5.

2 Euthanasia and Assisted Suicide

Jaro Kotalik MD, MA, FRCPC

Learning Objectives
1. To understand the terms euthanasia and assisted suicide and be able to distinguish between the different
types of euthanasia
2. To be aware of the position of euthanasia and assisted suicide in Canadian law and professional regulations
3. To provide an appropriate clinical response to patients or families who express interest in euthanasia or
assisted suicide

Case
John N., a 62-year-old truck driver who is divorced and has two adult daughters, is being admitted to hospital
because his symptoms of dyspnea and chest pain due to an incurable metastatic disease were not controlled at
home. At the end of the consultation with his physician, John is visibly anxious and says: "Doctor, when things
get really bad, I would like you to help me do away with myself . . . or finish me off by a needle or something.
Don't let me suffer!"

Questions
1. What is John N. asking for, and what would you, as his physician, be legally permitted to do?
2. How will you shape John N.'s care, given his attitude and your ethical and clinical obligations?

Discussion
Definitions
John's first suggestion to his physician is considered to be a request for assisted suicide, an act where someone
else provides the means or tools or advice but the person who wishes to die is the one who takes the actual step
that kills. His second suggestion ? that in a certain future situation he would prefer that his doctor, motivated by
compassion for his suffering, would directly, knowingly and intentionally terminate his life in a painless manner ?
is considered a request for voluntary euthanasia. Definitions of the various types of euthanasia are provided in
the text box below in relation to the present case.1,2 Other definitions of these terms are in circulation, which
complicates and confuses the debates about the moral implications of such actions.
About Euthanasia

Type of
Euthanasia

Description Related to This Case

Voluntary
Euthanasia

If, prior to the lethal injection, John N. had given free and informed consent to terminate his life

Non-Voluntary
Euthanasia

If John N. was no longer competent to consent, yet he was given the lethal injection without
consent

Involuntary
Euthanasia

If someone (physician or other), motivated by compassion, terminated John's life against his wishes
or without his free and informed consent

Note: Those who approve of euthanasia sometimes suggest that withdrawal or withholding of life-sustaining
interventions, such as dialysis or mechanical ventilation, also represents euthanasia, which they label as "passive
euthanasia."3 In contrast, most authors will say that removal of these life-saving interventions, when death is caused
by underlying disease, is not euthanasia and is to be described as "allowing someone to die." The distinction between
"passively allowing death from an underlying disease" and "actively ending life" is logically defensible and ethically and
legally essential. Similarly, some claim that euthanasia takes place if the use of drugs for pain control results in a
person's life being shortened. Most writers, including palliative care specialists, will maintain that such a situation
represents an adverse side effect of otherwise desirable palliative care and is not euthanasia. Whether death is intended
or merely foreseen makes a major difference to the morality of one's conduct.2 The term passive euthanasia is no longer
legitimately used.

Legal and Regulatory Issues

Suicide has been decriminalized in Canada since 1973, but assisting someone in suicide remains a crime. Article
241 of the Criminal Code of Canada makes it an indictable offence to counsel, aid or abet anyone to commit
suicide. A challenge to this section of the Code based on the Charter of Rights and Freedoms was mounted by
Mrs. Rodriguez in 1994. Although her case reached the Supreme Court of Canada, it was eventually rejected by a
narrow majority of judges.4
The legal status of euthanasia in Canadian law is unequivocal. In criminal law, euthanasia is equated with
culpable homicide, whether or not consent was given and regardless of whether it was carried out by a physician
or someone else, or whether it was voluntary, non-voluntary or involuntary.5 At times, Canadian courts issued
lenient sentences in cases where desperate family caregivers unable to alleviate severe suffering acted forcefully,
but without any personal gain, and took the life of a loved one.6 Professionals, however, may be expected to
meet a higher standard and to always act lawfully. For example, a physician in Halifax was charged after being
reported to have injected potassium chloride (KCl) into a distressed dying patient. Later on, a judge stated that
he had dismissed the case only because of lack of evidence that the KCl injection, if the physician did administer
it, was what led to the death of this patient, who also had received large amounts of analgesics.7 On the other
hand, administering pain-relieving medication in the dosages and frequencies necessary to achieve relief has
never been condemned by Canadian courts, even if pain medication may be implicated in the shortening of life.
Guidelines that help to distinguish palliative care from euthanasia are available.8
Court decisions as well as public policy express a general consensus that it is acceptable to forgo or discontinue
life-saving treatments if the decision is made with due care. The law makes a clear distinction between the active
termination of life, which is contrary to law, and allowing someone to die from an underlying disease, which is
often permissible and may even be required if the patient or surrogate decision-maker did not consent or
withdrew consent to a life-maintaining intervention.
Policy of the Canadian Medical Association states that the organization does not support euthanasia and assisted
suicide.1 The Association recognizes that it is the prerogative of society to decide whether the laws dealing with
these acts should be changed, but it wishes to contribute the perspective and concerns of the medical profession.
Many major medical organizations (such as the British, American and Australian medical associations) oppose
euthanasia and assisted suicide. The World Medical Association states that euthanasia is unethical.9
Euthanasia and assisted suicide are also illegal in most of the world. Exceptions are Holland, Belgium and some
cantons of Switzerland, which allow both acts, and the state of Oregon, which, since 1994, permits assisted
suicide under certain conditions.2
Physicians are strongly advised not to perform either euthanasia or assisted suicide, regardless of their personal
conviction about the matter.10

Ethical Issues
Important practical and legal differences exist between euthanasia and assisted suicide, but both acts raise
similar ethical issues and will be discussed together. In traditional medical ethics, euthanasia and assisted suicide
were seen as harmful acts and unacceptable transgressions against the rule of the Hippocratic Corpus "primum
non nocere" [first, do no harm]. At present, however, there is a divergence of views. Surveys indicate that a
significant proportion of the population, as well as of physicians as individuals, find euthanasia and assisted
suicide under certain conditions to be ethically justifiable.11
Among the major arguments in favour of euthanasia and assisted suicide are these: (a) respect for autonomy or
self-determination over one's own body requires us to allow competent people who decide that life is no longer of
value to them to choose the time of their death and to receive assistance to end their life; and (b) mercy
requires that euthanasia and assisted suicide be made available to those people who experience unrelieved
suffering in one or more of its many forms and also to those who wish to avoid what they perceive as indignity,
such as being dependent on others for care.
Major arguments against the acceptability of euthanasia and assisted suicide are as follows: (a) it is always
wrong for one person to intentionally kill another innocent person, even at their request, and overturning this
moral standard that can be traced through the history of humankind would undermine the value of and respect
for human life in general; (b) the moral approval of euthanasia and assisted suicide would devaluate and
threaten the most vulnerable people ? those who are ill, severely disabled or elderly ? who then would be
perceived, if not seeking euthanasia and assisted suicide, as an improper burden to themselves and others,
especially when health care resources are scarce; and (c) from a professional perspective, intentional killing
under any circumstances is contrary to the proper role of physicians.
Numerous publications discuss these and other arguments in detail.12?15 In essence, the main arguments in
favour of euthanasia and assisted suicide call attention to the interests of the individual, and the main arguments
against these acts call our attention to the interests of the community. If we judge that even voluntary
euthanasia and assisted suicide for some people would significantly harm many others and society at large, then
rejecting these acts on ethical grounds could represent a reasonable limitation on the exercise of personal
autonomy and mercy.
The ethical acceptability of "allowing someone to die" depends on the circumstances. If the patient does not give

free and properly informed consent, or removes previously given consent, to a life-saving intervention, the
physician has an ethical obligation not to intervene, even if death will eventually follow. It is also ethically
justified to withhold or withdraw an intervention that is unhelpful or that only prolongs the dying process in a
patient who has an incurable and progressive disease. However, it would be ethically deplorable and open to
legal challenge if a patient who consented to an available intervention that could be effective in prolonging his or
her life were "allowed to die," even if mercy was the motivation.16

Clinical Approach
Both acts that John N. proposes to his physician are legally prohibited and morally problematic, and the patient
ought to be told that. However, the physician cannot just dismiss such requests with a simple legal explanation.
The patient's request, even if it cannot be adopted, should inform the care that will be offered to him. The ethical
obligation of a professional caregiver is to grasp as fully as possible the patient's motivations, needs, concerns
and goals, and to seek all possible ways in which all of these could be addressed in an ethically, legally and
clinically responsible way.17 This is particularly so in this case because a request of John's type is unusual. The
majority of patients with an incurable illness desire all the prolongation of life that can be achieved by medical
interventions, even if their quality of life is diminished. Likely, John, in addition to his physical symptoms, is
experiencing emotional and other forms of distress, and his physician ought to consider referring him for full
psychological, social and spiritual assessment and care by a multidisciplinary team. If a diagnosis of depression
were made, a treatment should be offered. While John's present pain is being controlled, his fear of future pain,
isolation and loneliness may need to be addressed as well.18 The patient also needs to be made aware that he
can refuse any intervention, even life-saving treatment, that is offered to him and that he may provide, in writing
or verbally, advanced directives to his family for the time when he may not be capable to make decisions.
In John N.'s case, further assessment revealed that his father also had lung cancer and that he may not have
received appropriate end-of-life care. John was greatly distressed by his father's suffering and feared the same
fate. He also was concerned about being a burden to his daughters. John and his family received caring attention
from the care team comprising an oncologist, a palliative care nurse, a chaplain, a social worker and volunteers.
This overall attention went a long way in providing John with confidence and trust in his care team, as well as
assurance that he would not be abandoned. He knew that his comfort was of uppermost concern to the whole
team. During discussions about his care, the patient endorsed the idea of aiming for full control of his symptoms,
accepting drowsiness and the risk of premature death due to medication. John's children and friends rallied
around him, and he became more content even though his physical condition continued to deteriorate. When his
early remark about euthanasia and assisted suicide was mentioned to him by the physician, John dismissed the
idea.

References
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