Assisted suicide and euthanasia

Assisted dying is an umbrella term that covers any mechanism through which a patient is helped to die by somebody else, usually a doctor. There are two main types of assisted dying. One is assisted suicide, which is where the doctor would prescribe medication that the patient would take themselves, ending their life. The other type is euthanasia, which is where the doctor would actually end the patient’s life by, for example, injecting the patient with a lethal dose.

Photo by David Pereiras.

Assisted dying covers both of those ways in which doctors might help a patient to die. Both assisted suicide and euthanasia are illegal in many countries across the world, but in an increasing number of countries, the decision has been taken to legalise either assisted suicide or euthanasia, or both.

Arguments for legalising assisted dying

One of the most important arguments in favour of legalising assisted dying is that it’s the patient’s life, and the patient should have a right to make decisions about that life. These are autonomy-based arguments. But it isn’t just about autonomy, because hardly anyone would think that just because a patient wanted to end their life, their doctor should necessarily help them to do so.

Autonomy is tempered here by compassion and the idea that in some very limited circumstances, assisted dying might be a compassionate response to suffering. If a patient’s suffering can’t be relieved in any other way, and this is what they want, then it could be okay for a doctor to help them to end their lives. It’s an autonomy- and compassion-based argument in favour of legalisation.

You could also mount arguments in favour along the following lines: if people are going to travel abroad to do this, it might be better to regulate it within this country; or, if people are going to take the law into their own hands and help each other to die, again, might it be better to be regulated?

Arguments against legalisation

The main argument that’s mounted against legalisation has to do with protecting the vulnerable. This often takes the form of a slippery-slope argument. It’s the idea that even if we can be convinced that people who clearly have capacity know this is what they want – even if we’re sure that they’re not being manipulated or coming under any pressure to do this – we can’t be confident enough that there won’t be other vulnerable people who would be pressurised into doing this, or who would do it because they felt they were a burden. A lot of people who are worried about legalisation are mainly worried about the vulnerable.

Of course, there are people who object to assisted dying for religious reasons. If your faith means that you believe only God has the power to take life, then you would oppose somebody making this decision for themselves. But we generally think of faith as a personal matter, so it might decide your own view about whether you would ever access assisted dying, but it shouldn’t necessarily determine what other people who might not share your faith decide.

Other arguments against legalisation are that it might be negative for the patient-doctor relationship. Would patients be anxious if they thought their doctors could lawfully end their lives; would it affect trust? These debates generally pit patient autonomy and compassion against concern for the vulnerable, and there are compelling arguments on both sides.

The perspective of doctors

Interestingly, doctors are less in favour of legalising assisted dying than the wider population. Obviously, some doctors are in favour, but as a general pull, the support amongst doctors for legalisation tends to be lower than amongst the general public. One of the reasons for that is that doctors go into medicine to save lives. The purpose of becoming a doctor is to relieve suffering and save lives. For many doctors, it goes completely against the purpose of medicine to end life.

So, there are reasons for being concerned that doctors aren’t necessarily enthusiastic about involvement in assisted dying. But other doctors might say, I respect my patient’s wishes and I accept that suffering sometimes can be unbearable and unrelievable by palliative care. Where someone’s suffering is such that life has no meaning for them anymore and their pain is unbearable, some doctors would think that it was okay in that circumstance to end their patient’s life.

A decision of life and death

It’s also important to acknowledge that it’s not that unusual for doctors’ decisions to play a role in shortening patients’ lives. An obvious example would be removing a patient from life-prolonging treatment – switching off a ventilator, for example – which is something that doctors do with the result that the patient’s life will come to an end. Doctors might also give quantities of sedative or painkilling drugs that might have the side effect of stopping a patient from breathing and ending their lives. If we think that it’s okay for a doctor to switch off a life support machine, is it very different for a doctor to inject a patient with something that would end their lives?

Photo by sfam_photo.

For some people, switching off a life support machine and injecting a patient with a lethal substance are entirely different things and not connected in any way. One is an action which will end life, and the other is seen – certainly in the law – as an omission, as stopping to continue to provide life-prolonging treatment. But for other people, they’re actually rather similar. A doctor is doing something while deliberately knowing that their patient’s life will come to an end. If it’s okay in one circumstance, why not in another?

Assisted dying laws across the world

There are a range of countries throughout the world that have done something deliberately to legalise assisted dying or have used a loophole in the law to enable it to happen. The picture is really different throughout the world.

Switzerland, which is where quite a few people in Europe travel to access assisted suicide, hasn’t taken the decision to legalise this practice. What’s happened is that the Swiss Criminal Code says that assisted suicide is a criminal offence only if the motive is selfish. By default, that allows assisted suicide for compassionate reasons. What that means is that Swiss right-to-die societies have been able to provide access to assisted suicide to people because the motive for doing so is compassionate.

That’s a slightly unusual example, because that’s just a part of a criminal code that’s been used to provide lawful assisted dying. A more common example would be a decision taken to legalise assisted dying. That’s happened in the Netherlands, in Belgium, in Canada, in some states in Australia, and recently also in New Zealand.

Learning from legalisation

We can learn many things from these countries. Obviously, the laws are different in each country. From the Netherlands and Belgium, which have probably the longest experience of providing lawful euthanasia, mainly, and assisted suicide, we can learn that it is not that common a way to die. In a sense, regulation does allow doctors to say no to people whose requests they don’t think meet the statutory criteria.

But we can also learn some other rather interesting things from the Netherlands and Belgium. Doctors seem to be far less comfortable in those countries providing assisted dying for people whose suffering is mental or existential – their life has lost meaning for them, or they’re tired of life – than for people who are dying from cancer. There’s a lot of survey data involving doctors in those two countries which points to doctors finding assisted dying much more straightforward in the case of something like cancer than for mental health reasons, or for existential tired-of-life reasons. So that’s quite an interesting development.

Asserting control over the dying process

Photo by LBeddoe.

In the United States, there are now 10 states in which assisted dying is lawful. Oregon is the state with the longest-standing data. What we can see is that it hasn’t been, as some people feared, an option that’s been resorted to by people who are poor, who are opting for assisted dying because maybe they don’t have health insurance and they can’t afford high-quality care. Indeed, the evidence from Oregon – and this is replicated across the world – is that assisted dying is requested and used most frequently by people who we might think of as comparatively privileged. It tends to be people who are comparatively well off, comparatively well educated and who maybe lack religious faith.

The evidence suggests that these are people who have been able to exercise a good degree of control over their life, and their desire for assisted dying comes from the fear, and indeed the reality, of the loss of control over one’s life towards the end of life. For many people, this is an attempt to assert control over the dying process. This evidence gives the lie to the idea that people accessing assisted dying come from the more vulnerable sections of society. It suggests that they come from less vulnerable sections of society on average, although obviously there are exceptions.

How legalisation can provide reassurance

The most important aspect of debates over assisted dying is the reassurance its legalisation provides to people who are frightened of what lies ahead. A lot of evidence from countries which have legalised assisted dying shows that it provides a sort of comfort blanket to people. It enables them to bear what lies ahead in a much more fortified way, because they know they can say, ‘No, I want this to end now.’ The knowledge that you have some control, that you can draw a line under your suffering whenever you want to, helps people to bear suffering a whole lot more easily.

If we were to legalise assisted dying, there are a very small number of people who would take advantage of it because their suffering is unbearable, but it would provide reassurance to a much, much wider section of society who would know that they would have this element of control should they need it at the end. That idea of it being available to people as a way of providing reassurance to them is the most important thing here, because what many people are really frightened of is what lies ahead. If they know they can pull the plug on their suffering if they absolutely need to, then people are able to bear a whole lot more, and live happily, productively, constructively and joyously with the people around them for longer. That reassurance to people who are frightened of the future is the most important aspect for me.

Discover more about

the ethical and legal implications of assisted dying

Jackson, E., & Keown, J. (2011). Debating Euthanasia. Hart Publishing.

Jackson, E. (2008). Secularism, Sanctity and the Wrongness of Killing. BioSocieties, 3, 125–145.

Jackson, E. (2018). Legalising assisted dying: cross purposes and unintended consequences.Dalhousie Law Journal, 41 (pp. 60–91).

Assisted dying: ethical and legal implications