Attitudes and Practices of Euthanasia and Physician-Assisted Suicide in the United States, Canada, and Europe

T he ethics and legality of euthanasia and physician-assistedsuicide (PAS) continue to be controversial.1 In the early 20thcentury, multiple attempts at legalization were defeated.1 Recently, several countries have legalized the practices, and a num- ber of countries are considering legalization. At least since the late 1940s, polling agencies and others have assessed the public’s sup- port for euthanasia and PAS. Since the 1990s, researchers have stud- ied these practices and their consequences. This Special Commu- nication provides an overview of the legal status of euthanasia and PAS, reports an assessment of the attitudes and practices regard- ing euthanasia and PAS, and delineates questions needing further investigation.

Methods The published literature was searched beginning with surveys in 1947 until 2016, with a focus on original data from 3 main data sources: (1) surveys providing data on attitudes and practices; (2) data from jurisdictions that have legalized euthanasia, PAS, or both with re- porting requirements, specifically Oregon,2 Washington state,3 the Netherlands,4 and Belgium,5 that have provided data on preva- lence and practices; and (3) death certificate studies, conducted since 1990 in the Netherlands and Belgium, that have provided population- based assessments of practices. Death certificate studies from these countries confidentially surveyed the attending physicians of a ran- dom sample of deaths about the circumstances of patients’ deaths in which the physicians have been involved.6

Definitions Definitions of euthanasia and PAS vary between countries and are con- troversial (Table 1). For active euthanasia—or simply euthanasia—a person, usually a physician, actively and intentionally ends a pa- tient’s life by some medical means such as injection of a neuromus- cular relaxant.8,9 Consistent with laws in the Netherlands and Belgium, “euthanasia” is usually limited to voluntary cases—those in which the patient is mentally competent and explicitly requests euthanasia.7,10

Involuntary euthanasia occurs when the patient is mentally compe- tent but did not request euthanasia. Nonvoluntary euthanasia refers to cases when the patient is not mentally competent and could not request euthanasia. In the Netherlands, Belgium, and most European countries, involuntary and nonvoluntary cases are not deemed eu- thanasia but “termination of life without the patient’s explicit re- quest.” The term “passive euthanasia” should be avoided because it refers to terminating potentially life-sustaining treatments, not ad- ministration of a medical intervention to end a patient’s life. In the United States and many countries, terminating potentially life- sustaining treatments is deemed ethical and legal when performed with the patient or proxy’s agreement.

PAS occurs when lethal drugs are prescribed or supplied by the physician at the patient’s request and self-administered by the pa- tient with the aim of ending his or her life. In the United States there is debate as to whether the appropriate term for this practice is PAS, physician-assisted death, or physician aid-in-dying. We use PAS be- cause this term is more commonly used, especially in Europe, where physician-assisted death is a more inclusive term that includes

euthanasia, termination of life without the patient’s explicit re- quest, and PAS; we also focus on the substantive issues related to these practices rather than linguistic controversies.11

Legalization of Euthanasia and PAS In 1942, Switzerland became the first country to decriminalize as- sistance in suicide as long as there was no selfish motive by the per- son assisting such as obtaining inheritance (Table 2).17,18 From the 1980s onward this law was interpreted as legal permission to es- tablish organizations to facilitate assisted suicide, including for Swiss nonresidents.17

Since the 1980s, in the Netherlands euthanasia and PAS were tolerated as long as certain safeguards, such as the patient having unbearable suffering and explicitly requesting the life-ending inter- vention after due consideration, were adhered to. Then in 2002 both the Netherlands22,28 and Belgium20 legalized euthanasia and PAS (Table 2). Luxembourg followed in 2009.24 Euthanasia remains illegal in all US states (Table 2). However, since 1997, 5 US states—Oregon, Washington, Montana, Vermont, and California— have legalized PAS.12-16,29 In Canada, the Supreme Court ordered provinces to draft laws legalizing euthanasia by February 201625

(later extended to June 2016), after Quebec’s decision to legalize euthanasia in 2014.26 In June 2016, Canada’s parliament passed legislation legalizing both euthanasia and PAS.27 In 2015, Colombia permitted its first legal euthanasia.19 In July 1996, the Northern Ter- ritory of Australia legalized euthanasia, but this legislation was overturned 9 months later.30

The status of euthanasia and PAS is unclear in several coun- tries. For instance, German law does not criminalize suicide or per- sons helping in a suicide, but in November 2015, Germany forbid as- sistance in facilitating suicide in a commercial or business-like form, as available in Switzerland. Moreover, the German Medical Associa- tion’s code of conduct explicitly forbids physicians from perform- ing either euthanasia or PAS.

Guidelines and Safeguards There is variability in the age at which euthanasia and PAS are per- missible (Table 2). Throughout the United States, in Canada, and in Luxembourg, patients must be at least 18 years old. The Nether- lands allows patients as young as 12 to request euthanasia or PAS. In 2007 the Dutch government made it possible for a physician to end the life of severely malformed newborns without being pros- ecuted if due care criteria are met.31,32 Since 2014 Belgium permit- ted euthanasia and PAS regardless of age, as long as the person has capacity for discernment.20,21,33

Both substantive and procedural safeguards differ among coun- tries (Table 2). All US states require patients receiving PAS to have a prognosis for survival of 6 months or less. In the US, patients do not have to have unbearable pain or any symptom(s) despite treat- ment. For adults, the Netherlands, Belgium, and Luxembourg re- quire that patients have “unbearable physical or mental suffering” without prospect of improvement but do not require them to be ter- minally ill. Belgium does require that children receiving euthanasia be terminally ill.

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There is substantial variability in the procedural requirements (Table 2). All US states permitting PAS require a 15-day period be- tween 2 oral requests and a 48-hour waiting period between a final written request and dispensing of the prescription. In Canada there is a 10-day waiting period between a written request and provision of PAS. The Netherlands and Luxembourg do not have mandatory waiting periods. For nonterminally ill patients, Belgium requires a 1-month waiting period. No jurisdiction standardly requires a psychi- atric evaluation.

Colombia is the only jurisdiction that requires prior approval of euthanasia cases by an independent committee. Oregon, Washing- ton state, the Netherlands, and Belgium require reporting of cases to an official body after the intervention. In 2015, the first Belgian case was referred to the public prosecutor.34,35 In the Netherlands, between 2002 and 2015, 75 cases have been forwarded to the pub- lic prosecutor for noncompliance with legal safeguards, but none has been prosecuted.4 In Oregon, only 1 case of PAS is known to have been legally prosecuted.36

Public Attitudes Toward Euthanasia and PAS Assessing attitudes toward euthanasia and PAS is challenging be- cause of framing effects. Support varies substantially depending on the wording of survey questions; the provision of details about the patients, their prognosis, their medical diagnosis, and symptoms; how the interventions are characterized; and whether the ques- tions are focused on ethical acceptability, legalization, or some other endorsement (Table 3).37-41

Since at least 1947, Gallup, in a representative survey that more recently included approximately 1000 to 1500 individuals, has asked the US public, “When a person has a disease that cannot be cured, do you think doctors should be allowed to end the patient’s life by some painless means if the patient and his family request it?”37 The question leaves ambiguous the patient’s age, disease, prognosis, and any symptoms; presupposes that the life-ending act is necessarily painless; and adds family consent, which is neither an ethical nor le- gal requirement in any jurisdiction. Support for this practice in- creased from 37% in 1947 to 53% in the early 1970s (Figure 1). Sup- port plateaued in approximately 1990, with two-thirds of the United States population supporting ending a patient’s life. Subsequently, several, but not all, public opinion surveys in the United States ap- pear to have detected a decline in support from a peak of 75% in

2005 to 64% in 2012 (Figure 1). When the question was changed so the patient is in “severe pain” and the term “legalization” is added, but the action is a patient “suicide” rather than a physician ending the patient’s life, public support is consistently lower, by 10% to 15%.

Two aspects of these survey data are surprising. There is a lag between increases in support for euthanasia and PAS and the legal- ization of PAS in the United States. Also, there is higher public sup- port for euthanasia than PAS, yet euthanasia remains illegal.

In the United States, several characteristics are consistently as- sociated with favoring or opposing euthanasia and PAS. In general, white persons, men, younger persons, and the religiously unaffili- ated tend to be more supportive.42-47

In Europe, there has been no plateau of public support for euthanasia and PAS (Figure 2).48,49 Between 1999 and 2008 in most Western European countries support for euthanasia increased. Simultaneously, there has been no increase and even a decrease in acceptance of euthanasia and PAS in most Central and Eastern European countries. These changes seem correlated with a strong decline in religiosity in Western Europe and an increase in religios- ity in postcommunist Eastern Europe. Since legalization in 2002, sup- port for euthanasia has increased significantly in Belgium but de- clined slightly in the Netherlands.

Physician Attitudes Toward Euthanasia and PAS Surveys of physicians are limited by the same framing effects and inconsistent wording as public surveys. In addition, these surveys tend to have much smaller numbers of respondents, often use non- random sampling techniques, and have low response rates. How- ever, surveys in the United States, Europe, and Australia consis- tently demonstrate lower support for euthanasia and PAS among physicians than the public.50-60 For instance, in 2014, Medscape con- ducted a survey of physicians in 7 countries (n = 21 531) asking “should physician-assisted suicide be allowed.”61 US physicians were most supportive, with 54% agreeing, while a minority of physi- cians in Germany (47%), United Kingdom (47%), Italy (42%), France (30%), and Spain (36%) concurred that PAS should be permitted (eFigure in the Supplement).

In the United States, older but more methodologically rigorous surveys generally have shown that fewer than half of physicians support legalizing euthanasia and PAS.44,62-66 Contrary to the pub- lic, physicians are more likely to support PAS than euthanasia. Surveys

Table 1. Definitions of Euthanasia and Physician-Assisted Suicide

Predominant Term in Ethics Predominant Term in Research7 Definition

Voluntary active euthanasia Euthanasia When a person (generally a physician) administers a medication, such as a sedative and neuromuscular relaxant, to intentionally end a patient’s life with the mentally competent patient’s explicit request

Involuntary active euthanasia Ending a life without explicit patient request

When a physician or someone else administers a medication, such as sedative and neuromuscular relaxant, or other intervention, to intentionally end a patient’s life but without the mentally competent patient’s request

Nonvoluntary active euthanasia Ending a life without explicit patient request

When a physician or someone else administers a medication, such as sedative and neuromuscular relaxant, or other intervention, to intentionally end a patient’s life with a noncompetent patient who could not give informed consent because the patient is a child or has Alzheimer disease or other condition that compromises decision-making capacity

Physician-assisted suicide or physician-assisted death

Physician-assisted suicide When the physician provides medication or a prescription to a patient at his or her explicit request with the understanding that the patient intends to use the medications to end his or her life

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