveyed doctors believed PAS should be legal, but only 9 percent indicated that they would perform the practice if it were legal. The tension between honoring individuals' rights and adhering to moral or religious stances on life is at the center of these mixed feelings.
Patients' rights play a central role in health care and take on an additional importance in end-of-life care. According to the Consumer Bill of Rights and Responsibilities of 1997, commonly referred to as the Patient's Bill of Rights, patients have the right to receive accurate health information, choose their providers, participate in treatment decisions, and be treated with respect. Informed decisions regarding medical care are made when a patient actively understands the full breadth of available options, including their respective advantages, disadvantages, and potential outcomes. In determining treatment plans, patients are allowed to use directives to communicate their end-of-life wishes or to appoint other individuals to make treatment decisions on their behalf.
Much of the debate surrounding assisted suicide revolves around the complex ethical and legal issues inherent in determining whether patients have the right to make an informed decision to end their own life. Aid-in-dying advocates contend that a patient's right to refuse treatment constitutes a legal precedent for allowing a person to hasten their own death. PAS should be legal, they explain, because it amounts to the consistent application of the existing right to refuse treatment. Some have also noted that many doctors, who are well informed of their treatment options and the limitations of modern medicine, often choose paths that expedite death when facing their own terminal diagnoses.
Proponents of PAS contend that forcing a terminally ill person to continue living is unethical, with some adopting the more radical position that people who suffer from chronic illness and pain should also have access to aid-in-dying options. As much of the suffering associated with terminal illnesses cannot be eased, they maintain, providing these patients with the means to end their own lives enables them to avoid further physical, psychological, and emotional pain. Many patients who have sought aid-in-dying cite concerns over an eroding quality of life and choose to end their lives to avoid cognitive impairment or a loss of autonomy at the end of life.
Right-to-die supporters often note the high unassisted suicide rate among individuals with medical conditions that cause severe chronic pain. While exact rates are difficult to determine, researchers at the US Department of Veterans Affairs concluded in 2019 that chronic pain and pain intensity are risk factors. Earlier analyses have estimated that 20 percent of chronic pain sufferers engage in suicidal ideation and that chronic pain sufferers are at least twice as likely to commit suicide as nonsufferers. Some advocates of assisted suicide argue that it provides relief not only to those suffering from pain, injury, and illness but also to their loved ones, who might otherwise be forced to remain idle while a loved one who wishes to die suffers needlessly.
Objections to Assisted Dying
Opponents of PAS contend that hastening the end of someone's life when medical treatments and counseling could possibly treat pain or sustain life amounts to intentionally doing harm to the patient. Such critics state that doctors are expected to adhere to a standard of ethical conduct based on the Hippocratic Oath, which commonly includes a commitment to bring more benefit than harm through medical treatment. While modern versions of the oath have removed the vow not to administer poison or recommend its use, some physicians and ethicists argue that practicing PAS undermines long-established notions of medical integrity. Both the American Medical Association (AMA) and the American College of Physicians (ACP) oppose it on these grounds.
Many of those who oppose PAS refer to the potential for abuse or misapplication of the practice, particularly regarding vulnerable and aging patients. Some believe that widespread legalization could lead to its use as a cost-cutting measure or as a way of providing relief for burdened family members. In 2019 the National Council on Disability (NCD) published the Danger of Assisted Suicide Laws, which outlines and updates its long-held objections to PAS. The NCD cautioned that PAS poses a disproportionate risk of harm to elderly, poor, and disabled people and voiced concern that current laws could be vulnerable to exploitation by insurance companies. The NCD warned that this could contribute to the development of a legal framework that would allow insurers to refuse to pay for medically necessary interventions for nonterminal patients.
The NCD and some disability rights organizations base their opposition to PAS on the inadequacy of current laws to safeguard against abuse. These opponents believe that existing laws leave open the possibility that some people's lives will be ended without their fully informed consent, through mistakes or misdiagnoses, and due to insufficient competency with caring for disabled or elderly patients. Meanwhile, some professional organizations oppose PAS laws based on concerns that they encroach on the rights of providers who have moral objections to participating in a life-ending process. While Section 1553 of the Affordable Care Act (2010) prohibits any federal agency or program from discriminating against health-care providers for refusing to perform assisted suicide services, the NCD's 2019 report recommended that Congress pursue additional legal protections. Agencies like the Health and Medicine Division (HMD) of the National Academies of Sciences, Engineering, and Medicine, however, call for improving end-of-life care options and suggest that PAS should be just one option among a more inclusive and comprehensive range of choices.