Medical aid in dying: Ethical and legal issues

INTRODUCTION — Many parts of the world have seen increasing legalization of medical aid in dying (MAID), also referred to as physician-assisted dying (PAD), and voluntary active euthanasia (VAE). Although there remains variation in legal status internationally, as well as within the United States, a substantial population of patients have access to legal MAID. As a result, many clinicians, particularly those in the fields of oncology, palliative care, and hospice, will care for patients considering a hastened death.

This topic focuses on ethical, social, and legal aspects of these practices. Clinical aspects of self-administered MAID are discussed in more detail elsewhere. (See "Medical aid in dying: Clinical considerations".)

Other legal and ethical issues in palliative care, including palliative sedation, are presented elsewhere. (See "Ethical issues in palliative care" and "Legal aspects in palliative and end-of-life care in the United States" and "Palliative sedation".)

TERMINOLOGY

●Medical aid in dying or physician-assisted dying – This is a practice in which the physician provides a qualified patient, at their explicit request, with a prescription for a lethal medication that they can take on their own [1-4]. Other terms used to describe this practice that carry connotations include "physician-assisted suicide" (a negatively valenced term favored by opponents) and "death with dignity" (a positively valenced term favored by proponents) [5-8]. The legal terminology varies by location. As of August 2023, all statutes in the United States incorporate the substance of Oregon's original assertion that actions taken in accord with the statute shall not for any purpose constitute suicide, assisted suicide, mercy killing, or homicide under the law (table 1).

●Voluntary active euthanasia – Voluntary active euthanasia (VAE) or simply "euthanasia" are terms used to identify the practice whereby the clinician administers a lethal medication at the patient's request, usually by intravenous (IV) injection.

The term "euthanasia" varies sharply in its negative or positive connotations in different regions. In the Netherlands, "euthanasia" has generally positive connotations, associated with the Greek roots "eu" and "thanatos," or "good death" [9]. By contrast, the broader term "euthanasia" is avoided in Germany, where it is often associated with Nazi extermination policies, suggesting a politically motivated death that is against the victim's wishes or interests (involuntary euthanasia) [10]. The term "passive euthanasia," referring to death brought about by "allowing to die" or by withholding or withdrawing life-sustaining treatment, is no longer in common use in the United States or elsewhere [11].

LEGAL STATUS OF ASSISTED DYING — Medical aid in dying (MAID) and/or voluntary active euthanasia (VAE) are legal in several countries. An interactive world map provides updated information on all countries. Medical aid in dying is legal in several US states, and updated information is available from the Death with Dignity website. VAE is not legal anywhere in the United States. Information on the legal status of MAID in Canada is available through a government website.

REQUIREMENTS OF ASSISTED DYING PRACTICES

Medical aid in dying — There is considerable variation in the legal requirements across countries, including whether terminal illness is required. Other considerations that differ between countries include, but are not limited to, requirements regarding adult status, country of residence, the presence of psychiatric illness, physician versus other clinician participation, the need for a waiting period, and the use of advance directives [12]. Requirements in the United States are described in detail elsewhere. (See "Medical aid in dying: Clinical considerations", section on 'Legal requirements for medical aid in dying'.)

Voluntary active euthanasia — There is also considerable variation in the legal requirements for voluntary active euthanasia (VAE). In countries where VAE (and/or medical aid in dying [MAID]) are legal (eg, Belgium, Canada, Colombia, Luxembourg, the Netherlands, New Zealand, Portugal, and Spain), it is generally required that the patient be facing "unbearable" or "intolerable" suffering that cannot be alleviated in any way acceptable to the patient, but laws do not require that the patient be terminally ill. Australia states require self-administered oral administration as the default method, although if this is not possible, the clinician can seek governmental permission for intravenous (IV) administration. Switzerland permits IV administration but requires that the patient open the valve that releases the lethal medication.

Relative advantages of MAID versus VAE — In some countries where it is legal, VAE is widely considered to be morally equivalent to MAID and is subject to similar safeguards [13]. In other countries, where MAID is legal but VAE is not legal (eg, Austria, Germany, Italy, United States), VAE is generally regarded as ethically distinct from MAID and much less socially/morally acceptable [14]. In jurisdictions where both are legal, VAE is preferred over MAID. For example, while Canada permits both MAID and VAE, over 99.9 percent of patients use VAE [13].

Patients may find VAE psychologically easier, as the clinician takes direct responsibility for the final act, albeit at the patient's explicit request [15]. On the other hand, some patients and families may consider VAE to be disadvantageous in that the timing of the final act may depend (to some degree) on the clinician's availability, rather than solely on the patient and family's preference [16].

It can be argued that on a societal level, providing MAID without offering VAE unfairly discriminates against similarly situated patients who do not have the physical abilities to self-administer [17]. For example, in light of the difficulties for patients with neurodegenerative diseases to self-administer medications, clinicians have raised legal and ethical questions as to whether these individuals are being denied the same right to MAID, where there is a clinician willing to provide it, afforded to more able-bodied terminally ill patients. On the other hand, these patients can access MAID with assisted self-administration rather than VAE. In particular, some California physicians joined with amyotrophic lateral sclerosis (ALS) patients in a lawsuit in federal court asserting that denying physically weakened patients the right to assistance in self-administration violates the Americans with Disabilities Act, which insists on "reasonable accommodations" (in this case, "assistance") to provide equal access to health care [18,19].

Decision-making capacity — Almost all jurisdictions permitting MAID or VAE require a request from a patient with decision-making capacity [12]. There are some exceptions. For example:

●Belgium and the Netherlands permit capacitated patients to complete an advance directive directing the administration of VAE at a future time when they lack capacity (eg, in advanced dementia) [20,21]. However very few patients receive VAE from an advance euthanasia directive, and clinicians may be uncomfortable administering VAE when the patient cannot provide contemporaneous consent or assent [22,23].

●In March 2021, Canada amended its law to permit a waiver of the final consent requirement. While the patient must have capacity and otherwise be eligible at the time of request, they need not have capacity at the time of administration if they have a written arrangement with the clinician. While this goes partway to permitting advance requests, the Canadian Parliament is considering whether to allow advance requests for VAE [24].

UTILIZATION OF MAID AND VAE

●Patient characteristics – Oncology patients are primary utilizers of voluntary active euthanasia (VAE) and/or medical aid in dying (MAID) [13,20,25-30]. However, the overall percentage of patients with cancer has decreased as requests from patients with neurodegenerative diseases have increased [31-34].

●Reason for request – Among the most commonly reported reasons for a MAID request are loss of autonomy, inability to engage in enjoyable activities, and loss of dignity (table 2) [20,27,35]. Fear of uncontrolled pain is not usually a major determinant of interest in or use of MAID [27,29,35-37], although some studies have found a high symptom burden, including pain, in persons considering or requesting assistance in dying [38,39]. Other concerns which may prompt requests for MAID include financial burdens of treatment and fear of becoming a caregiving burden [27,29,30,36,38,40]. Depression, hopelessness, and general psychological distress are consistently associated with initial inquiries about MAID and VAE but not necessarily with carrying it out [38,40-46].

●Outcome – Most patients who inquire about the possibility of MAID or VAE do not follow through with a formal request, and of those who do, many do not die in this way. For example, in Oregon, only approximately two-thirds of patients who have received a prescription actually take it [29].

RESPONDING TO THE PATIENT’S REQUEST FOR ASSISTED DYING

Addressing the patient’s concerns — Regardless of whether clinicians personally support or reject the option of medical aid in dying (MAID) or voluntary active euthanasia (VAE), they should openly address inquiries about assisted dying [47]. General guidelines for responding to requests for assistance in dying are presented in the table (table 3). Addressing initial patient concerns are discussed in detail elsewhere. (See "Medical aid in dying: Clinical considerations", section on 'Clarify patient intentions and discuss options'.)

Patients should be referred to palliative care and hospice. (See 'Referral to palliative care and hospice' below.)

In all situations, patients should be made aware of all options other than MAID or VAE that are available to them for end-of-life care [1,48], but where MAID or VAE are legal, it is not the role of the physician to try to dissuade the patient from considering MAID by promoting other options. If the clinician has a personal conscience-based objection to MAID, then they have no duty to discuss that option with the patient because that might make them complicit in an act that they judge immoral or unethical. In most states, this is an exception to general duties of informed consent that require physicians to discuss all options that a reasonable patient would deem significant. Vermont physicians asserting a conscience-based objection must at least refer the patient to a source where they can learn about MAID. Objecting physicians in other states must only transfer the patient's records when the patient finds another physician willing to provide MAID [49].

Besides physical distress, the patient's suffering may include a broad range of psychosocial, spiritual, and existential factors, and every effort should be made to understand and address these aspects as well. Many of the nonphysical dimensions of suffering may be outside the competence of the main treating clinicians, so involvement of those with special expertise (eg, in psychiatry, chaplaincy, or social work) is critical. (See "Psychosocial issues in advanced illness" and "Assessment and management of depression in palliative care" and "Overview of comprehensive patient assessment in palliative care", section on 'Domains of palliative assessment' and "Overview of spirituality in palliative care", section on 'Differentiating spiritual, existential, and psychological suffering'.)

Responding to a request for medication long before planned ingestion — If the clinician is comfortable with the request and is practicing in a jurisdiction where MAID and/or VAE are legal, and if all the legal requirements are met, they may make a verbal commitment to provide such assistance in the future should the need arise.

In jurisdictions that permit only MAID, the patient may request to receive the medications well in advance, especially if long waiting periods between the initial request and the provision of the medication are required. However, this is not considered standard of care. Patients should be reassured that the medications will be available if and when they need them.

Clinicians must assure the patient that their request for MAID can be withdrawn at any time, whether or not the prescription has been already written, and that there is no obligation to use the medication.

Urgent requests — Some patients request urgent assistance in dying because of unacceptable suffering, even in the face of skillfully delivered state-of-the-art-and-science palliative care treatments. Such requests should be addressed explicitly. If the patient uses a euphemism for death or refers to it indirectly, ask for clarification. Do not assume that a wish for death to come soon is a request for a lethal prescription, but do not dismiss the request either.

Urgent requests should be treated as a "medical emergency" (table 3) [50]. The clinician need not provide MAID or VAE right now if prompt attention to the patient's suffering reveals other ways satisfactory to the patient of reducing distress. However, postponing attention or ignoring the patient's urgent plea can contribute to even greater distress [47]. An urgent request should elicit a rapid, comprehensive evaluation to be sure that the clinician understands the root cause(s) of the request: why is the request occurring at this particular point in time, why are usual palliative approaches inadequate, and why are alternative approaches (eg, intensification of symptom management, withdrawal of life-sustaining treatment, sedation for refractory symptoms) unacceptable [47,51-53] (see "Medical aid in dying: Clinical considerations"). Clinical guidance for clinicians in the United States is available from the American Clinicians Academy on Medical Aid in Dying (ACAMAID).

Ideally, a board-certified specialist in palliative care or hospice should review the case and provide a formal consultation on an urgent basis [1]. If a formal palliative care consultation is not available, a clinician in this situation should, whenever possible, discuss the case with an experienced colleague.

Understanding the family’s concerns — In addition to exploring the patient's concerns and preferences, meeting with close family and immediate caregivers may lead to a greater level of understanding of the patient's current suffering, provide important perspective on the potential meaning of the request, and possibly open options for better addressing it [54-56]. Unfortunately, not all families are sympathetic or able to work together in helpful ways in contexts such as these. A patient's refusal to inform close family members should be thoroughly explored and understood as part of the request evaluation. Statutes such as the Oregon Death with Dignity Act require the physician to indicate whether or not the patient has informed their family; in the first 25 years of Oregon's law, 6 percent of patients who died chose not to inform their families of their decision [29]. The family does not have legal veto power over a competent patient's decision to request or pursue MAID under a Death with Dignity Act. Even if the prescribing clinicians cannot confirm the patient's concerns and preferences with their family, they can confirm with a second clinician. Most MAID and VAE laws require prescribing/providing clinicians to confirm eligibility with a consulting/second-opinion clinician.

Assessing decisional capacity — When responding to inquiries or requests, it is important to ensure that the patient is thinking clearly, not delirious or psychotic, and not depressed in a way that is distorting judgment [57,58]. (See "Assessment of decision-making capacity in adults".)

A desire for death by a terminally ill patient is not clearly indicative of a mental health problem [59]. Such a request cannot be taken as a symptom of depression, demoralization, or mental illness. However, if there is concern that mental illness could be a factor in the request for MAID [60,61], or that decisional capacity may be impaired, psychiatric or psychological consultation may be legally required and should be obtained regardless. Clinicians should be aware of the legal requirements in their state or country in this regard. (See 'Patients with mental illness' below.)

Referral to palliative care and hospice — Referral to hospice and/or palliative care should be provided for all patients requesting MAID or VAE. Hospice programs are committed to providing effective management of pain and other symptoms and to ensuring adequate patient and family support, in any setting, through the last phases of the patient's life, including bereavement care for the family. Hospice care is typically offered when disease-directed treatments are no longer effective or acceptable to the patient and the prognosis is thought to be six months or less. Palliative care can and should be offered at any time during the illness.

Hospice, palliative care, and MAID or VAE are not incompatible; in fact, any patient seriously considering MAID or VAE should be receiving maximal acceptable efforts at palliation before a final decision about assisting death is made. In the United States, available reports suggest that the majority of patients utilizing MAID are enrolled in hospice [29,30]. (See "Hospice: Philosophy of care and appropriate utilization in the United States".)

Alternative treatments — When working with a patient who has requested MAID or VAE, the clinician should provide a clear account of alternatives that might both reduce or avoid suffering and be consonant with the patient's values and/or legal constraints.

Potential treatment options other than MAID and/or VAE that could be explored with a patient who faces intractable suffering include:

●Intensification of pain and symptom management – If the reason for considering MAID or VAE is intractable physical symptoms, systematic increases in potentially effective palliative treatments are an appropriate option [62]. There is widespread agreement that excellent symptom management does not accelerate death (and some evidence that it may even prolong life). There also are circumstances where clinicians must consider the risk of unintentionally hastening death because of the need for rapid escalation of opioids and/or benzodiazepines to manage severe terminal symptoms. This is a circumstance where the traditional rule of "double effect" may be said to apply, as the clinician can foresee that the rapid escalation of palliative treatment may hasten death, but does not intend it, and the severity of the patient's acute suffering warrants taking that risk [63]. (See "Ethical issues in palliative care" and "Ethical considerations in effective pain management at the end of life", section on 'Principle of double effect'.)

●Withdrawing from or foregoing life-sustaining therapy – There is a strong consensus, at least in the United States and Western Europe, about the ethical and legal permissibility of withdrawing from or foregoing life-sustaining therapy in seriously ill patients [64-68]. This is based primarily on the right to bodily integrity, ie, that patients have a right to accept or decline any potentially effective medical intervention that involves violation of their body in any way. (See "Ethical issues in palliative care", section on 'Applying principlism in palliative care'.)

Clinicians should pursue a full understanding of the "Why now?" of the decision and make certain that all palliative alternatives acceptable to the patient have been explored before activating the decision to withdraw or forego life-sustaining therapy. Examples of therapies that can be discontinued include both major mechanical interventions (eg, ventilatory support, dialysis, ventricular assist devices) and seemingly simple medicinal treatments (heart failure medications, insulin for type 1 diabetes, steroids for brain swelling, antibiotics, artificial fluids, and nutrition). Such "withdrawal of treatment" decisions are a common part of medical care practice and are not generally considered legally or ethically problematic, though some religions may find cessation of life-sustaining treatments, once started, morally problematic. Cessation of life-sustaining therapy requires careful management for symptom control and support during the subsequent dying process. (See "Ethical issues in palliative care", section on 'Withdrawing versus withholding treatment' and "Palliative care: Issues in the intensive care unit in adults" and "Kidney palliative care: Withdrawal of dialysis" and "Management of cardiac implantable electronic devices in patients receiving palliative care" and "Withholding and withdrawing ventilatory support in adults in the intensive care unit".)

●Voluntarily stopping of eating and drinking – Voluntary stopping of eating and drinking (VSED) is an option for those who are still capable of eating and drinking but choose to hasten death by completely stopping both nutrition and hydration [51,69,70]. VSED is distinct from the "natural" process of gradually losing the ability to eat and drink that often accompanies the late stages of illness. VSED requires considerable patient resolve, especially to stop drinking (appetite fades as patients become ketotic, but thirst persists and can be difficult to manage). Clinicians should play a central role in careful patient assessment before this process is initiated, and they may be needed to help palliate symptoms of oral mucosal dryness or delirium as the patient becomes dehydrated prior to death [71].

The dying process usually lasts 7 to 14 days from time of initiation if the patient is vigilant about avoiding all fluids. If only nutrition is refused, the dying process can extend over a much longer period and involve difficult issues around malnutrition. If symptoms (especially dry mouth) are not well managed, many patients may give up on the effort. VSED should never be casually recommended as a preferable alternative to MAID because it can be difficult for the patient to sustain, for the clinician to help manage, and for the family to watch [72]. However, both clinician surveys and anecdotal reports indicate it is a gentle and easy method [69,73,74]. (See "Stopping nutrition and hydration at the end of life", section on 'Voluntary cessation of intake'.)

●Palliative sedation – Palliative sedation is another option for responding to end-of-life suffering. There is a strong consensus about the permissibility of palliative sedation, particularly for suffering that is predominantly physical [75]. In these cases, clinicians use the minimal amount of sedation needed to relieve the suffering. This is often called "proportionate palliative sedation." A more extreme version, palliative sedation to unconsciousness, is a generally accepted option, especially for major end-of-life catastrophes (eg, bleeding out externally, acute agitated delirium at the end of life) [75]. (See "Palliative sedation", section on 'Other ethical concerns'.)

From an ethical standpoint, some theorists hold, under the principle of double effect, that the clinician does not "intend" death but merely "foresees" that death may occur from the attempt to relieve suffering through palliative sedation. Others challenge this distinction, asking how plausible is it that physicians could "foresee" that sedating to unconsciousness while withholding nutrition and hydration will result in death, yet not in some robust sense "intend" it [63,69]. (See "Palliative sedation", section on 'Other ethical concerns'.)

PRACTICAL CONSIDERATIONS

Guidance with medications — Information on practical aspects of medical aid in dying (MAID) as practiced in the United States is provided elsewhere (see "Medical aid in dying: Clinical considerations"). In Canada, advice on drug administration is provided by the Canadian Association of MAID Assessors and Providers (CAMAP). Legally required consultations by trained consultants, organized in the Support and Consultation for Euthanasia in the Netherlands (SCEN) to ascertain the use of correct drugs in the Netherlands started in 1998. In Belgium, a similar organization, the Life End information Forum (LEIF), was formed in 2003.

Information and consultation services for physicians — If a physician is considering providing access to MAID, the laws in United States jurisdictions (except New Mexico) require a second, independent opinion. Although not legally required, it is highly desirable that the second opinion be from someone with palliative care experience, without a principled objection to MAID. If the main treating physician is willing to assist but is not knowledgeable about prescribing and managing strategies, including recommended doses, ingestion strategies, and managing potential side effects, they may wish to contact the American Clinicians Academy on Medical Aid in Dying (ACAMAID) or one of the doctor-to-doctor consultation services available.

●In the United States, a service called Doc2Doc, provided by the advocacy organization Compassion & Choices, provides information for clinicians about a wide range of end-of-life practices, including MAID.

●In the United States, in February 2020, ACAMAID was formed to provide a patient to clinician referral system in addition to other relevant resources.

●In Canada, the Canadian Association of MAID Assessors and Providers (CAMAP) is a society of physicians and nurse practitioner that supports MAID and voluntary active euthanasia (VAE) assessors and providers in their work.

●The Support and Consultation for Euthanasia in the Netherlands (SCEN) makes consultants available under a service provided by the Royal Dutch Medical Association; they provide support and independent consultation from expert physicians to other physicians who have received a request for euthanasia in the Netherlands [76].

ETHICAL AND SOCIAL CONCERNS

Ethical arguments — General agreement has emerged about the moral permissibility of a patient refusing or discontinuing life-sustaining care, even when it means they will die, and this is now recognized in law [77]. But disagreement persists over the ethics of medical aid in dying (MAID) and voluntary active euthanasia (VAE).

●Proponents argue that the principle of autonomy justifies MAID and/or VAE. Autonomy, or self-determination, means that individuals have the right to pursue their own personal views of what kind of life is best, including when and how to die. Thus, to respect autonomy requires permitting individuals to weigh their own values and decide when it is better to end their lives rather than continue living in the face of terminal illness.

Opponents object that this construes autonomy too broadly and fails to take its limits into account, including challenges to the possibility of autonomy and limitation by the harm principle. The exercise of autonomy cannot include the ending of one's own life because that would mean ending the possibility of exercising autonomy and because ending one's own life would cause harm to others in multiple ways, including grief, loss of support, and setting dangerous precedents for others. They also point to classical writers on ethics, among them Aristotle, Thomas Aquinas, and Kant, who argued that suicide is deeply morally wrong. Proponents reply with examples of other writers on ethics, eg, Plato, the Stoics, and Hume, who did not oppose suicide in all circumstances and would not oppose it in this one.

●Second, proponents argue that the principles of mercy, nonmaleficence, and beneficence also support permitting MAID or VAE. In some cases of terminal illness, living creates more pain and suffering than death. It is also claimed that the reassurance of having the option of MAID or VAE, even if it is not used, can provide "psychological insurance" and be beneficial in the sense of relieving anxiety about the prospect of future pain and suffering.

Opponents argue that quality care for the dying is not always provided to such patients, leading to needless pain and suffering [78], and insist that adequate palliative care and hospice would relieve most pain and suffering. Proponents point out that, even with optimal end-of-life care, a small percentage of patients may still suffer uncontrolled pain and suffering. Opponents respond that it is unjustified to use the condition of these few patients as a justification to permit MAID/VAE for any dying patients. Proponents then reply that it is unethical to sacrifice the interests of a few persons to ostensibly serve the interests of others.

●Third, proponents argue that MAID and VAE may be considered not significantly different from terminating life-sustaining treatments, which is recognized as ethically justified. In both cases, the patient consents to hastened death, and in both cases, the physician intends to end the patient's life to relieve their suffering and takes some action to cause this to happen; the final result is the patient's death. If there is no difference in patient consent, physician intention, or the final result, there can be no difference in the ethical justification. (See "Ethical issues in palliative care", section on 'Requests to discontinue life-sustaining treatment'.)

Opponents counter that the distinction between intentionally ending a life and terminating life-sustaining treatments is reasonable based on the right to bodily integrity. The actual acts are different; injecting a life-ending medication or providing a prescription for one is not the same as removing or refraining from introducing an invasive, uncomfortable medical intervention. Patients who have life-sustaining interventions discontinued do not always die; some, such as Karen Ann Quinlan, live for years. (See "Legal aspects in palliative and end-of-life care in the United States", section on 'The Quinlan case'.)

Proponents respond that the physician's intention in MAID is not malevolent; the intention is to relieve the patient's suffering by making possible an earlier, easier death, at the patient's earnest request, when after all, the death is already in the process of occurring. Indeed, the intention may be just to provide the patient with peace of mind knowing that they have this option. In the United States, around one-third of patients who get MAID prescriptions do not ingest them [29]. They also insist that intention is not the only relevant factor and that the line between killing and letting die is not a sharp one; many other medical strategies for negotiating death, such as removing a ventilator or discontinuing artificial hydration and nutrition, foreseeably have death as the outcome, and it is implausible to claim that the physician does not intend this. It is simply not possible to distinguish reliably between "intended" and "unintended" consequences of a given act in these circumstances.

●Fourth, opponents argue that there are potential adverse consequences of permitting MAID or VAE. The medical profession could be corrupted, or expensive or burdensome patients could be urged, nudged, pressured, or coerced into requesting death. This argument, from the potential for abuse, is often called the "slippery slope" argument. However, proponents of legalization note that there is no available evidence for this argument and that the data from jurisdictions where MAID/VAE is already legal (eg, Oregon and the Netherlands) show that it is patients of privilege who die in this way: educated, affluent, White individuals rather than individuals who are poor, disabled, less educated, or from underrepresented racial and ethnic groups. Nevertheless, the risk of abuse argument continues to play a major role in public policy argumentation. (See 'Concerns about abuse' below.)

●Fifth, results of surveys of physicians find that, even in countries where MAID is illegal, physicians receive and carry out requests to hasten death in some situations [4]. Opponents warn that legalizing MAID or VAE may lead to further intrusion of lawyers, courts, and legislatures into the physician-patient relationship. Against this, proponents argue that legalization would bring honesty, clarity, and transparency to an existing practice.

Readers who are interested in pursuing arguments related to these controversies are referred to further sources [64,79].

Attitudes of the public and of physicians — Multiple surveys of public attitudes reveal divisions of opinion about the morality of MAID and VAE [41,80,81]. In most high-resource countries, public support for MAID and VAE has been increasing over the past decades, although support is more limited among physicians [81,82].

Some studies have found important divisions along social and religious lines [80]. There are also significant framing effects in the public's response to questions about MAID and VAE based not only on how the questions are phrased but also on how the answer categories are provided [41,80,83]. For example, there is consistently less support for the practice when framed using the word "suicide" than when the same practice is described using terms like "aid in dying" or "assisted death" [84]. In the United States, support for MAID is strongest when it concerns terminally ill patients who are experiencing severe pain [82].

Health care practitioners are represented on both sides of the debate over the boundaries of the physician's role in assisting in the death of a terminally ill patient [64,79,85]. One Colorado survey found that over 80 percent of physicians were willing to discuss MAID with a patient, or to refer for MAID [86]. In the Netherlands, 85 percent of physicians, similar to the general public, support VAE and MAID, and almost 60 percent of Dutch physicians have performed at least one case [87]. In the United States, certain specialties have been more supportive than others: surgical oncologists have supported euthanasia or MAID more often than medical oncologists [46]; psychiatrists, obstetricians, and gynecologists have been more supportive than internists, especially oncologists [4,88-90]; family or general practitioners have been more supportive than internists. Palliative medicine specialists in the United Kingdom and Canada were found to be particularly opposed [91,92].

We caution that this is a landscape in transition and that these relative positions may shift over time.

Position statements of professional organizations — In the 1990s and early 2000s, many professional organizations issued position statements opposing MAID and VAE. The American Medical Association (AMA) Code of Ethics, for example, was understood to prohibit physician participation in assisted suicide and euthanasia on the grounds that they are "fundamentally incompatible with the physician's role as healer, would be difficult or impossible to control, and would pose serious societal risks" [93]. In 2017, the American College of Physicians reiterated its opposition to MAID [94]. Most US state medical associations also oppose legalization, although many have adopted neutral or supportive positions [95].

Some professional medical organizations, such as the American Public Health Association (APHA), support MAID with eligibility criteria and safeguards equivalent to the Oregon Death with Dignity Act and reject the use of "inaccurate terms such as 'suicide' and 'assisted suicide'" [96]. The American College of Legal Medicine and the American Medical Women's Association has also endorsed MAID. Other professional medical organizations, such as the American Academy of Neurology and the American Academy of Family Physicians, have adopted a position of "engaged neutrality" [97,98].

Some hospice and palliative care organizations, such as the American Academy of Hospice and Palliative Medicine (AAHPM), maintain a position of "studied neutrality" on whether MAID should be legal; the AAHPM is neutral but expresses the concern that "it should not be routine medical practice" [99]. The International Association for Hospice and Palliative Care (IAHPC) believes that no jurisdiction should consider the legalization of VAE or MAID until it ensures universal access to palliative care services and appropriate medications, including opioids for pain and dyspnea [100]. It also supports the position of the European Association of Palliative Care (EAPC), which asserts that involuntary forms of euthanasia should not be recognized and should never be permitted [11]. The IAHPC also supports the International Children's Palliative Care Network (ICPCN) position, which states that "euthanasia is not part of children's palliative care and is not an alternative to palliative care" [101]. The Oregon Hospice & Palliative Care Association, by contrast, "supports the right of Oregonians to choose or not to choose any and all legal end of life options" [102].

The AMA, in 2019, after reviewing its historical opposition to MAID adopted a policy recommended by its Council on Ethical and Judicial Affairs (CEJA) [103]. This policy points to "the irreducible moral tensions at stake for physicians with respect to participating in assisted suicide," tensions evident in its own Code of Medical Ethics. The report notes the differing connotations of various terms (eg, "death with dignity," and "aid in dying" versus "physician-assisted suicide"), and it notes that physicians have widely divergent but equally strongly held views: "For some physicians, the sacredness of ministering to a terminally ill or dying patient and the duty not to abandon the patient precludes the possibility of supporting patients in hastening their death. For others, not to provide a prescription for lethal medication in response to a patient's sincere request violates that same commitment and duty. Both groups of physicians base their view of ethical practice on the guidance of Principle I of the AMA Principles of Medical Ethics: 'A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights.'"

The report is striking in its respect for views on both sides and emphasizes that physicians on either side of this debate may involve "thoughtful, morally admirable individuals" who hold diverging, yet equally deeply held and well-considered perspectives.

Thus, the report notes that "Opinion E-5.7 powerfully expresses the perspective of those who oppose physician-assisted suicide. Opinion 1.1.7 articulates the thoughtful moral basis for those who support assisted suicide."

●Opinion E-5.7 – "Physician-assisted suicide is fundamentally incompatible with the physician's role as healer, would be difficult or impossible to control, and would pose serious societal risks."

●Opinion 1.1.7 – "Preserving opportunity for physicians to act (or to refrain from acting) in accordance with the dictates of conscience in their professional practice is important for preserving the integrity of the medical profession as well as the integrity of the individual physician, on which patients and the public rely. Thus physicians should have considerable latitude to practice in accord with well-considered, deeply held beliefs that are central to their self-identities."

Noting that both these concerns are to be found in the Code, CEJA declined to amend it and decided to retain the term "physician-assisted suicide" as having the "greatest precision" and, most importantly, to clearly distinguish the practice from euthanasia. Thus, physicians who do provide assistance in dying and those who do not are understood to be acting in keeping with the provisions of the Code.

In general, professional medical associations have adopted one of about three positions:

●Opposed, primarily on the grounds that the physician is a healer and concerns about potential abuse.

●Neutral, including "engaged neutrality" encouraging conversation and debate, and acknowledging strong arguments on both sides and the need for more data. But this position is contested. On the one hand, it misses the opportunity to improve MAID where it is authorized [104]. On the other hand, it shirks professional societies' responsibility to take a stand on an issue central to the meaning of medical professionalism [105].

●In favor, primarily on grounds of patient autonomy. The decision about whether to practice is left to the judgment of the individual physician, acting in the interests of the patient.

In 2017, the American Association of Suicidology (AAS) issued a statement: "the practice of physician aid in dying, also called physician-assisted suicide, Death with Dignity, and MAID, is distinct from the behavior that has been traditionally and ordinarily described as 'suicide,' the tragic event our organization works so hard to prevent. Although there may be overlap between the two categories, legal physician-assisted deaths should not be considered to be cases of suicide and are, therefore, a matter outside the central focus of the AAS."

Again, we caution that this is a landscape in transition and that these positions may shift over time.

Concerns about abuse — Concerns about the potential for abuse of patients in vulnerable groups has played a major role in debates over legalization [106]. A 1997 study of MAID deaths in Oregon and MAID/VAE deaths in the Netherlands examined 10 potentially vulnerable groups: older adults, women, the uninsured, those with low educational status, the poor, members of underrepresented racial or ethnic groups, people with disabilities, people with sometimes stigmatized illnesses such as acquired immunodeficiency syndrome (AIDS), those with chronic physical or mental disabilities or chronic nonterminal illness, minors, and people with psychiatric illness, including depression and Alzheimer disease. This study found that, with the single exception of AIDS (largely based on data from before the development of potent antiretroviral drugs), the potential risks to vulnerable populations had not materialized; the majority of patients receiving MAID or VAE in both jurisdictions were comparatively well educated, affluent, and White [107].

Over the past years, concerns about abuse have been raised in Canada. There are several reported cases of noncompliance with MAID safeguards [108]. And there are several reported instances of Canadians seeking MAID for reasons such as poverty and a lack of access to adequate housing. There have been at least six reported instances of Veterans improperly being offered MAID by Veterans Affairs Canada employees [109]. While a Parliamentary Special Joint Committee on Medical Assistance in Dying heard these concerns, its February 2023 final report still recommends expanding MAID to mature minors, mental disorders, and advance requests [109]. Nevertheless, the Committee's report includes an important dissenting opinion and 44 expert witnesses who testified before the Committee issued their own dissenting report [110].

SPECIAL POPULATIONS

Children — Medical aid in dying (MAID) is legal under statutes in the United States only for adults 18 years of age or older. In the Netherlands, mature and relatively mature minors are understood to have some decision-making capacity and are not excluded under the guidelines, but because they are below the age of majority, they must be regarded as "vulnerable," and such decisions require heightened scrutiny. In the Netherlands, both MAID and voluntary active euthanasia (VAE) have been legal for minors between 12 and 16 years of age, requiring the consent of both parents. In 2020, the Netherlands extended MAID and VAE to children between 1 and 12. Belgium amended its law to allow euthanasia in minors in 2014 [111]. Colombia extended its law to allow euthanasia in minors in 2018. While Belgium, Colombia, and the Netherlands are the only places where this is allowed, Canada has been debating the issue [109].

Neonates — Euthanasia in neonates is sometimes discussed in connection with MAID/VAE. In these jurisdictions, euthanasia is regarded as a practice that, although extremely rare, is sometimes the best alternative in a bad situation where an infant is so severely affected that death is likely to occur anyway.

It is legal in the Netherlands under careful guidelines, known as the Groningen Protocol [51,112,113], which require heightened scrutiny and the informed consent of both parents; it is also legal in Belgium. In approximately 8 percent of deaths that occurred in Dutch infants under one year of age (about 87 deaths), all in newborns with spina bifida and hydrocephalus, the decision to stop life-sustaining treatments was followed by the "use of drugs with the explicit intention to hasten death" [114]. In 1 percent of all infant deaths (approximately 11 cases per year), drugs were administered with the intention of ending the infant's life when the infant was not dependent upon life-sustaining interventions. In the early Belgian cases, many of the infants were born prematurely and had intracranial hemorrhages, lung hypoplasia, or severe congenital malformations [115].

Importantly, the Groningen Protocol explicitly concerns infants who are not on life-sustaining interventions but who have "a hopeless prognosis and experience what parents and medical experts deem to be unbearable suffering." The authors of the protocol acknowledge that "it is difficult to define [such suffering] in the abstract." They give children with the most serious form of spina bifida as an example of the type of patient for whom the protocol was intended.

For some, the Groningen Protocol represents the very slippery slope they warned about when they opposed legalization of VAE and MAID. For others, it constitutes humane treatment of patients who are suffering without any prospect of improvement. While it is assumed that the parents have the best interests of their child at heart, their opinions and reasoning may be at odds with that of pediatricians and neonatologists in their roles as patient advocates. There is no doubt that such decisions involve painful circumstances for the parents and physicians; euthanasia is never performed unless the parents and physicians are in agreement about what best serves the welfare of the infant perceived as suffering intolerably without hope of recovery [116].

In the United States, euthanasia is not permitted in adults, much less neonates. When such cases of severe suffering and poor prognosis are faced, they are usually managed by a combination of aggressive symptom management and withdrawal of potentially life-sustaining therapies, accompanied by aggressive sedation if needed [117,118].

Patients with mental illness — In the United States, Death with Dignity statutes require decision-making capacity; where any mental illness, including depressive conditions, that affects decision-making capacity is suspected by either evaluating physician, a psychological or psychiatric consultation is required, and a positive finding can be grounds for exclusion. Hawaii requires a mental health screening for every patient seeking MAID, not only for those with suspected impaired capacity [49]. This is discussed elsewhere. (See "Medical aid in dying: Clinical considerations", section on 'Review legal requirements'.)

In the Netherlands and Belgium, euthanasia and MAID may be permitted for patients with psychiatric disorders because not all chronic psychiatric patients are found to be incompetent with respect to a request to be helped to die. The Dutch criterion for assistance in dying requires intolerable suffering that cannot be alleviated by any means acceptable to the patient, and the courts have established that this is not limited to physical pain or suffering. MAID/VAE in patients with mental illness is, nevertheless, controversial.

A 2015 study reviewing 66 cases of assisted dying by patients with psychiatric disorders in the Netherlands from 2011 to 2014, approximately two-thirds of them women, found that most patients had chronic, severe conditions with histories of attempted suicide and psychiatric hospitalization associated with personality disorders, social isolation, loneliness, depressive disorders (the primary psychiatric issue in 55 percent), psychotic posttraumatic stress or anxiety, or somatoform, neurocognitive, and eating disorders, as well as prolonged grief and autism [119]. Comorbidities with functional impairments were common. An editorial critiquing this study raised a number of concerns, among them the stability of the desire to die in some such cases, whether MAID/VAE served as a substitute for effective psychosocial intervention and support, and the fact that over half the patients refused at least some recommended treatment, usually on the basis of previously experienced and ineffective treatments [120].

There is disagreement between physicians when it comes to participating in ending the life of patients with psychiatric illness [121,122]. In a 2015 survey, only 34 percent of Dutch physicians found this conceivable [123]. Similar concerns are raised about the practice in Belgium, as well as concerns about inducing hopelessness in other psychiatric patients. The general view in the Netherlands and Belgium, however, is that the suffering involved in profound, intractable psychiatric disorders can be as severe as physical pain or suffering, and hence assistance in dying is warranted in at least some particularly difficult cases [124]. However, others raise the possibility that some correlates of suffering in psychiatric patients (such as low income) represent societal failures, for which assisted dying should not be used [125].

The issue of assisted dying for psychiatric disorders is also debated in Canada [124,126], where according to the 2015 Canadian Supreme Court ruling, the right to MAID is not limited to terminally ill patients but is available to a broader group suffering from a "grievous and irremediable medical condition (including an illness, disease, or disability) that causes enduring suffering that is intolerable to the individual in the circumstances of his or her condition," including psychiatric disorders [127,128]. MAID and VAE are not available on the grounds of mental illness until at least March 2024 while a Parliamentary review is conducted [129].

These questions are not directly relevant in the United States, where MAID is not legal for reasons of mental illness alone, but may be indirectly relevant where a patient's terminal physical illness is complicated by psychiatric issues that do not appear to interfere with their capacity for decision-making.

CHALLENGES FOR THE CLINICIAN

Personal and professional challenges — Health care practitioners, as well as ethicists, religious leaders, philosophers, lawyers, and laypersons with considerable palliative care knowledge, are represented on both sides of the debate over the boundaries of the physician's role in assisting in the death of a terminally ill patient [64,79]. However, no matter where clinicians stand ethically and morally on the permissibility of medical aid in dying (MAID) or voluntary active euthanasia (VAE), clinicians will still have to carefully consider and decide how they will respond to requests for assisted dying from their patients. Clinicians, ethicists, and lawmakers in different jurisdictions disagree about whether assisted dying should be reserved just for cases where excellent palliative care is insufficient to adequately relieve the suffering of a seriously ill patient, that is, as a "last resort," or whether patients facing eventual death may choose the timing and circumstances of their own death, given their own values, preferences, circumstances, and what counts for them as the "least worst" death among those they may face, and thereby forgo much of the predictable downhill course of their disease [130-132]. (See 'Urgent requests' above.)

Approaches to clinician limitations — Clinicians evaluating patients who have inquired about MAID and/or VAE must be aware of their own personal boundaries and the potential psychosocial consequences for themselves [133,134].

Formal or informal professional consultation, preferably with someone who has significant palliative care experience, is important. It may be challenging to find a colleague with the right amount of experience and expertise to provide clinical consultation and support. (See 'Information and consultation services for physicians' above.)

Strongly held clinician personal values that would prohibit participation in MAID or VAE should not be violated [39,135]. Nevertheless, patients for whom the possibility of MAID or VAE is important should not be "led on" by ambiguous promises to help if the clinician knows that they cannot assist. In such circumstances, clinicians who cannot help in this way should be prepared as early as possible to refer the patient to another clinician who can.

In all clinical environments, when exploring any end-of-life option, there is a need for honesty and clarity [52]. Physicians should emphasize their commitment to the patient and, above all, that the patient will not be abandoned by the clinician, even if there is disagreement about potential options such as MAID/VAE [130]. If the desired treatment cannot be provided by the main treating physician for moral reasons, they still have an obligation to seek common ground and a mutually acceptable approach with the patient to avoid the sense of feeling abandoned at this critical juncture [136].

SUMMARY AND RECOMMENDATIONS

●Terminology – Medical aid in dying (MAID), or physician-assisted dying (PAD), is a practice in which the physician provides a qualified patient, at their explicit request, with a prescription for a lethal medication that they can take on their own. Voluntary active euthanasia (VAE) or simply "euthanasia" are terms used to identify the practice whereby the physician administers a lethal medication at the patient's request, usually by intravenous (IV) injection. (See 'Terminology' above.)

●Legal status – These practices are legal in several countries. An interactive world map provides updated information on all countries. MAID is legal in several US states, and updated information is available from the Death with Dignity website. Voluntary active euthanasia is not legal anywhere in the United States. (See 'Legal status of assisted dying' above.)

●Requirements – There is considerable variation in the legal requirements for MAID and VAE across countries, including whether terminal illness is required. In some locations where both are allowed, there are specific requirements for each practice. Almost all jurisdictions permitting MAID or VAE require a request from a patient with decision-making capacity. (See 'Requirements of assisted dying practices' above.)

●Utilization – Oncology patients are primary utilizers of VAE and/or MAID, although the overall percentage of patients with cancer has decreased as requests from patients with neurodegenerative diseases have increased. Among the most commonly reported reasons for a MAID request are loss of autonomy, inability to engage in enjoyable activities, loss of dignity, symptom burden, and fear of pain (table 2). (See 'Utilization of MAID and VAE' above.)

●Addressing the patients concerns – General guidelines for responding to requests for assistance in dying are presented in the table (table 3). (See 'Addressing the patient’s concerns' above.)

●Urgent requests – Urgent requests should be treated as a "medical emergency" and addressed immediately (table 3). An urgent request should elicit a rapid, comprehensive evaluation to be sure that the clinician understands the root cause(s) of the request. (See 'Urgent requests' above.)

●Assessing decisional capacity – The clinician must ensure that the patient is thinking clearly, not delirious or psychotic, and not depressed in a way that is distorting judgment. If there is concern that mental illness could be a factor in the request or that decisional capacity may be impaired, psychiatric or psychological consultation may be legally required and should be obtained regardless. Clinicians should be aware of the legal requirements in their state or country in this regard. (See 'Assessing decisional capacity' above.)

●Referral to palliative care and hospice – Referral to hospice and/or palliative care is appropriate for all patients requesting MAID or VAE. (See 'Referral to palliative care and hospice' above.)

●Alternative treatments – All patients requesting MAID or VAE should be informed of alternatives that might both reduce or avoid suffering and be consonant with the their values and/or legal constraints. (See 'Alternative treatments' above.)

●Ethical concerns – Disagreement persists over the ethics of MAID and VAE, and there is variation in the attitudes of both the public and the medical profession. (See 'Ethical and social concerns' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Timothy Quill, MD, who contributed to an earlier version of this topic review.