Journal of Nursing Law, Volume 11, Number 3, 2007

Physician-Assisted Suicide:
Development, Status, and
Nursing Perspectives
Theresa F. Rose
Physician-assisted suicide remains a controversial and highly emotional topic. The perception of
suicide itself has transitioned from martyrdom in the ancient world to an anathema in modern
society. As the entire population gets older, the aging process lengthens, bringing more complex
and debilitating conditions along with it. For some, death is the merciful end of a long and arduous
journey. Being given the power to choose when and how to die may be the only decision remaining, but does a person really have the right to make that decision? Currently, Oregon is the only
U.S. state that allows physician-assisted suicide, stemming from the Death With Dignity Act enacted
in 1997, after years of courtroom and political battles. As of December 2006, 292 Oregonians have
died from lethal ingestion of a physician-prescribed narcotic, reflecting 0.3% of the total deaths
in Oregon. Between 1994 and 2006, at least 54 assisted suicide measures have been introduced in
21 states. All have been either tabled or defeated.
Keywords: assisted suicide; terminally ill; end of life; Death With Dignity Act

hysician-assisted suicide (PAS) remains a controversial and emotional topic. For centuries, issues
related to PAS have been zealously debated, with
neither the strongly held positions of both advocates
and opponents gaining much ground. Moral, spiritual,
ethical, political, and societal tenets have influenced
the reigning physicians and philosophers of each era.
Currently, those who favor PAS view the process as
ending in a peaceful, painless death, while those who
oppose it believe that the consequence of any form of
suicide results in spending eternity in hell.

HISTORICAL PERSPECTIVE
The ancient Greeks and Romans were tolerant of suicide, believing that life did not need to be prolonged
for any reason, especially if ongoing suffering was
the prognosis (Yount, 2000). However, one prominent
Greek physician, Hippocrates, advised his contemporaries against providing deadly medicine to their
patients in his famous Hippocratic Oath, thus introducing a new perspective (Yount, 2000). During the
4th century, Zeno, the founder of Stoicism, promoted

the idea of certain natural rights, which included the

right to commit suicide. According to the Stoics, the
best life was one lived in harmony with nature, that is,
God. The leaders of ancient Athens offered Socrates,
another 4th-century philosopher, a choice: lifelong
exile or suicide. According to the pundits of the time,
his monotheistic beliefs were corrupting the morals of
the impressionable young men of the city. At the age
of 71, he drank hemlock and died while in the company of his students (Boeree, 2000).
Early Christians held an ambivalent view of suicide,
as martyrdom was regarded with honor and admiration. One such example is the story of the young virgin
Pelagia of Antioch, who is about to be arrested by soldiers for her Christian faith. Aware of the fate of Christian virgins when imprisoned, Pelagia flees to the roof
of her home, throws herself into the river, and drowns.
Choosing death rather than endure moral dishonor held
great acclaim at that time; she was canonized as a result
(Gibson, 2006).
Beginning in the 5th century, public opinion began to
change. The theologian Augustine of Hippo (AD 354450)
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argued that suicide violated Gods law of thou shalt not

kill, and the act was deemed a mortal sin (Yount, 2000).
Condemnation of the practice continued to mount, and
by the 10th century, attempting suicide was regarded as
secular and criminal; people charged with this offense
were sent directly to prison. Ironically, these people
could be sentenced to death for their crime, albeit for
attempting to commit suicide (Rich & Butts, 2003). In the
13th century, Henri de Bracton introduced the idea into
English common law that attempting suicide by a sane
person be regarded as a punishable felony (Washington,
et al. v. Glucksberg, et al., 1997). For 300 years, the American colonies largely followed the English law of seizing
the deceaseds goods and chattel. In 1710, William Penn
of Pennsylvania broke with tradition and advocated
removing the stiff penalty of seizing the goods, which
had succeeded in merely punishing the innocent relatives of the deceased. This, however, did not demonstrate
a change in attitude toward the idea of suicide, but rather
a growing concession of not punishing the individuals
family for his or her offense (Washington v. Glucksberg,
1997). The change surfaced slowly, as advancements
emerged in the ability to prolong life.

DEFINITIONS AND CONCEPTS

With the advancement of science and medicine,
choices involving both life and death became more
complicated. Confusion regarding terminology hinders productive discussions between patients, families,
and health care providers. In order to reduce anxiety
and promote understanding, the formation of clear and
comprehensible communication is critical. Numerous
terms regarding assisted suicide have evolved, with
subtle but important differences.

Assisted Death
Assisted death encompasses both assisted suicide and
euthanasia. It is synonymous with assistance in dying
and Aid in Dying (AID). Assisted suicide results when
an individual provides a lethal dose of prescribed
medication to a patient with the intent of ending that
persons life (Torr, 2000). In order for assisted suicide to
occur under legal Oregon guidelines, the patient must
be physically and mentally capable of performing the
act of suicide without assistance (Torr, 2000).

Active Euthanasia
Euthanasia, also known as active euthanasia, differs from
assisted suicide in that the clinician rather than the
patient performs the act of drug administration. Active
euthanasia can be further divided into voluntary, invol-

untary, and nonvoluntary. Voluntary refers to a person

who requests euthanasia, involuntary refers to a person
who explicitly opposes euthanasia, and nonvoluntary is a
person who is incapable of stating his or her desires (Torr,
2000). Euthanasia is illegal in all countries except the
Netherlands, which allows voluntary euthanasia under
strict guidelines (Hurwitz, Picard, & Steinberg, 2006).

Passive Euthanasia
Passive euthanasia involves withholding or withdrawing
therapy, a term rarely used today due to the negative
connotation connected with the term euthanasia. Treatments, particularly chemotherapy or long-term dialysis, may become disproportionately burdensome to the
patient, where the benefit does not outweigh the physical
or emotional toll. Withdrawing or stopping life-supporting therapies, that is, cardiopulmonary resuscitation,
mechanical ventilation, or artificial nutrition, fall into this
category. Often referred to as allowing to die or letting
die, these practices are widely accepted as legally and
ethically sound (Yount, 2000). Without therapy, the health
care providers are allowing nature to take its course; the
patient dies due to the underlying medical condition.

Terminal Sedation
For the past few years, withdrawal of therapy has taken
a step further with the advent of terminal sedation.
Terminal sedation is defined as the deliberate termination of awareness for intractable pain or emotional
suffering (Torr, 2000). Terminal sedation combines two
separate procedures: withdrawal of life-sustaining therapies, including nutrition and hydration, and intentional
induction of unconsciousness (McStay, 2003). Terminal
sedation has been criticized as inhumane when compared with the more expeditious death from a lethal
overdose, while others view it as a method to circumvent the prohibited practice of physician-assisted suicide
(Torr, 2000). Terminal sedation is now being incorporated into hospices and palliative care institutions, with
strong moral, ethical, and legal viewpoints on either side.
However, both positions support the increased emphasis
on the importance of palliative and end-of-life treatment
(Yount, 2000). By allowing or not disallowing actions that
evoke such passion and emotion, the involvement of the
court system was inevitable.

LEGAL CHALLENGES
Compassion in Dying, et al. v. Washington
The legal issues of physician-assisted suicide have
received great interest in recent years; as medicine

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advances, court decisions and end-of-life choices have

become more and more applicable to everyones life.
One of the legal challenges to physician-assisted suicide
is located in the 14th Amendment, which states that no
person shall be deprived of the right to life, liberty, or
property without due process of law. Challenging a persons right to choose his or her time and type of death,
this lawsuit questioned whether Washington States
prohibition against causing or aiding suicide offended
the 14th Amendment of the United States Constitution.
Proponents of PAS claim that the 14th Amendment
liberty interest extends to the right for mentally competent, terminally ill adults to perform PAS, as asserted in
Compassion in Dying, et al. v. Washington (1994). Relying primarily on Planned Parenthood v. Casey (1992) and
Cruzan v. Director, Missouri Dept of Health (1990), the
Federal District Court for the Western District of Washington agreed that the 14th Amendment held a due
process liberty interest in the right to control ones time
and type of death. The District Court also stated that
the ban violated the 14th Amendments Equal Protection Clause, which requires that the state must treat
an individual in the same manner as others in similar
circumstances (Vacco, et al. v. Quill, et al., 1997).

Measure 16
Taking place concurrently in 1994, Oregon voters
ratified Measure 16, Oregons Death With Dignity Act
(DWDA) (1997) ballot initiative, by 51% to 49%. The
DWDA allows physicians to prescribe lethal doses
of medication, under proper safeguards and stringent guidelines, to terminally ill, mentally competent
patients. Within weeks, U.S. District Court Judge Hogan
issued a temporary restraining order against Measure
16, followed by an injunction preventing the state from
putting the law into effect. In 1995, Judge Hogan ruled
that Measure 16 was unconstitutional on the grounds
that it violated the 14th Amendment Equal Protection
Clause. The ruling was appealed to the U.S. Circuit Court
of Appeals (Yount, 2000). That same year, the Oregon
Death With Dignity Legal Defense and Education Center
was founded in response to the enormous court battle
ensuing over the ratification; its sole purpose was to
defend ballot Measure 16 (Death with Dignity, n. d.).

Washington v. Glucksberg
Legal tensions continued to intensify over the decision in
Compassion in Dying, et al. v. Washington (1994), now known
as Washington, et al. v. Glucksberg, et al. (1995/1996/1997).
Washington State appealed the decision, which was overturned in the 9th Circuit Court of Appeals on March 9,

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1995. The plaintiffs claimed religious bias by two of the

judges and petitioned for a rehearing. Almost a year to
the day later, the Appeals Court overturned the previous decision, en banc. The court cited that the ban on
assisted suicide was unconstitutional because it placed
an undue burden on the protected liberty interest (Washington v. Glucksberg 1995/1996/1997).

Supreme Court Ruling

As Compassion in Dying had aspired to from the beginning, the case found its way to the Supreme Court. The
question posed to the court was whether Washingtons
prohibition against assisted suicide violated the 14th
Amendment. Upon a writ of certiorari, the U.S. Supreme
Court reversed the decision. On June 26, 1997, the
Supreme Court asserted that the Washington ban on
PAS did not violate due process, either substantive or
as applied to mentally competent, terminally ill adults.
The states ban was deemed constitutional.

Vacco, et al. v. Quill, et al.

A similar Supreme Court decision, decided on the
same date as Washington v. Glucksberg (1997) was
Vacco, et al. v. Quill, et al. (1997). Oral arguments were
heard in tandem with Washington, et al. v. Glucksberg,
et al. (1995/1996/1997) but the cases were not combined. The 2nd Circuit Court of Appeals held that New
Yorks assisted-suicide ban did not violate the Equal
Protection Clause of the 14th Amendment. The court
also posited that state law may distinguish between the
withdrawal of life-sustaining treatment and physicianassisted suicide without violating the Equal Protection
clause. The Supreme Court disagreed with the 2nd
Circuits statement that ending or using life-sustaining
treatment is nothing more nor less than assisted suicide (Vacco v. Quill, 1997). The dissimilarities between
letting a patient die and making a patient die contain
vital, logical principles; causation and intent are wellestablished legal concepts and are clearly recognized
and defined in Cruzan v. Director, Missouri Dept of
Health (1990). In America, everyone is entitled to
refuse unwanted lifesaving medical treatment if they
are mentally competent; no one save the physicians
operating under the Oregon DWDA is permitted to
assist with a suicide (Oregon Department of Human
Services [ODHS], 2007).

Assisted Suicide Funding Restriction Act (ASFRA)

During the same period that the Supreme Court was
handing down decisions on Washington v. Glucksberg
(1995/1996/1997) and Vacco v. Quill (1997), Oregon

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voted in favor of the first state legalization of physicianassisted suicide. Another legal challenge occurred when
the then-Director of Oregons Medicaid program stated
publicly that he firmly believed that if the referendum
was passed, Federal funds from Medicaid would likely
be used to fund assisted suicide (Nightingale Alliance,
2004). The Assisted Suicide Funding Restriction Act
(ASFRA) of 1997 was passed to prevent this scenario. In
addition, the ASFRA (1997) was designed to demonstrate
the positive role that the Federal government exhibits in
caring for the ill and elderly (Nightingale Alliance, 2004).
The ASFRA (1997) amended the Public Health Services Act but stated clearly and unequivocally that
Federal funds would not be allowed to fund assisted
suicide. The ASFRA (1997) also indicates that any program that receives Federal funds may not participate
in or advocate assisted suicide in any way, including
but not limited to Medicare, Medicaid, military health
care, and disability programs. It does not apply to statefunded programs or privately funded programs (Nightingale Alliance, 2004). In response, Oregon acted swiftly.
Within one year of the signing of the ASFRA (1997),
Oregons Health Services Commission (HSC) voted 101
to provide state-funded physician-assisted suicide to the
states Medicaid patients (Yount, 2000).
The ASFRA (1997) is designed to target specific
groups who are at high risk for suicide, that is, those
with a terminal illness or chronic pain. Congress authorized the Department of Health and Human Services
(HHS) to provide grants aimed at improving palliative
medications for the terminally ill (Torr, 2000). It also
protects doctors from being falsely accused of performing PAS when prescribing large doses of narcotics for
pain management (Nightingale Alliance, 2004). However, any addition or change to the law proposing one
side of the argument invigorated the other into action.

LEGISLATIVE PROPOSALS
AND OUTCOMES
On May 13, 1997, the Oregon House of Representatives voted 3226 to send Measure 16 back to the voters
for repeal. On June 10, 1997, the Senate voted 20110
to pass the proposal. No challenge to a previous voting result had been attempted in Oregon since 1908.
In November of that year, Oregon voters retained
the legality of PAS by a 60% majority (Yount, 2000).
The original victory had been only by a 3% margin; the
voters had clearly demonstrated their unquestionable
position. As noted earlier, the U.S. Supreme Court had
granted states the right to determine this issue via the
June 26, 1997, decisions of Washington v. Glucksberg

(1997) and Vacco v. Quill (1997); consequently, there

did not appear to be any further Federal opposition and
the law went into effect.
Almost immediately, however, U.S. Representative
Henry Hyde (R-IL) proposed penalties to doctors who
prescribed controlled substances for the purpose of
committing suicide. In December 1997, Drug Enforcement Agency (DEA) chief Thomas Constantine stated
that physicians performing such acts would be in
violation of the Controlled Substances Act (CSA). Proponents of the law claimed to sue if the DEA followed
through on the charges (Yount, 2000). However, on
April 2, 1998, U.S. Attorney General Janet Reno notified Representative Hyde that she was reversing the
DEAs position. She indicated that the Department of
Justice would not prosecute physicians who had prescribed medications in order to hasten their patients
death. Attorney General Renos argument established
that the CSA was not designed to usurp states rights
as administrators of medical practice and the CSA was
implemented to prevent sale of illegal substances,
not to regulate the prescribing of legal medications.
In addition, Reno stipulated that the DWDA (1997) was
beyond the authority of the CSA (Yount, 2000).

License Suspension
John Ashcroft succeeded U.S. Attorney General Reno on
January 20, 2001. On November 20 of that year, Attorney General Ashcroft proposed license suspension for
physicians who wrote prescriptions for PAS. Attorney
Ashcroft based his viewpoint on the claim that physicians violated the CSA because controlled substances
could not be used to hasten death. On April 17, 2002,
U.S. District Judge Robert Jones issued a permanent
injunction against Attorney Ashcrofts order. Attorney Ashcroft and the U.S. Department of Justice
immediately appealed the ruling to the 9th Circuit
Court of Appeals (Dunn, Reagan, & Tolle, 2005). The
appeals court affirmed the block in 2004, saying that
the Attorney General did not have Congress authority and Attorney Ashcrofts interpretation of the CSA
interfered with the states regulation of medical practice. The court also asserted that Attorney Ashcroft
challenged the clear wording of the CSA and exceeded
his own authority (Dunn et al., 2005). The 9th Circuit
Court of Appeals denied the Attorney Generals rehearing request (ODHS, 2007).

Gonzales, et al. v. Oregon, et al.

The Attorney General turned to the U.S. Supreme Court
to review the 9th Circuit Courts decision. The Supreme

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Court agreed and oral arguments for Gonzales, et al. v.

Oregon, et al. (2005) were heard on October 5, 2005. The
question presented was whether the CSA may authorize
a transfer of power from the states to the Department
of Justice to determine the legal use of medications
(ODHS, 2007).
On January 17, 2006, the Supreme Court affirmed
the circuit courts decision. By a 63 majority, the
court stated that Attorney Ashcrofts authority did not
allow him the power to criminalize conduct originally
granted by state law and that the Bush administration
had inappropriately attempted to bring charges against
physicians exercising their right to participate in PAS
(Humphry, 2006). Chief Justice Roberts and Justices
Scalia and Thomas dissented (Dunn et al., 2005). In
addition, the Attorney Generals interpretation of the
phrases legitimate medical purpose and public interest
were recognized as not entitled to review due to the
Attorney Generals limited function under the CSA
(Dunn et al., 2005). The majority ruling of Justices
Ruth Bader Ginsberg, Sandra Day OConnor, Stephen
Breyer, John Paul Stevens, and David Souter supported
Anthony Kennedys statement that the Federal government may regulate physicians prescription writing
through the CSA, but only in the context of preventing
illegal drug trafficking (Humphry, 2006). It appeared
that the peoples vote to allow the DWDA (1997) was
finally unimpeded.

GUIDELINES TO THE DEATH

WITH DIGNITY ACT
The Death With Dignity Act (DWDA) (1997) contains
strict guidelines that physicians and patients must follow. The patient must be at least 18 years old, reside in
Oregon, and be mentally competent. The individuals
diagnosis is terminal with a prognosis of 6 months or
less. Two oral and at least one written request for a prescription are required; the oral request must be separated by a minimum of 15 days and the written request
must be signed by the patient in the presence of two
witnesses. Neither witness may be the patients physician or an employee of a health care facility providing
care for the patient. One witness may not be related to
the patient or be entitled to any portion of the patients
estate (Humphry, 2002). Once the first request is made,
a consulting physician must confirm the diagnosis and
the mental competency of the patient. If either physician believes the patient suffers from a psychological
disorder, the patient is required to see a psychiatrist
(Yount, 2000). At this time, the patient waits the
required 15 days and may then submit another oral

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request. The patient has the right to rescind the request

at any time (Humphry, 2002).
Alternative options to the DWDA (1997) must be
offered to the patient by the physician, that is, hospice
and palliative care. The physician must recommend but
cannot require patients to notify their families about the
request, and physicians are required to submit patients
rationale regarding their decision, such as fears of losing autonomy or control of body functions (ODHS,
2007). No doctor is required to participate in the DWDA
(1997) and the law clearly protects the participating
doctors from liability. In addition, the law specifically
states that a patients decision to choose the DWDA
(1997) shall not have an effect on life insurance, health
insurance, or any type of accident or annuity policy
(Humphry, 2002).

CURRENT STATISTICS
During the DWDAs first year (1998) in effect, 23 people
received prescriptions. From that group, 15 people died
after taking the medication and 6 died from their underlying illness. Two people were still alive at the end of
1998. In 1999, 33 prescriptions were written; 27 people
committed suicide using the medication (ODHS, 2007).
One person died after ingesting the medication from
a prescription written the previous year. The median
age of the 27 physician-assisted suicides in 1999 was 71.
The breakdown of the majority of the disease processes
included end-stage cancer (17 patients), amyotrophic
lateral sclerosis (4 patients), and chronic obstructive
pulmonary disease (4 patients). In 2000, the same number of people (27) committed suicide from physicianprovided prescriptions, with 39 prescriptions written
(ODHS, 2007). While the first and second years showed
an increase in patients choosing PAS, the third year
suggested that the increase would not necessarily continue (Sullivan, Hedberg, & Fleming, 2005).

Steady Increase
Contrary to the impression that the numbers of patients
requesting PAS would remain relatively level, the number of requests continued to rise (see Figure 1). In 2001,
44 prescriptions were written with 21 deaths by PAS. In
2002, 58 prescriptions were written with 36 deaths. Two
patients received the medication in 2001 but did not
use it until 2002, bringing the total number of deaths
in 2002 to 38. In 2003, 68 prescriptions were written
with 42 deaths; in 2004, 60 prescriptions were written
with 37 deaths, which illustrated the first decrease
in the number of prescriptions since the laws inception. One 2004 patient ingested the medication, lost

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Figure 1. Number of lethal prescriptions written compared with number of actual

deaths by prescription.

Figure 2. Number of deaths by terminal illness compared with number of people

alive at years end.

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consciousness after 25 minutes, but did not expire.

The patient regained consciousness 65 hours later and
subsequently died after 14 days, a total of 17 days after
ingestion; no further data are available to explain the
reason behind the long delay. A total of 64 prescriptions were written in 2005 with 32 deaths reported from
ingesting the medication. Little change was reflected in
2006, with 65 prescriptions written and 35 deaths from
lethal ingestion. Eleven patients died who had received
the medication the previous year, bringing the total
deaths in 2006 from DWDA to 46 (see Figure 1) (ODHS,
2007). Data were also collected on the number of
patients who requested the medication but did not use
it, either by choice or because their death was related
to the underlying illness (see Figure 2).
Patient who choose death with dignity in 2006 were
slightly older, with a median age of 74 years, compared
with the previous age of 69 years old. In contrast with
the 15 deaths in 1998, the number of people choosing
death with dignity has more than doubled. For every
10,000 Oregon deaths in 1998, 5.5 PAS deaths occurred.
In 1999, 9.2 PAS deaths, followed by 9.1 in 2000, 7.0 in
2001, 12.2 in 2002, 13.6 in 2003, 12.3 in 2004, 12.0 in 2005,
and 14.7 in 2006. In demographical comparison with the
85,755 Oregon decedents from 19972006, patients who
used PAS were Caucasian (97%), had attained higher education (41% with baccalaureate degrees), and had higher
percentages of malignancies (87%) (ODHS, 2007).
Over the past nine years, 292 Oregonians have died
from lethal ingestion of a physician-prescribed narcotic,
reflecting 0.3% of the total deaths in Oregon. During
that time, the prescribed medication consisted of either
secobarbital (43%), pentobarbital (56%), or a combination of secobarbital and amobarbital (.01%); one person
used secobarbital and morphine. In addition, physicians
provided prescriptions to be taken with the lethal medications, designed to increase stomach emptying and/or
to prevent nausea and vomiting (ODHS, 2007).
Leading up to the prior statistics and nationwide controversy began like many other far-reaching ventures:
one person with the desire to make a change.

THE BEGINNING
While relaxing in his garage in Santa Monica, CA, Derek
Humphry, author of Final Exit, conceived the concept
of the Hemlock Society, a group devoted solely to the
legalization of voluntary euthanasia and PAS. Started
in 1980, it became one of the largest and oldest organizations of its kind in America, educating thousands
of terminally ill and elderly Americans on methods
for a peaceful, pain-free death. Hemlock Society sup-

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147

port groups across the country offered emotional and

moral counseling for those who helped a loved one to
die, someone who may be facing this circumstance, or
a terminally ill person who is considering the choice
(Humphry, 2002). Hands-on assistance was not granted
in order to stay within the boundaries of the law, but an
unofficial belief exists that members did perform such
acts (Humphry, 2005). People who professed desires
to end their life stemming from depression or mental
illness were not appropriate for these groups and were
referred to the proper support systems (Humphry,
2002).

Public Response
The society drafted the first model of a bill to govern
euthanasia and PAS in 1986. Many other models followed, refined from the original version. By the mid1990s, membership had dropped from 46,000 to
approximately 18,000 as other states developed similar
organizations. Dissension began over the name, with
some feeling the name was tied too closely to Socrates,
a philosopher well known for his unorthodox views.
This, they felt, hindered their ability to assimilate
into the mainstream and gain acceptance by powerful organizations, such as the American Association of
Retired Persons (AARP). Others viewed the name as
gallows humor, which diminished the dignity of their
mission. Proponents of the name responded disparagingly toward the opposition, referring to the ignorance
of those who knew little or nothing about Socrates and
many other ancient Greeks who supported rational
suicide. Their argument embraced Socrates manner
of decision, as he spent hours debating the two options
offered by the rulers of Athens and concluded his life
with a well-thought, rational choice (Humphry, 2005).
In spite of the possibility of confusing a change in the
name with a change in the mission, the Board of Directors officially changed the name in 2003 to End-of-Life
Choices. Then, on January 1, 2005, Compassion in Dying
merged with End-of-Life Choices to become Compassion
and Choices. With headquarters in Denver, CO, and
Portland, OR, it has become the largest organization in
America promoting rational suicide for mentally competent people (Compassion and Choices, 2005).

Religious Views
Based on Christian doctrine, suicide is not an acceptable choice (Rich & Butts, 2003). The Christian stance
designates that the taking of ones own life is a sin, punishable by spending eternal life in hell. The argument
contends that only God Himself has the authority

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to give and take life, and as followers of that belief,

individuals are not allowed to take any life, including their own. The Jewish faith also applies a strict
anathema toward suicide. It is even suggested, in the
Jewish culture, that suicide may be regarded as worse
than murder. A murderer may repent after the deed,
but the person who takes his or her own life forfeits
that possibility. Death itself, which may be the conduit
for forgiveness, is the result of the aberrant offense
(Hurwitz et al., 2006). Islamic faiths also view suicide
as sinful, but humans are regarded as fallible. After
death, if a person is sincerely repentant for his or her
actions, Allah, as the God of Islam, will forgive him
or her. On the contrary, if they show no remorse for
their sins, they are destined to spend eternity in hell,
reenacting the manner in which they died, that is, if an
individual hanged himself, he will hang himself unceasingly throughout eternity (Nasr, 2002).

ANA POSITION AND NURSING

IMPLICATIONS
As public awareness increases about PAS, professional
organizations feel moral obligations to issue statements
of their positions. The American Nurses Association
(ANA) has come out vehemently against PAS, being one
of 50 health care organizations that signed an amicus
curiae opposing PAS in 1997. The amicus curiae was
submitted by the American Medical Association (AMA)
to the 9th and 2nd U.S. Court of Appeals, hearing the
cases of Washington v. Glucksberg (1997) and Vacco v.
Quill (1997). As indicated previously, both courts found
that no constitutionally protected right to PAS exists
(ANA, 1997).

Not Compatible With Nursing

The ANA posits that assisting an individual to die is not
compatible with the nurses role in society (ANA, 1994).
The act violates the Code for Nurses with Interpretative
Statements, along with the well-entrenched nursing
standard of indisputable ethics (ANA, 1994). While
the ANA strongly supports the patients right to selfdetermination, limits do exist. Nurses are not obligated
to comply with every request issued by the patient or
family; this allowance preserves the personal mores
and integrity of the individual nurse. Though a nurse
may refuse to perform a particular act, such decisions
should not be made injudiciously, and the rationale
should be explained to the patient or family (ANA,
1994). However, the International Council of Nurses
(ICN) Position Statement takes neither a supporting
or opposing standpoint on PAS, but recommends that

nurses be knowledgeable about current issues and legislation regarding end-of-life issues (Rich & Butts, 2003).
With PAS passed into law, the question remained as
to how the state of Oregons clinicians would regard
PAS. Oregon Health and Science University, School of
Nursing, mailed questionnaires to all Oregon hospice
nurses and social workers to request their viewpoints
on assisted suicide and the types of interactions they
had encountered with patients on the subject. Respondents (n = 391) reported that nearly two-thirds had discussions with patients regarding the subject of assisted
suicide; 22% of those respondents stated that they did
not feel comfortable having the conversations (Miller
et al., 2004). As modern medicine continues to discover more and more methods to combat disease and
thus prolong life, such conversations are only going to
become more prevalent. Several factors can contribute
to a patients initiation of such a discussion, such as
unrelieved pain or other symptoms of discomfort, fear
of isolation, fear of becoming a burden to the family,
or a sense of hopelessness. Nurses can use these conversations as a springboard to uncover deeper anxieties
and concerns, perhaps discovering a fear that has yet
to be addressed. Verbalizing suicidal thoughts does not
increase the risk of suicide and may provide a therapeutic outlet (Rosen & Amador, 1996).

Biomedical Model
The biomedical model of treatment so established in
this country focuses its objective almost solely on cure.
However, when a cure is no longer considered humanly
possible, the cure versus care controversy emerges.
Offering patients a quick, painless, and peaceful death,
albeit early, may be regarded by some physicians as an
accepted medical practice, but is it an accepted nursing
practice? Long regarded as the core of the profession,
caring has many faces and avenues. Assisted suicide
may end suffering, but can it be considered caring
(Dyer, 1999)?
Nurses are the front line for comprehending the enormous physical and emotional toll experienced by dying
patients and their families. The balance may become
indiscernible between maintaining life and providing a
peaceful and dignified death. As the distinction blurs,
nurses must be cognizant that their personal emotions
of grief, fear, helplessness, and anger can influence their
clinical decision making. At times, this may become rationalized into believing that the most humane decision is
to hasten death. However, the profession of nursing
stems from Hippocrates axiom of do no harm, which is
in moral opposition to killing another human being.

Rose

The tremendous advances in prolonging life have not

necessarily increased the level of human dignity, quality of life, or personal control. The once-unthinkable
topic of assisted suicide delineates the deficits in palliative and end-of-life care and obligates the nursing professional to provide the utmost in respectful and ethical
nursing care. Improving care of terminal patients may
prevent the patient from considering the alternative,
namely PAS (ANA, 1997). However, the contention
exists that a medical professionals refusal to participate
in PAS is tantamount to abandonment of a patient at
the time when he or she is most in need of compassion,
understanding, and sensitivity (Humphry, 2002).
While individual cases may be persuasive, the ANA
believes that a high potential for abuse exists with PAS,
particularly with vulnerable populations, that is, the
elderly, the poor, and the mentally and physically challenged. With declining resources related to changes in
Medicare and Medicaid funding, the possibility for abuses
becomes more plausible. Providing the option of PAS may
potentially weaken the goal of continuously improving
the quality of end-of-life care. The ANA also fears that the
availability of PAS could become an easy alternative to
the financial and emotional hardships of long-term care
(ANA, 1994).

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149

interventions. By meeting all of these elements, the

clinician is acting in a legal, moral, and ethical manner,
as recognized by the medical community. Not to offer
requested and necessary relief for intractable pain is
ignoring an ethical obligation to patients, while recognizing the patients right to refuse any and all therapies
(Torr, 2000).

REMAINING CHALLENGES
AND CONFLICTS
An additional challenge is the right to refuse life-sustaining treatment, which reflects the medical communitys
respect for autonomy and the wish to spare patients
from intolerable suffering (Orentlicher & Callahan,
2004). Autonomy allows individuals to make their own
choices, offering support to the legalization of PAS.
If a patient is unquestionably suffering, clearly close
to death and requesting an end to his or her agony,
a strictly regulated assisted suicide may be justifiable
(Orentlicher & Callahan, 2004). Unfortunately, the
nurse is often left alone to navigate the dying patients
requests for euthanasia or assisted suicide, and it is
often the nurse who witnesses the despair and anguish
of the patient and families (ANA, 1994).

The Clinicians Role

RULE OF DOUBLE EFFECT

The Rule of Double Effect (RDE), a bioethical doctrine
with moral implications, provides legal justification for
clinical actions that have two foreseeable effects: one
beneficial and one detrimental. During palliative care,
clinicians provide pain-relieving medication, usually of
a narcotic derivative. Narcotics may suppress the respiratory function, possibly leading to complete respiratory cessation and death. The beneficial effect is relief
of pain; the detrimental effect may be hastened death
(Yount, 2000).
The ANA supports RDE, recognizing the moral justification for sedation as a side effect of pain medication,
even when a nurse medicates a patient for pain relief
knowing it may also lead to death (Rich & Butts, 2003).
Three factors distinguish RDE from terminal sedation:
(1) the intention of the clinician, (2) the nature of the
action, and (3) the consent of the patient. The intent
for administering narcotics is to relieve pain, not to
cause death. The nature of the action is to prevent
suffering or avoid burdensome procedures, as when
treatments are withdrawn or procedures stopped. Consent of the patient is critical in confirming an action
as ethical, which may be in the form of advance directives, allowing the patient to accept or refuse medical

The conflict that nurses face regarding assisted suicide

is multifaceted and involves a much deeper capacity than the typical acute-care patient hospitalized
for a knee replacement or pneumonia. Assessing and
managing pain, recognizing that sleep does not necessarily indicate a pain-free patient, responding to
psycho-spiritual needs, assisting patients and families
in evaluating and articulating their values and beliefs,
along with the necessary discussions regarding treatment plans reflect some of the complex needs of these
patients. Many resources exist to educate nurses to
fulfill these key responsibilities, but nurses can feel
helpless when faced with these difficult circumstances
(Kiernan, 2006).
For the nurse dealing with these issues, the challenge is exploring the moral permissibility of assisted
suicide as the first step in uncovering personal opinions. Questions arise from self-reflection: Is elimination
of suffering always the highest goal or can suffering
have a purpose? Is suicide a purely personal act or does
the nurse have a responsibility to the patient to support
him or her? Does autonomy include allowing rational
people to take their own lives? Does religion play a role
in whether suicide is right or wrong? Is suicide courageous or cowardice? If a nurse concludes that suicide

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Vol. 11, No. 3

is wrong, based upon these and other considerations,

then the question is raised as to whether it is wrong
to assist in a suicide. Supporting the argument that it
is right to assist in the commission of an act when it is
believed that the act itself is inherently wrong presents
conflicting views; conversely, if a person believes that
individuals posses the free will, the autonomy, and
the liberty to take their own life, that person would be
expected to believe that assisting in the act is morally
permissible (Mathes, 2004).

support for PAS and euthanasia. It conflicts squarely

with both the AMAs and the ANAs most basic pledge
with society and destroys the trust between the clinician and the patient. However, proponents for PAS are
quick to point out that clinicians have been providing
covert assisted deaths for some time, and that the trust
is destroyed by the inability or the refusal of the clinician to relieve the suffering. By legalizing the act, strict
safeguards and regulations will prevent abuses and
remove the veil of secrecy (Torr, 2000).

Medical Ethics

Pending Legislation

As the argument continues over the legalization of

assisted suicide, the moral dilemma persists (Torr,
2000). If PAS became legal throughout the country, bioethicists and opponents believe that it would become
an everyday occurrence. Termed the slippery slope
theory, the argument states that taking one step onto
the slope will cause society to slide unimpeded to the
bottom (Rich & Butts, 2003). Advocates of this theory
postulate that patients will choose to die because they
have not received the kind of support services that
would make them want to stay alive. As health care
grows increasingly expensive, the possibility of underfunding services for people with terminal illnesses is
likely (Kiernan, 2006). It is not unusual to hear complaints that too much money is allocated to patients in
the final year of life. While legalizing PAS may seem
reasonable in principle, placing it into practice could
extend it beyond justifiable uses (Orentlicher & Callahan, 2004).
Some opponents of assisted suicide fear that the risk
of the slippery slope may lead society into choosing the
ones to die, that is, the mentally retarded, the poor, and
the Alzheimers patient. It has been suggested that families may attempt to coerce patients into accepting death
by prescribed medication if they cannot or will not take
care of them. The fear also exists that legalization will
hinder empirical research toward improving palliative
care. PAS will become an easy substitute to caring for
the terminally ill rather than being reserved as an option
when all attempts to alleviate suffering and torment
have failed (Peck, 1997). However, the fact that participants must be mentally competent and are required to
take the medication themselves reduces the power of
this argument. If a participant is physically unable to
self-administer the lethal medication without assistance,
the physician may not prescribe it (Dunn et al., 2005).
Nonmaleficence, the concept of do no harm, may
be the single most definitive argument opposing PAS
for the medical community. Medical organizations
have seized this professional obligation in refuting all

In March of this year, Californias Assembly Judiciary Committee passed AB-374, a proposal to legalize
physician-assisted suicide. With Republicans casting the
3 dissenting votes, the Democratic-controlled committee passed the proposal by a 73 decision. Introduced
February 15, 2007, the California Compassionate Choices
Act is identical to the assisted-suicide bill that failed during the 20052006 legislative session. However, the bill
failed to acquire enough votes to pass the legislative
deadline in June and has stalled in the California State
Assembly. Reintroduction of the bill is precluded until
January 2008 (California Catholic Conference, 2007).
Also in March 2007, the Vermont House of Representatives defeated the proposal known as H-44 to legalize physician-assisted suicide. Described as one of the most stunning upsets in recent memory, the vote of 8263 shocked
proponents of the bill, who were confident of a victory
but had predicted a close race (Move Beyond, 2007).
Between 1994 and 2006, at least 54 assisted suicide
measures have been introduced in 21 states, including
Wisconsin (AB-298), Rhode Island (HB 6080), Hawaii
(HB 675), and Arizona (HB 2572). All proposals are currently stalled (Hamlon, 2007).

CONCLUSION
The question of PAS continues to challenge society; ethical, moral, legal, and medical controversies surround
an emotionally charged issue. The traditional Western
medical model focuses on diagnosis, treatment, and
recovery; terminal illness does not neatly fit into this
design. With the ever-expanding ability to prolong
life, medicines great advances have created their own
tempest that requires reflection and reconciliation. No
formula exists for determining when and if society will
ever deem PAS as a morally acceptable act, but the tide
has already turned in one direction, namely Oregons
Death With Dignity Act. Nurses and all health care
professionals should have an awareness of their personal
views on the subject of PAS and be prepared to respond

Rose

professionally and respectfully to such requests, albeit

for or against. An excellent resource for health care
professionals is the Hospice Education Institute (HEI),
located in Essex, CT (http://www.healthy.net/pan/
CSO/cioi/HEI.HTM). The HEI teaches medical professionals and the public about hospice care and pain control for the terminally ill, and is dedicated to improving
end-of-life care (Yount, 2000). What should never be in
question, however, is nurses commitment to terminally
ill patients and their willingness to advocate for choices
made by these patients and their families.

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Biographical Data. Theresa F. Rose is an MSN candidate pursuing a degree in nursing education at Southern Connecticut
State University, New Haven, CT.
Correspondence regarding this article should be directed to
Theresa F. Rose, 69 Courtland Drive, Groton, CT 06340. E-mail:
ottilie4@sbcglobal.net