Assisted suicide and euthanasia

In brief

• Euthanasia is the intentional ending of another person’s life for their supposed benefit. It can be voluntary, non-voluntary, or involuntary. With euthanasia, one person (usually a doctor) ends the life of another (their patient).
• Assisted suicide is the act of assisting another person in ending their own life.
• Both assisted suicide and euthanasia are illegal in all parts of the UK.
• Only fourteen countries globally (7% of all countries) allow assisted suicide and/or euthanasia.
• Making assisted suicide and euthanasia legal discriminates against the most vulnerable in our society and can pressure them to end their lives.
• Evidence from overseas demonstrates that, incrementally, the ‘right to die’ has often extended from ‘hard cases’ to a more holistic provision, potentially including individuals with disabilities, mental illness and other chronic but non-life-threatening diseases, as well as minors.

What is euthanasia?

The term ‘euthanasia’ was used in ancient Greece to mean ‘a good death’.

It was only in the late 1800s that this term began to be used for the medical killing of patients who had no hope of recovery. The term was used as a euphemism, to avoid phrases such as ‘mercy killing’.

The ethicist John Keown cites a common and widely accepted definition of the term:

“Euthanasia is the active, intentional termination of a patient’s life by a doctor who thinks that death is a benefit to that patient”.

Euthanasia can come in three different forms.

1. Voluntary euthanasia – where the person being killed is mentally competent and gives informed consent to be killed.
2. Non-voluntary euthanasia – where the person being killed is not able to give their consent (due to disability, illness, or immaturity, for example), but it is thought that if they were able to give informed consent they would do so. In cases of non-voluntary euthanasia, somebody else consents on behalf of the person being killed.
3. Involuntary euthanasia – where the person being killed refuses informed consent or, in cases where someone is unable to consent due to disability, illness or immaturity, it is thought that they would not consent were they able to. The judgement of the person being killed is either not consulted, ignored, or overridden.

Advocates of legally available euthanasia typically support both voluntary euthanasia and non-voluntary euthanasia (in cases of a seriously disabled infant or someone with advanced dementia, for example), but not involuntary euthanasia.

Legal discussion of euthanasia typically assumes that it must be a physician who does the euthanasing, but, strictly speaking, under the definition given, there is no reason that it must be done by a physician rather than a nurse, another medical professional, or even a friend or family member.

A distinction is sometimes made between active and passive euthanasia. This is an unhelpful and confusing distinction. Some people think the withdrawal of treatment is passive euthanasia, but this is imprecise and confuses matters. There are circumstances in which it might be legal and morally permissible to withdraw treatment, but this is not euthanasia. 

What is assisted suicide?

Assisted suicide is the act of deliberately assisting another person to kill themselves, usually by providing lethal drugs that are then taken by the person seeking to kill themselves.

The main legal difference between assisted suicide and euthanasia is the identity of the person carrying out the act of killing. In euthanasia, the person is killed by a third party whereas in an assisted suicide, the person kills themselves.

Morally, there does not seem to be any real difference between euthanasia and assisted suicide as both involve the intentional killing of human life.

Assisted suicide in other jurisdictions is often referred to as ‘physician-assisted suicide’ (PAS) in reference to the involvement of a physician who is responsible for administering the lethal drugs to the patient.

What is assisted dying?

Assisted dying is a euphemism for assisted suicide, often employed to avoid the reality that the person seeking to die is suffering from suicidal ideation, which is a form of psychological distress that requires psychological care rather than lethal drugs.

What are the assisted suicide laws in the UK?

Assisted suicide in the UK is illegal under the Suicide Act (1961) and is punishable by up to 14 years in prison. Suicide itself is not illegal in the UK.

Euthanasia has no particular status under the law in the UK, and cases of euthanasia are typically treated as either murder or manslaughter depending on the circumstances. The maximum penalty is life imprisonment.

History of assisted suicide and euthanasia in the UK

1931 – Eugenicist, Dr C. Killick Millard proposed a Voluntary Euthanasia (Legislation) Bill for “incurable invalids”. [Daily Mirror 17 October 1931, p2 “Doctor’s Plea for the Right to Easy Death”].

1935 – Dr Millard and Lord Moynihan establish the British Voluntary Euthanasia Society (which changed its name to EXIT, and is now called Dignity in Dying).

1936 – Voluntary Euthanasia (Legislation) Bill rejected by the House of Lords.

1961 – Suicide Act (1961) made assisted suicide illegal and punishable by up to 14 years in prison.

1969 – Lord Raglan’s Voluntary Euthanasia Bill defeated in House of Lords.

1970 – Voluntary Euthanasia Bill debated in the House of Commons.

1976 – Incurable Patients Bill debated in the House of Lords. Arguably a ‘passive’ euthanasia bill.

1997 – Doctor Assisted Dying Bill proposed by Labour MP Joe Ashton rejected in the House of Commons by 234 to 89 votes.

2003 – Patient (Assisted Dying) Bill debated in the House of Lords.

2004 – Assisted Dying for the Terminally Ill Bill debated in the House of Lords and referred to a Select Committee.

2006 – Assisted Dying for the Terminally Ill Bill defeated by 148-100 votes in the House of Lords.

2014 – Lord Falconer introduced his Assisted Dying Bill into the House of Lords. The Bill proposed that any adult diagnosed with less than six months to live would be permitted assistance to end their own life. The Bill ran out of time.

2015 – Labour MP Rob Marris introduced the Assisted Dying Bill into the House of Commons based on the Lords Bill from the previous year. This would have legalised assisted suicide in England and Wales. The Bill was defeated by 330 votes to 118 votes.

2016 – Lord Hayward reintroduced the Assisted Dying Bill into the House of Lords. The Bill ran out of time.

2020 – Lord Falconer reintroduced his Assisted Dying Bill which ran out of time.

2021 – Baroness Meacher introduced an Assisted Dying Bill similar to previous iterations. The Bill ran out of time. 

2021 – Lord Forsyth introduced an amendment to the Health and Care Bill in the House of Lords that would have compelled the Government to draft an assisted suicide Bill to lay before Parliament. This was defeated by 179 votes to 145 votes.

Outside of the Houses of Parliament, there have been a number of legal challenges to the assisted suicide laws in the UK. So far, all such challenges have been rejected.

Public opinion on euthanasia and assisted suicide

There is debate over whether there is widespread support for introducing assisted suicide to the United Kingdom.

Assisted suicide advocates frequently cite polling commissioned and funded by assisted suicide campaigning group, Dignity in Dying, which shows a large majority of the general public support a change in the law. This group has repeated this polling a number of times with similar wording for the questions.

Academics have been highly critical of this polling, with two experts from the respected Institute for Social and Economic Research at Essex University, saying that the polling was ‘skewed and ambiguous’. 

Media coverage of the review of the polling outlined that “The survey… failed to give people the option to say they were ‘don’t knows’. Instead it pushed them into giving answers in favour of assisted dying by asking over-long and leading questions using loaded language – such as saying that assisted dying would help those in ‘unbearable suffering’. Answers in favour of assisted dying were placed first among the options for people considering the questions…”

Polling from overseas shows that when the words ‘assisted suicide’ are used in polls, the majority in favour of introducing assisted suicide falls, sometimes by up to 20%. 

Whether respondents to a poll are exposed to counterarguments to the introduction of assisted suicide also appears to have an impact on the percentages of respondents who state they support introducing assisted suicide. In one poll, undertaken by Savanta ComRes, of people in England, Scotland and Wales, support for assisted suicide dropped from 73% to 43% when respondents were presented with counterarguments. A poll that was run only in Scotland showed similar results.

Those opposed to assisted suicide cite polling that shows public scepticism among the public and MPs about introducing assisted suicide.

Polling from Savanta ComRes found that 51% of people, when asked if they “would be concerned that some people would feel pressurised into accepting help to take their own life so as not to be a burden on others if assisted suicide were legal”,  said yes. Only 25% disagreed.

In the same poll, 48% surveyed said that giving GPs “the power to help patients commit suicide” would “fundamentally change the relationship between a doctor and patient, since GPs are currently under a duty to protect and preserve the lives of patients”. Just 23% of people disagreed with that statement. 

Polling of Members of Parliament, conducted by YouGov, showed that only 35% of MPs supported a law change to allow “doctors to assist in the suicide of someone suffering from a terminal illness”. 

When MPs were asked if they would support a law change to allow “doctors to assist in the suicide of someone suffering from a painful, incurable but not terminal illness”, support dropped to only 16%.

There also appears to be confusion among members of the public about what introducing assisted suicide or euthanasia would actually change.

In October 2020, the ‘End of Life Choice Act’ became law in New Zealand through a binding referendum where a majority of voters supported the Act. However, according to group Euthanasia-Free NZ “Polling during the advance voting period showed that 80% of New Zealand adults were misunderstanding what the End of Life Choice Act would legalise”.

“Only 20% of respondents knew that this Act would not make it legal to turn off machines that are keeping people alive”.

Executive Officer of Euthanasia-Free NZ, Renée Joubert, said: “It seems that most New Zealanders voted for an end-of-life choice that is in fact already legal”.

As in the UK, in New Zealand, it is lawful to turn off a machine that is keeping someone alive artificially when in consultation with a doctor and where it is deemed medically appropriate. The polling suggests however that this was not widely known and 80% believed that the ‘End of Life Choice Act’ was making an end-of-life decision legal that was in fact already legal.

International laws for euthanasia and physician-assisted suicide 

Fourteen countries globally (7% of all countries) allow either assisted suicide, euthanasia or both.

Australia

Euthanasia and assisted suicide laws in Australia are largely governed on a state basis.

Assisted suicide is now legal in six states in Australia, but not legal in the Northern Territory and Australian Capital Territory (ACT).

Victoria was the first state to legalise assisted suicide in 2017, followed by Western Australia, South Australia, Tasmania, Queensland in 2021 and New South Wales in 2022 (the legislation in New South Wales will come into effect from 28 November 2023).

Queensland

The Voluntary Assisted Dying Act 2021 was passed in September 2021 and is available for those over 18 who are mentally competent and thought to have less than 12 months to live.

The Bill has been criticised because palliative care is often only available for those with only three months left to live.

The law will come into effect in January 2023.

South Australia

On 24 June 2021, the Voluntary Assisted Dying Bill 2020 was passed by the South Australian Parliament after 17 previous attempts over 26 years. The legislation has made assisted suicide and euthanasia legal. It is expected to come into force towards the end of 2022.

Any mentally competent adult, diagnosed with a medical condition that causes them ‘intolerable suffering’, and thought to have six months or less to live is eligible for assisted suicide or euthanasia. For some conditions, the length of time is 12 months.

Tasmania

The End-of-Life Choices (Voluntary Assisted Dying) Act 2021 comes into force on 23 October 2022. To be eligible to access assisted suicide, someone must be 18, have decision-making capacity and be suffering intolerably from a medical condition that is advanced, incurable, irreversible and will cause the person’s death in the next six months, or 12 months for neurodegenerative disorders.

Western Australia

The Voluntary Assisted Dying Act 2019 permits assisted suicide and euthanasia in the cases when a coordinating practitioner deems self-administration inappropriate, either due to the patient being physically unable to self-administer, the patient having concerns about self-administering, or another suitable method having been found to administer the lethal drugs. 

Patients must be mentally competent and suffering from an advanced, progressing and terminal illness with likely less than six months to live, or 12 months for neurodegenerative disorders. The Act came into force on 1 July 2021.

Victoria

The Voluntary Assisted Dying Act 2017 permits assisted suicide and euthanasia in cases where a patient is physically unable to self-administer the lethal drugs. Patients must be mentally competent and suffering from a terminal illness with likely less than six months to live, or 12 months for neurodegenerative disorders.

In the first 18 months of the Voluntary Assisted Dying Act 2017 (June 2019 – December 2020), 184 patients ended their own lives and a further 40 patients died from lethal drugs administered by their physician.

The total of 175 confirmed deaths in the first year of the Act far exceeded the expectations of the Victorian government, which anticipated about 12 deaths in the first year.

Austria

Assisted suicide was made legal in Austria in December 2021. The law permits assisted suicide in situations in which a person has a terminal illness or suffers from a permanent, debilitating condition. Each case must be approved by two doctors, at least one of whom must be an expert in palliative care.

There is a 12-week cooling down period between the assisted suicide being approved and taking place, however this can be reduced to 2 weeks if the person has a terminal illness.

The Care Alliance has highlighted that the person ending their life can “specify persons who are authorised to assist the person end the person’s life by ingesting the prescribed lethal poison – including by actively administering it, apparently even if the person loses decision-making capacity. This makes Austria the first jurisdiction to legalise euthanasia by lay persons (non-health practitioners), including family members, of a person who is unable to self-administer the lethal poison or who has lost decision-making capacity”.

Belgium

The Belgian Act on Euthanasia 2002 permits doctors to prescribe lethal drugs for self-administration and to administer lethal drugs to mentally competent terminally ill adults.

In February 2014, the Belgian Parliament approved an amendment to the Belgian Act on Euthanasia 2002 to allow euthanasia for children who experience “unbearable suffering”, following a voluntary and explicit request, parental consent, and provided that the child does not suffer from an intellectual disability or mental illness.

The latest report (2020) recorded 2,444 cases of assisted suicide and euthanasia, which is a decrease of 212 from 2019 but an increase from 2,357 cases in 2018. It represents around a 156% increase in just ten years since 2010 (953 cases). 

A report released in 2018, recorded the deaths of three minors aged 9, 11 and 17, which were carried out between 2016 and 2017. 

Canada

The Federal Government passed legislation on Medical Assistance in Dying (MAiD) in June 2016. Doctors are permitted to prescribe lethal drugs for self-administration and to administer lethal drugs to mentally competent terminally ill adults.

In March 2021, the Canadian Government amended the MAiD law to remove the requirement in the statute that death be “reasonably foreseeable”, after it was successfully challenged (to allow for assisted suicide in cases of non-terminal illness) in the Superior Court of Québec in 2019.

The second annual report on MAiD in Canada for 2020 showed an increase in MAiD deaths of 34.2% over 2019, which represented 2.5% of all deaths in Canada in 2020. From 2016 to 2020, there was a total increase of 646% in MAiD deaths.

In 2020, the strongest reasons for seeking MAiD were loss of ability to engage in meaningful life activities (84.9%), and loss of ability to perform activities of daily living (81.7%). In comparison, inadequate control of pain, or concern about it, accounted for 57.4% of cases. 35.9% cited their perception that they were a burden on family, friends or caregivers.

In 2020, 10.2% of MAiD cases involved neurological conditions.

In 2020, only 5% of MAiD patients were referred for psychiatric evaluation.

In 2020, fewer than 7 of the 7,595 MAiD deaths were self-administered.

Columbia

Euthanasia was made legal in Columbia in 1997 but no one died via euthanasia because ambiguity in the law meant that doctors feared being prosecuted. It was not until May 2015 that the health ministry intervened and issued guidelines for hospitals, which meant that if the conditions for euthanasia were met, doctors would not be prosecuted.

Colombia recorded the first case of legal euthanasia with the death of Ovidio González in June 2015.

In 2018, Colombia passed a resolution allowing euthanasia for children from six years of age. Parental consent is not required for children aged 14 or older.

Colombia is the only country to require euthanasia requests be approved by a committee consisting of a physician, a lawyer, and a psychiatric or psychological adviser.

As of April 2018, there have been 28 reported cases of euthanasia.

France

In 2016, following the case of car crash victim Vincent Lambert, the French Parliament approved a Bill that allowed a patient to request “deep, continuous sedation altering consciousness until death”. This would be permitted if the patient were terminally ill and would allow doctors to stop life-sustaining treatments. This could include water and nutrition.

Painkillers and sedation would be permitted even if this hastened death. This is sometimes said to be a kind of passive euthanasia.

Members of the French Parliament failed to introduce a law that would permit voluntary euthanasia in 2021.

Germany

Assisted suicide was formally legalised on 26 February 2020 by Germany’s Federal Constitutional Court.   

Luxembourg

The Right to Die with Dignity Act permits euthanasia and assisted suicide for mentally competent patients suffering from terminal illness. The Bill is extended to persons as young as 16, provided they have the authorisation of their parent or legal guardian.

From 2009 until 2018, there were 68 cases of euthanasia and 2 cases of assisted suicide.

In 2019, the Luxembourg Cabinet adopted a bill ruling euthanasia and assisted suicide as natural causes of death rather than suicides.

Netherlands

Euthanasia was effectively decriminalised by a court decision in 1984, and then by Parliament in 2001. In the first year, 1,882 deaths were recorded. This number increased to 6,938 in 2020 accounting for 4.1% of the total number of deaths in the Netherlands in that year.

The Termination of Life on Request and Assisted Suicide Act 2001 permits doctors to administer lethal drugs and to prescribe them for self-administration.

The 2018 Euthanasia Code of Practice made assisted suicide available to elderly people who are not terminally ill but suffering from “normal degenerative conditions that accompany ageing” which can be considered to cause “unbearable suffering with no prospect of improvement”. The Code was published by the regional committees to supervise the practice of euthanasia. Though these practices are recognised to involve “subjective” judgements of the “very personal” suffering of a patient, physicians were now in danger of “serious legal problems” if deemed negligent by the supervisory committee.

In April 2020, the Dutch Supreme Court ruled that patients with advanced dementia who have made a written advance request for euthanasia can receive it.

The latest annual report for 2020 shows an increase in the rate of euthanasia and/or assisted suicide by 9.1% on the notified numbers for 2019.

Furthermore, research suggests that more than 1,000 patients a year have their lives ended deliberately without their request.

The latest 5-yearly study for the period between 2005 and 2010 showed overall numbers of deaths by euthanasia had risen by more than 60% in 5 years.

Non-voluntary euthanasia is permitted for Dutch babies who have not reached their first birthday. Children between 12 and 15 can be euthanised with parental approval. Anyone over 16 is eligible for euthanasia if they make a considered, voluntary request and their suffering is “unbearable”. As of 2020, the Deputy Prime Minister, Hugo de Jonge, has been attempting to expand the provision in the current law to allow euthanasia for children under 12 years old.

Doctors are permitted to administer euthanasia to dementia patients without a prior agreement as to the time and manner of administration.

New Zealand

In 2019, the New Zealand Parliament passed the End of Life Choice Bill that permits doctors to prescribe drugs for self-administration to terminally ill patients who experience unbearable suffering who are likely to have less than six months to live and are sufficiently mentally capable to understand their decision. In cases where an individual is physically unable to self-administer, the doctor can administer the drugs themselves.

New Zealand became the first country in the world to introduce assisted suicide and euthanasia by popular vote in a binding referendum on 19 September 2020 and this came into force on 7 November 2021.

Polling at the time suggests that as many as 80% of voters were unclear about what they were voting for, thinking that the law would permit physicians to turn off life support. This, in fact, was already legal and not the subject of the referendum.

Portugal

In January 2021, the Portuguese Parliament passed legislation to permit physician-assisted suicide and euthanasia. However, the country’s Constitutional Court overturned the decision in March 2021, saying that the law was imprecise in identifying the circumstances under which assisted suicide and euthanasia can occur.

Spain

Spain made assisted suicide and euthanasia legal in March 2021. The law allows assisted suicide for adults with a “serious and incurable” condition or a “chronic or incapacitating” condition that causes “intolerable suffering”.

Switzerland

Swiss Criminal Code 1942 permits individuals to assist in another’s suicide as long as the motive for doing so is not ‘selfish’, such as for financial gain.

Since 1982 this law has allowed the organisation EXIT to promote assisted suicide for those “with unbearable symptoms” or “with unacceptable disabilities”. Foreign citizens can receive assisted suicide through organisations such as Dignitas.

Recent figures from December 2020 show that the number of assisted suicides has continued to increase annually, from 187 cases in 2003 to 1,009 cases in 2017 and 1,176 cases in 2018. This represents a more than 16% increase from 2017 to 2018 and around a 529% increase in the fourteen years since 2003.

USA

Assisted suicide and euthanasia law varies across different states.

California

The End of Life Option Act 2015 permits doctors to prescribe lethal drugs for self-administration to mentally competent patients suffering terminal illness and likely to die within six months.

From 2016 to 2020, there has been around a 292% increase in the number of deaths from assisted suicide.

Colorado

The End of Life Option Act 2016 permits doctors to prescribe lethal drugs for self-administration to mentally competent patients suffering terminal illness and likely to die within six months.

In 2020, prescriptions for lethal drugs increased by nearly 10% compared to 2019, and by around 161% compared to 2017.

Only five mental health providers’ confirmation was received for a total of 554 cases over three years.

The patient’s completed written request was received in only 417 of the 554 cases over three years.

Hawaii

Our Care, Our Choice Act 2019 permits doctors to prescribe lethal drugs for self-administration to mentally competent patients suffering terminal illness and likely to die within six months.

In 2020, 37 patients received prescriptions for lethal drugs. 32 of these patients died from ingesting these medicines.

In the first six months of 2020, there was one complication where a patient survived for six hours after taking the medication, two hours beyond the clinical guidance.

New Jersey

The Aid in Dying for the Terminally Ill Act 2019 permits doctors to prescribe lethal drugs for self-administration to mentally competent patients suffering terminal illness and likely to die within six months.

In 2020, there were 33 registered cases of assisted suicide.

New Mexico

The End-of-Life Options Act 2021 permits the prescribing of lethal drugs for self-administration to mentally competent patients suffering terminal illness and likely to die within six months.

Maine

The Death with Dignity Act 2019 permits doctors to prescribe drugs for self-administration to mentally competent patients suffering terminal illness and likely to die within six months.

There was one death from assisted suicide in the three-month period following the enactment of the Act.

Montana

Doctors may have a defence to assisting in a person’s suicide under a 2009 Montana Supreme Court ruling which declared that state law protects Montana doctors from prosecution for assisting in the suicide of terminally ill patients, but did not establish a right to assisted suicide.

Montana would have been the first US state to establish a constitutional right to die, but the majority judgement instead presented it as a policy question for the Montana legislature and citizenry.

The ruling was criticised by the dissenting justices for unreasonably broadening the law that had provided “no support for physicians shifting from idle onlookers of natural death to active participants in their patients’ suicides”.

Several legislative attempts to criminalise assisted suicide have failed in recent years.

Oregon

Oregon legalised physician-assisted suicide in 1997 following the passage of the Death with Dignity Act (DWDA) in 1994. This permitted doctors to prescribe lethal drugs for self-administration to mentally competent Oregon residents, above the age of 18, who are suffering terminal illness and are likely to die within six months.

The Death with Dignity Act passed in a general election by 51% to 49%, and was retained by voters in 1997 by 60% to 40%.

From January 2020, patients are exempt from the 15-day waiting period if it exceeds their likely life expectancy.

Oregon statute does not define participation under the DWDA as suicide. The Oregon Health Authority recommends that physicians record the terminal illness as the cause of death and the death as ‘natural’.

Subsequent to inquiries in 2017, the Oregon Health Authority freely admitted that ‘incurable illness’ can include illnesses for which life-sustaining treatment exists, and that the definition of ‘terminal illness’ is based on the likelihood of death within six months if such life-sustaining treatment is stopped. This can allow patients with chronic conditions, such as diabetes, to transform their condition into a terminal version by refusing appropriate treatment, such as insulin, and thus legally apply for assisted suicide.

The report for 2020 showed around a 28% increase in the number of DWDA deaths from 2019, which is over fifteen times more than the number of deaths in its first year of 1998.

The most significant end-of-life concern for patients between 1998 and 2020 was losing autonomy (90.6%), followed closely by less ability to engage in activities making life enjoyable (89.9%).

Concern about being or becoming a burden on family, friends, and caregivers ranked significantly higher (47.5%) than inadequate pain control, or concern about inadequate pain control (27.4%).

Only 3.6% of patients since 1998 have been referred for psychiatric evaluation.

10.8% of patients since 1998 have suffered from neurological diseases.

4.5% of patients since 1998 cited ‘financial implications of treatment’ among their end-of-life concerns.

The prescribing physician has been present at only 14.6% of DWDA deaths since 1998.

2.7% of patients since 1998 suffered complications such as difficulty ingesting, regurgitation, and seizure.

Notably, “Information about complications is reported only when a physician or another health care provider is present at the time of death”.

According to Oregon’s Prioritized List of Health Services 2020, cancer treatment is limited according to relative life expectancy while assisted suicide services are fully covered.

Vermont

The Patient Choice and Control at the End of Life Act 2013 permits doctors to prescribe drugs for self-administration to mentally competent patients suffering terminal illness and likely to die within six months.

Vermont is the only US state to require the attending physician to examine the patient in person.

Between 2013 and 2019, there have been 87 cases of assisted suicide, 34 of which occurred from 2017.

Washington

The Death with Dignity Act 2008 permits doctors to prescribe lethal drugs for self-administration to mentally competent patients suffering terminal illness and likely to die within six months.

In 2018, the number of deaths following the prescription of lethal drugs increased by 24% from 2017 and by 292% from 2009.

In 2018, only 38% of patients listed fears about pain and pain control as an end-of-life concern. The two highest concerns were loss of autonomy (85%) and reduced ability to engage in activities making life enjoyable (84%).

51% of patients cited concern about being a burden on their family, friends, or caregivers as a reason for seeking assisted suicide.

In 2018, only 4% of patients were referred for psychiatric or psychological evaluation.

In 2018, 50% of patients who died had known their physician for 25 weeks or less, including at least one case where the patient knew the physician for less than a week.

In 2018, 4% of patient deaths involved complications such as regurgitation, awakening, or seizures.

Washington DC

Death with Dignity Act 2017 permits doctors to prescribe lethal drugs for self-administration to mentally competent patients suffering terminal illness and likely to die within six months.

In 2018, there were 4 prescriptions for lethal drugs, two of which led to the patient’s death, whilst the other two patients died prior to consuming the drug.

Legal and ethical considerations

Euthanasia and physician-assisted suicide raise many legal and ethical considerations and much has been written on the topic.

Legal considerations and ethical considerations should be kept separate so far as possible, but there will be (as there should be) an inevitable blending of the two.

Vitalism

Vitalism – the view that it is our duty (or the physician’s duty) to keep someone alive for as long as possible regardless of any other considerations – no matter how much suffering that person is in, no matter how expensive the treatment is, no matter how much suffering the treatment causes.

Opponents of euthanasia and assisted suicide (EAS) do not endorse vitalism. 

They:

• do not think that medical professionals have a duty to keep someone alive for as long as possible regardless of any other considerations.
• recognise that it is often appropriate not to provide treatment to a patient even when not doing so will likely shorten their life.

There are circumstances in which a particular treatment, such as chemotherapy, has serious side effects and can make someone very ill. A very elderly person, who has advanced cancer and whose life might be extended by an aggressive dose of chemotherapy may refuse the treatment knowing it will shorten their life. The patient is under no legal or ethical obligation to take this treatment. The healthcare professional is under no ethical obligation to try to make them, and it would be illegal to force them.

As a general principle of law, if a patient is mentally competent, they are allowed to refuse any treatment, even knowing that doing so will likely shorten their life. This is an important principle and protection so that patients are not forced to take medication they do not want.

Judgements about the value of life

In almost all jurisdictions in which euthanasia and/or assisted suicide (EAS) has been made legal, the state (at least implicitly) makes judgements about the value of its citizens’ lives. It says that some lives are more valuable than others, or that some lives are more worth living than others.

To see this, consider how we react, individually and as a society, when someone is suicidal.

Ordinarily, when a person is struggling with suicidal thoughts, we do everything we can to help them. As a society, we want to dissuade them from ending their lives. We rightly recognise that suicide is a tragedy.

However, for people who are very ill, who are frail or otherwise thought to be close to death, many people have a very different reaction.

While we want to discourage suicide in general, EAS legislation implies that for those with six months or less to live, rather than dissuade them from their suicidal ideation, we want to enable their suicide.

EAS legislation often makes a distinction between those who are terminally ill, and those who are not, saying that it is ‘reasonable’ or ‘okay’ for people who are terminally ill to end their lives through an (assisted) suicide, but that it is not ‘reasonable’ or ‘okay’ for anyone else.

In other words, in discriminating against people who are thought to be terminally ill in this manner, the state is implicitly judging that some lives are less worth living than others. It is making a judgement about the value of their lives and coming to the conclusion that the lives of people who are terminally ill matter less than everyone else’s.

The slippery slope

There are two types of slippery slope

1. The practical slippery slope
2. The logical slippery slope

The practical slippery slope argument against EAS involves pointing to jurisdictions that have already made EAS legal, and observing that, as time goes on, they tend to relax the laws and make access to EAS easier and easier. As a matter of fact, this is exactly what has happened in Belgium, Canada and the Netherlands, among others.

The logical slippery slope argument against EAS involves consideration of the very motivation or logic behind making EAS legal in the first place. Proponents of EAS frequently cite suffering as the reason to make EAS legal. If that is the primary motivation though, then why limit EAS to those with only six months left to live? There are surely many people who are suffering but have more than six months left to live. If the argument to legalise EAS is based on people’s suffering, then those who are suffering but have longer than six months left to live should be allowed it too.

The Netherlands has slowly worked out the logical slippery slope since it made EAS legal. It has made EAS available for newborn babies whose suffering is “unbearable and with no prospect of improvement”, and for those who are “tired of living“.

Autonomy

Often supporters of EAS argue that keeping EAS illegal fails to respect people’s autonomy. Therefore, it should be made legal.

However, appeals to autonomy are usually misplaced as legislation throughout the world indicates. For example, legislation typically requires that a person be ‘terminally ill’ or that they meet certain other requirements in order to undergo a physician-assisted suicide or euthanasia. But, if the motivation for making EAS legal is respect for autonomy, then the law should not limit the autonomy of those who wish to die but are not terminally ill.

In other words, if autonomy is what matters, then EAS should be available to everyone who is mentally competent.

The most extreme iteration of this idea can be found in the work of Australian euthanasia activist Philip Nitschke who advocates “rational suicide”. Here the autonomy of the person with a wish to die is paramount.

No jurisdiction promotes this extreme view of autonomy, although, arguably, the Netherlands comes close.

Prognoses are often incorrect

It is very difficult to accurately judge how long someone has left to live. Doctors will readily admit that it is far from certain, in many individual cases, how long someone will live and therefore very difficult to say whether they will live less than six months or not. Furthermore, studies conducted on prognostic accuracy in palliative care have concluded that clinicians’ predictions are “frequently inaccurate”. 

End-of-life concerns

Another argument against assisted suicide and euthanasia is the fact that many of those who end their life in this way mention concerns that have nothing to do with physical suffering or pain. Many of the reasons they give for wanting to end their lives are psychological and social reasons.

The state of Oregon, which made assisted suicide legal in 1997, provides data on people who ended their lives through assisted suicide, and records their ‘end-of-life concerns’.

• 89.9% were concerned about being “less able to engage in activities making life enjoyable”
• 90.6% were concerned about “losing autonomy”
• 73.6% were concerned about “loss of dignity”
• 47.5% were concerned about being a “burden on family, friends/caregivers”
• 43.1% were concerned about “losing control of bodily functions”
• 27.4% were concerned about “inadequate pain control, or concern about it”
• 4.5% were concerned with the “financial implications of treatment”

The majority of these concerns are not medical concerns at all. While everyone can sympathise with the real suffering the “loss of autonomy”, “loss of dignity” and concerns about being a “burden” can create, these are social and psychological problems that merit social and psychological solutions and treatments.

Good family and friends and, just as importantly, proper palliative care, are able to alleviate these concerns to a great degree. Assisted suicide and euthanasia, do nothing to alleviate these concerns. They only end the life of the person with the concerns.