Image Source: Wikimedia Foundation
Author: Nicholas Christos
The contemporary landscape of the Death with Dignity movement embodies a nuanced interplay of legal, political, and ethical considerations, both within the United States and on a global scale. This analysis explores the multifaceted realm of physician-assisted suicide (PAS) and euthanasia, offering an in-depth examination of recent legislation and pivotal case law shaping the discourse surrounding end-of-life decision-making. Within the United States, a patchwork of state-level initiatives has emerged, culminating in the legalization of PAS in several jurisdictions, each with its own set of eligibility criteria and procedural safeguards. Moreover, this analysis extends beyond national boundaries to explore the diverse approaches to PAS and euthanasia adopted by countries worldwide, navigating through a complex terrain of cultural, religious, and legal perspectives. By critically evaluating recent developments in legislation and case law, this piece seeks to illuminate the evolving landscape of the Death with Dignity movement and its profound implications for individual autonomy, medical ethics, and societal values.
The debate over PAS and euthanasia is intrinsically linked to fundamental human rights, as it touches upon the principles of autonomy, dignity, and the right to freedom from inhumane treatment. This section explores how PAS and euthanasia intersect with human rights. One of the core arguments for PAS and euthanasia is the right to personal autonomy. Proponents assert that individuals should have the authority to make decisions about their own bodies and lives, including the right to choose when and how to die. This perspective emphasizes that terminally ill patients should have the power to avoid prolonged suffering by deciding to end their lives on their own terms.[1] The right to autonomy is recognized in various human rights instruments, such as Article 1 of the Universal Declaration of Human Rights (UDHR), which states, "All human beings are born free and equal in dignity and rights." Proponents argue that denying terminally ill patients the option of PAS or euthanasia violates this fundamental right to autonomy.[2] Furthermore, Article 3 of the UDHR states, "Everyone has the right to life, liberty and security of person." Proponents assert that forcing terminally ill patients to endure unbearable pain and suffering constitutes cruel and inhuman treatment. Allowing these patients the option of PAS or euthanasia is seen as a humane and compassionate response that aligns with their right to be free from torture and degrading treatment, as protected under Article 5 of the UDHR: "No one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment."[3] Also, international human rights bodies, such as the European Court of Human Rights, have increasingly recognized the need to consider the quality of life and suffering in decisions related to end-of-life care. While not uniformly endorsing PAS or euthanasia, these bodies acknowledge the complexity of the issue and the importance of addressing suffering.[4]
PAS and euthanasia laws in the United States are primarily determined at the state level, resulting in various regulations across different jurisdictions. As of 2024, ten states and the District of Columbia have legalized PAS in some form. These states include Oregon, Washington, California, Vermont, Colorado, Hawaii, New Jersey, Maine, New Mexico, and Montana (via court rulings).[5] Each state's laws regarding PAS may have distinct eligibility criteria, procedural safeguards, and reporting requirements. For example, some states require individuals to have a terminal illness with a prognosis of six months or less to live, while others have more flexible criteria.[6] Most states with PAS laws have built-in protections for patients, including multiple requests for medication, waiting periods, counseling requirements, and second medical opinions. Many states allow healthcare providers and institutions to conscientiously object to participating in PAS procedures, although the extent of this exemption varies.[7]
Recent years have witnessed increased legislative activity regarding PAS and euthanasia in several states. Some states have introduced bills aimed at legalizing or expanding access to PAS or euthanasia, often seeking to broaden eligibility criteria or streamline the process. Conversely, other states have proposed legislation to restrict or ban PAS, citing concerns about patient vulnerability, potential abuse, and ethical considerations.[8]
A couple states will now be specifically discussed. Vermont legalized PAS through the Patient Choice and Control at End of Life Act, which was enacted in May 2013 and became effective in 2014.[9] The law allows mentally competent, terminally ill adults with a prognosis of six months or less to request a prescription for lethal medication. Patients must make multiple requests for medication, including a written request signed in the presence of witnesses, and undergo counseling to ensure informed decision-making. Vermont's PAS law was passed through the legislative process rather than a voter referendum. The bill was introduced in the Vermont House of Representatives and the Senate, where it underwent committee hearings, debates, and revisions before being passed and signed into law by Governor Peter Shumlin.[10] Since the enactment of Vermont's PAS law, terminally ill patients have had the option to request and receive medication to end their lives on their own terms. Vermont's Department of Health oversees the implementation and monitoring of the law, including collecting data on the number of patients who request and use PAS.[11] Colorado legalized PAS through the Colorado End-of-Life Options Act, which was approved by voters in a ballot initiative in November 2016 and went into effect in December 2016.[12] The law allows mentally competent, terminally ill adults with a prognosis of six months or less to request a prescription for lethal medication. Patients must make multiple requests for medication, undergo counseling, and wait for specified periods to ensure informed decision-making. Colorado's PAS law, Proposition 106, was passed by voter referendum, with approximately 65% of voters supporting its legalization.[13] The initiative faced opposition from religious groups and some healthcare organizations but garnered significant support from advocates for patient rights and end-of-life autonomy. Since the enactment of Colorado's PAS law, terminally ill patients have had the option to request and receive medication to end their lives if they meet the eligibility criteria. The Colorado Department of Public Health and Environment oversees the implementation and monitoring of the law, including collecting data on the number of patients who request and use PAS.[14]
Finally, exploring specific internationally significant cases can help demonstrate the issues related to human rights and legal ambiguity involved. First, in the United States, Washington v. Glucksberg (1997) originated from a lawsuit filed by physicians, patients, and advocates challenging Washington State's ban on physician-assisted suicide.[15] Dr. Harold Glucksberg, along with three other physicians and three terminally ill patients, argued that the ban infringed upon patients' rights to make end-of-life decisions and violated the Due Process Clause of the Fourteenth Amendment. The plaintiffs contended that terminally ill patients should have the option to seek assistance in ending their lives peacefully if they were suffering unbearably. The Supreme Court, however, unanimously ruled against the plaintiffs. The Court held that there was no fundamental right to physician-assisted suicide enshrined in the Constitution. Chief Justice Rehnquist, delivering the opinion of the Court, emphasized the state's interests in protecting vulnerable individuals, preventing potential abuse or coercion, and upholding the integrity of the medical profession.[16] The ruling left the door open for states to continue prohibiting physician-assisted suicide while allowing them to explore alternative end-of-life care options. In Canada, Carter v. Canada (2015) challenged Canada's criminal laws prohibiting physician-assisted dying. The plaintiffs argued that the criminal code provisions infringed upon their rights under the Canadian Charter of Rights and Freedoms, including the rights to life, liberty, and security of the person.[17] They contended that individuals facing intolerable suffering due to a grievous and irremediable medical condition should have the right to seek assistance in dying. The Supreme Court of Canada, in a unanimous decision, declared the criminal code provisions prohibiting physician-assisted dying unconstitutional. The Court recognized that the ban deprived individuals of their autonomy and subjected them to unnecessary suffering. The ruling emphasized the importance of respecting patients' choices and ensuring access to compassionate end-of-life care.[18] The Court suspended the declaration of invalidity for one year to allow Parliament to craft legislation consistent with the Charter. Lastly, in France's Constitutional Council decision of 2021, a law permitting terminally ill patients to request deep and continuous sedation that may lead to death, effectively legalizing passive euthanasia under certain conditions, was upheld.[19] The law was adopted after extensive debates in parliament and aimed to provide terminally ill patients with additional end-of-life options. The Constitutional Council's decision affirmed the principles of patient autonomy and dignity while sparking debates about medical ethics and the role of healthcare providers in end-of-life care.[20]
The evolving legal landscape underscores the necessity for continuous evaluation and adaptation of policies to address emerging ethical, medical, and societal issues. The experiences of states and countries that have legalized PAS and euthanasia serve as critical case studies for jurisdictions considering similar legislation. They highlight the importance of comprehensive regulatory frameworks that prioritize patient safety, informed consent, and ethical medical practices.
[1] UN Human Rights Office of the High Commissioner. "The Right to Autonomy and Human Dignity." Available at OHCHR.
[2] United Nations. "Universal Declaration of Human Rights." 1948. Available at UDHR.
[3] United Nations. "Universal Declaration of Human Rights." 1948. Available at UDHR.
[4] European Court of Human Rights. "Case of Pretty v. The United Kingdom." ECHR, 2002.
[5] National Conference of State Legislatures. (n.d.). End-of-life options: State statutes.
[6] American Medical Association. (2023). Physician-assisted suicide legislative update.
[7] Death with Dignity National Center. (n.d.). Death with Dignity Acts: State by state guide.
[8] Compassion & Choices. (2023). Legislative updates.
[9] Vermont Department of Health. (n.d.). Death with Dignity Act.
[10] Ballotpedia. (n.d.). Vermont Patient Choice and Control at End of Life Act (2013).
[11] Vermont Legislature. (n.d.). Bill Status: H.199 (2013-2014).
[12] Colorado Department of Public Health and Environment. (n.d.). End of Life Options Act.
[13] Ballotpedia. (n.d.). Colorado End-of-Life Options Act, Proposition 106 (2016).
[14] Colorado Legislative Council Staff. (2017). Ballot Issue Analysis: Proposition 106, End-of-Life Options Act.
[15] U.S. Supreme Court. (1997). Washington v. Glucksberg, 521 U.S. 702.
[16] Thomas, K. (1997). The Supreme Court and Physician-Assisted Suicide - Rejecting Assisted Suicide but Embracing Euthanasia. New England Journal of Medicine, 337, 1236-1242.
[17] Supreme Court of Canada. (2015). Carter v. Canada (Attorney General), 2015 SCC 5.
[18] The Canadian Press. (2015, February 6). Supreme Court of Canada strikes down ban on doctor-assisted suicide. CBC News.
[19] French Constitutional Council. (2021). Decision n° 2021-923 QPC.
[20] Chrisafis, A. (2021, March 9). France passes law allowing 'deep sedation' for terminally ill patients. The Guardian.
References
UN Human Rights Office of the High Commissioner. "The Right to Autonomy and Human Dignity." Available at OHCHR.
United Nations. "Universal Declaration of Human Rights." 1948. Available at UDHR.
European Court of Human Rights. "Case of Pretty v. The United Kingdom." ECHR, 2002.
National Conference of State Legislatures. (n.d.). End-of-life options: State statutes.
Death with Dignity National Center. (n.d.). Death with Dignity Acts: State by state guide.
Compassion & Choices. (2023). Legislative updates.
American Medical Association. (2023). Physician-assisted suicide legislative update.
Vermont Department of Health. (n.d.). Death with Dignity Act.
Ballotpedia. (n.d.). Vermont Patient Choice and Control at End of Life Act (2013).
Vermont Legislature. (n.d.). Bill Status: H.199 (2013-2014).
Colorado Department of Public Health and Environment. (n.d.). End of Life Options Act.
Ballotpedia. (n.d.). Colorado End-of-Life Options Act, Proposition 106 (2016).
Colorado Legislative Council Staff. (2017). Ballot Issue Analysis: Proposition 106, End-of-Life Options Act.
U.S. Supreme Court. (1997). Washington v. Glucksberg, 521 U.S. 702.
Thomas, K. (1997). The Supreme Court and Physician-Assisted Suicide - Rejecting Assisted Suicide but Embracing Euthanasia. New England Journal of Medicine, 337, 1236-1242.
Supreme Court of Canada. (2015). Carter v. Canada (Attorney General), 2015 SCC 5.
The Canadian Press. (2015, February 6). Supreme Court of Canada strikes down ban on doctor-assisted suicide. CBC News.
French Constitutional Council. (2021). Decision n° 2021-923 QPC.
Chrisafis, A. (2021, March 9). France passes law allowing 'deep sedation' for terminally ill patients. The Guardian.