Eight Reasons not to legalize Physician Assisted Suicide

From the Anscombe Bioethics Centre.

1. Physician Assisted Suicide (PAS) would not address the urgent needs of the dying

One attraction of PAS is that it is thought to address the suffering of the dying.  However, much of this suffering can be alleviated in other ways.  For some conditions there is a need for further research, to develop new techniques to treat difficult-to-manage pain.  Most urgent, however, for most people, is widening access to palliative care so that people do not die in distress with treatable but untreated symptoms.  PAS not only carries undue risk, threatening patients, professionals and the ethos of solidarity that is the basis of ethical healthcare; it also fails to address this wider problem.  How are we as a society to help people live well through life and into old age, and care for those who are dying?  This is the real challenge and legalizing PAS does nothing to address it.  On the contrary, the ‘quick fix’ of PAS would be a dangerous distraction from this urgent task.

2. Legalizing PAS would threaten those with disabilities

In practice PAS divides patients into two groups: those judged to have lives ‘worth living’ and those with lives ‘not worth living’, for whom death would be a reasonable option that should be made available to them.  PAS would not apply to the healthy, but to those who are sick and disabled.  Advocates of PAS typically claim to be concerned only with dying people and not to be disparaging those living with disabilities.  However, the motivation for seeking assisted suicide seems most often a concern not about dying but about living with disability.  People fear being a ‘burden’ on family or society, or regard dependency as a ‘humiliation’, or perceive as an ‘indignity’ the prospect of limited control over their bodily functions.   This is why legalizing PAS is a direct threat to disabled people.  It undermines their right to be regarded as of equal worth, and also challenges their own sense of self-worth.  Small wonder that disability groups are at the forefront of opposition to PAS.

3. Legalizing PAS would jeopardize the suicidal

The legalization of PAS would send out the message that suicide can be an appropriate response to the burdens and stresses of life:  physical, psychological and social.  This would endanger those with suicidal feelings.  Against this, some have argued that PAS could function as ‘an effective form of suicide prevention’[1] because giving people control would allow them to put off the act of suicide.  However, US states that have allowed PAS – Oregon, Washington, Montana and Vermont – have all experienced increases in suicide.  In Oregon, which legalized PAS in 1997, non-assisted suicide among those aged 35-64 increased by 49% between 1999 and 2010 (compared to 28% nationally);[2] this is without adding the increasing numbers ending their lives by physician assisted suicide.  Legalizing PAS ‘normalizes’ suicide.  It is a danger to all who struggle with suicidal thoughts.

4. Legalizing PAS would undermine a foundational principle of law and justice

All human beings possess, in virtue of our common humanity, an equal and intrinsic dignity.  It is contrary to justice and human solidarity intentionally to kill an innocent human being (that is, someone not engaged in unjust aggression).  This principle equally excludes assisting someone to kill themselves.   Even if someone loses sight of their dignity and value (whether through pain, suffering, or loneliness) they nevertheless remain a member of the human community and valuable in themselves and deserve care, not encouragement to kill themselves.  This principle explains why the law in England (and in the vast majority of countries) imposes a blanket ban on assisting suicide.

5. Legalizing PAS would undermine a key principle of medical ethics

Professional medical ethics also subscribes to a belief in the fundamental equality in dignity of all patients, and in the wrongness of intentionally ending their lives.  It is not, however, ‘vitalistic’: it does not require life to be preserved at all costs.  It allows effective medical treatment or the withdrawal of futile or burdensome treatment even if life may shortened as a side-effect and does not require treatment to be imposed on patients against their wishes.  Doctors must maintain ‘the utmost respect for human life’.  This commitment, fundamental to the trust between doctors and patients, dates from the Hippocratic Oath which excluded the giving of ‘a lethal draught’ even at the patient’s request.[3]  Medical bodies such as the World Medical Association, the BMA and the Royal College of Physicians remain steadfastly opposed to the legalization of Physician Assisted Suicide.

6. Legalizing PAS would undermine a key principle of palliative care

Palliative treatment and care, pioneered by the hospice movement in the UK, relieves the pain and distressing symptoms that can be experienced by the dying, and integrates the psychological and spiritual dimensions of patient care.  Palliative care affirms life but regards dying as a normal and natural process.  It is a key principle of palliative care that it ‘intends neither to hasten nor to postpone death’.  PAS, by contrast, aims to hasten death and thus stands in fundamental contradiction to the ethos of palliative care.  The Association for Palliative Care and the great majority of palliative care physicians worldwide remain opposed to PAS.

7. PAS is but a first step to euthanasia, both voluntary and non-voluntary

Those seeking to change the law currently advocate PAS for the ‘terminally ill’ and/or those with ‘unbearable suffering’.  However, if it is ethical to provide lethal drugs to those who can swallow them, why deny a lethal injection to those too disabled to swallow the drugs?  Many advocates of PAS in the UK admit that they regard it as merely a ‘first step’ to following countries like the Netherlands, which allows both PAS (lethal prescriptions) and voluntary euthanasia (lethal injections with the patient’s consent).  Furthermore, if voluntary euthanasia is justified to relieve suffering with the patient’s consent, why not provide non-voluntary euthanasia to relieve the suffering of a patient who is incapable of requesting it, like a baby or a person with dementia?  The Dutch courts legalized voluntary euthanasia in 1984.  In 1996, they legalized non-voluntary euthanasia for disabled infants.

8. PAS would be uncontrollable

It would be impossible to ensure effective control of PAS.  The experience of jurisdictions that have relaxed their laws shows that their so-called ‘safeguards’ are largely illusory.  For example, in the Netherlands, since legalization in 1984, thousands of cases have gone unreported by doctors, thousands of patients have been given lethal injections without request, and lethal injections for disabled infants are now lawful.  The Belgian experience since 2002 has proved no less disturbing.  The ‘review’ process in Oregon is even weaker than in those countries, and we lack comprehensive research into precisely what is happening there.  And numbers continue to rise.  Oregon witnessed an increase of 44% last year alone.  In Switzerland, which has the longest history of PAS, one in three suicides of Swiss citizens in 2012 was by PAS (508 out of 1480).  And, as the numbers increase, the notional safeguards are applied less and less frequently.  In Oregon, the proportion of people referred for psychiatric evaluation prior to PAS decreased from 37% in 1999 to less than 3% in 2013.[4]

For a pdf of this paper see here. For the full GUIDE TO THE EVIDENCE see here.

[For further background see: Gormally ‘Euthanasia and Assisted Suicide: Seven Reasons Why They Should Not Be Legalized’ http://www.bioethics.org.uk/article/1/Euthanasia J. Keown ‘Physician-Assisted Suicide: Some Reasons for Rejecting Lord Falconer’s Bill’ http://www.carenotkilling.org.uk/public/pdf/falconer-bill—john-keown.pdf H. Watt ‘The Case Against Assisted Dying’ http://www.bioethics.org.uk/images/user/CaseAgainstAsstDying.pdf ]

[1] A claim made by the Swiss assisted-suicide organisation EXIT and by other advocates of PAS.

[2] http://www.comedsoc.org/Suicide_-_Oregon_Ranked_2nd.htm?m=66&s=520

[3] D.A. Jones ‘The Hippocratic Oath I: its content and the limits to its adaptation’ Catholic Medical Quarterly Vol. 54, No. 3, August 2003. http://www.cmq.org.uk/CMQ/2003/hippocratic_oath.htm

[4] http://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/

see also D.A. Jones, ‘Assisting the suicidal and caring for the dying’ Thinking Faith 27 June 2014 https://www.thinkingfaith.org/articles/assisting-suicidal-and-caring-dying