Duke Medical Ethics Journal

Introduction

Questions of medical euthanasia and assisted suicide encompass some of the most controversial and complicated topics of discussion in the medical sphere, and are implicated in both debates around scientific viability as well as philosophical and moral dilemmas. While discussions and advocacy surrounding a “right to die” are relatively new to the medical field (beginning in the late 20th century), they present serious challenges to our holistic understanding of the role of physicians and our interpretation of cornerstones of medicine, such as the Hippocratic Oath, on the whole. Such discussions of private medical decisions are also remarkable—and controversial—because they implicate public officials (namely physicians) and therefore constitute an area in which both scientific research and public policy are crucial to forming ethical, legal, and just regulations. This article provides a background on the history of physician-assisted suicide and its current status in the US.

However, before discussing the ethics and policy implications of assisted suicide, we must first establish specificity in the terms of the practice. Specifically, there is a significant distinction between euthanasia and assisted suicide in nationwide policy. In cases of euthanasia, the physician involved in the particular cases administers a lethal dosage of medication to the patient by the patient’s request. Euthanasia can involve either passive euthanasia, in which life-sustaining treatments (such as ventilators) are withheld from the patient to cause death, or active euthanasia, when individuals intentionally use lethal substances to end a patient’s life. These two categories are often distinguished through “letting die” (passive euthanasia) and “killing” (active euthanasia). While some forms of voluntary euthanasia are legally permissible in some European countries under very stringent and specific medical standards, such as The Netherlands, the act is currently illegal in every state and territory in the United States and is prosecutable as manslaughter or second-degree murder. Assisted suicide, on the other hand, is legal in several states (primarily on the West Coast), and involves the patient themselves taking a lethal dose of medication that is prescribed by a physician; no outside individual may be directly involved in the death and patients must be both mentally and physically capable to take the medication individually. Assisted suicide policies similarly involve high standards and levels of scrutiny that must first be met by the patient before any prescriptions can be made.

 

A History of Physician-Assisted Suicide Policy in the United States

“Right to Die” Beginnings

Advocacy for the “right to die” movement in the US primarily began in the 1980s and 1990s with the ignition of public conversation and debates surrounding patients’ families being able to request stopping ventilator support and nutrition provided through feeding tubes for patients in vegetative states with little to no chance of improvement. Instances surrounding these ethical and medical issues were largely resolved on a case-by-case basis with individual patients, depending if patients had provided advance directives regarding their medical treatment and if their legal guardians or families had particular input about their medical choices that involved removing life support. Advocates for this right heavily emphasized patients’ families’ autonomy and non-intervention in their personal liberties, as protected by the Constitution. Today, ten states currently permit physician-assisted death for terminally ill patients with a life expectancy of six months or less: Oregon, Washington, Montana, Vermont, California, Colorado, DC, Hawaii, New Jersey, and Maine. Other states are also considering pieces of legislation in this realm or have a large advocacy group presence for the right to die.

Jack Kevorkian

Serious legal and policy considerations surrounding physician-assisted suicide were ignited in the late 1990s with vast media coverage of American pathologist and proponent of assisted suicide Jack Kevorkian, who advocated for increased access to the right and himself assisted at least 130 patients in committing medical suicide. Kevorkian, who eventually lost his medical license for such practices, gave patients with neurological disorders (such as MS) or terminal illness the ability to end their lives through euthanizing drugs or carbon monoxide. He required that patients express a clear wish to die and believed that a patient had to be suffering—but not necessarily terminally ill—to be assisted in suicide. Opponents of Kevorkian claimed that his methods were unorthodox and inappropriate, and that his counseling was too brief, lacking psychiatric evaluations of patients with mental illness in many cases. Kevorkian also faced strict backlash from the American Medical Association and numerous disability-rights advocacy groups for his methods and practices. Kevorkian was later convicted of second-degree murder in 1999 of the ALS patient Thomas Youk; he served an eight-year sentence and was later released on parole on the condition that he would not discuss, advocate for, or assist any patients in medical suicide. Although Kevorkian’s procedures are still considered to be unorthodox and haphazard, the media coverage of his practices helped ignite the right to die movement in the US.

Oregon Death with Dignity Act (1994)

The Death with Dignity Act, a citizen-initiated referendum passed in 1994, made Oregon the first state in the US to legalize a form of physician-assisted suicide. The law allows terminally ill patients with a life expectancy of 6 months or fewer to request a prescription for life-ending medication from their physician. The Oregon DWDA’s 2022 yearly report stated that 431 individuals received prescriptions for lethal medication and 278 of those patients ingested the medication and died. 85% of patients were 65 years or older and 96% were white, with the most common diagnoses being cancer, heart disease, and neurological diseases. Since the law’s passage in 1997, a total of 3,712 people have obtained prescriptions from their physicians and 66% of those patients (2,454 people) have ingested them and died. The legislation still remains viable in the state and popular with voters, and no significant controversies or challenges have affected the law’s implementation thus far. However, it is also important to note that only an extremely small portion of individuals in Oregon actually utilize this law, as the requirements are restrictive in nature and prescriptions require efficient access to physicians willing to prescribe medications—only 0.2% of all deaths in Oregon were the result of lethal medications ingested under the DWDA, a fact that largely disproves the theory of “suicide contagion” proposed by anti-assisted death advocates.

Washington v. Glucksberg (1997)

The 1997 Supreme Court case Washington v. Glucksberg represented one of the most significant legal challenges regarding physician-assisted death, specifically in Washington state. In a unanimous decision, the Supreme Court ruled in the case that Washington’s ban on physician-assisted suicide was not unconstitutional and did not violate the Due Process Clause of the Fourteenth Amendment, which prohibits states from depriving individuals of life, liberty, or property without due process. Because the right to assisted suicide was not a fundamental liberty interest and not “deeply rooted” in the nation’s history, the court held that the ban was rational and vital in protecting medical ethics and human life. Furthermore, the justices held that bans on assisted suicide protected disabled and poor Americans, who may have greater motivation to end their lives because of outside influences of coercion or socioeconomic/psychological distress—the legalization of the practices would lead to a “slippery slope” on euthanasia policy. 

However, while the court upheld Washington’s ban in 1997, the decision does not have significant legal weight on the state level today because of state-level legislation that has been passed essentially nullifying the decision. For example, the Washington Death with Dignity Act, a ballot referendum passed 58–42% by Washington voters in 2008 in a form of direct democracy, provides for regulations permitting assisted suicide in select cases similar to Oregon’s law on assisted death, making Washington the second state to legalize physician aid in dying. The Washingtong DWDA was also followed by a number of states on the West Coast adopting provisions for assisted death through referendum and ballot initiatives, which a majority of voters largely agree upon. The decision in Glucksberg therefore represents a clash between state and federal level policy regarding assisted death: while bans were deemed constitutional at the federal level, state legislation has largely differed. Additionally, there have been no major Supreme Court rulings on assisted death since Glucksberg and policy has been relegated to the states to decide, resulting in vastly different legislation across state lines, with some (such as Oregon and Washington) having well-established guidelines and regulations, and other states (such as Virginia) with no policies at all.