euthanasia dissertation pdf

Euthanasia: A good death or an act of mercy killing: A global scenario

• November 2021
• Clinical Ethics 17(2)

• Kastuba Medical College, Mangalore, Manipal Academy of Higher education, Manipal

• Harvard Medical School

• Manipal Academy of Higher Education

Discover the world's research

• 25+ million members
• 160+ million publication pages
• 2.3+ billion citations
• Nevena Aljinović
• Kutbuddin Aibak

• Lynda Lynda López Benavides
• Bregje D Onwuteaka-Philipsen
• Lindy Willmott

• Anđela MILORADOVIĆ

• Thomas Reisch

• Maud Maessen
• Marcel Zwahlen
• Rory Watson
• Recruit researchers
• Join for free
• Login Email Tip: Most researchers use their institutional email address as their ResearchGate login Password Forgot password? Keep me logged in Log in or Continue with Google Welcome back! Please log in. Email · Hint Tip: Most researchers use their institutional email address as their ResearchGate login Password Forgot password? Keep me logged in Log in or Continue with Google No account? Sign up

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Ann Med Surg (Lond)
• v.75; 2022 Mar

Euthanasia and assisted suicide: An in-depth review of relevant historical aspects

Yelson alejandro picón-jaimes.

a Medical and Surgical Research Center, Future Surgeons Chapter, Colombian Surgery Association, Bogotá, Colombia

Ivan David Lozada-Martinez

b Grupo Prometheus y Biomedicina Aplicada a las Ciencias Clínicas, School of Medicine, Universidad de Cartagena, Cartagena, Colombia

Javier Esteban Orozco-Chinome

c Department of Medicine, RedSalud, Santiago de Chile, Chile

Lina María Montaña-Gómez

d Department of Medicine, Keralty Salud, Bogotá, Colombia

María Paz Bolaño-Romero

Luis rafael moscote-salazar.

e Colombian Clinical Research Group in Neurocritical Care, Latin American Council of Neurocritical Care, Bogotá, Colombia

Tariq Janjua

f Department of Intensive Care, Regions Hospital, Minnesota, USA

Sabrina Rahman

g Independent University, Dhaka, Bangladesh

End-of-life care is an increasingly relevant topic due to advances in biomedical research and the establishment of new disciplines in evidence-based medicine and bioethics. Euthanasia and assisted suicide are two terms widely discussed in medicine, which cause displeasure on many occasions and cause relief on others. The evolution of these terms and the events associated with their study have allowed the evaluation of cases that have established useful definitions for the legal regulation of palliative care and public policies in the different health systems. However, there are still many aspects to be elucidated and defined. Based on the above, this review aimed to compile relevant historical aspects on the evolution of euthanasia and assisted suicide, which will allow understanding the use and research of these terms.

• • The history of euthanasia and assisted suicide has been traumatic.
• • The church and research have been decisive in the definition of euthanasia.
• • The legal framework on the use of euthanasia and assisted suicide has been strengthened.

1. Introduction

Euthanasia and assisted suicide are two topics discussed throughout history, mainly because they fall within the scope of life as a human right, which has been universally defended for many years [ 1 ]. However, the mean of the word euthanasia as good death generates conflicts at social, moral, and ethical levels. Mainly because death is a loss, it is difficult to understand it as something positive and; additionally, several historical events such as the Nazi experiments related the term euthanasia more to murder than to a kind and compassionate act [ 1 ]. More current texts mention that euthanasia is the process in which, through the use or abstention of clinical measures, the death of a patient in an incurable or terminal condition can be hastened to avoid excessive suffering [ 2 ].

The difference between euthanasia and assisted suicide is that in the latter, the patient takes the final action; however, both practices can be combined in the term assisted death [ 2 ]. At present, several countries authorize assisted death, including Holland, Luxembourg, and Canada [ 3 ]. Belgium and Colombia have regulations that decriminalize only euthanasia; other places where assisted suicide is legal are Switzerland and five states of the United America states, specifically Oregon, Vermont, Washington, California, and Montana [ 2 , 3 ]. Spain recently joined the list of countries that have legislated on euthanasia through the organic law March 2021 of March 24 that regulates euthanasia in that state in both public and private institutions [ 4 ]. The fact that more and more countries were joining the legislation on euthanasia and assisted suicide has brought to light the opinion of thinkers, politicians, philosophers, and physicians. Several nations have initiated discussions on the matter in their governmental systems. Latin America is trying to advance powerfully in this medical-philosophical field. Currently, in Chile, the “Muerte digna y cuidados paliativos” law, which seeks to regulate the issue of euthanasia and assisted suicide in the country, is being debated in Congress [ 5 ].

It is essential to know the point of view of physicians on euthanasia and assisted suicide, especially taking into account that these professionals who provide care and accompany patients during this moment, which, if approved, would involve the medical community in both public and private health systems. Although it seems easy to think that physicians have a position in favor of the act of euthanasia because they are in direct and continuous contact with end-of-life situations, such as palliative care, terminally ill, and critically ill patients. It is important to remember that the Hippocratic medical oaths taken at the time of graduation of professionals are mostly categorical in mentioning the rejection of euthanasia and assisted suicide [ 6 ]. Furthermore, it is also important to note that many of the oldest universities in the Western world originated through the Catholic Church; and just this creed condemns the practice of euthanasia and continues to condemn it to this day. This situation generates that many medical students in these schools have behaviors based on humanist principles under the protection of faith and religion and therefore reject the possibility of euthanasia [ 7 , 8 ].

The relevance of the topic and the extensive discussion that it has had in recent months due to the COVID-19 pandemic added to the particular interest of bioethics in this topic and the need to know the point of view of doctors and other health professionals on euthanasia and assisted suicide.

2. Origin and meaning of the term euthanasia

The word euthanasia derives from the Greek word “eu” which means good, and the word “thanatos” which means death; therefore, the etymological meaning of this word is “good death”. Over time the evolution of the meaning has varied; even as we will see below was considered a form of eradication of people categorized under the designation of leading a less dignified life. Assisted suicide is a condition in which the patient is the one who carries out the action that ends his life through the ingestion of a lethal drug but has been dispensed in the context of health care and therefore called assisted. This care is provided by a physician trained in the area. However, it requires the prior coordination of a multidisciplinary team and even the assessment by an ethics committee to determine that the patient is exercising full autonomy, free from coercion by the situation he/she is living and free from the fatalistic desires of a psychiatric illness [ 9 ]. In a more literary sense, the word euthanasia meaning of “giving death to a person who freely requests it in order to free himself from suffering that is irreversible and that the person himself considers intolerable” [ 9 ].

Some authors go deeper into the definition and consider that for the meaning of euthanasia, are necessary to consider elements that are essential in the word itself; such as the fact that it is an act that seeks to provoke death and that carried out to eliminate the suffering in the person who is dying. Other elements with a secondary character in the definition are the patient's consent (which must be granted respecting autonomy and freedom in the positive and negative sense; that means the fact must be not be coerced in any way). Another element is the terminal nature of the disease, with an irreversible outcome that generates precariousness and a loss of dignity. The third secondary element is the absence of pain of the death through the use of drugs such as high-potency analgesics, including opioids, high-potency muscle relaxants, and even anesthetic drugs. Finally, the last element is the health context in which the action is performed (essential in some legislations to be considered euthanasia) [ 10 ]. According to the World Health Organization, the union of these two components is the current definition of euthanasia, which describes as “the action performed by a person to cause the painless death of another subject, or not preventing death in case of terminal illness or irreversible coma. Furthermore, with the explicit condition that the patient must be suffering physical, emotional, or spiritual and that affliction is uncontrollable with conventional measures such as medical treatments, analgesics, among others; then the objective of euthanasia is to alleviate this suffering” [ 11 ]. Unfortunately, the term euthanasia has been misused over the years, and other practices have been named with this word. An example of this situation occurred during the Nazi tyranny when the word euthanasia concerned the murder of people with disabilities, mental disorders, low social status, or gay people. At that time, euthanasia was even a simultaneous practice to the Jewish genocide [ 11 ].

Not only has the term been misused; also exists an enormous variability of terms to refer to euthanasia. For example, the laws created to regulate euthanasia have different names around the world; in the Netherlands (Holland), the law that regulates this practice is known as the law of termination of life; in Belgium, it is called euthanasia law, in France, it is called euthanasia law too. In Oregon (USA), it is called the death with dignity act; in California, it is the end of life option act. In Canada is called the medical assistance in dying act. Victoria (Australia) is the voluntary assisted dying bill, but all these denominations refer to the already well-known term euthanasia [ 11 ].

3. Evolution of euthanasia and assisted suicide: digging into historical events

To understand the evolution and relevance of these concepts should analyze the history of euthanasia and assisted suicide; from the emergence of the term, going through its first manifestations in antiquity; mentioning the conceptions of great thinkers such as Plato and Hippocrates; going through the role of the Catholic Church; mainly in the Middle Age, where following the thought of St. Thomas Aquinas, self-induced death or death contemplated by own will, was condemned. Later, with the renaissance age and the resurgence of science, technology, and the arts, the term euthanasia made a transition to a form similar to what we know today from thinkers such as Thomas More and Francis Bacon. Finally, the first signs of eugenics were known in London, Sweden, Germany, and the United States in the twentieth century. There was a relationship with the term euthanasia that was later used interchangeably, especially in the Nazi regime, to denote a form of systemic murder that sought to eradicate those who were not worthy of living a life.

Since the sixties, with emblematic cases, the path towards the decriminalization of euthanasia began in some countries, especially concerning the cessation of extreme support measures in cases of irreversible illness or a terminal condition. The practice has progressed to the appearance of laws on euthanasia in several countries.

4. Euthanasia and assisted suicide in ancient times

In book III of Plato's “The Republic”, the author stated that those who live their lives amidst illnesses and medicines or who were not physically healthy should be left to die; implying that it was thought that people in these conditions suffered so much that their quality of life diminished, which seemed understandable to these thinkers. However, other authors such as Hippocrates and his famous Hippocratic oath sought the protection of the patient's life through medicine, especially in vulnerable health conditions prone to fatal outcomes. This Hippocratic oath is the same oath that permeates our times and constitutes an argument among those who mark their position against euthanasia and assisted suicide [ 12 , 13 ].

Other texts that collect thoughts of Socrates and his disciple Plato point out that it was possible and well understood to think of ceasing to live in the face of a severe illness; to consider death to avoid a long and torturous agony. This fact is compatible with the conception of current euthanasia since this is the end of this health care procedure [ 13 ].

In The Republic, the text by Plato, the physician Heroditus is also condemned for inventing a way to prolong death and over manage the symptoms of serious illnesses, which is currently known as distanasia or excessive treatment prolongs life. This kind of excessive treatment prolongs the sick person's suffering, even leading him to maintain biological signs present but in a state of alienation and absolute dependence on medical equipment such as ventilators and artificial feeding [ 13 ]. However, the strongest indication that Euthanasic suicide was encouraged in Greece lies in other thinkers such as the Pythagoreans, Aristotelians, and Epicureans who strongly condemned this practice, which suggests that it was carried out repeatedly as a method and was therefore condemned by these thinkers [ 12 , 13 ]. According to stoicism, the pain that exceeded the limits of what was humanly bearable was one of the causes for which the wise man separates himself from life. Referring to one of the nuances that euthanasia touches today, that is, at a point of elevated suffering, the dignity and essence of the person are lost, persisting only the biological part but in the absence of the person's well-being as a being. In this sense, Lucius Seneca said that a person should not love life too much or hate it; but that person should have a middle ground and end their life when they ceased to perceive life as a good, worthy, and longed-for event [ 1 , 12 ].

During the Roman Empire and in the territories under its rule, it was believed that the terminally ill who commit suicide had sufficient reasons to do so; so since suicide caused by impatience and lack of resolution to pain or illness was accepted, when there was no access to medicines. In addition, there was little development in medicine during that time, and many of the sick died without treatment [ 12 ]. This situation changed later with the emergence of the Catholic church; in this age, who attempted against own life, was deprived of burial in the ground. Saint Augustine said that the suicide was an abominable and detestable act; from 693 AD, anyone who attempted against his physical integrity was excommunicated. Rejecting to the individuals and their lineage, depriving them of the possibility of attending the funeral and even expelled from cities and stripped of the properties they owned [ 12 , 13 ].

4.1. Euthanasia and assisted suicide in the Middle Age

During the Middle Age, Catholicism governed the sciences, arts, and medicine; the sciences fell asleep. Due to this solid religious tendency and the persistence of Augustinian thought, suicide was not well seen. It was not allowed to administer a lethal substance to a person to end the suffering of a severe or terminal illness [ 9 , 12 ]. People who took their own lives at this time could not be buried “Christianly”; therefore, they did not have access to a funeral, nor to the accompaniment of their family in a religious rite. Physical suffering and pain were then seen as a path to glorification. Suffering was extolled as the form that god purified the sin, similar to the suffering that Jesus endured during his Calvary days. However, a contrary situation was experienced in battles; a sort of short dagger-like weapon was often used to finish off badly wounded enemies and thus reduce their suffering, thus depriving them of the possibility of healing and was called “mercy killing” [ 12 ].

5. Euthanasia in renaissance

With the awakening of science and philosophy, ancient philosophers' thoughts took up again, giving priority to man, the world, and nature, thus promoting medical and scientific development. In their discourse, Thomas More and Francis Bacon refer to euthanasia; however, they give a eugenic sense to the concept of euthanasia, similar to that professed in the book of Plato's Republic. It is precise with these phylosophers that the term euthanasia got its current focus, referring to the acceleration of the death of a seriously ill person who has no possibility of recovery [ 12 ]. In other words, it was during this period that euthanasia acquired its current meaning, and death began to be considered the last act of life. Therefore, it was necessary to help the dying person with all available resources to achieve a dignified death without suffering, closing the cycle of life that ends with death [ 13 , 14 ].

In his work titled “Utopia”, Thomas More affirmed that in the ideal nation should be given the necessary and supportive care to the dying. Furthermore, in case of extraordinary suffering, it can be recommended to end the suffering, but only if the patient agrees, through deprivation of food or with the administration of a lethal drug; this procedure must be known to the affected person and with the due permission of authorities and priests [ 12 , 13 ]. Later, in the 17th century, the theologian Johann Andreae, in his utopia “Christianopolis”, contradicts the arguments of Bacon and Moro, defending the right of the seriously ill and incurably ill to continue living, even if they are disturbed and alienated, advocating for the care based on support and indulgence [ 15 , 16 ]. Similarly, many physicians rejected the concepts of Plato, Moro, and Bacon. Instead, they focused on opposing euthanasia, most notably in the nineteenth century. For example, the physician Christoph Hufeland mentioned that the doctor's job was only to preserve life, whether it was a fate or a misfortune, or whether it was worth living [ 16 ].

5.1. Euthanasia in the 20th century

Before considering the relevant aspects of euthanasia in the 20th century, it is vital to highlight the manuscript by Licata et al. [ 17 ], which narrates two episodes of euthanasia in the 19th century. The first one happened in Sicily (Italy) in 1860, during the battle of Calatafimi, where two soldiers were in constant suffering, one because he had a serious leg fracture with gangrene, and the other with a gunshot wound. The two soldiers begged to be allowed to die, and how they were in a precarious place without medical supplies, they gave them an opium pill, which calmed them until they died [ 17 ]. The second episode reported by Licata et al. [ 17 ] was witnessed by a Swedish doctor named Alex Munthe; who evidenced the pain of many patients in a Parisian hospital. So he decided to start administering morphine to help people who had been seriously injured by wolves and had a poor prognosis; therefore, the purpose of opioid use was analgesia while death was occurring.

It is also important to highlight the manuscript entitled “Euthanasia” by S. Williams published in 1873 in “Popular Science Monthly”, a journal that published texts by Darwin, Edison, Pasteur, and Beecher. This text included the report for the active euthanasia of seriously ill patients without a cure, in which the physicians were advised to administer chloroform to these patients or another anesthetic agent to reduce the level of consciousness of the subject and speed up their death in a painless manner [ 16 ].

Understanding that euthanasia was already reported in the nineteenth century, years after, specifically in 1900, the influence of eugenics, utilitarianism, social Darwinism, and the new currents of thought in England and Germany; it began in various parts around the world, projects that considered the active termination of life, thus giving rise to euthanasia societies in which there were discussions between philosophers, theologians, lawyers, and medical doctors. Those societies discussed diverse cases, such as the tuberculous patient Roland Gerkan, who was considered unfit and therefore a candidate to be released from the world [ 16 ]. The scarcity of resources, famine, and wars were reasons to promote euthanasia as a form of elimination of subjects considered weak or unfit, as argued in texts such as Ernst Haeckel's. However, opponents to the practice, such as Binding and Hoche, defended the principle of free will in 1920 [ 16 ].

5.2. Euthanasia in the time of the Nazis

As mentioned above, the term euthanasia was misused during this period; approximately 275,000 subjects (as reported at the Nuremberg International Military Tribunal 1945–1946), who had some degree of physical or mental disability, were killed during Adolf Hitler's Euthanasia program [ 13 ]. However, the Nazis were not the first to practice a form of eugenics under the name of euthanasia, since the early 1900s in London had already begun the sterilization of the rejected, such as the blind, deaf, mentally retarded, people with epilepsy, criminals, and rapists. This practice spread to different countries like Sweden and the United States [ 13 , 16 ].

For the Nazis, euthanasia represented the systematic murder of those whose lives were unworthy of living [ 13 ]. The name given to this doctrine was “Aktion T4”. At first and by law, from 1939, the hospitals were obliged to account for all disabled newborns, which led to the execution of more than 5000 newborns utilizing food deprivation or lethal injection [ 12 , 18 ].

A year before that law, in 1938, one of the first known cases of euthanasia in children arose in Germany. That history called the story of child K, in which it was the father of the minor who asked Hitler in writing for euthanasia for his son because the child had a severe mental disability and critical morphic disorders. Hitler gave his consent to carry out the procedure on child K, and thus the program began to spread throughout the Aleman territory. Since then, physicians and nurses had been in charge of reporting the newborns with alterations, arising the “Kinderfachabteilugen” for the internment of children who would be sentenced to death after a committee's decision [ 12 , 18 , 19 ]. A list of diseases and conditions that were considered undesirable to be transmitted to Hitler's superior Aryan race was determined; thus, any child with idiocy, mongolism, blindness, deafness, hydrocephalus, paralysis, and spinal, head, and hip malformations were eligible for euthanasia [ 19 ].

Subsequently, the program was extended to adults with chronic illness, so those people were selected and transported by T4 personnel to psychiatric sanatoriums strategically located far away. There, the ill patients received the injection of barbiturate overdoses, and carbon monoxide poisoning was tested as a method of elimination, surging the widely known gas chamber of the concentration camp extermination; this situation occurred before 1940 [ 12 , 19 ]. Again, physicians and nurses were the ones who designated to the patients to receive those procedures; in this case, these health professionals supported Nazi exterminations. They took the patients to the sanatoriums, where psychiatrists evaluated them and designated with red color if they should die and with a blue color if they were allowed to live (this form of selection was similar in children) [ 12 , 13 , 19 ]. In this case, the pathologies considered as criteria for death were those generating disability such as schizophrenia, paralysis, syphilis with sequelae, epilepsy, chorea, patients with chronic diseases with many recent treatments, subjects of non-German origin and individuals of mixed blood [ 19 ]. Once in the sanatoriums, they were informed that they would undergo a physical evaluation and take a shower to disinfect themselves; instead, they were killed in gas chambers [ 12 , 13 ]. Despite the church's action in 1941 against Nazis and after achieving suspension of the Aktion T4 project; the Nazi supporters kept the practices secretly, resuming them in 1942, with the difference that the victims were killed by lethal injection, by an overdose of drugs, or left to starve to death, instead of the use of gas chambers. This new modified form of euthanasia, which did not include gas chambers, became known as “savage euthanasia” [ 12 , 13 , 19 ].

5.3. Euthanasia since the 1960s

In September 1945, trials began for crimes perpetrated by Nazi supporters; the victorious Allied forces conducted these trials at the end of the war. During these tribunals, cases of human experimentation were identified and the public exposure of the Nazi euthanasia program. After the Nuremberg trials and the abolition of Nazi experiments, a series of seven documents emerged, among which the Nuremberg code containing the ten basic principles for human research stood out [ 20 , 21 ].

After these judgments, biotechnology was accelerated, with the apparition of new techniques to intervene in the health-disease process. Additionally, the increase in life expectancy and the appearance of diseases that chronically compromise the state of health of people generated a change in the conception of the critically ill patient and the terminal state of life [ 20 , 21 ]. Cases such as Karen Ann Quinlan brought to the forefront the issue of euthanasia and precisely the control of extreme treatment measures. Karen, a young American woman, was left in a vegetative state due to severe neurological damage following alcohol and barbiturate intoxication. After six months in that state and under the guardianship of a Catholic priest, Karen's parents requested the removal of the artificial respirator, arguing that in her state of consciousness prior to the incident, she had stated that she disagreed with artificially maintaining life in comatose patients. The hospital refused to remove the ventilator, arguing the legal issues for the date, and the parents went to court, which in the first instance granted the hospital the right. Nevertheless, the New Jersey Supreme Court granted Karen Ann's right to die in peace and dignity. Despite the withdrawal of the artificial respirator, he continued to live until 1985, when he finally died [ [21] , [22] , [23] ].

Another important case was Paul Brophy, which also occurred in the United States. Paul was a firefighter in Massachusetts and went into a deep coma due to the rupture of a basilar artery aneurysm; initially, his family advocated for support measures but later requested the hospital to disconnect these means to allow death, as Paul had indicated when he was still conscious. The hospital refused to carry out this procedure, so the family went to court, where the removal of the support measures (gastrostomy) was initially denied. Hence, the family went to the state supreme court, achieving the transfer of Paul to another medical center where the gastrostomy was removed, leading to his death within a few days [ 23 ].

The case of Arthur Koestler, an influential English writer and activist diagnosed with Parkinson's disease and later with leukemia, who served as vice-president of the voluntary euthanasia society (Exit) and wrote a manual book with practical advice for euthanasia called “Guide to Self-Liberation”. He stood out because he applied one of his advice and ingested an overdose of barbiturates, causing his self-death. According to his writings, Koestler was not afraid of death but of the painful process of dying [ 23 ]. In this sense, it was a relevant case because it involved someone who held an important position in an association that advocated euthanasia, in addition to being the author of several works, which made him a recognized public figure [ 23 ].

Baby Doe was a case that also occurred in the United States; it was a small child with Down syndrome who had a tracheoesophageal fistula and esophageal atresia; in this case, surgery was necessary. On the advice of the obstetrician, the parents did not allow surgery, so the hospital managers took the case before a judge who ruled that parents could decide to perform or not the surgery. The case was appealed before a county judge who upheld the parents' power to make the decision, in the course of which the case became public and many families offered to take care of the child; however, before the case reached the supreme court, the child died at six days of age [ 23 ].

In the case of Ingrid Frank, a German woman who was in a quadriplegic state by a traffic accident, who initially sought rehabilitation but later insisted on being allowed to die; it was provided with a drink containing a cyanide solution that she drank. At the same time, she was filmed, which shows a kind of assisted suicide. For that reason, this is another case that deals with this issue and is important to know as background in the development of euthanasia and assisted suicide [ 22 , 23 ].

6. Current and future perspectives

The definition of brain death, the rational use of the concept of euthanasia and assisted suicide, and scientific literacy are the objectives of global bioethics to regulate euthanasia and assisted suicide, which can be accessible in all health systems [ [24] , [25] , [26] , [27] , [28] , [29] , [30] ]. End-of-life care will continue to be a subject of debate due to the struggle between biomedical principles, the different existing legal frameworks, and the general population's beliefs. Medical education and preparation in the perception of death, especially of a dignified death, seems to be the pillar of the understanding of the need to develop medical-legal tools that guarantee the integrity of humans until the end of their existence [ 31 , 32 ]. This is the reason why the new generations of physicians must be trained in bioethics to face these ethical conflicts during the development of their professional careers.

In addition, although the conception of bioethics belongs to the Western world, it is crucial to take into account the point of view of other cultures and creeds, for example, a study carried out in Turkey, where nursing students were questioned, found that many of them understood the reasons for performing euthanasia; however, they know that Islam prohibits it, as well as its legislation, and therefore they would not participate in this type of procedure [ 33 ]. Furthermore, Christianism and Islam prohibit euthanasia, but Judaism also prohibits it; in general, the so-called Abrahamic religions are contrary to any form of assisted death, whether it is active euthanasia, passive, or assisted suicide [ 34 ].

7. Conclusiones

The history and evolution of euthanasia and assisted suicide have been traumatic throughout human history. The church, politics, and biomedical research have been decisive in defining these concepts. Over the years, the legal framework and bioethical concepts on euthanasia have been strengthened. However, there is still much work to educate the general population and health professionals about end-of-life care and dignified death.

It is also important to remember that life is a concept that goes beyond biology. Currently, bioethics seeks to prioritize the concept of dignity, which must be linked to the very definition of life. Although the phrase is often heard that it is not necessary to move to be alive, what is important is that person feels worthy even if they have limited movement. The person's treatment must be individualized in bioethics since each individual is a unique unit. Therefore, medical paternalism must be abandoned. Instead, the subject must be more involved to understand their context and perception of life and dignity.

Ethical approval

It is not necessary.

Sources of funding for your research

Author contribution.

All authors equally contributed to the analysis and writing of the manuscript.

Provenance and peer review

Not commissioned, externally peer reviewed.

Research registration Unique Identifying number (UIN)

• 1. Name of the registry: Not applicable.
• 2. Unique Identifying number or registration ID: Not applicable.
• 3. Hyperlink to your specific registration (must be publicly accessible and will be checked): Not applicable.

Sabrina Rahman. Independent University, Dhaka, Bangladesh. [email protected] .

Declaration of interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

• Oxford Thesis Collection
• CC0 version of this metadata

The right to receive assistance in suicide and euthanasia, with particular reference to the law of the United States

Whether to legalize assisted suicide and euthanasia is among the most hotly debated legal and public policy issues today in the United States, as it is in many countries. In this Thesis, I first (in Chapters I and II) isolate the critical questions in this debate, the answers to which will likely determine the fate of assisted suicide and euthanasia in America's courts and legislatures: Is there historical precedent for allowing the practices? Do fairness concerns dictate that we ...

Email this record

Please enter the email address that the record information will be sent to.

Please add any additional information to be included within the email.

Cite this record

Chicago style, access document.

• MS.D.Phil.c.19040_ocr.pdf (pdf, 381.5MB)

Why is the content I wish to access not available via ORA?

Content may be unavailable for the following four reasons.

• Version unsuitable We have not obtained a suitable full-text for a given research output. See the versions advice for more information.
• Recently completed Sometimes content is held in ORA but is unavailable for a fixed period of time to comply with the policies and wishes of rights holders.
• Permissions All content made available in ORA should comply with relevant rights, such as copyright. See the copyright guide for more information.
• Clearance Some thesis volumes scanned as part of the digitisation scheme funded by Dr Leonard Polonsky are currently unavailable due to sensitive material or uncleared third-party copyright content. We are attempting to contact authors whose theses are affected.

Alternative access to the full-text

Request a copy.

We require your email address in order to let you know the outcome of your request.

Provide a statement outlining the basis of your request for the information of the author.

Please note any files released to you as part of your request are subject to the terms and conditions of use for the Oxford University Research Archive unless explicitly stated otherwise by the author.

Contributors

Bibliographic details, item description, terms of use, views and downloads.

If you are the owner of this record, you can report an update to it here: Report update to this record

Report an update

We require your email address in order to let you know the outcome of your enquiry.

• Research article
• Open access
• Published: 11 September 2019

Public and physicians’ support for euthanasia in people suffering from psychiatric disorders: a cross-sectional survey study

• Kirsten Evenblij   ORCID: orcid.org/0000-0002-5984-4959 1 ,
• H. Roeline W. Pasman 1 ,
• Agnes van der Heide 2 ,
• Johannes J. M. van Delden 3 &
• Bregje D. Onwuteaka-Philipsen 1  

BMC Medical Ethics volume  20 , Article number:  62 ( 2019 ) Cite this article

12k Accesses

20 Citations

1 Altmetric

Metrics details

Although euthanasia and assisted suicide (EAS) in people with psychiatric disorders is relatively rare, the increasing incidence of EAS requests has given rise to public and political debate. This study aimed to explore support of the public and physicians for euthanasia and assisted suicide in people with psychiatric disorders and examine factors associated with acceptance and conceivability of performing EAS in these patients.

A survey was distributed amongst a random sample of Dutch 2641 citizens (response 75%) and 3000 physicians (response 52%). Acceptance and conceivability of performing EAS, demographics, health status and professional characteristics were measured. Multivariable logistic regression analyses were performed.

Of the general public 53% were of the opinion that people with psychiatric disorders should be eligible for EAS, 15% was opposed to this, and 32% remained neutral. Higher educational level, Dutch ethnicity, and higher urbanization level were associated with higher acceptability of EAS whilst a religious life stance and good health were associated with lower acceptability. The percentage of physicians who considered performing EAS in people with psychiatric disorders conceivable ranged between 20% amongst medical specialists and 47% amongst general practitioners. Having received EAS requests from psychiatric patients before was associated with considering performing EAS conceivable. Being female, religious, medical specialist, or psychiatrist were associated with lower conceivability. The majority (> 65%) of the psychiatrists were of the opinion that it is possible to establish whether a psychiatric patient’s suffering is unbearable and without prospect and whether the request is well-considered.

The general public shows more support than opposition as to whether patients suffering from a psychiatric disorder should be eligible for EAS, even though one third of the respondents remained neutral. Physicians’ support depends on their specialization; 39% of psychiatrists considered performing EAS in psychiatric patients conceivable. The relatively low conceivability is possibly explained by psychiatric patients often not meeting the eligibility criteria.

Peer Review reports

The Dutch euthanasia law (2002) is widely accepted by the general public and health care professionals in The Netherlands [ 1 , 2 ]. In 2016, 88% of the Dutch general public supported the euthanasia law. In that same year, 57% of the Dutch physicians had at least once performed euthanasia or assisted suicide (EAS), and another 24% who had never performed EAS found it conceivable to do so in the future [ 3 ]. According to the euthanasia law, a person must be suffering unbearably from a medically classifiable disease to qualify for EAS. The law does not differentiate between somatic and psychiatric causes of suffering as long as the due care criteria are met [ 4 , 5 ]. However, research has shown that physicians’ support for EAS is associated with cause of suffering [ 6 , 7 ]. In 2011, 34% of the physicians could imagine performing EAS in patients with psychiatric disorders compared to over 80% in patients with cancer or another severe physical disease [ 7 ]. Of the general public, 28% found EAS acceptable in case of chronic depression [ 2 ]. In practice, 5% of EAS requests from people with psychiatric disorders were granted, corresponding to 1% of all 6585 reported EAS cases in the Netherlands [ 8 , 9 ].

Recently, there has been much attention for EAS in people with psychiatric disorders. The increasing incidence of EAS requests by psychiatric patients and documentaries illustrating the lives and suffering of people with psychiatric disorders requesting EAS broadcasted on national television have given rise to public and political debate, both nationally and internationally [ 10 , 11 , 12 ]. This study aims to explore support of the public and physicians for EAS in people with psychiatric disorders and examine factors associated with acceptance and conceivability of performing EAS in these patients. The following research questions will be addressed: (i) does the general public consider EAS in patients with psychiatric disorders acceptable, (ii) do physicians consider performing EAS in these patients conceivable, and (iii) which demographic and health or professional characteristics are associated with acceptance and conceivability of performing EAS?

Design and participants

In the context of the third evaluation of the Dutch Euthanasia act, a cross-sectional study was conducted amongst the general public and physicians in the Netherlands. Data were collected between May and September 2016, during this time two reminders were sent. This study did not require review by an ethics committee under the Dutch Medical Research Involving Human Subjects Act, as it did not involve imposing any interventions or actions and no patients were involved [ 13 ].

General public

An online questionnaire was distributed amongst the members of the CentERpanel which comprises 2641 households that were randomly selected from the pool of national postal delivery addresses [ 14 ]. All members aged above 16 years were invited to complete our online questionnaire. Participants who did not fill out any question about EAS were excluded ( n  = 5). Demographic characteristics were provided by CentERpanel.

A 12-page written questionnaire was sent to a random sample of 1100 general practitioners, 400 elderly care physicians, 1000 medical specialists (working in hospital) and 500 psychiatrists. Inclusion criteria were (i) having been working in adult patient care in the Netherlands for the last year and (ii) having a registered work or home address in the national databank of registered physicians (IMS Health). 343 physicians did not meet the criteria.

Questionnaire

Public acceptance of EAS in case of psychiatric suffering was operationalized as the level of agreement with following statement: “ I am of the opinion that patients with a psychiatric disorder should be eligible for EAS in case they ask for it” , ranging from 1 (completely agree) to 5 (completely disagree). This statement was part of a longer list of statements assessing the opinions with regard to eligibility for EAS including other specific settings / medical conditions. We did not specify whether the psychiatric disorder was the main motivation for the EAS request. Although this is the most straightforward interpretation of the question in this context, there may have been some ambiguity as to whether the psychiatric suffering was secondary to a primary somatic condition leading to the EAS request.

Other measurements included demographics (gender, age, household composition, educational level, ethnicity, considering philosophy important, urbanization level living area), health status (perceived general health, presence of depression) and EAS-related characteristics (experience with a relative requesting for EAS, opinion about the Dutch euthanasia law, and knowing that people with psychiatric disorders are eligible for EAS). Using a vignette, respondents were also asked (i) whether they agreed with the performance of EAS by a physician in case of treatment-resistant depression in a middle-aged women, and (ii) whether they would ask for EAS themselves if they would be in the patient’s position (Additional file  1 : Figure S1).

All physicians were asked whether they found it conceivable (yes/no) that they would ever perform EAS in patients with psychiatric disorders. This specification, “in patients with psychiatric disorders”, was omitted for psychiatrists as they presumably do not receive primary EAS requests from patients without psychiatric disorders. In the Netherlands, patients requesting EAS without a psychiatric disorder will usually not discuss their primary request with a psychiatrist, but rather with their general practitioner, although a psychiatrist might be consulted as a second opinion. Other measurements included demographics (gender, age, religious beliefs) and professional characteristics (specialty, years of experience, having completed palliative care training, being a palliative care consultant, being trained as independent consultant for the EAS procedure (SCEN-physician), ever having received/granted an EAS request either or not from patients with psychiatric disorders). Eight additional questions concerning opinions regarding EAS in people with psychiatric disorders were added to the questionnaire for psychiatrists.

Statistical analyses

First, univariable logistic regression analyses were performed to analyze which factors (demographics and health status) were associated with public acceptance of EAS. The five-point Likert Scale was dichotomized into EAS acceptable (agree or completely agree) and EAS not acceptable or neutral (disagree, completely disagree, and neutral). Next, all demographic and health factors were included in multivariable analysis. Manual stepwise backward selection (removal at p  > 0.10) was performed to identify the variables strongest associated with public acceptance of EAS. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated.

To analyse which demographics and professional factors were associated with conceivability of performing EAS an identical approach was applied starting with univariable logistic regression analyses followed by multivariable analyses using a manual stepwise backward selection. The variables ‘SCEN-physician’ and ‘ever having received/granted a request’ were not entered into the multivariable model due to collinearity with other variables in the model (age and specialty).

A total of 1965 eligible CentERpanel members (74%) responded. Table  1 provides an overview of their background characteristics. Of the respondents, 50.5% were male and 20.7% were 70 years or older. The majority (73.6%) were living with a partner and were Dutch (97.7%). Most (82.7%) respondents perceived their health to be (very) good and 4 % had a depression (self-reported). Of the people who supported the euthanasia law, 76.4% could imagine to request EAS themselves. A substantial group (38.1%) did not know whether or not psychiatric patients are eligible for EAS and 27.3% incorrectly assumed that they are not.

Of the 2657 eligible physicians, 1374 responded (52%). 20 were excluded because their specialty was unknown. The respondents’ background characteristics are shown in Table  2 . 78% of general practitioners, 47.8% of elderly care physicians, 22.7% of medical specialists and 3.7% of psychiatrists had ever performed EAS in general, i.e. not specifically in people with psychiatric disorders. 16.3% of the psychiatrists had received EAS requests from one or more patients with psychiatric disorders in the last year. General practitioners, elderly care physicians, and medical specialists were less likely (0.6–4.6%) to have received such a request.

The acceptability and conceivability of EAS in people with psychiatric disorders

Just over half of the general public (53%) were of the opinion that people with psychiatric disorders should be eligible for EAS in case they ask for it (Figure  1 ) and 15% strongly opposed this. Reviewing the hypothetical case of a middle-aged patient with treatment-resistant depression who asks her psychiatrist for physician-assisted suicide, 39% of the general public agreed with providing EAS in this case, 31% did not know whether or not to agree and 30% disagreed. 29% reported that they would ask a physician to end their own life if they would be in the patient’s position, 20% would not and 51% did not know (Additional file 1 : Figure S1). Of the physicians, general practitioners were most likely to consider performing EAS in people with psychiatric disorders conceivable (47%), followed by elderly care physicians (45%) and psychiatrists (39%) (Fig.  1 ). Medical specialists were least likely to find it conceivable (20%).

Public acceptance of EAS in people with psychiatric disorders and physician’s conceivability of performing EAS in these patients.* *General public: 19 missing (1.0%), physicians: 109 missing (8.1%). General practitioners, medical specialists and elderly care physicians were asked whether they found it conceivable that they would perform EAS in patients with psychiatric disorders. This specification, ‘in patients with psychiatric disorders’, was omitted for psychiatrists, as they presumably do not receive EAS requests from patients without psychiatric disorders

Determinants of public acceptance of EAS in case of psychiatric suffering

In univariable analyses age, educational level, ethnicity, importance of religious life-stance, and urbanization level showed significant associations with acceptance of EAS in case of psychiatric suffering (Table  3 ). The multivariable model showed that respondents who had a middle (OR 1.292 [1.017–1.641]) or higher educational level (OR 1.914 [1.517–2.416]), a Dutch ethnicity (OR 1.958 [1.026–3.736]), or who were living in a highly urbanized area (OR 1.267 [1.024–1.567]) were more likely to accept EAS. Those who deemed their religious life-stance important (OR 0.276 [0.215–0.354]) or who had a (very) good health (OR 0.754 [0.586–0.969]) were less likely to accept it.

Determinants of physicians’ conceivability of performing EAS

In univariable analyses age, religion, specialty, palliative care training, SCEN-physician, having performed EAS, and having received an EAS request from a psychiatric patient in the last year showed significant associations with conceivability of performing EAS in case of psychiatric suffering (Table  4 ). The multivariable model showed that physicians who had received EAS requests from psychiatric patients were more likely to find performing EAS conceivable (OR 1.828 [1.074–3.113]). Physicians who were female (OR 0.769 [0.599–0.988]), religious (OR 0.419 [0.320–0.549]), a medical specialist (OR 0.242 [0.171–0.340]), or a psychiatrist (OR 0.651 [0.455–0.932]) were less likely to find it conceivable.

The opinion of psychiatrists with regard to EAS in people with psychiatric disorders

The majority of the psychiatrists were of the opinion that it is possible to assess whether a psychiatric patient’s suffering is unbearable and without prospect of improvement (69.8%), and to establish whether a wish to die of a psychiatric patient is well-considered or the consequence of an underlying pathology (65.4%) (Additional file  2 : Table S1). These two assessments are part of the due care criteria, determining a patient’s eligibility for EAS. Also, 64.2% stated that providing assistance with suicide is compatible with a care provider relationship. Twenty-two percent of the psychiatrists were of the opinion that when deciding whether or not to grant a request, psychiatrists need to take account of the possibility that an effective therapeutic treatment might become available in future, and one fourth were of the opinion that physician assisted-suicide should not be used to prevent suicide.

Our results reveal that 53% of the general public were of the opinion that people suffering from psychiatric disorders should be eligible for EAS. Higher educational level, Dutch ethnicity, and higher urbanization level were associated with higher acceptance of EAS whilst a religious life stance and good health were associated with lower acceptance. Less than half of the physicians considered it conceivable to perform EAS in people with psychiatric disorders, especially psychiatrists and medical specialists showed restraint. Having received EAS requests from psychiatric patients before was associated with higher conceivability of performing EAS in case of psychiatric suffering. Being female, religious, medical specialist, or psychiatrist were associated with lower conceivability.

Comparing our results with results of a previous study (2010) using the same vignette demonstrates that the percentage of the general public supporting EAS in case of treatment-resistant depression has increased from 28% in 2010 [ 2 ] to 40% in 2016. Compared with 2010, general practitioners’ conceivability of performing EAS in case of psychiatric suffering increased as well, though the conceivability of medical specialists and elderly care physicians remained the same [ 7 ]. Our findings are in line with an (inter) national trend towards acceptance of EAS in general [ 2 , 15 , 16 , 17 , 18 ]. Surprisingly, psychiatrists’ conceivability of performing EAS decreased, from 47% in 1995 [ 19 ] to 39% in 2016. The establishment of the End-of-life clinic in 2012 may have contributed to this [ 11 ]. The clinic, which works with mobile teams of qualified physicians and nurses, was founded to provide EAS to patients who meet the statutory due care criteria but whose own physician does not feel competent or feels reluctant to provide EAS. Psychiatrists might be more inclined to give in to their reluctance to perform EAS now they can refer their patients to the End-of-life clinic. It is also possible that the increasing number of EAS requests to psychiatrists caused them to ponder their own position and made them more aware of the medical and ethical difficulties in this delicate matter resulting in more reluctance.

Corroborating the results of a previous study, this study showed that physicians’ specialty was associated with the conceivability of performing EAS in case of psychiatric suffering [ 7 ]. Medical specialists and psychiatrists were significantly less likely to consider performing EAS, possibly because they have less experience with EAS in general; i.e. they receive fewer requests and less frequently perform EAS [ 3 ]. The low conceivability among psychiatrists to perform EAS may also be related to their opinions regarding EAS in psychiatric practice. Based on our results, psychiatrists’ reticence to perform EAS seems to be caused neither by the conviction that assessing the capacity and suffering of patients is impossible, nor by the conviction that providing EAS is incompatible with a psychiatric care relationship. Their reticence rather may be explained by doubts about whether or not there still is prospect of improvement [ 9 ]. The unpredictability of the course and prognosis of psychiatric disorders and the large variety of treatment options for psychiatric disorders make it difficult to establish that there are no other reasonable treatment alternatives and that euthanasia is indeed the only option [ 20 , 21 , 22 , 23 ]. In addition, our results showed that one fifth of psychiatrists was of the opinion that psychiatrists should consider the possibility that effective treatment might become available in the future when deciding whether or not to grant a request. The Dutch Euthanasia Code and the guideline of the Dutch Association, however, do not require physicians to consider this solely theoretical possibility, but state that treatment should be effective ‘within the foreseeable future’. [ 23 , 24 ]

Strengths and limitations

The most important strengths of this study are the nationwide sample of the general public and physicians, representing different specialties, and the substantial response, especially of the general public. A possible limitation is selection bias. Although the CentERpanel aims to be representative of the Dutch general public, a comparison with the Dutch population register data of Statistics Netherlands [ 25 ] showed that the study participants were slightly older and higher educated, and that migrants were underrepresented. Furthermore, it is possible that the interpretation of the concept of ‘conceivability’ caused bias. Medical specialists may simply not consider it conceivable to perform EAS in patients whose suffering is solely of psychiatric nature because they are not responsible for the care of these patients. However, this does not hold for psychiatrists. Their reticence is most likely based on substantive reasons.

The general public shows more support (53%) than opposition (15%) as to whether patients suffering from a psychiatric disorder should be eligible for EAS, even though one third of the respondents remained neutral. Physicians’ support depends on their specialization. General practitioners and elderly care specialists are most positive; about half considers performing EAS conceivable. Fewer medical specialists (20%) and psychiatrist (39%) consider performing EAS conceivable. Although, over the years, conceivability increased for general practitioners and remained stable for medical specialists and elderly care specialists, it decreased amongst psychiatrists. As the majority of the psychiatrists were of the opinion that it is possible to establish whether a psychiatric patient’s suffering is unbearable and without prospect and whether the request is well-considered, the relatively low conceivability of performing EAS is possibly explained by psychiatric patients often not meeting the eligibility criteria as has been shown previously [ 9 ].

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Euthanasia and assisted suicide

A physician who is trained as independent consultant for the EAS procedure (SCEN: Support and Consultation on Euthanasia in the Netherlands)

Rietjens JA, van der Heide A, Onwuteaka-Philipsen BD, et al. A comparison of attitudes towards end-of-life decisions: survey among the Dutch general public and physicians. Soc Sci Med. 2005;61(8):1723–32.

Article   Google Scholar  

Kouwenhoven PS, Raijmakers NJ, van Delden JJ, et al. Opinions of health care professionals and the public after eight years of euthanasia legislation in the Netherlands: a mixed methods approach. Palliat Med. 2013;27(3):273–80.

Onwuteaka-Philipsen B, Legemaate J, van der Heide A, et al. Derde evaluatie Wet toetsing levensbeëindiging op verzoek en hulp bij zelfdoding [Third evaluation of the Termination of Life on Request and Assisted Suicide Act]. Den Haag: ZonMw; 2017.

Google Scholar  

Hoge Raad. Uitspraak Hoge Raad, de zaak-Brongersma 24 december 2002. Available from: https://uitspraken.rechtspraak.nl/inziendocument?id=ECLI:NL:PHR:2002:AE8772 .

Wet toetsing levensbeëindiging op verzoek en hulp bij zelfdoding (Act on termination of life on request and assisted suicide) [statute on the Internet] 2001 [Cited: 08-01-2018.]. Available from: http://wetten.overheid.nl/BWBR0012410/2014-02-15 .

van Tol D, Rietjens J, van der Heide A. Judgment of unbearable suffering and willingness to grant a euthanasia request by Dutch general practitioners. Health Policy. 2010;97(2–3):166–72.

Bolt EE, Snijdewind MC, Willems DL, et al. Can physicians conceive of performing euthanasia in case of psychiatric disease, dementia or being tired of living? J Med Ethics. 2015;41(8):592–8.

Regionale Toetsingscommissie Euthanasie. Jaarverslag 2017 [Internet] [Cited: 12-06-2018.]. Available from: https://www.euthanasiecommissie.nl/de-toetsingscommissies/uitspraken/jaarverslagen/2017/mei/17/jaarverslag-2017 .

Evenblij K, Pasman HRW, Pronk R, et al. Euthanasia and physician-assisted suicide in patients suffering from psychiatric disorders: a cross-sectional study exploring the experiences of Dutch psychiatrists. BMC Psychiatry. 2019;19(1):74.

Froggatt K, Vaughan S, Bernard C, et al. Advance care planning in care homes for older people: an English perspective. Palliat Med. 2009;23(4):332–8.

‘Psychiaters te bang bij euthanasie’. Psychiaters krijgen vanuit eigen kring kritiek op hoe ze omgaan met euthanasieverzoeken. NRC [newspaper on the Internet]. 26-10-2017 [cited 19-07-2018]. Available from: https://www.nrc.nl/nieuws/2017/10/26/psychiaters-te-bang-bij-euthanasie-13691181-a1578871 .

A woman’s final Facebook message before euthanasia: ‘I’m ready for my trip now...’ Assisted suicides in the Netherlands include a 29-year-old who had nothing wrong with her physically. The Guardian [newspaper on the Internet]. 2018 [cited 19-07-2018]. Available from: https://www.theguardian.com/society/2018/mar/17/assisted-dying-euthanasia-netherlands .

Centrale Commissie Mensgebonden Onderzoek [Central Committee on Research Involving Human Subjects]. 2017 [Cited: 09-02-2018.]. Available from: http://www.ccmo.nl/en .

CentERdata. [Cited: 22-05-2018.]. Available from: https://www.centerdata.nl/en/databank/centerpanel-data-0 .

Lee CH, Duck IM, Sibley CG. Demographic and psychological correlates of new Zealanders support for euthanasia. N Z Med J. 2017;130(1448):9–17.

Montague T, Nemis-White J, Aylen J, et al. Public and professional insights on end-of-life care: results of the 2016 health Care in Canada Survey. Healthc Q. 2017;20(2):18–21.

Smets T, Cohen J, Bilsen J, et al. Attitudes and experiences of Belgian physicians regarding euthanasia practice and the euthanasia law. J Pain Symptom Manag. 2011;41(3):580–93.

Dierickx S, Deliens L, Cohen J, et al. Euthanasia in Belgium: trends in reported cases between 2003 and 2013. CMAJ. 2016;188(16):E407–E14.

Groenewoud JH, van der Maas PJ, van der Wal G, et al. Physician-assisted death in psychiatric practice in the Netherlands. N Engl J Med. 1997;336(25):1795–801.

Holma KM, Holma IA, Melartin TK, et al. Long-term outcome of major depressive disorder in psychiatric patients is variable. J Clin Psychiatry. 2008;69(2):196–205.

Vergunst FK, Fekadu A, Wooderson SC, et al. Longitudinal course of symptom severity and fluctuation in patients with treatment-resistant unipolar and bipolar depression. Psychiatry Res. 2013;207(3):143–9.

Blikshavn T, Husum TL, Magelssen M. Four reasons why assisted dying should not be offered for depression. J Bioeth Inq. 2017;14(1):151–7.

Berghmans RLPHJ, Legemaate J, Nolen WA, Polak F, Scherders MJWT, Tholen AJ. Richtlijn verzoek om hulp bij zelfdoding door patienten met een psychiatrische stoornis. Utrecht: De Tijdstroom; 2009.

Euthanasia Code 2018. De toetsingspraktijk toegelicht. Den Haag. 2018 [Cited: 11-09-2018.]. Available from: https://www.euthanasiecommissie.nl/uitspraken/brochures/brochures/euthanasiecode/2018/euthanasiecode2018 .

Statistics Netherlands. [Cited: 22-05-2018.]. Available from: https://www.cbs.nl/en-gb/society/population .

Download references

Acknowledgements

The authors are grateful to all study participants for their contributions and to Inssaf El Hammoud for collecting the CentERpanel data.

This study was funded by the Netherlands Organization for Health Research and Development (ZonMw, project number 3400.8002). The funding source had no role in the design of the study, the collection, analysis and interpretation of data, the writing of the manuscript, and the decision to submit the manuscript for publication.

Author information

Authors and affiliations.

Department of Public and Occupational Health, Amsterdam Public Health research institute, Amsterdam UMC, Vrije Universiteit Amsterdam, P.O. Box 7057, 1007, MB, Amsterdam, The Netherlands

Kirsten Evenblij, H. Roeline W. Pasman & Bregje D. Onwuteaka-Philipsen

Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands

Agnes van der Heide

Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, UMC Utrecht, Utrecht, The Netherlands

Johannes J. M. van Delden

You can also search for this author in PubMed   Google Scholar

Contributions

KE, RP, AH, JD and BO designed the study. KE collected the data and performed data management and statistical analysis. KE, RP, AH, JD and BO interpreted the data. KE prepared the initial draft of this manuscript. RP, AH, JD and BO critically revised the manuscript for intellectual content and commented on subsequent drafts of the manuscript. KE, RP, AH, JD and BO contributed to the final draft of the manuscript and gave final approval for submission.

Corresponding author

Correspondence to Kirsten Evenblij .

Ethics declarations

Ethics approval and consent to participate.

This study did not require review by an ethics committee under the Dutch Medical Research Involving Human Subjects Act, since it did not involve imposing any interventions or actions and no patients were involved. Informed consent was assumed on return of the survey.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Additional file 1: figure s1..

Vignette: Mrs Langezaal is middle-aged. She is physically well, but mentally ill. She has been suffering from severe depression for years and her psychiatrist’s treatment has not worked. She regularly tells her physicians that she wants to die. She already has had one unsuccessful suicide attempt. Mrs Langezaal visits her psychiatrist and asks for physician-assisted suicide. The psychiatrist decides to honour her request and performs physician-assisted suicide.* * The general public was asked to reflect on this vignette. Number of missings: 22 (1.1%). (JPG 295 kb)

Additional file 2: Table S1.

Opinions of psychiatrists with regard to EAS in people with psychiatric disorders. (DOCX 18 kb)

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/ ), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Cite this article.

Evenblij, K., Pasman, H.R.W., van der Heide, A. et al. Public and physicians’ support for euthanasia in people suffering from psychiatric disorders: a cross-sectional survey study. BMC Med Ethics 20 , 62 (2019). https://doi.org/10.1186/s12910-019-0404-8

Download citation

Received : 15 February 2019

Accepted : 02 September 2019

Published : 11 September 2019

DOI : https://doi.org/10.1186/s12910-019-0404-8

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Assisted suicide
• Epidemiology
• Medical decision making
• Psychiatric disorders
• Public opinion

BMC Medical Ethics

ISSN: 1472-6939

• General enquiries: [email protected]

DSpace JSPUI

Dspace preserves and enables easy and open access to all types of digital content including text, images, moving images, mpegs and data sets.

• Newcastle University eTheses
• Newcastle University
• Faculty of Humanities and Social Sciences
• Newcastle Law School

Items in DSpace are protected by copyright, with all rights reserved, unless otherwise indicated.

• - Google Chrome

Intended for healthcare professionals

• My email alerts
• BMA member login
• Username * Password * Forgot your log in details? Need to activate BMA Member Log In Log in via OpenAthens Log in via your institution

Search form

• Advanced search
• Search responses
• Search blogs
• News & Views
• Euthanasia and...

Euthanasia and assisted dying: the illusion of autonomy—an essay by Ole Hartling

Read our coverage of the assisted dying debate.

• Related content
• Peer review
• Ole Hartling , former chairman
• Danish Council of Ethics, Denmark
• hartling{at}dadlnet.dk

As a medical doctor I have, with some worry, followed the assisted dying debate that regularly hits headlines in many parts of the world. The main arguments for legalisation are respecting self-determination and alleviating suffering. Since those arguments appear self-evident, my book Euthanasia and the Ethics of a Doctor’s Decisions—An Argument Against Assisted Dying 1 aimed to contribute to the international debate on this matter.

I found it worthwhile to look into the arguments for legalisation more closely, with the hope of sowing a little doubt in the minds of those who exhibit absolute certainty in the matter. This essay focuses on one point: the concept of “autonomy.”

(While there are several definitions of voluntary, involuntary, and non-voluntary euthanasia as well as assisted dying, assisted suicide, and physician assisted suicide, for the purposes of brevity in this essay, I use “assisted dying” throughout.)

Currently, in richer countries, arguments for legalising assisted dying frequently refer to the right to self-determination—or autonomy and free will. Our ability to self-determine seems to be unlimited and our right to it inviolable. The public’s response to opinion poll questions on voluntary euthanasia show that people can scarcely imagine not being able to make up their own minds, nor can they imagine not having the choice. Moreover, a healthy person answering a poll may have difficulty imagining being in a predicament where they simply would not wish to be given the choice.

I question whether self-determination is genuinely possible when choosing your own death. In my book, I explain that the choice will always be made in the context of a non-autonomous assessment of your quality of life—that is, an assessment outside your control. 1

All essential decisions that we make are made in relation to other people. Our decisions are affected by other people, and …

Log in using your username and password

BMA Member Log In

If you have a subscription to The BMJ, log in:

• Need to activate
• Log in via institution
• Log in via OpenAthens

Log in through your institution

Subscribe from £184 *.

Subscribe and get access to all BMJ articles, and much more.

* For online subscription

Access this article for 1 day for: £50 / $60/ €56 ( excludes VAT )

You can download a PDF version for your personal record.

Buy this article

• My Shodhganga
• Receive email updates
• Edit Profile

Shodhganga : a reservoir of Indian theses @ INFLIBNET

• Shodhganga@INFLIBNET
• The University of Burdwan
• Department of Law

Items in Shodhganga are licensed under Creative Commons Licence Attribution-NonCommercial-ShareAlike 4.0 International (CC BY-NC-SA 4.0).