Review

Journal of the Royal Society of Medicine; 2018, Vol. 111(11) 407–413

DOI: 10.1177/0141076818803452

Euthanasia and assisted dying: what is the current position

and what are the key arguments informing the debate?

Andreas Fontalis1 , Efthymia Prousali2 and Kunal Kulkarni3

1
St George’s University Hospitals NHS Foundation Trust, London SW17 0QT, UK
2
Aristotle University of Thessaloniki, 54124 Thessaloniki Greece
3
University Hospitals of Leicester NHS Trust, Infirmary Square, Leicester, LE1 5WW, UK
Corresponding author: Andreas Fontalis. Email: [email protected]

Summary years are inextricably intertwined with this complex

Assisted dying is a highly controversial moral issue incor-
topic, resulting in the continuing demand for amend-
porating both physician-assisted dying (PAD) and voluntary ments on current legislations.1 This review presents
active euthanasia. End-of-life practices are debated in many an overview of the current status of this topical
countries, with assisted dying receiving different consider- debate.
ation across various jurisdictions. In this paper, we provide
an analytic framework of the current position and the main
arguments related to the rights and moral principles con-
Definition and current legal framework
cerning assisted dying. Assisted dying proponents focus on Assisted dying is a general term that incorporates
the respect of autonomy, self-determination and forestall- both physician-assisted dying and voluntary active
ing suffering. On the other hand, concerns are raised euthanasia. Voluntary active euthanasia includes a
regarding the interpretation of the constitutional right to
physician (or third person) intentionally ending a per-
life and balancing this with the premise of assisted dying,
alongside the impacts of assisted dying on the doctor–
son’s life normally through the administration of
patient relationship, which is fundamentally based on drugs, at that person’s voluntary and competent
trust, mutual respect and the premise of ‘first do no request.2,3 Facilitating a person’s death without
harm’. Our review is underpinning the interpretation of their prior consent incorporates both non-voluntary
constitutional rights and the Hippocratic Oath with the euthanasia (when the patient is not capable of provid-
premise of assisted dying, alongside the impacts of assisted ing informed consent, e.g. vegetative state, young
dying on the doctor–patient relationship. Most clinicians child) and involuntary euthanasia (against patient’s
remain untrained in such decision making, with fears against will). Physician-assisted dying is defined as follows:
crossing key ethical divides. Due to the increasing number a physician intentionally helping a person to termin-
of cases of assisted dying and lack of consensus, our review ate their life by providing drugs for self-administra-
enables the integration of ethical and legal aspects and
tion, at that person’s voluntary and competent
facilitates decision making.
request.2,3 Consequently, in the first case a third
Keywords person acts resulting in patient’s death, whereas in
Assisted dying, bioethics, euthanasia, legal framework, physician-assisted dying the action is undertaken by
healthcare ethics the patient who is given lethal medication by a
physician.2
Received: 9th June 2018; accepted: 7th September 2018 Discussion regarding withholding or withdrawing
treatment and requesting assisted death has emerged
in association with the simultaneous expansion of
palliative care across the world. The World Health
Organization defines palliative care is an approach
Introduction that
Assisted dying remains a highly controversial
moral issue, with clinical, legal, political, religious improves the quality of life of patients and their
and ethical considerations playing an important families facing the problem associated with life-threa-
role. Lack of consensus and ongoing debate are fea- tening illness, through the prevention and relief of
tures of modern life, while the law generally sustains a suffering by means of early identification and impec-
broader, pluralist outlook. Advances in both life- cable assessment and treatment of pain and other
prolonging treatments and palliative care in recent problems, physical, psychosocial and spiritual.4

! The Royal Society of Medicine 2018

Article reuse guidelines: sagepub.com/journals-permissions
408 Journal of the Royal Society of Medicine 111(11)

It intends to neither hasten nor postpone death. We also combined free text searching with Medical
Nonetheless, in practice, terminally ill patients – Subject Headings (MeSH) terms and no restrictions
often with full mental capacity – may develop a loss were set in publication date, study design and publi-
of self-determination as their condition deteriorates cation status.
and express a desire for assisted dying to alleviate
intractable physical symptoms.
Assisted dying is an emotionally and ethically chal- Principles of bioethics
lenging subject, which understandably receives vary-
ing degrees of acceptance among different global
Autonomy and right to life
jurisdictions. Currently, there is legal provision for Beauchamp and Childress developed a standard
assisted dying (or variants) in only four European approach to bioethics and advocated for four prin-
countries (the Netherlands, Belgium, Switzerland ciples that lie at the heart of healthcare ethics and
and Luxemburg), Canada, Colombia and the United underpin decision-making.9,10 Respect for autonomy
States of America (USA) states of Oregon, is one of the fundamental concepts, in combination
Washington, Montana, Vermont, California, with justice, beneficence and non-maleficence.
Colorado and Washington, DC, representing nearly In medical practice, autonomy describes the right
18% of the US population.5,6 Switzerland is the only of competent adults to make informed decisions
country which permits the act of assisted dying per- about their own medical care, prior to any investiga-
formed by a non-physician. Moreover, non-Swiss citi- tion or treatment taking place. For a physician,
zens can exploit the Swiss law by visiting Switzerland respect for autonomy includes acknowledging and
in order to access assisted dying.7 In these more toler- preserving a patient’s right to self-determination
ant jurisdictions, palliative care is seen as an important and providing the necessary guidance, which would
link in the same chain as assisted dying in caring for allow for an informed and independent choice, free of
terminally ill individuals, rather than an alternative. coercion.
Elsewhere in the world, an assisted death remains a However, autonomy is far from a straightforward
criminal offence, prosecutable through various legal consideration. Onora O’Neill, in an attempt to scru-
routes. For example, in the UK, all forms of assisted tinise the context of autonomy in her Gifford lectures,
dying remain illegal and can be considered under crim- makes a clear and compelling distinction between the
inal laws of manslaughter or murder, or under the approach of John Stuart Mill and Kant regarding the
Suicide Act (1961), depending on the circumstances.6 subject of autonomy.11 As O’Neill vividly describes,
Prosecution guidelines were first issued by the Mill stretches the bound of choice and ‘sees individ-
Director of Public Prosecutions in 2009 following uals not merely as choosing to implement whatever
House of Lords ruling in the case of Debbie Purdy, desires they happen to have at a given moment, but as
which stated that there was ambiguous guidance taking charge of those desires, as reflecting on and
regarding when people would be prosecuted for selecting among them in distinctive ways’.11 The
encouraging or assisting suicide. The guidelines sug- Kantian version of autonomy is guided by a ‘practical
gest that while each case will be assessed on its relative reason’. Kant views autonomy as ‘a matter of acting
merits, individuals acting in the capacity of a health- on certain sorts of principles, and specifically on prin-
care professional are more likely to be prosecuted for ciples of obligation’ rather than a form of self-expres-
assisting or encouraging suicide, although to date no sion and supports that ‘there can be no possibility of
report-providing doctor or accompanying individual freedom for any one individual if that person acts
has been prosecuted for helping patients to travel without reference to all other moral agents’.12
abroad from the UK to end their life.8 In England O’Neill embraces the Kantian view and contextual-
and Scotland, three assisted dying bills have been pro- ises it as ‘principled autonomy’ compared to ‘indi-
posed and debated, largely based on the Oregon Death vidualistic autonomy’. O’Neill’s work vigorously
with Dignity Act (1997) from the USA, which permits illustrates the fragility of the concept of autonomy
assisted dying; none were passed. and its contingency on a number of other consider-
ations, particularly the network of human relation-
ships within which it features.
Methods The greatest expression of autonomous self-
We performed a systematic search of MEDLINE and determination is the right of ‘capacitous’ adults
EMBASE databases from conception to January to refuse any proposed intervention (irrespective of
2018. The search terms used were ‘euthanasia’, rationality), even if this decision could result in harm
‘assisted dying OR death’, ‘assisted suicide’, ‘medical or death, provided they are capable of freely reaching
ethics’, ‘autonomy’, ‘end of life’ and ‘sanctity of life’. a decision in the above manner. For this reason,
Fontalis et al. 409

Table 1. Article 8: Right to respect for private and family life. Table 2. Article 2: Right to life.

1. Everyone has the right to respect for his private and 1. Everyone’s right to life shall be protected by law. No one
family life, his home and his correspondence. shall be deprived of his life intentionally save in the execu-
tion of a sentence of a court following his conviction of a
2. There shall be no interference by a public authority with crime for which this penalty is provided by law.
the exercise of this right except such as is in accordance
with the law and is necessary in a democratic society in the 2. Deprivation of life shall not be regarded as inflicted in
interests of national security, public safety or the economic contravention of this Article when it results from the use of
wellbeing of the country, for the prevention of disorder or force which is no more than absolutely necessary:
crime, for the protection of health or morals, or for the
protection of the rights and freedoms of others.13 (a) in defence of any person from unlawful violence;

(b) in order to effect a lawful arrest or to prevent the

obtaining informed consent from a patient after they escape of a person lawfully detained;
have been offered all the relevant information regard-
ing their situation is of paramount importance. (c) in action lawfully taken for the purpose of quelling a riot
or insurrection.
During the past decades, the development of liberal
democracies has highlighted the significance of self-
determination, with healthcare systems increasingly
adopting more patient-centred approaches to care by which they could jeopardise their lives. The prin-
decisions. The right to bodily autonomy has also ciple of sanctity of life emerges frequently in modern
been enshrined under Article 8 (Table 1) of the discussion, particularly in Anglo-American bioethics,
European Convention on Human Rights (ECHR). surrounding public controversy about end of life and
Taking the above into consideration, Article 8 abortion issues. Yet, its moral foundation is rarely
encompasses inter alia the right to personal develop- unriddled and understood. The sanctity of life pos-
ment. In a technical legal sense within the jurisdiction ition asserts that life has sanctity and its value pre-
of Swiss law, it includes a patient’s choice to avoid vails all other values. No individual’s life deserves
what they consider an undignified and severe end to priority, and sanctity is attributed to life regardless
their life.14 Proponents of this highly contentious of the physiological status, imminence of death, suf-
argument claim that seriously ill patients should fering or individual’s wishes to live or die.19
have a choice in whether or not they wish to continue This argument is often associated, but not fully
living with a condition that undermines their inherent equated, with religious and cultural traditions that
dignity and personal identity,15 without violating the generally object to assisted death, because human
principle of sanctity of life. Therefore, it can be life is viewed as God’s sovereign creation. From a
argued that respecting autonomy inherently involves religious perspective, God is considered the only
the prima facie right of a patient to control the cir- one who can determine the beginning and end of
cumstances and time of death by requesting help in human life. The sanctity of life is a value also clearly
dying. This could minimise the suffering of an indi- mirrored under Article 9 of the European Convention
vidual or their family and improve the quality of the on Human Rights, which refers to freedom of
end of the patient’s life, as their wishes would be thought, conscience and religion.13 It is notable,
respected and dignity would be preserved.16,17 though, that Article 2 does not encompass assisted
A further dimension that can be considered is the dying, i.e. in situations where a person’s decision to
treating clinician’s ethical beliefs and values. During end their life has been taken independently and with
their training, most practising clinicians have not absolute perception of what it implied.
experienced the concept of assisted dying as an The crucial issue is therefore one of balance. Patient
expected duty in the context of patients’ autonomy.18 autonomy has to be balanced against the principle of
Nevertheless, it is important to consider the magni- sanctity of life. It should be acknowledged though that
tude of patients’ autonomy within modern society. the autonomy argument is secondary in its applicabil-
Individual liberty ought not to be viewed as absolute ity on whether assisted dying is ethically permissible
and exceptions to Article 8 should be provided in and cannot solely guide decisions on what is morally
favour of preservation and reverence to life.17,18 impermissible, as it constitutes only a piece of the
The right to life is guaranteed by Article 2 puzzle. The right to end a life that an individual
(Table 2) of the European Convention on Human finds intolerable has to be considered in association
Rights. Under Article 2, the State is enjoined to with its resulting impact on other rights, regulations
abstain from the deliberate and illicit taking of life, and the responsibilities of healthcare professionals in
as well as to protect vulnerable people against actions facilitating assisted dying.18
410 Journal of the Royal Society of Medicine 111(11)

Justice had an influential role in other jurisdictions.5 The

As discussed, justice constitutes one of the main four criteria comprised the agreement of another doctor,
fundamental principles of medical ethics. All individ- the assessment of the patient’s mental capacity and
uals in a society should be treated equally and impar- the presence of a terminal illness with less than six
tially. One of the arguments that has monopolised the months to live.24 Additional measures to ensure an
debate concerning assisted dying is the ‘slippery informed and unforced decision involved adequate
slope’. According to this, should assisted suicide be pain relief and access to end-of-life care.25 Assisted
established, then it might be applied in circumstances dying proponents support that safeguards and regu-
that fall outside the scope of morally permissible lations in place are very powerful since only one in
cases, such as in patients who may not be fully com- 50 terminally ill patients have a discussion about
petent.17 Furthermore, if a person is motivated by the process with their doctor and even fewer
means other than his own will, for example through complete it.26
external coercion, then patient autonomy is infringed. Rhetoric from opponents has raised concerns of
In this regard, concerns are raised about vulner- whether such safeguards could ever be adequate,
able populations, such as the terminally ill, the men- which appears to be a key argument in the debate
tally incapacitated and the elderly. There remains the in some jurisdictions as well. Consequently, any
understandable fear that assisted dying could poten- future legal permissibility of assisted dying should
tially lead society toward an attitude that suffering be developed in conjunction with clear regulatory
should not be a part of life, interdependency is a safeguards to ensure the abuse of assisted dying and
burden and the lives of disabled of terminally ill indi- protect vulnerable individuals from coercion.3. Such
viduals are not worth living.20 The implications safeguards must also preserve societal justice and
of such an attitude on vulnerable populations is ensure equitability and availability of healthcare is
clear, with individuals potentially forced or coerced not a deciding factor in assisted dying decision-
into assisted dying for reasons other than their own making.
free will.
The slippery slope argument is inordinately com- The Hippocratic Oath and the principles
plex and controversial evidence exists in the literature
of beneficence and non-maleficence
in favour of both sides. Cases of assisted dying in the
Netherlands grew from 1882 in 2002 to 5306 in The principles of beneficence and non-maleficence,
2014.21 Eight-one cases were concerned with demen- plainly described in the Hippocratic Oath, have
tia and 41 with mental health-related reasons only in been the foundation of medical ethics for many cen-
2014.6 In the light of data from Holland, the slippery turies. Beneficence states that a doctor should act in
slope argument is supported in a number of respects, the best interest of the patient. Non-maleficence states
e.g. concerns about legislation ‘creep’, lack of avail- ‘first, do no harm’ – ‘primum non nocere’.27
ability of good palliative care and fears in the vulner- Conformation to these fundamental principles is
able and elderly. Early data published from Oregon enshrined within Hippocratic Oath, which involve
were also concordant. The number of physician- aiming to benefit, or perhaps most importantly, not
assisted deaths progressively rose from 16 in 1998 doing any harm to a patient. Moreover, modern med-
to 71 during 2011; loss of autonomy (88.7%) and ical education in most countries follows legal and
ability to participate in enjoyable activities (90.1%) cultural opposition to an assisted death. Healthcare
were the two most commonly reported end-of life professionals are therefore currently not adequately
concerns.22 In increasingly financially constrained trained to participate in assisted dying. Professional
health and social care systems, fears have also been opinion also remains divided on whether further
raised regarding the impact of budget-cutting trends involvement would benefit or damage public percep-
and their potential impact on terminally ill individ- tion of the profession, given the potential conflict
uals for whom the alternatives are only high-cost between these two ethical principles. The UK’s med-
life-prolonging or quality-enhancing (rather than ical representative body, the British Medical
curative) treatments. Association (BMA), has acknowledged this lack of
However, recent data summarising the 20 years’ consensus, but clearly concludes with their view that
experience in Oregon suggest the opposite. assisted dying should not be made legal in the UK.28
According to the authors, patients requesting an However, the evolution of decision-making pro-
assisted death allegedly belong to a higher than aver- cesses in modern medicine, particularly regarding
age socioeconomic class and have a higher than aver- end-of-life decisions, and with patients increasingly
age education level.23 Oregon, the first state in the US at the heart of shared decision-making (e.g. the UK
to allow assisted dying, employed strict criteria that NHS’ ‘no decision about me, without me’ policy),
Fontalis et al. 411

have applied pressure on clinicians to reconsider their Table 3. Article 3: Prohibition of torture.
collective professional stance on assisted dying.
Indeed, an increasing number of legal challenges No one shall be subjected to torture or to inhuman or
from patients and assisted dying representative degrading treatment or punishment.
organisations are taking place worldwide to challenge
local legislation against an assisted death.
Assisted dying therefore challenges the conflict
faced between the ultimate purpose of modern med- Table 4. Article 9: Freedom of thought, conscience and
ical and social care and its founding ethical prin- religion.
ciples. Relief of suffering through an assisted death
can be argued as a distinct entity to palliative care, 1. Everyone has the right to freedom of thought, consci-
with the former – if safely and carefully considered – ence and religion; this right includes freedom to change his
potentially an important way of fulfilling a clinician’s religion or belief and freedom, either alone or in commu-
duty to preserve autonomy and do good for a patient nity with others and in public or private, to manifest his
– for example, in cases where alternatives are treat- religion or belief, in worship, teaching, practice and
ments which provide no benefit or do not prolong or observance.
improve the quality of life of a terminally ill 2. Freedom to manifest one’s religion or beliefs shall be
patient.27,29 A further consideration is that of an indi- subject only to such limitations as are prescribed by law and
vidual doctor’s ethical and moral beliefs, which are are necessary in a democratic society in the interests of
also an important factor should a patient request an public safety, for the protection of public order, health or
assisted death; indeed, the British Medical morals, or for the protection of the rights and freedoms of
Association has proposed that should assisted dying others.
legislation be derived, then there should be a clear
demarcation between those physicians who do and
do not offer this option.30 dying case is unique and its various facets should
therefore be approached carefully under the scope
of relevant legislation (e.g. European Convention
Freedom of thought, conscience and religion
on Human Rights Articles 2, 3, 8 and 9), and indi-
A further controversial issue is raised by Article 9 of the vidual/societal ethical and moral perspectives (Tables
European Convention on Human Rights, which pro- 1 to 4).
tects the rights of freedom of thought, conscience and
religion. Its impact on the assisted dying debate centres Implications of assisted dying in the doctor–patient
on whether requesting an assisted, dignified death con-
stitutes a manifestation of belief, therefore falling within
relationship
the remit of Article 9. Several European Court decisions As discussed, a key concern of the medical profession
have determined that individual views are entitled to remains the impact of legalisation of assisted dying
protection only if they ‘attain a certain level of cogency, on the doctor–patient relationship. This relationship
seriousness, cohesion and importance’.31 is fundamentally based on trust. Although aspects of
Seriousness and importance are undoubtedly justi- assisted dying may be considered in conflict with cer-
fied when considering an individual’s decision to end tain underlying ethical obligations placed upon doc-
their life. On the other hand, an informed desire to die tors, considering a patient’s autonomous wishes,
with dignity may well constitute a coherent and cogent alongside the moral perspectives of the doctor, is
view. For instance, it remains debatable whether also an important aspect of this relationship.32,33
approaching death through a solely palliative care This quandary is recognised by the Swiss Academy
lens constitutes a less dignified way to die than assisted of Medical Sciences in their ethical guidelines, which
dying.31 Article 9 may therefore provide a preferable acknowledges that ‘in certain special cases a doctor’s
framework for decisions relating to the right to die personal decision to assist a dying patient to commit
with dignity than Article 8, which focuses on a patients’ suicide is in accordance with his or her conscience
autonomy; while the former aims to protect truly coher- and has to be respected’.18
ent and cogent decisions, it may be argued that the The delicate balance between the views of patients,
latter in isolation could potentially open a bigger door doctors and society can pose an ethical dilemma, with
to a broader attitude towards assisted dying.13 the potential to serve a disruptive influence on the
Furthermore, Article 3 should also be considered sanctity of the doctor–patient relationship and nega-
as a safeguard, as this prohibits torture and degrad- tively distorting how society perceives the role and
ing treatment.17 Ultimately, each potential assisted motives of healthcare professionals. For example, as
412 Journal of the Royal Society of Medicine 111(11)

previously considered, particularly in healthcare sys- dying debate in a state of limbo. Whether assisted
tems where doctors play the role of gatekeeper to dying should be legalised (albeit with stringent con-
healthcare, a doctor’s support for an assisted death trols) remains controversial; as considered in this
for a terminally ill individual might be negatively essay, even the basic moral principles can conflict
interpreted as a conflict of interest, with a desire to when considering the arguments for and against
help relieve the social and economic burden of a supporting an assisted death, making consensus
patient’s illness upon society overriding the patient’s building far from straightforward.
individual interests. Ultimately, should appropriate Ultimately, individual patients’ autonomy should
safeguarding measures be deployed alongside rele- be balanced with a fundamental right to life, impacts
vant legislation, assisted dying may risk eroding doc- on the individual doctor–patient relationship and
tors’ professional integrity.34 wider society and the safeguards required to prevent
misuse of any assisted dying regulations. The chal-
Current position of doctors’ professional groups in lenge remains for society to decide where this balance
lies, guided by regional religious, cultural and legis-
the UK and the USA lative perspectives.
As expected, the discussion around adopting assisted Developing the required ethical competencies
dying has caused much controversy among the doc- among medical professionals is also key; given the
tors’ professional groups and bodies. Several profes- current absence of legal support for assisted dying
sional organisations in the UK have clearly expressed in most jurisdictions, most clinicians remain
their opposing views to assisted dying such as the untrained in such decision-making. Indeed with
British Medical Association, the Royal College of understandable fears against crossing key ethical div-
General Practitioners and the Royal College of ides, physician support for an assisted death tends to
Surgeons of England, whereas others maintain a neu- be lower than that of patients.36 Dying is a natural
tral position including the Royal College of Nursing, part of human life. With growing demand worldwide,
the Royal College of Psychiatrists and the Royal the assisted dying debate will increasingly come to the
Pharmaceutical Society.5 The Royal Society of fore – something healthcare professionals, politicians
Medicine has no policy on the issue since ‘its remit is and legislators cannot ignore.
the education of doctors and health professionals and
the promotion of debate, not the making of policy’.35 Declarations
In the US, the American Medical Association, rep- Competing Interests: None declared.
resenting nearly 250,000 members, vehemently
Funding: None declared.
opposes legalisation of assisted dying as does the
American College of Physicians with more than Ethics approval: Ethics approval was not required for this
150,000 members.6 review.

Guarantor: AF.
Conclusions Contributorship: AF and EP conceived, designed the study and
performed the literature search. All authors analysed the data and
The debate surrounding assisted dying is never far drafted the manuscript. All authors contributed to and approved
from the headlines, particularly while its legal status the final version of the manuscript.
in most jurisdictions remains inadequate and discur-
Acknowledgements: None
sive. However, alongside the evolution of palliative
care, there appears to be an increasingly vocal desire Provenance: Not commissioned; peer-reviewed by David
for legislation to support assisted dying in selected Misselbrook.
cases.21 Developing a sensitive balance between ORCID iD: Andreas Fontalis http://orcid.org/0000-0001-
established cultural norms and a progressive, well- 5547-288X
balanced, transparent and safe attitude towards
assisted dying is key.24 More patient-centred atti- References
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