By Vexen Crabtree 2012
Assisted dying is a form of palliative care (end of life care) where a doctor gives medication, or withdraws medication, in a way that purposefully brings about the death of a terminally ill patient. Switzerland's Dignitas is one place where people can go to find a final peace, and over 1,000 people have done so there, many from Germany and also some from the UK. By 2000, assisted suicide was also legal in Colombia, Belgium and the Netherlands but is illegal almost everywhere else1. It now legal in Luxembourg and in some states in the USA2. This is generally done by request of the patient, or if comatose, by request of their closest relatives. Assisted suicide is a form of suicide where a doctor first gives the patient the lethal medication for the patient to take themselves or, where the patient needs help in physically committing suicide if they can't do it themselves. This page argues for the careful de-criminalisation of both forms, and making it near-universally available.
|Suicide Rates Per 100k|
|52||Trinidad & Tobago||21.7|
|21||St Vincent & Grenadines||7.3|
Suicide as a human behaviour is recorded amongst the records of the most ancient civilisations. But reliable statistics on it are hard to collect. The World Health Organisation publishes the statistics used by the United Nations, which is duplicated in the long table on the right.
Almost universally, successful male suicide rates are much higher than female rates. However, female suicide attempts are more frequent than male attempts.
Countries with high suicide rates are a mixture between those riddled with organized criminal gangs, under-developed countries, and, highly developed countries. There are cultural and situational effects at work that persist in the long-term: nothing seems to lower the high suicide rates in Japan, Belgium and Finland. And some of the countries with the lowest rates are not particularly well developed socially. It seems there is no correlation between suicide rates and things like development, prosperity and national engagement in human rights.
Switzerland comes in as the country with the 17th highest suicide rate despite its liberal stance, with 36.2 suicides per 100,000 people.
Assisted suicide is illegal in most countries that have laws on suicide. Exceptions, according to circumstances, are in the Netherlands, Belgium, Luxembourg and Switzerland, and in the two USA states of Montana, Oregon and Washington4. In the UK suicide was decriminalised in the Suicide Act of 19615. The same law made it illegal to help another person do this legal act, and is punishable by up to 14 years in jail. But this isn't the whole story. Eight hundred Britons have signed up with Dignitas, and one hundred and sixty have voluntarily died there, aided to their end by physicians. In the last 6 years, at least 90 have travelled abroad to get help with committing suicide4. None of the Brits who travelled with them, or the relatives who helped them beforehand, have had a prosecution brought against them. A principal book on UK criminal law states that "if it is determined that the terminally ill person was competent, her local authority had no power to seek to maintain an injunction to restrain her spouse from complying with the wife's wishes to take her to Switzerland" to commit suicide5. This creates, in reality, a conflicting, contradictory and impractical state of law.
This situation has been seen before. The previous illegality of suicide did not merely cause post-mortem criminality but also had side-effects such as the forfeiture of property. The Suicide Act 1961 decriminalized suicide. Before this change, it had become practically abrogated in the same way that assisted suicide now is. I.e. in 1959 the police knew of 4,980 suicide attempts (of an estimated total of 25,000), and only prosecuted in 518 cases, many times in order to protect the attempter. Since 1961, the latter is now done via the Mental Health Act 1983.6. As with suicide, the same situation exists with assisted suicide except prosecutions are lower (nil). This was the context for the Commission on Assisted Dying, whose Final Report states "It is unclear why our society treats as criminal suspects the same people whom we do not have the inclination to prosecute".
Sufferers and victims of permanent life-destroying disease, and their relatives, do not find choosing to die an easy time in life. The contradictory and unclear nature of the law at the moment makes decision-making fraught with additional difficulties, which no doubt causes additional trouble for the family. The law should clearly permit or outlaw assisted suicide, and not outlaw-yet-permit it as it currently does.
Prosecutions of aiding and abetting in assisted suicide must be approved by the Director of Public Prosecutions (DPP), who at the present time has declared he will not pursue them given ordinary conditions6. 90 known cases have thusly been permitted4. Should there be such non-operational laws? When the DPP changes, we may see the law come back into use and of course those who have previously helped other die will find themselves in a very unsure position. This uncertainty places victims of terrible disease and their families underneath an additional Sword of Damocles; the law should be fixed and this harmful long-term uncertainty removed.
At present, sufferers have to organize to travel abroad, away from most of the friends and family and with an air of secrecy, to end their own lives. Whereupon those who help them know, more or less, that they will not be prosecuted. Instead, the law should be changed to allow these vulnerable people to die near their home, family and friends, still without fear of prosecution.
Some of those who have gone abroad to get help are known to have committed suicide earlier than they really wanted to because they knew they wouldn't physically be able to travel in future months.
There is no clear-cut reason why the state has to force people to live if they don't want to. One commenter calls it deeply sadistic to force helpless people to live in pain and misery if they don't want to.
A terminally ill patient says "I want to be remembered for me, not for someone frail, weak and not looking like 'me'!"7. Terminal illnesses can degrade a person's entire life to an extent that life is merely something to be endured, not lived. When such a patient wants to end their lives peacefully, there is seemingly no argument why they should be forced to continue.
Professional medical help with suicide is preferable to amateur help.
The argument that no-one wants to hear or admit is the financial once. End of life support can involve the full-time work of multiple carers and doctors for a potentially long period, and a heavy use of medical resources. In an aging world, such escalating use of resources is leading to wider acceptance of assisted suicide1. If a small number of such patients are determined to die with dignity, those resources can be used to help multiple other patients who want to live.
In 21.8% of all deaths, doctors and relatives make the decision to withhold support and allow a patient to die. Nearly 17% of all deaths are preceded by a period where doctors choose to keep a patient deeply asleep until they die (called palliative sedation). The numbers of those seeking assisted suicide would only add a fraction to this percent. In terms of the action taken by a third party in helping to achieve death, assisted suicide is milder than palliative sedation or the decision to cease providing life support.
The General Medical Counsel gives guidance for doctors involved in end of life care and recognises that the duty to preserve their patients' lives, but grants that when "In some circumstances these treatments may only prolong the dying process or cause the patient unnecessary distress." treatment can be withheld (sometimes alongside sedation)8. In end-of-life settings the requirement that doctors always try to save life is morally incorrect, and the law already recognizes this. Explicit sanction of assisted suicide should be made.
All investigations by the DPP are too late to prevent assisted suicides. As there are known circumstances under which no prosecution will occur, a framework should exist to ratify assisted suicides before they occur. Hence, the need for legalisation so those seeking assisted suicide can first see a psychologist doctor and be brought into the system.
Concerning Prejudice, Discrimination and Undue Pressure:
It is a matter of indirect discrimination that able-bodied people can commit suicide, whereas the most severely disabled cannot. In all other areas, the law stipulates that reasonable attempts must be made to avoid indirect discrimination by giving additional help, where required, to the disabled. Although it is not something most equality experts would like to discuss, there is a clear legal argument that some disabled people need assistance in order to retain equal access to suicide. Those with degenerative diseases also fall into this category.
There is no evidence of the slippery-slope argument that vulnerable people will be pressurized into committing suicide: this has not happened in countries where assisted suicide is already well established9. Not only that, but, able-bodied victims are more at threat of being convinced to kill themselves by those with non-altruistic motives on account of them being able to do so freely. Without a medical system for suicide, such pressures will remain completely off the radar and uncounted.
The call for change is not a recent development. In 2005 Parliament saw a Private Members Bill for the Assisted Dying of the Terminally Ill which set a popular framework for such legality: a physician could assist a patient who had made a declaration that they wished to die if witnessed by two individuals including a practising solicitor, not allowing those with vested interests. The patient had to be terminally ill and suffering from 'unbearable suffering'.
The 1970s to 1990s saw support for assisted suicide steadily rise from 69% to 80%10, which crept up to 82% by 200811. In 2010 YouGov survey found that in at least some circumstances, 88% supported assisted suicide and only 7% said it was completely wrong.12
In 2006 Lord Joffe's bill was proposed to Parliament. It would allow a patient to sign to say that they wanted to be given a lethal dose of medication that the patient then had to take themselves. This would only be available to those with less than 6 months of life left due to their illness, and who were suffering "unbearably", mentally fit and not depressed. Although this was only a partial solution that would be applicable to very few cases, the House of Lords blocked it.13.
Healthcare Professionals for Assisted Dying (HPAD) and Dignity in Dying, Friends at the End and many other campaign and lobby groups exist.
Lord Falconer, who later chaired the Commission on Assisted Dying, was once the UK's Lord Chancellor, and has long commented on the status of those who have helped loved ones end their suffering abroad:
“Though prosecuting those going with them has in no case been deemed in the public interest, many fellow travellers have been interviewed by police and waited for months to learn that no charges would be brought. It is "time now for the law to catch up with reality," he says. [... and proposes that] if someone declares before an independent witness his intention of committing suicide, and two doctors certify that he is terminally ill, a person accompanying him abroad for that purpose should not face prosecution.”
Lord Falconer's sensible declaration seems hard to fault, except for the fact that many of those who suffer from excruciatingly horrible and debilitating diseases that are not actually terminal illnesses. The law should allow the assisted suicide of those certified as per Lord Falconer's idea, with the addition of those certified to be unable to counter a disease that dominates every area of their life. Eighty percent of Britons support changing the law to allow assisted suicide14, and for simple reasons of compassion and freedom of choice, I agree. It is largely the general populace that are pushing for this change based on moral and compassionate instincts; the British Humanist Association, one of the largest non-religious ethical bodies, has submitted written evidence to the Commission on Assisted Dying, supporting assisted dying15.
Sir Terry Pratchett, the English author most famous for his Discworld novels, created a documentary called Choosing to Die which aired in 201116, as part of his campaign to get the law changed. It featured the millionaire Peter Smedley, suffering from a degenerative motor neurone disease, who went in secret to the Dignitas clinic while he was still fit and able to travel. The law should allow him to die in his own home without that additional constraint on the timing of his chosen path.
The Commission on Assisted Dying ran from Sep 2010 and published its final reports on 2012 Jan 05, after scrutinizing nearly 1300 essays and other evidence. It consisted of various highly experienced personnel from law, medicine, palliative care and other appropriate experts. The aims of the commission were to:
The commission concluded that the current situation is incoherent and the law is inadequate, as we saw in the section above, and that there is a strong case for providing a legal choice to die for a small number of sufferers, and such a framework was detailed and recommended by the commission; the only dissenter to this was Reverend Canon Dr James Woodward, who was the only commissioner explicitly representing a religious voice.
A standard model of assisted suicide has emerged, and this form has been taken by the most serious proposals, by which I mean, the proposals which have travelled the furthest towards becoming law and the ones which have been discussed formally.
The standard model of Assisted Suicide applies only to those who are terminally ill with less than a year to live, and allows only for that person to personally and physically take a dose of medicine that will kill them. This medicine is to be provided by a medical establishment, after a long series of carefully monitored checks have been made into the patient's case. Physical help cannot be given. This ensures that the patient is voluntarily taking their own life. The declaration that this is what they want to do must be witnessed by two doctors and a senior practicing lawyer, none of whom are allowed to have any non-professional involvement with the patient nor personally gain from hir death.
This is the formula adopted by the Commission for Assisted Suicide and by Lord Joffe's private member's bill of 2006.17
16.5% of all deaths in the UK are preceded by a period where doctors keep the patient permanently sedated or comatoze before death, due to unbearable symptoms, according to research in 2007/2008 by Professor Clive Seale. In 17.6% of these cases a conscious decision is then made to cause death. Therefore (at least) 3% of the deaths in the UK are the result of someone else choosing the moment of death. Aside from these cases, 21.8% of all deaths result from a non-treatment decision where treatment is withheld (this higher percent includes cases where the patient themselves demands non-treatment). The numbers of those seeking assisted suicide would be very few in comparison. In terms of the action taken by a third party in helping to achieve death, assisted suicide is milder than palliative sedation or the decision to cease providing life support.18
In 10% of palliative sedation cases, the patient was kept under for over a week, and only in a third of cases was the time period less than a day. The reasons given for using it were related to symptoms of permanent pain and psychological distress. 5% of cases record that the patient themselves talked about putting them to sleep, and, in twice as many cases the request was instead made by a relative. This is clearly a form of slow-acting assisted suicide: Prof. Seale notes that in The Netherlands and Belgium (for example) continuous sedation is carried out as an alternative to direct euthanasia.18.
The Mental Capacity Act 2005 allows clear-headed statements to be made that under specific conditions, someone does not want to have their life sustained. There are various common-sense restrictions: they have to be no longer capable of answering for themselves and there has to be no doubt that the patient was referring to the type of situation they are now in rather than a different type of situation. These living wills are just a specific type of suicide, but where it is not the person themselves who do the final acts.
It is strange for the law to allow permanent sedation during unnaturally preserved life in hospital, but to outlaw assisted suicide, when they both rest of the same moral foundation.
Various lobby groups exist that oppose any change in the law, or, want the law to more strictly deny any attempted assisted suicide, even for those who struggle abroad to kill themselves. Not Dead Yet UK is one such group: they argue that people's lives are "put at risk" by the available of help with suicide. Scope (the disabilities charity) and other groups worry about social pressure for burdensome people to kill themselves. This pressure needs to be specifically monitored by any procedures that are put in place to allow assisted dying, however, in the Netherlands and Oregon, where studies have been made, there is no evidence that vulnerable groups are over-represented amongst those who receive help in committing suicide9.
The ProLife Alliance fight battles against many aspects of modern life which they feel clashes with their values, such as advanced genetics science, abortion and stem-cell research. Their efforts have (or, may have) hampered and slowed scientific research into cures for many serious diseases and have therefore increased human suffering. Therefore, it is not surprising to also find this group opposing assisted suicide. Their reporting on the subject is far from subtle.
“I cannot scratch if I itch, I cannot pick my nose if it is blocked and I can only eat if I am fed like a baby [...] I have no privacy or dignity left. I am washed, dressed and put to bed by carers who are, after all, still strangers. You try defecating to order whilst suspended in a sling over a commode and see how you get on. I am fed up with my life and don't want to spend the next 20 years or so like this.”
Take their current top story posted on 2012 Mar 12, headlined as "Alarming decision from the High Court..." followed by an equally alarming first sentence: "Tony Nicklinson wants doctors to be allowed to kill disabled people"19. This is truly horrible. You can't just go out and murder disabled people! This is of course not the truth. Tony Nicklinson suffered a stroke and is completely paralysed from the neck down and suffering from what they call "locked-in" syndrome. His only way of communicating is via coded eye blinks. He has single-mindedly sought to end his own life - or rather, to have it ended. It is not that he wants doctors to kill disabled people, but, that he wants to fight through the courts to allow a doctor to kill him because he won't be able to do it himself when the time comes. He argues that once life reaches a certain non-liveability and a certain level of suffering - emotional or physical - patients should be able to request a lethal dose of medicine. Is ProLife, who give none of the details behind Tony's case, reporting the story accurately? One of their last statements in the article is to state that "Others who are just as disabled take a less pessimistic view and are glad to be living even in difficult circumstances."19 Fair enough - some people manage to cope - but what right does the world have to force a man to endure a continued life of suffering and misery where his only real action is to move his eyes? It is about choice. ProLife's agenda coincides with that of fundamentalist Christianity, and prevents them from understanding the moral issues involved in assisted suicide, and, their reporting prevents casual readers from gaining genuine understanding of it, too.
Although 80% of Britons support changing the law to allow assisted suicide in the UK14 the opposition is active. The Archbishop of Canterbury, Dr Rowan Williams, and Cardinal Cormac Murphy O'Connor, Archbishop of Westminster, were two of those who opposed Lord Joffe's bill in 2006, and they mustered 100,000 signatures against it.13. Both of these figures are one of the many senior Church of England who have an automatic, historical and non-democratic right to sit in the House of Lords, meaning, they have legislative clout. Instead of giving sufferers a choice, they emphasized (compulsory) care services.
Most religious people support assisted dying (being covered by the 80% in the UK who support it). Those who oppose it are possibly speaking with a louder voice: they do not represent as many people as they might believe.
Some religious organisations explicitly support it; for example the Chief Executive of Liberal Judaism, Rabbi Danny Rich, is tolerant of the idea.
Reverend Canon Dr James Woodward was the only commissioner on the Commission for Assisted Dying explicitly representing a religious voice, and he alone did not support the group's firm conclusion that in rare circumstances, people had a right to ask for help in ending their own lives. The final report of the Commission included an Appendix where the Anglican priest voiced his concerns. He has questions about the way culture views death, and says "there are important theological questions about suffering, personhood and the value of the vulnerable that need to inform a more open conversation about death and dying in Britain today". By "theological questions" he of course means Christian questions and no doubt has in mind the long-standing Christian stance against suicide: as Earthly suffering is a god-given punishment for the sins of Adam and Eve, and a test of faith, he cannot support its ending by physicians. His statement that these theological concerns need to 'inform' discussions in Britain simply means he wants Christian ideas to be heard, even though 80% of Britons support assisted suicide14 and as few as 34% believe in God.
When Demos researched opinions on whether assisted suicide should be legalized in the UK amongst those with terminal illnesses, only two patients opposed. Both were Christian who based their opinions on their faith: one of them didn't "believe in doctors" at all, and also, didn't think that anyone should ever help anyone else commit suicide. The other respondent said they didn't think it was right that people decide when to die, it should be up to God. Opponents also include solitary voices and some groups such as Catholic Voices.20.
Dr Khalid Hameed, a medical doctor and a Muslim, submitted written evidence to the Commission on Assisted Dying. He argued very simply that anyone who commits suicide or aids another in doing so would end up in hell (2012, p76).
Arguments from these sources have some serious flaws:
No-one will ever be forced to commit suicide (that'd be murder). So if some Christians think it goes against their beliefs, then, they can simply ignore it. Religionists should not assume that others have the same beliefs and, it is wrong for one religion to force others to adhere to its rules.
The entire medical professional is engaged with preventing death. The argument that it is God's choice means that we should no longer prevent and cure deadly diseases. We humans act out of compassion; this includes both saving life and, in very rare circumstances where there is no other way forward, to prevent suffering by allowing suicide.
I was also pleased to read Immanuel Kant discuss this in 1785, however, his conclusion against the topic is based on some pretty strange and spurious logic. Here it goes, in full - I'll explain a little more afterwards:
“A man reduced to despair by a series of misfortunes feels wearied of life, but is still so far in possession of his reason that he can ask himself whether it would not be contrary to his duty to himself to take his own life. Now he inquires whether the maxim of his action could become a universal law of nature. His maxim is: 'From self-love I adopt it as a principle to shorten my life when its longer duration is likely to bring more evil than satisfaction.' It is asked then simply whether this principle founded on self-love can become a universal law of nature. Now we see at once that a system of nature of which it should be a law to destroy life by means of the very feeling whose special nature it is to impel to the improvement of life would contradict itself and, therefore, could not exist as a system of nature; hence that maxim cannot possibly exist as a universal law of nature and, consequently, would be wholly inconsistent with the supreme principle of all duty.”
"Fundamental Principles of the Metaphysic of Morals" by Immanuel Kant (1785)21
His hiccup with the concept of a "universal law" comes from his drive to find a single Universal natural law that must be true in all circumstances, on which to base all other morals. Clearly, the lack of finding such a law in the morality of assisted suicide is not grounds for rejecting the concept of assisted suicide. But such were the windy inconsistencies of classical philosophy and its enthusiasts.
The Commission on Assisted Dying concluded firmly limited themselves to recommendations for who are diagnosed with a terminal illness and have less than a year to live (p27) although most people want this to also cover those who suffer from diseases that are completely detrimental to free life. But if people can chose to end their own lives after carefully monitored and scrutinized witnessing by impartial professional witnesses, why should this particular procedure be limited to those with serious life-destroying illnesses? A poll by MORI in 1987 revealed that 23% of us agreed that euthanasia should simply be available upon request by a patient no matter what the cause10, although this dropped to 13% according to a 2009 poll11.
If it is permissible for doctors to pronounce a disease so serious that a patient can volunteer to die, an individual should be able to declare themselves succumbed to nihilism, and therefore decide it is time for the end, even though there have no medical complaint. Pending medical investigation into temporary underlying causes such as curable neuronal or hormonal medical dysfunctions, such nihilistic declarations should be accepted.
Unregulated suicide causes emotional trauma in a family and community. Those who dive beneath moving trains and other pseudo-public acts of suicide should be encouraged to come into a medical environment to achieve the same end in a less disruptive manner.
Limits on the service must be strict:
The nihilist who wants to end hir own life must declare so in a meeting attended by a senior clinical psychologist, a practicing solicitor and a representative from the provider of the suicide service, none of which must have any personal involvement with the client nor any vested interest in his death (excepting the service representative, who has only a commercial interest).
There must be a one-year or 18-month cooloff period.
The patient must be checked for, and clear of, symptoms of temporarily-mind-altering depression or medically fixable emotional or neuronal imbalances.
The nihilist must be of sound mind and convince all witnesses that they fully understand the decision they are making.
They must attend 4-monthly checkup interviews during the cooloff period with the medical and legal witness and admit no doubt or change of mind.
After the last interview and (at least) before the last 3 months of the client's life, all the evidence and interviews must be reviewed by a different senior solicitor and another medical appointed professional. At this time, the final go-ahead it given. It is not suitable for the person's last months to be spent in doubt as to whether it can go ahead.
Patients with serious debilitating diseases can follow the same procedure as non-medical clients but without the fixed time line, and they can contractually state that given certain advances in their condition the date can be rapidly organized.
Patients should be allowed to die in their home country near friends and family, and not forced to travel abroad to do the same. The state has no right to force people to live in misery if they do not wish to. UK law already permits some forms of assisted suicide. Relatives and loved ones can help others travel abroad in order to end their lives at Dignitas in Switzerland: hundreds of cases are known to prosecutors, and they profess that under normal (moral) cases, no prosecutions will be brought. Living wills made in accordance with the Mental Capacity Act 2005 allow people to state under what criteria they wish to be allowed to die, and in 3% of end-of-life medical settings doctors and relatives make a decision to end life without even having ascertained explicit consent from the patient. In 22% of all deaths in the UK there has been a specific decision to act - or withhold acting - in a manner that causes death. Many patients are permanently sedated until death because their symptoms are severe: this is nothing but slow-acting effective assisted death. All that has clear moral and legal support. Assisted suicide is milder than cases where doctors and relatives choose to end life without explicit consent, and the much higher percent of cases where patients' wishes are respected in a manner than quickens their death. Assisted suicide cases are, and will remain, far fewer than any of these already-accepted methods of chosen death. To argue against assisted suicide is to reject the humanity and morality of these other similar situations.
The Guardian. UK newspaper. See Which are the Best and Worst Newspapers in the UK?. Respectable and generally well researched UK broadsheet newspaper..
i Newspaper. UK newspaper. See Which are the Best and Worst Newspapers in the UK?. Published by Independent Print Limited, London, UK. Respectable daily news paper.
The Economist. Published by The Economist Group, Ltd. A weekly newspaper in magazine format, famed for its accuracy, wide scope and intelligent content. See vexen.co.uk/references.html#Economist for some commentary on this source..
Commission on Assisted Dying
Final report published 2012 Jan 05 by Demos, accessed via www.demos.co.uk on 2012 Mar 05.
(2010) Future Agenda: The World In 2020. Published by Infinite Ideas.
Kant, Immanuel. (1724-1804) German philosopher.
(1785) Fundamental Principles of the Metaphysic of Morals. E-book. Amazon Kindle digital edition prepared by David J. Cole prepared by Matthew Stapleton. Translated by Thomas Kingsmill Abbott (1829-1913).
(2013) Human Development Report. This edition had the theme of The Rise of the South: Human Progress in a Diverse World. Published on the United Nation's HDR website at hdr.undp.org/.../hdr2013/ (accessed throughout 2013). UN Development Program: About the Human Development Index.
A MORI poll of 1,808 people in 1987, sponsored by two anti-euthanasia organisations, also found that a majority of respondents (72 per cent) were in favour of legalising some form of assisted dying. Looking at a more detailed breakdown, 49 per cent supported 'euthanasia' for a patient 'suffering from a severe illness' who is in 'a lot of pain', while nearly a quarter (23 per cent) agreed with the statement "Euthanasia should be made legal in all cases when the patient requests it"."^^
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