The world inches toward acceptance of patient autonomy and physician-assisted suicide as a humane way to cope with terminal illness.
By Joseph Chamie*
Death is an inevitable outcome for everyone. How one dies is a legitimate matter of concern for individuals and families, one that governments and courts should address rather than avoid. Physician-assisted suicide represents a fraction of all types of suicide, which together account for approximately 1.4 percent of annual deaths worldwide. Despite low incidence, the action to voluntarily end one’s life poses a dilemma – is assisted suicide a human right to be permitted or a homicide to be prohibited?
In contrast to euthanasia, by which medical practitioners oversee a procedure that ends a person’s life to relieve intractable suffering, assisted suicide typically involves a person choosing to end life through voluntary self-administration of a lethal dosage of drugs prescribed for that purpose. That distinction, however, is not always clear, especially when the person undertaking a suicide receives a physician’s aid directly or indirectly.
While suicide is a global phenomenon, with nearly 80 percent of suicides occurring in low- and middle-income countries, physician-assisted suicide has been allowed in only a few countries: Belgium, Canada, Colombia, Finland, Germany, Japan, Luxembourg, Netherlands, South Korea, Switzerland and the US states of California, Colorado, Hawaii, Montana, Oregon, Vermont and Washington as well as Washington, DC. The specific circumstances, diagnoses and requirements for the procedure vary among countries and states, and in general the guidelines are explicit and stringent, with approvals and responsibilities specified for patients and licensed medical authorities and protections for the mentally ill and incompetent.
The proportions of annual deaths reported as physician-assisted suicide are relatively low, typically less than a half of 1 percent. While proportions of assisted suicide have remained at those low levels, they have crept higher over time, as people become familiar with the procedure. For example, during the past two decades the proportion of deaths due to assisted suicides approximately doubled in the Netherlands, tripled in Washington and quadrupled in Oregon.
The most common illness of patients turning to physician-assisted suicide is all cancers combined, often followed in second place by amyotrophic lateral sclerosis, or ALS. In Oregon, for example, 77 percent of those electing assisted suicide during the period from 1998 to 2016 had cancer and 8 percent had ALS. Similar cancer rates among patients deciding on assisted suicide were reported in Belgium, 69 percent; Canada, 63 percent; the Netherlands, 71 percent; and the US states of California, 68 percent; Colorado, 64 percent; Vermont, 83 percent; and Washington state, 72 percent.
In general, the patients who decide on the procedure are motivated by symptoms, decreased quality of life and autonomy, a loss of sense of self and fears about the future. While each personal assessment is patient-specific, many who decide on suicide expect to relieve their suffering permanently and alleviate the burden for families and friends.
Some people travel far or relocate for the purpose of physician-assisted suicide. A few years ago, 29-year old Brittany Maynard with terminal brain cancer moved from California to Oregon to end her life. Recently, 104-year old David Goodall with diminished independence flew from his home in Australia to Switzerland to end his life. The issue was also popularized in the 2016 drama-comedy film, Youth in Oregon, in which an 80-year old terminally ill man travels by car from New York to Oregon for assisted suicide.
Most major religions, including Buddhism, Christianity, Hinduism, Islam, Judaism, oppose physician-assisted suicide. Among the Abrahamic religions, the opposition rests largely on the basic principle that life is sacred and only God, not the individual, should determine when their life ends. In Buddhism and Hinduism, suicide conflicts with their belief in karma and reincarnation. Religious opposition to assisted suicide, however, is not universal. The United Church of Christ and Unitarian Universalist Association affirm that individuals have the right to choose physician-assisted suicide and hold beliefs that God would favor ending suffering from a terminal illness.
The positions of physicians and professional medical organizations concerning assisted suicide vary, too. At the most general level, however, the divide among physicians on the sensitive and difficult issue of assisting a patient to commit suicide is between two fundamental medical principles: “do no harm” versus “relieve suffering.”
Some contend that the Hippocratic oath and medical ethics prohibit physicians from giving deadly drugs to anyone who asks. The American Medical Association and the American College of Physicians, for example, suggest that physician-assisted suicide is incompatible with the physician’s role as healer. In addition, those organizations argue that assisted suicide is difficult to control, poses serious societal risks and creates a slippery slope likely resulting in involuntary euthanasia. Others counter that the Hippocratic oath has been modified over time, and “do no harm” works both ways, suggesting it “harm” to prolong suffering. They point out that legalization in various jurisdictions has not been difficult to manage or control, neither posing serious societal risks nor creating a slippery slope. Moreover, in response to opposition of US medical associations, supporters note that 57 percent of American physicians support the option for the terminally ill.
Despite the proscriptions of major religious groups and lack of consensus among medical practitioners, large portions of the general public support physician-assisted suicide: In 13 of 15 countries surveyed in 2015, more than half of those interviewed supported legalization; the only exceptions were Poland and Russia, where slightly less than half said it should be legal. Another large-scale opinion survey covering 34 cities in China conducted several years ago found that more two-thirds of those polled do not object to euthanasia or assisted suicide. Available time-series survey data also point to increasing public support for physician-assisted suicide. In the United States and the United Kingdom, for example, polls conducted over the past 30 years show consistent majorities and growing support for assisted suicide, especially when the patient has an incurable disease or lives in severe pain.
Proponents argue that it is a basic human right to choose a timely and dignified death, especially for the terminally ill. Opponents contend that medical assistance in committing suicide does not constitute a fundamental human right, and palliative care and hospice can relieve pain and suffering. Another issue raised in the debate is that increased longevity and medical advances can delay death. Some patients fear that their lives may be prolonged unnecessarily or end in unbearable distress. Decisions by patients regarding the end of their life, it is argued, are personal decisions that governments should respect. Those who disagree maintain that government has a legitimate responsibility to protect life and restrict medical professionals and others from participating in actions to shorten a patient’s life.
Most people wish to die at home, avoiding a painful and burdensome end of life. Only20 percent of Americans die at home. Many say that rather than experiencing a long, drawn-out, emotionally and financially costly death in a medical facility with multiple interventions, they prefer a peaceful and painless death at home with dignity, a sense of emotional wellbeing and control over how people will remember them.
Societies should not avoid or dismiss the option. The emotional stresses of terminal illness and deciding on suicide are immense. A sibling and a close friend attempted suicide, with the friend eventually electing physician-assisted suicide, and I can assure readers that the consequences of end-of-life decisions extend well beyond the individual involved, with repercussions for family members, friends, colleagues and even distant acquaintances.
The debate is unlikely to be resolved soon. Still, a consensus may be slowly emerging. The compelling experiences in the small number of lead countries, public opinion trends and the concerns of the terminally ill point to decriminalization of assisted suicide with governmental and medical oversight and safeguards.
*Joseph Chamie is an independent consulting demographer and a former director of the United Nations Population Division.