Euthanasia and physician-assisted suicide refer to deliberate action taken with the intention of ending a life, in order to relieve persistent suffering.

In most countries, euthanasia is against the law and it may carry a jail sentence. In the United States, the law varies between states.

Euthanasia has long been a controversial and emotive topic.

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Assisted suicide: Is it an act of compassion?

The definitions of euthanasia and assisted suicide vary.

One useful distinction is:

Euthanasia: A doctor is allowed by law to end a person's life by a painless means, as long as the patient and their family agree.

Assisted suicide: A doctor assists a patient to commit suicide if they request it.

Voluntary and involuntary euthanasia

Euthanasia can also be classed as voluntary or involuntary.

Voluntary: When euthanasia is conducted with consent. Voluntary euthanasia is currently legal in Belgium, Luxembourg, The Netherlands, Switzerland, and the states of Oregon and Washington in the U.S.

Non-voluntary: When euthanasia is conducted on a person who is unable to consent due to their current health condition. In this scenario the decision is made by another appropriate person, on behalf of the patient, based on their quality of life and suffering.

Involuntary: When euthanasia is performed on a person who would be able to provide informed consent, but does not, either because they do not want to die, or because they were not asked. This is called murder, as it's often against the patients will.

Passive and active euthanasia

There are two procedural classifications of euthanasia:

Passive euthanasia is when life-sustaining treatments are withheld. The definitions are not precise. If a doctor prescribes increasing doses of strong painkilling medications, such as opioids, this may eventually be toxic for the patient. Some may argue that this is passive euthanasia.

Others, however, would say this is not euthanasia, because there is no intention to take life.

Active euthanasia is when someone uses lethal substances or forces to end a patient's life, whether by the patient or somebody else.

Active euthanasia is more controversial, and it is more likely to involve religious, moral, ethical, and compassionate arguments.

What is assisted suicide?

Assisted suicide has several different interpretations and definitions.

One is:

"Intentionally helping a person commit suicide by providing drugs for self-administration, at that person's voluntary and competent request."

Some definitions include the words, "in order to relieve intractable (persistent, unstoppable) suffering."

The role of palliative care

Since pain is the most visible sign of distress of persistent suffering, people with cancer and other life-threatening, chronic conditions will often receive palliative care. Opioids are commonly used to manage pain and other symptoms.

The adverse effects of opioids include drowsiness, nausea, vomiting, and constipation. They can also be addictive. An overdose can be life-threatening.

Refusing treatment

In many countries, including the U.S., a patient can refuse treatment that is recommended by a health professional, as long as they have been properly informed and are "of sound mind."

One argument against euthanasia or physician-assisted suicide is the Hippocratic Oath, dating back some 2,500 years. All doctors take this oath.

The Hippocratic Oath

The original oath included, among other things, the following words:

"I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect."

There are variations of the modern oath.

One states:

"If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty."

As the world has changed since the time of Hippocrates, some feel that the original oath is outdated. In some countries, an updated version is used, while in others, for example, Pakistan, doctors still adhere to the original.

As more treatments become available, for example, the possibility of extending life, whatever its quality, is an increasingly complex issue.

Euthanasia in the United States

In the U.S. and other countries, euthanasia has been a topic of debate since the early 1800s.

In 1828, the first anti-euthanasia law in the U.S. was passed in New York state. In time, other states followed suit.

In the 20th Century, Ezekiel Emmanual, a bioethicist of the American National Institutes of Health (NIH) said that the modern era of euthanasia was ushered in by the availability of anesthesia.

In 1938, a euthanasia society was established in the U.S., to lobby for assisted suicide.

Physician-assisted suicide became legal in Switzerland in 1937, as long as the doctor ending the patient's life had nothing to gain.

During the 1960s, advocacy for a right-to-die approach to euthanasia grew.

The Netherlands decriminalized doctor-assisted suicide and loosened some restrictions in 2002. In 2002 doctor-assisted suicide was approved in Belgium.

In the U.S., formal ethics committees now exist in hospitals, nursing homes and hospitals, and advance health directives, or living wills, are common around the world. These became legal in California in 1977, with other states soon following suit. In the living will, the person states their wishes for medical care, should they become unable to make their own decision.

In 1990 the Supreme Court approved the use of non-active euthanasia.

In 1994, voters in Oregon approved the Death with Dignity Act, allowing physicians to assist terminal patients who were not expected to survive more than 6 months.

The US Supreme Court adopted such laws in 1997, and Texas made non-active euthanasia legal in 1999.

The Terri Schiavo case galvanized public opinion in Florida and the U.S. Schiavo had a cardiac arrest in 1990, and spent 15 years in a vegetative state before her husband's request to allow her to pass was granted.

The case involved various decisions, appeals, motions, petitions, and court hearings over a number of years before the decision was made to disconnect Schiavo's life support in 2005.

The Florida Legislature, U.S. Congress, and President Bush all played a role.

In 2008, 57.91 percent of voters in Washington State chose in favor of the Death with Dignity Act, and the act became law in 2009.

Various arguments are commonly cited for and against euthanasia and physician-assisted suicide.

Arguments for

Freedom of choice: Advocates argue that the patient should be able to make their own choice.

Quality of life: Only the patient really knows how they feel, and how the physical and emotional pain of illness and prolonged death impacts their quality of life.

Dignity: Every individual should be able to die with dignity.

Witnesses: Many who witness the slow death of others believe that assisted death should be allowed.

Resources: It makes more sense to channel the resources of highly-skilled staff, equipment, hospital beds, and medications towards life-saving treatments for those who wish to live, rather than those who do not.

Humane: It is more humane to allow a person with intractable suffering to be allowed to choose to end that suffering.

Loved ones: It can help to shorten the grief and suffering of loved ones.

We already do it: If a beloved pet has intractable suffering, it is seen as an act of kindness to put it to sleep. Why should this kindness be denied to humans?

Arguments against

The doctor's role: Health care professionals may be unwilling to compromise their professional roles, especially in the light of the Hippocratic Oath.

Moral and religious arguments: Several faiths see euthanasia as a form of murder and morally unacceptable. Suicide, too, is "illegal" in some religions. Morally, there is an argument that euthanasia will weaken society's respect for the sanctity of life.

Patient competence: Euthanasia is only voluntary if the patient is mentally competent, with a lucid understanding of available options and consequences and the ability to express that understanding and their wish to terminate their own life. Determining or defining competence is not straightforward.

Guilt: Patients may feel they are a burden on resources and are psychologically pressured into consenting. They may feel that the financial, emotional, and mental burden on their family is too great. Even if the costs of treatment are provided by the state, there is a risk that hospital personnel may have an economic incentive to encourage euthanasia consent.

Mental illness: A person with depression is more likely to ask for assisted suicide, and this can complicate the decision.

Slippery slope: There is a risk that physician-assisted suicide will start with those who are terminally ill and wish to die because of intractable suffering, but then begin to include other individuals.

Possible recovery: Very occasionally, a patient recovers, against all the odds. The diagnosis might be wrong.

Palliative care: Good palliative care makes euthanasia unnecessary.

Regulation: Euthanasia cannot be properly regulated.

Opinions appear to be growing in favor of euthanasia and assisted suicide.

In 2013, researchers published findings of a survey in which they asked people from 74 countries their opinions on physician- assisted suicide.

Overall, 65 percent of respondents voted against physician-assisted suicide. In 11 of the 74 countries, the vote was mostly for.

In the U.S., where 1,712 respondents represented 49 states, 67 percent voted against. In 18 states, the majority were for physician-assisted suicide. These 18 did not include Washington or Oregon.

In 2017, a Gallup poll indicated that 73 percent of respondents were in favor of euthanasia in the U.S., and 67 percent were in favor of doctor-assisted suicide.

Among weekly churchgoers, Gallup found that 55 percent were in favor of a doctor ending the life of a patient who is terminally ill, compared with 87 percent of those who do not regularly attend church.

It is also a political issue. Gallup's 2017 poll found that almost 9 out of 10 liberals are in favor, compared with 79 percent of moderates and 60 percent of conservatives.

How many people die each year?

In countries where euthanasia or assisted suicide are legal, they are responsible for a total of between 0.3 and 4.6 percent of deaths, over 70 percent of which relate to cancer. In Oregon and Washington states, fewer than 1 percent of physicians write prescriptions that will assist suicide each year.