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Physician-Assisted Suicide and Euthanasia in the ICU: A Dialogue on Core Ethical Issues*

Goligher, Ewan C. MD, PhD; Ely, E. Wesley MD, MPH; Sulmasy, Daniel P. MD, PhD; Bakker, Jan MD, PhD; Raphael, John SSJ, BCC; Volandes, Angelo E. MD, MPH; Patel, Bhavesh M. MD; Payne, Kate JD, RN, NC-BC; Hosie, Annmarie RN, MPallCareAgeCare, PhD; Churchill, Larry PhD; White, Douglas B. MD, MAS; Downar, James MD, MHSc

doi: 10.1097/CCM.0000000000001818
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Objective: Many patients are admitted to the ICU at or near the end of their lives. Consequently, the increasingly common debate regarding physician-assisted suicide and euthanasia holds implications for the practice of critical care medicine. The objective of this article is to explore core ethical issues related to physician-assisted suicide and euthanasia from the perspective of healthcare professionals and ethicists on both sides of the debate.

Synthesis: We identified four issues highlighting the key areas of ethical tension central to evaluating physician-assisted suicide and euthanasia in medical practice: 1) the benefit or harm of death itself, 2) the relationship between physician-assisted suicide and euthanasia and withholding or withdrawing life support, 3) the morality of a physician deliberately causing death, and 4) the management of conscientious objection related to physician-assisted suicide and euthanasia in the critical care setting. We present areas of common ground and important unresolved differences.

Conclusions: We reached differing positions on the first three core ethical questions and achieved unanimity on how critical care clinicians should manage conscientious objections related to physician-assisted suicide and euthanasia. The alternative positions presented in this article may serve to promote open and informed dialogue within the critical care community.

1Interdepartmental Division of Critical Care Medicine, University of Toronto, ON, Canada.

2Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, ON, Canada.

3Department of Physiology, University of Toronto, ON, Canada.

4Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN.

5Center for Health Services Research, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN.

6Geriatric Research, Education and Clinical Center (GRECC), Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN.

7Department of Medicine, University of Chicago, Chicago, IL.

8Divinity School, University of Chicago, Chicago, IL.

9MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL.

10Department of Intensive Care, Erasmus MC University Medical Center, Rotterdam, the Netherlands.

11Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, NY.

12Departamento de Medicina Intensiva, Facultad de Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile.

13Department of Pastoral Care, St. Thomas West Hospital, Nashville, TN.

14Department of Medicine, Massachusetts General Hospital, Boston, MA.

15Department of Critical Care Medicine, Mayo Clinic, Phoenix, AZ.

16Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN.

17Vanderbilt University School of Nursing, Nashville, TN.

18School of Nursing, University of Notre Dame Australia, Sydney, NSW, Australia.

19Faculty of Health, University of Technology Sydney, NSW, Australia.

20Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN.

21Program on Ethics and Decision Making in Critical Illness, Department of Critical Care Medicine, University of Pittsburgh School of Medicine; Pittsburgh, PA.

22Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, ON, Canada.

*See also p. 356.

Dr. Ely received support for article research from the National Institutes of Health (NIH) and Veterans Affairs (VA) funding and VA awards. His institution received funding from the NIH and VA funding and VA awards. Dr. Payne received funding from Alive Hospice, Ethics Consultant Group, and Northwest Organization of Nurse Executives. Dr. Downar disclosed other (he is a member of the Physician’s Advisory Committee of Dying with Dignity Canada, a not-for-profit that worked toward the legalization of assisted death in Canada). The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: wes.ely@vanderbilt.edu

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