When Death is Sought Assisted

Suicide and Euthanasia in the

Medical Context
1995, New York State Task Force on Life and the
Law

Preface
Governor Mario M. Cuomo convened the Task Force on
Life and the Law in 1984, giving it a broad mandate to
recommend public policy on issues raised by medical
advances. That mandate included decisions about lifesustaining treatment. Assisted suicide and euthanasia
were not on the agenda initially presented to the Task
Force. Nor was the prospect of legalizing the practices
even remotely part of public consideration at that time.
Recently, however, public debate about the practices has
intensified. Although no major efforts to legalize assisted
suicide and euthanasia have been launched in New York
State, we chose to examine the practices and to release
this report in order to contribute to the debate unfolding in
New York and nationally.
Since the Task Forces inception, we have proposed four
laws to promote the right to decide about medical
treatment, including life sustaining measures. Three of
those proposals, establishing procedures for do-notresuscitate orders in health care facilities and in
community settings, and authorizing individuals to create
health care proxies, are now law. Our fourth proposal for
legislation is pending before the New York State
Legislature. It would grant family members and others
close to the patient the authority to decide about
treatment, including life-sustaining measures, for
individuals who are too young or too ill to decide for
themselves and who have not left advance treatment
instructions or signed a health care proxy.
In this report, we unanimously recommend that New
York laws prohibiting assisted suicide and euthanasia
should not be changed. In essence, we propose a clear line
for public policies and medical practice between forgoing
medical interventions and assistance to commit suicide or
euthanasia. Decisions to forgo treatment are an integral
part of medical practice; the use of many treatments
would be inconceivable without the ability to withhold or
to stop the treatments in appropriate cases. We have
identified the wishes and interests of patients as the
primary guideposts for those decisions.
Assisted suicide and euthanasia would carry us into new
terrain American society has never sanctioned assisted
suicide or mercy killing. We believe that the practices
would be profoundly dangerous for large segments of the
population, especially in light of the widespread failure of

American medicine to treat pain adequately or to diagnose

and treat depression in many cases. The risks would
extend to all individuals who are ill. They would be most
severe for those whose autonomy and well-being are
already compromised by poverty, lack of access to good
medical care, or membership in a stigmatized social
group. The risks of legalizing assisted suicide and
euthanasia for these individuals, in a health care system
and society that cannot effectively protect against the
impact of inadequate resources and ingrained social
disadvantage, are likely to be extraordinary.
The distinction between the refusal of medical treatment
and assisted suicide or euthanasia has not been wellarticulated in the broader public debate. In fact, the oftenused rubric of the right to die obscures the distinction.
The medias coverage of individual cases as a way of
presenting the issues to the public also blurs the
difference between a private act and public policy;
between what individuals might find desirable or feasible
in a particular case and what would actually occur in
doctors offices, clinics, and hospitals, if assisted suicide
and euthanasia became a standard part of medical
practice. Public opinion polls, focusing on whether
individuals think they might want these options for
themselves one day, also offer little insight about what it
would mean for society to make assisted suicide or direct
killing practices sanctioned and regulated by the state or
supervised by the medical profession itself.
We hope that this report will highlight certain critical
distinctions and questions for public consideration. We
also hope that the report and our recommendations will
improve access to pain relief and the palliation of
symptoms, not only for those who are terminally ill or
contemplating suicide, but for all patients.
We sought the opinions and expertise of many individuals
while developing our recommendations. We extend our
gratitude to all those who generously lent their time and
perspective to our discussion. Four individuals served as
consultants in our deliberations: Nessa Coyle, R.N.,
Jimmie Holland, M.D., Diane Meier, M.D., and Norton
Spritz, M.D. The report does not necessarily reflect their
personal views about assisted suicide and euthanasia, but
it does reflect their experience and insight in caring for
those who are severely and terminally ill. We benefitted
greatly from their expertise and their participation with us
as we explored these difficult questions. We also extend
our gratitude to Chris Hyman and Peter Millock who
provided invaluable guidance throughout our
deliberations.

Executive Summary
Over the past two decades, the right to decide about
medical treatment, including the right to refuse lifesustaining measures, has become a fundamental tenet

2 / New York State Task Force on Life and the Law / When Death is Sought
of American law. The Task Force has sought to make
this right a reality for the citizens of New York State,
recommending legislation on do-not-resuscitate
orders, health care proxies, and, most recently,
surrogate decision making for patients without
capacity. The Task Forces legislative proposals
reflect a deep respect for individual autonomy as well
as concern for the welfare of individuals nearing the
end of life.
Recent proposals to legalize assisted suicide and
euthanasia in some states would transform the right
to decide about medical treatment into a far broader
right to control the timing and manner of death. After
lengthy deliberations, the Task Force unanimously
concluded that the dangers of such a dramatic change
in public policy would far outweigh any possible
benefits. In light of the pervasive failure of our health
care system to treat pain and diagnose and treat
depression, legalizing assisted suicide and euthanasia
would be profoundly dangerous for many individuals
who are ill and vulnerable. The risks would be most
severe for those who are elderly, poor, socially
disadvantaged, or without access to good medical
care.
In the course of their research, many Task Force
members were particularly struck by the degree to
which requests for suicide assistance by terminally ill
patients are correlated with clinical depression or
unmanaged pain, both of which can ordinarily be
treated effectively with current medical techniques.
As a society, we can do far more to benefit these
patients by improving pain relief and palliative care
than by changing the law to make it easier to commit
suicide or to obtain a lethal injection.

In General
This report, like much of the current debate, focuses
solely on assisted suicide and euthanasia by
physicians, nurses, or other health care professionals.
In this report, assisted suicide refers to actions by
one person to contribute to the death of another, by
providing medication or a prescription or taking other
steps. With assisted suicide, the person who dies
directly takes his or her own life. In contrast,
euthanasia refers to direct measures, such as a
lethal injection, by one person to end another
persons life for benevolent motives. Both practices
are distinct from the withdrawal or withholding of
life-sustaining treatment in accord with accepted
ethical and medical standards.

The Clinical Background

Contrary to what many believe, the vast majority of

individuals who are terminally ill or facing severe
pain or disability are not suicidal. Moreover,
terminally ill patients who do desire suicide or
euthanasia often suffer from a treatable mental
disorder, most commonly depression. When these
patients receive appropriate treatment for depression,
they usually abandon the wish to commit suicide.
Depression is distinct from the normal feelings of
sadness generally experienced by terminally ill
patients. It is a myth that major clinical depression
ordinarily accompanies terminal illness.
While thoughts about suicide (suicidal ideation) are
a significant risk factor for suicide, many individuals
experience suicidal ideation but never commit or
attempt suicide. These thoughts can be an important
and normal component of coping with terminal
illness.
Uncontrolled pain, particularly when accompanied by
feelings of hopelessness and untreated depression, is
a significant contributing factor for suicide and
suicidal ideation. Medications and pain relief
techniques now make it possible to treat pain
effectively for most patients.
Despite the fact that effective treatments are
available, severely and terminally ill patients
generally do not receive adequate relief from pain.
Studies report that over 50 percent of cancer patients
suffer from unrelieved pain, even though patients wit
h cancer are more likely than other patients to receive
pain treatment.
Numerous barriers contribute to the pervasive
inadequacy of pain relief and palliative care in
current clinical practice, including a lack of
professional knowledge and training, unjustified fears
about physical and psychological dependence, poor
pain assessment, pharmacy practices, and the
reluctance of patients and their families to seek pain
relief.

Existing Law
Under New York law, competent adults have a firmly
established right to accept or reject medical
treatment, including life-sustaining measures.
Competent adults also have the right to create
advance directives for treatment decisions, such as a
living will or health care proxy, to be used in the
event they lose the capacity to make medical
decisions for themselves.
New York is one of two states in the nation that does
not currently permit the withdrawal or withholding of
life-sustaining treatment from an incapacitated adult
patient who has not signed a health care proxy or

3 / New York State Task Force on Life and the Law / When Death is Sought
provided clear and convincing evidence of h is or her
treatment wishes. Legislation proposed by the Task
Force, under consideration by the New York State
Legislature, would permit family members and others
close to the patient to decide about life-sustaining
treatment in these circumstances.
Neither suicide nor attempted suicide is a criminal
offense in any state. Like most other states, New
York prohibits assisting a suicide. Euthanasia is
barred by law in every state, including New York.
Suicide assistance generally constitutes a form of
second-degree manslaughter under New York law.
Euthanasia falls under the definition of seconddegree murder, regardless of whether the person
consents to being killed.
The provision of pain medication is legally
acceptable even if it may hasten the patients death, if
the medication is intended to alleviate pain or severe
discomfort, not to cause death, and is provided in
accord with accepted medical standards.
Neither the United States nor the New York State
Constitution grants individuals a right to suicide
assistance or euthanasia. Although the right to refuse
life-sustaining treatment is constitutionally protected,
the courts have consistently distinguished the right to
refuse treatment from a right to commit suicide. In
affirming the right to forgo treatment, the courts have
recognized the states legitimate interest in
preventing suicide.

Ethnical Issues
Three general positions about assisted suicide and
euthanasia have emerged in the ethical and medical
literature. First, some believe that both practices are
morally wrong and should not be performed. Others
hold that assisted suicide or euthanasia are legitimate
in rare and exceptional cases, but that professional
standards and the law should not be changed to
authorize either practice. Finally, some argue that
assisted suicide, or both assisted suicide and
euthanasia, should be recognized as legally and
morally acceptable options in the care of dying or
severely ill patients.
While many individuals do not distinguish between
assisted suicide and euthanasia on ethical or policy
grounds, some find assisted suicide more acceptable
than euthanasia, either intrinsically or because of
differences in the social impact and potential h arm of
the two practices.

The Task Forces Recommendations: Crafting

Public Policy

The Ethics of Assisted Suicide and Euthanasia

The members of the Task Force hold different views
about the ethical acceptability of assisted suicide and
euthanasia. Despite these differences, the Task Force
members unanimously recommend that existing law
should not be changed to permit these practice s.
Some of the Task Force members believe that
assisted suicide and euthanasia are inherently wrong,
because the practices violate societys long-standing
prohibition against ending human life. These
members believe that one person should not assist
another s death or kill another person, even for
benevolent motives.
Other Task Force members are most troubled by the
prospect of medicalizing the practices. They believe
that physician-assisted suicide and euthanasia violate
values that are fundamental to the practice of
medicine and the patient-physician relationship.
Some Task Force members do not believe that
assisted suicide is inherently unethical or
incompatible with medical practice. On the contrary,
they believe that providing a quick, less prolonged
death for some patients can respect the autonomy of
patients and demonstrate care and commitment on the
part of physicians or other health care professionals.
Nonetheless, these members have concluded that
legalizing assisted suicide would be unwise and
dangerous public policy.

The Social Risks of Legalization

The Task Force members unanimously concluded
that legalizing assisted suicide and euthanasia would
pose profound risks to many patients. For purposes of
public debate, one can describe cases of assisted
suicide in which all the recommended safeguards
would be satisfied. But positing an ideal or good
case is not sufficient for public policy, if it bears little
relation to prevalent social and medical practices.
No matter how carefully any guidelines are framed,
assisted suicide and euthanasia will be practiced
through the prism of social inequality and bias that
characterizes the delivery of services in all segments
of our society, including health care. The practices
will pose the greatest risks to those who are poor,
elderly, members of a minority group, or without
access to good medical care.
The growing concern about health care costs
increases the risks presented by legalizing assisted
suicide and euthanasia. This cost consciousness will
not be diminished, and may well be exacerbated, by
health care reform.

4 / New York State Task Force on Life and the Law / When Death is Sought
The clinical safeguards that have been proposed to
prevent abuse and errors would not be realized in
many cases. For example, most doctors do not have a
long-standing relationship with their patients or
information about the complex personal factors
relevant to evaluating a request for suicide assistance
or a lethal injection. In addition, neither treatment for
pain nor the diagnosis of and treatment for depression
is widely available in clinical practice.
In debating public policies, our society often focuses
on dramatic individual cases. With assisted suicide
and euthanasia, this approach obscures the impact of
what it would mean for the state to sanction assisted
suicide or direct killing under the auspices of the
medical community.
From the perspective of good health, many
individuals may believe that they would opt for
suicide or euthanasia rather than endure a vastly
diminished quality of life. Yet, once patients are
confronted with illness, continued life often becomes
more precious; given access to appropriate relief
from pain and other debilitating symptoms, many of
those who consider suicide during the course of a
terminal illness abandon their desire for a quicker
death in favor of a longer life made more tolerable
with effective treatment.
The Task Force members feel deep compassion for
patients in those rare cases when pain cannot be
alleviated even with aggressive palliative care. They
also recognize that the desire for control at lifes end
is widely shared and deeply felt. As a society,
however, we have better ways to give people greater
control and relief from suffering than by legalizing
assisted suicide and euthanasia.
Depression accompanied by feelings of hopelessness
is the strongest predictor of suicide for both
individuals who are terminally ill and those who are
not. Most doctors, however, are not trained to
diagnose depression, especially in complex cases
such as patients who are terminally ill. Even if
diagnosed, depression is often not treated. In elderly
patients as well as the terminally and chronically ill,
depression is grossly underdiagnosed and
undertreated.
The presence of unrelieved pain also increases
susceptibility to suicide. The undertreatment of pain
is a widespread failure of current medical practice,
with far-reaching implications for proposals to
legalize assisted suicide and euthanasia.
If assisted suicide and euthanasia are legalized, it will
blunt our perception of what it means for one
individual to assist another to commit suicide or to
take another persons life. Over time, as the practices
are incorporated into the standard arsenal of medical

treatments, the sense of gravity about the practices

would dissipate.
The criteria and safeguards that have been proposed
for assisted suicide and euthanasia would prove
elastic in clinical practice and in law. Policies
limiting suicide to the terminally ill, for example,
would be inconsistent with the notion that suicide i s
a compassionate choice for patients who are in pain
or suffering. As long as the policies hinge on notions
of pain or suffering, they are uncontainable; neither
pain nor suffering can be gauged objectively, nor are
they subject to the kind of judgments needed to
fashion coherent public policy. Euthanasia to cover
those who are incapable of consenting would also be
a likely, if not inevitable, extension of any policy
permitting the practice for those who can consent.
These concerns are heightened by experience in the
Netherlands, where the practices have been legally
sanctioned. Although Dutch law requires an explicit
request for euthanasia by the patient, a national study
in the Netherlands found that of approximately 3300
deaths annually resulting from mercy killing, l,000
deaths from euthanasia occurred without an explicit
request. Moreover, in some cases, doctors have
provided assisted suicide in response to suffering
caused solely by psychiatric illness, including severe
depression.

Caring for Severely Ill Patients

Professional medical standards should recognize the
provision of effective pain relief and palliative care,
including treatment for depression or referral for
treatment, as a basic obligation all physicians owe to
their patients. The legal prohibition age inst assisted
suicide and euthanasia should also guide professional
standards of conduct.
Physicians should seek their patients participation in
decisions about withdrawing or withholding lifesustaining treatment early enough in the course of
illness to give patients a meaningful opportunity to
have their wishes and values respected.
Health care professionals have a duty to offer
effective pain relief and symptom palliation to
patients when necessary, in accord with sound
medical judgment and the most advanced approaches
available.
New York State statutes and regulations should be
modified to increase the availability of medically
necessary analgesic medications, including opioids.
This should be done in a balanced manner that
acknowledges the importance of avoiding drug
diversion. Chapter 8 sets forth specific
recommendations for legal reform.

5 / New York State Task Force on Life and the Law / When Death is Sought
Physicians, nurses, and patients must be aware that
psychological and physical dependence on pain
medication are distinct phenomena. Contrary to a
widely shared misunderstanding, psychological
dependence on pain medication rarely occurs in
terminally ill patients. While physical dependence is
more common, proper adjustment of medication can
minimize negative effects.
The provision of appropriate pain relief rarely poses a
serious risk of respiratory depression. Moreover, the
provision of pain medication is ethically and
professionally acceptable even when such treatment
may hasten the patients death, if the medication is
intended to alleviate pain and severe discomfort, not
to cause death, and is provided in accord with
accepted medical practice.
The education of health care professionals about pain
relief and palliative care must be improved. Training
in pain relief and palliative care should be included in
the curriculum of nursing schools, medical schools,
residencies, and continuing education for health care
professionals.
Hospitals and other health care institutions should
explore ways to promote effective pain relief and
palliative care, and to remove existing barriers to
such care.
Public education is crucial to enhance pain relief
practices. Like many health care professionals,
patients and families often have an exaggerated sense
of the risks of pain medication, and are reluctant to
seek treatment for pain. Nurses and physicians should
create an atmosphere that will encourage patients to
seek relief of pain. Strategies for pain relief should
also maximize patients sense of control.
Insurance companies and others responsible for
health care financing should promote effective pain
and symptom management and address barriers that
exist for some patients.
Health care professionals should be familiar with the
characteristics of major depression and other
common psychiatric illnesses, as well as the
possibility for treatment. Major clinical depression is
generally treatable, and can be treated effectively
even in the absence of improvement in the underlying
disease. Patients should also receive appropriate
treatment for less severe depression that often
accompanies terminal illness.
Physicians should create an atmosphere within which
patients feel comfortable expressing suicidal
thoughts. Discussion with a physician or other health
care professional about suicide can identify the need
for treatment and make the patient feel less isolated.
This discussion does not prompt suicide; on the

contrary, talking with health care professionals often

decreases the risk of suicide.
When a patient requests assisted suicide or
euthanasia, a health care professional should explore
the significance of the request, recognize the patients
suffering, and seek to discover the factors leading to
the request. These factors may include insufficient
symptom control, clinical depression, inadequate
social support, concern about burdening family or
others, hopelessness, loss of self-esteem, or fear of
abandonment.