**7. Help from the doctor: physician assisted suicide**

#### **7.1 The approval process**

The goal of the process is for a patient to persuade a doctor to write a prescription for a lethal dose of medication that the patient can take without assistance. Those states and countries that have passed laws to protect physicians who help patients die have set out eligibility requirements that are quite similar. In general patients must be 18 or over, terminally ill with 6 months or less to live, able to give their own consent, able to administer medication to themselves, and able to request lethal medication on more than one occasion, usually with an additional request in writing. Switzerland does not require that the patient be terminally ill and does accept non-residents.

After the physician makes a prescription (sometimes after a mandated delay) the medication remains in the patient's keeping until used. Most laws suggest actions for the patient (tell the family, do not use the lethal dose in a public place, and return medication for safe disposal if unused) but none of these suggestions are attached to penalties for violation. In the USA a medical person is not required to attend death, and reports are requested but not mandated.

#### **7.2 The medications**

There is no single painless completely lethal pill that doctors can prescribe. No pharmacy has such a pill—governments would immediately prohibit distribution of any pill with such a high degree of lethality. A decade ago, doctors would have prescribed barbiturates, pentobarbital or secobarbital. However, in recent years manufacturers have removed some medications from the market (no pharmaceutical manufacturer wants to be known as the provider of death medications). When barbiturates were available, a pharmacist would provide enough medication to make a lethal dose if taken all at once. That might require, say, 3 months of one-a-day capsules that would have to be opened, dumped into a slurry with something like applesauce to disguise the bitter taste, and eaten all at once to avoid falling asleep before a lethal dose is ingested, perhaps to awaken the next day still alive—with a headache. All this is simply to say that these methods are neither easy nor foolproof; many things can go wrong. Self-medication to death can be a risky, sometimes unsuccessful business.

More often now, doctors prescribe a mixture of three to five medications intended to work together to provide death. Oregon's 2021 data summary [11] shows that although barbiturates were the most common medications through about 2018, various combinations of diazepam, digoxin, morphine sulfate, and amitriptyline, with or without phenobarbital, have been introduced and evolved, with replacement of one drug by another and variations in dose of each ingredient. The law does not specify the medication, but simply permits a lethal prescription. Since there is no laboratory in which a physician can test a new lethal mixture on humans, there is a real possibility that a new mixture will not work as well as hoped when given to a real patient.

Although doctors who assist are committed to providing painless and effective death, an untested mixture might lead to an unsuccessful suicide attempt, or it might lead to an attempt marred by suffering and agony, perhaps without a doctor even present.

Assisted suicide, by definition, means that nobody but the patient is supposed to administer medications. Physically assisting by, for example, forcing more medication into a semiconscious patient, could lead to being charged with a felony. It is not possible without risking prosecution to give more medication if the patient is already unconscious and cannot take more medication unassisted. In the rare countries that permit physicians to provide euthanasia by administering lethal medications, assisted suicide becomes much less common than euthanasia. When doctors give lethal medication, they do not stop until the patient is dead. Moreover, they can give intravenous medications that work almost instantaneously, as in the operating room, rather than prescribing massive doses of oral medications that may work slowly, may produce incomplete effects if doses are too low, may be inappropriate medications in the first place, or may cause vomiting and loss of medication that cannot be replaced because the patient is already falling asleep.

#### **7.3 Ethical issues**

Ethical issues that arise with assisted suicide concern selection of appropriate candidates, protection of candidates susceptible to coercion, custody of lethal medication once dispensed, accommodation for patients incapable of self-administration, and accuracy of tracking results. Patients with mental illness are presumed to be screened out, but only two states require mental health screening. Other states only suggest it. As mentioned, not every lethal dose is consumed, and no current mechanism tracks all the medication dispensed. There is no requirement for medical attendance at death, and no firm requirement for reporting events during medication administration. As written, the laws do not accommodate patients with physical disabilities that make self-administration impossible (quadriplegia, neurodegenerative diseases).

## **8. Help from the doctor: euthanasia**

#### **8.1 The approval process**

Countries that permit euthanasia are rare, but their criteria for eligibility for euthanasia share some elements. Patients who qualify to have doctors end their lives are generally required to be adults, capable of sound decisions, free of coercion, and suffering some sort of grievous and irreversible medical condition. In Canada, death needs to be foreseeable. Belgium requires constant and unbearable suffering that cannot be alleviated. Luxembourg requires a grave and incurable condition. Spain requires a serious or incurable illness or a chronic or incapacitating condition that causes intolerable suffering. Colombia requires a terminal illness but has expanded its reach to nonterminal illness such as chronic obstructive pulmonary disease or amyotrophic lateral sclerosis.

The Netherlands has experienced legalized euthanasia for longer than any other country and has broadened their criteria over the years. The Netherlands permits euthanasia for terminally ill children as young as 12 years old. In addition, in the Groningen Protocol [12], the Netherlands has authorized newborn euthanasia for

children born with unbearable suffering, if parents, their physician, and an independent physician agree. Dutch law requires hopeless and unbearable suffering, but a provision that would allow assisted death without a terminal illness for a person who feels they have completed life has been much discussed.

#### **8.2 The medications**

Medication given by a physician to end life can be given as a drink or can be administered intravenously. The drink is usually a strong barbiturate potion (10 grams or more), often preceded by an anti-nausea drug. Intravenous medications mirror those used to start a surgical anesthetic—a barbiturate when thiopental was easily available, and now more frequently propofol, followed by a paralyzing drug after the patient has lost consciousness. Though the medications may seem identical, the euthanasia protocol would be to give the medications and allow the patient to become unconscious, stop breathing, and die of oxygen shortage. The euthanasia patient never awakens. An operating room protocol, on the other hand, might use the same medications but would supplement the breathing and provide oxygen to keep the brain alive, monitoring every breath and every heartbeat to keep the patient stable, administering more anesthetic agent in the IV or by inhalation as needed for the patient to remain unconscious until time to awaken.

#### **8.3 Ethical questions**

Beyond those questions inherent in giving a doctor the freedom to take an action that ends a patient's life, questions around euthanasia tend to be of the "slippery slope" variety. That is, if it is permissible to end life for a 12-year-old, how about an unusually mature 10- or 11-year-old? What about a patient who asks for euthanasia when of sound mind, but now has such significant dementia that the patient can no longer confirm consent? If voluntary euthanasia is permitted, how about those cases where the patient can no longer consent but those charged with the patient's welfare are sure that the patient would have wanted life to end?
