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Abstract

Assisted suicide is a highly controversial practice and illegal in most jurisdictions around the world, although the number of countries that have decriminalized it is increasing. Public debates as well as legislative proposals and court judgments are often confounded by a failure to carefully distinguish assisted suicide from other end-of-life practices. Hence, this contribution will ﬁrst seek to clarify the concept of assisted suicide. Next, the practice itself is brieﬂy discussed, followed by a summary of current laws and regulations, and a cursory review of various sociocultural traditions and religious tenets in different countries around the world that appear to inﬂuence the ongoing practices and public opinions. In the last two sections, the ethics of assisted suicide is analyzed. Four sets of arguments (focused on pragmatics, consistency, rights, and beneﬁts) favoring this practice are discussed ﬁrst. In the ﬁnal section, three sets of arguments against legalization (focused on pragmatics, the role of physicians, and the sanctity or inviolability of human life) are reviewed.

Introduction

If a patient ends his or her own life, therein assisted by a third person, this is commonly called “assisted suicide.” The practice is legal in only a very small minority of jurisdictions around the world and then only if the assistance is rendered by a physician, so-called physician-assisted suicide (PAS). Consequently, for most countries reliable empirical data on medical opinions regarding PAS are lacking. Health-care professionals who have assisted in suicide may not be willing to answer survey questions forthrightly for fear that their anonymity cannot be guaranteed by the researchers. Furthermore, since they would only incur legal risk if they render assistance but not if they receive it, they may answer the survey differently if they assume the questions to apply to their own death as opposed to the death of their patients. Without making this distinction clear, it is difﬁcult to interpret a ﬁnding such as that by Yun and colleagues (2011) that Korean oncologists (approx. 7 %) are far less in favor of PAS than are cancer patients (approx. 52 %), family care givers (approx. 45 %), and the general public (approx. 50 %). To further complicate matters, surveys frequently cover nonrepresentative samples of physicians, such as only hospital-based physicians working in Sudan’s capital Khartoum (Ahmed et al. 2001).

Surveys seeking to ascertain the public’s views about PAS often suffer from similar shortcomings. They tend to cover only a small and nonrepresentative sample of the population, such as young university students in Kuwait (Ahmed et al. 2010) and India (Kable et al. 2012). One of the largest studies available covered more than 40,000 individuals in 33 European countries (Cohen et al. 2006), but only one question was asked: “Please tell me whether you think ‘euthanasia (terminating the life of the incurably sick)’ can always be justiﬁed, never be justiﬁed, or something in between.” While readily acknowledging that it is difﬁcult to truly gauge public opinion on such a complex issue by asking one question only, the researchers concluded that there is no common attitude toward euthanasia even within Europe, which presumably would be true as well about PAS.

Then there is the problem of interpreting the data collected. For example, many surveys have found that younger people are generally more in favor of PAS than are elderly. This difference could be due to older people representing older, more traditional, and hence negative views toward PAS. But it could also be due to young people lacking experience in coping with life’s exigencies and tragedies. And because surveying terminally ill and dying patients themselves often is unduly burdensome, very little is known about the wishes of such patients who are about to undergo PAS themselves. An exception is the study by Emanuel and colleagues from 2000 that surveyed seriously ill patients in the USA with less than 6 months of expected lifetime. They found that 60.2 % of these patients supported euthanasia or PAS in a hypothetical situation (which roughly corresponds with the 55 % of Korean cancer patients surveyed by Yun and colleagues mentioned above). But the American study also found that only 10.6 % of patients seriously considered euthanasia or PAS for themselves, and only 5.6 % discussed that wish with their primary care provider. The American survey did not distinguish between euthanasia and PAS, but Dutch statistics show that fewer than 10 % of patients prefer PAS over euthanasia. If that breakdown is applied to the American statistics – which is admittedly precarious since the views of Dutch patients may not be comparable to those of American patients – fewer than 1 % of terminally ill patients seriously consider PAS for themselves.

The failure to clearly distinguish between different practices (such as PAS, euthanasia, palliative sedation, and the withdrawing of futile life-sustaining treatment) complicates the interpretation of many surveys, as does the use of terms that can easily be misunderstood by those completing these surveys (such as “aid in dying”). Hence, this contribution ﬁrst seeks to clarify the concept of PAS. Next, the practice itself is brieﬂy discussed, followed by a summary of current laws and regulations, and a cursory review of various sociocultural traditions and religious tenets in different countries around the world that appear to inﬂuence the ongoing practices and public opinions. In the ﬁnal two sections, the ethics of PAS is analyzed, discussing ﬁrst arguments favoring this practice and its legalization and next arguments against.

Clarification Of The Concept

The concept “physician-assisted suicide” contains three separate terms, each of which merits closer analysis. Since “suicide” is the principal noun with the other two words modifying that noun, the third term will be analyzed ﬁrst.

Suicide

The word “suicide” literally means a self (-inﬂicted) death. Death is not caused by somebody else, not even at the request of the person killed. Rather, the person takes his own life. Although suicide is no longer illegal in most jurisdictions around the world, this change does not signal that suicide is widely considered a morally good event. It has retained a pejorative connotation in many cultures and faith traditions, and the desire to commit suicide is widely considered a pathological condition. Patients who are “suicidal” are hence considered ill and in need of treatment; their suicidal attempts are generally countered rather than promoted. This pejorative connotation underlies the common use by advocates of PAS of a term other than “suicide” in bills aimed at legalization of PAS, such as “physician aid in dying.”

Assisted

There can be many types of suicide, such as desperate, heroic, or compulsory suicide, as well as “assisted” suicide. In their advisory report on euthanasia and assisted suicide in Australia, White and Willmott (2012) deﬁne assisted suicide as follows: “A competent person dies after being provided by another with the means or knowledge to kill him or herself” (p. 7). Possible means include: giving the patient a book describing what pills to use, writing a prescription, handing the patient lethal drugs, or building a suicide machine (as did the American pathologist Jack Kevorkian) by which the patient can initiate the injection of lethal drugs. Some forms of assistance are more controversial than others. For example, it is widely held that patients should not be encouraged to end their own life, nor should even the suggestion to do so be made. But whatever the form of help, the ultimate responsibility for the life-ending act remains with the patient; the person assisting the patient is merely doing that: providing help.

This is the main difference between assisted suicide and euthanasia. The motive underlying both practices is usually the patient’s suffering; in both the aim is to end the patient’s life; and both practices usually presume that the patient freely wants this outcome. Hence, PAS and euthanasia differ only in who ultimately performs the life-ending act: the patient himself or a third person.

Among both advocates and opponents of these practices, there are some who argue that this difference is morally irrelevant. Hence, some advocates of PAS and euthanasia prefer to use a single label for both. Thus, appellants in the Canada v Carter case proposed to merge PAS and voluntary euthanasia in what they labeled “physician-assisted dying” or “physician-assisted death.” But this merger fails to acknowledge that many jurisdictions do in fact treat these two acts differently. If found guilty of assisting in the suicide of another person, the penalty tends to be more lenient than if found guilty of ending the life of that other person at the latter’s explicit request. And in the USA, a handful of states have legalized PAS, but none has legalized euthanasia.

However, the label “assisted suicide” is itself not without problems either. Since in most jurisdictions around the world all forms of suicide have been legalized, patients who try to end their own lives with the assistance of somebody else are not themselves committing an illegal deed. What is still illegal, however, is the act of rendering such assistance. Thus, the debate about the legalization of PAS is not really a debate about the legalization of physician-assisted suicide but about physician assistance in suicide. In the remainder of this entry, the acronym PAS will therefore refer to the act of assisting a patient in the latter’s suicidal act.

Physician

In almost all jurisdictions where assisting in suicide has been legalized, only physicians are allowed to engage in this practice. And most ethical debates on this topic, whether in the mass media or in scholarly journals, simply assume that if anybody shall be granted this right, then it should only be physicians, such that in the English language, the very name itself – PAS – now includes the word “physician.” Rare exceptions include White and Willmott’s 2012 report on Australia cited earlier, a 2013 British proposal of law (HL Bill 24) which explicitly allows a nurse to deliver the lethal medications as prescribed by a physician, and certain efforts in the Netherlands to circumvent physician power altogether and legally allow lay persons to assist in suicide (but which have not been successful so far).

Advocates of a physician monopoly on assisting in suicide can point out that if the recipients of such assistance are terminally ill patients, it makes logical sense to restrict the rendering of such aid to physicians. And if, as is true in most jurisdictions, such assistance shall only be administered after all other nonlethal means of relieving suffering have been found ineffective, only physicians can establish whether that criterion has been met. Finally, as is true of the execution of death penalty convicts, it is widely assumed that a medically procured death is more humane than any other way of ending life.

Opponents of restricting the practice to physicians typically counter that even if a physician has to be involved, for example, to determine whether a person is terminally ill, the assistance itself does not require much medical expertise. Other health professionals such as nurses and pharmacists can competently provide such assistance as well. More fundamental is the objection that physicians, precisely because of their professional role and responsibilities, should not provide life ending assistance; it is incompatible with their duty to protect life and heal patients. This objection is discussed in greater detail below.

The Practice Of PAS

In the Netherlands the number of PAS cases has remained low at approximately 1.44/1,000 deaths. Ever since the legalization of PAS and euthanasia in 2002, the incidence of PAS has consistently been far lower (<10 %) than the number of euthanasia cases. In the American state of Oregon, which only allows PAS (and not euthanasia), the incidence of PAS has gradually increased from 0.55/1,000 deaths in 1998 to 2.12/1,000 deaths in 2013. Although reliable evidence is scarce, it is commonly assumed that the incidence of PAS may be about the same in countries where PAS is still illegal.

In Oregon, the three most frequently mentioned motives for PAS were loss of autonomy (93.0 %), decreasing ability to participate in activities that made life enjoyable (88.7 %), and loss of dignity (73.2 %). And almost half of patients in 2013 (49.3 %) gave as an additional reason being a burden on family, friends, or caregivers.

Different jurisdictions have adopted practice guidelines that are quite distinct and sometimes even contrary. For example, the American state of Oregon requires the patient to be an Oregon resident. In contrast, Dutch law is silent on whether the patient has to be a Dutch citizen or Dutch resident, but the Dutch government assumes that it is impossible for a physician to assess whether a patient meets the main criteria about voluntariness and suffering when there exists no therapeutic relationship between them. As for the age of the patient, Oregon requires the person to be at least 18 years of age. Dutch law requires the parents to agree with the patient’s request if the patient is between 12 and 16 years of age; between 16 and 18, the parents merely have to be involved in the decision-making. In Oregon that patient must have been diagnosed with a terminal illness that will lead to death within 6 months. In contrast, in the Netherlands the patient must be undergoing unbearable suffering that cannot be relieved otherwise; the law is silent on the patient’s remaining time of life. In both Oregon and the Netherlands, the attending physician must report to the authorities that he/she assisted in a patient’s suicide. In Oregon, the health authorities only review a sample of the reports received each year. In the Netherlands, each reported case is reviewed by one of the ﬁve Regional Review Committees, though only the more challenging cases are examined in depth.

Legality

In the foregoing section, two jurisdictions were compared that have legalized PAS. They are still exceptions in that most jurisdictions in the world prohibit PAS. Jurisdictions can be classiﬁed in the following types.

Explicit prohibition on PAS as well as euthanasia. Most of the world’s jurisdictions fall in this category. It includes the rare case of the Northern Territory of Australia which permitted PAS (and euthanasia) in 1995 but then prohibited the practice again in 1997.
Explicit prohibition on PAS, but legalization of euthanasia. This situation is most unusual; the reversed situation is much more common (see “PAS is Explicitly Allowed in the Criminal Code and the Law Provides Speciﬁc Guidelines for the Practice of PAS; Euthanasia Remains Illegal” below). The prime example is the country of Belgium which legalized euthanasia in 2002 but not PAS, which remained a criminal offense. This unusual decision was motivated by the aforementioned belief that people who wish to end their own lives suffer from a psychiatric illness and medical intervention needs to be aimed at preventing suicide rather than enabling it. Ever since the adoption of the law, Belgian critics have argued that some patients would prefer to control their own death rather than hand it over to a physician, and that the same respect for patient autonomy that underlies the legalization of euthanasia should hence result in the legalization of PAS as well.

3A. PAS is not explicitly prohibited in the criminal code, but other restrictive laws and policies render the practice very rare; euthanasia remains illegal. Examples include Albania, Denmark, Finland, France, Germany, and Sweden. The criminal codes in these countries do not prohibit rendering assistance in suicide, but other legally binding duties (e.g., the duty not to abandon a person whose life is in danger or a physician’s duty to provide effective medical care to patients in need) keep the practice of PAS extremely rare. The American state of Minnesota also fell into this category until Dr. Kevorkian openly began assisting patients in suicide there and Minnesota changed the law and prohibited PAS.

3B. PAS is not explicitly prohibited in the criminal code and PAS is practiced rather frequently, but the law does not provide guidelines for the practice; euthanasia remains illegal. Switzerland is the best known example in this category. Ever since 1923, Article 115 of the Swiss Penal Code prohibits inciting or assisting somebody else to commit suicide if this is done for selﬁsh reasons. Hence, all forms of assisting in suicide for reasons other than selﬁshness are legally permitted. Because assisting in suicide is only legalized indirectly, no practical guidelines have been formulated in the law, and hence, no monopoly for physicians on the practice of assisting in suicide exists. Switzerland also stands out among countries that permit PAS in that it does not require Swiss nationality or even residence to be a candidate for PAS. As a result, about a quarter to a third of all cases of assisted suicide in Switzerland performed by the six registered right-to-die organizations involve non-Swiss residents who come to the country solely to end their lives (Gauthier et al. 2014).

3C. PAS is explicitly allowed in the criminal code and the law provides speciﬁc guidelines for the practice of PAS; euthanasia remains illegal. Examples include the American states of Oregon (1997), Washington (2008), and Vermont (2013).

Both PAS and euthanasia are explicitly allowed in the criminal code and the law provides speciﬁc guidelines for these practices. Examples of jurisdictions are the Netherlands (2001, taking effect in 2002), Luxemburg (2009), and the Canadian Province of Quebec (2014).
The situation is legally unclear. An example is the state of Montana in the USA where the Supreme Court found in favor of PAS under certain speciﬁed conditions in 2009, but the state’s legislature still has not passed a law explicitly regulating the practice. A similar situation exists in the country of Colombia where the Constitutional Court in 1997 approved voluntary euthanasia and again in 2010, but Colombia’s parliament never passed legislation regulating either PAS or euthanasia. In Uruguay, Article 27 of the Penal Code explicitly authorizes judges not to impose a penalty when a person whose previous life has been honorable commits a homicide motivated by compassion, induced by repeated requests of the victim. But again, PAS has not been explicitly addressed in the statutes of Uruguay. Finally, the Canadian Supreme Court in its 2015 decision in Carter v Canada (2015 SCC 5) found that persons who have a grievous and irremediable disease or disability that causes enduring suffering that is intolerable to the individuals in the circumstances of their condition may receive PAS. Phrased in this manner, it would seem the Court decriminalized PAS not only for terminally ill patients but for almost anybody who deems his disease or disability a source of unbearable suffering. But the Court also stated that its judgment applied only to persons with the speciﬁc life condition of Ms. Carter (amyotrophic lateral sclerosis), leaving it to provincial legislators to draft more precise regulations.

It is important to note that the aforementioned distribution of countries into various categories is ﬂuid. In many jurisdictions, bills are submitted with great regularity to legalize PAS and/or euthanasia, including, most recently, in China, France, Germany, Japan, and the UK. Australian legislatures have been busy discussing, on average, two bills on PAS each year for the past 20 years. In that same period, some 140 PAS bills were submitted to the legislatures of 27 different states in the USA.

Cultural And Sociopolitical Context

Most countries that have legalized PAS are relatively wealthy nations with advanced health-care systems. They have robust democratic political systems in which individual rights and responsibilities have been gaining in recognition and legal protection. All are historically Christian countries but increasingly diverse and increasingly secular. The aforementioned study by Cohen and colleagues in 33 European countries showed great variance in the acceptance of euthanasia, but the single most determinant factor of approval of euthanasia was the lack of religious afﬁliation. White and Willmott (2012) likewise found that opposition to the legalization of PAS and euthanasia in the legislature of Australia’s Northern Territory was driven primarily by religious afﬁliation, with all Catholic parliamentarians opposing legalized PAS and euthanasia and all but one of the politicians representing other Christian religions doing the same. Faith-based tenets also appear to drive the strong opposition to PAS in predominantly Muslim countries such as Sudan (Ahmed et al. 2001), Saudi Arabia (Mobeireek et al. 2008), and Turkey (Buken and BalsevenOdabasi 2013).

Most denominations within the three dominant monotheistic religions (Judaism, Christianity, and Islam) reject PAS because of the belief that people do not own their lives: Life is a gift from God and people are required to be good caretakers of their lives until a natural death occurs. This notion of a natural death also plays an important role in different traditional African cultures. For example, in religiously agnostic communities in Ghana, where death is seen by most elderly as a welcome rest after a long and strenuous life, death nevertheless has to come naturally. A nonnatural death is a taboo and ignominy to the dying person and his family. Hence, death procured through PAS is considered a bad death (Van der Geest 2002; Owusu-Dapaa 2013).

In secularized western countries, where traditional normative principles such as stewardship of the gift of life and acceptance of a natural death have been fading, the principle of respect for patient autonomy has been moving to the foreground. The patient’s own preference is an increasingly important factor in medical decisions in other countries as well. However, traditional values continue to constrain its impact. For example, Ahmed and colleagues (2010) have reported that in Kuwait, the wishes of elderly patients were thought to carry more weight than those of younger patients suffering roughly equally. This difference may reﬂect the deference traditionally allotted to the views of the elderly in Arabic societies. Similarly, in traditional communities in India, the importance of the patient’s request tends to be superceded by the patient’s age, such that PAS and euthanasia are deemed more acceptable for elderly patients. Here, the driving factor is not deference but the conviction that it is appropriate for an elderly person to die and thereby enable a transmigration of the person’s soul (Kable et al. 2012). But the Hindu understanding of transmigration is complicated. On the one hand, Hinduism condemns suicide; such a death increases the difﬁculties in subsequent lives. Hence, PAS, when done for selﬁsh motives, is rejected. On the other hand, Hindus have traditionally venerated enlightened people who voluntarily decided the mode of their death after a long journey of seeking spiritual tranquility. But since it is not clear whether PAS is really comparable to the practices of fasting, self-immolation, and drowning at holy places, many Hindus remain skeptic about PAS (Sinha et al. 2012).

Arguments In Favor Of Legalization

Pragmatic Arguments

The ﬁrst class of arguments in favor of legalization is pragmatic: Regardless whether PAS is a morally good or bad act, it is better to regulate it than to let the practice go underground. Empirical evidence does indeed suggest that even in countries where PAS is illegal, physicians do assist in patients’ suicide. However, it is not clear that the underground practice of PAS will cease once PAS is legalized. Dutch research shows that many instances of PAS still go unreported.

The Importance Of Consistency

It is a widely accepted principle in law that like cases should be adjudicated in a like manner. Hence, it would seem utterly inconsistent to prohibit assisting in some act when the act itself is perfectly legal. However, this line of reasoning overlooks that the decriminalization of suicide is not usually motivated by the conviction that suicide is a good thing that should be promoted, but by the realization that the threat of some court imposed penalty will not keep a desperate patient from committing suicide. In contrast, the threat of imprisonment is likely to discourage physicians from assisting suicidal patients. Hence, it is not inconsistent for a country to take suicide out of its penal code but keep PAS in.

Another example of reasoning from consistency starts off with the observation that in many countries, patients are legally able to bring about their own death by instructing their physicians to withhold or withdraw life-sustaining treatment. Consistency seems to demand that patients should also be able to elect a so-called “active” as opposed to “passive” mode of ending their lives and obtain a prescription for lethal drugs from their physicians. One of the two cases brought before the US Supreme Court in 2007 was based on this line of reasoning (Vacco v. Quill, 521 U.S. 793, 1997). But the Court disagreed, insisting that there is a fundamental difference between these two modes of dying. Indeed, in respecting a patient’s refusal of further life sustaining treatment, the physician is not assisting the patient in any way but is ceasing to assist the patient. Moreover, such respect does not logically demand that the physician intends the patient’s death.

A Rights Approach To PAS

The ﬁrst and most commonly advanced right based argument in favor of PAS is that patients have a negative or liberty right. This line of reasoning is closely related to the second argument from consistency mentioned above: The government may not force life-sustaining medical treatments onto patients but must respect their autonomy; by the same token, the government should not forcefully interfere in the agreement between two consenting adults where one freely asks the other to assist in the former’s suicide, and the latter freely agrees. This line of reasoning is highly persuasive but not beyond criticism. It hinges on the assumption that in committing suicide, a patient is not disproportionately harming third persons, and neither is the physician in rendering assistance. Yet in most countries that have decriminalized suicide, the government continues to promote other methods of preventing suicides, such as psychiatric treatment, thereby signaling that it does indeed have an interest in the lives of all, even of people who no longer have an interest in their own lives. Thus, allowing physicians to assist in suicide hinders the goal of suicide prevention.

The second right-based defense of legalization of PAS holds that patients not only have a negative right to PAS but a positive right as well. That is, they are entitled to assistance in their suicide. The problem with any positive right is that it presumes somebody else has a duty to make sure the claim is fulﬁlled. But few are willing to accept that physicians have a duty to render assistance in suicide. Even in the Netherlands, PAS is not considered a normal medical intervention, which a physician hence could not refuse to provide.

The third rights-based line of reasoning does not focus on patients’ rights but society’s rights. This line of reasoning is rarely advanced in the aforementioned jurisdictions that have already legalized PAS. But Chinese advocates of legalized euthanasia have supported their “Bill on the Support for the Shanghai Regional Regulation of Euthanasia” by arguing, among others, that “medicine must not just protect the rights of the individual, it must also accommodate those of the collective… Here, according to the authors, the Geneva Declaration of 1948 still hampers the legalization of euthanasia by its emphasis on individual human rights, omitting to pay sufﬁcient attention to improve the quality of life of the collective whole” (as reported by SleeboomFaulkner 2006, p. 207). More speciﬁcally, PAS beneﬁts the patient’s family if it relieves the family from ﬁnancial and social burdens, and there are signiﬁcant cost savings that society could attain by enabling PAS.

PAS Is Beneficial To The Patient

Occasionally, advocates of PAS will argue that death is itself good, at least in certain circumstances. In the same way as some deaths are premature, other deaths come too late. But this line of reasoning is rarely defended by health-care professionals. More commonly, they will hold that death itself is not a beneﬁt; it may even be a harm; but continued suffering is an even greater harm. Thus, PAS is beneﬁcial in that it prevents greater harm. This argument is very persuasive but presumes that there is no alternative way of relieving the patient’s suffering that is itself less harmful than death. Indeed, most protocols regulating PAS require that all other reasonable means of relieving suffering must have been tried before proceeding to PAS.

Some PAS protocols, however, presume that only the patient himself can determine what alternative means are reasonable. Thus, they only require physicians to present alternative modes of palliative care to the patient, but the patient may ﬁnd these alternatives non-beneﬁcial and opt for PAS instead. The physician may then proceed with PAS as the most beneﬁcial course of action under the circumstances. Critics of this second line of reasoning can point out that terminally ill patients who suffer unbearably and have become fully dependent on the care of family members and health professionals are unlike assertive consumers; they are neither eager nor able to shop around for health-care services that please them the most. Instead, they trust their physicians to develop care plans that are beneﬁcial.

Arguments Against Legalization

Besides objections to the arguments presented in the previous section, opponents of legalization of PAS typically bring forward the arguments presented below.

Pragmatic Arguments

Even if a theoretical case can be made in favor of PAS legalization, for example, in reference to patients’ rights as delineated above, there are pragmatic reasons not to do so. At least three types of pragmatic reasons can be distinguished.

The ﬁrst pragmatic reason not to attempt legalization of PAS is that there is no need to do so. In ever more countries, patients already have a right to refuse life-sustaining treatments they do not consider beneﬁcial, even if such a refusal will hasten death. And given the rapid development of different modes of effective palliative care, including new medications, innovative hospice facilities, and terminal sedation, situations in which PAS is needed should be extremely rare. Most legal systems already have mechanisms to deal with such extraordinary situations. Examples include the latitude judges have in (not) imposing a penalty, the discretion that prosecutors have to decide when (not) to prosecute, and speciﬁc articles in law codes that recognize that a person may have to violate the law in order to protect a more important social good. The problem with this line of reasoning is that it is at odds with the normal legislative approach. The default position is to always allow behaviors, unless there is an important reason for a legal prohibition thereof, rather than prohibiting behaviors unless there is an important reason to allow it. The burden of proof therefore should not be on advocates of decriminalization of PAS but on advocates of a continued prohibition; they need to provide afﬁrmative arguments why keeping PAS illegal is necessary.

The second pragmatic argument against legalization of PAS alleges that it is impossible to regulate the practice of PAS. Two types of regulatory challenges can be distinguished. First, all jurisdictions where PAS already has been legalized stipulate that the patient’s wish for PAS be fully free. But physicians lack the means to determine that this criterion is fully met. For example, it is extremely difﬁcult to determine whether a patient’s request for PAS is caused by socioeconomic pressures. In Oregon, the number of patients who ask for PAS among others because they consider themselves a burden to their families has continued to rise from 12 % in 1998 to 49.3 % in 2013. The reality of elder abuse, often at the hands of family members, further supports this concern about family pressures leading to requests for PAS unbeknown to the physician.

Similarly, economic pressures may drive patients to request PAS. Opponents of legalization commonly worry that efforts to curb the ever rising costs of health care are motivating the practice of PAS. At present, there is no persuasive evidence that in the countries that have legalized PAS, such pressures do indeed drive patients to request PAS. But these countries are all relatively wealthy, offering broad access to high-quality health-care services. In countries that still battle widespread poverty and lack of access to health care, such as mainland China (SleeboomFaulkner 2006), Ghana (Owusu-Dapaa 2013), India (Kable 2012), and Sudan (Ahmed 2001), such economic exigencies are much more likely to pressure patients into requesting PAS. Of course, this argument also goes the other way since health-care providers and hospitals earn money by extending the lives of patients. That some patients’ lives are extended for the wrong reasons does not, however, render invalid the stated concerns about patients’ lives being ended for the wrong reasons.

A second regulatory challenge is the historic difﬁculty of regulating physicians. It is widely believed that society has little choice but to trust that physicians will discipline their own ranks, the principal hallmark of a profession proper. Indeed, Oregonian and Dutch authorities rely primarily on the report of the physician who has engaged in PAS, without considering evidence from other sources. This is a most unusual method of legal control when compared to other acts covered in the Criminal Code. Advocates of legalized PAS can counter that precisely the continued acceptance of medicine’s status as a profession in combination with the practice of PAS being restricted to physicians only, justiﬁes legalization of PAS. If physicians can be trusted to operate on patients, prescribe dangerous medications, and submit patients to radiation, it stands to reason that they can be trusted as well to render assistance in patients’ suicide in a conscientious and professional manner.

The third regulatory challenge is not primarily concerned with the practice of PAS itself but with what may come after. This so-called “slippery slope” argument predicts that once the door is opened to legalized PAS, it will not be possible to restrain the practice and other forms of termination of patients’ lives will soon be promoted and legalized. Opponents can point to the so-called Groningen Protocol in the Netherlands which provides guidelines for ending the lives of newborns who are believed to be suffering unbearably; the protocol is now tolerated by the Dutch legal authorities even though it clearly violates the criteria set forth in the country’s law on PAS and euthanasia.

More subtle are concerns about changes in the social climate that legalization of PAS may effectuate. Opponents worry that such legalization will inevitably stigmatize individuals who do not make use of this option and thus become a burden on society. The Danish Council of Ethics (2006) has deplored the ever-increasing importance attributed to personal autonomy and the failure to acknowledge that people are always interdependent. Furthermore, if dependence on others for the most mundane aspects of life such as personal hygiene is undigniﬁed for terminally ill patients and justiﬁes PAS, it stands to reason that the lives of disabled persons, who are not terminally ill but equally dependent on others, are also undigniﬁed. That they have to live much longer in this allegedly undigniﬁed condition than a terminally ill person only makes their plight worse and PAS more justiﬁed. In short, if PAS is legalized, the potential exists that ever more categories of persons are deemed to have a right to PAS, criteria are loosened, and ultimately the idea may take hold that some patients have a moral obligation to elect PAS– a scenario already described by Thomas More in his Utopia from 1516.

Slippery slope arguments, while persuasive, are problematic from strictly logical perspective: Even if the practices that are predicted to develop subsequent to the legalization of a particular act are immoral, that does not render the act itself immoral. Advocates of PAS hence can reasonably contend that these future developments should be forcefully countered and even prohibited by law, but PAS itself should be legalized.

Objections Related To The Role Of A Physician

As mentioned above, without exception all jurisdictions that have decriminalized assistance in suicide have done so for physicians only. All other health professionals, and certainly lay persons, have remained subject to the prohibitions in the Criminal Code. Why the same monopoly surfaces in places as diverse as Quebec, Colombia, Luxemburg, and Australia’s Northern Territory, and what it tells us about society’s expectations of physicians, merits further reﬂection and research. However, that very same phenomenon has also become the foundation of an important source of opposition to PAS, speciﬁcally by medical associations themselves. While not taking a position of PAS as such, the European Association for Palliative Care (EAPC) has insisted that PAS is not part of palliative care proper because palliative care intends neither to hasten nor postpone death; the EAPC concludes that PAS is not a practice that palliative care specialists, in spite of their expertise in bringing about a better dying process, should be expected to perform (Materstvedt et al. 2003). The World Medical Association (WMA) more stringently prohibits all physicians from assisting in patients’ suicide as do a number of other country-speciﬁc medical associations. The WMA believes that procuring death is incompatible with the role of physicians as health-care providers and healers. Even in the Netherlands, assistance in suicide, while considered part of medical practice, is not considered “normal” medical practice, signaling that there is something abnormal about physicians’ performing life-ending acts.

The reasons for deeming PAS incompatible with the role of a physician (or, more broadly, a health professional) are diverse. There is the historic argument that the prohibition on providing patients with lethal medications can be traced back as far as the Hippocratic Oath. Sociologists may point out that in many countries, minority segments of the population do not share the dominant trust in the country’s physicians; when even medical decisions to forego treatments deemed futile are known to fuel such distrust, the legalization of PAS can put further strain on the public’s trust in the medical profession. Very different is the argument that physicians need protection against themselves. Physicians have great power but are still only human and prone to succumb to morally troublesome inﬂuences, whether a personal sense of failure when patients cannot be rescued, economic pressures aimed at maximizing revenue, or dominant societal ideas about what type of life is worth living.

Advocates of legalized PAS can object that the ethos and norms that bind physicians and shape the social contract between the profession of medicine and society differ in different parts of the world and in different eras, reﬂecting differences in traditions, culture, and dominant religious practices. Thus, there may be jurisdictions where a medical monopoly on assistance in suicide cannot be justiﬁed, but in others it can.

Sanctity Of Human Life

The ﬁnal class of arguments against legalization of PAS is much more expansive than either of the former two. It is not limited to pragmatic concerns, nor to physicians, but entails a principal objection to all forms of intentionally hastening the death of patients. The underlying principle is commonly known as the “sanctity of human life.” As the name indicates, it has faith-based roots, but it has become part of several legal traditions too (White and Willmott 2012). It captures the conviction that human life is inherently of value, irrespective of the particular condition, age, health, or social status of a person, and irrespective of whether others ﬁnd it valuable or even the person whose life it is. The principle hence is also known as the “inviolability of human life.”

Those subscribing to this principle typically understand it to trump not only the positive entitlement right to PAS mentioned above, but also the negative liberty right to PAS. Because human life is sacred and may never be violated, the state must protect human life. This explains why even homicide at the explicit request of the victim remains a crime in most countries. As mentioned earlier, not all means are equally suitable to protect human life; criminalization of suicide is now widely believed not to be an effective means. But criminalization of assistance in suicide is still believed to be so.

Surprisingly, the principle of the inviolability of human life can also be used to justify PAS, as did the Canadian Supreme Court in Carter v Canada. The Court argued that a blanket prohibition of PAS will lead to a loss of human life when patients who fear the prospect of dying a protracted death will instead elect to end their lives early.

Conclusion

Efforts to legalize the practice of PAS are steadily gaining popular support in many countries. This support appears driven, at least in part, by widespread fears of the prospect of protracted, unbearable suffering at the end of life. The social expectation, prevalent in most western societies, that people should be free, autonomous, and in charge of their own lives generates additional fears about becoming dependent and a burden on loved ones and society at large. At the same time, in countries where PAS has already been legalized, very few terminally ill patients elect to end their own lives through PAS. This paradox suggests that the aforementioned fears are not quite realistic and that PAS is not nearly as attractive an option to most terminally ill patients as most healthy voters believe it to be. Coupled with the sheer impossibility to truly regulate the practice of PAS and enforce legally adopted standards, it behooves countries considering legalization to act with great caution. Preventing the very need for PAS would seem a more prudent way forward.

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