Euthanasia and Physician Assisted Suicide: Attitudes, Practice and the Slippery Slope
Euthanasia and Physician Assisted Suicide
Attitudes, Practice and the Slippery Slope
1. Intro: What does it mean to die?
2. Definitions
a. Full Medical Treatment
b. Withdraw/Withold Life Sustaining Treatments
c. Palliative Care and Double Effect
d. Palliative Sedation
e. PAS
i. Voluntary
ii. Non-voluntary/Surrogate/Encouraged
f. Euthanasia
i. Voluntary
ii. Non-voluntary/Surrogate/Encouraged
3. History
4. Law and Current Practice
a. Netherlands
b. Oregon
c. The Rest of the USA
5. Physician Attitudes
a. WFUBMC Data
b. Articles
6. Public Attitudes:
7. Patient Attitudes:
8. Ethical Arguments:
a. Pro
i. Autonomy
ii. Relief of All Suffering
iii. Resource Allocation
iv. Increased awareness of EOL issues
b. Con
i. Abuse (Involuntary/surrogate/encouraged euthanasia)
ii. Role of Physician as Healer
iii. Closure while alive
iv. Missed diagnosis of depression
v. Decreased awareness of EOL Issues/Decreased Communication
9. The Slippery Slope
10. Talking about PAS/Euthanasia with patients
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Euthanasia and Physician Assisted Suicide: Attitudes, Practice and the Slippery Slope
Physician-assisted suicide (PAS) and euthanasia are two ideas that are able to provoke a large number of
emotions in people. Obviously, end-of-life (EOL) issues are going to be fraught with feelings, especially if one has
experienced the death of a close friend or relative. Currently the medical community, judicial system, and the
general public are involved in debates over the legalization of PAS and euthanasia in the United States and the
greater goal of improved EOL care for all people. Physicians need to be aware of the main issues. The Attorney
General, John Ashcroft, is currently attempting to overturn the Oregon Death with Dignity act. Understanding the
numerous ethical dilemmas is critical to informed decision making. Not only will it help physicians on a national
level, but it can also help physicians on the personal level in dealing with their patients. The data on euthanasia
and PAS is scant given
DEFINITIONS
The terms used in EOL care have multiple meanings and can be skewed to represent certain views.
Prudence lies in clarifying the terms used here, so confusion will be decreased and discussions can be enhanced.
The spectrum of options available at the end-of-life include: (1) Full medical treatment (2) Standard palliative care,
(3) Withdrawing and withholding of life-sustaining treatments, (4) Palliative sedation, (5) Physician-assisted suicide,
(6) Euthanasia, (7) Suicide.
Full medical treatment may include some aspects of palliative care such as pain control through use of
opioids, but is meant to reflect aggressive medical treatment at the end-of-life without use of hospice care, such as
use of the intensive care unit, surgeries, advanced cardiac life support.
Withdrawing and withholding of medical support is a legal medical practice, which involves the patient, if
competent, or the surrogate decision maker, if the patient is incompetent. Historically, this has not been an issue
ethically or legally for competent patients. The issue of incompetent patients, whose surrogate decision makers
disagree has been reviewed in the U.S. Supreme Court (Quinlan 1976, Cruzan 1990) and recently in the California
Supreme Court (Wendland v. Wendland, 2001). The issues surrounding these cases are extensive and beyond the
scope of this paper.
The Rule of Double Effect in Palliative Care
1. The nature of the act must be good or morally
neutral. (e.g. relief of pain with opioids).
2. The good effect (rule 1) and not the bad effect
(death) must be intended.
3. The bad effect (death) must not be a means to the
good effect (relief of suffering).
4. The good effect must be sufficiently desirable to
compensate for the allowing of the bad effect.
Adapted from Quill et al. NEJM 1997
Standard palliative care generally involves hospice to
some degree, but does not necessitate that hospice is involved. Palliative care ideally refers to optimal pain and
symptom management, emotional support from family and medical staff, and existential and faith support from
pastoral services. One of the common tools used in palliative care is the use of opioids for relief of dyspnea and
pain. As the end of life approaches, opioids may be increased by the physician with the primary goal of relieving
symptoms, with the foreseen but unintended risk of hastening death with use of opioids. By the ethical rule of
double effect (see figure 1), physicians have been allowed to give adequate pain control to those at the end-of-life.
(Quill TE NEJM 1997).
Palliative sedation is a proposed alternative to physician assisted suicide, which is currently legal in the
United States. Synonyms include terminal sedation and full sedation. Palliative sedation involves sedating a
patient with a goal of being unconscious for relief of severe physical symptoms, including pain, terminal delirium.
The patient eventually dies of dehydration, underlying illness or another intervening complication. (Quill TE Ann
Intern Med 2000)
PAS is defined as providing a prescription to a patient with the intention of ending his or her life with self-
administration of the medication. (Meier DE, et al. NEJM 1998) Issues arise when defining whether PAS is
voluntary or non-voluntary, which is frequently encountered during ethical and legal discussions. Non-voluntary
cases may arise when the patients competency is questioned (i.e. undiagnosed depression, dementia) or the
patient is unduly influenced by family, friends and/or physicians, also known as ‗encouraged PAS.‘ (REF?). Some
proponents of PAS have encouraged other terms that have less of a negative social connotation, such as physician
assisted self-deliverance, but these have not been recognized by the general public or researchers.
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Euthanasia and Physician Assisted Suicide: Attitudes, Practice and the Slippery Slope
A physician who administers a lethal dose of medicine to a patient with the primary intention of death is the
definition of euthanasia (Meier DE, et al. NEJM 1998). This is also known as active euthanasia, in contrast to the
historical misnomer passive euthanasia, which has been applied to withdrawing and withholding life-sustaining
treatments, and standard pain control under the rule of double effect. (Ezekial UTD). Euthanasia can be divided
Life-Sustaining Treatments
Advanced Cardiac Life Support
Mechanical Ventilation
Surgery
Dialysis
Blood Transfusions
Diagnostic Tests
Artificial Nutrition and Hydration
Antibiotics
Future Hospital, ICU Admissions
into voluntary and non-voluntary as well, depending on the
patients explicit request, competency, and outside influence.
HISTORY
The history of the discussion of euthanasia and PAS must first look at ancient medicine practice and the
th
Oath of Hippocrates. The original version from the 5 century B.C.E. states, ‗To please no one will I prescribe a
deadly drug, nor give advice which may cause his death.‘ The versions repeated at medical schools are updated
from the original and only 14% include a phrase prohibiting euthanasia, but the reasons for omission are not clear.
(Orr RD 1997) Hitler and Nazi Germany authorized the elimination of ―life unworthy of life,‖ including the sick and
disabled who were deemed incurable by physicians. It would be classified as non-voluntary euthanasia, and
opponents of euthanasia cite this as an example of a ‗slippery slope,‘ if voluntary euthanasia is legalized.
(http://www.us-israel.org/jsource/Holocaust/t4.html)
Although most would consider the debate over PAS and euthanasia to be a modern one, laws were drafted
in 1906 (Ohio) and 1936 (England) to allow euthanasia but were both defeated. Since then many euthanasia and
right-to-die societies have formed around the world, including The Hemlock Society (www.hospiceforhemlock.org),
the world right to die federation and the Euthanasia Research and Guidance Organization (www.finalexit.org).
More recently, Oregonian citizens passed the Oregon Death With Dignity Act (1994) allowing for PAS, the
Netherlands decriminalized euthanasia and PAS (2001), and Belgium decriminalized both in September of 2002.
Acts of euthanasia have even been carried out on television in both the United States and the Netherlands. (REF?)
More recently, Attorney General John Ashcroft has attempted to overturn the Oregon Death With Dignity Act,
stating the federal authority of the controlled substance act clarifies that PAS is not a ‗legitimate medical purpose.‘
By invoking federal control of states right to govern medical practice, the Attorney General is setting a precedent
that may end up in the Supreme Court as a battle over states rights in regulating medical practice. (Lowenstein,
NEJM 2002)
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Euthanasia and Physician Assisted Suicide: Attitudes, Practice and the Slippery Slope
Netherlands Voluntary Euthanasia and Physician
Assisted Suicide Criteria – Section 293(2) of the
Dutch Criminal Code
1. Patient’s request must be voluntary and
carefully considered.
2. Physician must be satisfied the patient’s
suffering was unbearable and terminal.
3. Patient must be informed of situation and
prospects.
4. Physician and patient must agree there are
no reasonable alternatives.
5. Consultation with one other independent
physician, who must see the patient, and
agree with items 1-4 above.
6. Physician must terminate the patient’s life
or provide assistance with suicide with due
care and attention.
LAW AND CURRENT PRACTICE:
The recent decriminalization of euthanasia and PAS in the Netherlands in April 2002 (both have been
permitted by courts since 1984), and the Oregon Death with Dignity Act allowing for PAS, passed in 1994 and
again after court challenges in 1997 have allowed for closer examination of the acts of PAS and euthanasia. Other
countries, such as Belgium and Switzerland allow physician assisted suicide by not prosecuting physicians, but
data are lacking for further study. (ERGO web site) Many countries and U.S. states have laws actively prohibiting
PAS and euthanasia, but few cases are ever brought to trial. Other attempts to pass laws allowing PAS have been
defeated in Hawaii, California, Michigan, and Maine. The Northern Territory of Australia also legalized voluntary
euthanasia for nine months before being overruled by the federal government. Only four people received
euthanasia under the law. (REF)
In 1997, the U.S. Supreme Court ruled unanimously (Washington v. Glucksberg, Vacco v. Quill) against
any constitutional right to PAS or euthanasia. Oregon‘s Death with Dignity Act was not overturned, because the
justices also ruled there is no constitutional prohibition to make PAS and euthanasia legal, and therefore states
may enact their own laws regarding physician involvement with hastening death. The Oregon Death with Dignity
Act contains criteria that must be met before one can prescribe barbiturates for PAS. (Figure 3). The Netherlands
also has criteria that must be fulfilled that are similar to Oregon.(Figure 4)
Multiple small studies have studied the acts of PAS and euthanasia among U.S. physicians. The difficulty
in comparing them lies in the subjective nature of the questions that are asked. Many questions may imply PAS or
euthanasia but are worded quite differently among studies.
The most comprehensive study into actual practice of euthanasia and PAS in the United States involved structured
in-depth telephone interviews to 355 randomly selected U.S. oncologists(emanuel JAMA 1998). The physicians
were screened with the following questions: ―Have you ever actually injected drugs to intentionally end a patient‘s
life?‖ and ―Have you ever actually prescribed drugs to a patient knowing the patient intended to use them to end his
or her life?‖ These questions were selected to avoid confusion between the terms euthanasia and physician
assisted suicide, and among other end-of-life practices, such as withdrawing and withholding medical treatments
and standard palliative care. 355 out of 489 eligible oncologists agreed to be interviewed and 56 (15.8%) answered
yes to one or both of the above two questions. After further investigation, 7 of the 56 (12.5%) did not actually
perform euthanasia or PAS, but had either misclassified withholding treatment or increasing morphine and were
therefore excluded from further analysis. Despite the carefully worded questions, physicians still confused the
ideas of PAS, euthanasia, withdrawing/withholding treatments and standard palliative care, which has also been
identified in the general public in numerous studies (REFS), thus leading to confusion when debating these
sensitive and emotional end-of-life issues.
Of the 38 oncologists identified to have performed euthanasia or PAS, 20 (52.6%, or 5.6% overall)
performed PAS, 17 (44.7%) performed euthanasia and 1 case was undecided after further review. 7 physicians
had previously misclassified themselves as PAS, but upon further review they were classified under euthanasia.
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Euthanasia and Physician Assisted Suicide: Attitudes, Practice and the Slippery Slope
Proposed safeguards have been published by advocates of PAS and euthanasia, and the safeguards are very
similar to the law in the Netherlands and Oregon. The study evaluated physician adherence to the proposed
primary and secondary safeguards (TABLE). As noted, there was inconsistence adherence, most notably in only
23 (60.5%) cases did the patient initiate and repeat the
To request a prescription for medication, the request. In 6 cases (15.8%), the patient was not involved in
Death with Dignity law requires that a patient the decision for PAS or euthanasia. Adherence to all three
must be: proposed primary safeguards was present in only 13
(34.2%) cases.
1. An adult (18 years of age or older) This study also identified that euthanasia and PAS
2. A resident of Oregon may have lasting effects on physicians, both good and bad.
3. Diagnosed with a terminal illness that will lead Since the effects on physicians who perform euthanasia and
to death within 6 months PAS are not well studied, the data presented are especially
interesting. 19 (52.6%) physicians claimed to ―receive
To receive a prescription, the following steps must comfort from having helped the patient by euthanasia or
be fulfilled by the patient: PAS,‖ while 9 (23.7%) regretted performing either PAS or
euthanasia. 12 (31.6%) stated that it affected their medical
make two oral requests to their physician, practice, but interestingly some (5) felt it made them more
separated by at least 15 days. sympathetic towards their patients, while others (6) stated
provide a written request to their physician that the performance affected them negatively.
witnessed by two individuals who are not The actual performance of euthanasia and PAS in the
family members or primary caregivers. United States may never be known for various reasons, but
may rescind his or her request at any time this study is a good first step in breeching the secrecy of
these currently illegal practices, and evaluating its‘ effects
To receive a prescription, the following steps must on physicians. The key limitations of this study is the low
be fulfilled by the prescribing physician: incidence of euthanasia and PAS in the United States and
issues surrounding confidentiality which may have led more
confirm the diagnosis and prognosis with a pro-euthanasia and PAS physicians to not participate
consulting physician. secondary to fear of litigation.
must concur with a consulting physician that The largest study of U.S. oncologists (3,299 of 8,715
the patient is capable American Society of Clinical Oncology members)
If either physician determines that the demonstrated rates of 10.8% for PAS and 3.7% for
patient's judgment is impaired, the patient euthanasia over their career (REF). The terms PAS and
must be referred for a psychological euthanasia were defined but physicians are still prone to
examination.
misclassify their actions (REF). The practices were also
must inform the patient of alternatives analyzed by oncology specialty (medical, surgical, radiation
including palliative care, hospice and pain
management options.
and pediatric) with a much higher rate of euthanasia by
pediatric oncologists (9.5%) as compared to all other
must request that the patient notify their next-
of-kin of the prescription request. oncology specialties (3.3%), and a much lower rate of
physician-assisted suicide in pediatric oncologists (4.5%) in
comparison to all other specialties (11.5%). Those who
Adapted from
http://www.dwd.org/law/safeguards.asp were unwilling to perform euthanasia or PAS were less
likely to increase morphine for pain control in a clinical
vignette (OR, 0.58 [CI, 0.43 to 0.79]), and reported
adequate training in end-of-life care (OR, 0.86 [CI, 0.79 to 0.95]). Those oncologists who were less spiritual were
more likely to perform euthanasia or PAS (OR, 1.77 [CI, 1.40 to 2.26]). In their discussion, Emanuel and
colleagues report physicians who reported receiving better training in end-of-life care were less likely to perform
euthanasia or PAS, and therefore better training in end-of-life care may lead to less need of a ‗last resort‘ such as
PAS or euthanasia. They also state oncologists who neither support nor performed euthanasia or PAS, were less
willing to increase opioids for patients with increasing pain, presumably from fear of litigation and misunderstanding
of the ethical rule of double effect. Unfortunately, they fail to connect the possibility that if these are the same
physicians with ‗better‘ training in end-of-life care, why would these oncologists not understand the important issues
of adequate pain control and double effect, and therefore fail at providing adequate palliative care to their patients.
Limitations of this study include they poor response rate (39.8%) and were part of a large survey as opposed to the
in-depth interviews in the previous study.
An excellent case study in euthanasia and PAS is the nation of The Netherlands. While only officially
decriminalizing PAS and euthanasia in 2001 (effective April 2002), the Netherlands have allowed the practices
since 1983, and instituted a new reporting requirement in 1990 for all cases. A study was commissioned in 1990
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Euthanasia and Physician Assisted Suicide: Attitudes, Practice and the Slippery Slope
and again in1995 to interview randomly selected physicians and review death certificates for incidence estimates of
PAS and euthanasia (TABLE). The increase in number of explicit requests was 9% but the increase in estimated
acts of euthanasia was much higher (21% in the interview study, 41% in the death certificate study). The raw data
may demonstrate that these changes are not significant secondary to the rare occurrences of these events and the
heavy reliance on estimates, but these were not published. Also, their was a increased knowledge of reporting
techniques between the two years of study. Because of these noticeable limitations in the study, it may be difficult
to use this data to justify a pro- or anti-slippery slope argument. But, it is concerning that the estimated incidence of
ending of life without the patients‘ request is 0.8% in 1995 (976 out of 128,824 deaths) (REF).
The paper expounds on the cases and notes the patients tended to be younger and have cancer, 52% had no
explicit request, but it was discussed or stated as a wish. Only 21% of these patients were competent, usually
unable to make further verbal contact. The cases were frequently discussed with colleagues (59%), nursing staff
(65%), or relatives (70%). In only 5% cases, it was not discussed with anyone. The drugs administered in these
cases tended to be morphine with (17%) or without (64%) other drugs (excluding neuromuscular relaxants), as
opposed to euthanasia which was performed more frequently with neuromuscular relaxants in combination with
other drugs (46%). The amount of time by which life was shortened was estimated to be less than 24 hours in 33%
of cases and less than 1 week in 91% of cases, as opposed to euthanasia and PAS cases, 17% less than 24 hours
and 59% less than 1 week.
The Oregon Death with Dignity (DWD) law enacted in October of 1997 provided an opportunity to study
U.S. physicians and patients‘ interactions with PAS. Each year, the Oregon Department of Human Services
publishes the data. (REF) The number of prescriptions in the first full year of the law was 24, with 16 patients
actually using the prescriptions successfully. This represented .06% of all deaths in Oregon in 1998. The number
of prescriptions has risen each year, 33 in 1999, 39 in 2000, and 44 in 2001, although the number of total deaths
under DWD has not followed the same pattern, 27 in 1999, 27 in 2000, and 21 in 2001. This represented .09%
(1999), .09% (2000), and .07% (2001) of all Oregon deaths. A majority of these patients were enrolled in hospice
(69-85%), and frequently suffered from cancer (63-87%)The primary end-of-life concerns expressed to the
physician included loss of autonomy (75-93%), loss of quality of life (62-82%) and losing control over bodily
functions (43-78%). Inadequate pain control was not a concern in a majority of patients, with only 5-30% of
patients stating poor analgesia as a end-of-life concern. This data is being reviewed by Oregon and independent
sources to help ensure accurate information on such a sensitive topic.
Oregon and the DWD law have also demonstrated a dedication to comprehensive end-of-life care,
including increasing insurance coverage for terminally ill indigent patients, opening communication between
physicians and patients (JAMA 2002 ref), the one of the lowest rates of in-hospital death (<25%), the one of the
highest rates of hospice use, and a leader in research funding to study death, dying and palliative care (REFS). In
addition, 76% of Oregon physicians made efforts to improve their knowledge of pain medication, 79% noted an
increased confidence in prescribing pain medication, and 30% increased hospice referrals.(JAMA Ganzini 2001)
ATTITUDES
Since euthanasia and PAS are not legal in much of the world, most studies have focused on the attitudes
of physicians. The studies are of varied quality and are difficult to compare to each other, for similar reasons
involved with researching the actual practice of euthanasia and PAS. Physicians have even been noted to confuse
the terminology, much like the American public (REF). The differences in framing of the question can have a
profound impact on the outcome. Emanuel‘s comprehensive review of physician attitude surveys, since 1991,
shows that 1.2-70% of physicians, residents and medical students support euthanasia and 8.6-69% of physicians,
residents and medical students support PAS (Emanuel Arch Int Med 2002). The wide variation makes this a
difficult area to make any definite conclusions, and further studies into physicians‘ attitudes towards PAS and
euthanasia may be of limited value.
Another limitation of these surveys is the heterogeneous participants. There can be large moral and ethical
differences between groups of physicians, who are given similar surveys. A survey of 56 surgical residents and 24
faculty oncologists by Bold et al.(REF), demonstrated that 86% of surgical residents were willing to assist any
patient (in 5 clinical scenarios) in physician-assisted death compared to only 19% of faculty oncologists. I
conducted another survey of internal medicine residents and faculty at Wake Forest University Baptist Medical
Center (WFUBMC) using the same clinical scenarios and questions as above (questions table). The survey was
placed in resident and faculty mailboxes and included definitions of euthanasia, and PAS, consistent with the
definitions described above. The demographics of the internal medicine residents included a 64% response rate,
mean age of 29 (range 25-45), and 31% of respondents were female, similar to the 27% distribution and mean age
of 29 among surgical residents in the Bold study. Willingness to assist any patient in PAS or euthanasia was 33%
among medicine residents, and 86% among surgical residents, a large difference that was also present in response
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Euthanasia and Physician Assisted Suicide: Attitudes, Practice and the Slippery Slope
to belief in physician assisted death. (TABLE) This table also shows data points for internal medicine attendings
given the same survey, and they showed similar percentages in response to euthanasia and PAS. The Bold article
did not publish if they provided definitions for surgical residents and oncologists prior to their completion of the
surveys. This may account for the increased numbers in support of PAS or euthanasia, due to confusion and
misclassification of PAS and euthanasia, as noted in other studies.
Other data points in the WFUBMC Internal Medicine study included self-reported importance of religion
(Likert scale) and denomination, competency in end-of-life care (Likert scale), and yes/no questions of: ―Has a
patient ever requested, from you, physician assistance with his/her death?‖ and ――Has a patient ever requested,
from you, euthanasia to assist with his/her death?‖ and ―Have you ever violated your conscience when providing
care to terminally ill patients? (Residents survey only). Among internal medicine attendings (n=13), 3 (23%) had
been asked by a patient for PAS, and 3 (23%) had a patient ask for euthanasia. The number of medicine residents
who had experienced similar requests was much less, 5 (10%) for PAS, and 3 (6%) for euthanasia. A large
number of residents, 10 (19%), stated they had violated their conscience in caring for a terminally ill patient. 5
(50%) had beliefs systems that endorsed PAS or euthanasia, and 5 (50%) did not support either. Further
exploration into the reasons for these feelings was not asked, but may need to be an area of study in the future
The degree religion plays in shaping ones end-of-life beliefs has been debated in the literature. In this
study, 10 of 22 (45%) residents and attendings who state religion is not an important part of their life (Likert scale 1-
3) supported euthanasia or PAS, while 19 of 45 (42%) resident and attendings who were religious supported
euthanasia or PAS. Individual belief systems were not found to be significant in declaring opposition or support for
physician aid in death. A study of U.S. oncologists, the factors associated with decreased support for euthanasia or
PAS include: (1) reluctance to increase morphine in a clinical vignette with a patient experiencing pain (odds ratio
[OR], 0.61, [CI, 0.48 to 0.77]); (2) sufficient time to talk about end-of-life care with their patient (OR, 0.79, [CI, 0.71
to 0.87]); (3) being religious (OR, 0.68 [CI, 0.64 to 0.74]); and (4) being Catholic (OR, 0.57 [CI, 0.45 to 0.72]. The
only factor associated with increased support for euthanasia and PAS was being a surgical oncologist.
There will continue to be surveys of physicians‘ attitudes towards PAS and euthanasia, but in light of the
above studies, it may be time to refocus our efforts on other aspects of end-of-life care. Studies showing support
for euthanasia and PAS will be used to further legislation, while other studies will be used in opposition. After
noting the limitations of these studies, such as heterogeneous respondents, question framing effects, unclear
definitions, misclassification, issues of confidentiality, it is obvious these surveys may be so extremely biased that
they may be unusable in comparison to each other.
The Slippery Slope. Where do we go from here?
There are multiple arguments for and against euthanasia and PAS. (TABLE). If PAS and euthanasia were
available all physicians and patients, one of the greatest fears is the potential for abuse by medical staff, and
families of the terminally ill. The strength of this fear may lie in that we are all aware of our own fallibility, and
therefore prone to suspicion of others‘ intentions. Once voluntary PAS and euthanasia is allowed, some believe
we, as a society, will perform non-voluntary euthanasia (patient is unaware of euthanasia) or involuntary euthanasia
(patient receives euthanasia against his will). But the fallacy of the slippery slope is that event B must obviously
follow event A, with out good reasoning. Medicine needs to study, now more than ever, the effects of two ongoing
experiments into the practices of euthanasia and PAS. Only knowledge can help us influence the direction PAS
and euthanasia take in the future. If we believe that PAS in Oregon under the DWD law, can actually increase
hospice use, pain control knowledge, and overall end-of-life care as the preliminary data shows, then a slippery
slope from endorsing PAS (event A) to improved palliative care (event B), would be an option I think more people
would prefer. But if we interpret the data in the Netherlands Remmelink survey which shows an estimated 976
people in 1995 (0.7% of all deaths), had euthanasia or PAS with out their consent, maybe euthanasia is not the
best option for our society. But upon further evaluation of these cases, it was shown approximately half had
discussed this option earlier, and the majority were unconscious and within 1 week of death as reported by the
physician. And in only 5% of cases was it discussed with no one in particular, so that may decrease the actual
incidence of involuntary euthanasia to less than 24. Out of the estimated 3,600, are 24 people an ‗acceptable loss‘
in providing the patient with the end-of-life options he or she wills? Is one too many? Only be investigating these
cases with more depth and providing adequate information to independent review boards, will we be able to
understand this difficult choice we make a society.
Investigation into the cause and effect of current legislative practices may lead us to the erroneous
evaluation slippery slope (REF), also known as ―post hoc ergo propter hoc‖ (―after, therefore because of‘). Do we
know that the DWD in Oregon actually was the force behind improved hospice referrals, or was it other policies that
may have been put in place at the same time, such as using pain as a fifth vital sign, or increasing number of
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Euthanasia and Physician Assisted Suicide: Attitudes, Practice and the Slippery Slope
hospice and palliative care physicians in Oregon? A more causal relationship must be sought before we advocate
all the benefits of Oregon‘s improved palliative care to PAS and the DWD law. Similarly, would the acts of non-
voluntary euthanasia in the Netherlands happen whether euthanasia was legal or not? It is possible legalization
may actually shed more light onto the practice and decrease it in the future with continued reporting of all cases of
euthanasia. Obviously, we need more information. We are in the infancy of modern euthanasia and PAS, and it is
important to build a strong ethical foundation for all physicians to use as they face the future of modern medicine,
so they don‘t fall down the slippery slope.
Web Sites of Interest
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Euthanasia and Physician Assisted Suicide: Attitudes, Practice and the Slippery Slope
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Orr RD, Pang N, Pellegrino, Siegler M. Use of the Hippocratic Oath: a review of twentieth century practices and a
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November 22, 1998
CBS's "60 Minutes" airs a videotape showing Kevorkian giving a lethal injection to Thomas Youk, 52, who suffered
from Lou Gehrig's disease. The broadcast triggers an intense debate within medical, legal and media circles.
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