Admittedly, relieving suffering through standard medical means is not always possible, but opening the door to suicide exposes us to a slippery slope. For example, although multiple safeguards against abuse were established when euthanasia was legalized in the Netherlands in 2002, there have since been reports of hundreds of individuals who may have been wrongly put to death.8

The deliberate taking of innocent human life is wrong, no matter the circumstances, and physicians should not do it. Because something is legal does not make it moral. Physicians and other caregivers who object to suicide as a solution to suffering should not be pressured to participate. The greatest need I see is for palliative care, that is, high-quality home care directed at comfort and dignity, insofar as chronic illness permits, to become more available.

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Timothy E. Quill, MD, Georgia and Thomas Gosnell Distinguished Professor in Palliative Care; professor of medicine, psychiatry and medical humanities, Palliative Care Division, University of Rochester School of Medicine, New York

We agree with the ACP ethics committee that all reasonable efforts should be made to address seemingly intractable suffering, including the steps outlined in the article. The question remains how to respond to those relatively infrequent, but very compelling, patients who still suffer unacceptably despite excellent care. Strategies need to be developed to respond to such patients in environments where physician-assisted death is legally available, and also where it is legally restricted. Clinicians need to respond to these cases based on knowledge of the law in their states, and also with respect for their own personal values.

In areas where physician-assisted death is legally available, our profession needs to study the processes for evaluating and responding to patients who request this option so we can learn more about the potential and limitations of the process, given that so little is empirically known about it.

Craig New, PhD, Center for Health Statistics, Oregon Health Authority

Trends have increased during the last 20 years. More physicians and terminally ill patients are participating, although they still comprise a small percentage (less than 1%) of each group. Patient characteristics have changed little over the years. Patients in Oregon tend to be highly educated, mostly white, with cancer or amyotrophic lateral sclerosis (ALS).

[Representatives of the Center for Health Statistics at Oregon Health Authority] are neutral with respect to the Death With Dignity Act (DWDA), and we only provide data. These data do alleviate concerns about whether DWDA patients are uneducated or have financial concerns; as you can see in the paper, our analysis showed the opposite.

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We point to some shortcomings of the system, such as the low number of psychological evaluations relative to prescription recipients and a lack of guidance after patients obtain their DWDA prescription.

[Regarding additional research needs], it is important to consider DWDA within the spectrum of end-of-life options, including cessation of eating and drinking; withdrawal of life support; the “halo” effect from opioid medications; and terminal sedation to relieve pain. There is little data on these other options, and such data would provide valuable context to the debate.


The ACP reaffirmed their stance against the legalization of physician-assisted suicide in a new position paper, while offering recommendations for physicians to address patients’ concerns pertaining to this topic. Accompanying editorials offer divergent views.


  1. Emanuel EJ, Onwuteaka-Philipsen BD, Urwin JW, Cohen J. Attitudes and practices of euthanasia and physician-assisted suicide in the United States, Canada, and Europe. JAMA. 2016; 316(1):79-90.
  2. Sulmasy LS, Mueller PS. Ethics and the legalization of physician-assisted suicide: an American College of Physicians position paper [published online September 19, 2017]. Ann Intern Med. doi: 10.7326/M17-0938
  3. Snyder L; American College of Physicians Ethics, Professionalism, and Human Rights Committee. American College of Physicians Ethics Manual: sixth edition. Ann Intern Med. 2012;156(1 Pt 2):73-104. 
  4. Kelley AS, Morrison RS. Palliative care for the seriously ill. N Engl J Med. 2015;373(8):747-755. 
  5. Kussmaul WG. The slippery slope of legalization of physician-assisted suicide [published online September 19, 2017]. Ann Intern Med. doi: 10.7326/M17-2072
  6. Quill TE, Arnold RM, Youngner SJ. Physician-assisted suicide: finding a path forward in a changing legal environment [published online September 19, 2017]. Ann Intern Med. doi:10.7326/M17-2160
  7. Francis N. Netherlands — 2017 euthanasia report card. Dying for Choice. Published May 4, 2016. Accessed September 26, 2017.