tag:theconversation.com,2011:/id/topics/right-to-die-11681/articlesRight to die – The Conversation2024-02-22T01:22:51Ztag:theconversation.com,2011:article/2238632024-02-22T01:22:51Z2024-02-22T01:22:51ZVoluntary assisted dying is different to suicide. But federal laws conflate them and restrict access to telehealth<figure><img src="https://images.theconversation.com/files/576955/original/file-20240221-30-6rt3ul.jpg?ixlib=rb-1.1.0&rect=125%2C224%2C2869%2C1773&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/depressed-elderly-widow-sitting-on-her-191917208">Daxiao Productions/Shutterstock</a></span></figcaption></figure><p>Voluntary assisted dying is now lawful in every Australian state and will soon begin in the <a href="https://www.justice.act.gov.au/justice-programs-and-initiatives/voluntary-assisted-dying-laws-in-the-act">Australian Capital Territory</a>.</p>
<p>However, it’s illegal to discuss it via <a href="https://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/Factsheet-Telehealth-Updates-April%202023">telehealth</a>. That means people who live in rural and remote areas, or those who can’t physically go to see a doctor, may not be able to access the scheme.</p>
<p>A federal private members bill, introduced to parliament last week, aims to change this. So what’s proposed and why is it needed?</p>
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<h2>What’s wrong with the current laws?</h2>
<p>Voluntary assisted dying doesn’t meet the definition of suicide under state laws. </p>
<p>But the Commonwealth Criminal Code <a href="https://www.aph.gov.au/About_Parliament/Parliamentary_departments/Parliamentary_Library/FlagPost/2023/August/Voluntary_Assisted_Dying_and_Telehealth#:%7E:text=Sections%20474.29A%20and%20474.29,material%20that%20counsels%20or%20incites">prohibits</a> the discussion or dissemination of suicide-related material electronically. </p>
<p>This opens doctors to the risk of criminal prosecution if they discuss voluntary assisted dying via telehealth.</p>
<p>Successive Commonwealth attorneys-general have failed to address the conflict between federal and state laws, despite persistent calls from state attorneys-general for necessary <a href="https://www.abc.net.au/news/2024-02-12/voluntary-assisted-dying-telehealth-ban-law-push/103456102">clarity</a>. </p>
<p>This eventually led to voluntary assistant dying doctor <a href="https://www.abc.net.au/news/2022-08-03/voluntary-assisted-dying-communication-laws-face-gp-legal-fight/101292042">Nicholas Carr</a> calling on the Federal Court of Australia to resolve this conflict. Carr sought a declaration to exclude voluntary assisted dying from the definition of suicide under the Criminal Code. </p>
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Read more:
<a href="https://theconversation.com/voluntary-assisted-dying-will-begin-in-wa-this-week-but-one-commonwealth-law-could-get-in-the-way-161982">Voluntary assisted dying will begin in WA this week. But one Commonwealth law could get in the way</a>
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<p>In November, the court <a href="https://search2.fedcourt.gov.au/s/search.html?collection=judgments&sort=date&meta_v_phrase_orsand=judgments%2FJudgments%2F&meta_2=carr+&meta_A=&meta_z=&meta_3=&meta_n_phrase_orsand=&query_sand=&query_or=&query_not=&query_phrase=&query_prox=&meta_d=23+november+2023&meta_d1=&meta_d2=&meta_7=&meta_4=&meta_B=">declared</a> voluntary assisted dying <em>was</em> considered suicide for the purpose of the Criminal Code. This meant doctors across Australia were prohibited from using telehealth services for voluntary assisted dying consultations. </p>
<p>Last week, independent federal MP Kate Chaney <a href="https://parlinfo.aph.gov.au/parlInfo/search/display/display.w3p;query=Id%3A%22legislation%2Fbillhome%2Fr7146%22;querytype=;rec=0">introduced a private members bill</a> to create an exemption for voluntary assisted dying by excluding it as suicide for the purpose of the Criminal Code. Here’s why it’s needed. </p>
<h2>Not all patients can physically see a doctor</h2>
<p>Defining voluntary assisted dying as suicide in the Criminal Code disproportionately impacts people living in regional and remote areas. People in the country <a href="https://www.ama.com.au/ama-rounds/8-december-2023/articles/ama-urges-attorney-general-amend-laws-relevant-vad-and">rely on</a> the use of “carriage services”, such as phone and video consultations, to avoid travelling long distances to consult their doctor. </p>
<p>Other people with terminal illnesses, whether in regional or urban areas, may be suffering intolerably and unable to physically attend appointments with doctors. </p>
<p>The prohibition against telehealth goes against the <a href="https://www.legislation.vic.gov.au/as-made/acts/voluntary-assisted-dying-act-2017">principles</a> of voluntary assisted dying, which are to minimise suffering, maximise quality of life and promote autonomy.</p>
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<img alt="Old hands hold young hands" src="https://images.theconversation.com/files/576959/original/file-20240221-28-e3qk81.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/576959/original/file-20240221-28-e3qk81.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/576959/original/file-20240221-28-e3qk81.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/576959/original/file-20240221-28-e3qk81.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/576959/original/file-20240221-28-e3qk81.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/576959/original/file-20240221-28-e3qk81.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/576959/original/file-20240221-28-e3qk81.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Some people aren’t able to attend doctors’ appointments in person.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/hands-that-care-nursing-home-2094784921">Jeffrey M Levine/Shutterstock</a></span>
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<h2>Doctors don’t want to be involved in ‘suicide’</h2>
<p>Equating voluntary assisted dying with suicide has a direct impact on doctors, who <a href="https://eprints.qut.edu.au/213858/1/99568951.pdf">fear</a> criminal prosecution due to the prohibition against using telehealth.</p>
<p>Some doctors may decide not to help patients who choose voluntary assisted dying, leaving patients in a state of limbo. </p>
<p>The number of doctors actively participating in voluntary assisted dying is already <a href="https://www.safercare.vic.gov.au/sites/default/files/2023-08/VADRB%20Annual%20Report%202022-23.pdf">low</a>. The majority of doctors are located in metropolitan areas or major regional centres, leaving some locations with very few doctors participating in voluntary assisted dying. </p>
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Read more:
<a href="https://theconversation.com/voluntary-assisted-dying-is-legal-in-victoria-but-you-may-not-be-able-to-access-it-208282">Voluntary assisted dying is legal in Victoria, but you may not be able to access it</a>
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<h2>It misclassifies deaths</h2>
<p>In state law, people dying under voluntary assisted dying have the cause of their death registered as “the disease, illness or medical condition that was the grounds for a person to access voluntary assisted dying”, while the <a>manner of dying</a> is recorded as voluntary assisted dying. </p>
<p>In contrast, only coroners in each state and territory can make a finding of suicide as a cause of death. </p>
<p>In 2017, voluntary assisted dying was defined in the <a href="http://www8.austlii.edu.au/cgi-bin/viewdoc/au/legis/vic/consol_act/ca2008120/s4.html">Coroners Act 2008 (Vic)</a> as not a reportable death, and thus not suicide. </p>
<p>The language of suicide is inappropriate for explaining how people make a decision to die with dignity under the lawful practice of voluntary assisted dying. </p>
<p>There is ongoing taboo and stigma attached to suicide. People who opt for and are lawfully eligible to access voluntary assisted dying should not be tainted with the taboo that currently surrounds suicide.</p>
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<h2>So what is the solution?</h2>
<p>The only way to remedy this problem is for the federal government to create an exemption in the Criminal Code to allow telehealth appointments to discuss voluntary assisted dying. </p>
<p>Chaney’s private member’s bill is yet to be debated in federal parliament. </p>
<p>If it’s unsuccessful, the Commonwealth attorney-general should pass regulations to exempt voluntary assisted dying as suicide. </p>
<p>A cooperative approach to resolve this conflict of laws is necessary to ensure doctors don’t risk prosecution for assisting eligible people to access voluntary assisted dying, regional and remote patients have access to voluntary assisted dying, families don’t suffer consequences for the erroneous classification of voluntary assisted dying as suicide, and people accessing voluntary assisted dying are not shrouded with the taboo of suicide when accessing a lawful practice to die with dignity.</p>
<p>Failure to change this will cause unnecessary suffering for patients and doctors alike.</p><img src="https://counter.theconversation.com/content/223863/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michaela Estelle Okninski is affiliated with Australasian Association of Bioethics and Health Law.</span></em></p><p class="fine-print"><em><span>Marc Trabsky's research for this article received funding from an Australian Research Council Discovery Early Career Researcher Award (DE220100064).</span></em></p><p class="fine-print"><em><span>Neera Bhatia receives funding from UKRI Arts and Humanities Research Council for an unrelated project. </span></em></p>It’s illegal to discuss voluntary assisted dying via telehealth, which means people who live in rural areas and those who can’t physically go to see a doctor may not be able to access the scheme.Michaela Estelle Okninski, Lecturer of Law, University of AdelaideMarc Trabsky, Associate professor, La Trobe UniversityNeera Bhatia, Associate Professor in Law, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1962642022-12-15T15:50:34Z2022-12-15T15:50:34ZCanada delays expanding medical assistance in dying to include mental illness, but it’s still a policy built on quicksand<figure><img src="https://images.theconversation.com/files/500879/original/file-20221213-14-4j61be.jpeg?ixlib=rb-1.1.0&rect=506%2C191%2C5867%2C4242&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The planned expansion of Canada's medical assistance in dying (MAID) law to include people with mental illnesses whose death is not imminent has been delayed, but not cancelled.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>The federal government admitted Thursday it needs more time before expanding Canada’s controversial medical assistance in dying (MAID) policy to enable MAID solely for mental illness.</p>
<p>Although the government had recently announced its intention to proceed with expanding MAID for those with mental health disorders by next March, <a href="https://www.ctvnews.ca/politics/feds-seeking-to-delay-expansion-of-medical-assistance-in-dying-laws-1.6196668">Justice Minister David Lametti said he had heard from medical experts that the health-care system wasn’t prepared to deal with patients who want to end their lives for mental health reasons</a>. He did not commit to a new deadline. </p>
<p>But the justice minister said Ottawa was only seeking to delay implementation of the MAID changes — it’s still clear the government remains intent on <a href="https://www.theglobeandmail.com/canada/article-maid-canada-mental-health-law/">further expanding its legislation to include mentally ill people who are suicidal and could get better</a>.</p>
<p>It’s one of many controversial elements of the proposed changes to the MAID legislation, and remains cause for concern.</p>
<p>Canada’s federal minister of disability inclusion recently expressed feeling devastated about Canadians being driven to <a href="https://www.cbc.ca/news/politics/assisted-dying-carla-qualtrough-1.6625412">seek assisted death through MAID — medical assistance in dying — due to lack of social supports</a>.</p>
<p>Some are pushing for <a href="https://nationalpost.com/news/quebec-college-of-physicians-slammed-for-suggesting-maid-for-severely-ill-newborns">MAID for infants</a>, while others think <a href="https://www.theglobeandmail.com/canada/article-maid-canada-mental-health-law/">non-dying disabled people on wait lists</a> should receive MAID. When <a href="https://www.thestar.com/politics/provincial/2022/11/29/justice-minister-david-lametti-under-fire-for-unbelievable-comparisons-between-euthanasia-and-suicide.html?rf">the minister of justice suggests we should make it easier for those ambivalent about suicide to die</a>, that is bone chilling.</p>
<p>When Canada embarked on this journey years ago, I cautioned about the importance of ensuring we <a href="https://www.theglobeandmail.com/opinion/how-mental-illness-complicates-assisted-dying/article30193498/">“do the least harm” with our expanding laws</a>. As physician chair of my hospital MAID team, I have seen the myths and realities that have fuelled our MAID expansion. </p>
<h2>False autonomy and false compassion</h2>
<p>As a society, we take comfort that MAID is provided for compassionate relief from suffering. Individually, MAID has been sold to Canadians as an autonomous choice, and framed as a right. When MAID was introduced in 2016, for those whose deaths were reasonably foreseeable, these principles may have been true. In contrast, our MAID expansion to non-dying disabled people has been misled by the fallacies of false autonomy and false compassion.</p>
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Read more:
<a href="https://theconversation.com/why-is-access-to-medically-assisted-death-a-legislated-right-but-access-to-palliative-care-isnt-161994">Why is access to medically assisted death a legislated right, but access to palliative care isn’t?</a>
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<p>True autonomy requires true choice. For those of us fortunate enough to live lives with privilege, choosing “death with dignity” can be sold as an autonomous choice. Yet we have now had marginalized Canadians living in poverty be given state-supported suicide who have openly said they chose MAID not to avoid suffering from illness, but because <a href="https://www.cbc.ca/news/canada/manitoba/sathya-dharma-kovac-als-medical-assistance-in-death-1.6605754">society had failed to provide them a chance to live with dignity</a>. </p>
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<img alt="A woman in a navy jacket" src="https://images.theconversation.com/files/500681/original/file-20221213-14387-fa7efg.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/500681/original/file-20221213-14387-fa7efg.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=458&fit=crop&dpr=1 600w, https://images.theconversation.com/files/500681/original/file-20221213-14387-fa7efg.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=458&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/500681/original/file-20221213-14387-fa7efg.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=458&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/500681/original/file-20221213-14387-fa7efg.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=575&fit=crop&dpr=1 754w, https://images.theconversation.com/files/500681/original/file-20221213-14387-fa7efg.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=575&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/500681/original/file-20221213-14387-fa7efg.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=575&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Minister of Employment, Workforce Development and Disability Inclusion Carla Qualtrough, pictured in the House of Commons on Dec. 8, recently described MAID requests driven by lack of social supports as devastating.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Justin Tang</span></span>
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<p>Most would be hard-pressed to argue it reflects true autonomy with a range of choices when the marginalized poor are enticed toward “painless” death to escape a painful life of poverty.</p>
<p>Canadians have rationalized that non-dying disabled people are being provided MAID in the name of compassion. However, it is not compassionate to provide death for one reason while pretending it is for another. We have reassured ourselves that MAID is for medical conditions that will not improve, or are irremediable. In the court cases that originally established MAID — which involved conditions like <a href="https://bccla.org/2012/10/in-memory-of-gloria/">ALS</a> and <a href="https://www.cbc.ca/news/canada/montreal/medically-assisted-dying-law-overturned-quebec-1.5280702">spinal stenosis</a> — or for medical conditions like cancers, that can be true.</p>
<p>However, evidence shows it is <a href="https://www.eagmaid.org/report">impossible to predict that a mental illness will not improve in any individual</a>. Yet expansion activists mistakenly believe they can make such predictions. Science tells us their chance of being right amounts to chance or less, with <a href="https://doi.org/10.1017/s0033291722002951">precision modelling showing only 47 per cent of “irremediability” predictions end up being correct</a> — which is worse than flipping a coin.</p>
<h2>False safety</h2>
<p>Perhaps most tragically, the twin pillars of false autonomy and false compassion fuelling the expansion agenda have been propped up by the third myth of false safety.</p>
<p>Until now, expansion activists have reassured that “<a href="https://www.suicideinfo.ca/local_resource/suicide-physician-assisted-death/">MAID is not suicide</a>.” When provided to help avoid a painful death for those who are dying, we can distinguish MAID from suicide. Yet when expanded to those seeking death for mental illness, evidence shows MAID becomes indistinguishable from suicide. <a href="https://cca-reports.ca/reports/medical-assistance-in-dying/">We cannot differentiate those seeking psychiatric euthanasia from suicidal individuals</a> who resume fulfilling lives after being provided suicide prevention, rather than facilitated death. </p>
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<span class="caption">Until now, expansion activists have reassured that ‘MAID is not suicide.’</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>All this sobering evidence is sadly borne out by our <a href="https://globalnews.ca/news/9176485/poverty-canadians-disabilities-medically-assisted-death/">now common headlines</a> of assisted suicide <a href="https://www.ctvnews.ca/health/woman-with-chemical-sensitivities-chose-medically-assisted-death-after-failed-bid-to-get-better-housing-1.5860579">being provided</a> to <a href="https://www.ctvnews.ca/health/woman-with-disabilities-nears-medically-assisted-death-after-futile-bid-for-affordable-housing-1.5882202">marginalized Canadians</a> seeking <a href="https://www.chatelaine.com/health/maid-assisted-death-poverty/">escape from life suffering</a> and <a href="https://toronto.citynews.ca/2022/10/13/medical-assistance-death-maid-canada/">poverty</a>. </p>
<p>The government-appointed federal panel, <a href="https://policyoptions.irpp.org/magazines/missing-the-mark-on-a-profound-social-change-with-maid-for-mental-illness/">chaired by an expansionist in favour of MAID for mental illness</a>, was responsible for providing safeguards, standards and guidelines for how to implement MAID for mental illness. Instead, the panel recommended that <a href="https://www.canada.ca/en/health-canada/news/2022/05/final-report-of-the-expert-panel-on-maid-and-mental-illness.html">no further legislative safeguards be required before providing death for mental illness, and did not provide any specific standards</a> for the length, type or number of treatments that should be tried before providing MAID. Its report even suggested society had made an “ethical choice” that MAID should be provided even if suicide and MAID were the same.</p>
<p>Two members of the initial 12-member panel resigned, including the <a href="https://www.hilltimes.com/story/2022/06/16/maid-expert-panel-recommendations-are-inadequate-contends-panel-member-who-resigned/270807/">health-care ethicist</a> and <a href="https://www.theglobeandmail.com/opinion/article-expert-panel-maid-mental-illness/">a mental health advocate panelist with lived experience</a>. </p>
<h2>Suicide prevention</h2>
<p>The whole issue of suicide prevention has been shockingly absent from many of these discussions, including those with key medical associations. In all of its consultations on <a href="https://www.justice.gc.ca/eng/csj-sjc/pl/charter-charte/c7.html">Bill C-7</a> leading up to the <a href="https://www.ctvnews.ca/politics/senators-amend-maid-bill-to-put-18-month-time-limit-on-mental-illness-exclusion-1.5302151">sunset clause</a>, the Canadian Psychiatric Association (of which I am a former past president) inexplicably <a href="https://www.cpa-apc.org/wp-content/uploads/Brief-JUST-12-Nov-2020-FIN.pdf">never once presented known evidence about suicide risks associated with mental illness</a>. </p>
<p>While some organizations such as the <a href="https://suicideprevention.ca/media/statement-on-the-expansion-of-medical-assistance-in-dying-to-those-without-a-reasonably-foreseeable-death/#:%7E:text=The%20Canadian%20Association%20for%20Suicide,process%20that%20is%20already%20happening">Canadian Association for Suicide Prevention</a> discussed the importance of preventing suicide, <a href="https://www.cpa-apc.org/wp-content/uploads/Brief-LCJC-23-Nov-2020-FIN.pdf">CPA never raised this crucial topic</a> — indeed they <a href="https://sencanada.ca/en/Content/Sen/Committee/432/LCJC/02ev-55071-e">avoided using any variant of the word “suicide.”</a></p>
<figure class="align-right ">
<img alt="A man in a dark suit and tie gestures with his hand." src="https://images.theconversation.com/files/500677/original/file-20221213-14838-oz0t5e.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/500677/original/file-20221213-14838-oz0t5e.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/500677/original/file-20221213-14838-oz0t5e.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/500677/original/file-20221213-14838-oz0t5e.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/500677/original/file-20221213-14838-oz0t5e.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=498&fit=crop&dpr=1 754w, https://images.theconversation.com/files/500677/original/file-20221213-14838-oz0t5e.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=498&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/500677/original/file-20221213-14838-oz0t5e.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=498&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Minister of Justice David Lametti in the House of Commons on Nov. 22, 2022. Lametti recently made controversial statements about MAID.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Adrian Wyld</span></span>
</figcaption>
</figure>
<p>With this vacuum of national leadership and evidence-based guidance, perhaps it is not surprising that our <a href="https://www.thestar.com/politics/provincial/2022/11/29/justice-minister-david-lametti-under-fire-for-unbelievable-comparisons-between-euthanasia-and-suicide.html?rf">minister of justice recently suggested that MAID “provides a more humane way for [people with mental illness] to make a decision” when “for physical reasons and possibly mental reasons, [they] can’t make that choice themselves to do it themselves.”</a></p>
<p>This remarkable statement, coming from the person entrusted with responsibly implementing Canada’s assisted dying laws, will keep me and many of my colleagues up at night.</p>
<h2>The need to pause</h2>
<p>I am not a conscientious objector. However it is clear to me that Canada’s planned expansion of MAID to mental illness is based on ignorance — if not outright disregard — of fundamental <a href="https://www.cdc.gov/suicide/prevention/index.html">suicide prevention principles</a>. It appears to ignore what drives the most marginalized people to consider death as an alternative to life suffering. Perhaps, though, it does not ignore the <a href="https://globalnews.ca/news/7407627/health-care-costs-canada-assisted-dying/">cost savings of providing MAID</a> rather than treatment and community support for dignified living.</p>
<p>The <em><a href="https://scc-csc.lexum.com/scc-csc/scc-csc/en/item/14637/index.do">Carter v. Canada</a></em> and <a href="https://www.canlii.org/en/qc/qccs/doc/2019/2019qccs3792/2019qccs3792.html?searchUrlHash=AAAAAQANdHJ1Y2hvbiBnbGFkdQAAAAAB&resultIndex=1"><em>Truchon v. Canada</em></a> court cases shaping MAID laws did not review or rule on MAID for mental illness. Expanding MAID within three months would have meant providing facilitated suicide for the mentally ill without any standards, or any consideration of the role of suicide prevention.</p>
<p>Postponing the March 2023 expansion of euthanasia for mental illness is the only responsible course. Canadians and mental health organizations recognized this and called for it, with the Canadian Association for Suicide Prevention and over 200 individual psychiatrists so far signing <a href="https://www.socpsych.org/calltoaction">a petition to this effect</a>, and the academic chairs of the departments of psychiatry across Canada <a href="https://www.theglobeandmail.com/canada/article-maid-delay-mental-illness-medical-experts/">joining this call for delay</a>. </p>
<p>To proceed with the planned changes would have been morally, medically and politically irresponsible. Moving forward, it will be important to ensure our future policies are evidence-based. Fortunately, the situation is not yet irremediable.</p>
<p><em>If you are experiencing suicidal thoughts, you need to know you’re not alone. If your life or someone else’s is in danger, call 911 for emergency services. For support, call Canada Suicide Prevention Service (CSPS) at 1-833-456-4566. Visit <a href="https://talksuicide.ca">Crisis Services Canada</a> for more resources.</em></p><img src="https://counter.theconversation.com/content/196264/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Karandeep Sonu Gaind is Chief of Psychiatry and physician chair of the Humber River Hospital MAiD team, a former president of the Canadian Psychiatric Association and a founding director of the nascent Society of Canadian Psychiatry, and was retained as an expert by the former Attorney General of Canada in the Truchon and Lamb cases.</span></em></p>Canada’s planned expansion of MAID to mental illness is based on ignorance — if not outright disregard — of fundamental suicide prevention principles.Karandeep Sonu Gaind, Professor of Psychiatry, University of TorontoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1857882022-06-29T14:36:01Z2022-06-29T14:36:01ZThe right to die: unpacking an ethical dilemma in South Africa<figure><img src="https://images.theconversation.com/files/471410/original/file-20220628-20-uu3f6k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Right to die activist Sean Davison (left) speaks to the press after three years of house arrest.</span> <span class="attribution"><span class="source">Brenton Geach/Gallo Images via Getty Images</span></span></figcaption></figure><p>Sean Davison, the euthanasia activist and co-founder of <a href="https://dignitysouthafrica.org/">DignitySA</a>, recently <a href="https://ewn.co.za/2022/06/23/i-didn-t-murder-them-i-helped-them-shares-euthanasia-activist-sean-davison">completed a sentence</a> of house arrest in South Africa for his role in the deaths of three people. He said he had not committed a crime or murder, but had helped these people because they were <a href="https://www.capetalk.co.za/articles/448020/i-didn-t-murder-them-i-helped-them-shares-euthanasia-activist-sean-davison">desperate</a> to die. Anrich Burger, Justin Varian and Richard Holland were suffering unbearably with no hope of recovery and unable to end their own lives. </p>
<p>The late South African emeritus Archbishop Desmond Tutu, in whose <a href="https://www.dailymaverick.co.za/article/2022-06-20-right-to-die-activist-sean-davison-vows-to-carry-on-fight-in-tutus-honour/">honour</a> Davison wants to fight to change the laws around assisted suicide, once <a href="https://theconversation.com/we-have-a-right-to-die-with-dignity-the-medical-profession-has-a-duty-to-assist-67574">wrote</a> that he would want the option of an assisted death. Tutu argued that dying people should have the right to decide how and when they wanted to leave this life.</p>
<p>Legislation in Canada, and a number of US states and European countries, for example, allows assisted suicide. But there are still billions of people around the world, as in South Africa, who do not have this right. </p>
<p>The question of whether this is a right is a debate that has been raging for years in medical ethics and within religious groups. </p>
<p>This article is not about the religious or strictly legal aspects of the debate. It grapples with the ethical tension between arguments against and for active forms of euthanasia – one of the most contested ethical subjects in the world. </p>
<h2>Arguments against active euthanasia</h2>
<p>There are broadly three arguments <a href="https://www.loot.co.za/product/k-moodley-medical-ethics-law-and-human-rights/kknf-4887-ga80?referrer=googlemerchant&gclid=EAIaIQobChMIuPLBqNbD-AIVTtPtCh2kTgIUEAQYASABEgKqrfD_BwE&gclsrc=aw.ds">against</a> active forms of euthanasia:</p>
<ul>
<li><p>only God has the authority to dispose over life and death</p></li>
<li><p>it is the role of medical doctors to preserve life and not to cause death</p></li>
<li><p>a doctor could abuse his or her position to take the lives of vulnerable patients, or patients might be killed against their wishes.</p></li>
</ul>
<p>Although these arguments must be considered, I prefer to put forward the arguments in support of the active forms of euthanasia.</p>
<p>But let’s first look for the sake of clarity at two forms of active euthanasia.</p>
<h2>Two kinds of active euthanasia</h2>
<p>One is known as voluntary active euthanasia. This is when death is intentionally brought about in the life of a patient who is competent to make such a decision, and where death is reasonably believed to be in the interest of and based on an informed request by the patient. The doctor’s act is the proximate cause of death. </p>
<p>The second form of active euthanasia is where a doctor assists a patient in suicide, called “physician-assisted suicide”. The doctor intentionally provides the means to a competent individual who then takes his or her own life. </p>
<p>In South Africa, both these forms of euthanasia are illegal. </p>
<h2>Constitutional and other supportive perspectives</h2>
<p>In a constitutional democracy, active euthanasia should not be dealt with primarily as a theological issue. Of course, people of faith may express their beliefs about it, but they should not expect to dictate the law. There are many citizens who do not share religious values.</p>
<p>Although legislation in South Africa prohibits active forms of euthanasia, I believe that it is not against the <a href="https://www.gov.za/documents/constitution/chapter-2-bill-rights">constitution</a>. The bill of rights includes three relevant rights:</p>
<ul>
<li><p>human dignity (article 10)</p></li>
<li><p>freedom and security of the person, including the right not to be treated or punished in a cruel, inhuman or degrading way (article 12(1))</p></li>
<li><p>bodily and psychological integrity, including the right to security in and control over one’s body (article 12(2)).</p></li>
</ul>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/we-have-a-right-to-die-with-dignity-the-medical-profession-has-a-duty-to-assist-67574">We have a right to die with dignity. The medical profession has a duty to assist</a>
</strong>
</em>
</p>
<hr>
<p>There is another point in favour of active euthanasia. The development of medical science means that people have more control over death and life than ever before. Although life has high value, it is not absolute.</p>
<p>People make decisions throughout their lives about their health. But when they are terminally ill, often in unbearable pain and suffering – and sometimes even losing their dignity – they are not allowed to decide when they want to die.</p>
<p>If someone is terminally ill and suffers badly, can a strong moral case not be made that such a person – within <a href="https://www.justice.gov.za/salrc/reports/r_prj86_euthen_1998nov.pdf">prescribed medical-ethical parameters</a>, evaluating the patient’s suffering, prognosis, mental competence, informed decision-making and clear communication – be assisted with the dying process? </p>
<h2>In support of active euthanasia</h2>
<p>Three arguments have been put forward in <a href="https://www.loot.co.za/product/k-moodley-medical-ethics-law-and-human-rights/kknf-4887-ga80?referrer=googlemerchant&gclid=EAIaIQobChMIuPLBqNbD-AIVTtPtCh2kTgIUEAQYASABEgKqrfD_BwE&gclsrc=aw.ds">support</a> of active euthanasia.</p>
<p><strong>Personal autonomy should be respected.</strong> This implies that a competent person has a moral right to make his or her own choice.</p>
<p><strong>Unbearable suffering should be prevented.</strong> Nobody should be forced to endure suffering – often at high medical cost.</p>
<p>When life is no longer good, and death is no longer bad, and when death is therefore preferred to continuing life, the role of medicine could change from healing and preserving life to helping someone die in a way that is compassionate, kind, gentle and respectful.</p>
<p>I believe everyone should be allowed to choose his or her “moment”. For me, active forms of euthanasia are not so much the termination of life, but rather the shortening of suffering and the dying process.</p>
<p><strong>Moral equivalence.</strong> Physician assisted suicide is like other practices that are already morally acceptable – such as passive euthanasia. </p>
<p>To withhold treatment is viewed as an omission while physician assisted suicide and voluntary active euthanasia are regarded as acts. But people are morally and legally <a href="https://www.loot.co.za/product/k-moodley-medical-ethics-law-and-human-rights/kknf-4887-ga80?referrer=googlemerchant&gclid=EAIaIQobChMIuPLBqNbD-AIVTtPtCh2kTgIUEAQYASABEgKqrfD_BwE&gclsrc=aw.ds">responsible</a> for both acts and omissions.</p>
<p>South Africa is a country where people hold different opinions. This diversity of opinions must always be considered, according to the constitution. South Africans did it with the termination of pregnancy (which was legalised) and the death penalty (which was scrapped).</p><img src="https://counter.theconversation.com/content/185788/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Chris Jones does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>People make decisions throughout their lives about their health. But when they are terminally ill they are not allowed to decide when they want to die.Chris Jones, Chief researcher, Department of Systematic Theology and Ecclesiology, head of Unit for Moral Leadership, Stellenbosch UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/976192021-12-26T07:13:40Z2021-12-26T07:13:40ZArchbishop Desmond Tutu: father of South Africa’s ‘rainbow nation’<figure><img src="https://images.theconversation.com/files/304935/original/file-20191203-67028-uqkr65.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Archbishop Desmond Tutu</span> <span class="attribution"><span class="source"> Epa/Ian Langsdon</span></span></figcaption></figure><p>Archbishop Emeritus Desmond Mpilo Tutu has <a href="https://ewn.co.za/2021/12/26/breaking-news-archbishop-desmond-tutu-passes-away">died</a> at the age of 90. </p>
<p>Archbishop Tutu earned the respect and love of millions of South Africans and the world. He carved out a permanent place in their hearts and minds, becoming known affectionately as “The Arch”. </p>
<p>When South Africans woke up on the morning of 7 April, 2017 to protest against then President Jacob Zuma’s <a href="https://www.nytimes.com/2017/03/31/world/africa/south-africa-pravin-gordhan-jacob-zuma.html">removal </a> of the respected Finance Minister Pravin Gordhan, <a href="https://www.sahistory.org.za/people/archbishop-emeritus-desmond-mpilo-tutu">Archbishop Tutu</a> left his Hermanus retirement home to join the protests. He was 86 years old at the time, and his health was frail. But protest was in his blood. In his view, no government was legitimate unless it represented all its people well.</p>
<p>There was still that sharpness in his words when <a href="http://ewn.co.za/2017/04/07/tutu-makes-rare-appearance-to-support-anti-zuma-march">he said that</a></p>
<blockquote>
<p>We will pray for the downfall of a government that misrepresents us.</p>
</blockquote>
<p>These words echoed his stance of ethical and moral integrity as well as human dignity. It is on these principles that he had fought valiantly against the system of apartheid and became, as the Desmond Tutu Foundation rightly <a href="http://www.tutufoundationusa.org/mission-vision/">affirms</a>, </p>
<blockquote>
<p>an outspoken defender of human rights and campaigner for the oppressed. </p>
</blockquote>
<p>But <a href="https://www.sahistory.org.za/people/archbishop-emeritus-desmond-mpilo-tutu">Archbishop Tutu</a> didn’t stop his fight for human rights once apartheid came to a formal end in 1994. He continued to speak critically against politicians who abused their power. He also added his weight to various causes, including HIV/AIDS, poverty, racism, homophobia and transphobia. </p>
<p>His fight for human rights wasn’t limited to South Africa. Through his <a href="http://www.tutufoundationusa.org/mission-vision/">peace foundation</a>, which he formed in 2015, he extended his vision for a peaceful world “in which everyone values human dignity and our interconnectedness”.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/301976/original/file-20191115-66937-1e6zrq4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/301976/original/file-20191115-66937-1e6zrq4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=404&fit=crop&dpr=1 600w, https://images.theconversation.com/files/301976/original/file-20191115-66937-1e6zrq4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=404&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/301976/original/file-20191115-66937-1e6zrq4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=404&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/301976/original/file-20191115-66937-1e6zrq4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=508&fit=crop&dpr=1 754w, https://images.theconversation.com/files/301976/original/file-20191115-66937-1e6zrq4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=508&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/301976/original/file-20191115-66937-1e6zrq4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=508&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Archbishop Tutu with the Dalai Lama at the Tibetan Children’s Village school in Dharamsala, in 2015.</span>
<span class="attribution"><span class="source">EFE-EPA/Sanjay Baid</span></span>
</figcaption>
</figure>
<p>He also became relentless in his support for the Dalai Lama, whom he considered his best friend. He condemned the South African government for refusing the exiled Tibetan spiritual leader a visa to deliver the <a href="http://www.sahistory.org.za/people/archbishop-emeritus-mpilo-desmond-tutu">“Desmond Tutu International Peace Lecture”</a> <a href="https://www.telegraph.co.uk/news/worldnews/africaandindianocean/southafrica/8807080/Tutu-South-African-government-is-worse-than-apartheid-after-Dalai-Lama-visa-row.html">in 2011</a>. </p>
<h2>Early years</h2>
<p>Archbishop Tutu came from humble beginnings. Born on 7 October, 1931 in Klerksdorp, in the North West Province of South Africa where his father, Zachariah was a headmaster of a high school. His mother, Aletha Matlare, was a domestic worker.</p>
<p>One of the most influential figures in his early years was <a href="https://www.sahistory.org.za/people/father-trevor-huddleston">Father Trevor Huddleston</a>, a fierce campaigner against apartheid. Their friendship led to the young Tutu being introduced into the Anglican Church. </p>
<p>After completing his education he had a brief stint teaching English and History at Madibane High School in Soweto; and then at Krugersdorp High School , west of Johannesburg; where his father was a headmaster. It was here that he met his future wife, Nomalizo Leah Shenxane. </p>
<p>It is interesting that he agreed to a Roman Catholic wedding ceremony, although he was Anglican. This ecumenical act at the very early stage in his life gives us a hint of his commitment to ecumenical work in later years. </p>
<p>He quit teaching in the wake of the introduction of the inferior <a href="https://www.sahistory.org.za/article/bantu-education-and-racist-compartmentalizing-education">“Bantu education”</a> for black people in 1953. Under the <a href="https://www.sahistory.org.za/archive/bantu-education-act-act-no-47-1953">Bantu Education Act, 1953</a>, the education of the native African population was limited to producing an unskilled work force. </p>
<p>In 1955 Tutu entered the service of the church as a sub-deacon. He got married the same year. He enrolled for theological education in 1958 and, after completing his studies, was ordained as a deacon of Saint Mary’s Cathedral in Johannesburg in 1960, and became its first black dean in 1975. </p>
<p>In 1962 he went to London to pursue further theological education with funding from the World Council of Churches. He earned a Master of Theology degree, and after serving in various parishes in London, returned to South Africa in 1966 <a href="http://www.sahistory.org.za/people/archbishop-emeritus-mpilo-desmond-tutu">to teach</a> at the Federal Theological Seminary at Alice, Eastern Cape. </p>
<p>One of the lesser known facts is that he had special interest in the study of Islam. He had wanted to pursue this in his doctoral studies, but this was not to be. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/301983/original/file-20191115-66957-7p8h3n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/301983/original/file-20191115-66957-7p8h3n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/301983/original/file-20191115-66957-7p8h3n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/301983/original/file-20191115-66957-7p8h3n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/301983/original/file-20191115-66957-7p8h3n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/301983/original/file-20191115-66957-7p8h3n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/301983/original/file-20191115-66957-7p8h3n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Archbishop Emeritus Desmond Tutu and his wife Tutu at the Youth Health Festival in Cape Town in 2016.</span>
<span class="attribution"><span class="source">EFE-EPA/Nic Bothma</span></span>
</figcaption>
</figure>
<p>The activities he was involved in in the early 1970s were to lay the foundation for his political struggle against apartheid. These included teaching in Botswana, Lesotho and Swaziland and, thereafter, a posting to London as the <a href="https://www.tutu.org.za/founders-journey/">Associate Director for Africa</a> at the Theological Education Fund, and his exposure to <a href="http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0259-94222016000100033">Black Theology</a>. He also visited many African countries in the early 1970s. </p>
<p>He eventually returned to Johannesburg as the dean of Johannesburg and the rector of St. Mary’s Anglican Parish in 1976. </p>
<h2>Political activism</h2>
<p>It was at St Mary’s that Tutu first confronted the then apartheid Prime Minister John Vorster, writing him <a href="https://www.sahistory.org.za/archive/letter-desmond-tutu-p-w-botha-letter-pretoria">a letter</a> in 1976 decrying the deplorable state in which black people had to live. </p>
<p>On 16 June <a href="https://www.sahistory.org.za/article/june-16-soweto-youth-uprising">Soweto went up in flames</a>, when black high school pupils protested against the forced use of Afrikaans as a medium of instruction, and were mowed down by apartheid police.</p>
<p>Bishop Tutu was thrust deeper and deeper into the struggle. He delivered one of his most passionate and fiery orations <a href="https://www.sahistory.org.za/article/bikos-imprisonment-death-and-aftermath">following the death in detention</a> of the black consciousness leader, Steve Biko in 1977.</p>
<p>His role as the <a href="http://sacc.org.za/history/">General Secretary of the South African Council of Churches</a>, and later as the rector of St. Augustine’s Church in Orlando West in Soweto, saw him become an ardent critic of the most egregious aspects of apartheid. This included the forced removals of black people from urban areas deemed to be white areas. </p>
<h2>A target</h2>
<p>With his growing political activism in the 1980s, the Arch became a target of the apartheid government’s full scale victimisation and faced death threats as well as bomb scares. In March 1980 <a href="https://www.upi.com/Archives/1981/04/16/South-Africa-revokes-bishops-passport/8490356245200/">his passport was revoked</a>. After much international outcry and intervention, he was given a “limited travel document” two years later to travel overseas.</p>
<p>His work was recognised globally, and he was awarded <a href="https://www.nobelprize.org/prizes/peace/1984/summary/">Nobel Prize for Peace</a> in 1984 for being a unifying leader in the campaign to resolve the problem of apartheid in South Africa. </p>
<p>He went on to receive more distinguished awards. He became the Bishop of Johannesburg in 1984, and the Archbishop of Cape Town <a href="http://www.sahistory.org.za/people/archbishop-emeritus-mpilo-desmond-tutu">in 1986</a>. In the following four years leading up to the release of Nelson Mandela after 27 years in prison, the Arch had his work cut out for him. This involved campaigning for international pressure to be brought on the apartheid through sanctions.</p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/301974/original/file-20191115-66932-1kefr5i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/301974/original/file-20191115-66932-1kefr5i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=860&fit=crop&dpr=1 600w, https://images.theconversation.com/files/301974/original/file-20191115-66932-1kefr5i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=860&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/301974/original/file-20191115-66932-1kefr5i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=860&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/301974/original/file-20191115-66932-1kefr5i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1081&fit=crop&dpr=1 754w, https://images.theconversation.com/files/301974/original/file-20191115-66932-1kefr5i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1081&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/301974/original/file-20191115-66932-1kefr5i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1081&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Archbishop Tutu received the Presidential Medal of Freedom from US President Obama in 2009.</span>
<span class="attribution"><span class="source">EFE-EPA/Shawn Thew</span></span>
</figcaption>
</figure>
<h2>Democracy years</h2>
<p>After 1994, he headed the <a href="http://www.justice.gov.za/trc/">Truth and Reconciliation Commission</a>. Its primary goal was to afford those who committed human rights abuses – for or against apartheid – the opportunity to come clean, offer legal amnesty to deserving ones, and to enable the perpetrators to make amends to their victims. </p>
<p>Two greatest moments in his personal life took his theological outlook beyond the confines of the Church. One was when his daughter Mpho declared she was gay and the church refused her same sex marriage. The Arch <a href="http://www.capetownmagazine.com/whats-the-deal-with/desmond-tutu/125_22_17533">proclaimed</a> </p>
<blockquote>
<p>If God, as they say, is homophobic, I wouldn’t worship that God. </p>
</blockquote>
<p>The second was when he declared his <a href="http://www.telegraph.co.uk/news/2016/10/07/archbishop-desmond-tutu-asks-for-the-right-to-an-assisted-death/">preference for assisted death</a>.</p>
<p>South Africa is blessed to have had such a brave and courageous man as The Arch, who truly symbolised the idea of the country as a <a href="https://www.bbc.com/news/world-africa-10734471">“rainbow nation” </a>. South Africa will feel the loss of the moral direction of this brave soldier of God for generations to come. <em>Hamba kahle</em> (go well) Arch.</p><img src="https://counter.theconversation.com/content/97619/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>P. Pratap Kumar receives funding from the National Research Foundation of South Africa. </span></em></p>Archbishop Desmond Tutu didn’t stop his fight for human rights once apartheid came to a formal end in 1994. He continued to speak critically against politicians who abused their power.P. Pratap Kumar, Emeritus Professor, School of Religion, Philosophy and Classics, University of KwaZulu-NatalLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1175772019-05-22T18:36:11Z2019-05-22T18:36:11ZVincent Lambert: what are the legal and ethical issues?<p>On Friday, May 10, 2019, the doctor at the Reims University Hospital in charge of monitoring Mr. Vincent Lambert informed his relatives of his decision to stop his treatments, and to set up a deep and continuous sedation during the week of May 20, until death.</p>
<p>It is not a question here of commenting on a decision that seems to indicate the imminent conclusion of the controversies that have developed since 2013. However, it is important to consider this particular case, as it seems to justify an evolution of the law of February 2, 2016 creating new rights for patients and people at the end of their lives, known as the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5118829/">“Claeys Leonetti” law</a>.</p>
<h2>Five decisions to stop treatment</h2>
<p>Since September 29, 2008, the day of the automobile crash that caused the major brain damage that left Mr. Vincent Lambert in a neurovegetative state deemed irreversible by his doctors, the decision to stop treatment has been made <a href="https://www.francetvinfo.fr/societe/euthanasie/vincent-lambert/affaire-vincent-lambert-les-cinq-fois-ou-l-arret-des-soins-a-ete-prononce_3441143.html">five times</a>. All these developments highlight the complexity of the decision-making process concerning people with cerebral palsy in a “non-responsive state of awakening”.</p>
<p>Since 2013, Vincent Lambert’s family members have been engaged in a <a href="https://www.theguardian.com/world/2019/may/21/french-court-orders-life-support-to-resume-for-man-in-vegetative-state">bitter legal battle over the discontinuation of care</a>. On the one hand, Mr. Vincent Lambert’s wife (as well as his sister and one of his nephews), who has also been his legal guardian since 2016, is asking for her husband to be sedated and his diet and hydration to be stopped. According to her, before his accident he had “clearly” indicated that he did not want any therapeutic persistence. On the other hand, Mr. Vincent Lambert’s parents, who are opposed to passive euthanasia, are asking for him to be kept alive and transferred to a specialised institution.</p>
<p>Legally speaking, the situation is complex, since Mr. Vincent Lambert is not at the end of his life, that he has not expressed with certainty his desire to stop care in the form of <a href="https://www.service-public.fr/particuliers/vosdroits/F32010">advance directives</a>, and that he is no longer in a position to do so. This context actually raises two very distinct questions: on the one hand, the living conditions of Mr. Vincent Lambert as a person with a brain disability, and on the other hand, the cessation of his care, i.e., nutrition and hydration for a person who is not at the end of his life.</p>
<h2>An inadequate care environment?</h2>
<p>The judicial and media focus on the decision to stop care seems to have overshadowed the essential issue of monitoring Mr Vincent Lambert’s current living conditions. The law of March 4, 2002, on the rights of patients and the quality of the health system specifies that “the patient has the right to respect for his dignity” and that “professionals shall use all the means at their disposal to ensure a dignified life for everyone until death.”</p>
<p>In May 2002, two months after the law was passed, a <a href="https://solidarites-sante.gouv.fr/fichiers/bo/2002/02-20/a0202031.htm">circular from the Ministry of Health</a> prescribed the conditions for “creating care units dedicated to people in a chronic vegetative state or in a <a href="https://www.nejm.org/doi/full/10.1056/NEJM199405263302107">pauci-relational state</a>”. In particular, the concept of “long-term care” for people “with disabling chronic diseases with risk of life threatening functional failure, requiring constant medical monitoring and continuous technical care” is mentioned.</p>
<p>This law must apply unconditionally to all persons, regardless of their cognitive impairments and the extent of their disabilities. Mr. Vincent Lambert is not in intensive care or at the end of his life: he should therefore benefit from the rights and care adapted to the comfort of a person with a disability.</p>
<p>However, being hospitalised at the Reims University Hospital, he does not benefit from the environment justified by his state of disability: absence of the adapted devices prescribed in the circular, contacts limited to the medical team and authorised relatives, closed room from which he is never taken out. This situation has been going on since 2013, the year in which the judicial procedure was initiated, which was supposed to lead quickly to a decision, but only after six years. From this point of view, it can be considered that the right to dignity, as defined both by <a href="https://www.legifrance.gouv.fr/affichCodeArticle.do?cidTexte=LEGITEXT000006072665&idArticle=LEGIARTI000006685743">Article L1110-2</a> of the Public Health Code and by the European Convention, is contested to Mr Vincent Lambert.</p>
<h2>The problem of stopping care in the absence of advance directives</h2>
<p>In its decision of April 24, 2019 approving the discontinuation of treatment, the State Council drew on the <a href="https://www.legifrance.gouv.fr/affichTexte.do?cidTexte=JORFTEXT000031970253&categorieLien=id">law of February 2, 2016</a>, “creating new rights for patients and people at the end of their lives”.</p>
<p>However, Mr. Vincent Lambert is not at the end of his life. Consequently, and in the absence of advanced directives, a decision to discontinue treatment can only be taken on the basis of unreasonable obstinacy, pursuant to Article L 1110-5-1 of the Public Health Code. This defines unreasonable obstinacy as the situation in which processing operations intended to keep a person alive “appear unnecessary, disproportionate or have no other effect than the artificial maintenance of life”.</p>
<p>However, for some experts consulted during the four successive collegial procedures, in particular those who submitted the November 22, 2018, report, the care provided to Mr. Vincent Lambert (which is now limited to diet and artificial hydration) does not constitute unreasonable obstinacy. They are only the ordinary accompaniment of a person in a state of altered consciousness. However, this same report confirms the patient’s “chronic irreversible vegetative state”.</p>
<p>Mr. Vincent Lambert’s future therefore depends on the outcome of an expert battle over the unreasonableness of continuing to care for a person with a disability. What is then to understand from these controversies, which will inevitably set a precedent?</p>
<p>First of all, the notion of “unreasonable obstinacy” as it exists in positive law gives rise to inadmissible mistakes in this area in a particularly sensitive context. Secondly, that the debate is not only legal, but also ethical: should it be noted that the consideration of a disability may constitute the major criterion for unreasonable obstinacy?</p>
<h2>Lives “unworthy to live”?</h2>
<p>In its report of May 5, 2014, the National Consultative Ethics Committee stated that</p>
<blockquote>
<p>“The situation of a person who has been in a state of minimal consciousness or pauci-relational state for several years represents a particular and extreme situation of severe and stable disability, not involving a vital prognosis, which is also that of other persons with multiple disabilities and unable to express their will.”</p>
</blockquote>
<p>In France, <a href="https://www.lemonde.fr/sante/article/2014/02/14/1500-personnes-dans-un-etat-proche-de-celui-de-vincent-lambert_4366808_1651302.html">several hundred people</a> now live in a state known as “pauci-relational” or “chronic vegetative”. From an ethical point of view, no authority has the authority to “think” as if it were obvious, that, totally dependent and hindered in their relational faculties, the persistence of their lives is a matter of “unreasonable obstinacy”. Otherwise, it would be necessary to refrain from resuscitating any person who is considered a priori not to regain his or her autonomy, and to question the status and rights of people in the advanced phase of progressive neurological diseases with cognitive impact, such as Alzheimer’s disease…</p>
<p>The case of Mr. Vincent Lambert shows that the concepts of the “end of life” and “unreasonable obstinacy” should be clarified with regard to people with such disabilities, in order to protect us from interpretations that are detrimental to the sick person. In addition, it provides an opportunity to reflect on the situations inherent in the chronicity of certain diseases, the consequences of progressive diseases or severe disabilities that limit or abolish the person’s cognitive faculties or even relational life. These human realities cannot be addressed solely through the lens of adjusting conditions to put an end to an existence considered unjustified. However, the question remains as delicate as it is to address a person who is not able to express his refusal of care or support…</p>
<p>Sometimes considered as a legal relentlessness resulting from intra-family controversies exacerbated by reckless public stances, particularly on the part of doctors, Vincent Lambert’s very particular case raises questions more widely about the effectiveness of our solidarity and concern for patients in situations of extreme vulnerability. These are all essential questions that will feed into the debate on the eve of the revision of bioethics laws, expected this summer.</p>
<hr>
<p><em>This article was translated from the original French by the <a href="https://www.universite-paris-saclay.fr/en/news/vincent-lambert-what-are-the-legal-and-ethical-issues">Université Paris-Saclay</a>.</em></p><img src="https://counter.theconversation.com/content/117577/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Les auteurs ne travaillent pas, ne conseillent pas, ne possèdent pas de parts, ne reçoivent pas de fonds d'une organisation qui pourrait tirer profit de cet article, et n'ont déclaré aucune autre affiliation que leur organisme de recherche.</span></em></p>The debate over Mr. Vincent Lambert’s decision to discontinue his care overshadowed equally important judicial and ethical issues. A look back at a complex situation that will set a precedent.Valérie Depadt, Maître de conférences en droit, Université Sorbonne Paris NordEmmanuel Hirsch, Professeur d'éthique médicale, Université Paris-SaclayLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/966982018-05-23T22:53:43Z2018-05-23T22:53:43Z‘Suicide tourism’ and understanding the Swiss model of the right to die<p>Two weeks ago, <a href="https://www.theglobeandmail.com/world/article-australian-man-104-dies-in-assisted-suicide-in-switzerland/">the 104-year-old Australian scientist David Goodall flew from his home in Western Australia to Switzerland to access assisted suicide</a> with the help of lifecircle and Exit International, two right-to-die societies.</p>
<p>Goodall was part of a broader but marginal phenomenon sometimes referred to as “suicide tourism.” This occurs when a person travels to Switzerland in order to access an assisted death, because this is forbidden or access criteria are more restrictive in their home country. </p>
<p>His story made headlines all around the world and fuelled public debates. Yet the media coverage has not promoted a greater understanding of the Swiss model of assistance in dying.</p>
<p>Cases of “suicide tourism” presented in the media typically say little about the functioning of the Swiss model. Instead, the coverage of “suicide tourism” speaks more to the state of the public debate in a given country on assistance in dying. </p>
<p>However, Switzerland is not only the final destination in the journey of a person towards death. It is also the starting point of recurrent public debates in the countries of origin of those foreign nationals seeking an assisted death in Switzerland.</p>
<p>The fact that citizens of one country make the decision to die in another country, far from their home and family, has a powerful effect on the public. It provides convincing evidence of determination and suffering. It also shows that other possibilities for regulating assistance in dying exist.</p>
<p><a href="http://www.trudeaufoundation.ca/en/community/samuel-blouin">I have been carrying out research for the last three years comparing Canada and Switzerland, more specifically the province of Québec and the canton de Vaud, Switzerland</a>. While I look at public policies, the main focus of my preliminary findings examine the meanings and experiences of those involved in assisted dying practices.</p>
<h2>Medical assistance in dying</h2>
<p>Some people undertaking this journey are conscious of the public appeal of their decisions, as shown by <a href="https://livestream.com/accounts/16944724/events/8197566/videos/174637802/player">the news conference held by Goodall</a> on May 9, 2018, before his death in Basel. Some, like Goodall, participate in a movement of older right-to-die activists advocating for <a href="https://doi.org/10.1111/soc4.12456">“old age rational suicide.”</a> For others, suffering related to a medical condition is the main motivation.</p>
<p>Switzerland sometimes shows up in the national conversation on assisted dying in Canadian news stories. The most well-known occurrence was the story of <a href="https://www.theglobeandmail.com/life/health-and-fitness/good-death-in-swiss-clinic-held-up-as-model/article4247221/">Kay Carter</a>, suffering from spinal stenosis, who died in Switzerland with the help of Dignitas, a Swiss right-to-die society. </p>
<p>Assisted dying was not yet legal in Canada. Following years of legal challenges in which Carter was one of the plaintiffs, her name is now attached to the <a href="https://scc-csc.lexum.com/scc-csc/scc-csc/en/item/14637/index.do?r=AAAAAQAPY2FydGVyIHYgY2FuYWRhAQ">Supreme Court of Canada decision</a> that decriminalized medical assistance in dying (MAiD) in Canada in 2015.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/220165/original/file-20180523-117628-h7go1z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/220165/original/file-20180523-117628-h7go1z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=429&fit=crop&dpr=1 600w, https://images.theconversation.com/files/220165/original/file-20180523-117628-h7go1z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=429&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/220165/original/file-20180523-117628-h7go1z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=429&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/220165/original/file-20180523-117628-h7go1z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=539&fit=crop&dpr=1 754w, https://images.theconversation.com/files/220165/original/file-20180523-117628-h7go1z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=539&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/220165/original/file-20180523-117628-h7go1z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=539&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Lee Carter, daughter of Kay Carter, speaks at a press conference on doctor-assisted death legislation, Bill C-14, while her brother, Price Carter, listens on Parliament Hill in Ottawa on April 21, 2016.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/ Patrick Doyle</span></span>
</figcaption>
</figure>
<p>In Québec, the <a href="http://www.worldcat.org/title/manon-le-dernier-droit/oclc/551397551">2004 documentary <em>Manon: Le dernier droit?</em></a> follows Manon Brunelle, a woman suffering from multiple sclerosis who left Canada to die with Dignitas in Switzerland. This film sparked a public conversation.</p>
<p>The legalisation of MAiD in Canada did not bring an end to so-called “suicide tourism” by Canadians. According to <a href="http://dignitas.ch/images/stories/pdf/statistik-ftb-jahr-wohnsitz-1998-2017.pdf">Dignitas’ statistics</a>, 60 Canadians used its service between 1998 and 2017, including 12 in 2017.</p>
<h2>Assisted dying as an act of citizenship</h2>
<p>Under the radar of international controversies, other Swiss right-to-die societies have developed practices that tend to go unnoticed.</p>
<p>Dignitas, which is only one out of eight Swiss right-to-die societies, garners most of the attention as it is perceived as the most controversial. <a href="https://www.thelocal.ch/20180518/head-of-swiss-assisted-suicide-group-dignitas-in-court-on-charges-of-profiteering">The founder, Ludwig Minelli, is currently being prosecuted</a> for making a personal profit out of three assisted suicides, which is prohibited by the <a href="https://www.admin.ch/opc/en/classified-compilation/19370083/201803010000/311.0.pdf">Swiss Criminal Code</a>. These charges have not yet been proven in court.</p>
<p>In Switzerland, assisted suicide has been tolerated since 1942 provided that the person assisting has no selfish motive. Moreover, the person requesting such assistance must self-administer the lethal drug and must have decision-making capacity.</p>
<p>Compared to the comprehensive Canadian federal and provincial laws on MAiD, Swiss regulation and safeguards can be perceived as lacking. However, this misses the meaning of assisted suicide in Switzerland.</p>
<p>Unlike in Canada, assisted suicide is an act of citizenship in Switzerland, not a health-care intervention. Switzerland proposes a much less medicalized approach to assisted dying.</p>
<h2>Swiss guidelines</h2>
<p><a href="https://doi.org/10.1111/bioe.12304">The Swiss model rests mostly on ethical guidelines drawn up by various health-care organizations and on the rules decided by right-to-die associations</a>. </p>
<p>For example, the nonprofit EXIT association active in the French-speaking region of Switzerland has more than 26,000 members who all have a vote at the annual general meeting. To become a member, a person must pay an annual fee of US$40 (equivalent to 40 Swiss Francs), be over 20 years old and also be a Swiss resident. The association provides assistance in suicide, free of charge, to its members. Nonresidents and minors are thus inadmissible.</p>
<p>Besides the legal requirements, the association has its own criteria according to which volunteers can help a member die. <a href="http://www.exit-geneve.ch/conditions.htm">These criteria include</a>:</p>
<p>» Suffering from an incurable disease or from an important invalidity or experiencing intolerable suffering.</p>
<p>» Or suffering from disabling polypathologies related to old age. </p>
<p>A consulting physician assesses whether or not the requester meets the criteria and, if they do, she will prescribe a lethal drug that a volunteer will bring. </p>
<p>Volunteers are not chosen on the basis of their professional qualifications but on their skills as accompanying persons — their capacity to demonstrate compassion and understanding.</p>
<p>After the death, the volunteer calls the police who will investigate the case. The public prosecutor will then decide whether or not criminal charges will be brought against the persons involved.</p>
<h2>Dignity at the end of life</h2>
<p>In Québec, the Act respecting end-of-life care was adopted in 2014 and entered into force in 2015. Besides creating a right to palliative care and regulating continuous palliative sedation among other things, the law legalized medical aid in dying which includes only euthanasia (administration by a doctor) and not assisted suicide (self-administration). In this context, assisted suicide was ruled out as an appropriate option because it “<a href="http://www.assnat.qc.ca/Media/Process.aspx?MediaId=ANQ.Vigie.Bll.DocumentGenerique_54787en&process=Default&token=ZyMoxNwUn8ikQ+TRKYwPCjWrKwg+vIv9rjij7p3xLGTZDmLVSmJLoqe/vG7/YWzz">does not reflect the values of medical support and safety</a>.”</p>
<p>The federal law legalized medical assistance in dying in 2016 and includes both euthanasia and assisted suicide.</p>
<p>Even though the federal legislation on MAiD allows for both euthanasia (administration by a doctor or nurse practitioner) and assisted suicide (self-administration), Canadians almost exclusively favour the first option. </p>
<p>According to a <a href="https://www.canada.ca/en/health-canada/services/publications/health-system-services/medical-assistance-dying-interim-report-sep-2017.html">report published in October 2017</a>, only five persons out of 2,149 have chosen a self-administered death. Thus, Switzerland might not be a model for Canada.</p>
<p>On the other hand, the comparison that I have been carrying out between Canada and Switzerland shows that assistance in dying can be considered not only as a patient’s but as a person’s decision. Just as there are non-medical options to assist birth, non-medical or less medical ways to assist death could be entertained.</p>
<p>Besides the option of palliative care and other social programs, the Swiss model is an invitation to imagine and consider other societal responses to the challenges of suffering and dignity at the end of life.</p><img src="https://counter.theconversation.com/content/96698/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Samuel Blouin receives funding from the Pierre Elliott Trudeau Foundation and has received funding from the Vanier Canada scholarship program of the Social Sciences and Humanities Research Council of Canada.</span></em></p>Recent stories in the media highlight the idea of suicide tourism to Switzerland. But what does that mean? How is the Swiss view of assisted dying different from the Canadian one?Samuel Blouin, PhD Candidate in Sociology and Pierre Elliott Trudeau Foundation Scholar, Université de Montréal and Université de Lausanne, Université de MontréalLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/731812017-04-11T11:31:20Z2017-04-11T11:31:20ZAssisted-dying laws are progressing in some places - the UK isn’t one of them<figure><img src="https://images.theconversation.com/files/160502/original/image-20170313-19263-1u32ujd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Route forward? Oregon was the first place to license doctors to supply lethal drugs to terminally-ill people.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/393721600?src=ADdVoiQuceEq1Pknwe4tig-1-11&size=medium_jpg">Christopher Boswell/Shutterstock.com</a></span></figcaption></figure><p>Six states in the US and four countries in Europe have legalised some form of assisted dying. Meanwhile, in December 2016, <a href="https://www.theguardian.com/society/2016/dec/10/man-urges-mps-to-back-assisted-dying-before-ending-his-life-at-dignitas">Andrew Barclay</a> – who suffered from advanced multiple sclerosis – became the latest person from the UK to travel to Switzerland to end his life. Barclay is one of <a href="https://www.theguardian.com/news/datablog/2014/jul/18/how-many-people-choose-assisted-suicide-where-it-is-legal">more than 244 terminally-ill Britons</a> who have had to travel abroad to end their life, legally.</p>
<p>It’s time for the UK to legalise some form of assisted dying and give people the right to choose when and how to die. The case of whether the law should change in the UK has been <a href="http://www.bloomsburyprofessional.com/uk/debating-euthanasia-9781847317711/">widely discussed</a>. Now we need to talk about how it should be done. The experience and legal rules in countries that already permit some form of assisted dying can act as a guide.</p>
<p>In England and Wales it is illegal, under the <a href="http://www.legislation.gov.uk/ukpga/Eliz2/9-10/60">Suicide Act 1961</a>, to assist or encourage another person to take their own life. (It is even illegal to attempt to assist or encourage another person to take their own life.) But <a href="http://www.cps.gov.uk/publications/prosecution/assisted_suicide.html">Crown Prosecution Service guidance</a> allows prosecutors to use their discretion, so prosecutions are rare. Numerous proposals to reform the act have failed. The <a href="https://www.publications.parliament.uk/pa/bills/cbill/2015-2016/0007/16007.pdf">latest proposal</a> was rejected by the House of Commons in September 2015 by 118 to 330 votes. </p>
<p>In Scotland, the situation is more complicated. It is not clear whether suicide or attempted suicide is, or ever has been, illegal under Scottish law. So, unlike England and Wales, there was no need for a law to make suicide or attempted suicide legal. Acts that may assist or encourage suicide or attempted suicide fall under the criminal law of homicide.</p>
<h2>The law in other places</h2>
<p>Oregon, US, was the first place in the world to pass a law that allows doctor-assisted dying. The <a href="https://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Pages/ors.aspx">law</a> in Oregon allows mentally-competent terminally-ill people who make a request, free from external pressure, to be given drugs to end their own lives. The person must be physically able to take the drugs. </p>
<p>Other states have followed Oregon: <a href="http://app.leg.wa.gov/rcw/default.aspx?cite=70.245&full=true">Washington</a> in 2009, <a href="http://www.leg.state.vt.us/docs/2014/Acts/ACT039.pdf">Vermont</a> in 2013, <a href="https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201520160SB128">California</a> in 2015 and <a href="http://www.leg.state.co.us/LCS/Initiative%20Referendum/1516initrefr.nsf/b74b3fc5d676cdc987257ad8005bce6a/99fbc3387156ab5c87257fae00748890/%24FILE/2015-2016%20145bb.pdf">Colorado</a> in 2016. A similar law was introduced in the <a href="http://lims.dccouncil.us/Download/33261/B21-0038-Introduction.pdf">District of Columbia</a> in February 2017. Montana also allows doctor-assisted dying but there is no written law. In 2009, the Montana Supreme Court decided in <a href="http://euthanasia.procon.org/sourcefiles/McCarter_Opinion_Montana.pdf">Baxter v Montana</a> that there is nothing in the court’s precedent or other practices saying that doctor-assisted dying is against public policy. <a href="https://www.deathwithdignity.org/states/minnesota/">Minnesota</a> and <a href="https://www.deathwithdignity.org/states/new-york/">New York City</a> are currently considering legalising doctor-assisted dying. </p>
<p>In South America, Columbia recognises the right to die. Similar to the US, it allows only terminally ill people access to doctor-assisted dying.</p>
<p>And in Europe, under the <a href="https://www.admin.ch/opc/en/classified-compilation/19370083/201701010000/311.0.pdf">Swiss criminal code</a>, assisted suicide is legal unless there are “selfish motives”. The <a href="http://www.samw.ch/dam/jcr:de64e102-1495-4c48-9fbd-1c7d4d45932f/guidelines_sams_end_of_life_2012.pdf">role of doctors</a> is indirect, but necessary, as they need to prescribe sodium pentobarbital, the drug used in Switzerland for assisted suicide. The assistance is mainly done by right-to-die voluntary organisations. <a href="http://www.dignitas.ch/?lang=en">Dignitas</a> is the most well known, perhaps because of the high number of non-Swiss citizens who have used it. The Benelux countries, <a href="http://wetten.overheid.nl/BWBR0012410/2014-02-15">the Netherlands</a> and <a href="http://www.health.belgium.be/sites/default/files/uploads/fields/fpshealth_theme_file/loi20020528mb_frnl.pdf">Belgium</a> in 2002, and <a href="http://www.legilux.public.lu/leg/a/archives/2009/0046/a046.pdf#page=7">Luxembourg</a> in 2009, allow both euthanasia and assisted dying (although Belgium only explicitly refers to the former). A person does not need to be physically able to take the life-ending drugs, unlike the US, as another person is allowed to help (euthanasia). The Benelux countries don’t allow just terminally ill people to request assisted dying. They use an “unbearable suffering” criterion that may cover physical and mental suffering. Under strict conditions, this may sometimes make people suffering from depression eligible.</p>
<h2>UK how-to</h2>
<p>There are many arguments in favour of legalising assisted dying, including personal autonomy, compassion, alleviation of suffering, dignity and choice. The UK government’s repeated reluctance to review the law is unacceptable, especially in light of frequent reports of people taking their own life <a href="http://www.islandecho.co.uk/news/pensioner-ended-life-garage-northwood">at home</a> or travelling abroad early in their disease to end their life. </p>
<p>The laws in the US and Europe point to an interesting distinction between two ways to legalise assisted death – one based on terminal illness and one based on unbearable suffering. Switzerland and Canada are straddling between the two types of eligibility options. In Switzerland, right-to-die organisations have their own criteria but do not limit the option to the terminally ill. In Canada, the <a href="http://www.parl.gc.ca/HousePublications/Publication.aspx?Language=E&Mode=1&DocId=8384014">2016 law</a> allows doctor-assisted dying for terminally ill people but without a prognosis necessarily having been made as to the specific length of time that they have remaining.</p>
<p>The UK should use the European experience and legal rules as an example. The terminal-illness criterion is limiting and excludes people suffering from non-terminal illnesses, including locked-in-syndrome, multiple sclerosis and people with serious mental health problems. This prolongs their suffering and denies them rights that terminally ill people are offered. The European model, although not without problems, is a more compassionate answer to the dying wishes of unfortunate and suffering people. It places them at the centre of the procedure, and makes their own experience of suffering a priority by not focusing on the characteristics of the terminal condition or disease.</p>
<p>It’s time for the UK to legalise some form of assisted dying. The experience and legal rules in the Benelux countries should form the basis for the discussion on reform. It is time to give people who are suffering – and not just terminally ill – the fundamental human right to control life and how to end it.</p><img src="https://counter.theconversation.com/content/73181/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nataly Papadopoulou does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>An assisted-dying law in the UK is long overdue.Nataly Papadopoulou, PhD Candidate, University of LeicesterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/608282016-06-10T17:29:12Z2016-06-10T17:29:12ZAid to dying: What Jainism – one of India’s oldest religions – teaches us<figure><img src="https://images.theconversation.com/files/126173/original/image-20160610-29225-9kpg6l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">What do different end-of-life conversations look like?</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/cat.mhtml?lang=en&language=en&ref_site=photo&search_source=search_form&version=llv1&anyorall=all&safesearch=1&use_local_boost=1&autocomplete_id=&search_tracking_id=tpPFBVoMuWQBuIVjju7BbA&searchterm=death&show_color_wheel=1&orient=&commercial_ok=&media_type=images&search_cat=&searchtermx=&photographer_name=&people_gender=&people_age=&people_ethnicity=&people_number=&color=&page=1&inline=318595376">Rose image via www.shutterstock.com</a></span></figcaption></figure><p>On June 9, <a href="http://www.nbcnews.com/news/us-news/patients-ponder-life-death-california-s-new-right-die-law-n588611">a law allowing patients</a> with terminal illnesses to end their lives with help from a physician came into effect in California, opening conversations about whether human life should be prolonged against the desire to die peacefully and with dignity.</p>
<p>A similar yet different conversation has been taking place in India for the past several years, but in reverse.</p>
<p>In one of India’s religious traditions, Jainism, those at the end of life can choose to embrace a final fast transition from one body to another. However, a recent court case has challenged the constitutionality of this practice. <a href="http://www.sunypress.edu/p-1637-nonviolence-to-animals-earth-an.aspx">As an expert</a> in the religions of India and a frequent visitor, I have been following this issue with keen interest. </p>
<h2>A rite to final passage</h2>
<p>While on a visit to a Jain university in Ladnun, Rajasthan in western India in 1989, I had an opportunity to observe the practice of “Sallekhana” or “Santhara,” a somber rite through which one fasts to death.</p>
<p>A group of enthusiastic nuns rushed me in for a blessing being imparted to an octogenarian nun, Sadhvi Kesharji, who had taken this vow 28 days earlier. The nun had been diagnosed with a fatal kidney disease and been treated, but to no avail. </p>
<p>It was an auspicious moment. Her spiritual preceptor, Acharya Tulsi, praised her six decades as a nun and noted the lightness of her spirit and the strength of her resolve which guaranteed safe passage into her next incarnation. </p>
<p>She passed away 12 days later, in a prayerful state.</p>
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<img alt="" src="https://images.theconversation.com/files/126171/original/image-20160610-29203-fmvnbk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/126171/original/image-20160610-29203-fmvnbk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=379&fit=crop&dpr=1 600w, https://images.theconversation.com/files/126171/original/image-20160610-29203-fmvnbk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=379&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/126171/original/image-20160610-29203-fmvnbk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=379&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/126171/original/image-20160610-29203-fmvnbk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=477&fit=crop&dpr=1 754w, https://images.theconversation.com/files/126171/original/image-20160610-29203-fmvnbk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=477&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/126171/original/image-20160610-29203-fmvnbk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=477&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">In Jainism, those at the end of life can embrace a final fast.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/cat.mhtml?lang=en&language=en&ref_site=photo&search_source=search_form&version=llv1&anyorall=all&safesearch=1&use_local_boost=1&autocomplete_id=&search_tracking_id=PsGbcBznXxduixvSfHvtjA&searchterm=jain%20nun&show_color_wheel=1&orient=&commercial_ok=&media_type=images&search_cat=&searchtermx=&photographer_name=&people_gender=&people_age=&people_ethnicity=&people_number=&color=&page=1&inline=120292858">Jain nun image via www.shutterstock.com</a></span>
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<p>This is not the only such case. It is estimated that some <a href="http://www.npr.org/sections/goatsandsoda/2015/09/02/436820789/fasting-to-the-death-is-it-a-religious-rite-or-suicide">200 Jains, both lay and monastic</a>, complete the final fast each year. Jains living elsewhere in the world observe the practice as well.</p>
<p>For example, two Jain women who were born in India but spent most of their adult lives in the United States <a href="http://channel.nationalgeographic.com/taboo/videos/fasting-to-death/">chose to fast</a> in the last days prior to death. Vijay Bhade, a Jain woman from West Virginia, entered a fast unto death in 1997. A more recent case was Bhagwati Gada, from Texas, who suffered from advanced stage cancer and decided to fast unto death in 2013, after going through multiple rounds of chemotherapy. </p>
<h2>Who are the Jains?</h2>
<p><a href="https://books.google.com/books/about/The_Jains.html?id=5ialKAbIyV4C">Jainism arose</a> more than 2,800 years ago in northeast India. It teaches a doctrine proclaiming the existence of countless eternal souls who, due to their actions or karma, bind themselves to repeated lifetimes. </p>
<p>These souls could manifest as elemental beings in the earth or water or fire or air. They could evolve to become micro-organisms and plants or eventually take forms as worms, insects, birds, reptiles or mammals.</p>
<p>By committing acts of goodness, they might take human form and ascend to a place of everlasting freedom at the highest limits of the universe, from which they continue to observe forever the repeated rounds of existence experienced by the many souls below. </p>
<p>Jains <a href="http://www.jainworld.com/book/jainism/ch11.asp">do not believe</a> in a creator God or an external controller. All experiences, good and bad, are due to one’s own exertions. The <a href="http://www.sacred-texts.com/jai/5vows.txt">key to spiritual ascent</a> resides in the performance of five vows also shared by Yogis and Buddhists in India: nonviolence, truthfulness, not stealing, celibacy and nonpossession. </p>
<p>Jains believe the practice of these vows helps release fettering karmas that impede the energy, consciousness and bliss of the soul. Every ethical success lightens the soul of its karmic burden. Mohandas Gandhi, the well-known leader of India’s independence, who grew up in the company of Jains, employed these vows personally and as a collective strategy of nonviolence to help India overcome the shackles of British colonization.</p>
<h2>Freedom yes, but can there be coercion?</h2>
<p>Up until recent years, the fast unto death process <a href="http://www.jinvaani.org/acharya-shri-shantisagar-ji.html">has been celebrated</a> with newspaper announcements that laud the monks, nuns, laymen and laywomen who undergo this vow. But of late, questions are being raised whether it can result in coercion and cruelty.</p>
<p>In 2006, a young lawyer in Rajasthan, Nikhil Soni, <a href="http://rhccasestatus.raj.nic.in/smsrhcb/rhbcis/judfile.asp?ID=CW%20%20%20&nID=7414&yID=2006&doj=8/10/2015">challenged the constitutionality</a> of this act, stating that it violates the anti-suicide laws that had been in put place by the British to stop the immolation of widows on their husband’s funeral pyre. The practice of widow burning has endured, despite many <a href="http://www.kashgar.com.au/articles/life-in-india-the-practice-of-sati-or-widow-burning">efforts to abolish the practice</a>. </p>
<p>The high court of Rajasthan ruled in favor of Soni in 2015, effectively making the practice of fasting to death punishable by law. However, some weeks later, the Supreme Court of India <a href="http://www.thehindu.com/news/national/supreme-court-lifts-stay-on-santhara-ritual-of-jains/article7600851.ece">placed a stay</a> on this ruling. The case is still awaiting its final verdict. Observant Jains claim this is an important part of their faith. </p>
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<img alt="" src="https://images.theconversation.com/files/126175/original/image-20160610-29219-1e9egp5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/126175/original/image-20160610-29219-1e9egp5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=398&fit=crop&dpr=1 600w, https://images.theconversation.com/files/126175/original/image-20160610-29219-1e9egp5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=398&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/126175/original/image-20160610-29219-1e9egp5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=398&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/126175/original/image-20160610-29219-1e9egp5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/126175/original/image-20160610-29219-1e9egp5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/126175/original/image-20160610-29219-1e9egp5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The fast is a spiritually guided process.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/cat.mhtml?lang=en&language=en&ref_site=photo&search_source=search_form&version=llv1&anyorall=all&safesearch=1&use_local_boost=1&autocomplete_id=&search_tracking_id=GGBTe2nRw-4xe0V7YDc-5Q&searchterm=jain%20monk&show_color_wheel=1&orient=&commercial_ok=&media_type=images&search_cat=&searchtermx=&photographer_name=&people_gender=&people_age=&people_ethnicity=&people_number=&color=&page=1&inline=172958246">Jain nun image via www. shutterstock.com</a></span>
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<p>Entering the fast requires counsel and permission from one’s spiritual advisor. And the process of rejection of food is gradual. First, one takes some yogurt, then only milk, then only juice, eventually moving from water to total rejection of any nutrition or hydration. </p>
<p>Physicians state that this is <a href="http://www.kevinmd.com/blog/2015/10/terminal-dehydration-a-gentle-way-to-die.html">not death by starvation</a> but by dehydration. The body automatically <a href="http://abcnews.go.com/Health/Schiavo/story?id=531907">goes into a state of ketosis</a> (when the body starts to break down stored fat for energy), often accompanied by a peaceful state. </p>
<h2>Rights versus rites approach</h2>
<p>What can we learn from such spiritual practices?</p>
<p>Debates on end of life focus on the “rights” approach, thus appealing to the rational mind. Spiritual traditions on the other hand assert that it makes no sense to prolong suffering. They use a “rites” approach to the inevitable passing of the human body. </p>
<p><a href="https://www.jstor.org/stable/23444173?seq=1#page_scan_tab_contents">Jains believe</a> that the soul has always been here, that the soul cannot be destroyed and that through the process of death, one transitions to a new body. </p>
<p>The Jain tradition shows how we can move without attachment into death rather than clinging to life. In their acceptance of the inevitable, they set an example that death is not an evil but an opportunity to reflect on a life well-lived and look forward to what lies ahead.</p><img src="https://counter.theconversation.com/content/60828/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>I serve on the Advisory Boards for the International school for Jain Studies in Delhi, the Jaina Studies Centre University of London & the Ahimsa Center in Pomona CA.</span></em></p>California now allows terminally ill people to end their lives. In the 2,800-year-old Jain tradition, individuals can choose to fast unto death, when it makes no sense to prolong suffering.Christopher Key Chapple, Professor of Indic and Comparative Theology, Loyola Marymount UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/562462016-04-14T15:44:36Z2016-04-14T15:44:36ZWhere can you choose to end your life?<p>The importance of confronting mortality and the right to make autonomous decisions are modern mantras – both within medicine and wider society. The <a href="http://www.bbc.co.uk/news/magazine-14374296">decriminalisation of suicide</a> in England and Wales in 1961 is an early example that life choices may also include making a choice to end one’s own life. Since then a number of jurisdictions have introduced legislation which provides assistance for those who choose to end their lives. </p>
<p>Given the repeatedly <a href="https://theconversation.com/the-battle-over-assisted-dying-in-the-uk-is-far-from-over-42560">unsuccessful attempts to introduce any such legislation in the UK</a>, it is interesting to look to <a href="https://theconversation.com/why-australia-hesitates-to-legalise-euthanasia-47867">other regimes that have overcome challenges and hurdles</a> to introduce assisted dying legislation. The number of these jurisdictions is still growing, albeit slowly – California is the most recent addition to the list: the state’s End of Life Option Act will <a href="http://www.huffingtonpost.com/entry/california-assisted-suicide-right-to-die-law_us_56e2f534e4b0860f99d8cce1">come into effect on June 9 2016</a>. </p>
<p>Terminology remains paramount in any legislative provision – and rightly so when it may be used to determine matters of life and death. While the words “euthanasia” and “assisted suicide” are often interchangeably used, there is an important distinction between the two when it comes to <em>who</em> is doing the killing. </p>
<p>In euthanasia, the responsibility for overseeing the death rests with a person other than the one who wishes to end their life. In assisted suicide, the assistance may be provided by another, but it is the person who wishes to die who has <a href="https://theconversation.com/uk-moves-to-join-countries-with-some-form-of-assisted-dying-but-a-way-to-go-yet-36311">the responsibility to bring about their own death</a>. The term “assisted dying” is increasingly being incorporated into legislative proposals to mean <a href="http://www.theguardian.com/society/2015/sep/11/mps-begin-debate-assisted-dying-bill">assistance which is being provided</a> to those who are terminally ill.</p>
<p>For me, the phrase “right to die” is a misnomer. As human beings we are all mortal, which brings with it a certainty that we are all going to die. We don’t need a “right” for this to happen – it is rather a matter of <em>when</em> rather than <em>if</em>. </p>
<p>If it is a “right” that is being requested then it may more accurately be described as the right to exercise autonomy, or self-determination about choices in our lives – including the ending of that life. Recent high-profile, highly emotive cases – <a href="http://news.bbc.co.uk/1/hi/uk/8185253.stm">such as that of Dianne Pretty</a> – in the UK courts appear to support this position. </p>
<h2>Where can you choose to die?</h2>
<p>The Netherlands is perhaps the best-known place where a person can choose to end their life in this way. The country introduced guidelines following a court case in 1973 and <a href="http://www.patientsrightscouncil.org/site/holland-background/">enacted subsequent legislation in 2001</a>. It was followed by Belgium in 2002 and <a href="http://www.loc.gov/law/foreign-news/article/luxembourg-right-to-die-with-dignity/">Luxembourg in 2009</a>. All three countries permit both euthanasia and assisted suicide. </p>
<p>Belgium is often cited as having <a href="http://www.pbs.org/newshour/bb/right-die-belgium-inside-worlds-liberal-euthanasia-laws-2/">the most “liberal”</a> physician-assisted suicide laws. Last year it extended the right to a physically healthy 24-year-old woman <a href="http://europe.newsweek.com/healthy-24-year-old-granted-right-die-belgium-329504">who was suffering from depression</a>. Similarly, The Netherlands does not restrict euthanasia to those with terminal illnesses, but rather some clinics have allowed patients with “unbearable suffering” to die. This includes a <a href="http://www.theguardian.com/lifeandstyle/2015/sep/11/assisted-dying-dutch-end-of-life-netherlands-unbearable-suffering">man who had been diagnosed with borderline dementia and a woman who had incurable tinnitus</a>.</p>
<p>Switzerland has <a href="http://www.patientsrightscouncil.org/site/switzerland/">permitted assisted suicide since 1942</a> but not euthanasia. Unlike other jurisdictions, the law does not require any involvement from a medical practitioner nor does it require the recipient to be a Swiss national. The country is unique in this respect – and this latter aspect has led to many high-profile and poignant cases of <a href="http://www.thesun.co.uk/sol/homepage/news/6588455/Bob-I-will-die-tomorrow-at-2pm-in-Swiss-suicide-clinic.html">individuals travelling</a> from their home country to Switzerland, in a practice referred to as “suicide tourism”.</p>
<p>Though the Colombian <a href="http://www.patientsrightscouncil.org/site/wp-content/uploads/2015/05/Colombia_Court_Decision_05_20_1997.pdf">Supreme Court ruled in 1997</a> that doctors should be allowed to end the lives of patients by euthanasia, it was not until 18 years later that formal guidelines were approved. The practice has faced strong opposition from the country’s catholic church, however, which has <a href="http://www.churchmilitant.com/news/article/Colombian-Bishops-Threaten-to-Shut-Down-Hospitals">threatened to close its hospitals in the country</a> if the government forces its doctors to offer euthanasia.</p>
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<figcaption><span class="caption">Right to die campaigner Brittany Maynard makes a passionate plea before her death by assisted suicide in 2015.</span></figcaption>
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<p>In the United States, California has become the fifth State and most recent jurisdiction to enact legislation which will permit an individual, who must be terminally ill, to receive “assistance” to end their life. The four other US States: Oregon (1994), Washington (2008), Montana (2009) and Vermont (2014) have the terminally ill criteria in their death-with-dignity laws, although they have <a href="http://time.com/3551560/brittany-maynard-right-to-die-laws/">enacted the rules in various ways</a>.</p>
<p>The California law was signed by the governor, Jerry Brown, in the aftermath of high-profile campaigning by <a href="http://www.people.com/article/brittany-maynard-right-to-die-bill-california-gov-brown">Brittany Maynard</a>, a 29-year-old woman who was diagnosed with terminal brain cancer. In her last few months, <a href="https://www.youtube.com/watch?v=Mi8AP_EhM94">she lobbied</a> for the legalisation of the right to die, eventually moving to Oregon from her home in California to end her life.</p>
<p>Legislation on physician-assisted suicide is <a href="http://www.cbc.ca/news/politics/assisted-dying-bill-tabled-1.3532698">expected to be introduced this month in Canada</a>. The change in law follows a <a href="http://www.huffingtonpost.ca/2015/02/06/right-to-die-supreme-court-canada-suicide_n_6628308.html">2015 human rights-based Supreme Court decision</a>, which overturned the ban on doctor-assisted suicide. </p>
<p>Physician-assisted suicide has been legal in Quebec since 2014. However, a requirement that two doctors must assess a patient’s suitability for medically assisted suicide has <a href="http://www.cbc.ca/news/canada/montreal/quebec-medical-assisted-dying-euthanasia-quebc-1.3452366">reportedly caused problems</a> after physicians were reluctant to come forward.</p>
<h2>Choosing the right</h2>
<p>Even if we accept that what is being sought is a right to exercise choices concerning how we end our lives, it is worth noting that most legislation which has been enacted does not actually confer a personal right to seek assistance to die. It is arguably broader than that, creating a framework, where – subject to certain conditions – it is lawful for that help to be provided. </p>
<p>For those countries and states which are still hesitant about introducing similar legislation, turning the focus away from death and instead focusing about choices in life could be a way forward. The distinction may be a fine one but it is fundamental – for it is only when we are alive that we can express what is important to us and make our wishes and values known. UK Supreme Court judge, Lord Hope, <a href="http://www.lawgazette.co.uk/law/human-rights-clarifying-the-law-on-assisted-suicide/52048.fullarticle">took a similar view</a> in the case of Diane Pretty, noting that the way a person “chooses to pass the closing moments of her life is part of the act of living”.</p><img src="https://counter.theconversation.com/content/56246/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alison Britton does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Where and how you have the right to legally end your life.Alison Britton, Professor of Healthcare and Medical Law, Glasgow Caledonian UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/562582016-03-30T10:41:50Z2016-03-30T10:41:50ZPalliative care or assisted dying? We just need to start talking more about ‘the right to die well’<figure><img src="https://images.theconversation.com/files/116601/original/image-20160329-13709-1fi8m94.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There doesn't need to be a choice between palliative care or assisted dying.</span> <span class="attribution"><span class="license">Author provided</span></span></figcaption></figure><p>In most parts of the world the proponents of palliative care and of assisted dying do not see eye to eye. Palliative care activists say the problems that lead to assisted dying requests can usually be dealt with in ways that do not hasten death. They promote quality of life and reject the idea of “dying on demand”. Supporters of assisted dying, on the other hand, argue that palliative care cannot be effective in every case. To them, the important thing is to respect autonomy and freedom of choice.</p>
<p>It’s unclear whether these two approaches can be reconciled. </p>
<p>Relations between supporters of palliative care and of assisted dying have a history of tension, even antagonism. Dame Cicely Saunders, founder of the modern hospice movement, <a href="http://www.independent.co.uk/news/obituaries/dame-cicely-saunders-498823.html">was fond of going head-to-head</a> in debates with members of the Voluntary Euthanasia Society in the 1960s, for example. More recently, the society’s change of name to <a href="http://www.dignityindying.org.uk/">Dignity in Dying</a> in 2006 antagonised the hospice and palliative care world by implying that its practitioners did not have the monopoly on a dignified end. </p>
<p>Just last year, a group of experts representing the <a href="http://pmj.sagepub.com/content/early/2015/11/18/0269216315616524">European Association for Palliative Care</a> again declared that the provision of euthanasia and assisted dying should not be included in the practice of palliative care – a position that has remained unchanged for the last two decades. </p>
<p>The British Medical Association likewise remains opposed to the legalisation of assisted dying in any form, though in a series of <a href="http://www.bma.org.uk/endoflifecare#settingthescene">recent reports</a> it said it now seeks “to move debate beyond oversimplistic for/against positioning to consider some of the complex issues surrounding physician-assisted dying, its potential complexities and changing legislative and practical frameworks”.</p>
<p>Over the years, however, palliative care has struggled to gain traction. Indeed, my own research has shown that just 20 countries in the world have achieved “<a href="http://www.ncbi.nlm.nih.gov/pubmed/23017628">advanced integration</a>” of their palliative care services with the wider health and social care system.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/apbSsILLh28?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Palliative care physician BJ Miller discusses what really matters at the end of life for TED Talks.</span></figcaption>
</figure>
<p>The <a href="https://theconversation.com/is-the-uk-really-the-best-place-in-the-world-to-die-48766">UK is ranked the best place to die</a> when it comes to palliative care, according to an index constructed by the Economist Intelligence Unit (EIU). But there have been obvious failings and shortcomings in the delivery of palliative care at scale. We see these in the furore over the <a href="https://www.gov.uk/government/publications/review-of-liverpool-care-pathway-for-dying-patients">Liverpool Care Pathway</a> and in <a href="http://www.ombudsman.org.uk/reports-and-consultations/reports/health/dying-without-dignity">poor reports on end of life care from the ombusdman</a> and the <a href="http://www.cqc.org.uk/content/response-progress-report-end-life-care">Care Quality Commission</a>. </p>
<p>Would legalised assisted dying have any bearing on these problems? We only have a few examples to go on.</p>
<h2>Legalising assisted death</h2>
<p>Euthanasia and/or physician assisted dying are currently legal in just four countries: the Netherlands (2001), Belgium (2002) and Luxembourg (2009) have all legalised <em>euthanasia</em>. This means it is legal in these countries, provided certain procedures and protocols are followed, for a doctor to kill a patient at their informed and competent request.</p>
<p>In the US, individual states have focused their efforts on the legalisation of <em>physician assisted suicide</em>, though the broader term “aid in dying” is now being adopted by some. This involves a doctor in a process to prescribe lethal drugs to a person who, <a href="https://www.deathwithdignity.org/learn/healthcare-providers/">following defined procedures</a>, has resolved to end their own life by taking the drugs, and then does so. It was legalised in Oregon in 1997 and more recently was taken up by Washington State, Montana, and Vermont. California will soon follow when its <a href="https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201520160SB128">End of Life Option Act</a> comes into effect on June 9.</p>
<p>By long standing arrangement, Switzerland does not prosecute those who assist a suicide, provided they do not benefit from the outcome.</p>
<p>In locations where either physician assisted suicide or euthanasia are legalised, there is no evidence this inhibits the development of palliative care. In Oregon, most of the very small numbers of people who avail themselves of the Death with Dignity Act are actually on hospice programmes. In the Netherlands, palliative care services, research and education appear to have thrived in the period since euthanasia was fully legalised, though they were underdeveloped before that. </p>
<p>Belgium provides the most interesting example: it has almost 200 palliative care services, is in <a href="http://www.who.int/nmh/Global_Atlas_of_Palliative_Care.pdf">the list of 20 countries with “advanced integration” of palliative care</a> and was ranked fifth worldwide in the <a href="http://www.eiuperspectives.economist.com/healthcare/2015-quality-death-index">EIU’s “quality of death” index</a>. It is also home to academic research groups studying end of life issues as well as leading professors in the field – yet in Belgium about <a href="http://www.ieb-eib.org/fr/document/belgian-euthanasia-increases-by-89-in-four-years-382.html">one death in 20</a> results from euthanasia. </p>
<h2>The Flanders model</h2>
<p>Something unique has happened in the Flanders region of Belgium: the practice of euthanasia and the delivery of palliative care have been <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4263821/">brought together in a single “integral” model</a>. Here no contradiction is seen delivering the best pain and symptom management and the holistic psycho-social support that palliative care has to offer, while also enabling a person’s life to be ended at their request, by a physician. </p>
<p>The Flanders model offends some and inspires others. But, as the authors of <a href="http://www.bmj.com/content/336/7649/864">one of the few studies</a> on the matter conclude: </p>
<blockquote>
<p>Most values of palliative care workers and advocates of euthanasia are shared. If Belgium’s experience applies elsewhere, advocates of the legalisation of euthanasia have every reason to promote palliative care, and activists for palliative care need not oppose the legalisation of euthanasia.</p>
</blockquote>
<p>Should assisted dying and the delivery of palliative care exist side by side? Their shared aim would be to provide relief from suffering, support dignity and also allow the freedom to determine the manner and timing of one’s own death. Flanders and Oregon hint that this approach can work, and we intend to look at this further in our Wellcome Trust-funded study on <a href="http://www.gla.ac.uk/research/az/endoflifestudies/projects/globalinterventions/">Global Interventions at the End of Life</a>.</p>
<p>It is perhaps time to bring down the ethical and ideological wire fence which has for so long separated the two approaches to the end of life: palliative care and assisted dying. Once this barrier has been removed we might more fully explore how best to deliver dignity and choice to the growing number of people who will die in the world every year.</p><img src="https://counter.theconversation.com/content/56258/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David Clark receives funding from The Wellcome Trust Grant number 103319/Z/13/Z. </span></em></p>The assisted dying debate usually focuses on the moment of death - not those leading up to it.David Clark, Professor of Medical Sociology, University of GlasgowLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/296582014-07-27T20:24:13Z2014-07-27T20:24:13ZDo people really have the right to a rational suicide?<figure><img src="https://images.theconversation.com/files/54955/original/pq6rk2j5-1406454340.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Historical evidence of suicide rates varying with the philosophy of the times urges caution about adopting an unqualified libertarian stance that privileges autonomy above all else.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/biomedical_scraps/7006377871/in/photolist-2rFKa8-eZ388S-eZ39dU-7L3zbR-bV9HU3-58CXej-5EJgg-gtPUSx-eZ38YU-eYQMaF-eZ38AL-8cKTd3-bqm1VD-aDuQPe-eYQP6r-8DmFmy-5xUKe-7pzST8-bF8w3t-87XHHK-cQay4s-4Utxu8-7znPm-7M3Yhy-u1kYc-8RCTFY-8RzKyn-9gvRuw-fNwZAD-uPTdz-4RB4Gr-4RB1eM-eYQMHt-bqkBRn-bqm1Vx-5nsPvk-VQZuK-beKSDM-eYQNrx-eUqiWX-4RB4Gt-4xeUZ-dwtG7f-9heqYS-hVAorq-3cu8tX-7HHQJ-bRNq96-bRNqeH-6gHsgX">Arallyn!/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>Seven Australians will <a href="https://www.lifeline.org.au/About-Lifeline/Media-Centre/Suicide-Statistics-in-Australia/Suicide-Statistics">die today</a> as a result of suicide, the leading cause of death in young Australian men. So the media interest surrounding one in particular, that of <a href="http://www.abc.net.au/news/2014-07-03/nitschke-criticised-over-45yo-mans-suicide/5570162">45-year-old Nigel Brayley’s suicide</a>, needs some explanation. </p>
<p>The <a href="http://www.theguardian.com/world/2014/jul/24/euthanasia-campaigner-dr-philip-nitschke-suspended-by-medical-board">sensational midnight meeting</a> that led to the suspension of euthanasia campaigner Dr Philip Nitschke’s medical registration for his role in that suicide was certainly newsworthy, though Nitschke’s activities do not wholly depend on his license to practice medicine.</p>
<p>Most likely interest is driven by the linked ideas of a “right to die” and “<a href="http://www.abc.net.au/7.30/content/2014/s4053344.htm">rational suicide</a>”, terms that have been used repeatedly by Nitschke in explaining his support for Brayley’s actions. Neither idea is new (both stem from libertarian ideas of individual autonomy), nor is the drug Nembutal, which Brayley used, a new or unique means to achieve death through suicide. </p>
<p>But there’s a back-story here that’s essential to making sense of the theatre surrounding Brayley and Nitschke.</p>
<h2>The right to die and rational suicide</h2>
<p>First “the right to die”. This right is not listed in the <a href="http://www.un.org/en/documents/udhr/">Universal Declaration of Human Rights</a>. <a href="http://www.un.org/en/documents/udhr/index.shtml#a5">Article 5</a>, which prohibits torture and inhuman treatment, certainly implies a right to relief of suffering at end of life, and it finds legal support in many jurisdictions (including Victoria). </p>
<p>But the language of rights is any case bewildering, as it imposes an obligation on others (your right to die becomes my obligation to kill) and invariably engages with opposing rights. Consider the role of a doctor in a botched suicide attempt, for instance.</p>
<p>While it has served as useful shorthand for supporters of the evolving idea of providing exceptions to the Crimes Act in certain cases of deliberate killing by commission or omission, the “right to die” is ethics reduced to a bumper sticker and does little to further our understanding. </p>
<p>And as a statement of the bleeding obvious – we all are born with a right to die that cannot be infringed. Only the suffering associated with our dying can be changed.</p>
<p>Rational suicide, on the other hand, has been with us for millennia. Acceptance that there are some circumstances where you should kill yourself or knowingly allow yourself to be killed is widespread in most cultures, including western Christian ones. </p>
<p>Few advocates of suicide could have been more cogent than a former dean of St Paul’s Cathedral, <a href="http://www.luminarium.org/sevenlit/donne/meditation16.htm">the poet John Donne</a>:</p>
<blockquote>
<p>If man knew the gaine of death, the ease of death, he would solicite, he would provoke death to assist him by any hand which he might use.</p>
</blockquote>
<p>Arguments against rational suicide based on a revealed truth that our bodies and lives do not belong to us do not convince philosophers or the broad public that suicide could never be a rational choice. And a scientific assumption that all suicide is due to mental illness is unproven and unprovable. </p>
<p>So rational suicide exists, but does that make it right? Suicide may be rational (that is, it may have clear and understandable reasons) but Nitschke’s conclusion, that we should accept it and educate people on how to carry it out painlessly, is deeply flawed. </p>
<p>For all the millennia that rational suicide has found supporters, it has encountered systematic opposition based broadly on the idea of public interest.</p>
<h2>Your life and the public interest</h2>
<p>This “public interest” led to the <a href="http://www.bbc.com/news/magazine-14374296">criminalisation of rational suicide</a> in England in the 13th century (you had to be considered sane to be prosecuted; about one in eight were).</p>
<p>Punishment was also meted out to surviving family members, who were <a href="http://www.bbc.com/news/magazine-14374296">stripped by the Crown of all their belongings</a>, an early function of the coroner.</p>
<p>In his <a href="http://www.lonang.com/exlibris/blackstone/bla-414.htm">1825 Commentaries on the Laws of England</a>, Sir William Blackstone called suicide a:</p>
<blockquote>
<p>crime against God and nature, as well as a crime of depriving the King of a subject. </p>
</blockquote>
<p>Though suicide was decriminalised in England in 1950 (and 17 years later in Australia), we still use the word “commit” with suicide, a term otherwise reserved for murder and sin. </p>
<p>Nowadays, the law prohibits suicide in more specific settings, <a href="http://www.ncbi.nlm.nih.gov/pubmed/507056">guided by a US case</a> that suggested, among other things, that “protection of the interests of innocent third parties” and “maintaining the integrity of the medical profession” could weigh against self-determination. </p>
<p>Philosophers vigorously disagree, but most continue to see contemporary reasons to question rational suicide, <a href="http://jme.bmj.com/content/25/6/457.full.pdf">some arguing that the idea is nonsensical</a>, while others argue that <a href="http://plato.stanford.edu/entries/suicide/#AutRatRes">intervention to prevent suicide is warranted</a> in any case, as an assessment of rationality is difficult to make.</p>
<p>The pragmatic findings that suicide commonly has an impulsive element, and that failed suicide may be associated with good quality survival, lend weight to the view that attempting to prevent suicide is a greater good than making it safer and more accessible.</p>
<p>The historical evidence that suicide rates vary with the philosophy (zeitgeist) of the times, with surges during the <a href="http://en.wikipedia.org/wiki/Age_of_Enlightenment">Age of Enlightenment</a> and more recently with <a href="http://en.wikipedia.org/wiki/Romanticism">the Romantics</a>, urges some caution in adopting an unqualified libertarian stance that <a href="https://theconversation.com/strange-bedfellows-euthanasia-same-sex-marriage-and-libertarianism-29651">privileges autonomy over all else</a>.</p>
<p>At a time when extreme libertarian philosophers still find free will “unintelligible”, there are grounds for caution in embracing libertarianism as a the principle upon which we judge acts of terminal self harm.</p>
<p>Rational suicide may exist, but is as sad as that driven by mental illness. It deserves our attention and our compassion, but not our complicity.</p>
<p><em>Anyone seeking support and information about suicide can contact <a href="https://www.lifeline.org.au/">Lifeline</a> on 131 114 or <a href="http://www.beyondblue.org.au/">beyondblue</a> 1300 22 46 36</em></p><img src="https://counter.theconversation.com/content/29658/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Saul does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Seven Australians will die today as a result of suicide, the leading cause of death in young Australian men. So the media interest surrounding one in particular, that of 45-year-old Nigel Brayley’s suicide…Peter Saul, Senior Specialist in Intensive Care and Head of Clinical Unit in Ethics and Health Law, University of NewcastleLicensed as Creative Commons – attribution, no derivatives.