Assisted suicide is gaining acceptance in North America and Western Europe. What mars this acceptance of a reasonable option for individuals in dire and hopeless medical situations is that physicians and nurses are sometimes glossing what is actually euthanasia as assistance in suicide. There is a real danger that growing acceptance of assisted suicide will result in greater practice of euthanasia by physicians and nurses.
Somewhat ahead of public debate on assisted suicide, I published The Last Choice in 1990. In that book I argued for the rationality of choosing to die in medically dire and hopeless situations. At that time assisted suicide was still widely opposed on ethical and religious grounds and was standardly illegal in North America. In 1998, I followed up with a revised version of The Last Choice because assistance in suicide for medically despairing individuals was being discussed more than before and had gained some public support. As discussion of assisted suicide continued to increase and it began to be practiced in some areas, I published Choosing to Die in 2008 and Coping with Choices to Die in 2011. I also published a number of journal articles on the topic, the earliest being “Foucauldian Ethics and Elective Death” in the Journal of Medical Humanities in 2003, and the most recent being “Personhood, Preemptive Suicide, and Legislation,” in Ethics, Medicine and Public Health in 2016. In these works, I supported the choice to die in punishing, self-destructing, and irredeemable circumstances as well as provision of assistance when stricken individuals are physically incapable of taking their own lives.
In the thirty some years that have passed since I first worked on assisted suicide, I have witnessed its greater acceptance as well as its legalisation in some constituencies. At the time of this writing, assisted suicide is legal in in Canada and in the U.S. in California, Colorado, Oregon, Vermont, and Washington. Assisted suicide is also legal in Western Europe in the Netherlands, Switzerland, and Germany, though in Germany there are more restrictive specifications than in the Netherlands and Switzerland.
Regrettably, as many opponents of assisted suicide feared, there is a “slippery slope” from legitimate practice of assisted suicide to illegitimate euthanasia. I argued against the slippery-slope contention but have come to have reservations about my earlier position because of evidence that some physicians and nurses are increasingly performing what they see as compassionate euthanasia under the guise of assisting suicide. These well-intentioned physicians and nurses take patients in dire and hopeless medical conditions as desiring assistance in dying even if the patients do not explicitly express that desire. The operant assumption is that terminally ill individuals tacitly indicate a desire to die through their repeated expressions of anguish.
However, even if motivated by compassion, euthanasia is the ending of life decided on and carried out by someone other than the person whose life is ended. Not only does even compassionate euthanasia take the decision out of the hands of the patients involved, it also ignores the possibility that those patients are not requesting assistance in dying because they are unwilling to violate strongly held ethical principles or religious beliefs.
Another contributing factor to the drift to euthanasia is that regardless of its continued illegality in many countries and states, some physicians and nurses covertly assist in suicide. A likely trend-setting instance was the suicidal assistance provided by an anonymous physician to Sue Rodriguez. Rodriguez, who in effect became a Canadian right-to-die activist, suffered from ALS and wanted desperately to die but could not take her own life without help. In 1994, fairly soon after her appeal for help in dying was discussed in the media and rejected by the courts as illegal, an unidentified physician assisted her suicide. Physicians and nurses who covertly assist in suicide may be driven by compassion for patients who are invariably suffering and undergoing the personal lessening due to ever-larger doses of medication that relieve pain at the cost of mental deterioration. But covert assistance of this sort seriously undermines commitment to legality in the medical profession by establishing an unacknowledged practice and, likely worse, contributing to a dangerous attitude regarding human life.
It is a short step from legally or covertly assisting suffering patients’ request for help in dying and compassionately anticipating or assuming such requests on the basis of patients’ situations and complaints. It is also a step facilitated by the options open to physicians and nurses. For example, lethally increasing or failing to administer required medication is an act that may well go unnoticed and, if noticed and questioned, can be explained away as erroneous.
In addition to questionable practices on the part of physicians and nurses, there is what amounts to an increasing indifference on the part of the public toward medically effected compassionate euthanasia. The cases that do attract media attention are the extraordinary ones, such as when on June 1, 2017, The New York Times reported that a nurse at a retirement home in Canada killed eight patients by injecting them with insulin. What mainly captured media and public attention was that the nurse did not act for compassionate reasons. Instead she did what she administered lethal doses of insulin because of self-confessed anger at her own situation. Lacking this sort of atypical element, assistance in suicide and compassionate euthanasia no longer merit media attention and public concern.
Greater public acceptance of assisted suicide will unquestionably bring with it proportionately increased implementation of euthanasia under the guise of assisted suicide. Underlying this development is something more profound than some physicians and nurses feeling licensed to compassionately accelerate death for terminal patients. The medical profession is facing an ageing population, longer-lived patients, and hugely growing costs. A deep change in attitude towards human life is prioritising practical considerations. This point was brought home to me when I spoke with an older man who told me that he had just seen his physician and added: “When you hit seventy-five, you disappear.”