Physician-assisted dying: Understanding, evaluating, and responding to requests for medical aid in dying

Authors:: Timothy E Quill, MD; Margaret P Battin, MFA, PhD
Section Editor:: Robert M Arnold, MD
Deputy Editor:: Diane MF Savarese, MD

INTRODUCTION

Euthanasia and physician-assisted dying (PAD) burst into the United States public arena in 1988 with the publication of “It’s over, Debbie” [1]. This article stirred an emotional debate, with many people criticizing what they saw as nonvoluntary euthanasia involving a lethal injection delivered by a physician who did not know the patient and who had only ambiguous evidence of her wishes (“Let’s get this over with”) [2,3]. The case later turned out to be a fabrication. A later (true) case report describing a patient, “Diane,” with a terminal illness who made an intensely personal decision for a physician-assisted death involving a self-administered drug prescribed only after extensive discussion with her own physician was received with less criticism and more balanced discussion; it was eventually considered by a grand jury, which recommended against indicting her physician [4]. Less volatile discussion and legal toleration had already begun in the Netherlands in the early 1970s, but it was these two cases, “Debbie” and “Diane,” that set the stage for the current disputes in the United States over PAD.

In recent years, much of the developed world, those countries with long life expectancies, highly developed health care systems, and mortality characterized primarily by diseases with long downhill courses (cancer, heart and other organ system failure, and dementia), has seen the emergence of end of life debates and increasing pressures for legalization of, as it is increasingly frequently called, medical aid in dying (MAiD).

Many physicians, particularly those in the fields of oncology and palliative care, will be faced with a request for assistance in dying sometime in their professional lifetimes. No matter where clinicians stand ethically and morally on the permissibility of this practice, and regardless of whether these practices are legally permitted or prohibited in a given jurisdiction, clinicians have to carefully consider and decide how they will respond to these requests.

This topic focuses first on the background definitional and theoretical aspects of physician-assisted death, including the ethical, legal, and public policy issues surrounding euthanasia and assisted suicide, and then on clinical aspects of evaluating and responding to such requests, emphasizing the importance of full evaluation, including the adequacy of palliative care and the availability of alternative treatments to alleviate suffering, and finally on practical approaches that respect the values of the patient, the family, and the clinician, as well as the particular legal constraints under which they reside.

BACKGROUND DEFINITIONAL AND THEORETICAL ASPECTS: ETHICAL, LEGAL, AND PUBLIC POLICY ISSUES

Appropriate terminology is debated:

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Literature review current through: Jun 2018. | This topic last updated: Jan 12, 2018.

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