Original Articles and Reviews The Psychology of Euthanasia Why There Are No Easy Answers Miguel Ricou1,2 and Tony Wainwright3 1Faculty of Medicine, University of Porto, Porto, Portugal 2Department of Psychology and Education, Portucalense University, Porto, Portugal 3Department of Psychology, University of Exeter, UK Abstract: Voluntary euthanasia has been legalized in several countries and associated with this development there has been much discussion concerning the relationship between the ethical principle of autonomy and the respect for human life. Psychological science should make a significant contribution to understanding how polarizing positions may be taken in such debates. However, little has been written concerning the implications of this research for the euthanasia debate and about the contributions of psychology. In the same way, very little is written about the psychologist’s role in countries where voluntary euthanasia or assisted suicide is legalized. We take as a starting assumption that there are no solutions that will meet everyone’s wishes or needs, but that an understanding of psychological ideas, can assist in developing strategies that may help people with opposing views come to some agreement. In our view, it is fundamental to a fruitful analysis, to leave aside a polarized approach and to understand that an eventual answer to the question of how we approach voluntary euthanasia will only be achieved after the hard process of carefully considering the consequences of having either legalized voluntary euthanasia or its prohibition, in the context of a psychological understanding. Keywords: euthanasia, suffering, psychology, ethics, decision-making Voluntary euthanasia has been legalized in several coun- tries,1 and in others it is being considered. This trend toward legalization has led to much debate concerning competing ethical principles (Youngner & Arnold, 2016). As an example, in Portugal, where discussion about legisla- tion has been in progress for some time, the head of Portu- gal’s national nurses association alleged that euthanasia is already being carried out, despite it currently being illegal (https://www.bioedge.org/bioethics/nurse-ignites-debate- over-euthanasia-in-portugal/11783) and this provoked intense debate and criminal investigations into the medical staff concerned. There are clearly very strong feelings involved here, but our contention is that there is no right or wrong answer. In discussing the issues arising from ethics at the end of life, as in the case of voluntary euthanasia2 or assisted suicide, our contention is that taking an absolutist position – that there is a “right or wrong” answer – will not be helpful. We intend to outline the boundaries between the values or principles that are in contention and to develop some ideas about how these may be, at least partially, reconciled, using psy- chological ideas as our framework. When we consider the decision to end our life, either ...

1. Original Articles and Reviews
The Psychology of Euthanasia
Why There Are No Easy Answers
Miguel Ricou1,2 and Tony Wainwright3
1Faculty of Medicine, University of Porto, Porto, Portugal
2Department of Psychology and Education, Portucalense
University, Porto, Portugal
3Department of Psychology, University of Exeter, UK
Abstract: Voluntary euthanasia has been legalized in several
countries and associated with this development there has been
much discussion
concerning the relationship between the ethical principle of
autonomy and the respect for human life. Psychological science
should make a
significant contribution to understanding how polarizing
positions may be taken in such debates. However, little has been
written concerning
the implications of this research for the euthanasia debate and
about the contributions of psychology. In the same way, very
little is written
about the psychologist’s role in countries where voluntary
euthanasia or assisted suicide is legalized. We take as a starting
assumption that
there are no solutions that will meet everyone’s wishes or
needs, but that an understanding of psychological ideas, can
assist in developing
strategies that may help people with opposing views come to
some agreement. In our view, it is fundamental to a fruitful

2. analysis, to leave
aside a polarized approach and to understand that an eventual
answer to the question of how we approach voluntary euthanasia
will only be
achieved after the hard process of carefully considering the
consequences of having either legalized voluntary euthanasia or
its prohibition, in
the context of a psychological understanding.
Keywords: euthanasia, suffering, psychology, ethics, decision-
making
Voluntary euthanasia has been legalized in several coun-
tries,1 and in others it is being considered. This trend
toward legalization has led to much debate concerning
competing ethical principles (Youngner & Arnold, 2016).
As an example, in Portugal, where discussion about legisla-
tion has been in progress for some time, the head of Portu-
gal’s national nurses association alleged that euthanasia is
already being carried out, despite it currently being illegal
(https://www.bioedge.org/bioethics/nurse-ignites-debate-
over-euthanasia-in-portugal/11783) and this provoked
intense debate and criminal investigations into the medical
staff concerned.
There are clearly very strong feelings involved here, but
our contention is that there is no right or wrong answer. In
discussing the issues arising from ethics at the end of life, as
in the case of voluntary euthanasia2 or assisted suicide, our
contention is that taking an absolutist position – that there is
a “right or wrong” answer – will not be helpful. We intend
to outline the boundaries between the values or principles
that are in contention and to develop some ideas about
how these may be, at least partially, reconciled, using psy-
chological ideas as our framework.

3. When we consider the decision to end our life, either in
the case of suicide or voluntary euthanasia, we are facing a
complex challenge that involves privileging one of at least
two main principles: the principle of autonomy which
may be seen as also promoting respect for human dignity;
or the principle of respecting life, also related to the princi-
ple of nonmaleficence (Beauchamp & Childress, 2001). It is
also the case that if you take the view, as we do, that there
are no absolute values or principles here, (see, e.g., (Engel-
hardt, 1999) the main decision for any society, is to draw a
conscious and considered boundary between these two cen-
tral values. Of course, many people hold that there are
absolute values or principles, as in the case of some faith
communities, but our view is that these can only be used
a guide, not a prescription in secular societies where many
faiths, and those with no faith, have to live together.
Here we explore the consequences of either undervalu-
ing the principle of autonomy, for example, in a society
where voluntary euthanasia as a personal choice does not
exist, and the parallel consequences where the value of life
may be thought to be diminished in society where voluntary
euthanasia is available as part of public policy.
1 In Europe Euthanasia and Assisted Suicide are legalized in the
Netherlands, Belgium, and Luxembourg. Also in Europe there
are two more
countries – Switzerland and Germany – with laws allowing
Assisted Suicide. In the rest of the World just in Colombia
Euthanasia and Assisted
Suicide are legal. In Japan, although there is not a law,
Euthanasia and Assisted Suicide are not illegal. Assisted
Suicide is also legal in Canada
and in five states of USA – Oregon, California, Colorado,
Washington, and Montana.

4. 2 Where we use the term euthanasia alone, we mean by this
voluntary euthanasia.
� 2018 Hogrefe Publishing European Psychologist (2019),
24(3), 243–256
https://doi.org/10.1027/1016-9040/a000331
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This paper will also aim to explore the role that psychol-
ogy can play in helping an individual make the best deci-
sion, given their circumstances. There are very few
published studies about psychology and hastened death,
which is unexpected, given the importance of this area
for clinical practice. We believe psychology should play a
major role whether in the discussion of legalizing or not
euthanasia or assisted suicide, or in the work with people
who ask to die. Furthermore we will develop some ideas
on the role of the professional psychologist in this field.
Finally we hope to outline what psychology can contribute
to the development of public policy in this area.
Conceptualization and Definitions

9. It will be useful to introduce our argument with some his-
tory and some definitions. Euthanasia comes from two
Greek words: eu, meaning good, and thanatos, meaning
death. Contemplating this, we can say that, at least in its
original meaning, euthanasia refers the promotion of dying
as a good experience (as far as that is possible) and so
would include the idea of voluntariness as well as active
engagement, even when this involves the assistance of
another person.
From a historical point of view it is believed that Francis
Bacon was the first to write about euthanasia in a medical
context in 1605 where he says:
“Nay further, I esteem it the office of a physician not
only to restore health, but to mitigate pain and dolors;
and not only when such mitigation may conduce to
recovery, but when it may serve to make a fair and
easy passage.” (Bacon, 1605/2000, p. 100)
Over the years, attitudes to euthanasia have changed, and
particularly in Europe and the United States there have
been increasing numbers of jurisdictions making voluntary
euthanasia legal or at least decriminalizing it (Youngner &
Arnold, 2016).
One reason for the change in attitudes to voluntary
euthanasia has been the rapid advance in medical treat-
ment that has allowed life to be sustained much longer,
for example, through intensive care, than hitherto. This
has meant that increasing numbers of patients survive only
by being kept alive through artificial means and has pro-
duced situations in which ethical concerns raise major chal-
lenges (McDermid & Bagshaw, 2009). It has also been
argued that this shift in opinion reflects an even longer
trend that has seen science and technology offer meth-

10. ods for fixing the world’s problems and even death is
now seen as a possible fixable problem. Euthanasia could
then be viewed as consistent with this idea, that it provides
a way of controlling, if not preventing, death (Harari, 2016).
In the UK, there have been many debates and legal chal-
lenges to the current prohibition, but these have not been
successful (Bowcott, 2017).
Over 20 years ago, the UK House of Lords Select Com-
mittee on Medical Ethics, for example, made a clear dis-
tinction between prolonging life unnecessarily and the
voluntary refusal of treatment – orthothanasia – on the
one hand, and euthanasia on the other, and this distinction
has been maintained ever since: autonomy in refusing
treatment being maintained, but autonomy for receiving a
lethal drug, for example, being denied.
“With respect to euthanasia, may I first indicate
that in our deliberations we defined voluntary eutha-
nasia, at the request of the individual concerned, as
being a deliberate intervention undertaken with
the intention of ending a life so as to relieve intract-
able suffering; an act which must inevitably termi-
nate life. We were unanimous in concluding that
the right to refuse medical treatment is far removed
from the right to request assistance in dying.” (House
of Lords Selection Committee on Medical Ethics,
1994)
Defining Our Terms: Voluntary Euthanasia,
Nonvoluntary Euthanasia, and Involuntary
Euthanasia
There are some further distinctions that need to be made,

11. as they play an important role in debates and firstly we deal
with “voluntary euthanasia,” “nonvoluntary euthanasia,”
and “involuntary euthanasia.”
Voluntary euthanasia is performed with the consent of
the person. This is the term that we shall be using when
we discuss legalization later in this paper, as its fundamen-
tal purpose is to respect the wishes and autonomy of the
person concerned.
The second term is nonvoluntary euthanasia where the
person is not able to give consent. As a consequence it is
harder to argue that here autonomy is being respected.
However, in situations where the person lacks capacity,
for example, they are in a coma or a persistent vegetative
state, if food and fluids are withdrawn or life support is
turned off, the procedure can be described as nonvoluntary
euthanasia. This term is also commonly applied to cases in
which the person is a minor and may not be able to make
their own judgment. Usually, in these cases, it is the family
who ask for euthanasia, representing the person’s will. In
the same way, previously expressed wishes, as in advance
European Psychologist (2019), 24(3), 243–256 � 2018 Hogrefe
Publishing
244 M. Ricou & T. Wainwright, The Psychology of Euthanasia
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16. ly
.
healthcare directives, can be on the basis of a nonvoluntary
euthanasia, if at the time the person lacks capacity.
The third term – involuntary euthanasia – refers to the sit-
uation where the person is killed against their expressed
will or, at least, without their consent. A major example
was the Nazi T4 or “Euthanasia Programme,” where many
disabled people were put to death, and indeed the first gas
chambers were used for killing people with a learning dis-
ability (Lifton, 1986). In more recent times the term has
been applied to cases of euthanasia where it is alleged that
consent was not given, or the person was not correctly
assessed, raising doubts about whether the persons con-
cerned had really expressed a wish to die (Singer, 2003;
Gillon, 1999). Our literature review suggests there is insuf-
ficient research on the psychological issues here, and that a
much fuller application of psychology in the debates on
how any policy is implemented, would be beneficial in
avoiding some of the risks of involuntary euthanasia taking
place. In the same way, it is possible to argue that when a
society accepts voluntary euthanasia, as time goes by, the
practice becomes more and more acceptable, so people
are not so strict with the criteria that are applied for some-
one to receive euthanasia (Pelligrino, 1998). In that way,
voluntary euthanasia slides to involuntary euthanasia. We
will come to this issue when discussing the idea of a “slip-
pery slope.”
Active Euthanasia, Passive Euthanasia,
Orthothanasia, Disthanasia, and

17. Physician-Assisted Suicide
Finally there are some further terms that need to be made
clear for the purposes of our discussion; these are active
euthanasia, passive euthanasia, orthothanasia, disthanasia,
and physician-assisted suicide (Table 1).
In active euthanasia – a third person (usually a medical
professional) deliberately does something that causes the
person’s death – an act of commission. In passive euthana-
sia something is not done – an act of omission – whereby
the effect is the ending of the person’s life (an example of
this might be a patient refusing medical treatment that
would have kept them alive). The term orthothanasia (from
the Greek “normal death”) refers to a person’s right to
refuse treatment, even if this leads to their dying. The dif-
ference in meaning between passive euthanasia and
orthothanasia is that, in cases of passive euthanasia, people
do want to die, while in cases of orthothanasia people do
not want to die, per se, but rather want to deal with the neg-
ative effects or consequences of their treatment or condi-
tion. This difference makes it easier in general for people
to accept the latter as ethically justified, and goes some
way to explain why orthothanasia is usually legally accepted
and passive euthanasia is not (Singer 1995).
Another term that it will be useful to be clear about is dis-
thanasia (from the Greek “bad death”). This refers to the
situation, for example, where a person’s life is prolonged,
perhaps against their will, through what may be regarded
as disproportionate means, perhaps causing a person with
an incurable condition additional and unnecessary suffer-
ing. Disthanasia can be therefore understood in some ways
as standing as the opposite of voluntary euthanasia as it
may extend suffering instead of promoting its end by a

18. “good death.” Of course, disthanasia is an unacceptable
practice in health care.
The final term we would like to introduce is physician-
assisted suicide. This describes the situation where a doctor
provides a patient with the means to end their own life but
Table 1. Definitions
Person
asks to
die
Person
doesn’t ask
to die
because
he/she
is not
autonomous
Person
doesn’t
ask to
die
Person
doesn’t want
to die,
but refuses
treatment*
Someone
kills the
patient

19. The patient
kills
themself
with help
Death
resulting
from
withholding
treatment
Prolonging
life with
disproportionate
means
Active voluntary euthanasia X X
Passive voluntary euthanasia X X
Active nonvoluntary euthanasia X X
Passive nonvoluntary euthanasia X X
Active involuntary euthanasia X X
Passive involuntary euthanasia X X
Orthothanasia X X
Dysthanasia X
Physician-assisted suicide X X
*Usually legal in most countries.

20. � 2018 Hogrefe Publishing European Psychologist (2019),
24(3), 243–256
M. Ricou & T. Wainwright, The Psychology of Euthanasia 245
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takes no part in its administration – this being left to the
patient themselves. Some have argued that from an ethical
perspective, physician-assisted suicide and voluntary eutha-
nasia are much the same (Brock 1995; Dixon 2012), since
in situations where the administration of medication is
the means of dying, whether it is administered by the doc-
tor or by the patient, from an ethical perspective, makes lit-
tle difference. Those who are in favor of physician-assisted
suicide argue that in these circumstances, the patient is the
ultimate cause of their own death, and this ensures that it
really is their decision – that they were clearly motivated
to take their own life. In the same way the possibility of sub-
tle coercion, error, and other abuses are reduced (Battin
1991; Quill, Cassel, & Meier 1996).
One issue that these definitions have in common con-
cerns the motivation of the person concerned and raises

25. an important question of how can this be assessed. How
sure can we be that the person is motivated to die for the
“right” reasons and not being pressured into it by others,
or by a mistaken belief that this is the only course open
to them? Research on those who narrowly escape killing
themselves in suicide attempts support the idea that people
can change their minds and often do (Seiden, 1978); but for
those who are successful, there is no way of knowing of
course.
Nevertheless, we can argue that those who defend
assisted suicide, as a way to ensure that the person’s moti-
vation is fully engaged with dying, is to admit that in gen-
eral, it is hard to be sure what someone’s real reasons are
when they are asking to die. We will come back to that
when we will be discussing the role of psychology.
Euthanasia – Potentially Conflicting
Values
Values and Social Norms
The question of euthanasia and human rights, their rela-
tionship with personal values, and how they may come into
conflict with each other, is an important theme in this dis-
course. In addition, social norms change as societies
develop and the interplay between social norms and per-
sonal values is an important further consideration. In gen-
eral, societies across the world and their associated
cultures have been evolving in a way that promotes human
rights in many different ways and so the discussion of
euthanasia is often located in that framework, that is, a dis-
cussion about rights (Pegram, 2015).
The first of these personal values is dignity and there has
been an increasing focus on people’s dignity, and other

26. rights, that enlarge a person’s opportunity to differentiate
themselves from others, and to assert their own individual
identity (Pinker, 2011). In such a framework, each individ-
ual is taught that they are unique, making them the only
one who truly knows what is best for them. One of the con-
sequences of this is that when we are faced with a situation
where we are trying to judge what is best for another per-
son, it means accepting and respecting the other person’s
will and also their autonomy, and only by doing this will
we be treating them with dignity (Ricou, Sá, & Nunes,
2017).
Another fundamental value that is clearly important in
this context is how we judge the importance or indeed
the value of human life. It is a truism to say that people
in general appreciate and value their lives, so it is almost
impossible to imagine a modern society where human life
is not respected. In fact, if people did not cherish life in their
social relationships, the social order would swiftly break
down. So in the context of this discussion of euthanasia,
we are proposing that there are two central values that
are in play: dignity (that is operationalized as respect for
autonomy) and respect for human life.
Absolute and Relative Values
Whether values are regarded as absolutes or change
depending on circumstances has a significant impact on
ethical decision-making (Neumann & Olive, 2003). Taking
the position that there are absolute values or principles is to
accept that there are absolute right things and absolute
wrong things, which is contrary to the global consensus that
people have different world views. Of course, respecting
differences does mean accepting that we live in a world
where people with absolute values and people with more

27. relative values will need to coexist.
In clinical practice, given this situation, professionals
working with absolute principles will find particular ethical
challenges, since they will need to work with everyone
including those whose values differ from their own (Page,
2012). Beauchamp and Childress (2001), in their moral
common theory, talk about middle-level principles. These
are principles that can be considered absolutes, except
when they conflict between each other. When they do con-
flict, the professional should analyze the situation and
define which principle should be, in that particular situa-
tion, prioritized, and should try to reach some form of
resolution.
As argued later in this paper, in the case of euthanasia,
there is a conflict between the principle of autonomy and
the principle of nonmaleficence; neither one nor the other
can be treated as an absolute, but they are extremely
European Psychologist (2019), 24(3), 243–256 � 2018 Hogrefe
Publishing
246 M. Ricou & T. Wainwright, The Psychology of Euthanasia
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32. important. Our main goal is to understand the possible
implications of the overvaluing of one principle compared
to the other. What can happen if we overvalue autonomy
compared with nonmaleficence when accepting euthana-
sia? On the other hand, if we overvalue nonmaleficence,
are we being paternalistic? And how can we evaluate people
to understand if what they are expressing represents his or
her best interest?
In conclusion, if we accept that there are no absolute
principles, the role of the health professional is to choose,
in each particular case, which principle should be priori-
tized. Because the values we are talking about (value of
autonomy and value of life) are strongly endorsed in con-
temporary western societies, with differing views about
how they should be implemented, it is not reasonable to
leave these decisions alone to the health professional. The
legal system is the vehicle through which such competing
views can be regulated that provides the overall framework.
The best law needs to take account of the possible conse-
quences of the different possible choices and we explore
that in the remainder of this paper.
Respecting Autonomy
A psychologist, in the same way as a medical doctor, always
works intending the best outcome for his client or patient.
The difficulty is to understand, in these cases, what repre-
sents the best outcome, respecting life or respecting
autonomy.
It is known that well-being is highly related to the per-
son’s ability to adapt to new circumstances in life. When

33. something, like a terminal disease, happens in a person life,
suffering will prevail if the person is not able to adapt to the
new circumstances imposed. Respecting autonomy is
respecting the way the person thinks it will allow them to
adapt and have the chance of pursuing a fulfilling future.
In this way respecting someone’s autonomy is also a way
to promote the person adaptation, because only the person
knows the best way to adapt to the changes that have befal-
len them.
Nevertheless, whereas autonomy is an important guiding
principle, it is insufficient to capture the full range of com-
plex issues involved in end-of-life decision-making (APA,
2000). People change their minds often and there is sub-
stantial variation in the will to live which suggests that a
desire to die is inherently changeable (Maier & Newman,
1995; Chochinov, Tataryn, Clinch, & Dudgeon, 1999); there
are emotional states that can interfere with people’s deci-
sions; we know people can be rational but the decision pro-
cess is not simple and involves many, sometimes
competing, variables (Haidt, 2001; Damásio, 2010). The
decision to commit suicide is a good example of the
difficulty we face in understanding if a person’s decision
always represents the best decision as we know from psy-
chological science that decision-making under stressful cir-
cumstances is subject to biases that may not lead to the best
outcome (Mather & Lighthall, 2012). Given this evidence-
base we believe that psychology has a major role to play
here.
Euthanasia and Suicide – A Right or an
Absence of Choice
Euthanasia, Suicide, and Rights
Issues concerning euthanasia are closely connected with

34. those surrounding suicide. It is only in recent times that sui-
cide has been decriminalized in some countries and it is still
regarded as deeply wrong by many of the major world reli-
gions and indeed, perhaps because of this, religious belief
may act to reduce suicide risk (Cook, 2014; Lawrence,
Oquendo, & Stanley, 2016; Stack & Kposowa, 2011; Wu,
Wang, & Jia, 2015). So the question arises, should there
be a legal right to suicide? In most jurisdictions where it
is no longer a criminal offense, there is no right to suicide
as such. If we were to advocate for such a right, how would
we go about defining it? There would be strong views about
this on both sides, as some people would regard suicide as
acceptable as it would fit with their views about personal
autonomy, whereas others would regard it as, for example,
in the Catholic Church, as a Mortal Sin.
We believe, no matter the perspective someone can have
about suicide, that it would be possible for someone to want
to die (Schramme, 2013). So, the question should be if we,
as a society, should let people do it, or should we restrain
them, because it would be always impossible to know, for
sure, which people, between the ones who express the idea
of committing suicide, want really to die and which people
will change their minds.
Different Types of Suicide
One question that arises is whether there are different types
of suicide and we can turn to Durkheim’s classic study
(1897/2001) and list four types of suicide: egoistic, anomic,
fatalist, and altruistic. Considering this last, it becomes
obvious that suicide can have social motivations: the indi-
vidual kills himself due to a social cause which he/she con-
siders a more important value than his own life. In the case
of a suicide bomber carrying out a terrorist attack, for
instance, there is a belief in a more important value than
the innate wish to preserve one's own life (Joiner, 2014).

35. Given this, we can say that suicide may be a rational option;
a person may chose to die in a rational way.
� 2018 Hogrefe Publishing European Psychologist (2019),
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M. Ricou & T. Wainwright, The Psychology of Euthanasia 247
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A

36. m
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or
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a

37. lli
ed
p
ub
lis
he
rs
.
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ar
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is
in
te
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s
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fo

38. r t
he
p
er
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na
l u
se
o
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in
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du
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r a
nd
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to

39. b
e
di
ss
em
in
at
ed
b
ro
ad
ly
.
Sleek (1996) also states an important point regarding sui-
cide: when it is performed by individuals who live with an
incurable disease it can be seen as providing a sense of
comfort once it gives the patient the chance to choose the
moment he/she is going to die. In the opposite way, we also
know that, often, people claim they want to die and after all
they change their minds.
How Do We Know if Someone Would Regret Their
Decision if They Lived?
One key fact here is that most of the people with suicidal
intention, or even having attempted to kill themselves,
end up changing their minds (Maser et al., 2002). Only a
small minority go on to commit suicide (Klonsky, May, &

40. Saffer, 2016). However, of course, this data is compromised
as we cannot ask those who do commit suicide whether
they had a change of heart before they died.
Nevertheless, given this discussion, it is always possible
for a person to change their mind. They may wish to die
at a particular moment, but if they survive, they may be
very grateful. On the other hand, they may not, and telling
the difference between these two situations is very difficult.
From the evidence that we have, it is relatively common for
people to have second thoughts, so that it is clearly better to
err on the side of assuming that someone may change their
minds as if they do die, there is no chance to regret it or
otherwise.
The Role of Professionals
While there are no absolute methods for assessing a person
wishes and whether they are likely to change their minds
concerning their wish to die, psychologists always draw
on whatever scientific evidence is available to inform their
judgment; this means that their starting assumption is that
it would be highly probable that the person might wish to
die at one point in time but would be likely to change their
minds.
But this issue becomes more complicated for doctors.
Usually they are the only professional group that would
are legally accredited to perform euthanasia, where it is
legal3 (Pereira, 2011). And why is that? Medical codes of
ethics are clear; they must relieve a patient’s suffering
and/or cure them whenever possible. Therefore, when con-
fronted with a patient whose pain or disease cannot be
cured and they are likely to continue suffering despite treat-
ment, the doctor considering their obligation to relieve the
suffering, can think about euthanasia being in the patient’s
best interests.

41. Taking into account the question of euthanasia, doc-
tors and psychologists roles are particularly different as
the former ought to decide whether to inject a lethal dose
of drugs in the patient and the latter works with the possi-
bility of the person wanting to live and therefore explores
that chance, not having to accept death nor the means of
inducing it.
But a bigger moral issue can be generated if we think
about a great mistake: keeping alive a person who wants
to die and letting a person die who wants to live. How do
we act if it is not possible to know for sure if the person will
change their mind or not? Perhaps it would be fair to agree
that, after knowing the person very well, and understanding
their particular situation, it would be possible to make an
informed guess about whether the person will or will not
change their mind concerning their wish to die.4 Neverthe-
less to build a law without a scientific evidence-base to eval-
uate these possibilities it would be a very hard task, if not
impossible. In that way, psychology has the responsibility
to develop knowledge that would be able to bring more
light in this subject.
The Need for a Law
Due to the importance of respecting autonomy and also
respecting life, given the risks of a mistake that would result
from privileging either in any particular case, our view is
that only legislation can provide the necessary safeguards.
This is one of the great paradoxes professionals face since
they should always make decisions in line with their profes-
sional principles (Ricou et al., 2017). In each case they
should always consider the particular circumstances for
each person and what would be in their best interests.
Rules, deontological and legal ones, are made for general
or normal situations, and it is impossible to have a law that

42. will get the best solution for everyone (Vilches, 2001). Rules
and laws represent the professional or social norm and are
a clear guide, but each person is an individual and may or
may not conform to these norms. Given that everyone is
different and has differing needs, the responsibility of each
professional is to decide, taking into account, but not
being controlled by, these norms, adapting their practice
to each person. That’s why professionals shouldn’t slavishly
follow rules, they should work with their guiding ethical
principles. Of course they need to know the rules, because
they can’t disrespect them, but they have the responsibility
to try solutions that will fit in the rules but solutions found
after a professional reasoning based in the professional
principles.
3 Switzerland seems to be the only exception to that. It is
possible there, for nonmedical doctors to perform the assisted
suicide. It only requires
that the motive be unselfish (Hurst & Mauron, 2003).
4 It is clear in this statement the importance of a
multidisciplinary work. To assess, counseling, understand the
social and family context, know
the patient’s problem or disease you need, at least, doctors,
psychologists, nurses, and social workers. In fact, you need the
same health
professionals usually are part of a palliative care team.
European Psychologist (2019), 24(3), 243–256 � 2018 Hogrefe
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248 M. Ricou & T. Wainwright, The Psychology of Euthanasia
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43. s
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44. ol
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45. .
T
hi
s
ar
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le
is
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te
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l u

46. se
o
f t
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in
di
vi
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to
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at

47. ed
b
ro
ad
ly
.
Of course, rules are made, in part, because people in gen-
eral can’t have the responsibility to decide simply using
their own principles, at least about important societal val-
ues. Euthanasia potentially puts into conflict two funda-
mental values, so clearly society will need rules and laws.
The consequence may be, of course, that it will be more dif-
ficult to find solutions that will fit the best interest for each
person, because the rules will cover general circumstances,
not particular cases.
In this way we need to find the fairest rules, including
all the possible criteria to try to provide solutions in most
situations, knowing that it will not be possible to find a solu-
tion that fits everyone’s interests. This is the profes-
sional role, trying to find and advocate for the best client
solution; this is also where science can play a part, trying
to develop the knowledge and evidence-base to make more
fair laws, a research field that has not had the attention it
deserves.
Crisis, Pain, Suffering, and
Decision-Making
Crisis
Having discussed the relationship between suicide and

48. euthanasia it is clear that both situations are associated with
some sort of crisis in a person’s life.
The term “crisis” has been defined as a decisive change,
an acute moment of imbalance (Jalley, 2001), in other
words, a turning point. The particular form of the crisis will
vary but facing death inevitably leads to a reassessment of
the person’s relationship with others, and indeed of their
own life history. This can itself be a painful process and
can be seen as both a cause and also an outcome of this
critical transition – from life to death. However, life crises
are not necessarily of such magnitude and while they
may be challenging, they can be an important source of
change and development. Indeed the research on post-trau-
matic growth as a counter to overly pessimistic approaches
to difficult experiences is a case in point (Chen & Wu,
2017).
Suffering
The concept of suffering is not straightforward, either in the
context of either physical or psychological pain. Raus and
Sterckx (2015), in their chapter on euthanasia and mental
suffering, provide a comprehensive overview of the differ-
ent ways in which this construct has been understood. Their
particular focus was the rationale for allowing euthanasia
for conditions where a diagnosable condition could be iden-
tified and where there was severe suffering, but not where
the same suffering was encountered without such a diagno-
sis. Their conclusion is that the logic and ethical validity for
this distinction is weak, but nevertheless there are grounds
for maintaining it. How people respond to pain therefore
takes many forms (Cassel, 1982). The literature has many
definitions of psychological pain and there have been self-
report measures associated with these definitions. These

49. have been shown to have some limited validity and reliabil-
ity, although some are better than others (Tossani, 2013).
As a summary, we can affirm that the role of suffering in
a person’s life can play a positive role in personal develop-
ment; in other words, suffering can lead the individual to
mobilize their energy toward an adaptation to the circum-
stances that led to the suffering, and to act on them. In this
way, suffering can be transformative.
However there will be situations where the challenge of
adaptation is too great. Under these circumstances a person
may request euthanasia, as they do not see any prospect of
being able to adapt.
It is probably impossible in principle to distinguish people
who can adapt from those who cannot; though, it is clear
that for some people under some circumstances adaptation
would be highly improbable. Nevertheless, as mentioned
earlier in this article, people do change their minds and a
particularly clear example is known as the “Oregon Para-
dox” (Lee, 2010). Here people, who go through the various
complicated steps of being assessed for euthanasia and suc-
cessfully receive the necessary clearance, experience a
boost to their well-being and wish to live longer. The para-
dox arises from the newly acquired capacity to end their
lives sooner. While this has been seen in those with termi-
nal illnesses, it may also apply to others where they achieve
the option of ending their lives and this itself becomes a
turning point.
Decision-making about euthanasia is a difficult task and
involves much emotional effort by the person involved, pos-
sibly family and friends and the care team. This process is
not easy and different people may have different capacities
in this area (Dees et al., 2013).

50. This is the point where euthanasia could be considered –
for those who cannot adapt – being clear, however, that it is
very difficult to be sure about whether someone really can-
not adapt, or just needs more time.
Medical Doctors Conflicts With
Beneficence and Nonmaleficence
Having explored suffering, some aspect of which is associ-
ated with a person’s request for euthanasia, and have
briefly characterized issues concerning the right to life
and personal autonomy, we shall now consider two
related concepts from medical ethics: beneficence and
� 2018 Hogrefe Publishing European Psychologist (2019),
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M. Ricou & T. Wainwright, The Psychology of Euthanasia 249
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51. ri
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52. n
or
o
ne
o
f i
ts
a
lli
ed
p
ub
lis
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rs
.
T
hi
s
ar
tic
le
is
in

53. te
nd
ed
s
ol
el
y
fo
r t
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p
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na
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o
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54. u
se
r a
nd
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n
ot
to
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e
di
ss
em
in
at
ed
b
ro
ad
ly
.
nonmaleficence (Beauchamp & Childress, 2001), the
injunction to only do good and never to do harm. Both of

55. these ideas are central to what you might call the “medical
conscience” and will come into play when a request for
euthanasia is made.
Based on these considerations, we must take into
account that all health professionals, such as doctors, are
professionally obliged to pursue the well-being of their
patients and avoid inflicting harm and it is clearly a chal-
lenge to conceive of killing someone, even on their own
request, as being consistent with this. This then leads to
efforts to minimize suffering as much as possible, and to
whether euthanasia would be one approach that would
indeed minimize suffering (and through this reasoning
legitimize it) or by contrast, bring the patients chance for
future happiness to an end.
Concluding this section there is a strong case to be
made that there are some individuals under some circum-
stances who would not be able to adapt to the situation
and their life conditions are such that they may make
a rational choice that death is preferable to life, hard
though this is for a professional committed to saving life
to accept.
We can then draw the conclusion that respecting the per-
son’s autonomy includes understanding that some people
cannot adapt and would be condemned to suffer; and that
for them, euthanasia would be a possible way to bring the
suffering to an end. The problem, as already pointed out,
is to accurately determine who those people are – some-
thing we are currently unable to do.
The Slippery Slope Argument –
Respecting Nonmaleficence
Having reviewed the main arguments that are made in sup-

56. port of the practice of euthanasia, we now turn to those
arguments that are made to oppose it, and we will first con-
sider the “slippery slope” (Pereira, 2011). This makes the
case that once it is established, it becomes a socially accept-
able norm, and is applied in ways that may never have been
intended. A similar idea in military terms is called “mission
creep” (http://tinyurl.com/euthanasia-mission-creep).
The fear is that there is a gradual shift from voluntary
euthanasia, with informed consent, and excellent safe-
guards, to involuntary as the approach is more generally
accepted, and the society is desensitized to the ethical con-
cerns raised when euthanasia was first introduced. Essen-
tially people get used to things. In addition, there are
some strong arguments that the incentives will be there
to extend the range of those who will be affected by this
process.
Incentives That Lead to “Mission Creep”
Firstly, we shall consider the economic and financial ques-
tion. In other words, keeping patients alive hooked into hos-
pital machines becomes costly after a while and therefore,
unplugging the devices, killing the patient, ends up being an
economical benefit to the hospital as it stops the costs and
frees up beds. (Finlay, Wheatley, & Izdebski, 2005)
Since the global financial crash of 2008, there has been
an emphasis on “austerity” policies that have had a major
impact on health across Europe (Quaglio, Karapiperis,
Van Woensel, Arnold, & McDaid, 2013) and it is not hard
to imagine that with euthanasia a relatively cost-saving
intervention, policymakers would become more interested
in it. Pelligrino (1998, p. 87), an authority on palliative care
medicine, made this point, when he wrote:

57. “In a society as obsessed with the costs of health care
and the principle of utility, the dangers of the slippery
slope. . .are far from fantasy. . .
Assisted suicide is a half-way house, a stop on the
way to other forms of direct euthanasia, for example,
for incompetent patients by advance directive or sui-
cide in the elderly. So, too, is voluntary euthanasia a
half-way house to involuntary and nonvoluntary
euthanasia. If terminating life is a benefit, the reason-
ing goes, why should euthanasia be limited only to
those who can give consent? Why need we ask for
consent?”
He also stresses that the healthcare managers and doctors
have an interest in freeing up beds, so they can treat more
patients, have better clinical outcomes for those that do not
have euthanasia, and also for increasing profits.
As we noted earlier, proponents of euthanasia argue
that the main reason some doctors support voluntary eutha-
nasia is because they strongly value the patients’ right to be
treated as autonomous human beings who can make deci-
sions involving what happens with their lives. Nevertheless,
there is some evidence that cost-conscious doctors are
more likely to honor their patients’ requests for death as
a study carried out in 1998 found that those who are
cost-conscious and “practice resource-conserving medi-
cine” are significantly more likely to write a lethal prescrip-
tion for terminally-ill patients (Sulmasy, Ely, & Sprung,
2016; Sulmasy, Linas, Gold, & Schulman, 1998). Putting
this into a broader context, we know from the field of
behavioral and organizational ethics that perverse incen-
tives like this play an important role in calibrating ethical
decision-making (Bazerman & Banaji, 2004; Bazerman &
Tenbrunsel, 2011).

58. The issue of cost saving can work both ways, however. It
is possible that the money saved by offering the choice of
European Psychologist (2019), 24(3), 243–256 � 2018 Hogrefe
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250 M. Ricou & T. Wainwright, The Psychology of Euthanasia
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59. A
m
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an
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60. a
lli
ed
p
ub
lis
he
rs
.
T
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s
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is
in
te
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61. fo
r t
he
p
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so
na
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62. to
b
e
di
ss
em
in
at
ed
b
ro
ad
ly
.
euthanasia would release funds for improving palliative
care and other hospice services. It may also work, in the
opposite direction, where there would be an argument that
palliative care would become increasingly unnecessary as
people would be encouraged to take up the offer of eutha-
nasia rather than extending their lives with more complex
treatments.
As noted by Pelligrino (1998), another concern is if vol-
untary euthanasia were to become legal, it would not be
long before involuntary euthanasia would occur. A person
might feel pressure, whether real or imagined, to request
euthanasia in order to relieve the family’s suffering or dis-

63. tress caused by the person’s illness or its costs, especially
where the family has few resources. One of the main rea-
sons people give for asking to die is feeling a burden to their
families (Kelly et al., 2003; Lulé et al., 2014). It is also pos-
sible that the family may encourage the person to request
euthanasia, in either direct or more subtle ways. In these
situations the person concerned is quite vulnerable and it
is not difficult to imagine that they might feel pressurized
to seek an early death. Under these circumstances, it would
be important to assess the wider context. If they were under
such pressure, can we really call it a voluntary decision?
Putting aside considerations of direct family pressure,
where euthanasia has become established and is seen as
a normal option, people may feel a more general social
pressure to end their life, as they will be seen, and may
see themselves, as taking resources away from others
who may be thought to be more entitled.5
Finlay et al. (2005) also point out that once patients have
the choice of euthanasia, doctors will feel under an obliga-
tion to offer it for all those who are eligible, even to those
who have not asked about it. There is then a consequential
risk of lowering the patients morale and lead them to take
an option they would prefer not to take.
So here we see some of the limitations on our ability to
judge autonomous decision-making and leads logically to
questioning how legitimate it is to regard the person as fully
autonomous. This is particularly problematic and raises
fundamental issues of responsibility since, of course, eutha-
nasia once administered is not reversible.
The question of whether there is a slippery slope is now
an empirical one. There are jurisdictions where euthanasia
has been an option for many years, and it is possible to see

64. how far the changes predicted with this argument have
happened. There is a mixed story here and arguments on
both sides, although the consensus is that there are exten-
sions to the original law likely to take place. This can be
seen, for example, in the Belgian experience where the
choice is now extended to children, where this would not
have been considered when the initial laws were passed
(Byock, 2016).
The Role of Psychology
As we have discussed, one of the major problems in decid-
ing whether euthanasia can be in the person’s best interest,
is related to limitations in our ability to judge autonomous
decision-making. In situations where the national law per-
mits euthanasia or assisted suicide, we believe psycholo-
gists skills set can play a role in evaluating a client’s
ability to make an informed decision; we also believe their
knowledge and skills can also evaluate the degree to which
the wish to die is likely to persist over time. In every case,
psychologists should have a continuing role as part of their
counseling relationship. However, this is not apparently
happening both in countries where hastened death is legal
or illegal (see below).
The Role of Psychology: Literature Review
In the literature review we conducted concerning psychol-
ogy and hastened death, we found very little evidence
about the role of psychology or of psychological practice.
The research was carried out in the electronic databases
APA PsycNET, EBSCO, EuropePMC, PubMed, Sage, Scien-
ceDirect, SpringerLink, Wiley Online Library. We also used
the Google search engine. The keywords euthanasia,

65. assisted suicide, hasten death, desire to death, end of life
decisions, and psychology were used in English and Por-
tuguese. The combination of words used was euthanasia
and psychology; assisted suicide and psychology; hasten
death and psychology; desire to death and psychology;
and end of life decisions and psychology.
To guide the selection of the articles, inclusion, and
exclusion criteria were defined. Inclusion criteria were:
(a) the publications between 2000 and 2017;
(b) texts in English and Portuguese;
(c) studies in the field of psychology and/or that consider
psychosocial factors; and
(d) quantitative and qualitative surveys were considered.
As it is a theme that was not well represented in the litera-
ture, we also included literature reviews or theoretical dis-
cussion about euthanasia and psychology and/or assisted
suicide and psychology. Exclusion criteria included:
(a) studies in other languages;
5 It is curious to know that in the Netherlands the feeling that
one is a burden to others can be a factor contributing to the
unbearable nature of
suffering, so a criteria to accept voluntary euthanasia (Regional
Euthanasia Review Committees [RTEs], 2016).
� 2018 Hogrefe Publishing European Psychologist (2019),
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M. Ricou & T. Wainwright, The Psychology of Euthanasia 251
T
hi

66. s
do
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e
A
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ch

67. ol
og
ic
al
A
ss
oc
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or
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o
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a
lli
ed
p
ub
lis
he
rs

68. .
T
hi
s
ar
tic
le
is
in
te
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s
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y
fo
r t
he
p
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so
na
l u

69. se
o
f t
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in
di
vi
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n
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to
b
e
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ss
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at

70. ed
b
ro
ad
ly
.
(b) studies that did not consider themes in the field of psy-
chology; and
(c) studies preceding year 2000.
Applying the inclusion criteria we just identified 17 articles.
Most of them (9) are from Canada (Galbraith & Dobson,
2000; Rodin et al., 2008; Wilson et al., 2000, 2007) and
Australia (Hudson et al., 2006; Kelly et al., 2003; Mitchell
& Owens, 2000; Robinson, Kissane, Brooker, & Burney,
2017; Sanson et al., 2008), 2 from United States of America
(Emanuel, Fairclough, & Emanuel, 2000; Suarez-Almazor,
Newman, Hanson, & Bruera, 2002) and just 6 are from
Europe (Bellido-Pérez, Monforte-Royo, Tomás-Sábado,
Porta-Sales, & Balaguer, 2017; Caputo, 2015; Lulé et al.,
2014; Mystakidou, Parpa, & Katsouda, 2005; Mystakidou,
Parpa, Katsouda, Galanos, & Vlahos, 2004; Rodríguez-Prat,
Balaguer, Booth, & Monforte-Royo, 2017) and none of them
from countries where hasten death is legalized. Seven are
literature reviews or theoretical discussion. In three papers
(Galbraith & Dobson, 2000; Mitchell & Owens, 2000; San-
son et al., 2008) the authors argue that psychologists
should be involved in the capacity assessment process,
which we believe is logical. Nevertheless, we believe psy-
chology should go further and try to assess not just capacity

71. but also the ability to make really informed decisions. Sev-
eral studies about suicide (Maia & Ricou, in press) show
that there are some factors that contribute to the probability
of people committing suicide. It would be important to
understand which of those factors can contribute to hasten
death request. All the others articles just mention the gen-
eral role of psychologists, as in counseling and alleviating
distress with families. In the same way Sanson et al.
(2008) advocate that psychologists should play a role in
decisions, advocacy and with the work after euthanasia
with families and professionals. Nevertheless, none of those
papers suggest any kind of intervention techniques. There is
an inventory for assessing the wish to hasten death, appar-
ently the most widely used (Bellido-Pérez et al., 2017). In
one systematic literature review (Caputo, 2015) the main
conclusions were very similar; that there is a little role for
psychology in situations where there has been a request
to hasten death.
Ten articles studied patients’ perceptions about the legal-
ization/acceptance of euthanasia or assisted suicide in
terms of psychological and social factors. The wish to die
was frequently associated with less religiosity, reduced
functional status, pain, lower levels of social support, and
loss of dignity. Most of the papers indicate that greater per-
ception of being a burden for others and a diagnosis of
depression were the main factors contributing for the wish
to die. Depressive symptoms are naturally very common in
those patients and consequently the diagnosis is difficult to
make. None of those papers discuss the level of depression
that should be considered as grounds for accepting or
rejecting the wish to die as valid. Nevertheless two papers
(Emanuel et al., 2000; Wilson et al., 2007) argue that
depression can increase the probability of the patient
changing their minds about hastening death, so they pro-

72. pose psychologists have an intervention role with those
patients. Feeling a burden to others is one of the other most
cited reasons for the wish to die. The main motivation, in
this case, is the patient’s perception that they are the cause
of suffering for other people, not their own suffering. Feel-
ing a burden it is one of the reasons for suffering considered
grounds for a euthanasia request in the Netherlands’ law. It
is stated that the feeling that one is a burden to others can
be a factor to contribute to the unbearable nature of suffer-
ing (RTEs, 2015). Nevertheless it would be important to
understand, in those cases, if the family actually feel the
patient as a burden, and what kind of suffering the patient’s
decision to die will cause in that same family. This should
be, probably, another task for psychologists.
Someone considering choosing to die is facing perhaps
the most important decision a person can take, one laden
with very significant psychological issues. Given both the
significance to the person and these important psychologi-
cal dimensions, psychological professionals need to become
much more visible in end of life decisions (APA, 2000) and
play a much more central role on the ongoing debate
(Caputo, 2015). Psychologists have several areas of compe-
tence, including assessment, counseling, and research that
can contribute to the support of dying persons and/or to
persons who express a wish to die. These skills include
identifying factors that can be defined as catalysts or as
inhibitors of the client ability to adapt perhaps personality
or other individual factors. There is not a strong evi-
dence-base supporting the work of psychologists in this
field, but psychological studies in the associated field of sui-
cide prevention shows that it would be possible to under-
stand much more about these wish to die requests (Maia
& Ricou, in press).
Another issue is clarifying how likely is it that the

73. client will either change their mind, and adapt to the cur-
rent situation, or remain convinced that death is the best
option; and how long should be allowed for this process.
As we have already stated (Emanuel et al., 2000; Wilson
et al., 2007), there are correlations with depressive symp-
toms, there being a higher probability of changing their
mind about wish to die, the higher their depression score.
But which other variables can contribute to it? And, how
long should we wait for the person to change their
mind? And what can the psychologist do in the meanwhile
working with the patient? All those questions need answers
that can have a strong influence in a law about euthanasia
European Psychologist (2019), 24(3), 243–256 � 2018 Hogrefe
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252 M. Ricou & T. Wainwright, The Psychology of Euthanasia
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74. gh
te
d
by
th
e
A
m
er
ic
an
P
sy
ch
ol
og
ic
al
A
ss
oc
ia
tio
n

75. or
o
ne
o
f i
ts
a
lli
ed
p
ub
lis
he
rs
.
T
hi
s
ar
tic
le
is
in
te

76. nd
ed
s
ol
el
y
fo
r t
he
p
er
so
na
l u
se
o
f t
he
in
di
vi
du
al
u

77. se
r a
nd
is
n
ot
to
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e
di
ss
em
in
at
ed
b
ro
ad
ly
.
or assisted suicide and currently the evidence is not
available.
The psychologist needs to also be mindful of the external

78. factors that may come into conflict with the person’s deci-
sion. Sanson et al. (2008) propose an advocacy process with
the patient and his/her family to better understand the
motivations for dying. We also believe this should be a task
for psychologists more than any other professionals given
their specific skills set and knowledge base.
Identifying individuals where there is absolutely no doubt
about their wish to die, and who would maintain this wish
and would benefit from the opportunity to do so is an
impossibility. Society, through the law, has to provide a
timeframe where it will be acceptable to reach a credible
decision, and psychology can provide what research evi-
dence there is to support the development of such a time-
frame. In another way psychologists could play an
important role in public and other professional’s education
about issues related to death (APA, 2000; APS, 2008; San-
son et al., 2008).
As noted above psychologists can have a powerful influ-
ence on clients’ decisions. Because of this, psychologists
should always recognize the possibility for biases in their
work, particularly being aware of their own views about
euthanasia and assisted suicide. They should be highly cog-
nizant about their personal opinions concerning euthanasia
so they can work in an appropriate way (APS, 2008). They
also should have proper training in the field of end-of-life
psychology to ensure they have the skills and competence
in assessing and counseling with this client group.
Psychologists also play an important role working with
the families of clients who ask to die. Sometimes, there
can be conflicts between family members, and perhaps
between family members and the client about the best
way forward. Psychologists can play a role facilitating com-
munication, and helping families to resolve or reconcile

79. such issues. In the same way psychologists can help other
health professionals involved in such challenging situations
and also support them in dealing with the powerful emo-
tions that can arise.
There is much research about suicide and palliative
care, but very little about end-of-life decisions (Carmona,
Santos, & Fonseca, 2011; Caputo, 2015). This is an area
where psychological science should develop its research
effort so that we improve our ability to assess how final
the wish to die is in these situations and also about the
way this kind of wish, where there are irrevocable conse-
quences develops. Psychology can contribute to the design
of a legal framework that takes account of personal vari-
ables that contribute to the wish to die being a finalized
choice, thereby avoiding as far as possible, non-intentional
involuntary euthanasia.
Final Considerations
Our conclusion from this review is that there is no panacea,
meaning that the case of euthanasia has the form of a clas-
sical ethical dilemma, where there are problems with all the
available options. When a society legislates on this subject –
and there is no doubt at all that the conditions surrounding
the process of dying ought to be legislated – the law is likely
to be framed as one that is considered most suitable to
most people in most cases. By definition, that idea sepa-
rates us from casuistry, which shall be considered by the
health professionals, but escapes from legal and legislative
control.
Given this possible legal framework for euthanasia, it fol-
lows that, despite the approach taken having widespread
social support, it will always be unfair to some people, as
is the case with any legislation. Given this, it again follows

80. that in a society where euthanasia is an active practice,
there will be people who even though they meet the criteria
previously established for euthanasia, and also consciously
affirm their wish to die, would not, in fact, actually want it.
As discussed earlier, we know people who very clearly
say they want to die, and even attempt to kill themselves,
but change their minds. In these cases, there is a risk that
those people would die even though they had the capacity
to adapt to their situation and therefore to end their suffer-
ing in other ways. For those who die, of course, this could
never be determined as this process – euthanasia – is irre-
versible, and this should be a reason to be more sure when
considering someone request for dying than for any other
reason.
Likewise, we also must not disregard the fact that in soci-
eties where euthanasia is legally forbidden, there will be
people incapable to adapt to their situation, unable to
relieve their suffering and hence will genuinely want to
die and will not be allowed to, being condemned to live
with their suffering.
The main problem will always be to determine who in
fact are those people that we can state without a single
doubt that they truly want to die; knowing that, legalizing
euthanasia, the tendency will be a slippery slope; summariz-
ing, we have to be conscious that we face a major dilemma
which consists in both situations: of keeping alive a person
who wants to die and letting die a person who wants to live.
In conclusion, whatever the choices defined by any soci-
ety are, it will be fundamental to acknowledge the lack of
perfect solutions to this matter which would solve every-
one’s situations. Thus, it is essential to take into account
the possible and predictable consequences of adopting

81. one or other policy, in order to reduce to the minimum
the injustice that any decision at this level will cause
to some people. The decision will always be the one
� 2018 Hogrefe Publishing European Psychologist (2019),
24(3), 243–256
M. Ricou & T. Wainwright, The Psychology of Euthanasia 253
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e

82. A
m
er
ic
an
P
sy
ch
ol
og
ic
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ss
oc
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tio
n
or
o
ne
o
f i
ts

83. a
lli
ed
p
ub
lis
he
rs
.
T
hi
s
ar
tic
le
is
in
te
nd
ed
s
ol
el
y

84. fo
r t
he
p
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85. to
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ly
.
considered less onerous to the majority, but should put
greater emphasis on protecting all of those who can become
more vulnerable according to the choices made. Psychology
has, in this context, a major role to play. Nevertheless, as
far as we have been able to ascertain, psychological profes-
sionals are not specifically included in any legislation con-
cerning euthanasia or assisted suicide. Furthermore there
are very few studies in this important area. Most of the pub-
lications concern the issues arising from conflicting princi-
ples and very few about decision-making in the context of
dying.
When someone is aware of all the possible problems

86. and/or merits of legalizing or not euthanasia, they will be
able to find the best solution. Democracy works after the
choices of people, where the majority take the lead role.
So, in the ideal situation is for there to be very widespread
understanding of these issues and the decision should be
taken by the majority, or we believe better still, by those
elected to represent the people.
We have then a long path to walk, to develop knowledge
that helps us to better understand the way people choose
and the way those choices represent in fact their best inter-
est. Knowing this it would be possible to provide much
more information for the general population about the pos-
sible consequences of maintaining or changing the law.
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104. n
ot
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Received August 3, 2017
Revision received November 16, 2017
Accepted January 23, 2018
Published online August 16, 2018
Miguel Ricou
Faculty of Medicine
University of Porto
Alameda Prof. Hernâni Monteiro
4200-519 Porto
Portugal
[email protected]
Miguel Ricou (PhD) is an Assistant
Professor of Bioethics and of Pallia-
tive Care, both at the Faculty of
Medicine of Oporto University, and
also an Assistant Professor of Psy-
chopathology at Portucalense
University. He acts as President of
the Ethics Committee of the Order of
Portuguese Psychologists and sup-
ports the EFPA Board of Ethics in
form of the Portuguese Representa-
tive.
Tony Wainwright is a clinical psy-
chologist with many years experience
working in the UK National Health
Service. His main areas of clinical
practice have been with older people

108. and those with long-term mental ill
health. He has had a long-standing
interest in the field of professional
ethics and its links with human
rights. He also has a strong com-
mitment to the field of applied psy-
chology in public health and how the
way we are damaging the environ-
ment leading to climate change and
biodiversity loss has impacted on
social justice and human rights. He
is the deputy academic director on
the University of Exeter Doctorate in
Clinical Psychology Programme
where he teaches on ethics, leader-
ship and human rights.
European Psychologist (2019), 24(3), 243–256 � 2018 Hogrefe
Publishing
256 M. Ricou & T. Wainwright, The Psychology of Euthanasia
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113. Death Studies, 38: 582–588, 2014
Copyright © Taylor & Francis Group, LLC
ISSN: 0748-1187 print/1091-7683 online
DOI: 10.1080/07481187.2013.820228
The Role of and Challenges for Psychologists
in Physician Assisted Suicide
Shara M. Johnson, Robert J. Cramer, Mary Alice Conroy, and
Brett O. Gardner
Department of Psychology, Sam Houston State University,
Huntsville, Texas, USA
Physician assisted suicide (PAS) poses complex legal and
ethical dilemmas for practicing
psychologists. Since the passage of the Oregon Death with
Dignity Act in 1997, Montana
and Washington have passed similar legislation. Despite the law
requiring competence
evaluations by medical and psychological professionals,
existing psycholegal literature
inadequately addresses the role of psychologists in the PAS
process. This article reviews
legal statutes and analyzes ethical dilemmas psychologists may
face if involved. We con-
sider competence both generally and in the context of PAS.
Suggestions are made for
psychologists completing competence assessments and future
directions to improve com-
petence assessments for PAS are provided.
Human beings possess greater lifespans than at any point
in history due to advancements in modern medicine and
technology. The average lifespan in 1900 was 47.3 years;
by 1997 it was 76.5 (Kramarow, Lentzner, Rooks, Weeks,

114. & Saydah, 1999). The trend has continued: From 1980 to
2005, life expectancy increased by nearly four years
(National Center for Health Statistics, 2010). Although
living longer is generally viewed as a blessing, society is
witnessing increased rates of chronic disease and termi-
nal illness as a result (National Center for Health
Statistics, 2010). Advances in medical technology can
often postpone these deaths, but many view a life pro-
longed by dialysis, ventilators, and feeding tubes as unde-
sirable (Sears & Stanton, 2001).
In the United States, people are increasingly express-
ing an interest in controlling the way their lives end should
they be diagnosed with a terminal illness or chronic con-
dition that yields a poor quality of life (Cerminara &
Perez, 2000). As a result, every state has legalized advance
directives, which allow individuals to specify the circum-
stances in which particular life sustaining treatments may
be refused or withdrawn, ensuring that their wishes are
respected in the event they are rendered incompetent to
make their own medical decisions (Sears & Stanton,
2001; Werth, Lewis, & Richmond, 2009).
Physician assisted suicide (PAS) and euthanasia are
alternative end-of-life decisions. PAS and euthanasia
both hasten the death of an individual, but the two con-
cepts meaningfully differ in the role of the physician
(Cerminara & Perez, 2000; Sears & Stanton, 2001).
Physicians carrying out a request for PAS provide indi-
viduals with the means, generally prescription medica-
tion, to end their life; individuals decide if and when to
use the means. Euthanasia indicates cases in which the
physician administers the lethal dose of medication with
the intention of killing the patient (Cerminara & Perez,
2000; Sears & Stanton, 2001).

115. This review examines PAS from both legal and ethical
perspectives, and discusses issues related to assessment of
competence in patients requesting PAS in an effort to
clarify the role and duties of psychologists participating
in competence evaluations. The practice of PAS is widely
considered to be a criminal offense; however, the practice
is currently legal in Oregon, Washington, and Montana
(Oregon Death with Dignity Act [ODDA], 1995;
Washington Death with Dignity Act [WDDA], 2008;
Baxter v. Montana, 2009). PAS is also a highly controver-
sial topic from an ethical standpoint and the duties of
psychologists involved in the process remain unclear.
Thus, we present arguments regarding the rationality of
suicide as a framework for understanding the debate that
surrounds the acceptability of PAS. We include a review
Received 29 September 2012; accepted 6 June 2013.
Address correspondence to Shara M. Johnson, Department of
Psychology, Sam Houston State University, Huntsville, TX
77341.
E-mail: [email protected]
THE ROLE OF AND CHALLENGES FOR PSYCHOLOGISTS
583
of the ambiguous ethical obligations of psychologists
involved in PAS. In addition, guidelines for psychologists
tasked with determining competence are critiqued, and
we offer practical suggestions for completing the evalua-
tion. Lastly, we identify areas for future research to
improve PAS competence evaluations.

116. PHYSICIAN ASSISTED SUICIDE LEGISLATION:
CRITERIA AND THE ROLE OF MENTAL HEALTH
PROFESSIONALS
In 1994, voters passed the ODDA (1995), which became
available for use at the end of 1997 following a failed
attempt to have the law repealed (Werth, Benjamin, &
Farrenkopf, 2000). To qualify for PAS, an individual must
be (a) a resident of Oregon (Oregon Revised Statute [ORS]
127.860 § 3.10), (b) at least 18 years old (ORS 127.805 §
2.01), (c) terminally ill, which two physicians agree will
result in death within 6 months (ORS 127.820 § 3.02), and
(d) making an informed decision (ORS 127.830 § 3.04).
Furthermore, (e) the individual must make three requests
to his or her attending physician, two oral and one written
(ORS 127.840 § 3.06). The oral requests must be made at
least 15 days apart, and an additional waiting period of 48
hr must pass between the written request and the prescrip-
tion (ORS 127.850 § 3.08). Lastly, (f) the physician must
offer to stop the process following the second oral request,
which the individual must refuse (ORS 127.845 § 3.07).
According to ODDA, to receive the life ending pre-
scription, the patient must be considered to be making an
“informed decision,” which is
based on appreciation of the relevant facts and after
being fully informed by the attending physician of: a) his
or her medical diagnosis; b) his or her prognosis; c) the
potential risks associated with taking the medication to
be prescribed; d) the probable result of taking the medi-
cation to be prescribed; and e) the feasible alternatives,
including, but not limited to, comfort care, hospice care,
and pain control. (ORS 127.800 § 1.01.7)

117. As the law is written, a mental health professional
should only become involved in requests for PAS when
either the attending or consulting physician believes the
patient is “suffering from a psychiatric or psychological
disorder or depression causing impaired judgment” and
makes a “counseling referral” (ORS 127.825 § 3.03). It is
up to “the person performing the counseling” to deter-
mine that the patient is no longer suffering from the psy-
chological disorder causing impaired judgment and
capable of continuing with PAS. However, the definition
of capable provided by the ODDA, “the ability to make
and communicate health care decisions to health care
providers” is too vague to serve as a guide for psycholo-
gists asked to make such a determination (ORS 127.800 §
1.01; Werth et al., 2000). Guidelines do not exist and no
recent court cases have clarified what constitutes
decisional competency in PAS (Werth et al., 2000).
Two other states have followed Oregon. In 2008,
Washington voted to adopt an assisted suicide law
(WDDA, 2008). In 2009, the District Court of Montana
held that state residents’ constitutional rights of individ-
ual privacy and human dignity grant the right of a “com-
petent, terminally ill patient to die with dignity” (Montana
Death with Dignity Act [MDDA], 2009). The Montana
Court went on to permit patients to use the assistance of
their physician in obtaining a prescription for a lethal
dose of medication, but specified that the patient is
responsible for deciding to self-administer the medication
and induce death (Baxter v. Montana, 2009).
ARGUMENTS FOR AND AGAINST PAS
Understanding variant perspectives on suicide itself is
necessary to fully evaluate the ethical issues involved in

118. PAS. From a medical model, suicidal ideation is com-
monly considered symptomatic of mental illness and irra-
tionality (Sullivan, Ganzini, & Younger, 1998). As proof,
thoughts of death are listed among diagnostic criteria for
depression in the Diagnostic and Statistical Manual (4th
ed., text rev.; American Psychiatric Association, 2000),
much clinical literature is devoted to assessing and pre-
venting suicide (e.g., Bryan, Corso, Neal-Walden, &
Rudd, 2009; Cukrowicz, Wingate, Driscoll, & Joiner,
2004; Kleespies & Dettmer, 2000; Wingate, Joiner, Walker,
Rudd, & Jobes, 2004), and numerous organizations (i.e.,
American Association of Suicidology, American
Foundation for Suicide Prevention, and International
Association for Suicide Prevention) are committed to pre-
venting suicide (Silverman, 2000). Furthermore, the
implication that suicidal ideation indicates incapacitating
pathology extends into the legal arena and is used to jus-
tify involuntary commitment and mental health treatment
(Sullivan et al., 1998).
Although a wide body of research on suicide exists, it
focuses primarily on prediction and prevention; very little
conceptualizes suicide as a rational alternative (Werth,
1998; Widiger & Rinaldi, 1983). This emphasis likely
reflects a denial of circumstances that may render a life
no longer worth living and common fears about death.
Two arguments support suicide prevention. The first is
the link between suicidal ideation and psychopathology
(Widiger & Rinaldi, 1983). Indeed, presence of suicidal
ideation results in a lower Global Assessment of
Functioning score, which is a rating of psychological dys-
function. Suicidal behavior also mimics four features
common among mental disorders: the low base rate for
suicide represents a deviation from normal behavior, it is
viewed as undesirable by society, it is indicative of high
levels of distress, and it impairs functioning in one or

119. more domains (Widiger & Rinaldi, 1983). The second is
584 S. M. JOHNSON ET AL.
the ambivalence of the individual toward death.
Individuals who are in, or seek, treatment during their
suicidal crisis are perceived to be ambivalently committed
to ending their own life and receptive toward intervention
(Widiger & Rinaldi, 1983).
Belief in an inherent right to autonomy and acknowl-
edgement of the possibility that death can be a desirable
alternative to life are arguments used by those who lobby
for an acceptance of suicide (Silverman, 2000; Widiger &
Rinaldi, 1983). Autonomy proponents believe that indi-
viduals have the right to oversee their own goals and des-
tinies, which includes the manner and timing of their
death. They argue psychologists’ duty to commit or refer
a patient who is experiencing suicidal ideation fully
removes the autonomy from the patient so that the psy-
chologist assumes control over the suicidal patient
(Abeles & Barlev, 1999). They also point out that circum-
stances may arise in which the individual experiences
unbearable suffering or permanent impairment, and
death would be a merciful relief (Silverman, 2000;
Widiger & Rinaldi, 1983). From this perspective, there is
little perceived difference between PAS and acceptable
end-of-life alternatives, such as refusal or withdrawal of
life sustaining treatment (Jamison, 2000).
Opponents of PAS cite numerous concerns. One com-
mon argument is that PAS would be unnecessary if termi-
nally ill patients had adequate palliative care (Cerminara
& Perez, 2000; Jamison, 2000; Rosenfeld, 2000). It is

120. argued that more effective pain management for termi-
nally ill patients and additional social support for the
patient and family should be developed. Another fre-
quently cited argument against PAS is monetary; PAS is
less expensive than extensive palliative treatment and
might be more frequently used when medical resources
are scarce (Rosenfeld, 2000). Furthermore, it has been
theorized that should such a scarcity arise, PAS may be
used more frequently with members of vulnerable soci-
etal groups, such as minorities, individuals with disabili-
ties, and those of low socioeconomic status (Rosenfeld,
2000). Lastly, there is fear that legalizing PAS will lead to
a slippery slope in which euthanasia and assisted death
for patients not suffering from a terminal illness also
become legal (Rosenfeld, 2000). In fact, White and
Callahan (2000) proposed that “the most disastrous long-
term effect of legal PAS would be to legitimate suicide as
a socially acceptable way of dealing with pain and suffer-
ing of life and the end of life” (p. 333).
THE ROLE OF PSYCHOLOGISTS
The legal statutes recommend that a psychologist become
involved in PAS when there are concerns regarding the
patient’s decisional capacity due to the presence of psy-
chopathology, such as depression (ODDA, 1995; WDDA,
2008; MDDA, 2009). There appears to be a consensus
that the training psychologists receive in assessment,
psychopathology, and cognitive impairment qualifies
them to assist in determining whether a patient is capable
to consent to PAS (Farberman, 1997; Farrenkopf &
Bryan, 1999; Werth et al., 2000; Werth et al., 2009). It has
been proposed that psychologists with forensic training
may be uniquely qualified to evaluate competence
requests in PAS, given their training and experience with

121. issues related to competence and capacity (Ganzini,
Leong, Fenn, Silva, & Weinstock, 2000). Indeed, a survey
of forensic psychiatrists revealed that the majority had
professional experience with competence evaluations and
end-of-life decisions, with 74% having conducted compe-
tence evaluations for individuals refusing life sustaining
treatment, 54% having personally cared for a family
member or close friend who was suffering from a termi-
nal illness, and 67% having witnessed the suffering of a
dying family member or friend (Ganzini et al., 2000).
There is no consensus regarding the extent to which
the psychologist should be involved in the process and the
statutes provide no guidance aside from allowing for the
assessment. According to Farrenkopf and Bryan (1999),
when consulting on a case of PAS, the psychologist
should first clarify the reason for the referral, which may
be an evaluation of competence, but may also include
treatment of a disorder and treatment designed to
improve competence. In addition to performing the
assessment, Farberman (1997) proposed that psycholo-
gists serve as protectors of the patient’s rights and pro-
vide support for the patient’s family.
In a survey of Oregonian psychologists, further dis-
agreement regarding the psychologist’s role was revealed.
Sixty-two percent of those willing to perform the evalua-
tion indicated they would take no further action after
providing the referring physician with a report (Fenn &
Ganzini, 1999). However, 28% reported they would sup-
port the patient in completing the request, whereas 10%
reported they would actively work to prevent the suicide
(Fenn & Ganzini, 1999).
ETHICAL CONSIDERATIONS
FOR PSYCHOLOGISTS