Euthanasia, Assisted suicide and the Medical Profession: ‘Keep Doctors Out of It’.

Doctors are not necessary for the regulation or practice of euthanasia and assisted suicide
Many doctors want no part in euthanasia or assisted suicide, including some who, on a personal level, are not opposed in principle. As stated in “An Open Letter to New Zealanders” signed to date by more than 300 doctors, “Doctors are not necessary in the regulation or practice of assisted suicide.”1

There is evidence that the key reason proponents of a law change insist on the ongoing and unquestioned association between euthanasia/assisted suicide and the medical profession is a political one – a means of providing a cloak of medical legitimacy while promoting the idea that euthanasia and assisted suicide are a form of ‘medical treatment’. 

Euthanasia proponents such as Rob Jonquiere from the Netherlands openly admit that campaigners in The Netherlands originally wanted to argue for euthanasia on the grounds of ‘self-determination’ (that is, on the basis of unfettered personal choice and without needing to fulfil any particular conditions such as being terminally ill). However, it was deemed necessary at the time for doctors to be involved in order to gain public acceptance. To quote Jonquiere who has visited New Zealand: “Politicians recognized immediately the importance that only a medical perspective would make legalization of assisted dying possible.” 2

Patients look to their doctors, not just for treatment, but also in many cases (and especially where they are seriously-ill) for guidance.  How a doctor responds to a request for ‘something to end it all’ has a significant impact on a patient’s outlook. Palliative doctors and nurses report that patients ask for 'help to end it all', not because they are serious about dying, but to show they are up against it and to seek reassurance.  If euthanasia or assisted suicide were available, and a doctor responded positively to a request for 'assisted dying', he or she risks sending the message, however unintended, that the patient's condition and outlook are every bit as bad as the patient fears and that death is the best option. As stated by one doctor:

In my practice, more than two dozen patients have discussed assisted suicide with me. Most did not have a terminal diagnosis. One inquiry came from a patient with a progressive form of multiple sclerosis. He was in a wheelchair yet lived an active life as a general contractor. I asked him how the disease affected his life. He acknowledged that MS was a major challenge and told me that if he got too much worse, he might want to "just end it." I told him I could understand his fear and frustration and even his belief that assisted suicide might be a good option. I also told him that should he become sicker or weaker, I would work to provide him the best care and support available. No matter how debilitated he might become, his life was, and would always be, inherently valuable. As such, I said that would I not recommend nor would I participate in his suicide. He simply replied: "Thank you."

The way that physicians respond to patients' requests for lethal drugs has a profound effect on their choices and their view of themselves and their inherent worth. Such patients deserve doctors who will support them through their illnesses, not offer them a quick exit. 3

The changing set-up of GP medical practices in various countries such as the United Kingdom and New Zealand also makes it much less likely that, in the future, patients will have a single doctor that they see regularly. This is likely to have implications for doctors’ deeper knowledge of their patients. As Living and Dying Well state: “In these days of the multi-partner GP practice and fewer home visits, many doctors know little of their patients' lives beyond the consulting room or the hospital ward.” In the UK this has resulted in doctors expressing concern “about their ability to make judgements which go way beyond the medical field – judgements about, for example, how well-considered, settled and voluntary is a request for PAS.” 4 This is precisely what doctors would be asked to do in any future physician-assisted euthanasia or physician-assisted suicide regime. 

Euthanasia and assisted suicide contravene medical ethics
Professional medical groups, such as the New Zealand Medical Association (NZMA) and world Medical Association (WMA), abide by long-established ethical codes to guide their members, codes that draw on principles developed over many centuries of reflecting on what is good for the profession and good for society (patients). In both the Western and Eastern traditions of medicine one of the most important principles is embodied in the maxim that doctors should first do no harm to their patients. This has long been understood, in ethics and in practice, as establishing a ‘clear line’ that doctors will never cross to intentionally end the lives of their patients. The WMA 5 and NZMA 6 position statements that euthanasia and assisted suicide would remain unethical even if they became lawful reflects the view of the majority of those in the medical profession that maintaining the integrity of their profession requires that they not compromise the ‘first do no harm’ principle, upon which the trust of the public resides, by becoming involved in either euthanasia or assisted suicide. 

Other key medical professional groups within New Zealand have similar views, including the Australia and New Zealand Society of Palliative Medicine 7 and Palliative Care Nurses New Zealand 8. The British Geriatrics Society position on Physician Assisted Suicide (2015) also speaks directly to the impact assisted suicide will have on medicine when it states that “crossing the boundary between acknowledging that death is inevitable and taking active steps to assist the patient to die changes fundamentally the role of the physician, changes the doctor-patient relationship and changes the role of medicine in society … [and] will lead to a change in attitude to death in society and also within the medical profession.” 9 In the UK the Royal College of Physicians has stated that a doctor’s duty of care for patients “does not include being in any way part of their suicide”, and this sentiment is shared by the BMA, the Royal College of Surgeons of England, the Royal College of General Practitioners and the Association for Palliative Medicine. Moreover, an opinion survey of 1,000 UK GPs in 2015 revealed that only one in seven of them would be prepared to consider a request for PAS. 10

It is hard to imagine that so many medical groups would take such a hard-line stance towards the involvement of the medical profession in euthanasia and assisted suicide if they believed that it would be in the best interests of the doctor-patient relationship or if they thought it would impact positively (or even neutrally) on the high-trust relationship that currently exists between society and the medical professions. The European Association for Palliative Care, which includes amongst its members countries where euthanasia and assisted suicide are allowed, stated: “if the ending of life becomes another option [for physicians], this might jeopardise the relationship between patient and physician.”  11

Physician assisted suicide or euthanasia act in opposition to the physician’s role as ‘healer’ which may not involve ‘cure’ but the support of a patient’s journey towards “integrity and wholeness.” 12 Bourdreau and Somerville also note that “most physicians accept the healer role as a fundamental and enduring characteristic of the profession” and that this role is incompatible with “serving as a collaborator in requested death.” 13 Randall and Downie see it as a matter of getting the fundamental question right: 

It is … essential that the correct question is posed. It should be whether AS/VE, as part of the justice system and involving a legal procedure including safeguards, should be legalised. The question should not be whether ‘physician-assisted suicide’ or ‘euthanasia by doctors’ should be legalised, since it is simply irrational to consider AS/VE as ‘treatments’ or ‘healthcare interventions’. Instead, AS/VE must be debated in a context where they are explicitly excluded from the healthcare domain. 14

Impact of euthanasia and assisted suicide on medical practitioners and their integrity
In addition to the effects on the profession, and on the physician’s role as healer, there is the potential negative impact of taking part in physician assisted suicide or euthanasia on individual doctor’s well-being. One report found: 

Physician participation in assisted suicide or euthanasia can have a profound harmful effect on the involved physicians. Doctors must take responsibility for causing the patient's death. There is a huge burden on conscience, tangled emotions and a large psychological toll on the participating physicians. Many physicians describe feelings of isolation. Published evidence indicates that some patients and others are pressuring and intimidating doctors to assist in suicides. Some doctors feel they have no choice but to be involved in assisted suicides. Oregon physicians are decreasingly present at the time of the assisted suicide. 15

The fact that in places where assisted suicide is available, such as Oregon and Washington State, “less than 1 percent of licensed physicians write prescriptions for physician-assisted suicide per year” 16 further emphasises the view that doctors by and large reject the idea that ending the lives of their patients is congruent with their profession or in the best interests of their patients. 

Insofar as physicians enjoy societal trust, it is because since Hippocrates, physicians have maintained solidarity with those who are sick and disabled, seeking only to heal and refusing to use their skills and powers to do harm. That is why Doctors Without Borders treats injured Taliban soldiers. It is why physicians have refused to participate in capital punishment, or to be active combatants, or to cooperate with torture. It is why physicians have refused to help patients commit suicide. Many patients with terminal illness fear unbearable pain or other symptoms. The physicians’ role is to care for them in their illness so as to relieve pain or otherwise help them bear up under the symptoms they endure. Many patients loath the prospect of abject debility. The physician’s role is to maintain solidarity with those whose health is diminished, not to imply that debility renders a patient’s life not worth living. 17

It is well-established that, in countries where euthanasia is legally available, compliance remains a critical issue with significant numbers of doctors failing to report cases of euthanasia, and considerable numbers of people being euthanised by doctors and nurses without having provided explicit consent. In both Belgium 18 and the Netherlands 19,20 there is robust evidence that euthanasia in these countries is regularly carried out without an explicit patient request, even though that is required by law. Various studies have also established that large numbers of cases of euthanasia in Belgium and the Netherlands are not reported, as is required by law in both countries. One study in Belgium found that only half of all estimated cases of euthanasia were reported to the Federal Control and Evaluation Committee. 21 In the Netherlands it was found that about 20% of cases of euthanasia were not reported, as is required under the Euthanasia Act. 22

The fact that ineligible patients are receiving lethal prescriptions, and that reporting of cases is deficient, implicates the medical profession in a way that is only negative and which is certain to impact negatively on the high levels of trust that the public currently place in the institution of medicine and in the medical profession considered as a whole. 

All of the above evidence points to the fact that there are very real risks posed by the introduction of physician-assisted euthanasia and physician-assisted suicide for the integrity of the medical profession and the quality of the relationship between doctors and patients. 

There is also evidence from around the world which shows that certain groups, including some of the most vulnerable people in society, already have good reasons (based on their lived reality) to mistrust the medical profession without the added risks that would be posed by a euthanasia or assisted suicide regime. 60 percent of respondents in an NOP omnibus survey, carried out in 2004 for the UK Voluntary Euthanasia Society, felt that elderly people might be more nervous of going into hospital if euthanasia were to be legalised. 23

A recent article by Jennifer Cohen in Voices in Bioethics describes a history of unethical research on African Americans and refers to a 2006 study which found that African Americans had higher levels of distrust in physicians because of their knowledge of historical unethical experimental treatment of African Americans. 24 More specifically, it is widely known that the introduction of euthanasia in the Northern Territory in 1995 created a negative backlash amongst many of the Aboriginal people, most of all the Aboriginal Health Workers themselves who were concerned “that their position within their own communities might be irreparably damaged by the existence of the legislation.” 25

Medically assisted euthanasia and assisted suicide dangerous in an ableist society
Speaking from his own personal experience, New Zealander Dr John Fox reflects insightfully on the impact of co-opting the medical profession in the practice of euthanasia or assisted suicide: 

It’s that trust, that moment of connectedness and care, I rely on as a disabled person. And it’s that trust assisted dying attacks. It tears the trust between medical professionals and their patients that doctors will cure, not kill. It brings the spectre of killing as an option to every death bed, to every overworked administrator, to every hospital looking for budget cuts. 26

Similarly, Baroness Jane Campbell (a disability and human rights activist who has spinal muscular dystrophy) told fellow peers in the UK to 

… imagine that it is already law and that I ask for assistance to die. Do your Lordships think that I would be refused? No; you can be sure that there would be doctors and lawyers willing to support my right to die. Sadly, many would put their energies into that rather than improving my situation or helping me to change my mind. The Bill offers no comfort to me. It frightens me because, in periods of greatest difficulty, I know that I might be tempted to use it. It only adds to the burdens and challenges which life holds for me. 27

Carol Cleigh Sutton succinctly summarises the impact of legalising euthanasia or assisted suicide on disabled people when she writes: 

The very heart of the argument for assisted suicide/euthanasia is that an individual may be better off dead than disabled. The fact that this argument can be made in respectable public forums demonstrates just how ableist this society is … ableism, like racism and sexism, is an ugly prejudice that society holds towards its minority members …This ideology, which we call Better Dead Than Disabled, permeates ableist society, but even more deeply infects the medical system, and the more society in general accepts it, the more we encounter it every time we have to deal with medicine. 28

It is naïve to think that the confidence and trust that disabled people have in the medical profession will not be further harmed by the introduction of euthanasia and assisted suicide.

Concluding comments
The European Association for Palliative Care (2015) has stated that “the impact of characterising euthanasia as a medical treatment on physicians’ professional identity and on the institutions of medicine and law has not been evaluated yet.” 29 This means that the question is, at best, ‘wide-open’. 

We have presented an argument that the practice of medically assisted euthanasia or medically-assisted suicide will pose a real risk for the medical professions themselves, will negatively shape the way in which the medical professions will come to be regarded in the future and will potentially undermine the quality of care for patients at the end of life, in particular those who are disabled.

Margaret Somerville puts it well: “Health-care professionals need a clear line that powerfully proves to them, their patients, and society that they do not inflict death; both their patients and the public need to know with absolute certainty -- and be able to trust -- that this is the case. Anything that would blur the line, damage that trust, or make them less sensitive to their primary obligations to protect life is unacceptable. Legalizing euthanasia would do all of these things.” 30

Early in the 52nd New Zealand Parliament MPs will have to consider the possibility of legalising euthanasia and/or assisted suicide in the form of David Seymour’s Bill. While we will continue to argue that any changes to the current law are unnecessary and dangerous and while this will continue to be debated and challenged by proponents, all should be able to agree that the risks and problems associated with involving doctors, combined with the fact that doctors are not necessary in the regulation or practice of assisted suicide, means that parliament must reject outright any proposed Bills that have doctors at their centre. The evidence points to this being the most coherent and ethically defensible response.




[2] Fourth Annual SOARS Lecture (London – September 20, 2013).

[3] William L. Toffler. “A Doctor-Assisted Disaster for Medicine”. Wall Street Journal (online)Aug 17, 2015.








[11] Board Members of the EAPC., "Euthanasia and Physician-Assisted Suicide: A White Paper from the European Association for Palliative Care." Palliative Medicine (2015).

[12] Boudreau, J. Donald, and Margaret A. Somerville. "Euthanasia is not medical treatment." British medical bulletin 106.1 (2013).

[13] Ibid.

[14] Randall, Fiona, and Robin Downie. "Assisted suicide and voluntary euthanasia: role contradictions for physicians." Clinical Medicine 10.4 (2010): 323-325.

[15] Stevens, Kenneth R. "Emotional and psychological effects of physician-assisted suicide and euthanasia on participating physicians." The Linacre Quarterly 73.3 (2006): 203-216.

[16] Emanuel, E J., B. Onwuteaka-Philipsen, J W. Urwin, and J. Cohen. "Attitudes and Practices of Euthanasia and Physician-Assisted Suicide in the United States, Canada and Europe." JAMA 316, no. 1 (2016): 79-90.

[17] Yang, Y. Tony, and Farr A. Curlin. "Why physicians should oppose assisted suicide." Jama 315.3 (2016): 247-248.

[18] Chambaere, Kenneth, et al. "Physician-assisted deaths under the euthanasia law in Belgium: a population-based survey." Canadian Medical Association Journal 182.9 (2010): 895-901. Of 208 deaths reported, 66 were without an explicit request. In 77.9% of these cases, the decision was not discussed with the patient.

[19] Onwuteaka-Philipsen, B.D. et al. “Trends in end-of-life practices before and after the enactment of the euthanasia law in the Netherlands from 1990 to 2010: a repeated cross-sectional survey.” The Lancet, 2012; 380: 908-15. In 2010, of 475 deaths as a result of euthanasia, 13 (2.7%) were without an explicit patient request.

[20] Van der Maas, Paul J., et al. "Euthanasia, physician-assisted suicide, and other medical practices involving the end of life in the Netherlands, 1990–1995." New England Journal of Medicine 335.22 (1996): 1699-1705. In 1995, 0.7% of deaths involved ending the patient’s life without the patient’s explicit, concurrent request.

[21] Van der Maas, Paul J., et al. "Euthanasia, physician-assisted suicide, and other medical practices involving the end of life in the Netherlands, 1990–1995." New England Journal of Medicine 335.22 (1996): 1699-1705. In 1995, 0.7% of deaths involved ending the patient’s life without the patient’s explicit, concurrent request.

[22] Van der Heide, Agnes, et al. "End-of-life practices in the Netherlands under the Euthanasia Act." New England Journal of Medicine 356.19 (2007): 1957-1965.

[23] at 223.

[24] Jacobs, Elizabeth A., et al. "Understanding African Americans' views of the trustworthiness of physicians." Journal of general internal medicine 21.6 (2006): 642-647

[25] Report to Aboriginal Reference Group: Rights of the Terminally ill Act Education Program, at 1 (July 23, 1996).




[29] Radbruch, Lukas, et al. "Euthanasia and physician-assisted suicide: a white paper from the European Association for Palliative Care." Palliative medicine30.2 (2016): 104-116.