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“An indelible mark” the response to participation in euthanasia and physician-assisted suicide among doctors: A review of research findings

Published online by Cambridge University Press:  25 July 2019

Brian Kelly
School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia Consultation-Liaison Psychiatry, Hunter New England Local Health District, Newcastle, Australia
Tonelle Handley*
School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
David Kissane
Department of Psychiatry School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC, Australia
Marina Vamos
School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia Consultation-Liaison Psychiatry, Hunter New England Local Health District, Newcastle, Australia
John Attia
School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
Author for correspondence: Tonelle Handley, School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, NSW2308. Email:



The debate regarding euthanasia and physician-assisted suicide (E/PAS) raises key issues about the role of the doctor, and the professional, ethical, and clinical dimensions of the doctor-patient relationship. This review aimed to examine the published evidence regarding the response of doctors who have participated in E/PAS.


Original research papers were identified reporting either qualitative or qualitative data published in peer-reviewed literature between 1980 and March 2018, with a specific focus on the impact on, or response from, physicians to their participation in E/PAS. PRISMA and CASP guidelines were followed.


Nine relevant papers met selection criteria. Given the limited published data, a descriptive synthesis of quantitative and qualitative findings was performed. Quantitative surveys were limited in scope but identified a mixed set of responses. Where studies measured psychological impact, 30–50% of doctors described emotional burden or discomfort about participation, while findings also identified a comfort or satisfaction in believing the request of the patient was met. Significant, ongoing adverse personal impact was reported between 15% to 20%. A minority of doctors sought personal support, generally from family or friends, rather than colleagues. The themes identified from the qualitative studies were summarized as: 1) coping with a request; 2) understanding the patient; 3) the doctor's role and agency in the death of a patient; 4) the personal impact on the doctor; and 5) professional guidance and support.

Significance of results

Participation in E/PAS can have a significant emotional impact on participating clinicians. For some doctors, participation can contrast with perception of professional roles, responsibilities, and personal expectations. Despite the importance of this issue to medical practice, this is a largely neglected area of empirical research. The limited studies to date highlight the need to address the responses and impact on clinicians, and the support for clinicians as they navigate this challenging area.

Review Article
Copyright © Cambridge University Press 2019

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Chochinov, HM (2016) Physician-assisted death in Canada. Journal of the American Medical Association 315, 253254.CrossRefGoogle ScholarPubMed
Chung, GS, Yoon, JD, Rasinski, KA and Curlin, FA (2016) US physicians’ opinions about distinctions between withdrawing and withholding life-sustaining treatment. Journal of Religious Health 55, 15961606.CrossRefGoogle ScholarPubMed
Critical Appraisal Skills Programme (2013) Qualitative Research Checklist. Oxford: CASP.Google Scholar
De Vries, AMM, Gholamrezaee, MM, Verdonck-de Leeuw, IM, de Roten, Y, Despland, JN, Stiefel, F and Passchier, J (2018) Physicians' emotion regulation during communication with advanced cancer patients. Psychooncology 27, 929936.CrossRefGoogle ScholarPubMed
Dobscha, SK, Heintz, RT, Press, N and Ganzini, L (2004) Oregon physicians’ response to requests for assisted suicide: a qualitative study. Journal of Palliatiave Medicine 7, 451461.CrossRefGoogle Scholar
Draper, B, Kõlves, K, De Leo, D and Snowdon, J (2014) The impact of patient suicide and sudden death on health care professionals. General Hospital Psychiatry 36, 721725.10.1016/j.genhosppsych.2014.09.011CrossRefGoogle ScholarPubMed
Emanuel, EJ, Daniels, ER, Fairclough, DL and Clarridge, BR (1998) The practice of euthanasia and physician-assisted suicide in the United States: Adherence to proposed safeguards and effects on physicians. Journal of the American Medical Association 280, 507513.CrossRefGoogle ScholarPubMed
Emanuel, EJ, Onwuteaka-Philipsen, BD, Urwin, JW and Cohen, J (2016) Attitudes and practices of euthanasia and physician-assisted suicide in the United States, Canada, and Europe. Journal of the American Medical Association 316, 7990.CrossRefGoogle ScholarPubMed
Ganzini, L, Nelson, HD, Schmidt, TA, Kraemer, DF, Delorit, MA and Lee, MA (2000) Physicians’ experiences with the Oregon Death with Dignity Act. New England Journal of Medicine 342, 557563.CrossRefGoogle ScholarPubMed
Ganzini, L, Goy, ER and Dobscha, SK (2008) Prevalence of depression and anxiety in patients requesting physicians’ aid in dying: cross sectional survey. British Medical Journal 337, a1682.CrossRefGoogle ScholarPubMed
Georges, AA, The, AM, Onwuteaka-Philipsen, BD and van der Wal, G (2008) Dealing with requests for euthanasia: a qualitative study investigating the experience of general practitioners. Journal of Medical Ethics 34, 150155.CrossRefGoogle ScholarPubMed
Guest, R, Baser, R, Li, Y, Brown, AE, Scardino, P and Kissane, DW (2011a) Cancer surgeons’ distress and well-being, I: the tension between a culture of productivity and the need for self-care. Annals of Surgical Oncology 18, 12291235.CrossRefGoogle Scholar
Guest, R, Baser, R, Li, Y, Brown, AE, Scardino, P and Kissane, DW (2011b) Cancer surgeons’ distress and well-being, II: Modifiable factors and the potential for organizational interventions. Annals of Surgical Oncology 18, 12361242.CrossRefGoogle Scholar
Granek, L, Bartels, U, Scheinmann, K, Labrecque, M and Barrera, M (2015) Grief reactions and impact of patient death on pediatric oncologists. Pediatric Blood Cancer 62, 134142.CrossRefGoogle ScholarPubMed
Hannes, K. Cochrane Collaboration Qualitative Methods Group (2011) Critical appraisal of qualitative research. In Noyes, J, Booth, A, Hannes, K, Harden, A, Harris, J, Lewin, S and Lockwood, C (eds), Supplementary Guidance for Inclusion of Qualitative Research in Cochrane Systematic Reviews of Interventions Version 1. Available at Updated August 2011.Google Scholar
Haverkaate, I, van der Heide, A, Onwuteaka-Philipsen, BD, van der Maas, PJ and van der Wal, G (2001) The emotional impact on physicians of hastening the death of a patient. Medical Journal of Australia 175, 519522.CrossRefGoogle Scholar
Hendry, M, Pasterfield, D, Lewis, R, Carter, B, Hodgson, D and Wilkinson, C (2013) Why do we want the right to die? A systematic review of the international literature on the views of patients, carers and the public on assisted dying. Palliative Medicine 27, 1326.CrossRefGoogle ScholarPubMed
Hudson, P, Hudson, R, Philip, J, Boughey, M, Kelly, B and Hertogh, C (2015) Physician-assisted suicide and/or euthanasia: pragmatic implications for palliative care [corrected]. Palliatiave & Supportive Care 13, 13991409.CrossRefGoogle Scholar
Kelly, BJ, Burnett, PC, Pelusi, D, Badger, SJ, Varghese, FT and Robertson, MM (2004) Association between clinician factors and a patient's wish to hasten death: terminally ill cancer patients and their doctors. Psychosomatics 45, 311318.CrossRefGoogle Scholar
Kissane, DW, Clarke, DM and Street, AF (2001) Demoralization syndrome – A relevant psychiatric diagnosis for palliative care. Journal of Palliative Care 17, 1221.CrossRefGoogle ScholarPubMed
Kissane, DW (2004) The contribution of demoralization to end-of-life decision making. The Hastings Center Report 34, 2131.CrossRefGoogle Scholar
Kohlwes, RJ, Koepsell, TD, Rhodes, LA and Pearlman, RA (2001) Physicians’ responses to patients’ requests for physician-assisted suicide. Archives of Internal Medicine 161, 657663.CrossRefGoogle ScholarPubMed
Moher, D, Liberati, A, Tetzlaff, J and Altman, DG (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Medicine 6, e1000097.CrossRefGoogle ScholarPubMed
Muskin, PR (1998) The request to die: role for psychodynamic perspective on physician-assisted suicide. Journal of the American Medical Association 279, 323328.CrossRefGoogle ScholarPubMed
Obstein, KL, Kimsma, G and Chambers, T (2004) Practicing euthanasia: the perspective of physicians. Journal of Clinical Ethics 15, 223231.Google ScholarPubMed
Quill, TE (2018) Dutch practice of euthanasia and assisted suicide: a glimpse at the edges of the practice. Journal of Medical Ethics 44, 297298.CrossRefGoogle Scholar
Rholf, V and Bennett, P (2005) Perpetration-induced traumatic stress in persons who euthanize nonhuman animals in surgeries, animal shelters, and laboratories. Society & Animals 13, 201219.Google Scholar
Riou, F, Aubry, R, Pontone, S and Pennec, S (2015) When physicians report having used medical drugs to deliberately end a patient's life: findings of the “End of Life in France” survey. Journal of Pain & Symptom Management 50, 208215.CrossRefGoogle Scholar
Robinson, S, Kissane, DW, Brooker, J and Burney, S (2015) A systematic review of the Demoralization Syndrome in individuals with progressive disease and cancer: a decade of research. Journal of Pain and Symptom Management 49, 595610.CrossRefGoogle ScholarPubMed
Robinson, S, Kissane, DW, Brooker, J and Burney, S (2016) A review of the construct of demoralization: history, definitions, and future directions for palliative care. American Journal of Hospice and Palliative Medicine 33, 93101.CrossRefGoogle ScholarPubMed
Robinson, S, Kissane, DW, Brooker, J, Hempton, C and Burney, S (2017) The relationship between poor quality of life and desire to hasten death: a multiple mediation model examining the contributions of depression, demoralization, loss of control, and low self-worth. Journal of Pain & Symptom Management 53, 243249.CrossRefGoogle ScholarPubMed
Slavin, RE (1995) Best evidence synthesis: an intelligent alternative to meta-analysis. Journal of Clinical Epidemiology 48, 918.CrossRefGoogle ScholarPubMed
Snijdewind, MC, van Tol, DG, Onwuteaka-Philipsen, BD and Willems, DL (2016) Developments in the practice of physician-assisted dying: perceptions of physicians who had experience with complex cases. Journal of Medical Ethics 44, 292296.CrossRefGoogle ScholarPubMed
Stone, J and Moskowitz, GB (2011) Non-conscious bias in medical decision making: what can be done to reduce it? Medical Education 45, 768776.CrossRefGoogle ScholarPubMed
Tan, ASL and Gallagher, TH (2017) Discussing adverse outcomes with patients. In Kissane, DW, Bultz, BD, Butow, PN, Bylund, CL, Noble, S and Wilkinson, S (eds), Oxford Textbook of Communication in Oncology and Palliative Care, 2nd Edn. Oxford: Oxford University Press, pp. 249256.Google Scholar
Van der Heide, A, Onwuteaka-Philipsen, BD, Rurup, ML, Buiting, HM, van Delden, JJ, Hanssen-de Wolf, JE, Janssen, AG, Pasman, HR, Rietjens, JA, Prins, CJ, Deerenberg, IM, Gevers, JK, van der Maas, PJ and van der Wal, G (2007) End-of-life practices in the Netherlands under the Euthanasia Act. New England Journal of Medicine 356, 19571965.CrossRefGoogle ScholarPubMed
Van der Lee, ML, van der Bom, JG, Swarte, NB, Heintz, AP, de Graeff, A and van den Bout J (2005) Euthanasia and depression: a prospective cohort study among terminally ill cancer patients. Journal of Clinical Oncology 20, 66076612.CrossRefGoogle Scholar
Van Marwijk, H, Haverkate, I, van Royen, P and The, AM (2007) Impact of euthanasia on primary care physicians in the Netherlands. Palliative Medicine 21, 609614.CrossRefGoogle ScholarPubMed
Walker, J, Hansen, CH, Martin, P, Symeonides, S, Ramessur, R, Murray, G and Sharpe, M (2014) Prevalence, associations, and adequacy of treatment of major depression in patients with cancer: a cross-sectional analysis of routinely collected clinical data. Lancet Psychiatry 1, 343350.CrossRefGoogle ScholarPubMed
White, BP, Willmott, L and Ashby, M (2011) Palliative care, double effect and the law in Australia. Internal Medicine Journal 41, 485492.CrossRefGoogle ScholarPubMed