Spread of assisted dying shines spotlight on difficult decisions

The right to control your death is a principle that societies have debated for centuries. But, as more countries prepare to legalise medically-assisted dying, the reality of allowing the practice is sparking fresh ethical arguments.

Some form of assisted dying is now legal in 9 countries, as well as in 11 US states and parts of Australia. Parliaments in other countries are also considering such laws, including those in France and the UK crown dependencies of Jersey and the Isle of Man.

This shift in the power of the state and the medical profession — over not only how citizens live their lives but also how they end them — is forcing difficult decisions, including the consequences of passing the laws so far.

The laws that have been passed vary in scope and eligibility. Most allow only physician-assisted suicide in cases of terminal illness with a survival prognosis of six months to one year.

However, the term “assisted dying” can refer to both assisted suicide and euthanasia. The former is when a person is legally prescribed lethal drugs that they administer themselves. Euthanasia, on the other hand, is typically defined as the act of deliberately ending another person’s life to relieve suffering, usually involving the assistance of a physician — and is legal in far fewer places than assisted suicide.

More people are making use of the new laws, where they have been passed. In Canada, for example, assisted dying accounted for 4.1 per cent of all deaths in 2022, according to official figures. That proportion reached 7 per cent in Quebec last year, according to a Radio Canada report.

In the Netherlands, the proportion rose from 5.1 per cent in 2022 to 5.4 per cent last year, according to official data.

This increased uptake of what Canada calls “medical assistance in dying” stands in contrast with what had been expected when the practice was passed into federal law in 2016. Gaétan Barrette, then the health minister for Quebec and a former radiologist, said in 2016 that he thought “there would be perhaps a hundred [of these deaths]”. In 2022, the figure for the province was 4,800.

Trudo Lemmens, a law professor at the University of Toronto and co-author of the Ethical Review Report into Jersey’s proposals, says he was concerned about the rapid uptake in Canada, while noting that “different models [of legislation] have different implications”.

One of the concerns is how the legislation “induces” death in those who would otherwise continue living. “When a state says it’s legal for physicians to help people die, it's the state confirmation of the reasonableness of a form of suicide for elderly and disabled persons who qualify,” says Lemmens. “And this impacts on societal perceptions and self-perception of the value of their lives.”

The Anscombe Bioethics Centre, a Catholic research institute in England, says there is also evidence of an increase in unassisted suicide after assisted suicide becomes law. The review of published research, by David A Jones, the centre’s director and professor in bioethics at St Mary’s University, says that promoting euthanasia or assisted suicide “seems to contradict the principle that ‘every suicide is a tragedy’.”

The review also references research by Sourafel Girma and David Paton, economics professors at Nottingham university, that finds the legal changes have a bigger impact on women than men. The authors calculated that assisted suicide laws increase total suicide rates by 18 per cent, or 40 per cent among women, in a study that draws on data over 30 years from US states.

But Girma and Paton find “weaker evidence” that assisted suicide laws mean more people take their own lives without assistance: they say the rise is 6 per cent among everyone and 13 per cent among women.

These findings challenge the claim made by pro-euthanasia groups that many people with terminal illnesses choose to take their own lives unaided, and that these people would instead die with medical assistance if it were legal.

Another worry is that assisted dying regimes devalue the life of disabled people and constitute a form of “ableism” — discrimination in favour of able-bodied people. Phil Friend from Not Dead Yet, an organisation representing disabled people with concerns about the legal changes, says it is vital to ensure support and care are prioritised over the option of assisted death, which is usually cheaper.

Some campaigners fear that the economic savings from reduced medical bills — especially as societies continue to grow more elderly — may influence politicians to withhold objections on financial grounds.

“In essence, many disabled people believe that legalising assisted suicide, even with intended safeguards, would reinforce negative societal attitudes towards disability and put already vulnerable individuals at further risk of coercion and abuse,” says Friend.

However, campaigners in favour of assisted dying maintain that such laws already work safely in many parts of the world. Dying with Dignity says that UK laws preventing assisted dying are out of date and “out of step with the way we live today”.

“Each day that Westminster [parliament] delays, more dying people are forced into desperate decisions, with 650 each year taking drastic, often violent action to end their own lives. Others spend thousands of pounds to die alone in Switzerland, often having left their loved ones at the departure gates to shield them from the threat of prosecution,” they add.

They also say that doctors tend to be supportive of the changes, and that respect for personal autonomy and the importance of quality of life trump other concerns.

Among doctors, though, there is a further debate about what legalising assisted dying means for them.

The British Medical Association has been neutral on the question of changing the law on assisted dying since 2021. The union told the FT that, if legislation were to be introduced, it would want to see law “that gives doctors a genuine choice” about whether and how to participate.

However, the American Medical Association has taken an opposing stance, describing assisted suicide as “fundamentally inconsistent with the physician’s professional role”. As a result, it “opposes any bill to legalise physician-assisted suicide”.

Richard Huxtable, professor of medical ethics and law at Bristol university, who also contributed to Jersey review, has observed increasing exploration of whether there needs to be a physician involved. “Some are asking: do we need a medical doctor to provide this? It’s an open question,” he says.

Huxtable argues that extending the criteria to apply to adults with unbearable suffering has generated many of the most morally questionable cases.

“It is troubling . . . when you read about people who have psychological factors, existential and social concerns including loneliness, or feel they are being a burden on others,” he says. “You really have to query has this gone too far?”