By: Gabriela Ibanez
Navigating the realm of end-of-life decisions requires a delicate balance of sensitivity and awareness of the deeply personal nature of such choices, as well as the diverse perspectives surrounding this subject. To ensure clarity throughout this exploration, the terms at hand are defined as follows: “physician-assisted dying” or “assisted dying” refers to the practice where a medical professional aids a patient in ending their own life, often by prescribing medication. In contrast, “euthanasia” involves a doctor administering a lethal dose of medication directly to the patient, at the patient’s request. Physician-assisted dying laws typically address both practices within their legislation. It’s important to note that the term “assisted suicide” will not be used, as it can be misleading, given that individuals seeking physician-assisted death are not attempting to end an otherwise open-ended span of life but rather seeking a reduction of their final hours or days through medication. For individuals grappling with terminal illnesses or unbearable suffering, the emergence of physician-assisted dying laws can represent a crucial avenue to exercise autonomy and determine the circumstances of their final moments. The global and state-level approaches to assisted dying laws exhibit very diverse ethical perspectives, legislative frameworks, and cultural considerations.
In countries like Switzerland, the Netherlands, and Belgium, where physician-assisted dying is legal under specific circumstances, stringent protocols and safeguards are often in place. These may include mandatory waiting periods, multiple medical consultations, and criteria ensuring the patient’s full mental capacity and consent. In addition, some U.S. states such as Oregon, Washington, and California have protections in place for these end-of-life choices. These states have legalized physician-assisted dying through specific legislation and case law that emphasizes rigorous eligibility criteria and reporting requirements. Conversely, other U.S. states and numerous countries maintain stringent prohibitions on physician-assisted dying, asserting the primacy of preserving life and safeguarding against potential abuses or slippery slopes. This stark dichotomy reflects the ongoing debate surrounding the ethics and practical implications of physician-assisted dying.
The novel “In Love: A Memoir of Love and Loss,” by Amy Bloom, provides a moving exploration of the values surrounding end-of-life decisions particularly in the context of individuals facing illnesses like early-onset Alzheimer’s. The story revolves around Brian Ameche, who, by his mid-sixties, is confronted with the bleak realities of his condition. While Brian is still able to function and make decisions, he expressed a preference to end his life on his terms. Amy, his loving wife, chooses to support him in this challenging journey. In the United States, only a handful of states have death-with-dignity laws and even so there is a required prognosis of “six months or less to live.” In the absence of suitable options within the United States, this narrative turned toward Switzerland and the organization Dignitas where Bryan was afforded the option to end his life on his own terms.
For states that have legalized physician-assisted dying in the United States, specific criteria govern the legal access to end-of-life medication given that euthanasia is generally prohibited. Patients must be 18 years or older, residents of states where the practice is legal, and have six months or less to live. The patient must be mentally competent and make multiple requests for the medication through both verbal and written means, ensuring voluntary decision-making. Additionally, the physician must engage in an independent conversation with the patient to verify the autonomy of the request. Importantly, patients must be capable of self-administering the medication. As there are no lists of participating healthcare providers, individuals are required to initiate discussions with doctors who also retain the right to refuse involvement.
On a federal level, the United States’ perspective on physician-assisted dying laws remains focused on preserving life, as seen in legal battles such as Vacco v. Quill, which reached the Supreme Court of the United States. In this case, physicians argued that New York’s physician assisted-dying ban, preventing them from prescribing lethal medication for mentally competent, terminally ill patients, violated the Fourteenth Amendment’s Equal Protection Clause. The Supreme Court, aligning with New York, recognized the state’s interests in preserving life, preventing suicide, and maintaining the role of physicians as healers. Canada’s approach, in contrast, is shaped by the Supreme Court of Canada’s decision in Carter v. Canada which held that criminal laws prohibiting assistance in dying infringed upon rights protected under the Canadian Charter of Rights and Freedoms. The Court deemed these restrictions to interfere with the liberty and security of individuals who are suffering from terminal medical conditions by constraining their ability to make decisions concerning their bodily autonomy and subjecting them to enduring intolerable suffering.
In countries like the Netherlands there is strong advocacy for the right to determine one’s own end-of-life choices, which is reflected not only in the legalization of assisted dying, but also in the acceptance of euthanasia as a legitimate option. Both of these options are available to individuals facing unbearable circumstances with no prospect of improvement. Notably, in the Netherlands, minors as young as 12 years old can request euthanasia although parental consent is required. However, for patients 16 years or older formal parental consent is not necessary. Similarly in Belgium euthanasia is permitted for individuals not necessarily terminally ill, including those suffering from psychiatric disorders or dementia, but under the strict conditions outlined in the Belgian Act on Euthanasia. Substantively, the request for euthanasia must be voluntary, well-considered, and not the result of external pressure. Additionally, the individual must be legally competent at the time of expressing the request and experiencing constant and unbearable physical or psychological suffering resulting from a serious disorder with no reasonable treatment alternatives or prospects for improvement.
Views vary regarding the success of these laws. While designed primarily with terminal cancer cases in mind, the requests have expanded to encompass a broader spectrum of conditions over time. Although cancer patients still constitute the majority of requests, there is a noticeable rise in requests associated with advanced psychological disorders. Disability advocacy groups have expressed concerns regarding the potential consequences of increased prevalence of euthanasia and assisted dying. They worry that this trend may inadvertently create pressure on individuals living with non-terminal conditions to consider ending their lives prematurely. Furthermore, people lacking financial support may be pushed into assisted dying. Family members burdened with health care debt may be encouraged to seek options such as physician assisted death. The discourse surrounding physician assisted dying laws underscore the complex interplay between individual autonomy, medical ethics, and societal values. While countries like the Netherlands and Belgium have embraced these laws as a means of affirming personal autonomy in end-of-life decisions, debates persist regarding their broader impact on vulnerable populations and the sanctity of life.
