pros of physician assisted suicide essay

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Arguments in Favor of Right-to-Die Legislation

There are many arguments about whether people should have the right to die when they choose, intentionally and by design, to end their own perceived pain and suffering .

Differences of Opinion

Most of the arguments for and against the right to die are ideological, based on many important aspects of civility: the law, religion or spiritual beliefs, ethics, and social mores. Opinions vary based on personal experiences, belief systems, age, culture, and other aspects of humankind that influence how we think about important aspects of life.

Where the Right to Die Is Legal

In the United States, with the exception of a small number of states which have passed right-to-die legislation, a doctor who injects a patient who wants to die with a lethal drug and kills him would technically have committed murder.   Proponents of right-to-die legislation desire a legal remedy for doctors who assist their suffering patients in ending their lives. Outside of the United States, euthanasia is the law of the land in Canada, the Netherlands, Colombia, Belgium, Luxembourg, and Switzerland.

Understanding Right-to-Die Laws

Right-to-Die legislation, also known as physician-assisted death or aid in dying, gives mentally competent adult patients with a terminal illness and a prognosis of six months or less to have the ability to request and receive a prescription medication to bring about their death. Most statutes under consideration at the state level are modeled after Oregon’s Death with Dignity Act, which requires two physicians to confirm the patient’s residence, diagnosis, prognosis, mental competence, and voluntariness of the request to die.   In addition, two waiting periods are required.

The Pros for Right-to-Die Laws

Here are some arguments in favor of giving patients the right to die and protecting healthcare providers who carry out those wishes. Compare these arguments in favor of death with dignity and the right to die against  the cons .

• A patient's death brings him or her the end of pain and suffering.
• Patients have an opportunity to die with dignity, without fear that they will lose their physical or mental capacities.
• The overall healthcare financial burden on the family is reduced.
• Patients can arrange for final goodbyes with loved ones.
• If planned for in advance, organs can be harvested and donated .
• With physician assistance , patients have a better chance of experiencing a painless and less traumatic death (death with dignity).
• Patients can end pain and suffering when there is no hope for relief.
• Some say assisted death with dignity is against the Hippocratic Oath; however, the statement “first do no harm” can also apply to helping a patient find the ultimate relief from pain through death.
• Medical advances have enabled life beyond what nature might have allowed, but that is not always in the best interest of the suffering patient with no hope of recovery.
• A living will, considered a guiding document for a patient's healthcare wishes, can provide clear evidence of a patient's decisions regarding end-of-life care.

Pereira J. Legalizing euthanasia or assisted suicide: the illusion of safeguards and controls . Curr Oncol . 2011;18(2):e38-45. doi:10.3747/co.v18i2.883

Battin MP, Van der heide A, Ganzini L, Van der wal G, Onwuteaka-philipsen BD. Legal physician-assisted dying in Oregon and the Netherlands: evidence concerning the impact on patients in "vulnerable" groups . J Med Ethics . 2007;33(10):591-7. doi:10.1136/jme.2007.022335

By Trisha Torrey  Trisha Torrey is a patient empowerment and advocacy consultant. She has written several books about patient advocacy and how to best navigate the healthcare system. 

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• CLINICAL SPOTLIGHT | 
• General Medicine
• Hospital Medicine

October 5, 2017

Pros and Cons of Physician-Assisted Suicide

Abigail zuger, md.

The American College of Physicians again declines to endorse the practice but provides articulate commentary both in support and in opposition.

Twenty years ago, Oregon became the first state in the U.S. to legalize physician-assisted suicide (PAS). Thirty other states have debated and rejected similar legislation, whereas 5 states and the District of Columbia have legalized PAS or enabled it by judicial ruling. This ongoing national conversation has prompted the American College of Physicians (ACP) to reconsider its 2001 position paper against the practice — and once again, the organization has declined to endorse it. In a position paper supplemented by several independent commentaries, reasons to support and to disagree with the ACP decision were reviewed.

Writing on behalf of the ACP, Sulmasy and Mueller note that proponents of PAS consider it to be a logical extension of physicians' obligations to respect patient autonomy, to relieve suffering, and to support their patients during moments of crisis. PAS opponents counter by citing intrinsic professional obligations to avoid doing harm, as well as longstanding specific injunctions against colluding in suicide. Opponents point out that patient autonomy is not an absolute right, and they worry that societal acceptance of PAS might start “a slow slide down a slippery slope” toward acceptance of involuntary euthanasia; this is the concern that prompts many advocacy groups for disabled people to firmly oppose PAS.

Sulmasy and Mueller review the confusing ethical landscape of end-of-life care, including physicians' duties to honor patients' decisions to stop or forego lifesaving treatments and to medicate pain even if pain medication might shorten life. However, the authors emphasize that terminal illness brings many kinds of suffering: not only physical pain and clinical depression that should be addressed medically, but also spiritual and existential suffering that seldom can be addressed medically and that perhaps should not be seen as projects for physicians to undertake.

“Is it reasonable to ask medicine to relieve all human suffering?” these authors ask. “Is a medicalized death a good death?” They conclude that medicalizing death even further, with a doctor providing a terminal prescription, “does not address the needs of dying patients and their families. What is needed is care that emphasizes caring in the last phase of life.” To this end, they include in their discussion a 12-step plan for physicians to use when caring for dying patients.

Writing in disagreement with the ACP, Quill and colleagues first note that they support this 12-step plan. They add, however, that if the process proves unsuccessful, “all legally available last-resort options should be explored.” They urge physicians who cannot personally support a patient's wish for help with suicide to help the patient find a doctor who can. “We are concerned that concluding a guideline by stating ‘physicians should not do this' is a problematic public health response,” these authors write. “Even if one personally disagrees with the behavior, studying it might tell us much about the state of end-of-life care and how it can be improved.”

Writing in support of the ACP's decision, Kussmaul notes that the “slippery slope” objection to PAS might be dismissed as alarmist but is not easily refuted. He cites statistics from the Netherlands (where PAS has long been legal) indicating that, in 2015, “hundreds of persons were put to death without their express consent or because of psychiatric illness, dementia, or just ‘old age.'” Kussmaul cites the moral standard that underlies many people's opposition to suicide, specifying that “human life has intrinsic worth and dignity and that its value extends beyond the individual to the community,” and stating that he believes it is a value that persists even if the individual temporarily or permanently stops believing in it himself or herself.

Finally, Hedberg and New of Oregon's Health Authority provide statistics on the state's PAS activity. From 1998 through June 2017, 1857 Oregon residents (about 0.2% of all decedents) received “death with dignity” prescriptions, and 1186 (64%) ingested the drugs; 1179 died from the medications, and 7 regained consciousness. Six of these seven have since died of their underlying illnesses. The most common underlying diseases in these patients were cancer (77%) and amyotrophic lateral sclerosis (8%). Reasons cited for suicide usually were loss of autonomy (91%) and inability to enjoy usual activities (90%), whereas pain and financial concerns were mentioned by only 26% and 4% of patients, respectively. Patients who requested help with suicide were younger and far more likely to be college-educated than other Oregon patients with similar illnesses. Only 374 physicians (0.6% of the state's total) participated in the program, and most of those who did (62%) wrote only one prescription.

Many physicians feel strongly one way or the other about physician-assisted suicide, and most others probably aren't sure what they feel. Regardless of their thoughts on this topic, all physicians and medical students should read the articles in this series. The data and the issues are presented with clarity, passion, and a balanced concern for the welfare of patients and their doctors.

Dr. Paul Mueller is an Associate Editor for NEJM Journal Watch General Medicine and an author of the ACP position paper. He had no role in selecting or summarizing this paper for NEJM Journal Watch.

Sulmasy LS and Mueller PS. Ethics and the legalization of physician-assisted suicide: An American College of Physicians position paper. Ann Intern Med 2017 Sep 19; [e-pub]. ( http://dx.doi.org/10.7326/M17-0938 . opens in new tab )

Quill TE et al. Physician-assisted suicide: Finding a path forward in a changing legal environment. Ann Intern Med 2017 Sep 19; [e-pub]. ( http://dx.doi.org/10.7326/M17-2160 . opens in new tab )

Kussmaul WG 3rd. The slippery slope of legalization of physician-assisted suicide. Ann Intern Med 2017 Sep 19; [e-pub]. ( http://dx.doi.org/10.7326/M17-2072 . opens in new tab )

Hedberg K and New C. Oregon's death with dignity act: 20 years of experience to inform the debate. Ann Intern Med 2017 Sep 19; [e-pub]. ( http://dx.doi.org/10.7326/M17-2300 . opens in new tab )

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• Disclosures

Disclosures for Abigail Zuger, MD, at time of publication

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Physician-assisted suicide is gaining popularity. But there are better options.

The French philosopher Albert Camus once said, “There is but one severe philosophical problem, and that is suicide.” It is a problem we are still grappling with today.

Ten states and the District of Columbia have legalized physician-assisted suicide, and there is momentum across the country to pass similar legislation. States like Arizona, Massachusetts, Minnesota, New York and Pennsylvania are now actively considering it.

To be clear, physician-assisted suicide is contrary to the teaching of the Catholic Church and to the American Medical Association’s ethical code . The vast majority of hospice care providers also oppose it . In 2015, a multiyear study by the Institute of Medicine, titled “ Death and Dying in America ,” outlined alternatives to physician-assisted suicide, but few of its recommendations have been adopted.

Instead, the political popularity of physician-assisted suicide persists. Advocates argue that it helps with pain management and supports individual autonomy. In Minnesota, state Representative Andy Smith, a Democrat from Rochester, justified its legalization by saying , “We’re trying to put more compassion into the medical system.”

There is pressure on groups like the A.M.A. and hospice associations to reverse their official positions that assisted suicide is contrary to their missions.

The media is another source of the momentum for assisted suicide. For example, Steven Petro contributed an essay to The New York Times last December titled “ I Promised My Sister I Would Write About How She Chose to Die . ” The author’s younger sister, Julie, was diagnosed with advanced ovarian cancer; after surgery and chemotherapy, she said she was no longer interested in “‘Hail Mary’ treatments—drugs with many side effects, often used out of desperation or denial.” She told Mr. Petro, “I don’t want to die like that,” and said that physician-assisted suicide was “about taking control of my life.”

And in January, The Boston Globe published “ Dying on Lynda’s Terms ,” about a woman with terminal cancer who moved from Connecticut to Vermont to take advantage of latter’s physician-assisted suicide law. She challenged a residency requirement in the law, saying it violated the U.S. Constitution, and Vermont waived the requirement for her, then scrapped it altogether . This precedent could make physician-assisted suicide a legal option for anyone willing to travel to states that allow it. The article closes with a touching description of Lydia’s death with family and friends.

Such articles are putting pressure on groups like the A.M.A. and hospice associations to reverse their official positions that assisted suicide is contrary to their missions. There is also a new physicians’ association called the American Clinicians Academy on Medical Aid in Dying , whose mission is “developing, improving, and supporting best practices for the care of patients considering or completing medical aid in dying.”

Some respected medical ethicists are also changing their attitudes about physician-assisted suicide. Arthur L. Caplin of the New York University Medical School, in a recent interview with the website Medscape , said, “I think it is an option that makes some sense. I am well aware that we also need to make sure that people know about hospice.”

Dr. Caplin’s last point is a critical one. If the public and physicians better understood hospice and palliative care, these two options might well address all the concerns of patients about end-of-life care.

If the public and physicians better understood hospice and palliative care, these two options might well address all the concerns of patients about end-of-life care.

The real problem with physician-assisted suicide is that it attempts to treat symptoms (patients no longer wishing to live) and not the cause of their despair (a broken health care system). Patients are not educated about, nor referred to, hospice and palliative care in a timely fashion. So they end up receiving excessive and painful treatments that add unnecessary suffering. They turn to assisted suicide from fear of being “overtreated” by the health system.

One piece of evidence for this view is a recent study by the Penn School of Medicine showing that more than 70 percent of those who selected physician-assisted suicide over a 20-year period were cancer patients, who often undergo extensive chemotherapy and radiation treatments. In some cases, these treatments might be avoided by timely referrals to palliative care.

The experience of nations like the Netherlands, Belgium, Canada and Australia, which have offered physician-assisted suicide for decades, also raises concerns that safeguards against abuse of the practice have been weakened. These safeguards, such as requiring a terminal diagnosis and a careful assessment of a patient’s mental capacity, are intended to ensure that physician-assisted suicide is allowed only when appropriate.

What starts as a “compassionate” and rarely used option can metastasize into something like euthanasia, especially in certain populations.

Writing in the National Review last year, Alexander Raikin said that he has interviewed many health care professionals in Australia and Canada who are considering leaving their profession because of the increased social pressure for patients to consider physician-assisted suicide:

David D’Souza, a physician in Ontario, told me, “I think already there’s a lot of abuse going on, and I’m seeing it in my own practice,” including when families pressure loved ones to die so that estates or insurance payouts become available sooner. “It’s making me think twice about whether I should be continuing in geriatric care.”

In short, what starts as a “compassionate” and rarely used option can metastasize into something like euthanasia, especially in certain populations. The Penn School of Medicine study indicates that the people who have chosen physician-assisted suicide since it was legalized in their states tend to be white, male and religiously unaffiliated—and also that they most often cite a loss of autonomy and dignity as the reasons for choosing suicide, rather than for relief from physical pain.

Physician-assisted suicide does not adequately answer the problem of older citizens facing a dire death experience. State governments should focus their energy on meaningful reforms to real problems rather than on superficial solutions that start us down a slippery slope. Below are three opportunities to benefit dying patients by reducing bureaucracy and increasing real compassion in health care.

Stop using medical coding to determine compensation to primary care physicians.  The biggest (but seldom discussed) problem in health care today is using medical coding to determine provider payments. Coding has made health care billing exceedingly complex, and it doesn’t recognize physician services that are difficult to quantify—like conversations with a patient. As a result, physicians spend twice as much time on administrative documentation as they do seeing patients. No wonder health care lacks compassion!

This coding system also discourages physicians from talking to other physicians regarding shared patients. So no one is paid to coordinate patient care, much less discuss delicate end-of-life issues. This payment system has also driven physicians away from primary care, geriatrics and palliative care. But we need physicians in these areas to care for a growing aging population with multiple chronic illnesses.

Code-based payments to primary physicians are a major cause of fragmented health care. Federal legislation to change how we compensate primary care physicians will improve compassion and reduce fragmented care.

Improve access and education about palliative care and hospices. These two important care options are clinically, economically and legally designed to be underutilized by the health system. Simple changes to the payment model would help address this flaw. In addition, palliative care should be taught more in medical school, and patients should educate themselves about this option. State governments could also require patients to complete advanced directives in order to receive Medicaid, or provide financial incentives for patients to take classes in palliative and end-of-life care.

Help families manage their fear of death. Everyone—patients, families and physicians—fears death. As with many things, education is the best medicine to address this fear, but education requires extensive dialogue, and, as noted above, insurance companies do not compensate physicians for crucial conversations surrounding end-of-life care. Again, state Medicaid policy is another opportunity to encourage patients to learn about viable alternatives to physician-assisted suicide.

It is always difficult to change such a complex system, but as we wait, health care becomes increasingly expensive and far less compassionate. Unfortunately, physician-assisted suicide follows in that flawed tradition.

The real solution to the problem is to implement proven practices for improving end-of-life care. Of course, those familiar with the wisdom of Catholic teaching and the ethical code of the A.M.A. already know that.

Michael D. Connelly is C.E.O. emeritus of Mercy Health and author of the new book The Journey’s End: An Investigation of Dying in Modern America.

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Arguments for and Against Physician-Assisted Suicide

The right to legally end your own life is a heavily debated issue..

Posted September 16, 2020 | Reviewed by Gary Drevitch

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Although September is designated National Suicide Awareness Month, there are those who think about suicide 12 months of the year. They may be survivors of suicide loss—the family and friends of those who have taken their own lives—or they may be people who often contemplate suicide or have already made attempts. Articles and anecdotes of suicide published during the month of September and at other times most often focus on prevention. But there’s another side to the story.

Many people believe that ending one’s own life is a human right, particularly for those who are terminally ill and suffering from indescribable pain or impairment. In the United States, however, it is only a right for those in the nine places where physician-assisted death is now legal when strict guidelines are followed. In Oregon, Washington, Vermont, Maine, Hawaii, California, Colorado, New Jersey, or the District of Columbia, eligible, terminally ill patients can legally seek medical assistance in dying from a licensed physician. In all of these places, a physician can decide whether or not to provide that assistance. At the same time, other states—Alabama, Arizona, Georgia, Idaho, Louisiana, New Mexico, Ohio, South Dakota, and Utah—have, in recent years, strengthened their laws against assisted suicide. In 2018, for instance, Utah amended its manslaughter statute to include assisted suicide.

In a nutshell, it works like this: The patient orally requests legal medical assistance in dying from a qualified physician. That physician must assess and confirm the patient’s eligibility and also inform the patient of alternative treatments that provide pain relief or hospice care. At that point, a second physician must confirm the patient’s diagnosis and mental competence to make such a decision. If deemed necessary, either physician can require the patient to undergo a psychological evaluation. The patient must then make a second oral request for assistance. Once approved, the original physician writes a prescription for lethal medication (usually a high-dose barbiturate powder that must be mixed with water) that the patient can self-administer when and where they choose, as long as it is not in a public place. Some people never fill the prescription or fill the prescription but never take the medication. Those who do generally fall asleep within minutes and die peacefully within a few hours.

Several organizations have been formed to both support and oppose physician-assisted dying for moral, ethical, and legal reasons. Groups such as Death with Dignity and Compassion and Choices are in favor of what they call “medical aid in dying” and work to provide assistance and lobbying efforts to initiate legal “right to die” programs in every state. They support patient autonomy and choice, particularly in the case of terminal illness. To these groups and their supporters, most of whom come to this side of the issue as a result of agonizing personal experience, death with dignity is a human rights issue and those who are suffering are entitled to a peaceful death.

On the other side of the debate, groups like the Patients Rights Council and Choice Is an Illusion work to tighten laws against euthanasia and medical aid in dying. They fear a complete lack of oversight at the moment of death, as well as normalization of the process to the degree that patients will feel they must relieve their families of the burden they are inflicting by living with their illness. They are concerned that decisions will be made by others on behalf of those too ill to speak for themselves. These groups believe the job of a physician is to find ways to eliminate patients’ suffering, not the patients themselves. They do not believe a physician is qualified to make the decision to assist in ending a life.

In the end, no group really wants assisted suicide to be the final answer, but those who favor medical aid in dying see little recourse for those living with unbearable chronic pain , who are terminally ill, and who have no hope of improving the quality of their lives because medical science has not yet caught up with our modern potential for longevity.

Compassion and Choices: https://compassionandchoices.org/

Death with Dignity: https://www.deathwithdignity.org/

Patients Rights Council: http://www.patientsrightscouncil.org/site/

Choice is An Illusion: https://www.choiceillusion.org/2019/04/in-last-ten-years-at-least-nine-…

Susan McQuillan is a food, health, and lifestyle writer.

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Euthanasia and physician-assisted suicide: a systematic review of medical students’ attitudes in the last 10 years

Alejandro gutierrez-castillo.

1 Researcher, School of Medicine, Monterrey Institute of Technology and Higher Education, Nuevo León México, Mexico.

Javier Gutierrez-Castillo

Francisco guadarrama-conzuelo, amado jimenez-ruiz.

2 Neurology Resident, Department of Neurology, National Institute of Medical Science and Nutrition Salvador Zubirán, Ciudad de México, México.

Jose Luis Ruiz-Sandoval

3 Professor, Department of Neurology, Civil Hospital of Guadalajara “Fray Antonio Alcalde”, Jalisco, México.

This study aimed at examining the approval rate of the medical students’ regarding active euthanasia, passive euthanasia, and physician-assisted-suicide over the last ten years. To do so, the arguments and variables affecting students’ choices were examined and a systematic review was conducted, using PubMed and Web of Science databases, including articles from January 2009 to December 2018.

From 135 identified articles, 13 met the inclusion criteria. The highest acceptance rates for euthanasia and physician-assisted suicide were from European countries. The most common arguments supporting euthanasia and physician-assisted suicide were the followings: ( i ) patient’s autonomy (n = 6), ( ii ) relief of suffering (n = 4), and ( ii ) the thought that terminally-ill patients are additional burden (n = 2). The most common arguments against euthanasia were as follows: ( i ) religious and personal beliefs (n = 4), ( ii ) the “slippery slope” argument and the risk of abuse (n = 4), and ( iii ) the physician’s role in preserving life (n = 2). Religion (n = 7), religiosity (n = 5), and the attributes of the medical school of origin (n = 3) were the most significant variables to influence the students’ attitude. However, age, previous academic experience, family income, and place of residence had no significant impact.

Medical students' opinions on euthanasia and physician-assisted suicide should be appropriately addressed and evaluated because their moral compass, under the influence of such opinions, will guide them in solving future ethical and therapeutic dilemmas in the medical field.

Introduction

Death by itself is not part of an ethical dilemma, as all lives are bound to end since the moment of conception, and human beings confront death through their personal beliefs, religion, and cultural context. Regardless of the natural and unavoidable causes of death, debate over death focuses on how to control it as well as on who and how should perform the death-related practices in medical field. The important role of physicians in this debate is that they are often both the judge and the executor of such practices ( 1 ). Several physicians believe that the idea of promoting death is against Hippocratic Oath and their primary role as healer, while others may reject the idea based on their moral or religious values ( 1 ).

The issues on control over death can be divided into two broad categories: euthanasia and physician-assisted suicide (PAS). Euthanasia is further divided into active euthanasia (AE) or passive euthanasia (PE), according to the role that the physician plays in the process. The term PE is no longer used in some countries, and the term Therapy Withdrawal (TW) is replaced as the physician’s role is limited to suspending treatment or stopping additional measures that artificially prolong life. In TW, the physician acts as a mere observer while the disease advances and ends the patient’s life. However, in AE, the physician operatively engages in ending patient's life by administering a toxic substance that accelerates death ( 2 ). In PAS, the physician intentionally helps the patient to commit suicide by providing drugs for their self-administration at the patient’s competent and voluntary request ( 3 ). The differences among aforementioned approaches have implications that surpass their moral approval, as the medical actions involved in these approaches are regulated by law. According to the American Medical Association (AMA), AE and PAS are in conflict with physicians’ healing role. Furthermore, their management are quite challenging, if not completely impossible, and they entail grave risks to the society ( 4 ). However, PE, described as withdrawal or withholding life-sustaining treatment, is ethically acceptable for a patient capable of decision-making, and if an intervention is not expected to achieve the patients’ goals for care or desired quality of life ( 4 ).

The contributions of this study are as follows: ( i ) quantitative assessment of medical students’ approval rate for AE, PE and PAS over the last ten years, ( ii ) analysis of the most common arguments validating such practices, and ( iii ) evaluation of the variables that can influence a personal position on the topic. This study aimed at answering the following questions: What is the percentage of euthanasia or PAE approval among medical students? What are the most common arguments associated with the approval or rejection of euthanasia or PAE? What are the variables affecting the approval or rejection of euthanasia and PAE?

This study was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) ( 5 ) ( Figure 1 ).

PRISMA flowchart

The literature searches in April 2019, included articles published between January 2009 and December 2018, and focused on PubMed and Web of Science as the primary electronic databases. The databases were searched using the following search strings: (medical students) AND (euthanasia OR Physician-assisted suicide).

Our review focused on original cross-sectional descriptive studies in English whose main population, or part of it, was composed of medical students and quantified their personal views regarding the legalization or practice of PAS or euthanasia.

Only original descriptive articles that quantitatively addressed the first focused question in the last ten years were included. The excluded cases were the followings: ( i ) Review articles, book chapters, conference papers, and letters to the editor; ( ii ) Non-neutral reports, where the authors expressed their views or stated an opinion on the topic; ( iii ) Articles whose main population consisted of physicians, nurses, or any group other than undergraduate medical students; ( iv ) Articles for which the complete text could not be found online; and, ( v ) Articles written in languages other than English.

Records were initially screened according to the titles and abstracts. Relevant abstracts and articles without an abstract were selected for full-text review. Articles selected in the first screening were carefully read and analyzed to determine whether they addressed the first focused question and whether they fulfilled the inclusion criteria. Further analyses were made to determine if they described any argument or variable that could persuade medical students to take a positive or negative side.

A total of 135 articles were identified after the database search (63 in PubMed and 72 in Web of Science); 97 non-duplicate documents were screened by the title and abstract. From the 25 articles eligible for full-text review, 13 fulfilled the inclusion criteria and were selected for further analysis ( 6 - 18 ). Reasons for exclusion of 12 remaining articles were as follows: ( i ) use of a language other than English (n = 2); ( ii ) absence of a full-text version online (n = 3); ( iii ) inclusion of a study population different than undergraduate medical students (n =3); and, ( iv ) failure to address the first focused question (n = 4).

From the 13 selected articles, seven ( 6 - 12 ) were published between 2014 and 2018 and six ( 13 - 18 ) were published between 2009 and 2013. Two studies were from Africa ( 7 , 9 ), four were from America ( 6 , 8 , 12 , 14 ), one was from Asia ( 15 ), and six were from Europe ( 10 , 11 , 13 , 16 - 18 ). The countries involved included Austria (n = 1) ( 18 ), Belgium (n = 1) ( 11 ), Brazil (n = 1) ( 12 ), Canada (n = 1) ( 14 ), Germany (n = 1) ( 10 ), Greece (n = 1) ( 18 ), Mexico (n = 2) ( 6 , 14 ), Pakistan (n = 1) ( 15 ), Poland (n = 2) ( 13 , 16 ), and South Africa (n = 2) ( 7 , 9 ).

Eight articles addressed the approval rate of medical students regarding legalization of AE, PE or PAS ( 7 - 9 , 11 , 13 , 15 - 17 ); ten stated a positive attitude toward AE exclusively ( 6 - 12 , 15 , 17 , 18 ); six addressed acceptance of PE ( 6 , 9 , 10 , 12 , 14 , 18 ); and, six addressed acceptance of PAS ( 7 , 8 , 10 , 14 , 15 , 18 ). Two articles addressed the students’ personal views on AE, PE or PAS, whether exclusively or conjunctively ( 13 , 16 ). The results are summarized in Table 1 .

Percentage of approval for AE, PE, and PAS, as well as the legalization of euthanasia or PAS.

Out of eight articles that addressed the positive views on legalization of the procedures, the lowest acceptance rate was 26% ( 13 ) and the highest 97% ( 11 ). The lowest and highest acceptance rates were as follows: ( i ) 14.2% ( 15 ) and 52% ( 18 ) for AE, ( ii ) 45.7% ( 12 ) and 83.3% ( 10 ) for PE, and ( iii ) 32.8% ( 15 ) and 69.7% ( 18 ) for PAS. The highest acceptance rates in the four scenarios were observed among students in European countries ( 10 - 12 , 15 ), while the lowest acceptance rates were related to Pakistan ( 15 ) and Brazil ( 12 ).

Eight articles ( 6 - 8 , 11 , 15 - 18 ) were related to second main question addressing students’ arguments for or against the practice of AE, PE or PAS. The most common arguments supporting AE, PE or PAS practice were as follows: ( i ) patients’ autonomy (n = 6) ( 6 - 8 , 11 , 16 , 17 ); ( ii ) relief of suffering or beneficence (n = 4) ( 7 , 11 , 16 , 17 ); and, ( iii ) the thought that terminally-ill patients are additional burden (n = 2) ( 11 , 18 ). Less relevant arguments included the followings: ( i ) legality of the procedure ( 6 ); ( ii ) educational or clinical experience ( 8 ); and, ( iii ) quality of life or life expectancy ( 18 ). The most common arguments against AE, PE or PAS were the followings: ( i ) religious or personal beliefs (n = 4) ( 7 , 8 , 15 , 18 ); and, ( ii ) “slippery slope” argument or risk of abuse (n = 4) ( 7 , 8 , 16 , 18 ); and, ( iii ) physicians’ responsibility to preserve life ( 7 , 18 ). The results are summarized in Table 2 .

Students’ arguments in favor or against the practice of euthanasia or PAS

Regarding the third focused question, 11 articles ( 6 - 9 , 11 , 12 , 14 - 18 ) highlighted variables that could cause the medical students to approve or disapprove AE, PE or PAS practices. Religion was the most significant variable that had a negative impact (n = 7) ( 6 - 8 , 11 , 12 , 14 , 16 ), followed by religiosity (n = 5) ( 6 , 12 , 14 , 15 , 18 ) as the second most significant variable. Moreover, university of origin for the medical students (n = 3) ( 12 , 14 , 16 ) and previous experience with euthanasia or palliative sedation in a relative (n = 1) ( 11 ) were other named variables. Non-significant variables included the followings: ( i ) age (n = 3) ( 6 , 12 , 17 ); ( ii ) previous academic experience regarding end-of-life decisions (n = 2) ( 11 , 16 ); ( iii ) family income (n = 1) ( 12 ); and, ( iv ) size or place of residence (n = 1) ( 16 ). Variable of gender in influencing the students’ opinions showed mixed results: significant ( 6 , 16 ) and non-significant ( 11 , 12 , 14 , 17 , 18 ). Similarly, for variable of medical students’ current academic year, three studies considered it to be significant ( 9 , 15 , 17 ) and one study reported it as irrelevant ( 6 ). The summarized results are shown in Table 3 .

Significant variables that affect the posture of medical students towards euthanasia or PAS

Despite the great diversity of opinions regarding AE, PE and PAS, the percentage of approval for AE was lower than those of PE or PAS in all analyzed scenarios ( 6 - 18 ). Regarding AE approval, the study of Kontaxakis et al. was the only one that reported an acceptance percentage higher than 50%, under special circumstances ( 18 ). If these results are compared to those of other groups, such as general population ( 19 ) or post-graduate students ( 11 ), the approval rate is usually higher than 50%. In contrast, physicians tend to show a negative attitude toward the topic ( 19 , 20 ). The relevance of clinical experience, as a variable that could influence the acceptance of euthanasia or PAS, was discussed by Marais et al. ( 9 ) and Hassan et al. ( 15 ), who reported different results depending on whether the students were at preclinical level (without active experience with patients) or on clinical rotations. Marais et al. stated that higher clinical-level correlated to medical students’ greater empathy towards patients and respect for their autonomy. This correlation was demonstrated by a 20% difference in acceptance rate for AE between preclinical and clinical students, which dropped to 10% when they were asked if they will perform an assisted-dying procedure ( 9 ). Hassan et al. found lower acceptance rate for euthanasia or PAS among senior medical students; the attitude toward euthanasia, however, split to 50% against and 50% undecided, highlighting a higher percentage of indecision among seniors than freshmen ( 15 ). Seniors stated that through clinical exposure, medical students become more aware that some diseases are incurable ( 15 ). However, a 2018 study by the authors of article ( 6 ) did not identify academic rank as a variable that could influence medical students’ attitude toward this topic. That study focused only on preclinical students in the first three years of medical school, justifying the uniformity of opinions and highlighting that exposure to patients affected medical students’ views regardless of their academic school year.

Until now, AE has been legalized in Belgium ( 11 ), the Netherlands ( 19 ), Luxemburg ( 19 ), Colombia ( 21 ), Uruguay ( 21 ), and Canada ( 8 ); Three countries where AE is legal are European ( 11 , 19 ), which justify that why the majority of the papers that met the present study’s inclusion criteria were published in this continent where the debate is open. In Belgium, the only country included in this study where AE is currently legalized, Roelans et al. reported that the approval percentage of the legalization of euthanasia to be 97% ( 11 ); a real legal environment, along with personal or professional experience in scenarios of assisted death, can create more favorable attitude among medical students ( 11 ). In Canada, another country where these practices are legalized, the study by Bator et al. was performed a year before the Canadian laws’ modification to abolish the penalization of euthanasia ( 8 ). These political discussions may affect medical students’ attitude toward acceptance.

Religion is defined as a moral institution with a unified system of values, beliefs and practices related to what is considered sacred ( 22 - 23 ). Religion is one of the most common variables mentioned by researchers to influence medical students’ views on euthanasia ( 6 - 8 , 11 , 12 , 14 - 16 , 18 ). Moreover, religion affects several other areas of medicine, such as adherence to treatment or the decision-making process in high-risk procedures ( 22 ). In seven studies that described religion as a relevant variable, five found Catholicism to be the most frequently self-reported religion ( 6 , 11 , 12 , 14 , 16 ), and less frequently ones were Christianity ( 7 ) and Islam ( 15 ). Conversely, the medical students who considered themselves atheists or those who did not actively practice any religion tended to have a more positive view towards AE, PE, and PAS for both patients and themselves ( 8 , 11 , 12 , 14 - 16 , 18 ). Different, sometimes conflicting views can be observed among various religions. In 2007, Sprung et al. studied the attitude of physicians towards PE; Catholics, Protestants and those with no religious affiliation compared to Jews, Greek Orthodoxies or Muslims had higher acceptance rate for therapy withdrawal ( 23 ). According to the Roman Catholic religion, practitioners are not obligated to ward off death at all costs, but they should not deliberately intervene to accelerate this process ( 24 ). The principle of “sanctity of life” categorizes life as a basic value as it establishes a direct relationship with God, and condemns any intervention that seeks to end this relationship ( 24 ). This principle could explain a more negative attitude toward AE and a mildly open posture toward PE. Studies that described a majority of the Catholic population and addressed the attitude of PE had acceptance rate higher than 50%, except one study from Poland ( 16 ). Leppert et al. did not separate the opinions in favor of or against AE, PE, or PAS, and considered that the students’ view could be influenced by the statements of the last Polish Pope, John Paul II ( 16 ). Regarding Islam, negative attitude is generally stated toward the topic ( 7 , 15 , 23 ). The Quran forbids self-harm and consenting to end life, which can be related to terminally-ill patients consenting to euthanasia ( 25 ). In Islam, death is not the final destination, and therefore a believer should keep facing difficulties despite suffering to stay alive ( 25 ). However, the concept of religion has to be differentiated from religiosity or religiousness, referring to the influence of religion on daily life and intrinsic values. A positive experience with religion, mainly described as a growing spirituality or closeness to God, empowers patients to undertake greater risks in their treatments ( 22 ). Regarding euthanasia, the greater the religiosity, the more opposition towards euthanasia ( 6 , 15 ). This association is in line with our previous study’s findings, where the participants who were described as strong believers showed a predominant negative view towards AE and PAS as well as inflexibility to change their original position in different scenarios ( 6 ). Similarly, Hassan et al. reported the lowest acceptance rate for AE, in a study involving predominately Muslim participants, which 17% of them identified themselves as very religious ( 15 ).

The main arguments on euthanasia are related to the bioethical principles. Autonomy, the most common argument stated by the medical students to support this practice ( 6 - 8 , 11 , 16 , 17 ), derives from the Greek auto (self) and nomos (rule) and refers to the individuals’ ability to make independent choices about their treatment ( 7 ). However, the state of autonomy in relation to euthanasia varies depending on whether autonomy is considered an intrinsic or moral value. In the former, patients would have free will in decision-making about their life or death ( 26 ), and in the latter —according to the Kantian perspective—death threatens autonomy by eliminating the individual who would otherwise exercise autonomy ( 27 ). Another argument to support euthanasia is relief from suffering, based on the principle of beneficence, as it considers the induction of death as a better alternative to avoid unnecessary suffering ( 28 ). The opponents of euthanasia argue that the elimination of suffering by death may not be the best alternative considering the followings: ( i ) increasing interest and research on palliative care and ( ii ) management of patients’ psychiatric conditions (e.g., depression), which may adequately relieve their suffering ( 28 , 29 ). The most common arguments against these practices were as follows: ( i ) personal and religious beliefs ( 7 , 8 , 15 , 18 ); ( ii ) risk of abuse, sometimes referred to as the “slippery slope” argument ( 7 , 8 , 16 , 18 ); and, ( iii ) the physicians’ role in preserving life ( 7 , 18 ). According to the argument of the “slippery slope”, if specific types of actions receive permission, then society will be coerced in permitting further morally wrong actions ( 30 , 31 ). As a classic example of this argument, in the Netherlands, where initially euthanasia was only approved for terminally-patients, the criteria were later expanded to allow euthanasia for chronically-ill patients and those suffering from severe psychiatric conditions. Subsequently, euthanasia was legally allowed for incompetent patients, including children ( 31 ). Opponents of the “slippery slope” argument state that for euthanasia to be considered as part of the risk of abuse argument, it must initially be condemned as morally wrong, an argument that in their opinion is dependent merely on personal experience ( 31 ). The final argument against euthanasia is the Hippocratic Oath’s view of the physicians’ role as healers. The Hippocratic Oath was first proclaimed in 400 BC and established one of the earliest codes of ethics for the medical profession ( 32 ). Because of its tradition and relevance, it is still frequently taken by medical students during their training or upon its completion. One of its lines states that physicians will not give poison to anyone though asked to do so, nor they would suggest such a plan ( 6 ), a line that contradicts modern-day views of euthanasia. This presumptive allegiance to the Hippocratic Oath may explain why students from newer, urban, public, and bigger universities usually have a more positive attitude towards euthanasia and PAS than students from older schools with more traditional values ( 12 , 14 , 16 ).

The relevance of understanding the medical students’ attitudes towards euthanasia and PAS lies not only in their values as present-time insights, but also as input data to generate strategies that optimize their education and address future medical dilemmas. Even though medical students usually have sufficient knowledge about euthanasia ( 15 ), they lack understanding of end-of-life care. Eyigör stated that most medical students believe that they have not received a complete education on palliative care or training on communication skills regarding palliative-care patients ( 33 ). A better understanding of end-of-life care, including euthanasia and PAS, for medical students, is essential, even if these practices are not currently legalized in their countries as related debates on the topic are not expected to end shortly.

A major limitation of this study was the use of non-standardized questionnaires to research the main focused questions, as they provide varied responses that are difficult to categorize and analyze adequately. Even if a students’ view on euthanasia or PAS is markedly positive or negative, the format of the questionnaire may not accurately address the real answer. Moreover, questions asked directly may obtain different answers than those asked indirectly; questions with clinical case scenarios or with only binary true or false answers could further alter the results. Another limitation was the use of only two electronic databases, which could narrow results. This limitation could also limit the number of countries included in the study, which may prevent the global perspective from being reflected.

Seeking a global perspective from medical students over a particular course and then describing that perspective is complex. This complexity is not only due to the great diversity of opinions, but also due to the geographical, social, cultural, and temporal context influencing their decisions. This study aimed to objectively describe the medical students’ attitude towards AE, PE, and PAS practices as well as to analyze the variables and arguments surrounding these practices. To summarize, PE and PAS are more accepted than AE, and the most critical arguments in favor of these practices are the respect for autonomy and the relief of suffering. Personal beliefs and the social role of the physician as a healer are the most common arguments against these practices. Even though a consensus may not be reached easily or soon, continuing the discussion about end-of-life decisions is essential because the debates over these practices and the necessity for such decisions will unavoidably linger. Medical students must be aware of different perspectives on the topic to make an informed decision in related circumstances.

Citation to this article:

Gutierrez-Castillo A, Gutierrez-Castillo J, Guadarrama-Conzuelo F, Jimenez-Ruiz A, Ruiz-Sandoval JL. Euthanasia and physician-assisted suicide: a systematic review of medical students’ attitudes in the last 10 years. J Med Ethics Hist Med. 2020; 13: 22

Conflict of Interests

The authors declare that they have no conflict of interests.