• Voluntary Active Euthanasia: Patient is administered a lethal substance or undergoes an end of life procedure with their consent
  • Voluntary Passive Euthanasia: Patient is not given treatment or is taken off life support devices with their consent
  • Physician Assisted Suicide: Physician provides patient with a lethal substance and instructions to be followed at a later point in time

The legality of voluntary active euthanasia in the United States has been highly contested since the mid 19th century and continues to be a divisive issue today. Voluntary active euthanasia involves a direct action by an individual to end another person’s life with their consent.  

While voluntary active euthanasia is currently prohibited in all 50 states, passive euthanasia–which involves the omission of treatment–is legal if an individual sets up an advance directive, or a set of instructions for what to do if they are unable to make decisions for themselves. One common form of passive euthanasia are do not resuscitate or ‘DNR’ requests. When a patient or a proxy signs a DNR request that a physician agrees to, they will not receive cardiopulmonary resuscitation (CPR) if their heart stops beating. 

One alternative to voluntary active euthanasia is physician assisted suicide, where a patient commits suicide through means or information provided by a licensed physician. The difference between voluntary active euthanasia and physician assisted suicide is in the individual administering the drugs or treatment. While the physician (or any other party) administers the lethal substance in voluntary active euthanasia, it is the patient who self administers the treatment in physician assisted suicide 

Physician assisted suicide is currently legal in nine U.S. states as well as the District of Columbia despite significant opposition. Groups such as the American Medical Association strictly condemn the practice as “fundamentally incompatible with the physician’s role as healer.” 

Proponents of physician assisted suicide argue that individuals have the right to take their own life, especially within the context of a debilitating disorder. In response, several states have passed what are referred to as ‘Death with Dignity’ Acts, which allow patients diagnosed with a terminal illness, who have less than six months to live, to seek physician assisted suicide provided they have rational decision making capabilities. 

Upon request by a patient in states that have Death with Dignity Acts, physicians are required to inform them of the alternatives they have in palliative (pain relieving) care and other treatments. 

A second physician must then confirm that the patient has a prognosis of death within six months and is not impaired in any way through mental illness.

Infographic by Anish Natarajan/Bruin Medical Review.

There are a few ethical issues in determining whether physician assisted suicide should be legalized as a medical procedure available to patients, terminal or otherwise. One common example is whether a physician has a greater duty towards respecting the autonomy of a patient who requests voluntary active euthanasia or to a presupposed duty to prevent harm to the patient. While respecting a patient’s right to make decisions regarding their treatment, certain physicians view the practice of euthanasia as contradictory to their beliefs on what the role of a doctor should be. 

As a part of the graduation ceremony, most medical schools have their students recite some form of the Hippocratic Oath (or in some cases, the Osteopathic Oath) which prohibits the use of euthanasia as well as physician assisted suicide. The original text specifies “I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan.” However, the Hippocratic Oath has been changed to a large extent by most modern institutions, with only 14% of current Oaths in the U.S. containing this line. Because of these alterations, it is difficult to gauge the moral relevance of the Hippocratic Oath as a set of inviolable rules rather than as a modifiable guideline. 

When opponents of voluntary active euthanasia bring up the Hippocratic Oath, the semantics of the original text is often not their main point of argument. What is really at issue is whether or not a physician has an obligation to society to abstain from participating in actions that could bring harm to a patient. We must ask ourselves whether a physician’s role is to maintain the life of the patient, or to maintain their quality of life. In some ways this question has been answered to an extent in how medical care is practiced. 

Whether or not treatment is available for several debilitating disorders, a great emphasis is placed on palliative care. Therefore, there is clearly some emphasis that we place on treatment that provides no other service than relieving pain. In the cases of patients that are affected by Death with Dignity Acts (those with terminal illnesses and less than six months to live), end of life procedures can provide that same service.

One of the main arguments in favor of end of life procedures is that they promote a person’s right to take their life and exercise a freedom of choice in doing so. The issue that occurs when this argument is extended from physician assisted suicide to voluntary active euthanasia is that while a patient may have a right to end their own life, a physician does not have an obligation to perform the act themselves. Following this line of thinking, physician assisted suicide may be justified as it is the patient who self medicates whereas voluntary active euthanasia may not.

Those who endorse both procedures, on the other hand, argue that the physician is equally responsible for the end of the patient’s life in both physician assisted suicide and voluntary active euthanasia. Despite the physician not necessarily being present when a patient takes their life during physician assisted suicide, the patient is still acting under physician advisement. 

Despite the arguments of those who draw a distinct line between physician assisted suicide and voluntary active euthanasia, the difference between the two practices is not quite so significant. One common hypothetical brought up in this debate is whether a physician is culpable if they give lethal drugs to a patient knowing that the patient intends to give them to someone else. If a physician is considered to be at fault for causing the death of another human being despite not administering the drugs themselves, then they should be considered responsible for a patient in the case of physician assisted suicide.The difference between the two procedures is negligible, as both involve a patient entering into an agreement with a physician that would end their life. It doesn’t necessarily matter who administers the treatment so long as it is a voluntary act on the part of the patient.

If we consider physician assisted suicide and voluntary active euthanasia to be morally equivalent in terms of the role a physician plays, then the ultimate issue is whether or not people have a right to do with their life as they see fit. If life is considered to be a means to its own end, then anything that hastens death or causes it must inherently be morally wrong. However, if life is seen as something that exists in the service of some other ideal, then ending a patient’s life is justified if it is in the service of that ideal. If the purpose of life is happiness and not just living for the sake of living, then we cannot deny the requests of patients who would rather end their life with dignity than choose to face months of excruciating pain.

Fundamentally, the divide between proponents and opponents of end of life procedures lies in what is valued more. Whether it be physician autonomy vs patient autonomy or quality of life vs length of life, the choice to support or oppose physician assisted suicide and voluntary active euthanasia lies in what we consider to be a moral good. When the duty of a doctor conflicts with the autonomy of a patient, the only resolution must be a fundamental shift in our understanding of the part a physician plays in our society. 

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