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Ethics,
Medicine
and
Public
Health
(2015)
1,
431—441
Available
online
at
ScienceDirect
www.sciencedirect.com
DOSSIER
‘‘DESIRES
TO
LIVE
AND
DIE’’
/Thoughts
An
argument
for
physician-assisted
suicide
and
against
euthanasia
Un
argument
pour
le
suicide
médicalement
assisté
R.
Cohen-Almagor
School
of
Politics,
Philosophy
and
International
Studies,
The
University
of
Hull,
Cottingham
Road,
Hull
HU6
7RX,
United
Kingdom
Received
10
September
2015;
accepted
4
October
2015
Available
online
19
November
2015
KEYWORDS
Autonomy;
Dignity;
End-of-life;
Euthanasia;
Physician-assisted
suicide;
Quality-of-life
Summary
The
article
opens
with
the
hypothesis
that
the
default
position
that
should
guide
healthcare
providers
when
treating
patients
at
the
end-of-life
is
that
patients
opt
for
life.
In
the
absence
of
an
explicit
request
to
die,
we
may
assume
that
patients
wish
to
continue
living.
Thus,
the
role
of
the
medical
profession
is
to
provide
patients
with
the
best
possible
conditions
for
continued
living.
The
article
makes
a
case
for
physician-assisted
suicide
legislation.
It
examines
the
‘quality-of-life’
argument,
and
the
issue
of
the
patient’s
autonomy
and
competence.
It
is
argued
that
(1)
quality-of-life
is
a
subjective
concept.
Only
the
patient
can
conclude
for
herself
that
her
quality-of-life
is
so
low
to
warrant
ending
it,
and
that
(2)
only
competent
patients
may
request
ending
their
lives.
Patients’
lives
should
not
be
actively
terminated
by
the
medical
team
without
the
explicit
consent
of
patients.
The
article
then
probes
the
role
of
physicians
at
the
end-of-life,
arguing
that
medicine
should
strive
to
cater
to
the
wishes
of
all
patients,
not
only
the
majority
of
them.
Physicians
should
not
turn
their
backs
to
justified
requests
by
their
patients.
Physicians
are
best
equipped
to
come
to
the
help
of
patients
at
all
stages
of
their
illness,
including
their
end-of-life.
At
the
same
time,
in
ending
life,
the
final
control
mechanism
should
be
with
the
patient.
Thus,
physician-assisted
suicide
is
preferred
to
euthanasia
in
order
to
lower
the
possibility
of
abuse
and
of
ending
the
lives
of
patients
without
their
consent
and
against
their
wishes.
As
matters
of
life
and
death
are
grave,
they
should
be
taken
with
utmost
seriousness,
requiring
the
instalment
of
ample
checks
against
abuse
and
facilitating
mechanisms
designed
to
serve
the
patient’s
best
interests.
The
article
concludes
with
19
careful
and
detailed
guidelines
for
physician-assisted
suicide.
These
are
necessary
measures
designed
to
ensure
that
the
best
interests
of
the
patients
are
served
as
they
wished.
©
2015
Elsevier
Masson
SAS.
All
rights
reserved.
E-mail
address:
R.Cohen-Almagor@hull.ac.uk
http://dx.doi.org/10.1016/j.jemep.2015.10.011
2352-5525/©
2015
Elsevier
Masson
SAS.
All
rights
reserved.
432
R.
Cohen-Almagor
MOTS
CLÉS
Autonomie
;
Dignité
;
Fin
de
vie
;
Euthanasie
;
Suicide
assisté
par
un
médecin
;
Qualité
de
vie
Résumé
L’article
commence
par
l’hypothèse
que
la
position
par
défaut
qui
doit
guider
les
fournisseurs
de
soins
de
santé
lors
du
traitement
de
patients
à
la
fin
de
la
vie
est
que
les
patients
optent
pour
la
vie.
En
l’absence
d’une
demande
explicite
de
mourir,
nous
pouvons
supposer
que
les
patients
souhaitent
continuer
à
vivre.
Ainsi,
le
rôle
de
la
profession
médicale
est
de
fournir
aux
patients
les
meilleures
conditions
possibles
pour
poursuivre
la
vie.
L’article
fait
un
cas
pour
la
législation
du
suicide
assisté
par
un
médecin.
Il
examine
l’argument
«
qualité
de
vie
»,
et
la
question
de
l’autonomie
et
de
la
compétence
du
patient.
On
fait
valoir
que
(1)
la
qualité
de
vie
est
un
concept
subjectif.
Seul
le
patient
peut
conclure
pour
lui-même
que
sa
qualité
de
vie
est
si
faible
pour
justifier
y
mettre
fin,
et
(2)
que
les
seul
le
patient
compétent
peut
demander
de
mettre
fin
à
sa
vie.
Il
ne
devrait
pas
être
mis
fin
activement
à
la
vie
des
patients
par
l’équipe
médicale
sans
le
consentement
explicite
des
patients.
L’article
explore
ensuite
le
rôle
des
médecins
à
la
fin
de
la
vie,
en
faisant
valoir
que
la
médecine
doit
s’efforcer
de
répondre
à
toutes
les
attentes
des
patients,
pas
seulement
à
la
majorité
d’entre
elles.
Les
médecins
ne
devraient
pas
tourner
le
dos
aux
demandes
motivées
de
leurs
patients.
Les
médecins
sont
les
mieux
équipés
pour
venir
en
aide
à
leurs
patients
à
tous
les
stades
de
leur
maladie,
y
compris
en
fin
de
vie.
Dans
le
même
temps,
en
fin
de
vie,
le
mécanisme
de
réglage
final
doit
se
faire
avec
le
patient.
Ainsi
le
suicide
médicalement
assisté
est
préférable
à
l’euthanasie
pour
réduire
les
abus
comme
mettre
fin
à
la
vie
des
patients
sans
leur
consentement
ou
contre
leur
volonté.
Comme
les
questions
de
la
vie
et
de
la
mort
sont
graves,
elles
doivent
être
prises
avec
le
plus
grand
sérieux.
L’article
conclut
sur
19
directives
précises
et
détaillées
concernant
le
suicide
médicalement
assisté.
Ces
mesures
nécessaires
visent
à
assurer
le
meilleur
intérêt
des
patients.
©
2015
Elsevier
Masson
SAS.
Tous
droits
réservés.
Introduction
During
one
of
my
conversations
with
Isaiah
Berlin
we
dis-
cussed
end-of-life
issues.
Isaiah
told
me
a
personal
story
about
one
of
his
friends
who,
at
that
time,
experienced
some
health
problems.
Later,
he
reflected
on
our
discussion
in
writing.
Isaiah
wrote:
My
friend
did
indeed
collapse,
his
leg
was
cut
off,
he
did
not
eat
because
he
could
not.
He
expressed
no
wish
to
die.
The
doctors
saved
him;
he
is
still
in
a
bad
state
but
is
unaware
of
it,
and
is
quite
cheerful.
He
proposes
to
go
on
living,
but
this
is
unlikely
to
last
long
[1].
This
letter
encapsulates
some
of
the
major
concerns
at
the
end-of-life.
These
concerns
can
be
formulated
in
ques-
tions:
•what
is
the
patient’s
condition?
•what
are
the
patient’s
wishes?
•what
do
we
mean
by
‘‘quality-of-life’’?
•what
is
the
significance
of
the
patient’s
autonomy
and
competence?
•what
are
the
roles
of
the
medical
profession
at
the
end-
of-life?
In
this
article,
I
will
unfold
these
questions,
addressing
two
additional
questions:
•whether
we
should
have
end-of-life
legislation,
which
includes
euthanasia
and/or
physician-assisted
suicide?
•what
might
be
the
impact
of
such
legislation
on
society?
This
article
makes
a
case
for
physician-assisted
sui-
cide
legislation.
Such
legislation
should
be
put
under
close
scrutiny
and
examined
on
an
annual
basis.
If
the
alarm
sounds
of
the
opposition
prove
to
be
justified,
then
it
will
be
the
task
of
the
medical
profession
and
the
legislature
to
secure
remedies
against
premature
killing.
In
France,
the
Conseil
national
de
l’Ordre
des
médecins
(CNOM,
the
National
Council
of
the
College
of
Physicians)
has
endorsed
euthanasia
[2],
and
the
French
parliament
has
opened
a
debate
on
euthanasia
in
January
2015
[3].
In
the
past,
Presi-
dent
Franc¸ois
Hollande
affirmed
his
aim
to
legalise
voluntary
euthanasia
and
called
for
a
national
debate
on
the
issue
[4,5].
Indeed,
in
France
and
other
parts
of
the
world
the
discussion
should
continue
in
earnest,
reflecting
on
changes
in
reality
and
always
aspiring
to
protect
the
patients’
best
interest.
The
patient’s
condition
and
wishes
Discussions
about
the
appropriate
treatment
at
the
end-
of-life
should
be
reserved
to
patients
who
are
suffering
from
an
incurable
disease,
whose
quality-of-life
is
deemed
by
the
patients
themselves
as
low,
when
death
becomes
for
them
an
attractive
proposition.
In
most
cases,
such
discussions
are
reserved
for
cancer
patients.
Cancer
is
a
very
painful
condition,
and
some
patients
find
it
intoler-
able
[6—8].
Unfortunately,
current
medical
knowledge
has
not
mastered
adequate
treatment
for
many
forms
of
can-
cer.
When
a
patient’s
life
is
saturated
with
pain,
when
her
entire
existence
is
focused
on
her
suffering
and
on
the
means
to
provide
relief
from
suffering,
the
normally
high
value
ascribed
to
life
deteriorates,
and
thoughts
about
the
alter-
native
to
life
might
become
dominant.
Most
patients
would
like
to
continue
living.
As
in
the
Isaiah
Berlin
story,
empirical
research
has
shown
that
the
yearning
to
live
is
very
strong.
I
have
visited
more
than
thirty
hospitals
in
Israel,
England,
Canada,
USA,
Australia,
New
Zealand,
the
Netherlands,
and
Belgium.
Most
patients,
even
in
the
most
dreadful
conditions,
opt
for
life.
This
is
more
so
An
argument
for
physician-assisted
suicide
and
against
euthanasia
433
when
patients
are
Catholic,
Jewish,
or
Muslim
[9].
This
is
less
so
in
the
Netherlands
and
Flemish-Belgium
[10,11].
But,
the
general
picture
is
clear:
we
all
possess
a
zeal
for
life.
There-
fore,
whenever
we
are
unclear
about
the
patients’
wishes,
the
default
position
we
should
take
is
that
the
patients
opt
to
live
[12].
Only
a
small
minority
of
patients
expressly
wish
to
die.
Thus,
our
starting
hypothesis
is:
H1.
The
default
position
is
that
patients
opt
for
life.
In
the
absence
of
an
explicit
request
to
die,
we
may
assume
that
patients
wish
to
continue
living.
Thus,
the
role
of
the
medi-
cal
profession
is
to
provide
patients
with
the
best
possible
conditions
for
continued
living.
‘Quality-of-life’
Many
supporters
of
euthanasia
advance
the
quality-of-life
argument
[13—15].
The
term
‘quality-of-life’
has
many
pos-
itive
connotations
when
used
in
a
general
social
context.
For
instance,
we
speak
of
improving
the
quality
of
citizens’
lives
by
providing
them
with,
for
example,
job
opportunities
and
cultural
events,
and
by
making
efforts
to
decrease
air
pollu-
tion.
People
use
the
term
‘quality-of-life’
when
describing
the
different
ways
by
which
they
advance
their
comfort,
their
status,
and
their
tranquillity.
Likewise,
in
medicine
the
term
‘quality-of-life’
has
positive
connotations,
for
example
in
rehabilitation,
physiotherapy,
cosmetic
treatments,
pal-
liative
care,
psychiatry,
and
psychology.
However,
when
we
deal
with
end-of-life
issues,
ethicists
who
side
with
euthana-
sia
use
the
term
‘quality-of-life’
in
a
negative
sense
more
often
than
in
a
positive
one,
meaning
that
they
do
not
seek
to
improve
the
patient’s
life
but
to
end
it
[16,17].
In
their
discussions,
the
‘quality-of-life’
concept
often
serves
to
jus-
tify
the
termination
of
life.
Even
supporters
of
euthanasia
and
of
granting
the
patient
a
right
to
decide
her
own
destiny
express
suspicion
regarding
this
concept.
In
his
testimony
before
the
House
of
Lords
Select
Committee
on
Medical
Ethics,
Ronald
Dworkin
explicitly
denounced
‘quality-of-life’
as
‘‘a
mischievous
term’’,
saying
clearly:
‘‘I
do
not
like
it
very
much’’.
Dworkin
explained
that
the
term
‘quality’
sug-
gests
some
sort
of
felt
experience
or
pleasure
—
how
much
pleasure
is
being
felt.
Instead,
he
would
like
to
refer
to
the
idea
of
a
‘good
life’
where
‘good’
is
not
merely
a
matter
of
how
it
feels,
but
it
is
also
a
matter
of
a
structure,
a
narrative
[18].1
‘Quality-of-life’
is
a
subjective
concept:
one’s
quality-
of-life
is
determined
by
one’s
personal
life
circumstances.
There
is
a
place
to
consider
the
quality
of
a
particular
life,
but
the
decision
as
to
what
considerations
constitute
justifications
for
termination
of
that
life
should
be
left
to
the
patient.
We
need
to
distinguish
between
situations
in
which
the
justification
for
terminating
life
is
voiced
by
the
patients
themselves,
and
situations
in
which
other
parties
—
physicians,
nurses,
hospital
managers,
ethicists,
relatives
—
postulate
justifications
for
terminating
patients’
lives.
Whenever
possible,
each
individual
should
decide
for
her-
self
what
constitutes
a
life
of
quality,
and
at
what
point
it
becomes
devoid
of
quality
or
essence.
As
in
the
Berlin
1For
further
discussion,
see
in
Further
reading:
Cohen-Almagor
R,
Shmueli
M.
story,
no
one
else
should
conclude
for
a
patient
that
her
life
is
meaningless
when
she
finds
some
value
in
it,
just
as
no
one
else
should
demand
to
prolong
life
at
all
costs
when
the
patient
herself
asks
for
her
death.
The
objection
to
paternalism
on
this
issue
is
absolute.
This
is
not
to
say
that
a
life
devoid
of
certain
distin-
guishing
features
(consciousness,
self-responsibility,
human
dignity),
or
a
life
in
which
certain
features
are
present
(suf-
fering
and
pain)
is
necessarily
void
of
quality.
Patients
may
decide
that
in
the
absence
of
certain
quality
characteristics
their
lives
are
no
longer
worth
living.
For
example,
some
may
think
that
a
life
devoid
of
consciousness
or
devoid
of
memory
(dementia)
is
not
a
meaningful
life.
Patients
experiencing
some
suffering
might
complain
of
loss
of
human
dignity.
But
others
may
think
that
their
dignity
is
preserved
even
as
they
experience
unimaginable
suffering.
While
some
may
see
life
in
terms
of
an
absolute
value
others
may
perceive
life
differently.
Some
perceive
life
as
a
means
to
achieve
self-fulfillment,
to
develop
human
abilities,
to
experience
discoveries,
thrills,
and
achievements.
Some
think
that
life
in
itself
is
of
no
value,
but
rather
is
a
precondition
for
the
existence
of
any
value
whatsoever.
When
denied
the
abil-
ity
to
actualize
their
choice,
some
people
find
no
reason
to
live.
The
dreariness
and
distress
in
which
they
live
could
lead
them
to
the
conclusion
that
death
is
preferable.
Argument
one:
quality-of-life
is
a
subjective
concept.
Only
the
patient
can
conclude
for
herself
that
her
quality-
of-life
is
so
low
to
warrant
ending
it.
Patient’s
autonomy
and
competence
The
decision
of
whether
to
preserve
a
life
or
terminate
it
should
remain
in
the
hands
of
the
patient
when
she
is
able
to
express
such
an
opinion.
The
liberal
state
should
help
preserve
life.
The
liberal
state
should
not
insist
on
pro-
longing
the
lives
of
patients
who
feel
that
such
an
action
would
negate
their
dignity.
The
issue
is
far
more
complex
when
patients
are
unable
to
express
an
intelligible
and
autonomous
opinion,
be
it
because
they
are
too
young,
men-
tally
defective,
or
unconscious.
Such
patients
lack
autonomy
and
the
ability
to
determine
their
destiny.
Where
adult
and
no-longer-autonomous
patients
are
con-
cerned,
we
must
first
examine
whether
they
had
stated
an
opinion
about
extending
a
life
before
their
autonomy
was
lost.
If
the
patients
had
explicitly
and
clearly
stated
in
writing
and/or
recording
(audio,
video)
that
they
were
not
interested
in
prolonging
life
under
such
conditions,
their
opinion
should
be
respected.
In
the
event,
however,
that
the
patients
stated
previously
that
upon
reaching
a
cer-
tain
future
state
of
illness
they
would
prefer
to
die,
but
when
they
actually
reached
that
state
they
show
signs
of
preferring
to
cling
to
life,
we
must
respect
their
present
choice.
Building
on
the
Berlin
story,
a
patient
may
state
that
in
case
of
deterioration
of
her
physical
and
men-
tal
condition
beyond
recognition,
she
would
prefer
to
die.
Upon
reaching
an
advanced
stage
of
atrophy,
however,
she
nonetheless
shows
signs
of
happiness
when
seeing
her
rela-
tives,
or
expresses
some
interest
in,
say,
flowers,
food
or
her
friends,
it
may
be
concluded
that
the
patient
finds
some
value
in
her
present
unfortunate
condition.
Therefore,
we
must
ignore
prior
instructions
to
the
contrary
and
allow
the
434
R.
Cohen-Almagor
continuation
of
her
life.2People
have
the
right
to
change
their
minds
and
we
should
not
deny
them
that
right.
In
accordance
with
H1,
it
is
always
better
to
err
on
the
side
of
life.
If
it
is
not
possible
to
determine
the
patient’s
past
and
present
desires,
and
there
are
no
signs
that
the
patient
wishes
to
continue
living,
then
the
decision
should
be
made
by
the
medical
team
in
cooperation
and
consultation
with
those
who
are
close
to
the
patient:
blood
relatives,
her
friends
and
other
beloved
people.
By
‘‘beloved
people’’
it
is
meant
the
people
around
the
patient’s
bed,
those
who
care
about
the
patient,
who
devote
their
time
and
energies
to
contribute
to
the
patient’s
well-being.
The
Benelux
countries
(the
Netherlands,
Belgium
and
Luxemburg)
and
recently
(2014)
the
Canadian
province,
Quebec
[19],
have
legislated
euthanasia.
Among
the
wor-
rying
data
in
all
the
Dutch
euthanasia
reports
from
1990
until
the
present
is
that
0.2—0.8
percent
of
deaths
were
the
result
of
the
use
of
lethal
drugs
not
at
the
explicit
request
of
the
patient.
There
were
1000
cases
(0.8%)
with-
out
explicit
and
persistent
request
in
1990,
and
900
such
cases
(0.7%)
in
1995
[20].
This
number
remained
unchanged
in
2001.
In
2005,
there
were
550
cases
(0.4%)
[21,22].
The
ending
of
life
without
a
patient’s
explicit
request
occurred
most
frequently
among
people
dying
at
an
age
younger
than
65
years
[23].
Physician-assistance-in-dying
without
an
explicit
request
by
the
patient
may
have
involved
patients
who
were
not
able
to
express
their
wishes,
such
as
neonates
or
comatose
patients;
patients
whose
competency
to
express
well-considered
preferences
was
doubtful,
such
as
patients
with
dementia
or
psychiatric
disorders;
or
com-
petent
patients
for
whom
physician-assistance-in-dying
was
the
result
of
an
implicit
request
or
an
agreement
to
hasten
death
[24].
The
2010
report
shows
that
ending
the
patient’s
life
without
an
explicit
request
declined
from
0.4%
to
0.2%
[25].
It
is
reiterated
that
under
Dutch
law,
it
is
illegal
to
terminate
life
when
the
patient
is
not
fully
competent.
In
Belgium,
a
1998
study
conducted
in
Flanders
showed
that
decisions
to
end
life
were
common
among
general
prac-
titioners.
In
Flanders,
where
60%
of
the
Belgian
population
resides,
more
than
5%
of
all
deaths
in
general
practice
(some
1200
cases)
resulted
from
the
use
of
drugs
with
the
explicit
intention
of
shortening
the
patient’s
life
[26].
The
rate
of
administration
of
lethal
drugs
to
patients
without
their
explicit
request
was
3.2%
[27].
The
Euthanasia
Act
came
into
force
in
2002.
Eight
years
later
in
2010,
the
use
of
life-ending
drugs
without
explicit
request
was
recorded
in
1.8%
of
deaths
[28],
and
in
2013,
it
was
1.7%
of
deaths
[29].
These
rates
are
higher
than
that
recorded
in
2001
(1.5%)
but
they
are
significantly
lower
than
the
rate
recorded
in
1998
before
the
legislation
of
the
Euthanasia
Act
(3.2%)
[28,30].
Use
of
life-ending
drugs
without
explicit
request
involved
patients
who
were
80-year
old
or
older
(52.7%),
those
with
a
disease
other
than
cancer
(67.5%),
and
those
in
hospital
(67.1%).
The
decision
was
not
discussed
with
the
patient
in
77.9%
of
cases.
Physicians
explained
that
the
decision
was
not
discussed
because
the
patient
was
comatose
(70.1%),
had
dementia
(21.1%),
or
because
discussion
would
have
2For
a
contrasting
view
see
in
Further
reading:
Dworkin
R.
been
harmful
to
the
patient’s
best
interest
(8.2%)
[28].
It
should
be
noted
that
the
law
specifically
stipulates
that
‘‘the
patient
is
an
adult
or
an
emancipated
minor,
capable
and
conscious
at
the
time
of
his/her
request;’’
[31]
thus,
lives
of
comatose
and
demented
patients
should
not
be
terminated
under
the
Euthanasia
Act.
It
should
also
be
noted
that
end-
ing
the
lives
of
patients
without
their
request
is
taking
place
in
Belgium
more
than
in
all
other
countries
that
document
such
practice,
including
the
Netherlands
[21].3
Physicians
were
asked
when
they
end
the
lives
of
patients
without
explicit
request
and
the
answers
highlighted
two
situations:
shortening
the
length
of
the
patient’s
final
phase
of
agony
during
the
last
phase
of
the
dying
process,
and
facilitating
the
death
of
the
‘‘terminally
ill,
demented
and
inhumanly
deteriorated
patient’’
[32].
Their
aims
are
to
shorten
the
length
of
misery
considered
to
be
futile,
ensure
a
relatively
comfortable
death
and,
most
worryingly,
alleviate
the
burden
of
the
next
of
kin
[32].4
The
liberal
state
has
an
obligation
to
protect
the
vulner-
able.
Given
that
ending
patients’
lives
without
request
is
more
common
than
euthanasia
[33]
and
the
significant
num-
ber
of
terminal
sedation
cases,
it
is
suggested
to
urge
the
Dutch
and
Belgian
medical
profession
to
consider
physician-
assisted
suicide
(PAS),
a
practice
that
is
not
common
in
the
Netherlands
or
in
Belgium
[33],
instead
of
euthana-
sia.
About
2%
of
Dutch
and
Belgians
die
from
euthanasia,
where
the
physician
administers
the
lethal
drugs
(i.e.
the
last
act
is
performed
by
the
physician),
and
less
than
0.1%
by
physician-assisted
suicide,
where
the
patient
ingests
the
lethal
drug
provided
by
the
physician
(i.e.
the
last
act
is
performed
by
the
patient)
[30].
Although
34%
of
Dutch
gen-
eral
practitioners
prefer
assisted
suicide,
only
22%
offer
the
two
options
to
patients
requesting
assisted
dying
[34].
While
morally
speaking
euthanasia
may
be
warranted
[35],
the
potential
for
abuse
is
substantial.
A
fine
line
exists
between
moral
consideration
and
the
implementation
of
a
policy.
As
shown,
research
conducted
in
the
Netherlands
and
in
Belgium
does
not
indicate
that
both
countries
have
prop-
erly
addressed
abuse
concerns.
Many
patients
are
still
killed
involuntarily.
The
Dutch
and
Belgians
are
researching
the
way
their
dying
patients
are
being
handled
in
a
medical
con-
text.
Their
cultures
of
self-searching
are
certainly
necessary.
Until
we
can
be
sure
that
euthanasia
is
not
abused
on
a
policy
level,
control
should
remain
with
patients,
not
with
physi-
cians.
PAS
ensures
that
end-of-life
procedures
are
restricted
only
to
competent
patients.
Argument
two:
only
competent
patients
may
request
ending
their
lives.
Patients’
lives
should
not
be
actively
terminated
by
medical
professionals
without
the
explicit
consent
of
the
patient.
The
role
of
physicians
Now
we
need
to
discuss
the
troubling
issue
of
whether
or
not
it
is
within
the
physician’s
responsibility
to
terminate
3For
comparative
discussion,
see:
van
der
Heide
A,
Deliens
L,
Faisst
K,
et
al.
4For
further
discussion,
see
in
Further
reading:
Pivodic
L,
Van
den
Block
L,
Pardon
K,
et
al.;
Cohen-Almagor
R,
‘‘First
Do.
.
.’’.
An
argument
for
physician-assisted
suicide
and
against
euthanasia
435
life.
Physicians
who
are
opposed
to
active
euthanasia
find
no
dignity
in
killing
a
patient,
and
express
anxiety
about
the
character
of
a
society
in
which
doctors
assume
such
a
responsibility
[36,37].
Many
physicians
believe
that
their
role
does
not
include
killing.
They
argue
that:
•if
society
accepts
the
need
for
active
euthanasia
then
such
an
act
can
be
committed
by
any
person;
•society
must
not
make
physicians
its
official
executioners;
•the
physician’s
role
is
to
heal,
to
help
patients
and
to
relieve
their
suffering;
•physicians
should
not
be
assigned
the
additional
task
of
execution.
In
response,
let
me
first
demur
and
say
that
I
resent
the
use
of
the
term
‘executioner’.
Support
for
active
euthanasia
is
not
associated
with
the
acceptance
of
execution
in
soci-
ety.
One
of
the
physician’s
roles
is,
indeed,
to
ease
patients’
suffering.
The
daily
practice
in
hospitals
demonstrates
that
sometimes
the
only
way
to
achieve
this
objective
also
short-
ens
the
patient’s
life.
We
are
dealing
with
a
population
of
patients
with
reasons,
drives
and
wills.
Failing
to
listen
to
those
reasons,
drives
and
wills
would
lead
to
gross
paternal-
ism:
an
unjustified
action
that
takes
the
responsibility
away
from
the
patient.
Such
behaviour
is
unjustified
because:
•the
person
for
whom
the
physician
acts
paternalistically
is
competent;
•the
conduct
in
question
is
involuntary
and
coercive.
Is
it
the
task
of
a
physician
to
keep
a
person
alive
against
that
person’s
will?
How
do
we
respond
to
that
small
group
of
patients
who
have
lost
their
appetite
for
life
and
plead
for
their
doctors
for
help?
While
some
may
argue
that
it
is
not
among
the
physician’s
responsibilities
to
provide
mercy
killing,
the
question
remains
as
to
whether
we
should
ignore
the
patient’s
wishes
and
whether
another
professional
body
exists
in
society
that
could
take
responsibility
for
this
trou-
bling
task.
As
for
the
first
question,
if
physicians
ignore
the
patients’
wishes,
left
with
the
option
of
committing
suicide.
How-
ever,
many
patients
are
reluctant
to
do
so
because
they
are
anxious
about
the
possibility
of
waking
up
to
an
even
more
dreadful
condition.
Failing
to
take
the
correct
medication
or
the
adequate
dose
of
medication,
their
condition
might
deteriorate
further,
resulting
in
a
reduced
quality-of-life,
and
they
would
still
be
alive.
Patients
need
the
assistance
of
the
medical
profession.
As
for
the
second
question,
whether
it
is
conceivable
to
ask
another
association
or
social
group
(family
and
close
ones
of
the
patient)
to
assume
this
responsibility,
my
answer
is
conclusive.
It
is
impossible
to
act
on
matters
of
health
without
medical
opinion.
I
see
no
escape
from
including
physicians
in
the
decision-making
process.
While
I
seek
an
answer
for
all
patients,
including
those
who
wish
to
die,
those
who
object
to
active
involvement
of
physicians
in
end-
ing
patients’
lives
ignore
those
patients
who
suffer
from
incurable
diseases
and
express
their
wish
to
die.
Obviously
those
who
are
opposed
to
euthanasia
should
not
be
expected
to
commit
an
act
that
contradicts
their
conscience;
that
would
be
as
paternalistic
as
ignoring
the
patient’s
will.
How-
ever,
there
are
physicians
who
might
agree
with
this
line
of
reasoning
and
who
would
not
necessarily
regard
active
euthanasia
as
contrary
to
their
medical
and
moral
con-
science.
Argument
three:
medicine
should
strive
to
cater
to
the
wishes
of
all
patients,
not
only
the
majority
of
them.
Physi-
cians
should
not
turn
their
backs
on
justified
requests
from
their
patients.
Physicians
are
best
equipped
to
come
to
the
help
of
patients
at
all
stages
of
their
illness,
including
their
end-of-life.
Euthanasia
vs.
physician-assisted
suicide
Before
my
first
research
fieldtrip
to
the
Netherlands,
my
thesis
was
pro-euthanasia.
This
was
no
longer
the
case
after
that
trip.
Faced
with
evidence
of
abuse,
I
could
no
longer
support
euthanasia.
I
still
think
that
there
are
cases
where
euthanasia
might
be
warranted.
Philosophically
speaking,
a
strong
ethical
argument
for
the
practice
can
be
made.
But
in
the
realm
of
practice,
upon
witnessing
the
Dutch
cavalier
view
on
death
and
dying,
I
could
no
longer
support
such
a
policy.
Policy
is
for
the
entire
society,
not
for
specific
cases.
Indeed,
policy
might
affect
specific
people
and
disservice
them,
harming
their
best
interest.
I
am
unable
to
endorse
such
a
dangerous
policy
[38—45].
Delineating
the
legislation
within
the
confines
of
physician-assisted
suicide
is
designed
to
prevent
abuse.
The
last
act
should
lie
squarely
with
the
patient
who
ingests
the
lethal
poison,
prepared
by
the
physician.
It
is
the
patient
who
commits
suicide
with
the
help
of
the
physician.
The
physician
mixes
the
lethal
medication
into
food,
and
the
patient
eats
it
by
herself.
If
the
patient
did
not
give
consent,
she
should
not
be
manipulated
or
forced
to
take
the
poi-
son
or
take
it
without
her
knowledge.
Furthermore,
the
vast
majority
of
patients
who
request
death
are
cancer
patients
who
are
able
to
swallow
[6,46,47,7].
For
the
small
minority
of
patients
who
are
unable
to
swallow,
I
agree
that
keeping
them
alive
in
a
state
of
suffering
against
their
will
would
be
cruel.
Documented
and
explained
reasons
for
making
excep-
tion
to
the
rule
could
be
made
to
warrant
euthanasia
in
such
special
and
few
circumstances.
As
a
supporter
of
physician-assisted
suicide,
I
believe
that
for
some
patients
this
is
the
preferred
and
the
right
option.
Some
strong-willed
patients
would
like
to
decide
the
time
of
their
death.
Only
they
can
say:
‘‘Enough
is
enough.
Now
it
is
time
to
say
good
bye,
because
I
can
no
longer
cope
with
my
state,
and
because
medicine
does
not
have
a
cure
for
me.’’
Physician-assisted
suicide
can
be
the
solution
especially
for
suffering
cancer
patients,
at
the
last
stage
of
their
lives.
It
is
humane
to
cater
to
these
people,
enabling
them
to
die
in
their
own
bed,
in
the
company
of
their
loved
ones.
The
Dutch
and
the
Belgians
do
not
pay
much
notice
to
the
distinction
between
voluntary
physician-assisted
suicide
and
active
euthanasia.
I
believe
the
distinction
is
important
and
viable.
Physician-assisted
suicide
hands
control
to
the
patients
until
the
very
last
moment
of
their
lives,
prevents
possible
abuse,
and
assures
that
they
indeed
wanted
to
die.
Restricting
aid-in-dying
legalization
to
physician-assisted
suicide
seems
to
limit
the
number
of
hastened
deaths
and
their
increase
over
time.
This
might
be
partly
due
to
a
higher
psychological
threshold
towards
assisted
suicide
and
more
stringent
procedural
rules
excluding
non-terminally
ill
patients
[48].
It
is
reit-
erated
that
in
most
cases
patients
are
able
to
do
the
436
R.
Cohen-Almagor
final
act
to
terminate
their
lives.
In
the
rare
occasions
of
complete
paralysis
or
suffocation,
when
the
patient
is
absolutely
unable
to
activate
the
lethal
needle,
only
then
might
the
doctor
commit
the
final
act
of
mercy
[9,49].
Argument
four:
in
ending
life,
the
final
control
mecha-
nism
should
be
with
the
patient.
Thus,
physician-assisted
suicide
is
preferred
to
euthanasia
in
order
to
lower
the
pos-
sibility
of
abuse
and
of
ending
the
lives
of
patients
without
their
consent
and
against
their
wishes.
For
and
against
physician-assisted
suicide
legislation
Those
who
oppose
aid-in-dying
legislation
argue
that
it
is
too
risky.
Such
legislation
might
change
the
medical
culture
and
harm
patients,
especially
vulnerable
populations.
The
opposition
emphasises
that
only
very
few
patients
ask
to
end
their
lives;
thus,
it
is
not
prudent
to
change
the
nature
of
medicine
to
include
killing
for
the
sake
of
the
few.
The
role
of
the
medical
profession
is,
and
should
remain,
healing
[50].
On
the
other
hand,
those
who
endorse
aid-in-dying
leg-
islation
perceive
it
as
a
health
right
and
as
a
human
right.
Medicine
should
assist
those
who
wish
to
decide
the
moment
of
their
death.
They
maintain
that
the
role
of
medicine
is
not
fixed
but
rather
in
flux.
In
the
past,
abortion
was
prohibited
where
now
it
is
legal
[51].
At
present,
genetic
enhancement
poses
similar
new
challenges
[52—54].
Supporters
of
aid-in-dying
legislation
take
very
seriously
the
‘‘change
of
culture’’
argument.
There
are,
indeed,
risks
involved
in
such
legislation.
The
aid-in-dying
motivation
is
to
help
patients
in
need,
not
to
open
the
road
for
abuse.
They
believe
it
is
possible
to
install
sufficient
safeguards
against
abuse.
And,
if
the
culture
changes
and
cases
of
abuse
are
recorded,
then
the
legislature
should
be
called
into
action
to
amend
the
law
and
secure
ample
solutions.
Life
and
death
must
be
put
under
a
close
scrutiny.
Sufficient
control
mech-
anisms
should
be
in
place.
End-of-life
procedures
should
be
monitored
on
an
annual
basis,
analysing
developments
and
ascertaining
that
vulnerable
patients
are
not
put
at
risk.
Tellingly,
the
Oregon
Hospice
Association
that
initially
opposed
the
PAS
legislation,
found
no
evidence
that
assisted
dying
in
Oregon
has
undermined
end-of-life
care
or
harmed
the
best
interests
of
vulnerable
populations
[55].
While
I
believe
medicine
should
attempt
to
cater
to
the
needs
of
all
patients,
and
that
a
humane
death
is
one
in
which
patients
die
at
home,
surrounded
by
their
loved
ones,
I
am
not
certain
that
physician-assisted
suicide
is
warranted
for
each
and
every
society.
End-of-life
practices
should
be
just
in
theory
and
also
just
in
their
application.
If
the
risks
are
too
high,
if
PAS
legislation
might
change
the
medical
practice
for
worse
as
far
as
patients
are
concerned,
then
it
should
be
amended,
overhauled,
or
abandoned.
The
discus-
sion
should
continue
in
earnest.
Argument
five:
life
and
death
concerns
are
grave.
Aid-
in-dying
legislation
should
be
undertaken
with
the
utmost
seriousness,
requiring
the
instalment
of
ample
checks
against
abuse
and
facilitating
mechanisms
designed
to
serve
the
patient’s
best
interests.
Guidelines
for
physician-assisted
suicide
(PAS)
The
right
to
die
with
dignity
includes
the
right
to
live
with
dignity
until
the
last
minute
and
the
right
to
part
from
life
in
a
dignified
manner.
There
are
competent,
adult
patients
who
feel
that
the
preferable
way
for
them
to
part
from
life
is
through
physician-assisted
suicide.
I
wish
to
promote
physician-assisted
suicide
because
I
recognize
that
individuals
should
have
the
power
to
decide
end-of-life
issues,
and
because
I
oppose
euthanasia.
I
devel-
oped
these
guidelines
following
fieldtrips
to
Israel,
the
United
Kingdom,
the
Netherlands
and
Belgium.
Let
me
con-
clude
with
the
following
recommendations
and
suggestions.
Guideline
1
Physicians
are
best
equipped
in
terms
of
knowledge
and
expertise
to
provide
aid-in-dying.
It
is
the
only
profession
that
can
come
to
aid
patients
who
insist
on
having
their
right-
to-die.
The
medical
profession
is
in
flux.
The
rapid
scientific
and
technological
progress,
the
rise
of
chronic
disease,
the
ability
to
keep
chronic
patients
alive
for
many
years,
and
the
democratization
of
knowledge
are
all
important
in
the
shap-
ing
of
medicine.
The
medical
profession
should
be
attentive
to
wishes
of
all
patients,
and
strive
to
accommodate
their
wishes.
Guideline
2
The
physician
should
not
suggest
assisted
suicide
to
the
patient.
Instead,
it
is
the
patient
who
should
have
the
option
to
ask
for
such
assistance.
Initiation
by
the
physician
might
undermine
the
trust
between
the
patient
and
the
physi-
cian,
conveying
to
patients
that
the
physician
is
giving
up
on
them
and
values
their
lives
only
to
the
extent
of
offer-
ing
assistance
to
die.
Such
an
offer
might
undermine
the
will
to
live
and
to
explore
further
avenues
for
treatment.
My
fieldwork
in
the
Netherlands
revealed
that,
many
times,
the
patients
did
not
ask
for
euthanasia.
It
was
the
doctor,
a
trusted
general
practitioner
whom
the
patient
had
known
for
many
years,
sometimes
30
or
40
years,
who
offered
death
to
the
patient
with
cancer.
This
practice
may
compromise
the
issue
of
voluntariness;
it
is
difficult
for
many
patients
to
contest
the
advice
of
a
loyal
general
practitioner.
[56]
The
GP
may
present
before
the
patient
the
range
of
avail-
able
options
without
manipulation,
and
with
due
respect
for
patient’s
life
and
wishes.
Guideline
3
The
request
for
physician-assisted
suicide
of
an
adult,
com-
petent
patient
who
suffers
from
an
intractable,
incurable
and
irreversible
disease
must
be
voluntary
[31,57].
The
deci-
sion
is
that
of
the
patient
who
asks
to
die
without
pressure,
because
life
appears
to
be
the
worst
alternative
in
the
cur-
rent
situation.
The
patient
should
state
this
wish
repeatedly
over
a
period
of
time.
We
must
verify
that
the
request
for
physician-assisted
suicide
does
not
stem
from
a
momen-
tary
urge,
an
impulse,
a
product
of
passing
depression.
This
emphasis
of
enduring
request
is
one
of
the
requirements
An
argument
for
physician-assisted
suicide
and
against
euthanasia
437
of
the
Dutch
and
Belgian
legal
guidelines
[58].
It
should
be
ascertained
with
a
signed
document
that
the
patient
is
ready
to
die
now,
rather
than
depending
solely
upon
directives
from
the
past.
Guideline
4
At
times,
the
patient’s
decision
might
be
influenced
by
severe
pain.
The
Oregon
Death
with
Dignity
Act
requires
the
attending
physician
to
inform
the
patient
of
all
feasi-
ble
alternatives,
including
comfort
care,
hospice
care
and
pain
control
[59—61].
The
proposed
British
Assisted
Dying
Bill
(2014),
prepared
by
Lord
Falconer,
requires
that
the
patient
‘‘has
been
fully
informed
of
the
palliative,
hospice
and
other
care
which
is
available
to
that
person’’
[62].
Quality
indica-
tors
in
palliative
care
should
be
checked
to
ensure
that
the
patient
received
adequate
care
from
the
caregivers
[63].
Guideline
5
The
patient
must
be
informed
of
the
situation
and
the
prog-
nosis
for
recovery
or
escalation
of
the
disease,
with
the
suffering
that
it
may
involve.
There
must
be
an
exchange
of
information
between
physicians
and
patients
[31,64].5Bear-
ing
this
in
mind,
we
should
be
careful
to
use
neutral
terms
and
to
refrain
from
terms
that
might
offend
patients
and
their
loved
ones
[65—70].
Guideline
6
It
must
be
ensured
that
the
patient’s
decision
is
not
the
result
of
familial
and
environmental
pressures.
At
times,
patients
may
feel
that
they
constitute
a
burden
on
their
loved
ones.
It
is
the
task
of
social
workers
to
examine
patients’
motives
and
to
see
to
what
extent
they
are
affected
by
various
external
pressures
(as
opposed
to
a
truly
free
will
to
die).
A
situation
could
exist
in
which
the
patient
is
under
no
such
pressure,
but
still
does
not
wish
to
be
a
burden
to
others.
Obviously,
we
cannot
say
that
the
feelings
of
patients
toward
their
loved
ones
are
not
relevant
to
the
decision-making
process
[71—74].
Guideline
7
The
decision-making
process
should
include
a
second
opin-
ion
in
order
to
verify
the
diagnosis
and
minimize
the
chances
of
misdiagnosis,
as
well
as
to
allow
the
discovery
of
other
medical
options.
A
specialist,
who
is
not
dependent
on
the
first
physician,
either
professionally
or
otherwise,
should
provide
the
second
opinion
[11,31].
The
patient’s
attending
physician,
who
supposedly
knows
the
patient’s
case
better
than
any
other
expert,
must
be
consulted,
and
all
reason-
able
alternative
treatments
must
be
explored.
The
Oregon
Death
with
Dignity
Act
requires
that
a
consulting
physician
examine
the
patient
and
her
relevant
medical
records
and
subsequently
confirm,
in
writing,
the
attending
physician’s
diagnosis
that
‘‘the
patient
is
suffering
from
a
terminal
5Many
bill
proposals
to
legislate
PAS
in
the
United
States
specify
certain
information
that
must
be
communicated
by
the
physician
to
the
patient
before
honouring
her
request.
disease.’’
Furthermore,
the
consulting
physician
must
ver-
ify
that
the
patient
is
capable,
is
acting
voluntarily,
and
has
made
an
informed
decision
[75].6
Guideline
8
It
is
advisable
for
the
selection
of
the
consultant
to
be
deter-
mined
by
a
small
committee
of
specialists
who
will
review
the
requests
for
physician-assisted
suicide.
This
is
in
order
to
avoid
the
possibility
of
arranging
deals
between
physicians
(‘‘you
will
consult
for
me
regarding
Mr.
Jones,
approving
my
decision,
and
I
will
consult
for
you
regarding
Ms.
Smith,
approving
your
decision’’).7
Guideline
9
Some
time
prior
to
the
act
of
physician-assisted
suicide,
a
physician
and
a
psychiatrist
are
required
to
visit
and
examine
the
patient
so
as
to
verify
that
this
is
the
genuine
wish
of
a
person
of
sound
mind
who
is
not
being
coerced
or
influenced
by
a
third
party.
The
conversation
between
the
physicians
and
the
patient
should
be
held
without
the
presence
of
fam-
ily
members
in
the
room
in
order
to
avoid
familial
pressure.
A
date
for
the
procedure
is
then
agreed
upon.
The
patient’s
loved
ones
will
be
notified
so
that
they
can
be
present
right
until
the
performance
of
the
act,
making
the
day
an
inti-
mate,
family
occasion.
Guideline
10
The
patient
can
rescind
at
any
time
and
in
any
manner.
This
provision
is
granted
under
the
Oregon
Death
with
Dignity
Act
[76].
Chapter
III,
Article
4
of
the
Belgian
Euthanasia
Law
says
that
patients
can
withdraw
or
adjust
their
euthanasia
declarations
at
any
time
[77].
The
proposed
British
Assisted
Dying
Bill
(2014)
holds
that
the
patient
may
revoke
the
aid-
in-dying
request
at
any
time
and
that
revocation
need
not
be
in
writing
[62].
Guideline
11
Physician-assisted
suicide
may
be
performed
only
by
a
physi-
cian
and
in
the
presence
of
another
physician.
I
am
very
much
opposed
to
family
members
administering
assisted
sui-
cide
(or
euthanasia),
as
I
think
it
can
lead
to
abuse.
The
decision-making
team
should
include
at
least
two
physicians
and
a
lawyer
who
will
examine
the
legal
aspects
involved
and
ensure
there
is
protocol
in
place
as
a
control
mecha-
nism
against
possible
abuse.
Perhaps
a
public
representative
should
also
be
present