Over the last few years, the United States has seen a significant increase in the number of states allowing physician-assisted suicide.1 Similar to euthanasia, where a doctor intentionally causes a patient's death, physician-assisted suicide involves the prescription of lethal drugs that patients can then take themselves.
Currently, 10 states and the District of Columbia allow for physician-assisted suicide.2 As of 2023, residency requirements no longer apply in some of these states. Nonresidents can legally travel to these locations to end their lives. This process is known as death tourism.
Death tourism, also called suicide tourism, has always existed, but it is slowly growing more common. This is not only due to changing laws but because doctors and clinics in those states are marketing their services to nonresidents.3 Today, Vermont, having changed its law in May 2023, is technically the only state where this is legal.4
Residency requirements in other states, however, are often not obeyed. This is particularly true in Oregon. After a 2022 lawsuit regarding the residency requirement, the Oregon Medical Board and the Oregon Health Authority agreed to stop enforcing the rule and are pushing to change the law.5
While Vermont's legal change is too recent to provide data on its effects, Oregon has some of the best information available. Yet it also has out-of-state data limitations. For instance, Oregon tracks physician-prescribed suicide deaths through death certificates. But it only receives death certificates for Oregon residents or for people who die in the state. If an out-of-state resident received a prescription in Oregon but then left the state to die, that person's death would not be included in the physician-assisted suicide statistics.
Current statistics show that people from out of state seeking PAS in Oregon make up only around 1% of known deaths, but the true number may be much higher.6
Physician-assisted suicide and euthanasia are often relatively popular ideas, at least in principle. Nearly three-fourths of American adults support voluntary euthanasia to some degree.7 One study revealed that around 60% of doctors believe that physician-assisted suicide should be legal.8
The same study, however, also shows that doctors are misinformed about relevant facts. Nearly half (49%) of respondents said that pain is the most common reason that people seek physician-assisted suicide. But, as the study reveals about Oregon respondents, "physical pain is not even in the top five reasons why patients seek PAS." Instead, it is often an attempt to regain some sense of control.
One study reports that, rather than becoming an option for those in extreme situations, the legalization of physician-assisted suicide is often directly linked to the elimination of other options for patients.9
In Oregon, legalized physician-assisted suicide has been accompanied by substantial cuts to over 150 services for the elderly and for people with disabilities or terminal illnesses. Additional attempts were made to limit funding for powerful painkillers and block funding for antidepressants.
In essence, the legalization of physician-assisted suicide in the state was followed almost immediately by the rationing of healthcare for the poor. Funding for countless actual healthcare programs was terminated and replaced with coverage for lethal prescriptions categorized as treatments and comfort care.
Because of these changes, the study reports, "Dying patients in Oregon are nearly twice as likely to experience moderate or severe pain during the last week of life, as reported by surviving relatives, compared with patients before the law took effect."
Patients and even doctors themselves have a startling lack of control in the process of PAS.10 For example, the law allows other people, such as a patient's heir, to talk for them during the process of requesting physician-assisted suicide, and there is no oversight for its administration.
Doctor shopping is another issue. If a doctor denies a prescription, patients may go from one doctor to another until they finally find one willing to give them a lethal dose. In fact, before officials stopped tracking this data in Oregon, they found that 59% of patients were rejected by at least one doctor before finding one willing to prescribe the lethal drug.11
This means that these doctors may have little actual doctor-patient relationship with the people they are prescribing to.
In some states, the consultation required before prescribing "suicide drugs" can be done virtually without even a face-to-face meeting with a doctor.12 This matter is only made more problematic through death tourism, in which patients may have no relationship at all with their doctors.
While people may believe that there are laws and to prevent abuse, these safeguards are regularly ignored. One report found that, in violation of the law, nearly half of euthanasia cases in Belgium were not reported by doctors.13 Many of these cases did not meet medical requirements either.
Additionally, when physician-assisted suicide is legally recognized, nurses and doctors may circumvent restrictions to end their patients' lives.14 In doing so, they ignore codes of conduct and regulations put in place to protect patients.
While many people may still believe that physician-assisted suicide is a personal choice, it may not be a choice that is always freely made. Patients in states or countries that legalize this practice may be pressured about the decision and made to feel like a burden if they do not end their lives.
As we see in the state of Oregon, the percentage of patients seeking physician-assisted suicide because they felt like a burden on their family rose massively after legalization and continues to do so. Between 1997 and 1998, when it was legalized, only 13% of patients sought physician-assisted suicide to avoid being a burden.15 In 1999, that number had increased to 26%.16 According to the most recent report in 2021, more than 54% of people feared that they would become a burden if they did not kill themselves.17
Reports show that physician-assisted suicide may be motivated by feelings of guilt or fears over medical costs rather than a desire to escape pain.18 Whether these feelings are prompted by others or come solely from selfless places, this sense of the infirm being nothing more than a burden may be exacerbated by the legality of medical assistance in death.
One of the biggest dangers of physician-assisted suicide is forced euthanasia. Not only are there pressures on patients to seek suicide, but family members or those with a power of attorney may make the choice for them whether they like it or not.
This step from physician-assisted suicide to euthanasia - from prescribing drugs to administering them - is not a large one.
Many cases of euthanasia don't involve explicit patient consent. A survey of 2021 death certificates in the Netherlands, for example, revealed 517 such deaths.19 An earlier study found that almost one in every five people who are euthanized in the Netherlands did not give explicit consent. In Belgium, the number of involuntary euthanasia cases is three times higher.20
This includes not just situations where patients cannot consent, such as when they are in a coma, but situations where they have the capacity but have not actually given their consent.
The legalization of physician-assisted suicide is an incredibly appealing idea to many people. Having control of the time and place of one's death, as well as a right to die, can seem attractive and just. But we cannot ignore the dangerous outcomes of such policies on both individuals and society.
When we flirt with death, there is no easy stopping point.21 The exceptions of yesterday become the policies of today, and what safeguards we create to protect patients will be called nothing more than barriers to access tomorrow. Physician-assisted suicide will become euthanasia, euthanasia will become involuntary, and the society we create from there will not be safe for anyone.