tag:theconversation.com,2011:/us/topics/assisted-suicide-4237/articlesAssisted suicide – The Conversation2024-03-11T12:25:16Ztag:theconversation.com,2011:article/2237072024-03-11T12:25:16Z2024-03-11T12:25:16ZShould people suffering from mental illness be eligible for medically assisted death? Canada plans to legalize that in 2027 – a philosopher explains the core questions<figure><img src="https://images.theconversation.com/files/580759/original/file-20240308-16-9f5ja6.jpg?ixlib=rb-1.1.0&rect=15%2C0%2C2101%2C1409&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">In advocates' eyes, expanding access to a medically assisted death helps people protect their autonomy at a crucial time.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/close-up-of-a-young-womans-hand-holding-the-hand-of-royalty-free-image/1408213220?phrase=hands+death+love+bed&adppopup=true">Eva HM/iStock via Getty Images Plus</a></span></figcaption></figure><p>Imagine that you have lived with an illness for years. The suffering this illness has caused is devastating – so much that you wish to die. You no longer feel like the person you were before. You have been to see specialists, have tried the best treatments, but nothing works.</p>
<p>This is many people’s reality, and not only because of physical disorders and disease. Chronic mental illness can be just as crushing. Starting in March 2024, Canada planned to make medical assistance in death, or MAID, available to people with mental illness – <a href="https://www.justice.gc.ca/eng/cj-jp/ad-am/bk-di.html">expanding a program</a> already available to patients with terminal or chronic physical illness. In 2022, more than 13,000 people in Canada died with medical assistance, according to <a href="https://www.canada.ca/content/dam/hc-sc/documents/services/medical-assistance-dying/annual-report-2022/annual-report-2022.pdf">a government report</a>.</p>
<p>In February, however, the government announced <a href="https://www.canada.ca/en/health-canada/news/2024/02/the-government-of-canada-introduces-legislation-to-delay-medical-assistance-in-dying-expansion-by-3-years.html">a three-year delay</a> for the controversial program, saying the health care system needs more time to prepare.</p>
<p>When it is enacted in March 2027, this new provision will make Canada one of the few countries that allow MAID for mental illness. These include <a href="https://doi.org/10.3389/fpsyt.2022.895387">the Netherlands</a> <a href="https://pegasos-association.com/requirements/">and Switzerland</a>. Only a minority of U.S. states, such as Maine and Oregon, <a href="https://deathwithdignity.org/states/">allow any kind of MAID</a>, though many others have debated it – and none allow it for mental illness.</p>
<p>Critics say there are inadequate safeguards and <a href="https://www.cbc.ca/news/opinion/opinion-assisted-dying-maid-legislation-mental-health-1.5452676">a dearth of health care coverage</a> for psychiatric and psychological issues, which could prompt people to view MAID as their only alternative. They also point to the difficulty of predicting whether or not someone’s mental illness will eventually get better.</p>
<p>MAID activists believe that access to this choice for patients with mental illness is morally required. But even people <a href="https://www.cbc.ca/news/politics/medical-assistance-in-dying-mental-illness-delay-1.7098313">not opposed to Canada’s new provision</a> are concerned about whether the system is ready.</p>
<p>As <a href="https://www.gonzaga.edu/college-of-arts-sciences/faculty-listing/detail/kulp">a philosopher</a> who specializes in <a href="https://ecommons.luc.edu/luc_diss/1277/">end of life ethics</a> and physician-assisted death, I research a distinction that is at the heart of this debate. There is a subtle but crucial difference between being acutely suicidal – an experience that may pass – and, after long consideration, desiring death in the face of suffering. </p>
<h2>My body, my decision?</h2>
<p>Plenty of people oppose MAID – often called physician-assisted death – under any circumstances, including terminal physical illness. Some believe it <a href="https://www.cccb.ca/media-release/statement-by-the-canadian-conference-of-catholic-bishops-on-the-non-permissibility-of-euthanasia-and-assisted-suicide-within-canadian-health-organizations-with-a-catholic-identity/">violates the sanctity of human life</a>. </p>
<p>Others have qualms about asking doctors, who are normally concerned about the preservation of human life, <a href="https://www.thepublicdiscourse.com/2019/11/57243/">to participate in ending it</a>. In other words, they emphasize nonmaleficence, the obligation to do no harm – <a href="https://doi.org/10.1159/000509119">one of the core tenets of medical ethics</a>.</p>
<p>Many proponents, on the other hand, base their arguments on two other core tenets: beneficence – the obligation to benefit the patient – and autonomy. <a href="https://doi.org/10.1093/acprof:oso/9780195140279.003.0002">Autonomy arguments</a> usually assume that a government is only justified in restricting citizens’ liberty if exercising that liberty would cause harm to other people.</p>
<p>Advocates of physician-assisted death emphasize that ending one’s own life does not harm other people, suggesting that the government has no business curtailing the patient’s choices. Legalization ensures that citizens can make their own decisions about one of the most personal and value-laden times of life.</p>
<p>In medical ethicists’ view, in order for a person to be considered autonomous, they must be able to act intentionally and with an understanding of the potential consequences of their actions. Additionally, an autonomous person is reasonably free from undue influence – such as family members pressuring them or financial considerations that restrict their choices. </p>
<p>When it comes to physical illness, ethicists who <a href="https://philpapers.org/rec/RIDMAI-2">argue that physician-assisted death is morally permissible</a> view patients as free actors exercising their autonomy if they meet several criteria: they are terminally and chronically ill, have worked with medical professionals over time and have established an unchanging desire to end their suffering.</p>
<h2>Thorny issues</h2>
<p>Experiences of mental illness, however, raise serious questions about patients’ autonomy.</p>
<p>Mental illnesses often limit a person’s ability to govern their own lives free from the effects of their illness. For instance, a patient with <a href="https://theconversation.com/mariah-carey-says-she-has-bipolar-disorder-a-psychiatrist-explains-what-that-is-94893">bipolar I disorder</a> is not fully autonomous during the middle of a manic episode. Were it not for their disease, they would be less likely to engage in the types of behaviors that characterize a manic episode, such as reckless spending or risky sexual encounters.</p>
<p>Yet this is not true for all mental illnesses, or at all times. A person with well-treated bipolar 1 disorder will have periods in which <a href="https://www.samhsa.gov/mental-health/bipolar">their symptoms are under control</a>. In fact, it is in these periods of lucidity when <a href="https://www.nytimes.com/2023/12/27/world/canada/medical-assisted-death-mental-illness.html">some bipolar patients</a> decide their own death would be preferable to the suffering they endure. </p>
<p>Moreover, proponents of <a href="https://www.nytimes.com/2023/04/21/opinion/medical-assistance-dying-mental-illness-maid.html">extending physician-assisted death to mental illness</a> believe that the approval process can protect people who request it when acutely suicidal or who have not yet received adequate treatment.</p>
<p>In Canada’s proposed system, a mentally ill person requesting MAID must have been informed of all reasonable treatment options. They must also demonstrate a sustained desire to receive MAID, including waiting for 90 days after their application. Finally, the patient must have two doctors certify that their suffering is “<a href="https://www.justice.gc.ca/eng/rp-pr/other-autre/ad-am/p1.html">grievous and irremediable</a>” in any way the patient finds acceptable.</p>
<p>One key issue in preparing Canada’s health care system is whether providers have received enough training <a href="https://www.canada.ca/en/health-canada/services/publications/health-system-services/advice-profession-medical-assistance-dying.html#a7">to differentiate someone who is acutely suicidal</a> from someone who is in a frame of mind to make this decision thoughtfully. If someone is experiencing an acute desire to die that may be a symptom of their illness, most ethicists would find MAID morally impermissible. If, however, a mentally ill person <a href="https://www.reuters.com/world/americas/shes-47-anorexic-wants-help-dying-canada-will-soon-allow-it-2023-07-15/">has spent years suffering</a>, has exhausted reasonable treatment and has maintained a desire to die for some time, some ethicists believe MAID is appropriate.</p><img src="https://counter.theconversation.com/content/223707/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Maria Kulp does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Assessing a patient’s autonomy can be more difficult when mental illness is the main source of their suffering.Maria Kulp, Associate Professor of Philosophy, Gonzaga UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2082822023-07-03T02:15:19Z2023-07-03T02:15:19ZVoluntary assisted dying is legal in Victoria, but you may not be able to access it<figure><img src="https://images.theconversation.com/files/534247/original/file-20230627-19-xawsky.jpg?ixlib=rb-1.1.0&rect=0%2C198%2C7348%2C4704&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/senior-man-sitting-on-wheelchair-alone-1012812838">Shutterstock</a></span></figcaption></figure><p>Voluntary assisted dying is legal in <a href="https://eprints.qut.edu.au/238547/">five Australian states</a> with the sixth, New South Wales, following in November 2023. The territories are <a href="https://theconversation.com/territories-free-to-make-their-own-voluntary-assisted-dying-laws-in-landmark-decision-heres-what-happens-next-195291">now permitted</a> to legalise voluntary assisted dying, with the Australian Capital Territory <a href="https://yoursayconversations.act.gov.au/voluntary-assisted-dying-in-ACT">intending</a> to do so by the end of 2023.</p>
<p>Victoria was the first state to implement voluntary assisted dying in 2019. After four years, its legislation requires a formal review. Western Australia’s legislation, which started in 2021, requires a review after just two years. Both reviews are due to start soon.</p>
<p>Patients’ experiences of seeking voluntary assisted dying will be central to these reviews. In today’s Medical Journal of Australia, we <a href="https://doi.org/10.5694/mja2.52004">report</a> on the first study of patients’ voluntary assisted dying experiences in Victoria, as described in interviews with family caregivers. </p>
<p>We found five key barriers to accessing voluntary assisted dying in Victoria.</p>
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Read more:
<a href="https://theconversation.com/voluntary-assisted-dying-will-soon-be-legal-in-all-states-heres-whats-just-happened-in-nsw-and-what-it-means-for-you-183355">Voluntary assisted dying will soon be legal in all states. Here's what's just happened in NSW and what it means for you</a>
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<p>First, patients had difficulty finding doctors willing and qualified to assess eligibility for voluntary assisted dying. </p>
<p>Second, the voluntary assisted dying application process often took a long time and sometimes delays occurred. This was especially hard for very sick patients who had little time left. </p>
<p>Third, some hospitals, aged care facilities and other health-care <a href="https://bmcmedethics.biomedcentral.com/articles/10.1186/s12910-023-00902-3">institutions objected</a> to being involved in voluntary assisted dying. Often, patients could not be assessed for voluntary assisted dying in these facilities, nor receive or take the voluntary assisted dying medication there.</p>
<p>The final two barriers were legal ones. The Victorian law <a href="https://eprints.qut.edu.au/132073/">prohibits health practitioners from raising voluntary assisted dying</a> with patients. Patients needed to know they had to be the one to ask about voluntary assisted dying. </p>
<p>Legal concerns also mean health practitioners in Victoria <a href="https://eprints.qut.edu.au/207083/">cannot use telehealth</a> for voluntary assisted dying consultations. This required some patients to travel to appointments, sometimes over great distances, causing pain, distress and hardship.</p>
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<img alt="Older person cuts meal on tray" src="https://images.theconversation.com/files/534248/original/file-20230627-19-ufsunt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/534248/original/file-20230627-19-ufsunt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/534248/original/file-20230627-19-ufsunt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/534248/original/file-20230627-19-ufsunt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/534248/original/file-20230627-19-ufsunt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/534248/original/file-20230627-19-ufsunt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/534248/original/file-20230627-19-ufsunt.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 aged care facilities object to being involved in voluntary assisted dying.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/elderly-lady-eating-healthy-lunch-bed-2146362593">Shutterstock</a></span>
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<p>These five barriers meant patients were sometimes unsure about how to seek voluntary assisted dying and where to get information. They also caused suffering for patients and families, and led to delays in accessing voluntary assisted dying. </p>
<p>Access was more difficult for people in regional areas or with neurodegenerative conditions, such as motor neurone disease.</p>
<h2>Who provides help and support?</h2>
<p><a href="https://www.health.vic.gov.au/sites/default/files/migrated/files/collections/factsheets/t/the-statewide-voluntary-assisted-dying-care-navigator-service-factsheet---final.docx">Statewide voluntary assisted dying care navigators</a> are government-funded health professionals who help patients navigate the system. Some hospitals and health services also appointed local voluntary assisted dying coordinators. Described as the “jewel in the crown”, their guidance was especially helpful when patients started the voluntary assisted dying process and were unsure what to do.</p>
<p>Finding a supportive doctor willing and qualified to assess eligibility for voluntary assisted dying was often a turning point for patients. But this sometimes depended on luck.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/voluntary-assisted-dying-will-be-available-to-more-australians-this-year-heres-what-to-expect-in-2023-196209">Voluntary assisted dying will be available to more Australians this year. Here's what to expect in 2023</a>
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<p>The <a href="https://www.alfredhealth.org.au/news/state-wide-pharmacy-service-for-voluntary-assisted-dying/">statewide pharmacy service’s</a> education and support when providing the voluntary assisted dying medication was very reassuring for patients and families. </p>
<p>These facilitators helped patients navigate a complex and rigorous voluntary assisted dying assessment process and to feel more supported and confident. Participants repeatedly commended the commitment and compassion of doctors, navigators and pharmacists.</p>
<p>Aside from some logistical challenges in the system’s early days (which improved over time), once patients contacted a willing doctor or navigator they generally felt well-supported. </p>
<h2>How can voluntary assisted dying systems be improved?</h2>
<p>We propose the following steps to improve patient access:</p>
<ul>
<li><p>ensure patients have clear and readily available information about voluntary assisted dying so they can make earlier contact with care navigators</p></li>
<li><p>encourage more doctors to be involved, including by offering <a href="https://www.mja.com.au/journal/2023/218/1/access-voluntary-assisted-dying-australia-requires-fair-remuneration-medical">adequate remuneration</a> </p></li>
<li><p>require doctors who don’t want to provide voluntary assisted dying to refer patients to a willing doctor, or provide navigators’ contact details</p></li>
<li><p>allow doctors to raise voluntary assisted dying as an option and to use telehealth when appropriate</p></li>
<li><p><a href="https://eprints.qut.edu.au/210842/">regulate objections by institutions</a> so access to voluntary assisted dying is not blocked</p></li>
<li><p>adequately resource and support integral system roles including navigators and the statewide pharmacy service.</p></li>
</ul>
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<img alt="Older person holds walking stick" src="https://images.theconversation.com/files/534249/original/file-20230627-23-rjhwty.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/534249/original/file-20230627-23-rjhwty.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/534249/original/file-20230627-23-rjhwty.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/534249/original/file-20230627-23-rjhwty.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/534249/original/file-20230627-23-rjhwty.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/534249/original/file-20230627-23-rjhwty.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/534249/original/file-20230627-23-rjhwty.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&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">Patients need clear and reliable information.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/narrabri-nswaustralia-12032017-elderly-woman-sitting-1555766930">Shutterstock</a></span>
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<p>A safe system that allows only patients who meet the strict eligibility criteria to choose voluntary assisted dying is critical. However, our research shows significant barriers impede access and limit choice. </p>
<p>Some of these barriers are specific to Victorian law, such as doctors not being able to raise voluntary assisted dying. But others, such as limits on using telehealth, have <a href="https://eprints.qut.edu.au/229735/">implications for the rest of Australia</a>.</p>
<p>For states reviewing their system, and jurisdictions implementing voluntary assisted dying or considering passing laws permitting it, access must be an important consideration too.</p>
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Read more:
<a href="https://theconversation.com/what-happens-if-you-want-access-to-voluntary-assisted-dying-but-your-nursing-home-wont-let-you-183364">What happens if you want access to voluntary assisted dying but your nursing home won't let you?</a>
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<p><em>A summary of our research is available <a href="https://eprints.qut.edu.au/240605/1/Barriers_and_facilitators_to_accessing_VAD_family_perspectives_Research_briefing.pdf">here</a>. Information about contacting voluntary assisted dying care navigators in your state is available <a href="https://research.qut.edu.au/voluntary-assisted-dying-regulation/contact-us/">here</a>.</em></p><img src="https://counter.theconversation.com/content/208282/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ben White receives funding from the Australian Research Council, the National Health and Medical Research Council and Commonwealth and State Governments for research and training about the law, policy and practice relating to end-of-life care. In relation to voluntary assisted dying, he (with colleagues) has been engaged by the Victorian, Western Australian and Queensland Governments to design and provide the legislatively-mandated training for doctors involved in voluntary assisted dying in those States. He (with Lindy Willmott) has also developed a model Bill for voluntary assisted dying for parliaments to consider. He is a part-time member of the Queensland Civil and Administrative Tribunal, which has jurisdiction for some aspects of this state's voluntary assisted dying legislation. Ben is a recipient of an Australian Research Council Future Fellowship (project number FT190100410: Enhancing End-of-Life Decision-Making: Optimal Regulation of Voluntary Assisted Dying) funded by the Australian Government. This research is funded by that Future Fellowship project.</span></em></p><p class="fine-print"><em><span>Eliana Close is currently appointed on an Australian Research Council Future Fellowship (project number FT190100410: Enhancing End-of-Life Decision-Making: Optimal Regulation of Voluntary Assisted Dying) funded by the Australian Government. She was employed on projects funded by the Victorian, Western Australian, and Queensland Governments to develop legislatively-mandated training for medical practitioners and nurse practitioners providing voluntary assisted dying.</span></em></p><p class="fine-print"><em><span>Lindy Willmott receives or has received funding from the Australian Research Council, the National Health and Medical Research Council and Commonwealth and State Governments for research and training about the law, policy and practice relating to end-of-life care. In relation to voluntary assisted dying, she (with colleagues) has been engaged by the Victorian, Western Australian and Queensland Governments to design and provide the legislatively-mandated training for doctors involved in voluntary assisted dying in those States. She (with Ben White) has also developed a model Bill for voluntary assisted dying for parliaments to consider. Lindy Willmott is also a member of the Queensland Voluntary Assisted Dying Review Board and the Queensland Civil and Administrative Tribunal, but writes this piece in her capacity as an academic researcher. She is a former Board member of Palliative Care Australia.</span></em></p><p class="fine-print"><em><span>Ruthie Jeanneret is a PhD Candidate on an Australian Research Council Future Fellowship (project number FT190100410: Enhancing End-of-Life Decision-Making: Optimal Regulation of Voluntary Assisted Dying) funded by the Australian Government. She was employed on projects funded by the Victorian, Western Australian, and Queensland Governments to develop legislatively-mandated training for medical practitioners and nurse practitioners providing voluntary assisted dying.</span></em></p>Finding a supportive doctor willing and qualified to assess your eligibility for voluntary assisted dying sometimes depends on luck.Ben White, Professor of End-of-Life Law and Regulation, Australian Centre for Health Law Research, Queensland University of TechnologyEliana Close, Senior Research Fellow, Australian Centre for Health Law Research, Queensland University of TechnologyLindy Willmott, Professor of Law, Australian Centre for Health Law Research, Queensland University of Technology, Queensland University of TechnologyRuthie Jeanneret, PhD Candidate, Queensland University of TechnologyLicensed 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/1294242020-02-18T13:55:36Z2020-02-18T13:55:36ZAssisted dying is not the easy way out<figure><img src="https://images.theconversation.com/files/315377/original/file-20200213-11000-c1rktt.jpg?ixlib=rb-1.1.0&rect=13%2C84%2C4311%2C2874&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The stress over their ability to swallow can provoke a great deal of anxiety in patients.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/senior-womans-hands-drinking-glass-water-1142021786">eyepark/Shutterstock.com</a></span></figcaption></figure><p><a href="https://www.nytimes.com/2019/07/08/health/aid-in-dying-states.html">One in every five Americans</a> now lives in a state with legal access to a medically assisted death. In theory, assisted dying laws allow patients with a terminal prognosis to hasten the end of their life, once their suffering has overcome any desire to live. While these laws may make the process of dying less painful for some, they don’t make it easier. Of the countries that have aid-in-dying laws, the U.S. has the <a href="https://www.bbc.com/news/world-34445715">most restrictive</a>. Intended to reduce unnecessary suffering, the laws can sometimes have the opposite effect. </p>
<p>My work as a medical anthropologist explores the field of medicine from a cultural angle, focusing primarily on <a href="https://www.press.uchicago.edu/ucp/books/book/chicago/B/bo25956731.html">birth</a> and <a href="https://undark.org/2017/10/19/death-dying-america-anthropologist/">death</a>. Over the past four years, I’ve studied how access to a medically assisted death is transforming the ways Americans die. I have spent hundreds of hours accompanying patients, families and physicians on their road to an assisted death. And, I have witnessed some of these deaths firsthand. </p>
<p>This research has taught me one thing: An assisted death is not the path of least resistance. For many, it is the path of most resistance. Those who pursue it face a range of barriers, at a time when their health is rapidly declining. Some patients navigate these waters successfully and manage to secure the coveted bottle of life-ending medication. Others give in to the opposition or simply run out of time. </p>
<h2>History of the laws</h2>
<p>The country’s first right-to-die law, Oregon’s Death with Dignity Act (1994), came after a fierce, century-long struggle to give terminally ill patients access to some form of medical assistance in dying.</p>
<p>Legislators in Ohio and Iowa proposed the first two of these bills in 1906. Known as the “<a href="https://daily.jstor.org/history-euthanasia-movement/">chloroform bills</a>,” they envisioned the use of chloroform on fatally ill or injured patients to induce their death, but their terms were so flawed that they never saw the light of day. Other <a href="https://www.finalexit.org/chronology_right-to-die_events.html">legislative bills</a> – introduced in Nebraska in 1937, Florida in 1967 and Idaho in 1969 – met similar fates. </p>
<p>When a committee of lawyers, physicians and activists sat down to craft Oregon’s <a href="https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Documents/statute.pdf">Death with Dignity Act</a> in 1993, similar <a href="https://www.finalexit.org/chronology_right-to-die_events.html">ballot initiatives</a> had recently failed in Washington (1991) and California (1992). To appease vocal opposition, lawmakers laced the Oregon statute with a long list of restrictions and safeguards.</p>
<p>Unlike all previous proposals, the Oregon measure no longer allowed for euthanasia. That’s the act of injecting a patient with a lethal dose of narcotics. Under the law, patients would have to ingest the lethal dose themselves – a final protection meant to ensure the absolutely voluntary nature of their death. The act also introduced a 15-day waiting period between a patient’s first and second request, intended as a period of reflection. </p>
<p>It worked. Oregonians narrowly approved the measure, but a three-year legal stay prevented it from being enacted. In 1997, Oregonians <a href="https://ballotpedia.org/Oregon_Repeal_of_%22Death_with_Dignity%22,_Measure_51_(1997)">reaffirmed their support</a> for the act, and it became law. Since then, <a href="https://www.deathwithdignity.org/take-action/">each state</a> that has added an assisted dying law to their books has either followed the strict Oregon model or, in the case of <a href="https://www.capitol.hawaii.gov/session2018/bills/HB2739_HD1_.pdf">Hawaii</a>, added more constraints. Those include requiring a mandatory mental health exam and a 20-day waiting period in between requests. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/315114/original/file-20200212-61917-cmd00h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/315114/original/file-20200212-61917-cmd00h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=396&fit=crop&dpr=1 600w, https://images.theconversation.com/files/315114/original/file-20200212-61917-cmd00h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=396&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/315114/original/file-20200212-61917-cmd00h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=396&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/315114/original/file-20200212-61917-cmd00h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=498&fit=crop&dpr=1 754w, https://images.theconversation.com/files/315114/original/file-20200212-61917-cmd00h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=498&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/315114/original/file-20200212-61917-cmd00h.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">MPs in the parliament of Victoria in Australia react after Victoria passed legislation Nov. 22, 2017 to allow assisted dying.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/harriet-shing-mp-and-colleen-hartland-mp-react-as-the-bill-news-photo/877314916?adppopup=true">Getty Images/Scott Barbour</a></span>
</figcaption>
</figure>
<h2>The letter of the law</h2>
<p>Unlike other countries that permit assisted dying, such as Canada, the Netherlands and Belgium, in the U.S. intolerable suffering and an incurable medical condition alone are not enough to qualify someone for an aided death. A patient must already be within six months of the end of their life – coinciding with the admission criteria for hospice. That means protracted degenerative diseases with open-ended prognoses like amyotrophic lateral sclerosis (ALS) don’t usually qualify, at least not until a patient’s breathing becomes severely compromised. </p>
<p>Every year, <a href="https://www.civilbeat.org/2020/01/report-too-many-people-are-dying-while-waiting-for-medical-aid-in-dying/">dozens of eligible patients</a> who apply for an assisted death are so close to the end of their life that they die during the mandated waiting period. And by the time a patient becomes eligible for an assisted death, they may have missed the window when they are able to ingest the lethal medication. In contrast to their Canadian, Dutch and Belgian colleagues, American physicians cannot administer these drugs to their patients. </p>
<p>Lou Libby, a pulmonologist from Portland, Oregon, told me that the physical manifestations of many advanced neurodegenerative diseases bump up against this requirement. Again, consider ALS. Alongside their diminishing ability to breathe, patients with ALS almost always lose their ability to swallow. </p>
<p>“You have to be able to ingest the medication yourself. And here you have all these patients who can’t even swallow.” </p>
<p>As I learned during my research, the stress over their ability to swallow can provoke a great deal of anxiety in patients, particularly when it comes to correctly timing their death. Taking the medication too early means cutting short a life still worth living; waiting too long means possibly missing their chance. To have the kind of death they prefer, some patients choose to die earlier than they would have liked.</p>
<h2>Cultural roadblocks</h2>
<p>Despite popular backing for medical assistance in dying – <a href="https://news.gallup.com/poll/235145/americans-strong-support-euthanasia-persists.aspx">seven in 10 Americans</a> support it – the cultural stigma and moral ambivalence around these laws remain potent. Across the country, many <a href="https://www.theguardian.com/society/2020/jan/28/catholic-hospitals-lead-fight-against-access-drugs-assisted-dying">religiously owned</a> health systems decline to participate in their state’s assisted dying law. </p>
<p>In <a href="https://www.bendbulletin.com/lifestyle/health/rural-oregonians-still-face-death-with-dignity-barriers/article_e41a5836-8bd6-5680-b37d-07517d3b9335.html">rural parts</a> of Oregon and along the coastal corridor, where Catholic health systems often run the only hospital in town, patients routinely struggle to find two physicians who will approve their request, or a pharmacist who will fill their prescription. <a href="https://endoflifewa.org/wp-content/uploads/2012/11/Courtney-Campbell-Hastings-Center-9-10.pdf">Many hospices</a> refuse to cooperate with a patient’s desire to seek an assisted death, leading patients to feel abandoned. <a href="https://www.nap.edu/read/25131/chapter/7#103">Many assisted living and nursing facilities</a> still prohibit the practice under their roof, forcing patients to make alternative arrangements, sometimes at a nearby motel. In trying to reclaim control over the way they die, these patients often are being stripped of some of that control in the process. </p>
<p>Medical aid-in-dying will become an even bigger issue as baby boomers face the end of their lives. It is mainly older patients who want access to an assisted death. In Oregon, for example, nearly 80% of those who sought medical assistance in dying <a href="https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Documents/year21.pdf">in 2018</a> were 65 or older. Boomers, as in many other aspects of their lives, likely <a href="https://business.time.com/2013/08/14/a-good-death-how-boomers-will-change-the-world-a-final-time/">will want more say over their deaths</a>.</p>
<p>Assisted dying reframes how we, as a society, understand the potential of medicine, not as a way to extend life but to mitigate the process of dying. Patients who endure intractable, painful diseases sometimes reach a moment when the prospect of staying alive feels worse than the prospect of dying. At that point, the idea of having a say over the timing and manner of their death can bring <a href="https://www.nytimes.com/interactive/2019/12/05/sports/euthanasia-athlete.html">enormous comfort</a>. But few are aware of all the hurdles they must clear to exercise this kind of control.</p>
<p>[ <em>Like what you’ve read? Want more?</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=likethis">Sign up for The Conversation’s daily newsletter</a>. ]</p><img src="https://counter.theconversation.com/content/129424/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anita Hannig does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Nine states and the District of Columbia currently have laws that permit assisted dying, but the laws are so restrictive that they are often more hurdle than help.Anita Hannig, Associate Professor of Anthropology, Brandeis UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1283862019-12-06T01:08:04Z2019-12-06T01:08:04ZWestern Australia looks set to legalise voluntary assisted dying. Here’s what’s likely to happen from next week<figure><img src="https://images.theconversation.com/files/305300/original/file-20191205-16501-10c01s4.jpg?ixlib=rb-1.1.0&rect=1%2C5%2C997%2C666&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">If the bill clears its final hurdle next week, Western Australia will become the second state in Australia after Victoria to legalise voluntary assisted dying.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/man-holding-hand-giving-support-comfort-1576363936?src=57e52c98-f962-4eca-908c-997df30b1588-1-19&studio=1">from www.shutterstock.com</a></span></figcaption></figure><p>Western Australia is on the brink of becoming the second state in Australia to legalise voluntary assisted dying, with its upper house last night <a href="https://www.abc.net.au/news/2019-12-05/wa-voluntary-euthanasia-law-passes-upper-house-vote/11771302">passing the Voluntary Assisted Dying Bill 2019 (WA)</a>. </p>
<p>A total of 55 amendments to the <a href="https://ww2.health.wa.gov.au/%7E/media/Files/Corporate/general%20documents/Voluntary%20assisted%20dying/PDF/Voluntary-Assisted-Dying-Bill-2019.pdf">initial version of the bill</a> were passed. The bill will return to the lower house next week to review the amendments.</p>
<p>If these amendments are ratified as expected, WA will follow the historic <a href="https://www2.health.vic.gov.au/hospitals-and-health-services/patient-care/end-of-life-care/voluntary-assisted-dying">introduction of voluntary assisted dying in Victoria</a>, where the option has been available since June 2019.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1202535291786948609"}"></div></p>
<h2>Remind me again, how did we get here?</h2>
<p>WA Premier Mark McGowan <a href="https://www.mediastatements.wa.gov.au/Pages/McGowan/2019/08/Landmark-voluntary-assisted-dying-legislation-to-be-introduced.aspx">announced</a> the government’s voluntary assisted dying bill in August 2019.</p>
<p>The proposed legislation was developed after recommendations from a <a href="https://www.parliament.wa.gov.au/Parliament/commit.nsf/(Report+Lookup+by+Com+ID)/71C9AFECD0FAEE6E482582F200037B37/%24file/Joint%20Select%20Committe%20on%20the%20End%20of%20Life%20Choices%20-%20Report%20for%20Website.pdf">parliamentary inquiry into end of life choices</a>, and subsequent <a href="https://ww2.health.wa.gov.au/%7E/media/Files/Corporate/general%20documents/Voluntary%20assisted%20dying/PDF/voluntary-assisted-dying-final-report.pdf">ministerial expert panel on voluntary assisted dying</a>. </p>
<p>After <a href="https://www.abc.net.au/news/2019-09-07/voluntary-euthanasia-debate-brings-out-worst-in-wa-parliament/11485370">lengthy debate</a>, the bill <a href="https://www.abc.net.au/news/2019-09-24/voluntary-euthanasia-bill-passes-through-wa-lower-house/11544362">passed the lower house in September</a> (45 votes to 11). </p>
<p>Debate in the upper house was also extensive, and <a href="https://www.abc.net.au/news/2019-10-31/vad-opponents-accused-of-filibustering/11656258">hundreds of amendments to the bill were proposed</a>. A total of 55 amendments were eventually included, and the bill <a href="https://www.abc.net.au/news/2019-12-05/wa-voluntary-euthanasia-law-passes-upper-house-vote/11771302">passed the upper house last night</a> by 24 votes to 11.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-fear-that-dare-not-speak-its-name-how-language-plays-a-role-in-the-assisted-dying-debate-86308">The fear that dare not speak its name: how language plays a role in the assisted dying debate</a>
</strong>
</em>
</p>
<hr>
<h2>What does the proposed legislation permit?</h2>
<p>The initial version of the bill featured <a href="https://www.parliament.wa.gov.au/publications/tabledpapers.nsf/displaypaper/4013204c4272e00709c300b0482584820008706e/$file/tp-3204.pdf">102 “safeguards”</a>, including the regulation of access, the request and assessment process, administration and management of the voluntary assisted dying substance, mandatory reporting, protections for health practitioners, and oversight mechanisms.</p>
<p>As outlined in <a href="https://ww2.health.wa.gov.au/%7E/media/Files/Corporate/general%20documents/Voluntary%20assisted%20dying/PDF/Voluntary-Assisted-Dying-Bill-2019.pdf">the proposed legislation</a>, to access voluntary assisted dying in WA a person would need to:</p>
<ul>
<li><p>be aged 18 years or more, and</p></li>
<li><p>have lived in WA for at least 12 months, and be an Australian citizen or permanent resident, and</p></li>
<li><p>have the capacity to make decisions about voluntary assisted dying, and </p></li>
<li><p>be acting voluntarily and without coercion.</p></li>
</ul>
<p>The person would also need to be diagnosed with a disease, illness, or medical condition that is:</p>
<ul>
<li><p>advanced and progressive, and anticipated to cause death, and</p></li>
<li><p>anticipated to cause death within no more than six months, or no more than 12 months for those with a neurodegenerative diagnosis, and</p></li>
<li><p>causing suffering to the person that cannot be relieved in a way the person considers tolerable.</p></li>
</ul>
<p>A person would not be eligible to access voluntary assisted dying only because they have a disability or are diagnosed with a mental illness.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/in-places-where-its-legal-how-many-people-are-ending-their-lives-using-euthanasia-73755">In places where it's legal, how many people are ending their lives using euthanasia?</a>
</strong>
</em>
</p>
<hr>
<p>Protections for health practitioners include provisions for “conscientious objection”. They would have the right to refuse to participate in the request and assessment process, and to participate in the prescription, supply, or administration of the voluntary assisted dying substance, including being present when it is administered.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/305498/original/file-20191205-39018-1kmjl62.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/305498/original/file-20191205-39018-1kmjl62.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/305498/original/file-20191205-39018-1kmjl62.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/305498/original/file-20191205-39018-1kmjl62.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/305498/original/file-20191205-39018-1kmjl62.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/305498/original/file-20191205-39018-1kmjl62.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/305498/original/file-20191205-39018-1kmjl62.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/305498/original/file-20191205-39018-1kmjl62.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"></a>
<figcaption>
<span class="caption">In Western Australia, eligible patients are expected to be able to request voluntary assisted dying in about 18 months.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/medicine-age-health-care-people-concept-326634497?src=74625a3d-7000-4c70-8ac0-f32c669809e6-1-0&studio=1">from www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>Most of the amendments passed by the upper house <a href="https://www.sbs.com.au/news/assisted-dying-set-to-be-legalised-in-wa-after-laws-pass-upper-house">will not substantively change</a> the eligibility criteria or process to access voluntary assisted dying from the model initially proposed.</p>
<p>WA’s proposed approach is broadly similar to <a href="https://theconversation.com/voluntary-assisted-dying-will-soon-be-legal-in-victoria-and-this-is-what-you-need-to-know-111836">the Victorian regime</a>, although there are several <a href="https://theconversation.com/was-take-on-assisted-dying-has-many-similarities-with-the-victorian-law-and-some-important-differences-121554">key differences</a>. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/was-take-on-assisted-dying-has-many-similarities-with-the-victorian-law-and-some-important-differences-121554">WA's take on assisted dying has many similarities with the Victorian law – and some important differences</a>
</strong>
</em>
</p>
<hr>
<h2>What happens next?</h2>
<p>In a special sitting next week, the WA lower house will vote on each of the amendments. Given support for the legislation in the lower house already, <a href="https://www.sbs.com.au/news/wa-assisted-dying-laws-pass-the-upper-house">it is anticipated the amendments will be ratified</a>. </p>
<p>If the bill passes as expected, it will be about 18 months until the law comes into effect in WA.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/passed-away-kicked-the-bucket-pushing-up-daisies-the-many-ways-we-dont-talk-about-death-77085">Passed away, kicked the bucket, pushing up daisies – the many ways we don't talk about death</a>
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<p>Following a similar process to Victoria, there will be an “implementation period”. This will allow time to develop resources for health services, health practitioners, and community members, and for training.</p>
<p>WA will also establish a Voluntary Assisted Dying Board, an independent statutory body to oversee voluntary assisted dying.</p>
<p>Overall, health services and health practitioners in WA, including those who choose not to participate, will need to prepare for the state’s introduction of voluntary assisted dying.</p><img src="https://counter.theconversation.com/content/128386/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Courtney Hempton receives funding from the Australian Government (Research Training Program Scholarship) and the Australian Research Council. She has previously been affiliated with the Monash Health Voluntary Assisted Dying Working Group and Voluntary Assisted Dying Steering Committee.</span></em></p>A marathon round of amendments and parliamentary debate will likely see voluntary assisted dying implemented in WA in around 18 months. It’s time to start preparing.Courtney Hempton, Associate Research Fellow, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1265802019-11-11T19:00:57Z2019-11-11T19:00:57ZAs NZ votes on euthanasia bill, here is a historical perspective on a ‘good death’<figure><img src="https://images.theconversation.com/files/300825/original/file-20191108-10935-w4iaqq.jpg?ixlib=rb-1.1.0&rect=70%2C149%2C5163%2C3201&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Critics of assisted suicide often raise moral objections while proponents focus on the trauma of terminally ill patients. But all arguments have a long history.</span> <span class="attribution"><span class="source">from www.shutterstock.com</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span></figcaption></figure><p>This week New Zealand’s parliamentarians will vote on the third reading of the <a href="https://www.parliament.nz/en/pb/bills-and-laws/bills-proposed-laws/document/BILL_74307/end-of-life-choice-bill">End of Life Choice Bill</a>. </p>
<p>Much public discussion on the merits of euthanasia has centred around the role of the medical practitioner as healer. Some doctors and conscientious objectors worry that physician-assisted suicide will alter the <a href="https://www.rnz.co.nz/news/political/392774/seymour-unfazed-by-doctors-letter-against-end-of-life-choice-bill">relationship between doctors and their patients</a>. They argue it is unethical, often invoking the <a href="https://www.medicinenet.com/script/main/art.asp?articlekey=20909">Hippocratic oath</a>. </p>
<p>The oldest code of medical ethics, the oath dates to around the fourth century BC and is still sworn by doctors today. It specifically <a href="https://www.jstor.org/stable/pdf/24624423.pdf?refreqid=excelsior%3Ace52758660d62b03cd7c96af548f9691&seq=1#page_scan_tab_contents">forbids physicians from administering lethal drugs</a>, among its other precepts.</p>
<p>Some critics of the bill present religious and moral objections against euthanasia, while proponents have focused on the trauma and pain of terminally ill patients and their families. All these arguments have a long history.</p>
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Read more:
<a href="https://theconversation.com/in-places-where-its-legal-how-many-people-are-ending-their-lives-using-euthanasia-73755">In places where it's legal, how many people are ending their lives using euthanasia?</a>
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<h2>The art of dying well</h2>
<p>Like the Hippocratic oath, euthanasia (in its literal meaning of “good death” in ancient Greek) <a href="https://www.sciencedirect.com/science/article/abs/pii/S0277953603005756">first appeared</a> around the fourth and third century BC. Ancient Roman emperors, at death’s door, were known to <a href="https://www.goodreads.com/book/show/37440902-of-the-advancement-and-proficience-of-learning">consume wine, drugs and other palliatives to ease their dying</a>. Good emperors were believed to deserve a dignified death, and often <a href="https://www.sciencedirect.com/science/article/abs/pii/S0277953603005756">staged them</a>. </p>
<p>In pre-modern Europe, <a href="http://www.helsinki.fi/collegium/journal/volumes/volume_18/Death%20and%20Dying%20in%20Medieval%20and%20Early%20Modern%20Europe.pdf">experiencing a good death</a> and intentionally shortening the agony of dying were separate matters. From 1400 on, there was a thriving trade in <a href="http://www.deathreference.com/A-Bi/Ars-Moriendi.html">advice books on the art of dying</a>. These instructed readers on how to prepare their souls for a “good death” and the Christian afterlife. </p>
<p>Prayers, rituals and information about what to expect offered practical guidance for attaining salvation. Christian theologians saw euthanasia as “<a href="https://books.google.co.nz/books?id=uYNbwVzdPm4C&printsec=frontcover&dq=Bartolomeo+Castelli,+Amaltheum+Castello-Brunonianum,+sive,+Lexicon+medicum&hl=en&sa=X&ved=0ahUKEwjfh_KcgdnlAhUOfH0KHeapA44Q6wEIOzAB#v=onepage&q=euthanasia&f=false">a blessed and peaceful death of the faithful</a>”. </p>
<p>Whether and how people sought to hasten or ameliorate death is less clear. Scholars only began considering the doctor’s role in enabling euthanasia in the late 16th century.</p>
<h2>Early ideas about assisted dying</h2>
<p>In 1605, English lawyer, statesman and natural philosopher <a href="https://www.biography.com/scholar/francis-bacon">Francis Bacon</a> wrote that the physician’s office extends to <a href="https://books.google.co.nz/books/about/Bacon.html?id=bslNAQAAMAAJ&printsec=frontcover&source=kp_read_button&redir_esc=y#v=onepage&q&f=false">matters of health as well as dying</a>. In his words, a physician ought “not only to restore health, but to mitigate dolours, and torments of Diseases”. If there was no hope of the patient’s recovery, everything should be done “to make a fair and easie passage out of life”.</p>
<p>Bacon called this “fair and easie passage” euthanasia. Importantly, he distinguished between “outward” euthanasia and the soul’s peaceful transition to the afterlife. While the latter remained the purview of the spiritual realm, Bacon placed the former within medicine’s province.</p>
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<img alt="" src="https://images.theconversation.com/files/301052/original/file-20191111-194641-1v74pou.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/301052/original/file-20191111-194641-1v74pou.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=594&fit=crop&dpr=1 600w, https://images.theconversation.com/files/301052/original/file-20191111-194641-1v74pou.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=594&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/301052/original/file-20191111-194641-1v74pou.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=594&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/301052/original/file-20191111-194641-1v74pou.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=747&fit=crop&dpr=1 754w, https://images.theconversation.com/files/301052/original/file-20191111-194641-1v74pou.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=747&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/301052/original/file-20191111-194641-1v74pou.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=747&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">A devil and an angel weigh up a dying man’s soul. From Hieronymus Bosch: The seven deadly sins.</span>
<span class="attribution"><span class="source">from Wikimedia commons</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
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<p>Until recently, historians believed active euthanasia did not exist in pre-modern Europe, but historian of medicine <a href="https://www.medizingeschichte.uni-wuerzburg.de/stolberg.html">Michael Stolberg</a> has <a href="https://www.springer.com/gp/book/9783319541778">challenged this notion</a>. </p>
<p>A physician in 1660s Antwerp, <a href="https://www.dbnl.org/tekst/bran038biog01_01/bran038biog01_01_0550.php">Michiel Boudewijns</a>, wondered whether doctors could help their terminal patients die. While moved by patients in agony, Boudewijns urged Christian doctors to observe the fifth commandment and the Hippocratic rule of “do no harm”. He cautioned his colleagues against undertaking risky procedures and acting on compassion to expedite death in hopeless cases. </p>
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Read more:
<a href="https://theconversation.com/how-hypothetical-designs-can-help-us-think-through-our-conversations-about-euthanasia-125975">How hypothetical designs can help us think through our conversations about euthanasia</a>
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<h2>A matter of trust</h2>
<p>Physicians also feared patients would lose trust in them if they knew they shortened dying patients’ lives. It was not until the late 17th century that facilitating dying sparked public debate among scholars. In 1678, Caspar Questel, a Silesian lawyer active in Saxony, wrote about assisted dying in the homes of ordinary people. </p>
<p>Methods to accelerate dying ranged from acts of faith and folklore to illegal actions. Questel had discovered that family members, nurses, nuns and other carers removed the pillow from under the head of the dying person. It was a widespread custom that was believed to quicken death. </p>
<p>Other forms of assistance included opening a window so the soul of the dying person would be encouraged to leave the body and meet God, placing lit candles around the gravely sick and placing the dying on the ground or putting them outdoors. More fatal actions involved suffocating the dying with a pillow or cutting their veins. Exercising empathy for the suffering of the dying was weighed against the risk of being charged for their premature deaths.</p>
<p>In present-day New Zealand, if this week’s vote is in favour of euthanasia, the option for assisted dying will still need to be ratified in <a href="https://www.rnz.co.nz/news/political/401616/key-vote-for-referendum-on-voluntary-euthanasia-looms">a referendum next year</a>. </p>
<p>Clearly, cultural customs, prevailing medical ethics and beliefs about death and the afterlife have evolved over time. Today discussions about euthanasia involve a wider range of participants than in pre-modern Europe. The distance between learned professionals and everyone else has narrowed. Civil rights, legal precedents and protections have given us a new language and ethics through which to understand fraught issues concerning our health, body and death.</p><img src="https://counter.theconversation.com/content/126580/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Catherine Abou-Nemeh 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>The arguments in favour or against euthanasia have a long history, going back to the Hippocratic oath that doctors still swear today.Catherine Abou-Nemeh, Lecturer in Early Modern History, Te Herenga Waka — Victoria University of WellingtonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1259752019-11-06T16:34:04Z2019-11-06T16:34:04ZHow hypothetical designs can help us think through our conversations about euthanasia<figure><img src="https://images.theconversation.com/files/300434/original/file-20191106-12455-1ez92se.jpg?ixlib=rb-1.1.0&rect=8%2C0%2C5742%2C3837&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Speculative design highlights many of the questions we still need to ask when it comes to euthanasia. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/senior-man-holding-hand-his-ill-419729023?src=df818fb6-26e6-49f8-b807-83d3d5dacbbc-1-9">Photographee.eu/Shutterstock</a></span></figcaption></figure><p>Belgian Paralympic athlete Marieke Vervoort revealed two years ago that in 2008, she had been <a href="https://theconversation.com/marieke-vervoort-and-how-the-right-to-euthanasia-can-help-some-people-to-live-better-65485">approved to receive euthanasia</a>. The Paralympian was an accomplished wheelchair racer, having won gold and silver at the London 2012 Paralympics, and silver and bronze at the 2016 Rio Games. However, she suffered from an <a href="https://www.bbc.co.uk/sport/disability-sport/50145393">incurable degenerative muscle disease</a> that caused constant pain, seizures, and in Vervoort’s case, paralysis in her legs. In October 2019, Vervoort made the decision to end her life through euthanasia at the age of 40. </p>
<p>Euthanasia remains a <a href="https://www.care.org.uk/our-causes/sanctity-life/arguments-for-and-against-euthanasia">controversial medical procedure</a>. <a href="https://www.nhs.uk/conditions/euthanasia-and-assisted-suicide/#:%7E:targetText=Euthanasia%20and%20assisted%20suicide,person's%20life%20to%20relieve%20suffering.&targetText=Assisted%20suicide%20is%20the%20act,another%20person%20to%20kill%20themselves.">Euthanasia</a> is when a person makes a conscious decision to die, and asks for help in doing so. This might be receiving a doctor or other person to help them. It’s different from assisted suicide, where someone assists an person in taking their own life but the final deed is still done by the individual. </p>
<p>While some proponents, like Vervoort, argue that it can ease suffering, and give a person <a href="https://www.nbc-2.com/story/41220297/belgian-paralympian-marieke-vervoort-dies-aged-40-through-euthanasia">agency over their own life</a>, others argue that euthanasia is unnatural, and is difficult to properly control – especially in the case of patients who might not be able to fully consent. </p>
<p>Euthanasia has been legal in Belgium since 2002. However, it’s still currently <a href="https://www.theguardian.com/news/2019/jul/15/euthanasia-and-assisted-dying-rates-are-soaring-but-where-are-they-lega">only legal in a handful of countries</a>, including the Netherlands, Luxembourg, and Canada. Although Vervoort felt euthanasia gave her agency over her own life – especially as her condition worsened – her death still highlights many aspects of the moral and legal questions that need to be answered when it comes to euthanasia. Much of the current debate still taking place wonders whether anyone should be able to access it, under what circumstances, and the extent to which we should honour the individual’s choice. </p>
<h2>Having the right conversations</h2>
<p>My research sought to provide insight into how we can frame our conversations around euthanasia, through speculative design. The field of design is often described as a problem-solving activity. However, many problems are often simply too complex to be solved. The <a href="https://mitpress.mit.edu/books/speculative-everything">field of speculative design is unique</a> – it’s a method of designing that uses hypothetical prototypes or scenarios to highlight problems rather than solve them. Speculative designs can help <a href="http://www.auger-loizeau.com/projects/toothimplant">consider any potential unintended consequences</a> in a proposed scenario. </p>
<p>I sought to address the complicated moral dilemma of euthanasia by creating <a href="https://vimeo.com/231854700">The Plug</a>, an applied thought experiment which aimed to think through the <a href="https://repository.lboro.ac.uk/articles/Design_as_a_provocation_to_support_discussion_about_euthanasia_The_Plug/9351113/1">consequences of patient control</a> in euthanasia for dementia. </p>
<p>Some terminal conditions, such as dementia, pose more complications for euthanasia. For example, in the Netherlands, an increasing number of people are <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4929163/">opting to use euthanasia</a> after being diagnosed with dementia. An advance euthanasia directive is a document in which a person outlines what decisions should be made in the future, should they be unable to make those decision themselves. Currently, many advance directives make statements such as, “when I am no longer myself,” or “when I can’t recognise my children”, to outline when euthanasia should be administered. However, these conditions are hard to measure and comply with. </p>
<p>These advance euthanasia directives are also largely ignored by physicians having to perform euthanasia, because the symptoms of dementia clash with due care criteria – <a href="https://jme.bmj.com/content/34/9/e12#:%7E:text=These%20criteria%20hold%20that%3A%20there,be%20medically%20and%20technically%20appropriate.">the criteria</a> that a patient must fulfil in order to be administered euthanasia.</p>
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Read more:
<a href="https://theconversation.com/if-assisted-dying-is-legalised-who-gets-to-decide-whose-life-is-worth-living-108625">If assisted dying is legalised, who gets to decide whose life is worth living?</a>
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<p>In the Netherlands, one study found that <a href="https://doi.org/10.1111/j.1532-5415.2005.53354.x">only 3% of advance directives</a> are complied with. A person with dementia is often unable to consent at the time of death, which makes it difficult to establish whether the person’s suffering is “hopeless and unbearable” – one of the <a href="https://bmjopen.bmj.com/content/7/10/e017628">due care criteria for euthanasia</a> in the Netherlands.</p>
<h2>A hypothetical implant</h2>
<p>The Plug is a hypothetical implanted <a href="https://blogs.bmj.com/medical-ethics/2018/03/05/advance-euthanasia-directives-in-the-spotlight/">advance euthanasia directive</a> that would trigger a swift and painless death once the conditions described in the advance euthanasia directive are reached. My research was intended to address several issues, such as the rights of a person whose personality might be changed because of dementia, the need for advance directives to be much more detailed, as well as the difficulty that physicians may face when performing euthanasia. </p>
<p>The Plug would deal with the consent issue by creating a situation where the person requesting euthanasia is the one who consents. The person they might become as a result of dementia is deliberately excluded in this scenario in order to address who should have the right to decide – the person before dementia, or during dementia. </p>
<p>The Plug would hypothetically be installed in cognitively competent people who might be afraid of developing and living with dementia. The device would be connected to other health-trackers and sensors installed in the home – and potentially even loved ones – to measure if the pre-programmed conditions the patient wants to avoid are coming to pass. If this was the case, The Plug would be triggered, causing the person to die peacefully in their sleep. This scenario was designed to ask a number of questions about advanced euthanasia directives, including how conditions can be measured, and, if they can’t, what decision should be made – and whether it still should. </p>
<p>The <a href="https://repository.lboro.ac.uk/articles/Provoking_the_debate_on_euthanasia_in_dementia_with_design_/9338840">applied thought experiment of The Plug</a> has encouraged much conversation among expert stakeholders. It raised awareness about the need for advance directives to be much more specific. Additionally it highlighted the need to acknowledge the contrast in the rights of a person before and after living with dementia. The role of general practitioners was seen as very important, and it is recommended that these doctors initiate end-of-life conversations early, both with the patient and their loved-ones. In places where euthanasia becomes legal, GPs may need additional support or education in order to be able to do this well.</p>
<p>In order to die with dignity, people are increasingly planning their own death. But dementia complicates matters. A person requesting euthanasia must be suffering intolerably and must be able to confirm the request at time of death. However, in many cases with dementia, that “wish” can no longer be confirmed when the time comes. As debates around euthanasia continue, it’s important to consider all the inherent moral dilemmas that come with it.</p><img src="https://counter.theconversation.com/content/125975/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Marije De Haas has received funding for this research from Design Star, Centre for Doctoral Training, Arts and Humanities Council, UK. </span></em></p>Many people might want to choose how, when, and under what circumstances they die – but diseases like dementia can complicate advance euthanasia directives.Marije De Haas, Lecturer, designer, Loughborough UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1220002019-09-26T21:27:59Z2019-09-26T21:27:59ZWhy people choose medically assisted death revealed through conversations with nurses<figure><img src="https://images.theconversation.com/files/293967/original/file-20190925-51421-1h9vzhm.jpg?ixlib=rb-1.1.0&rect=31%2C18%2C3013%2C1903&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Without an understanding of the complexities of medically assisted dying, it's difficult for patients and families to make good decisions.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Since Canada <a href="https://www.parl.ca/DocumentViewer/en/42-1/bill/C-14/royal-assent">legalized Medical Assistance in Dying (MAiD)</a> in 2016, as of Oct. 31, 2018, more than <a href="https://www.canada.ca/en/health-canada/services/publications/health-system-services/medical-assistance-dying-interim-report-april-2019.html">6,700 Canadians have chosen</a> medications to end their life. </p>
<p>Canadians who meet eligibility requirements can opt to self-administer or have a clinician administer these medications; the vast majority of people choosing MAiD have had their medications delivered by physicians or nurse practitioners. Canada is the first country to permit nurse practitioners to assess for medically assisted dying eligibility and to provide it.</p>
<p>The precise meaning and implications of MAiD — in particular, who can request medical assistance in dying in Canada — is still evolving through court rulings. Québec’s Supreme Court recently struck down the <a href="https://globalnews.ca/news/5888949/quebec-court-medically-assisted-dying-law/">reasonably foreseeable death requirement under the Criminal Code</a> and the end-of-life requirement under Québec’s <a href="http://legisquebec.gouv.qc.ca/en/ShowDoc/cs/S-32.0001">Act Respecting End-of-Life Care</a>. </p>
<p>Without the requirement of a reasonably foreseeable death, it is likely that other <a href="https://www.thelawyersdaily.ca/business/articles/15413/landmark-ruling-on-medically-assisted-death-may-set-stage-for-more-challenges">legal challenges will occur to extend assisted dying to other groups such as those whose sole underlying condition is severe mental illness</a>.</p>
<h2>Involvement of nurses</h2>
<p>Our research has explored how the <a href="https://doi.org/10.1177/1527154419845407">nursing profession is regulating the new area of responsibility</a> towards medically assisted dying and how <a href="https://doi.org/10.1177/0969733019845127">nursing ethics</a> might guide <a href="https://journals.lww.com/advancesinnursingscience/Fulltext/2019/07000/Ethical,_Policy,_and_Practice_Implications_of.7.aspx">policy and practical implications of nurses’ experiences</a>. </p>
<p>Current legislation guards the right of health-care providers to conscientiously object to participation in MAiD. Nurses who do <a href="https://doi.org/10.1111/nin.12308">conscientiously object</a> have a professional obligation to inform their employers of that objection, to report requests for MAiD, and to not abandon their clients. They also must ensure that their choices are based on “<a href="https://www.cna-aiic.ca/%7E/media/cna/page-content/pdf-en/code-of-ethics-2017-edition-secure-interactive">informed, reflective choice and are not based on prejudice, fear or convenience</a>.” </p>
<p>The nurses who surround the process of medically assisted dying are an important source of insight into the complex and nuanced <a href="http://pesut-lab.sites.olt.ubc.ca/projects-2/maid/">conversations our society needs to have about what it is like to choose, or be involved with, this new option at the end of life,</a> and to be involved in supporting patients and their families toward death with compassion.</p>
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<img alt="" src="https://images.theconversation.com/files/293901/original/file-20190924-51457-1ffq5oo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/293901/original/file-20190924-51457-1ffq5oo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/293901/original/file-20190924-51457-1ffq5oo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/293901/original/file-20190924-51457-1ffq5oo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/293901/original/file-20190924-51457-1ffq5oo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/293901/original/file-20190924-51457-1ffq5oo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/293901/original/file-20190924-51457-1ffq5oo.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">Researchers are following how the nursing profession is regulating nurses’ involvement in medically assisted dying.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<h2>Impoverished stereotypes</h2>
<p>Our most recent research involved interviews with 59 nurse practitioners or registered nurses across Canada who accompanied patients and families along the journey of medically assisted dying or who had chosen to conscientiously object. Nurses worked across the spectrum of care in acute, residential and home-care settings. </p>
<p>During our research, and as we followed media stories, we became aware that as with other morally contentious issues, involvement in MAiD has often been discussed in one-dimensional ways: We noted stereotypes of health-care providers and patients who <a href="https://www.calgaryjournal.ca/more/living/4716-i-ll-see-myself-out-medical-assisted-dying.html">heroically conquer suffering, death and the system by taking control</a> of what might otherwise have been a difficult and prolonged dying. We also observed caricatures of <a href="https://www.timescolonist.com/opinion/op-ed/lawrie-mcfarlane-do-religious-principles-outweigh-a-peaceful-death-1.23919174">oppositional or religious right-wing persons and institutions</a> who stand in the way of compassion and dignity. </p>
<p>Neither of these perspectives do justice to the complexities of MAiD as it is enacted. Without an understanding of those complexities, it is difficult for patients and families to make good decisions. </p>
<h2>Nurses accounts of MAiD</h2>
<p>Nurses told us that medically assisted dying is about so much more than the act itself. Medically assisted dying is a conversational journey with patients that lasts weeks or even months. </p>
<p>These discussions patients have over time with skilled and compassionate health-care professionals help to determine whether this is what they really want, or whether there are other options that might relieve their suffering. </p>
<p>Conversations between patients and their families are essential to negotiating a common understanding and moving forward together. </p>
<p>Indeed, evidence has suggested that these conversations, when experienced as meaningful by patients, may help to alleviate the suffering that leads to the request for a medically assisted death. This is particularly true if the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5553124/">suffering has arisen from the sense of isolation</a>. </p>
<p>If and when patients decide to proceed with MAiD, then conversations are required to ensure that all of the organizational details (what, where, when, how) are patient-centred choices and that those who are involved know the part they are to play. After the act of medically assisted dying, it is compassionate conversations that support families in navigating an uncharted bereavement process. </p>
<p>So yes, medically assisted dying is about supporting autonomy, but it is also about understanding that autonomy exists within, and is shaped by, our constellation of relationships. We need to be talking more about the essential nature of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4828197/">what it means to have a good death</a>.</p>
<h2>Complex reasons to choose death</h2>
<p>MAiD is often spoken of as the definitive intervention that ensures control over the alleviation of suffering. But, we have learned that MAiD can also be chosen as the antidote to a system that fails in compassion or equitable palliative care access. </p>
<p>It may seem the perfect solution for rural and remote patients who <a href="https://www.cihi.ca/sites/default/files/document/access-palliative-care-2018-en-web.pdf">want a home death but are unable to find sufficient palliative care in their context</a>. </p>
<p>It may seem the best option for patients who do not want to enter what they perceive to be the <a href="https://pjb.mycpanel2.princeton.edu/wp/index.php/2016/08/15/elderhood-a-case-for-abolishing-nursing-homes-in-the-united-states/">dehumanizing environments of</a> <a href="https://www.cbc.ca/news/canada/british-columbia/als-bc-man-medically-assisted-death-1.5244731">residential care</a>. </p>
<p>We heard a story of one man who had overstayed the time allowed on a palliative care unit. His doctor was a conscientious objector to medically assisted dying so each time health professionals planned to transfer him to residential care, the man asked for a medically assisted death. In doing so his stay in palliative care was assured. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/293963/original/file-20190925-51410-1sfcwoo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/293963/original/file-20190925-51410-1sfcwoo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/293963/original/file-20190925-51410-1sfcwoo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/293963/original/file-20190925-51410-1sfcwoo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/293963/original/file-20190925-51410-1sfcwoo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/293963/original/file-20190925-51410-1sfcwoo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/293963/original/file-20190925-51410-1sfcwoo.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">We need to ensure that inequitable access or lack of caregiving networks do not become the default reasons for requesting a medically assisted death.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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</figure>
<p>We heard other stories of patients who were <a href="https://spcare.bmj.com/content/8/2/184">not willing to tax their caregivers any longer</a>, particularly if those caregivers sent cues that they were exhausted. </p>
<p>So, while medically assisted dying does promise control over people’s suffering, it can also be used as a form of resistance to a challenging system or depleted support. </p>
<p>We need to plan ways to ensure that inequitable access or <a href="https://www.theglobeandmail.com/canada/article-with-a-looming-aging-crisis-who-is-helping-the-caregivers/">lack of caregiving networks</a> do not become the default reasons for requesting a medically assisted death. </p>
<h2>Deeply impactful</h2>
<p>Nurses emphasized how important it is to have preparatory conversations repeatedly. Organizing an assisted death is labour-intensive for all involved; it requires thoughtful and detailed planning within the care system and among families and support networks.</p>
<p>Often the first time that patients and families hear a detailed explanation of the process is when the nurse or the physician first assesses eligibility.
Nurses said it is not uncommon for patients to experience uncertainty, to vacillate in their decision around an assisted death, or to experience fear at the moment of death. </p>
<p>It is tough to talk about your uncertainty when so many have invested time and energy into planning your death. At the time of assisted death, nurses and physicians go to extraordinary lengths to ensure a “good death” by normalizing the process, fulfilling patient wishes and providing exemplary clinical care. </p>
<p>Despite all of this, the death is often deeply impactful because it is so different than the death we have known where people gradually fade away.
Persons receiving medically assisted death are fully there one minute, and gone the next. </p>
<p>Within minutes they go from talking, to unconscious, to a grey pallour that signifies death, and this “greying” affects even seasoned health-care providers. The death can provoke an array of overwhelming emotions in health-care providers and families alike, both positive and negative.</p>
<p>With the changing landscape of medically assisted dying in Canada, the need for reflective conversations becomes ever more urgent. We need to better understand how medically assisted dying changes the nature of death to which we have become accustomed and how those changes impact all those involved.</p>
<p>[ <em>Deep knowledge, daily.</em> <a href="https://theconversation.com/ca/newsletters?utm_source=TCCA&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>. ]</p><img src="https://counter.theconversation.com/content/122000/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Barbara Pesut receives funding from Canadian Institutes of Health Research. She is affiliated with NNPBC.
</span></em></p><p class="fine-print"><em><span>Sally Thorne participates on research teams funded by Canadian Institutes of Health Research and is a member of the Board of Directors for both the Michael Smith Foundation for Health Research and the Association of Nurses and Nurse Practitioners of British Columbia.
</span></em></p>Nurses who surround the process of medically assisted dying are an important source of insight into the real conversations our society needs to have about what it’s really like.Barbara Pesut, Professor, School of Nursing, University of British ColumbiaSally Thorne, Professor, School of Nursing, University of British ColumbiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1063242018-11-09T02:23:57Z2018-11-09T02:23:57ZEncouraging suicide or committing manslaughter?<figure><img src="https://images.theconversation.com/files/244222/original/file-20181107-74783-1f0rak6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A 69-year-old man is in jail for encouraging his wife to commit suicide so he could get the $1.4 million from her life insurance policies. </span> </figcaption></figure><p>Jennifer Morant, 56, died of carbon monoxide poisoning in her car in November 2014. Last month, a jury found her husband, Graham Morant, 69, guilty of two crimes under <a href="http://www.austlii.edu.au/cgi-bin/viewdoc/au/legis/qld/consol_act/cc189994/s311.html">section 311</a> of Queensland’s <em>Criminal Code Act 1889</em>: counselling her to commit suicide, and aiding her to do so. He had repeatedly encouraged Jennifer to commit suicide (counselling), and had even driven her to a hardware store to purchase the equipment she used to kill herself (aiding).</p>
<p>Jennifer Morant suffered from chronic illnesses, including depression, anxiety and back pain. But this was not a case where a loving husband helped his terminally-ill wife to end her suffering. Instead, the Court found that Morant had been motivated by greed, and that the self-styled religious leader wanted access to the $1.4 million from his wife’s life insurance policies so he could build a religious retreat. </p>
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Read more:
<a href="https://theconversation.com/could-long-distance-bullies-in-australia-face-up-to-20-years-in-jail-for-encouraging-suicide-79908">Could long-distance bullies in Australia face up to 20 years in jail for encouraging suicide?</a>
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<p>Justice Peter Davis of the Supreme Court of Queensland sentenced Morant to ten years in <a href="http://www.austlii.edu.au/cgi-bin/viewdoc/au/cases/qld/QSC/2018/251.html">prison.</a> He is believed to be the first person in Australia to be sentenced for counselling suicide. </p>
<p>The maximum penalty for this offence in Queensland is life, but in some other jurisdictions can be as low as five years’ imprisonment - so the same offence in NSW or Victoria would attract a much lighter penalty.</p>
<p>Morant was aware his wife was thinking about killing herself, and encouraged and helped her to do so, according to the Supreme Court of Queensland. So a key question is: should he have been charged with a more serious offence, such as murder or manslaughter?</p>
<p>The answer relates to the unusual status of suicide under the criminal law, and the extent to which the law assumes people act “voluntarily” and of their own free will.</p>
<h2>The legal status of suicide</h2>
<p>For half a century, suicide has not been a crime in Australia (though in practice, of course, only attempted suicide could be prosecuted). As a result, Morant could not be found guilty of complicity - often called “aiding and abetting” - in his wife’s suicide.</p>
<p>Mostly, telling someone else to commit a crime can mean both people are charged: the person who actually did the crime is the main offender, and the person who counselled them is an accessory.</p>
<p>But for a person to be an accessory, the other person must have committed a crime. Given that suicide has been decriminalised, Morant could not be charged as an accessory to his wife’s death; her behaviour was not a crime.</p>
<h2>Suicide as a voluntary act</h2>
<p>Another issue is the voluntariness of suicide. The criminal law is reluctant to assign responsibility to a person for the voluntary acts of another.</p>
<p>Justice Davis said Jennifer Morant “voluntarily sat in the car with the windows and doors all closed” and therefore caused her own death. </p>
<p>Although this was not a matter Justice Davis was required to adjudicate, he suggested that Graham Morant did not legally cause his wife’s death and could not, therefore, be responsible for manslaughter or murder.</p>
<p>However, there is precedent in <a href="http://www.austlii.edu.au/cgi-bin/viewdoc/au/cases/vic/VicLawRp/1933/7.html?context=1;query=russell;mask_path=au/cases/vic/VicLawRp">Australia</a> and other jurisdictions which suggests that a person could be found to be guilty of manslaughter in broadly analogous circumstances. We explore this issue in a recent article in the <a href="http://journals.sagepub.com/doi/abs/10.1177/1037969X18802455">Alternative Law Journal</a>, and it is illustrated in a couple of cases from the United States.</p>
<h2>Encouraging suicide can constitute manslaughter</h2>
<p>In 1961, a Massachusetts man was <a href="http://masscases.com/cases/sjc/343/343mass19.html">convicted of involuntary manslaughter</a> after encouraging and helping his wife to commit suicide. </p>
<p>After he told her that he was going to obtain a divorce, she threatened suicide. He said she had tried twice before and was too “chicken”, then told her to get a rifle they owned, loaded it for her and told her how to position it so she could shoot herself. She did so, killing herself, and he was convicted of manslaughter.</p>
<p>In another US case, currently <a href="http://www.bostonherald.com/news/local_coverage/2018/10/sjc_hears_michelle_carter_s_appeal_for_freedom">pending a decision by an appeal court</a>, a woman, now 22, was found guilty last year of involuntary manslaughter after texting her suicidal boyfriend with messages encouraging him to take his life. </p>
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Read more:
<a href="https://theconversation.com/will-guilty-verdict-in-teen-texting-suicide-case-lead-to-new-laws-on-end-of-life-issues-79712">Will guilty verdict in teen texting suicide case lead to new laws on end-of-life issues?</a>
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<p>Prosecuting someone like Graham Morant for manslaughter should not be dismissed as fanciful. According to court judgements in this case, the Morants had been married 14 years, and his wife had previously contemplated suicide and was thinking of it in the days before her death. The prosecution also argued that he had told her that she ‘was not strong enough to survive the raptures which were imminent’, a reference to his belief the end-times were coming.</p>
<p>When sentencing Morant, Justice Davis said that he “took advantage of her vulnerability as a sick, depressed woman”.</p>
<p>In short, the court found that Graham Morant exploited both his wife’s vulnerable mental state and the trust inherent in their intimate relationship in order to benefit financially from her death.</p>
<p>We as a society are becoming increasingly aware of the effects of psychological coercion in the context of family violence, and the extent to which a person can overbear the free will of their partner. Consequently, Justice Davis’ conclusion that it wasn’t necessary to make detailed findings about Jennifer Morant’s emotional state or mental health is perhaps surprising.</p>
<h2>Greed versus compassion</h2>
<p>There are, of course, numerous issues to be addressed before people are held responsible for manslaughter for causing someone else’s suicide. </p>
<p>For instance, one key issue concerns motivation. Should the law respond differently to financially-motivated offenders and altruistically motivated offenders whose behaviour is driven by love (such as <a href="https://www.abc.net.au/news/2013-02-26/husband-avoids-jail-in-voluntary-euthanasia-case/4540870">Heinz Klinkermann in Victoria</a>)?</p>
<p>In the United Kingdom, for example, prosecutors are expressly told to take into account whether the offender was “wholly motivated by compassion” when deciding whether to even prosecute someone for causing <a href="https://www.cps.gov.uk/legal-guidance/suicide-policy-prosecutors-respect-cases-encouraging-or-assisting-suicide">another person’s suicide</a>.</p>
<p>Whatever approach we adopt, it is important that an accused’s criminal conviction is commensurate with their moral culpability.</p>
<p><em>* If this article raises any concerns for you, please contact Lifeline on 13 11 14 or BeyondBlue on 1300 22 4636.</em></p><img src="https://counter.theconversation.com/content/106324/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A 69-year-old man is in jail for encouraging his wife to suicide but some have wondered why he wasn’t charged with a more serious offence.Marilyn McMahon, Deputy Dean, School of Law, Deakin UniversityDr Paul McGorrery, PhD Candidate in Criminal Law, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/875702018-01-08T03:57:04Z2018-01-08T03:57:04ZHow does assisting with suicide affect physicians?<figure><img src="https://images.theconversation.com/files/200845/original/file-20180104-26169-16fulj.jpg?ixlib=rb-1.1.0&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/medical-syringe-doctors-hands-on-patients-398371651?src=zApkQ3soziZScBtoFq1Sig-1-1">Art_Photo via www. Shutterstock.com</a></span></figcaption></figure><p>When my mother was in her final months, suffering from a heart failure and other problems, she called me to her bedside with a pained expression. She took my hand and asked plaintively, “How do I get out of this mess?” </p>
<p>As a physician, I dreaded the question that might follow: Would I help her end her life by prescribing a lethal drug?</p>
<p>Fortunately for me, my mother tolerated her final weeks at home, with the help of hospice nurses and occasional palliative medication. She never raised the thorny question of what is variously termed “medical aid in dying” or <a href="https://www.medscape.com/viewarticle/885866#vp_2">“physician-assisted suicide.”</a> </p>
<p>As a son and family member who has witnessed the difficult final days of parents and loved ones, I can understand why support for MAID/PAS is <a href="http://news.gallup.com/poll/183425/support-doctor-assisted-suicide.aspx">growing</a> among the general public. But as a physician and medical ethicist, I believe that MAID/PAS flies in the face of a 2,000-year imperative of Hippocratic medicine: “Do no harm to the patient.”</p>
<p>Studies point out that even many doctors who actually participate in MAID/PAS remain uneasy or <a href="https://jamanetwork.com/journals/jama/article-abstract/187854%5D">“conflicted”</a> about it. In this piece, I explore their ambivalence.</p>
<h2>Assisted suicides</h2>
<p>In discussing end-of-life issues, both the general public and physicians themselves need to distinguish three different approaches.</p>
<p>MAID/PAS involves a physician’s providing the patient with a prescription of a lethal drug that the patient could take anytime to end life. In contrast, active euthanasia or <a href="http://www.bbc.co.uk/ethics/euthanasia/overview/introduction.shtml">“mercy killing”</a> involves causing the death of a person, typically through a lethal injection given by a physician. Finally, the term “passive euthanasia” refers to hastening the death of a terminally ill person by removing some vital form of support. An example would be disconnecting a respirator.</p>
<h2>Increasing international acceptance</h2>
<p>In the U.S. some form of legislatively approved MAID/PAS (but not active euthanasia) is <a href="https://euthanasia.procon.org/view.resource.php?resourceID=000132">legal</a> in five states and the District of Columbia. In my home state – following a passionate debate – the Massachusetts Medical Society recently decided to <a href="http://www.masslive.com/news/index.ssf/2017/12/mass_medical_society_rescinds.html">rescind its long-held opposition</a> to the practice. MMS has taken a position of <a href="http://www.masslive.com/news/index.ssf/2017/12/mass_medical_society_rescinds.html">“neutral engagement,”</a> which it claims will allow it to “serve as a medical and scientific resource … that will support shared decision making between terminally ill patients and their trusted physicians.” </p>
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<img alt="" src="https://images.theconversation.com/files/200846/original/file-20180104-26163-fz1u4h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/200846/original/file-20180104-26163-fz1u4h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=437&fit=crop&dpr=1 600w, https://images.theconversation.com/files/200846/original/file-20180104-26163-fz1u4h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=437&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/200846/original/file-20180104-26163-fz1u4h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=437&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/200846/original/file-20180104-26163-fz1u4h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=549&fit=crop&dpr=1 754w, https://images.theconversation.com/files/200846/original/file-20180104-26163-fz1u4h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=549&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/200846/original/file-20180104-26163-fz1u4h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=549&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">Physician-assisted suicide is finding more acceptance.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-doctor-giving-helping-hands-elderly-262436840">Ocskay Bence</a></span>
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<p>In a few countries, MAID/PAS has grown increasingly common. In Canada, for example, MAID/PAS was <a href="http://www.npr.org/sections/thetwo-way/2016/06/18/482599089/canada-legalizes-physician-assisted-dying">legalized in 2016</a>. In Belgium and the Netherlands, both <a href="https://www.washingtonpost.com/opinions/europes-morality-crisis-euthanizing-the-mentally-ill/2016/10/19/c75faaca-961c-11e6-bc79-af1cd3d2984b_story.html?utm_term=.94c68af85b89">active euthanasia and physician-assisted suicide </a> are permitted by law, even for patients whose illnesses may be treatable, as with major depression; and whose informed consent may be compromised, as in Alzheimer’s disease. In the Netherlands, a proposed <a href="http://thefederalist.com/2017/06/30/netherlands-considers-euthanasia-healthy/">“Completed Life Bill”</a> would allow any persons age 75 or over who decide their life is “complete” to be euthanized – even if the person is otherwise healthy. </p>
<h2>U.S. physician response</h2>
<p>Among U.S. physicians, MAID/PAS remains controversial, but national data point to its increasing acceptance. A report published in December 2016 found 57 percent of <a href="http://www.healthleadersmedia.com/physician-leaders/poll-many-doctors-have-wished-patient-had-right-die">doctors agreed that physician-assisted death</a> should be
available to the terminally ill – <a href="http://www.healthleadersmedia.com/physician-leaders/poll-many-doctors-have-wished-patient-had-right-die">up from 54 percent in 2014 and 46 percent</a> in 2010. </p>
<p>Perhaps this trend is not surprising. After all, what sort of physician would want to deny dying patients the option of ending their suffering and avoiding an agonizing, painful death? </p>
<p>But this question is misleading. Most persons requesting PAS are not actively experiencing extreme suffering or inadequate pain control. Data from the Washington and Oregon PAS programs show that <a href="http://www.nejm.org/doi/full/10.1056/NEJMsa1213398">most patients choose PAS</a> because they fear loss of dignity and control over their own lives.</p>
<h2>Some physicians feel conflicted</h2>
<p>Physicians who carry out assisted suicide have a wide variety of emotional and psychological responses. In a structured, in-depth <a href="https://jamanetwork.com/journals/jama/article-abstract/187854">telephone interview survey</a> of 38 U.S. oncologists who reported participating in euthanasia or PAS, more than half of the physicians received “comfort” from having carried out euthanasia or PAS. </p>
<p>“Comfort” was not explicitly defined, but, for example, these physicians felt that they had helped patients end their lives in the way the patients wished. However, nearly a quarter of the physicians regretted their actions. Another 16 percent reported that the emotional burden of performing euthanasia or PAS adversely affected their medical practice.</p>
<p>For example, one physician felt so “burned out” that he moved from the city in which he was practicing to a small town. </p>
<p>Other data support the observation that MAID/PAS can be emotionally disturbing to the physician. </p>
<p><a href="http://www.ohsu.edu/xd/education/schools/school-of-medicine/departments/clinical-departments/radiation-medicine/about/faculty-staff/kenneth-stevens.cfm">Kenneth R. Stevens Jr.</a>, an emeritus professor at Oregon Health and Science University, reported that for some physicians in Oregon, <a href="http://www.tandfonline.com/doi/pdf/10.1080/20508549.2006.11877782?needAccess=true">participation in PAS was very stressful</a>. For example, in 1998, the first year of Oregon’s “Death with Dignity Act,” 14 physicians wrote prescriptions for lethal medications for the 15 patients who died from physician-assisted suicide.</p>
<p>The state’s annual 1998 report observed that:</p>
<blockquote>
<p>“For some of these physicians, the process of participating in physician-assisted suicide exacted a large emotional toll, as reflected by such comments as, ‘It was an excruciating thing to do … it made me rethink life’s priorities,’ ‘This was really hard on me, especially being there when he took the pills,’ and ‘This had a tremendous emotional impact.’”</p>
</blockquote>
<p>Similarly, reactions among European doctors suggest that PAS and euthanasia <a href="http://www.tandfonline.com/doi/abs/10.1080/20508549.2006.11877782">often provoke strong negative feelings</a>. </p>
<h2>Why the discomfort?</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/200848/original/file-20180104-26166-i5b9sv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/200848/original/file-20180104-26166-i5b9sv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=356&fit=crop&dpr=1 600w, https://images.theconversation.com/files/200848/original/file-20180104-26166-i5b9sv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=356&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/200848/original/file-20180104-26166-i5b9sv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=356&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/200848/original/file-20180104-26166-i5b9sv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=447&fit=crop&dpr=1 754w, https://images.theconversation.com/files/200848/original/file-20180104-26166-i5b9sv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=447&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/200848/original/file-20180104-26166-i5b9sv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=447&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Feeling conflicted.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/geriatric-nurse-holding-hands-senior-man-329394167?src=zApkQ3soziZScBtoFq1Sig-1-4">Robert Kneschke</a></span>
</figcaption>
</figure>
<p>As a physician and medical ethicist, I am opposed to any form of physician assistance with a patient’s suicide. Furthermore, I believe that the term “medical aid in dying” allows physicians to avoid the harsh truth that they are helping patients kill themselves. This is also the view of the very influential <a href="http://annals.org/aim/fullarticle/2654458/ethics-legalization-physician-assisted-suicide-american-college-physicians-position-paper">American College of Physicians</a>. </p>
<p>I believe that the ambivalence and discomfort experienced by a substantial percentage of PAS-participating physicians is directly connected to the Hippocratic Oath – arguably, the most important foundational document in medical ethics. <a href="http://www.greekmedicine.net/whos_who/The_Hippocratic_Oath.html">The Oath clearly states</a>: </p>
<blockquote>
<p>“I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect.” </p>
</blockquote>
<p>In 5th century BC Greece, Hippocrates was something of a revolutionary in this respect. As the classicist and medical historian, <a href="https://academic.oup.com/jhmas/article-abstract/XXI/2/173/699618?redirectedFrom=PDF">Ludwig Edelstein</a> has <a href="https://books.google.com/books?id=ehQgAQAAMAAJ&focus=searchwithinvolume&q=hippocrates">pointed out</a> some non-Hippocratic physicians probably did provide poisons to their dying patients, in order to spare them protracted suffering. Hippocrates opposed this practice, though he did not believe that terminally ill patients should be exposed to unnecessary and futile medical treatment.</p>
<p>Palliative care specialist <a href="http://irabyock.org/about-ira-byock/">Ira Byock</a> has <a href="https://www.pbs.org/wgbh/frontline/article/the-shadow-side-of-assisted-suicide/">observed</a> that:</p>
<blockquote>
<p>“From its very inception, the profession of medicine has formally prohibited its members from using their special knowledge to cause death or harm to others. This was – and is – a necessary protection so that the power of medicine is not used against vulnerable people.” </p>
</blockquote>
<p>Indeed, when patients nearing the end of life express fears of losing control, or being deprived of dignity, <a href="https://jamanetwork.com/journals/jama/article-abstract/2482333">compassionate and supportive counseling</a> is called for
– not assistance in committing suicide.</p>
<p>To be sure, comprehensive palliative care, including home hospice nursing, should be provided to the subset of terminally ill patients who require pain relief. But as physician and ethicist <a href="https://www.aei.org/scholar/leon-r-kass/">Leon Kass</a> has <a href="https://www.firstthings.com/article/1996/08/dehumanization-triumphant">put it</a>:</p>
<blockquote>
<p>“We must care for the dying, not make them dead.”</p>
</blockquote><img src="https://counter.theconversation.com/content/87570/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ronald W. Pies does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The Massachusetts Medical Society recently reversed its long-held opposition to physician-assisted suicide. A psychiatrist notes many physicians are painfully conflicted about participating.Ronald W. Pies, Emeritus Professor of Psychiatry, Lecturer on Bioethics & Humanities at SUNY Upstate Medical University; and Clinical Professor of Psychiatry, Tufts University School of Medicine, Tufts UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/878752017-11-23T14:15:15Z2017-11-23T14:15:15ZWhy doctors need to improve the way we discuss assisted dying<p>Assisted dying can be a divisive and polarising subject. But there is one aspect on which most people probably agree – the need to improve the conversations people have about death.</p>
<p>At the moment, there is uncertainty in the UK regarding what people – especially <a href="http://www.pulsetoday.co.uk/gps-asked-to-provide-patients-with-medical-reports-for-dignitas/20000658.article">health professionals</a> – can and cannot say when the topic of assisted dying comes up. Conversation can become especially stilted when it turns to patients obtaining the medical documentation required for an assisted death abroad. </p>
<p>The situation requires <a href="http://bjgp.org/content/67/664/515">clarification</a>. Currently, if a doctor in the UK writes a specific report to help with an assisted death abroad (three organisations in Switzerland accept UK citizens), the General Medical Council (GMC) may view this as a “fitness to practice” issue. </p>
<p>However, if a doctor provides copies of medical records, even with the knowledge that they will be used for an assisted death, it is <em>not</em> a fitness to practice issue. The GMC’s position is that this would be “too far removed from the act of suicide to constitute encouragement or assistance”. Yet the doctor can still refuse this request for documentation. (The patient can then appeal to the information commissioner under the Data Protection Act 1998, but this may be unsuccessful.)</p>
<p>The desire to hasten death affects a significant proportion of dying people – not just the small proportion who undergo an assisted death. In places where a form of assistance to die is legal, such as the US state of Oregon, <a href="http://www.nejm.org/doi/full/10.1056/NEJM200002243420806#t=abstract">just 10-20%</a> have their request agreed to. The ability to talk about these desires and the presence of an option can “<a href="https://www.theguardian.com/lifeandstyle/2014/oct/26/cancer-assisted-dying-jo-beecham">make the future feel navigable</a>”.</p>
<p>It is hard to measure how common a desire to hasten death is. One study revealed it was <a href="http://spcare.bmj.com/content/1/2/140">up to 11%</a> within people in a UK hospice. The meaning behind this desire is varied, ranging from an avenue to begin talking about dying more generally through to wanting greater control.</p>
<p>I started my <a href="http://assisteddyingresearch.wordpress.com">own research</a> after noticing two major barriers in the conversations about assisted dying between doctors and patients. First, the Swiss organisations advise applicants not to divulge the reason for a request for medical documents due to the risk of refusal. Second, the uncertainty surrounding professional guidance means patients are not telling doctors about their plans or fears (and they may not be asked about them). </p>
<p>These barriers are affecting the crucial therapeutic alliance between doctor and patient. They also remove opportunities to highlight the specific needs of the dying. The fact that people change their mind about hastening their death is a reason to address their fears upfront – not push them away or ignore them. Yes, end-of-life care needs more funding, but this is of no use if those that need it do not feel they can be heard.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/196114/original/file-20171123-18012-v30qeh.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/196114/original/file-20171123-18012-v30qeh.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=416&fit=crop&dpr=1 600w, https://images.theconversation.com/files/196114/original/file-20171123-18012-v30qeh.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=416&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/196114/original/file-20171123-18012-v30qeh.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=416&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/196114/original/file-20171123-18012-v30qeh.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=523&fit=crop&dpr=1 754w, https://images.theconversation.com/files/196114/original/file-20171123-18012-v30qeh.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=523&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/196114/original/file-20171123-18012-v30qeh.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=523&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">‘Travel plans’ often go undiscussed.</span>
<span class="attribution"><span class="source">Dignity in Dying</span></span>
</figcaption>
</figure>
<p>Sadly, this is what is borne out in Dignity in Dying’s recent publication <a href="https://features.dignityindying.org.uk/true-cost-dignitas/">The True Cost: How the UK Outsources Death to Dignitas</a>. The report revealed a large discrepancy between those who felt they <em>should</em> be able to discuss these desires (82%) with those who felt that they <em>would</em> (32%). One respondent commented: </p>
<blockquote>
<p>I wish there was somebody that was medical that you could talk to and [who could] explain … I just wish there were people you could talk to.</p>
</blockquote>
<p>Another recalled a doctor saying: “You know you can’t talk about this sort of thing.”</p>
<h2>Dying to talk</h2>
<p>Throughout the publication runs a desire for openness to be able to talk about thoughts they are having, researching and acting upon. Instead, people encounter systemic obstruction, disapproving prejudgement and arbitrary practices. At its worst, the document highlights active silencing of these voices – people being told they mustn’t talk about assisted dying with anyone involved in their care. </p>
<p>Being able to talk openly about a desire to hasten death serves a vital palliative and therapeutic function. The opportunity to discuss perceptions of dying on the patient’s – rather than the profession’s – terms would help people to consider what it means (for them) to die. It could also serve to reaffirm social bonds, empower self-identity and give a voice to suffering. </p>
<p>Yet currently, people are possibly going abroad to die <a href="http://www.tandfonline.com/doi/abs/10.1080/01459740.2016.1255610">without ever talking</a> to a healthcare professional about it.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"847526849748094976"}"></div></p>
<p>Everyone wants to work towards getting our only experience of death right. For this to occur, the medical profession must avoid its dominance over end-of-life discussions, and seek instead to address the concerns of the dying – whatever they are. If not, the harm caused by the current fudge of legislative and professional guidance will not only go unrecognised, it will grow. </p>
<p>Listening and discussing requests to hasten death is not remotely illegal. The <a href="https://www.gmc-uk.org/18_JUNE_2015_When_a_patient_seeks_advice_or_information_about_assistance_to_die.pdf_61449907.pdf">GMC itself states</a> that doctors should “be prepared to listen and to discuss the reasons for the patient’s request”.</p>
<p>Improving these conversations is an urgent middle ground that both sides of the assisted dying debate can surely agree on. It is vital that the voices of the dying are heard.</p><img src="https://counter.theconversation.com/content/87875/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>1) PhD Studentship from the National Institute for Health Research: School For Primary Care Research.
2) Member of Healthcare Professionals For Assisted Dying.
The views and opinions expressed are those of the authors and do not necessarily reflect those of the NIHR, NHS or the Department of Health.</span></em></p>At the moment there is too much left unsaid.Paul Teed, PhD candidate, School of Population Health Sciences, Bristol Medical School, University of BristolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/863082017-11-05T19:17:45Z2017-11-05T19:17:45ZThe fear that dare not speak its name: how language plays a role in the assisted dying debate<figure><img src="https://images.theconversation.com/files/193134/original/file-20171103-26430-14st33e.png?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Jacques-Louis David/The Conversation</span></span></figcaption></figure><p>Arguments in the “euthanasia debate” (as it is colloquially referred to in Australia) hinge in part on the language used to describe “death”.</p>
<p>The inevitability and permanence of death make it a taboo fraught with fears (such as fear of losing loved ones, fear of the afterlife, fear of what happens to the body after death).</p>
<p>When it comes to fear, politicians are slick verbal smugglers, sneaking messages under our noses. Conservative pollsters found “global warming” was scary so they gave us “climate change”. Richard Nixon knew white voters afraid of minorities would respond well to “law and order”.</p>
<p>Those involved in the “euthanasia debate” draw on similar tactics. Are we talking about “assisted dying” – as the name of the bill suggests – or are we talking about “assisted suicide”? Does it even matter?</p>
<h2>Debating a ‘good death’ in the Victorian parliament</h2>
<p>Three terms loomed large a few weeks ago in the debate in parliament: “euthanasia”, “assisted dying” and “assisted suicide”.</p>
<p>Those who supported the <a href="https://www2.health.vic.gov.au/about/health-strategies/voluntary-assisted-dying-bill">Voluntary Assisted Dying (VAD) Bill</a> tended to use the phrase “assisted dying” throughout the debate. A preliminary token count (factoring out references to the name of the bill) shows 678 references to “assisted dying” from October 17-19. The lion’s share of these were made by the bill’s proponents.</p>
<p>Conversely, those who opposed the bill favoured the terms “euthanasia” and “assisted suicide”. There were 264 references to “euthanasia” and 205 to “assisted suicide” across the three days. These terms were most often used by the bill’s opponents.</p>
<p>In fact, the bill’s opponents took issue with its euphemistic tone. Deputy Premier James Merlino <a href="https://www.parliament.vic.gov.au/images/stories/daily-hansard/Assembly_2017/Assembly_Weekly_Aug-Dec_2017_Book_13.pdf">argued in the debate</a> that “language is important” and pointed out the reticence of the bill’s proponents to use “confronting words” like “euthanasia” or “suicide”.</p>
<p>Also during the debate, opponents made multiple references to comedian/actor Liz Carr and her show <a href="https://theconversation.com/assisted-suicide-a-musical-that-asks-us-to-think-critically-about-the-portrayal-of-euthanasia-69172">Assisted Suicide: The Musical</a>.</p>
<p>Liberal MP Robert Clark highlighted one particular scene in Carr’s play in which societies engaging in euthanasia seek the most “palatable term” for what they do. These societies acknowledge, in Clark’s words, “to call it by its true name would be a big setback for their cause”.</p>
<p>Why do these words matter to politicians? Should they matter to us?</p>
<h2>To name the tiger or to not name the tiger?</h2>
<p>Cultures avoid naming the things they fear the most.</p>
<p>The <a href="https://rowman.com/ISBN/9780739106501/Changing-Pathways-Forest-Degradation-and-the-Batek-of-Pahang-Malaysia">Batek</a>, a nomadic group inhabiting peninsular Malaysia’s tropical forests, fear and revere tigers. Consequently, hunters often use avoidance terms like “animal of the forest” or the mocking “smelly paws” to discuss them.</p>
<p>Modern English speakers linguistically dance around the concept of death with the same care and mocking humour as the Batek do the tiger. Among other things, we frame death in terms of “rest” (“rest in peace”), “loss” (for example, “my condolences on your loss”) and “a journey” for “the departed” (“pass away” originally referred to the soul’s “departure” from the body for the “journey” to heaven or hell). </p>
<p>We can also, with an irreverent nod to dark humour and idiomatic expression, “buy the farm”, “push up daisies” or “kick the bucket”. These seemingly frivolous statements can often have dark origins. For instance, “kick the bucket” is likely either a reference to suicide by hanging or an old way of killing of pigs (in both cases, the living thing is tied to a beam, and a bucket kicked from under them).</p>
<p>Such dark humour perhaps enables us to cope with death by downgrading its significance.</p>
<p>Returning to the current debate, opponents of Victoria’s VAD bill most commonly use the terms “euthanasia” and “assisted suicide”. They are sometimes used interchangeably, but also separately, as they have differing meanings (the former entails more direct involvement of a doctor or another person).</p>
<p>The Oxford English Dictionary (OED) traces the earliest uses of “euthanasia” to the mid-17th century, deriving from the Greek <em>eu-</em> “good or well” and <em>thanatos</em> “death”. It is worth noting in light of the current debate that this <em>eu-</em> also appears in “euphemism” – loosely, “good speaking”. </p>
<p>Euthanasia originally had this general sense of “good death” until the 18th and 19th centuries when it came to signify the “means” or “actions” to bring on a good death.</p>
<p>Words associated with taboo topics often taken on negative connotations, and euthanasia is no exception. We see similar processes at work with “coffin”, which once meant a “small basket” in French, and was originally a reference to the container in which we place our dead.</p>
<p>Opponents of the VAD bill also draw on the negative connotations of “assisted suicide”. Suicides are, of course, highly stigmatised. Moreover, the use of “suicide” conjures up a series of other negative words containing the element <em>–cide</em> (from the Latin “slayer of”), including “homicide” and “fratricide”.</p>
<p>Many of these <em>–cide</em> words are first noted in English in the 15th century but “suicide” (from the Latin <em>suī</em> “of oneself”) did not appear until the 18th century. Before this, the act was known, among other things, as “self-destruction”, “self-homicide”, “self-murder” and “self-slaughter”. The OED notes the first appearance of “assisted suicide” in 1976.</p>
<p>Proponents of the VAD bill favour “assisted dying”, which, of course, is in the name of the bill itself. The OED shows the first appearance of “assisted dying” in 1988 in the British magazine The Contemporary Review. It appears in an article referencing Sigmund Freud’s request that his life end early rather than suffer unduly from his inoperable cancer. </p>
<p>The term “dying” is arguably the more neutral of the two terms (though how accurately it represents the act will relate to one’s philosophical or religious viewpoint).</p>
<p>While we are squeamish about the concept of death, we may be coming to terms with the use of the word “death” itself. Linguists Keith Allan and Kate Burridge <a href="https://books.google.com.au/books/about/Forbidden_Words.html?id=b2rCLYHjDMgC&redir_esc=y">studied</a> obituaries and “In Memoriam” notices in the early 2000s, and found only a single of these contained the verb “die” or the noun “death”. </p>
<p>However, last year PhD scholar Pawel Migut studied online obituaries and found “died” to be the most common reference to the process in 12 US states (“passed away” seemingly <a href="http://mentalfloss.com/article/77544/most-distinctive-obituary-euphemism-died-each-state">remains</a> the most common euphemism across the US on the whole). </p>
<h2>Naming the tiger or slick political strategy?</h2>
<p>Politicians’ choices to use “euthanasia” and “assisted suicide” or “assisted dying” have demonstrable political impact, as evidenced by a 2013 Gallup <a href="http://news.gallup.com/poll/162815/support-euthanasia-hinges-described.aspx?utm_source=alert&utm_medium=email&utm_campaign=syndication&utm_content=morelink&utm_term=Politics">poll</a>.</p>
<p>This poll found that 70% of Americans supported ending “a patient’s life by some painless means” when they were suffering from an incurable disease. However, support dropped to 51% when Americans were asked whether they supported a request to “assist the patient to commit suicide.” </p>
<p>So then, it is worth noting that the selection of “assisted dying” or “assisted suicide” might reflect our pollies’ attitudes. But it just as equally may be an effective political act, playing to our fears of death, and those words we use to name, or either to not name, our cultural tiger.</p><img src="https://counter.theconversation.com/content/86308/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Howard Manns 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>Whether politicians refer to ‘assisted dying’, ‘assisted suicide’ or ‘euthanasia’ tells us a lot about how they feel about the issue, and the emotional response they aim to convey.Howard Manns, Lecturer in Linguistics, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/854452017-10-20T00:24:57Z2017-10-20T00:24:57ZDying a good death: what we need from drugs that are meant to end life<figure><img src="https://images.theconversation.com/files/190331/original/file-20171016-27757-1er7sj7.jpg?ixlib=rb-1.1.0&rect=7%2C43%2C1000%2C471&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There are a few drugs that can end life, and how we want to die should be considered. </span> <span class="attribution"><span class="source">from www.shutterstock.com</span></span></figcaption></figure><p>Generally speaking, health care is aimed at relieving pain and suffering. This is also the motivation behind euthanasia – the ending of one’s own life, usually in the case of terminal illness characterised by excruciating pain.</p>
<p>There has been <a href="http://www.theage.com.au/victoria/assisted-dying-euthanasia-advocates-slam-victorian-drug-cocktail-proposal-20171006-gyw7cr.html">debate in Victoria</a> about the drugs that should be used to end life if euthanasia is legalised. So which medications can we ensure would facilitate the best, medically-supervised death?</p>
<h2>Medicine as poison</h2>
<p>When it comes to the question of which medicines can, or even are meant to, kill us, the most important thing to remember is the <a href="https://www.nature.com/articles/nnano.2011.87">old adage</a>:</p>
<blockquote>
<p>The dose makes the poison.</p>
</blockquote>
<p>This concept is one on which the whole discipline of toxicology and medicines is founded. This is the meaning of the well-known symbol of the snake, wound around the bowl of Hygeia (the Greek goddess of health), representing medicine, which you see in pharmacies and medical centres around the world. The intertwining of poison and health care is a longstanding concept in the therapeutic use of medicines. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/190921/original/file-20171018-32361-1s1esrw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/190921/original/file-20171018-32361-1s1esrw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/190921/original/file-20171018-32361-1s1esrw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/190921/original/file-20171018-32361-1s1esrw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/190921/original/file-20171018-32361-1s1esrw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/190921/original/file-20171018-32361-1s1esrw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/190921/original/file-20171018-32361-1s1esrw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/190921/original/file-20171018-32361-1s1esrw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Medicine is poison - depending on the dose.</span>
<span class="attribution"><span class="source">from www.shutterstock.com</span></span>
</figcaption>
</figure>
<p>This is a very intricate science, and the reason we conduct clinical research. We need to trial different doses of new drugs to meticulously establish a safe but effective threshold for use.</p>
<p>In more practical terms, this means too much of any medicine can cause harm. Take, for example, the humble paracetamol. When taken following correct guidelines, it is a perfectly safe, effective pain killer used by millions of people worldwide. But taken in excessive quantities, it can cause irreparable liver damage, and if the patient is not given an antidote in a hospital, could lead to death.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/ruling-on-assisted-dying-drug-nembutal-sets-important-precedent-73362">Ruling on assisted dying drug Nembutal sets important precedent</a>
</strong>
</em>
</p>
<hr>
<h2>What drugs are used in assisted dying?</h2>
<p>The group of drugs most commonly used to end life is called the barbiturates. They cause the activity of the brain and nervous system to slow down. These drugs, used medicinally in small doses, can be taken short-term to treat insomnia, or seizures in emergencies. In different doses and administration techniques, these preparations can also be used as anaesthesia, to make us sleep through surgery.</p>
<p>An overdose of barbiturates is fatal. A large dose will effectively make the brain slow down to a point where it stops telling the body to keep the respiratory system working, and breathing ceases. </p>
<p>Both secobarbital capsules and pentobarbital (usually known as the brand name, Nembutal) liquid - (not to be mistaken for epilepsy medication phenobarbital) have been used either alone or in combination for physician-assisted suicide or euthanasia. They are also used in injectable forms for animal euthanasia.</p>
<p>These two products are <a href="https://link.springer.com/article/10.2165/00002512-199915050-00001">tried and tested</a>, have the advantage of years of use with the benefit of knowing the exact dose range needed, and with few adverse effects reported (such as unexpected pain, drawn-out death or failed death). </p>
<p>Their safety and efficacy in inducing a peaceful, swift and uneventful death has been <a href="https://link.springer.com/article/10.2165/00002512-199915050-00001">proven around the world</a>. They are the <a href="https://jamanetwork.com/journals/jama/fullarticle/2532018">preferred drugs</a> in the Netherlands, Belgium, Switzerland and some USA states where euthanasia is legal.</p>
<p>Other options exist, whether in combination or alone, but have limited evidence of use in euthanasia. Some drugs that cause excessive muscle relaxation and respiratory distress can end life, as can some pain killers commonly used in palliative care. </p>
<p>Drugs can also be used that fatally lower blood sugar levels, cause heart attack, or block messages from the brain to the muscles, causing paralysis. </p>
<p>While all of these drugs are legally available in Australia, they could cause a long, protracted death, with many more side effects that could cause distress and suffering at the end of life. Nembutal and its relatives are less likely to do so, with greater evidence from international practices than any other drugs that can end life.</p>
<h2>The ‘best’ death</h2>
<p>In Australia, Nembutal and secobarbital can be used for animals, but are illegal for human use. This makes implementation of the newly proposed euthanasia law in Victoria slightly more difficult. The proposed legislation does not seek to legalise the use of Nembutal and its relatives - but suggests a “drug cocktail” be concocted by a compounding pharmacist.</p>
<p>The Victorian government has reportedly <a href="http://www.theage.com.au/victoria/assisted-dying-euthanasia-advocates-slam-victorian-drug-cocktail-proposal-20171006-gyw7cr.html">approached Monash University’s pharmacy department</a> to research the kind of pill that could be developed if the legislation passes. Therefore, no final description of this product has been released. </p>
<p><a href="http://www.theage.com.au/victoria/assisted-dying-lethal-dose-set-to-be-cocktail-of-legal-drugs-washed-down-with-oj-20170920-gyl473.html">Some have suggested</a> the mixture will be in powder form made with pain killers to induce a coma and eventually cause respiratory arrest. It may also use sedatives and muscle relaxants, a drug to slow down the heart, and an anti-epileptic to prevent seizure and induce relaxation of muscles. The constituents and doses are yet to be determined.</p>
<p>It’s difficult at this early stage to predict how this concoction would work and whether it would be easier or safer to use than drugs already tried and tested. This proposed product would need to be tested and results compared, as all new drugs are. </p>
<p>What is needed is a drug or a mixture of drugs that produce a painless, relatively quick and peaceful passing. We do not wish to see further suffering in the form of seizures, prolonged distress and pain. If no solution is certain, it would be wise to fall back on simply legalising what is already tried and tested. </p>
<hr>
<p><em>If you or someone you know needs help contact Lifeline’s 24-hour helpline on 13 11 14, SANE Australia on 1800 18 7263 or the Beyondblue Info Line 1300 22 4636.</em></p><img src="https://counter.theconversation.com/content/85445/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The drug we know induces the best death for suffering patients is still illegal in Australia.Betty Chaar, Senior Lecturer, University of SydneySami Isaac, PhD Candidate (Pharmacy Practice), University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/836312017-10-10T22:47:07Z2017-10-10T22:47:07ZWho will be the doctors of death in a time of assisted suicide?<figure><img src="https://images.theconversation.com/files/189070/original/file-20171005-6575-iqsezw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Medical assistance in dying has been legal in Canada since July 2016, but there are no 'specialists' responsible for doctor-assisted suicide and many doctors are overwhelmed with requests. </span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Medical assistance in dying (MAID) became a reality in Canada when <a href="http://www.parl.ca/DocumentViewer/en/42-1/bill/C-14/royal-assent">legislation was passed</a> in July 2016. This is the hastening of death through a lethal dose of medication — either by self-ingestion (assisted suicide) or physician injection (euthanasia). </p>
<p><a href="http://www.cbc.ca/news/politics/medical-assistance-death-figures-1.4344267">More than 2,000 Canadians</a> have received MAID, administered by a number of physicians. Few of those doctors are palliative care specialists, who are purposely <a href="http://www.cspcp.ca/wp-content/uploads/2015/10/CSPCP-Key-Messages-FINAL.pdf">keeping their distance from MAID</a> to avoid further stigmatization as the physicians of death. They do not want to be associated with treatment failure, or viewed as only providing care to those who have either <a href="http://nationalpost.com/health/when-to-give-up-treatment-or-comfort-for-late-stage-cancer">given up</a> or been deemed hopeless. </p>
<p>This has left MAID without leadership or co-ordination, leading to unequal access and confusion among the public and health-care providers.</p>
<p>I am a palliative care physician at Queen’s University who teaches medical students, residents and other health-care providers. I am adjusting to the new reality of palliative care in the MAID era. Many patients and families ask me about it and a fair number receive it. One patient asked me to be there for his MAID death. </p>
<p>I speak to nursing and physician groups and at <a href="http://www.queensu.ca/eventscalendar/calendar/events/barry-smith-symposium-end-life-care-death-and-dying">public events</a> where I can be simultaneously applauded and criticized for not providing doctor-assisted suicide as part of my palliative care. At these events, there is always uncertainty about MAID: the ethics, legalities, practicalities (how, where, by whom). And there are questions about the comfort of health-care providers with an intervention aiming to administer death rather than stave it off.</p>
<h2>Doctors who improve quality of life</h2>
<p>To understand why palliative care does not wish to “own” MAID requires an understanding of the <a href="http://www.who.int/cancer/palliative/definition/en/">meaning of palliative care</a>. </p>
<p>Palliative care is an approach that improves the quality of life of patients and their families facing a life-threatening illness by preventing and relieving suffering through treatment of pain and other problems — physical, psychosocial and spiritual. It is often provided alongside disease-focused treatments like chemotherapy, radiation or surgery.</p>
<p>Traditionally, palliative care has mostly provided care to <a href="http://www.cancer.ca/en/about-us/for-media/media-releases/national/2016/palliative-care-report-2016/?region=on">patients with cancer</a>, but it is appropriate for anybody with advanced diseases of organs like the <a href="https://www.heartandstroke.ca/heart/conditions/heart-failure">heart</a>, <a href="https://www.lung.ca/copd">lung</a>, <a href="https://www.kidney.ca/kidney-disease">kidneys</a> and <a href="https://www.liver.ca/patients-caregivers/liver-diseases/cirrhosis/">liver</a>. And for those with nervous system disorders like <a href="https://www.als.ca/about-als/">ALS</a> or <a href="http://www.alzheimer.ca/en/About-dementia">dementia</a>. Palliative care is also <a href="http://www.sickkids.ca/patient-family-resources/paediatric-advance-care-team/index.html">provided to children</a> with the above illnesses and also those with congenital disorders.</p>
<p>Research shows that palliative care can <a href="https://doi.org/10.1191/026921698676226729">improve symptom control</a>, <a href="https://dx.doi.org/10.1001/jama.2009.1198">quality of life</a> and, in some cases, <a href="https://dx.doi.org/10.1056/NEJMOa1000678">lead to improved survival</a>. But palliative care is still often seen as the care provided “when nothing else can be done” and when <a href="https://dx.doi.org/10.1503/cmaj.151171">someone is close to death</a>. </p>
<p>This causes problems where patients don’t want to see palliative care “too early” and their doctors are reluctant to refer for <a href="https://dx.doi.org/10.1002/cncr.24206">similar reasons</a>. This shrinks the time in which doctors can help with symptoms and care plans for the future. A large cancer centre in the U.S. noted this problem and changed the name of their “palliative care” team to “supportive care.” </p>
<p>There was an immediate <a href="https://dx.doi.org/10.1634%2Ftheoncologist.2010-0161">41 per cent increase in referrals</a> and those referrals came earlier due to less stigma around the name.</p>
<h2>Reducing suffering, not stopping life</h2>
<p>Admittedly, palliative care and MAID are both trying to treat suffering, but the methods are different: palliative care does not try to speed up (or slow down) death whereas MAID expressly speeds up death. Palliative care tries to reduce suffering by treating physical, psychosocial and spiritual distress whereas MAID stops suffering by stopping life. </p>
<p>Before MAID was legalized, patients whose suffering couldn’t be fixed by other means would get palliative sedation to reduce their awareness and suffering until they died.</p>
<p>While most palliative care doctors don’t provide MAID, we’re not all opposed to its legalization. I support a person’s choice to hasten their death if they have “grievous and irremediable” suffering, which is the terminology used in the <a href="http://www.cbc.ca/news/politics/supreme-court-says-yes-to-doctor-assisted-suicide-in-specific-cases-1.2947487">Supreme Court decision</a>. There are some patients that, despite our best interventions, still suffer a bad death. Many more patients never get the “best” intervention as they <a href="https://beta.theglobeandmail.com/news/national/canadians-lack-proper-access-to-palliative-care-study-finds/article28122378/">can’t access expert palliative care</a> where they live or the system is too overburdened to provide care.</p>
<h2>Who will be the doctors of death?</h2>
<p>So who should have responsibility for MAID? There are no “specialists” that reliably provide MAID, and many doctors struggle to manage the requests of patients. The few doctors who provide it are generally doing it on top of their regular work, risking burnout. </p>
<p>A new group — the <a href="http://camapcanada.ca/">Canadian Association of MAID Assessors and Providers</a> — provides peer support and clinical guidelines. They are also trying to keep up with a legal landscape that is <a href="https://beta.theglobeandmail.com/news/national/ontario-judge-rules-woman-fits-criteria-for-medically-assisted-death/article35375467/">changing frequently</a>, especially around the <a href="http://www.cbc.ca/news/canada/british-columbia/assisted-dying-law-canada-moro-1.4294809">“reasonably forseeable” death</a> clause which was included in the legislation but has not been defined and thus is subject to varying interpretation.</p>
<p>They are also expecting legal challenges regarding “<a href="http://www.cbc.ca/news/politics/doctor-assisted-death-minors-1.3466769">mature minors</a>” and patients with advanced directives who are not able to request MAID, such as those with advanced dementia. Currently only adults who are mentally competent to consent at the time of the MAID procedure are eligible to receive it. Nobody can ask for MAID in a living will or have their loved ones request it on their behalf.</p>
<p>In the end, palliative care doctors, providers of MAID and the public all have the same goal: to alleviate suffering, to maximize quality of life and to respect autonomy for those suffering from life-limiting illnesses. </p>
<p>Almost everyone agrees that palliative care needs to be strengthened in Canada with more education, capacity and funding. Better palliative care will mean less suffering for patients. For those who request MAID due to their suffering, they should be able to access it in an equitable, respectful and expedient way. </p>
<p>End-of-life care remains an uncomfortable but critically important topic and is really the responsibility of everyone.</p><img src="https://counter.theconversation.com/content/83631/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Craig Goldie 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>More than 2,000 Canadians have chosen medical assistance in dying (MAID) since legalization in 2016. But palliative care doctors aren’t embracing assisted suicide as part of their job.Craig Goldie, Assistant Professor, Palliative Physician, Queen's University, OntarioLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/806602017-07-12T00:38:57Z2017-07-12T00:38:57ZDeath as a social privilege? How aid-in-dying laws may be revealing a new health care divide<figure><img src="https://images.theconversation.com/files/177397/original/file-20170707-6227-10p428h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Debbie Ziegler, mother of the late Brittany Maynard, in Sacramento in September 2015, encouraging the passage of California's End-of-Life Options Act. Maynard, who had brain cancer, had to move to Oregon so she could end her life legally in 2014. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Assisted-Suicide/e24ce7b081db4fd28c565d3fa5b71094/16/0">AP Photo/Carl Costas</a></span></figcaption></figure><p>The California Department of Public Health has just released a report that detailed the number of terminally ill patients over the past year who took advantage of the <a href="http://www.familydocs.org/eol/end-of-life-option-act">California End-of-Life Options Act</a> (EOLA), a law that allows certain patients to request a lethal dose of medication to end their lives. This report comes a year after EOLA went into effect on June 9, 2016. </p>
<p>According to the <a href="https://www.cdph.ca.gov/Pages/CDPHHome.aspx">report</a>, 258 individuals began the end-of-life process, which requires multiple oral and written requests and discussions with doctors before receiving the medication. Of this group, 90 patients received a prescription to end life but did not take it, while 111 individuals died from ingesting the drugs.</p>
<p>Supporters believe aid-in-dying laws are important for terminal patients because they provide an option to end life on their terms, rather than in a hospital or hospice setting. Indeed, there is a growing consensus in the United States in favor of aid-in-dying. According to a May 2017 Gallup Poll, <a href="http://www.gallup.com/poll/211928/majority-americans-remain-supportive-euthanasia.aspx">73 percent of U.S. adults</a> surveyed believe a doctor should be allowed to help a terminally ill patient end his or her life if the patient makes the request. Six states and the District of Columbia permit <a href="https://www.deathwithdignity.org/take-action/">aid-in-dying</a>, and more states are considering similar laws. </p>
<p>One critical question is whether these laws make the process accessible to everyone who wants this option.</p>
<p>I am a sociologist who studies aid-in-dying laws and how law influences end-of-life choice. People often ask: Who is the typical person who pursues this option? My research looks at this question with data I combined from California along with Oregon and Washington, states that have published information about the people who use aid-in-dying laws.</p>
<h2>A fairly homogeneous group</h2>
<p>In California, 258 people began the end-of-life process between June 2016 and June 2017, lower than the 431 requests in 2015 in Oregon and Washington combined. California’s EOLA may ultimately result in more requests, given the state’s large population.</p>
<p><iframe id="C1yRx" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/C1yRx/2/" height="550px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>The numbers we have – predominantly based on Oregon and Washington patients – indicate that aid-in-dying patients are more likely to be male, white, over 65 years old and with the minimum of a bachelor’s degree. </p>
<p><iframe id="HI7ws" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/HI7ws/4/" height="500" width="600" style="border: none" frameborder="0"></iframe></p>
<p>Why is a fairly homogeneous population using these laws more than others? </p>
<p>There may be many factors why these older white men are overrepresented, including access to doctors willing to help, religious beliefs or having peers with similar attitudes about aid-in-dying. </p>
<p>It is important, however, to also consider other explanations that may restrict access for certain populations. </p>
<p>Physicians are not required to help a patient who requests end-of-life options. New research shows that doctors struggle with professional and personal ethics around helping terminally ill patients and whether they should be required to inform patients who may not know about these laws. </p>
<p>Also, studies suggest racial differences about end-of-life choices are both cultural and structural. <a href="http://www.pewforum.org/religious-landscape-study/racial-and-ethnic-composition/">Pew Research Center</a> shows African-Americans and Latinos are more religious, which includes belief in God, church attendance and prayer. Virtually all <a href="http://www.telegraph.co.uk/news/politics/10969783/Religious-leaders-unite-to-condemn-assisted-dying-law.html">religions condemn aid-in-dying</a> except the Unitarian Universalist Church. Religiosity explains a possible correlation between race and attitudes concerning aid-in-dying. </p>
<p>However, <a href="http://online.liebertpub.com/doi/abs/10.1089/109662104773709369">studies</a> also report racial disparities with end-of-life care can be explained by the high cost of health care, lack of awareness regarding end-of-life care options, language barriers and high levels of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1913079/">distrust in medical professionals</a>. </p>
<p>The growing number of aid-in-dying laws in more racially diverse states may change these trends. California is more diverse than other states, so it will be a state to watch in the years to come. </p>
<h2>Barriers in life and in death</h2>
<p>As more states consider aid-in-dying laws and discussions around end-of-life options are growing, it is important to question the statistics and what they do and don’t reveal. </p>
<p>Statistics about aid-in-dying provide transparency concerning a process where patients are given an option over their end-of-life plans. Statistics also reveal that not everyone who pursues aid-in-dying actually takes the medication. In fact, <a href="https://www.cdph.ca.gov/Programs/CHSI/CDPH%20Document%20Library/CDPH%20End%20of%20Life%20Option%20Act%20Report.pdf">42 percent</a> of patients who received medication did not ingest it.</p>
<p>Some organizations are advocating on behalf of patients who would like to end their lives. Organizations such as <a href="https://www.compassionandchoices.org/communities/doctors-for-dignity/">Compassion & Choices</a> and the <a href="http://coalitionccc.org/">Coalition of Compassionate Care of California</a> work to bridge the gap between patients and providers by offering presentations to doctors and directories of medical professionals willing to help patients who choose this route.</p>
<p>The statistics are important to help identify patterns that may be the result not simply of different attitudes about end-of-life options, but rather structural barriers that keep certain groups from pursuing options at life’s end.</p><img src="https://counter.theconversation.com/content/80660/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jill D. Weinberg does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>People who seek aid in dying tend to be white men older than 65, a new analysis shows. While this could be due to religious views, here’s why it could also be because of lack of access.Jill D. Weinberg, Assistant Professor of Sociology, Tufts UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/795642017-07-05T20:07:46Z2017-07-05T20:07:46ZViewpoints: should euthanasia be available for people with existential suffering?<figure><img src="https://images.theconversation.com/files/174113/original/file-20170616-519-10jl6t1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Existential suffering refers to an individual experiencing a lack of meaning or sense of purposelessness in life.</span> <span class="attribution"><a class="source" href="https://unsplash.com/search/beach?photo=zUI1hH5uXgE">Zack Minor/Unsplash</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>Euthanasia debates often focus on people experiencing unbearable physiological or psychological suffering. But <a href="http://www.nejm.org/doi/full/10.1056/NEJMms1700606">research suggests</a> “loss of autonomy” is the primary reason for requesting euthanasia, even among patients with terminal cancer. <a href="http://jme.bmj.com/content/37/12/727.short">There have also been suggestions</a> existential suffering could be one of the main motivations behind such requests. </p>
<p>Existential suffering refers to an individual experiencing a lack of meaning or sense of purposelessness in life. Such sentiments bring feelings of weariness, numbness, futility, anxiety, hopelessness and loss of control, which may lead a dying patient to express <a href="http://www.sciencedirect.com/science/article/pii/S0272735807001341">a desire for death</a>. </p>
<p>Some <a href="http://jme.bmj.com/content/40/2/104.short">bioethicists argue</a> it is inconsistent to allow euthanasia for terminal illness but not for existential suffering, as both are a source of profound pain and distress. While existential suffering usually tracks closely with catastrophic illness, it’s worth considering a situation in which there are no motivating medical reasons for a request for euthanasia or assisted suicide. Should a person be eligible purely on the basis they no longer wish to live?</p>
<p><a href="http://www.independent.co.uk/life-style/health-and-families/health-news/gill-pharaoh-healthy-former-nurse-75-takes-own-life-at-assisted-dying-clinic-after-deciding-old-age-10433954.html">A case in point</a>: a largely healthy retired palliative care nurse in the UK who ended her life at an assisted suicide clinic in Switzerland. Should she have received medical aid in dying based on her carefully considered decision that she did not want to subject herself to the perceived awfulness of the ageing process?</p>
<hr>
<h2>The case against</h2>
<p><strong>Xavier Symons, Research Associate, University of Notre Dame Australia</strong></p>
<p>Some may think people who request euthanasia do so because of excruciating and unremitting pain. The reality is almost always more complex. <a href="https://www.ncbi.nlm.nih.gov/pubmed/19771571">Literature</a> on <a href="https://www.mja.com.au/journal/2017/206/8/euthanasia-and-physician-assisted-suicide-focus-data">assisted dying</a> suggests individuals who request euthanasia are typically suffering from a profound sense of purposelessness, loss of dignity, loss of control, and a shattered sense of self. </p>
<p>A 2011 study of Dutch <a href="https://www.ncbi.nlm.nih.gov/pubmed/21947807">patients who requested euthanasia</a> indicated that “hopelessness” – the psychological and existential realisation one’s health situation will never improve – was the predominant motivation of patients who requested euthanasia. </p>
<p>And a recently published Canadian study of <a href="http://www.nejm.org/doi/full/10.1056/NEJMms1700606">requests for medical assistance in dying</a> stated “loss of autonomy was the primary reason” motivating patients to end their lives. Symptoms also included “the wish to avoid burdening others or losing dignity and the intolerability of not being able to enjoy one’s life”.</p>
<p>One option to address such requests is to establish a state apparatus to assist patients in ending their lives. An alternative, and one I would advocate, is to address deficiencies in health care infrastructure, and attempt to alleviate the unique suffering that drives patients to request euthanasia in the first place. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/176564/original/file-20170703-32638-1foib3v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/176564/original/file-20170703-32638-1foib3v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/176564/original/file-20170703-32638-1foib3v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/176564/original/file-20170703-32638-1foib3v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/176564/original/file-20170703-32638-1foib3v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/176564/original/file-20170703-32638-1foib3v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/176564/original/file-20170703-32638-1foib3v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/176564/original/file-20170703-32638-1foib3v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Spiritual or existential care can help someone who feels their life has lost meaning.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
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<p>New approaches to end of life care, such as <a href="https://theconversation.com/spiritual-care-at-the-end-of-life-can-add-purpose-and-help-maintain-identity-55636">spiritual or existential care</a>, engage at a deep level with the complexity of the suffering of patients with terminal illness. And, as has been stressed by <a href="http://www.abc.net.au/news/2017-05-26/calls-to-prioritise-palliative-care-before-passing-euthanasia/8561960">several</a> <a href="http://www.theaustralian.com.au/opinion/columnists/paul-kelly/legalise-euthanasia-and-compassionate-society-dies-too/news-story/edac86177f0480632d02da83a2225c6d">commentators</a>, there is a need to improve access to palliative care in poorer regions, and provide optimal symptom management for patients wishing to die at home. </p>
<p>We could hypothesise about various situations where a person might request euthanasia without having a medical condition. Someone might wish to hasten their death because they are <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1467-8519.2007.00535.x/full">tired of life</a> or <a href="http://www.bbc.com/news/uk-england-london-33759490">afraid of ageing or death</a>. </p>
<p>These cases are interesting insofar as they are not motivated by an underlying pathology. Yet there is much reason for concern. </p>
<p>Sanctioning euthanasia for the tired of life veers too close to a government endorsement of suicide. Where the state has a significant stake in suicide prevention, sanctioned euthanasia for existential suffering is not only counterproductive, it’s dangerous. Fundamentally, we would erode any meaningful difference between cases of suicide we regard as acceptable, and those we see as regrettable and befitting state intervention. </p>
<p>We might regard it as regrettable that an educated, wealthy 30-year-old takes their own life due to an existential crisis. Yet it is difficult to say how this is different in morally relevant respects from a 75-year-old who feels their life is complete and is undergoing an existential crisis. </p>
<hr>
<h2>The case for</h2>
<p><strong>Udo Schuklenk, Professor and Ontario Research Chair in Bioethics, Queen’s University, Canada</strong></p>
<p>This discussion is mostly hypothetical. There seem to be few, if any, <a href="https://www.rijksoverheid.nl/binaries/rijksoverheid/documenten/rapporten/2016/02/04/rapport-adviescommissie-voltooid-leven/01-adviescommissie-voltooid-leven-voltooid-leven-over-hulp-bij-zelfdoding-aan-mensen-die-hun-leven-voltooid-achten.pdf">real-world cases</a> where a competent person’s request for an assisted death is not motivated by an irreversible clinical condition that has rendered their lives not worth living in their considered judgement.</p>
<p>For instance, <a href="https://www.rijksoverheid.nl/binaries/rijksoverheid/documenten/rapporten/2016/02/04/rapport-adviescommissie-voltooid-leven/01-adviescommissie-voltooid-leven-voltooid-leven-over-hulp-bij-zelfdoding-aan-mensen-die-hun-leven-voltooid-achten.pdf">in the Netherlands</a>, most people who ask for euthanasia and who are not suffering from a catastrophic illness, typically experience a terrible quality of life that is caused by an accumulation of usually age-related ailments. These involve anything from incontinence to deafness, blindness, lack of mobility and the like. </p>
<p>We do not give up on life for trivial reasons. Just think of the many refugees who – on a daily basis – are willing to risk their lives to escape an existence they do not consider worth living. Ending their lives is not typically on top of their to-do list. </p>
<p>The case of the anti-choice activists – who deny there is ever a justifiable reason for euthanasia – has been <a href="http://onlinelibrary.wiley.com/doi/10.1111/bioe.12372/full">intellectually and politically</a> defeated. None of the jurisdictions that have decriminalised assisted dying have reversed course, and more jurisdictions are bound to make this end-of-life choice available. </p>
<p>Public support remains strong in each permissive jurisdiction, particularly so in <a href="https://link.springer.com/article/10.1007/s00038-013-0461-6">Belgium and the Netherlands</a> where the majority of citizens support the existing laws.</p>
<p>Inevitably the question of scope must be addressed: who ought to be eligible to ask for and receive assistance in dying? If a competent person wishes to see their life ended for non-medical reasons, and asks for assistance to do so, I think <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1467-8519.2011.01939.x/abstract">a just society</a> ought to oblige him or her if the following conditions are met: </p>
<ol>
<li>the person has decisional capacity (is of “sound mind”)</li>
<li>the decision is reached voluntarily (without coercion)</li>
<li>no reasonable means are available, that are acceptable to the person, that would render their lives worth living again in their own best judgement</li>
<li>based on everything we know, the condition that motivated their request is irreversible.</li>
</ol>
<p>The view that medicine is a profession aimed only at maintaining life, regardless of a patient’s quality of life, <a href="https://us.macmillan.com/books/9780312144012">is dying its own death</a>. If a clinical, psychological or other professional intervention does not benefit a patient to such an extent that they consider their continuing existence worthwhile, by definition that is not a beneficial intervention. </p>
<p>Equally, if an intervention, at a burden acceptable to the person, renders in their considered judgement their lives worth living again, they will not ask for an assisted death.</p>
<p>In most corners of the world people have fought hard to increase their individual freedoms to live their lives by their own values. A significant state interest is harmed if the state wishes to infringe on such autonomy rights.</p>
<hr>
<p><strong>Xavier Symons</strong></p>
<p>It is true the health system, and indeed the state, should respect patient autonomy. Yet in practice we often put other considerations ahead of concerns like autonomy. Patients may not receive the treatments they request for a variety of reasons, like they may be prohibitively expensive, have a negligible chance of success, or no medical justification. </p>
<p>I believe if it is harmful to the interests of the state to legalise euthanasia for patients without a terminal illness, then the state has a right to refuse. </p>
<p>Significantly more research needs to be conducted on the social impacts of euthanasia, and physician assisted suicide, for patients without a medical condition. In this case, we have no <a href="http://www.oregon.gov/oha/ph/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Pages/index.aspx">“Oregon model”</a> – an assisted suicide regime seen by many as an example of a safe and well-regulated system – to confirm or assuage our concerns. Jurisdictions such as Oregon only allow assisted suicide for patients with a terminal illness.</p>
<hr>
<p><strong>Udo Schuklenk</strong></p>
<p>I echo Xavier’s plea to improve health care in order to improve our quality of life, and, as a likely corollary of this, to reduce the number of requests for medical aid in dying. However, even in the best of all possible health care worlds, unless unbearable suffering itself has been eliminated, some patients will ask for an assisted death. No amount of “dignity therapy” rhetoric and references to small-scale studies changes that fact of the matter. </p>
<p>Xavier correctly mentions some reasons for doctors justifiably not providing certain patient-requested medical care. They are all based in different ways on harm-to-others justifications such as resource allocation rationales, or are futility-related (arguably also a case of harm-to-others given the reality of limited health care resources). This reasoning is not applicable to the case under consideration given the self-regarding nature of the request. </p>
<p>Xavier is correct that the state would be under no obligation to legalise euthanasia for not catastrophically ill patients if that was significantly harmful to the interests of the state. However, there is no evidence that the availability of euthanasia is harmful to state interests.</p>
<hr>
<p><em>If this article has raised issues for you or anyone you know, call or visit Lifeline 13 11 14 <a href="http://www.lifeline.org.au">www.lifeline.org.au</a>, or the Suicide Call Back Service 1300 659 467 <a href="http://www.suicidecallbackservice.org.au">www.suicidecallbackservice.org.au</a></em></p><img src="https://counter.theconversation.com/content/79564/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Udo Schüklenk received funding from the Royal Society of Canada while he chaired the work of an international expert panel tasked with drafting a report on end-of-life decision-making in Canada.</span></em></p><p class="fine-print"><em><span>Xavier Symons 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>Imagine this situation: a person has no medical illness but wishes to end his or her life purely because he or she no longer wishes to live. Should they be eligible for euthanasia or assisted suicide?Xavier Symons, Research Associate, University of Notre Dame AustraliaUdo Schüklenk, Ontario Research Chair in Bioethics and Public Policy, Queen's University, OntarioLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/797122017-06-20T01:34:38Z2017-06-20T01:34:38ZWill guilty verdict in teen texting suicide case lead to new laws on end-of-life issues?<figure><img src="https://images.theconversation.com/files/174586/original/file-20170619-22108-1iz4y2f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Michelle Carter after being found guilty of involuntary manslaughter.</span> <span class="attribution"><span class="source">AP/ Glenn C. Silva</span></span></figcaption></figure><p>In Massachusetts, a 17-year-old girl named Michelle Carter repeatedly urged her boyfriend, who had a history of mental illness, to kill himself. And <a href="http://www.bostonglobe.com/metro/2017/06/16/michelle-carter-guilty-suicide-testing-trial/To0pxezEP0hArZdX8k0DtN/story.html">then, he did</a>.</p>
<p>As Conrad Roy III sat in his truck in 2014 and was overcome by carbon monoxide, he had second thoughts. With everything going as planned, he got scared, opened the door and got out. That’s when Carter sent him <a href="http://law.justia.com/cases/massachusetts/supreme-court/2016/sjc-12043.html">a text message</a> that said, as she recounted later to a friend: “I fucking told him to get back in… because I knew he would do it all over again the next day and I couldn’t have him live the way he was living anymore. I couldn’t do it I wouldn’t let him.”</p>
<p>After reading Carter’s message, 18-year-old Roy, who’d been receiving Carter’s text messages throughout the evening urging him to go ahead with his suicide plan, got back into the truck and breathed his last.</p>
<p>A tragedy? Of course. An atrocious and cold-hearted action by Carter? Obviously. Morally contemptible? By almost any ethical standard. </p>
<p>But as a law professor and defense attorney, I note two additional questions that come to my mind. First, was it criminal? And second, what are the implications for the judge’s verdict finding Carter guilty of manslaughter?</p>
<h2>Words alone?</h2>
<p>Massachusetts does not have a law specifically outlawing one person encouraging another to commit suicide. Some have criticized the verdict on that ground. But the common law (that is, the law developed over time by judges) of homicide in the Commonwealth of Massachusetts has <a href="http://law.justia.com/cases/massachusetts/supreme-court/2016/sjc-12043.html">recognized for 200 years</a> that what Carter did was a crime.</p>
<p>In 1816, <a href="http://www.wsc.mass.edu/mhj/pdfs/murder%20by%20counseling.pdf">George Bowen</a>, described at the time as a “hardened and abandoned wretch” serving time in the Northampton jail for petty larceny, convinced a prisoner in the cell next to his to kill himself, one day before the prisoner’s scheduled execution. Bowen was placed on trial for murder. Isaac Parker, the chief justice of the Supreme Judicial Court, instructed the jury that if they were convinced beyond a reasonable doubt that Bowen’s words “procure[d] the death” of his prison neighbor, then they should return a guilty verdict. Bowen’s jury acquitted him. But the legal principle remained, a point recognized by the <a href="https://supreme.justia.com/cases/federal/us/521/702/case.html">United States Supreme Court in 1997</a> when it relied on the Bowen decision in a case holding that there is no constitutional right to assisted suicide. </p>
<p>In 2016, when Michelle Carter’s lawyers challenged the manslaughter indictment against her, Justice Parker’s successors upheld the notion that someone’s words alone can be the deciding factor in a homicide case if they are uttered in a context that makes them reckless and wanton, and actually cause another’s death.</p>
<p>The judge in the Carter case, who decided the case once she chose to have a trial without a jury, found exactly that. He concluded that the evidence showed Carter’s words actually caused Conrad’s suicide that night, and that she uttered them with a reckless and wanton disregard for their probable consequence. The guilty verdict, for all the controversy over whether words alone can kill, was well within the mainstream of Massachusetts law.</p>
<p>But what is more troubling are the implications of the verdict. </p>
<h2>End-of-life advice</h2>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/174584/original/file-20170619-22108-1e5i185.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/174584/original/file-20170619-22108-1e5i185.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/174584/original/file-20170619-22108-1e5i185.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=410&fit=crop&dpr=1 600w, https://images.theconversation.com/files/174584/original/file-20170619-22108-1e5i185.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=410&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/174584/original/file-20170619-22108-1e5i185.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=410&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/174584/original/file-20170619-22108-1e5i185.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=515&fit=crop&dpr=1 754w, https://images.theconversation.com/files/174584/original/file-20170619-22108-1e5i185.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=515&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/174584/original/file-20170619-22108-1e5i185.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=515&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">California lawmakers hear testimony on proposed legislation allowing doctors to prescribe life-ending medication to terminally ill patients in 2015.</span>
<span class="attribution"><span class="source">AP Photo/Rich Pedroncelli, File</span></span>
</figcaption>
</figure>
<p>Of course, the judge’s actions decided only the case before him. But now the genie is out of the bottle. Who else might find the engine of the criminal justice system bearing down on him or her because of words less morally bankrupt than Michelle Carter’s? </p>
<p>Do doctors <a href="https://scholar.google.com/scholar_case?case=15777514628045960849&hl=en&as_sdt=6&as_vis=1&oi=scholarr">advising patients</a> about <a href="http://law.justia.com/cases/new-mexico/supreme-court/2016/35-478.html">end-of-life</a> decisions have to worry about criminal prosecution if a patient stops taking medicine and dies as a result? Will family members have to urge their terminal relatives to do everything in their power to stay alive, lest they be prosecuted on the same theory as Carter’s?</p>
<p>In practical terms, such prosecutions will be possible only when the authorities find out about them. Unless you leave a trail of emails and text messages behind, you’re less likely to be found out. But that is not solace enough. A criminal law that is broad enough to encompass behavior that should not be punished can create unwarranted fear. And no one seriously contends that doctors or relatives counseling mature adults close to death should have to act in the shadow of a potential homicide prosecution.</p>
<p>We could just depend on the good sense of our elected prosecutors to stay their hand in such cases. But those who responsibly participate in end-of-life decisions by others should not have to rely on the discretion of people who are in the business of administering our system of punishment. </p>
<p>The <a href="http://law.justia.com/cases/massachusetts/supreme-court/2016/sjc-12043.html">Massachusetts Supreme Judicial Court’s opinion</a> allowing the Carter case to go to trial gave a subtle hint that it would not look kindly on an extension of its ruling to these kinds of cases. The opinion took pains to point out that what Carter did was substantively different from the situation of “a person offering support, comfort, and even assistance to a mature adult who, confronted with such circumstances, has decided to end his or her life.”</p>
<p>But this kind of limiting language in a court’s opinion is simply dicta, or nonbinding. To provide a concrete and meaningful limit to the principle on which Carter was convicted would require legislative action, certainly in Massachusetts where the Carter verdict will have the most impact.</p>
<p>Perhaps it is now time for the Commonwealth’s laws to address this issue directly, eliminating all doubts about whether “words can kill,” and providing a safe harbor for those whose soothing words seek to make a dying person’s last days more tranquil. Massachusetts’ reaction to this tragic case can be a model for the nation.</p><img src="https://counter.theconversation.com/content/79712/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David Rossman does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>When do words at an end-of-life decision constitute a crime? A law professor explains why lawmakers should act to clear up the gray area that remains.David Rossman, Professor of Law, Boston UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/760792017-05-01T07:46:26Z2017-05-01T07:46:26ZFactCheck Q&A: do 80% of Australians and up to 70% of Catholics and Anglicans support euthanasia laws?<figure><img src="https://images.theconversation.com/files/164777/original/image-20170411-31879-xfdeki.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Author Nikki Gemmell speaking on Q&A. </span> <span class="attribution"><span class="source">ABC Q&A</span></span></figcaption></figure><p><strong>The Conversation fact-checks claims made on Q&A, broadcast Mondays on the ABC at 9:35pm. Thank you to everyone who sent us quotes for checking via <a href="http://www.twitter.com/conversationEDU">Twitter</a> using hashtags #FactCheck and #QandA, on <a href="http://www.facebook.com/conversationEDU">Facebook</a> or by <a href="mailto:checkit@theconversation.edu.au">email</a>.</strong></p>
<hr>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/8nQZ7fYo8U8?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Excerpt from Q&A, April 10, 2017. Quote begins at 5.30.</span></figcaption>
</figure>
<blockquote>
<p>I’m speaking for 80% of the Australian population here who support the euthanasia laws and in terms of Catholics and Anglicans, I’m speaking for up to 70% of them as well. <strong>– Author Nikki Gemmell, speaking on Q&A, April 10, 2017.</strong></p>
</blockquote>
<p>The Victorian government is expected to introduce a bill in the second half of this year to legalise euthanasia. If passed, the laws would be the first in Australia to legalise assisted dying since the Northern Territory’s euthanasia laws were overturned in 1997. </p>
<p>During a discussion on Q&A, author Nikki Gemmell – who has been arguing to <a href="http://www.theaustralian.com.au/life/weekend-australian-magazine/by-her-own-hand/news-story/d8f599d6056b795c7756c41721fa9420?nk=5ccf14ef1fcd83b6bfe4a2862a38a2fe-1493271471">legalise euthanasia</a> since sharing the story of her mother’s <a href="http://www.abc.net.au/news/2017-03-20/nikki-gemmell-explores-euthanasia-debate-after-mothers-death/8347548">“horrifically lonely”</a> death – said 80% of Australians and up to 70% of Catholics and Anglicans support euthanasia laws.</p>
<p>Is that right?</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"851406250231218176"}"></div></p>
<p><em>(Thanks to all the Q&A viewers who requested this FactCheck: see more viewer tweets at the end of this article.)</em></p>
<h2>Checking the source</h2>
<p>When asked for sources to support her statement about Australians’ support for euthanasia laws, Gemmell supplied The Conversation with a table listing 10 polls conducted in Australia on the topic of euthanasia between 2007 and 2016. </p>
<p>The table shows support for euthanasia ranging between 66% and 85% over the years from 2007-16. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/166224/original/file-20170421-12658-1twswrk.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/166224/original/file-20170421-12658-1twswrk.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/166224/original/file-20170421-12658-1twswrk.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=383&fit=crop&dpr=1 600w, https://images.theconversation.com/files/166224/original/file-20170421-12658-1twswrk.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=383&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/166224/original/file-20170421-12658-1twswrk.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=383&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/166224/original/file-20170421-12658-1twswrk.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=481&fit=crop&dpr=1 754w, https://images.theconversation.com/files/166224/original/file-20170421-12658-1twswrk.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=481&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/166224/original/file-20170421-12658-1twswrk.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=481&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Opinion poll results, Australia.</span>
<span class="attribution"><span class="source">Table provided by Nikki Gemmell.</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>The Conversation has independently verified each of these polls.</p>
<p>As for her statement that up to 70% of Catholics and Anglicans support euthanasia laws, Gemmell pointed The Conversation to a <a href="http://christiansforve.org.au/public-opinion/">website</a> run by Christians Supporting Choice for Voluntary Euthanasia.</p>
<p>The website refers to a <a href="https://cdn.theconversation.com/static_files/files/4/76079-2017-04-24-polling-Dying_With_Dignity_Summary_Report_V2.pdf?1518043685">2007 Newspoll survey</a> of more than 2,400 people commissioned by <a href="https://www.dwdv.org.au/">Dying with Dignity Victoria</a>, which found 74% of Catholic/Roman Catholic respondents and 81% of Anglican/Church of England respondents surveyed thought doctors should be allowed to provide “a lethal dose to a patient experiencing unrelievable suffering and with no hope of recovery”.</p>
<p>Gemmell also provided a link to <a href="http://www.dwdnsw.org.au/documents/2013/POLL%20WHITE%20PAPER%202012.pdf">a document</a> published by <a href="http://www.yourlastright.com/">YourLastRight.com</a>, a group of seven not-for-profit pro-euthanasia societies across Australia.</p>
<p>The document refers to a <a href="https://cdn.theconversation.com/static_files/files/6/76079-2017-04-24-polling-121104_Dying_with_Dignity_Report_Revised.pdf?1518043821">2012 Newspoll survey</a> of more than 2,500 people, commissioned by YourLastRight.com. That poll asked the question:</p>
<blockquote>
<p>Thinking now about voluntary euthanasia. If a hopelessly ill patient, experiencing unrelievable suffering, with absolutely no chance of recovering asks for a lethal dose, should a doctor be allowed to provide a lethal dose, or not? </p>
</blockquote>
<p>In that poll, 77% of Catholic/Roman Catholic and 88% of Anglican/Church of England respondents said yes. </p>
<h2>A critical look at the polls</h2>
<p>The first thing to remember is that not all polls are created equal. Random sample, population-based studies, conducted in a way that maximises the opportunity to participate (such as postal surveys), with well-designed questionnaires, non-leading questions and rigorous data analysis are the “gold standard” for surveys of public opinions and beliefs. </p>
<p>A closer examination of the polls is warranted – so let’s look in more detail at the some of the key surveys Gemmell cites, including from The Australia Institute, ABC Vote Compass, Newspoll and others.</p>
<h2>Surveys that ask about people with “unrelievable suffering”</h2>
<p>First, let’s look at the Australia Institute and Newspoll results. These surveys asked whether respondents supported voluntary euthanasia for people experiencing “unrelievable suffering”, often in the context of a terminal illness. But it’s important to note that “unrelievable suffering” is only <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2265314/">one of the reasons</a> people request assistance to die.</p>
<p>In <a href="http://www.tai.org.au/node/1914">2012 the Australia Institute</a> commissioned a survey (1,422 respondents) and reported that 71% supported:</p>
<blockquote>
<p>the legalisation of voluntary euthanasia for people experiencing unrelievable and incurable physical and/or mental suffering.</p>
</blockquote>
<p>In a <a href="http://www.tai.org.au/sites/defualt/files/MR%20Survey%20results%20attitudes%20to%20voluntary%20euthanasia_8.pdf">2010 survey</a> (1,294 respondents), the Australia Institute asked: </p>
<blockquote>
<p>This question is about voluntary euthanasia. If someone with a terminal illness who is experiencing unrelievable suffering asks to die, should a doctor be allowed to assist them to die?</p>
</blockquote>
<p>75% of respondents said “yes, voluntary euthanasia should be legal”. Of the respondents who identified as Christians, 65% said voluntary euthanasia should be legal.</p>
<p>The quality of the Australia Institute research was generally acceptable. To ensure that the survey was representative of the Australian population, sampling quotas were applied by age, gender and territory, and data were post-weighted based on the profile of the adult Australian population. </p>
<p>However, I note some limitations with the 2010 Australia Institute poll: </p>
<p>a) This was an online survey, which would have excluded many older people and potentially people from lower socio-economic backgrounds who may have had limited access to computers, as well as some Aboriginal and Torres Strait Islander people. </p>
<p>In a series of <a href="http://epubs.scu.edu.au/aslarc_pubs/17/">stratified, population-based postal surveys</a> my colleagues and I conducted in Queensland and <a href="https://espace.library.uq.edu.au/view/UQ:153431">the Northern Territory</a> between 1995 and 2002, participants were asked about their level of support for “terminally ill people who decide they no longer wish to live”. In those studies, 65%-75% of respondents said euthanasia should be legally available, but those aged 75 and over were the <em>least</em> likely to agree with this.</p>
<p>There was also <a href="http://www.aph.gov.au/binaries/senate/committee/legcon_ctte/completed_inquiries/1996-99/euthanasia/report/report.pdf">concern</a> among Aboriginal and Torres Strait Islander people in the Northern Territory about the <a href="http://www.nt.gov.au/lant/parliamentary-business/committees/rotti/rotti95.pdf">introduction in 1995 of laws legalising euthanasia</a> (<a href="http://www.nt.gov.au/lant/parliamentary-business/committees/rotti/parldebate.shtml">overturned in 1997</a>). Had there been more participation among older people and Aboriginal and Torres Strait Islander people in the Australia Institute poll, the results may have shown less acceptance of voluntary euthanasia.</p>
<p>(b) The question itself was problematic. As mentioned earlier, “unrelievable suffering” is not the only reason people request assistance to die. The main reasons for requests for assistance to die include <a href="https://www.ncbi.nlm.nih.gov/pubmed/27380345">loss of control</a>, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2265314/">dignity and independence</a>; and having “had enough” or being “ready to go” – not just “unrelievable suffering”.</p>
<p>If someone is experiencing unrelievable suffering, there should be a thorough investigation of their pain and symptom management, and other causes of distress, with the option of terminal sedation for unmanageable suffering.</p>
<p>Then there are Newspoll’s findings from <a href="https://cdn.theconversation.com/static_files/files/4/76079-2017-04-24-polling-Dying_With_Dignity_Summary_Report_V2.pdf?1518043685">2007</a>, <a href="https://cdn.theconversation.com/static_files/files/5/76079-2017-04-24-polling-091005_Euthanasia_Study.pdf?1518043791">2009</a> and <a href="https://cdn.theconversation.com/static_files/files/6/76079-2017-04-24-polling-121104_Dying_with_Dignity_Report_Revised.pdf?1518043821">2012</a>, from surveys commissioned by Dying With Dignity Victoria, Dying with Dignity NSW and YourLastRight.com respectively. </p>
<p>In those surveys, 80-85% of respondents answered yes to the question:</p>
<blockquote>
<p>Thinking now about voluntary euthanasia. If a hopelessly ill patient, experiencing unrelievable suffering, with absolutely no chance of recovering asks for a lethal dose, should a doctor be allowed to provide a lethal dose, or not? </p>
</blockquote>
<p>Again, that is very leading question, which limits its credibility.</p>
<h2>Surveys with less leading questions</h2>
<p>Since 2013, the Australian Broadcasting Corporation (ABC) has run national and statewide surveys using an online tool called <a href="https://votecompass.abc.net.au/">Vote Compass</a>, developed by <a href="http://voxpoplabs.com/">data scientists from Canada</a> in collaboration with political scientists from the <a href="http://electionwatch.unimelb.edu.au/australia-2016/articles/votecompass">University of Melbourne</a>. It allows voters to respond to political and social issues on an opt-in basis.</p>
<p>The <a href="http://www.abc.net.au/news/2016-05-25/vote-compass-euthanasia/7441176">2016 Vote Compass survey</a> (201,404 respondents) found 75% of respondents strongly agreed or somewhat agreed with the statement:</p>
<blockquote>
<p>Terminally ill patients should be able to legally end their own lives with medical assistance.</p>
</blockquote>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/166443/original/file-20170424-12650-de82yb.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/166443/original/file-20170424-12650-de82yb.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/166443/original/file-20170424-12650-de82yb.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=142&fit=crop&dpr=1 600w, https://images.theconversation.com/files/166443/original/file-20170424-12650-de82yb.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=142&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/166443/original/file-20170424-12650-de82yb.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=142&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/166443/original/file-20170424-12650-de82yb.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=179&fit=crop&dpr=1 754w, https://images.theconversation.com/files/166443/original/file-20170424-12650-de82yb.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=179&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/166443/original/file-20170424-12650-de82yb.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=179&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><a class="source" href="http://www.abc.net.au/news/2016-05-25/vote-compass-euthanasia/7441176">ABC Vote Compass 2016</a></span>
</figcaption>
</figure>
<p>The same result – 75% agreement – was reported when the question was asked in the <a href="http://www.abc.net.au/news/2013-08-29/vote-compass-gay-marriage-euthanasia-abortion/4918494">2013 Vote Compass survey</a> (effective sample size of 422,403).</p>
<p>In the <a href="http://www.abc.net.au/news/2013-08-29/vote-compass-gay-marriage-euthanasia-abortion/4918494">2013</a> and <a href="http://www.abc.net.au/news/2016-05-25/euthanasia-debate:-abcs-vote-compass-reveals-how/7446590">2016</a> Vote Compass polls, 70%/71% of Catholics and 66%/68% of Protestants, respectively, strongly or somewhat agreed with the statement, as well as 77% from the Uniting Church in 2013. </p>
<p>As ABC Vote Compass itself <a href="http://www.abc.net.au/news/2016-05-12/vote-compass-data-reporting-faq/7409492">readily acknowledges</a>, Vote Compass is not a random sample, and it is not a poll. The sample is self-selected, although results are weighted to be representative of the Australian population.</p>
<p>The statement ABC Vote Compass asked people to respond to on this issue – “terminally ill people should be able to end their lives with medical assistance” – was much better than the one asked by the Australia Institute. It’s a less leading question, and doesn’t depend on unrelievable suffering.</p>
<h2>Support falls if euthanasia is not being requested for terminal illness</h2>
<p>It’s also worth noting that some polls, such as the <a href="https://www.ipsos-mori.com/Assets/Docs/Polls/economist-assisted-dying-topline-jun-2015.pdf">2015 Ipsos Mori/Economist</a> poll Gemmell cited, show support for voluntary euthanasia drops to as low as 36% if the patient’s condition is not terminal and the patient is “mentally or emotionally suffering”, rather than “physically suffering”.</p>
<p>More than 2,000 adults surveyed in Australia in 2015 were asked:</p>
<blockquote>
<p>Do you think it should be legal or not for a doctor to assist a patient aged 18 or over in ending their life, if that is the patient’s wish, provided that the patient is terminally ill (where it is believed that they have 6 months or less to live) of sound mind, and expresses a clear desire to end their life?</p>
</blockquote>
<p>73% of respondents said yes, it should be legal. They were also asked:</p>
<blockquote>
<p>Do you think it should be legal or not for a doctor to assist a patient aged 18 or over in ending their life, by the doctor administering life-ending medication?</p>
</blockquote>
<p>The “yes” response dropped to 64% for this question (which didn’t specify the patient’s health status). Support dropped again when people were asked: </p>
<blockquote>
<p>Do you think that it should be legal or not for a doctor to assist a patient in ending their life, if they are not terminally ill, but are physically suffering in a way that they find unbearable and which cannot be cured or improved with existing medical science? </p>
</blockquote>
<p>In these circumstances, 58% said “yes, it should be legal”. When the words “physically suffering” were swapped with “mentally or emotionally suffering”, support dropped to 36%. </p>
<h2>Some polls show Catholics and Christians are against euthanasia</h2>
<p>Not all polls or surveys on this issue are represented in the table that Gemmell provided. One example is the <a href="http://www.2016ncls.org.au/about/announcing-2016-ncls">National Church Life Survey</a>, conducted every five years for 25 years, which surveys churchgoers and local church leaders from more than 20 Christian denominations. It is run by <a href="http://www.ncls.org.au/">NCLS Research</a>, and is supported by the <a href="http://ume.nswact.uca.org.au/">Uniting Mission and Education</a>, the <a href="https://www.anglicare.org.au/">Anglicare</a> Diocese of Sydney, the <a href="https://www.catholic.org.au/">Australian Catholic Bishops Conference</a> and the <a href="http://www.acu.edu.au/">Australian Catholic University</a>.</p>
<p><a href="https://cdn.theconversation.com/static_files/files/7/76079-2017-04-24-polling-NCLS_Fact_Sheet_14011_Attitudes_to_euthanasia.pdf?1518043858">In 2011</a> a sample of Catholic, Anglican and Protestant churchgoers were asked:</p>
<blockquote>
<p>Do you agree or disagree: ‘People suffering from a terminal illness should be able to ask a doctor to end their life?’</p>
</blockquote>
<p>Only 24% of respondents agreed or strongly agreed; 26% were neutral or unsure, and 50% disagreed or strongly disagreed. Results broken down by denomination are as follows:</p>
<p><em>Responses to the statement “the terminally ill should be able to ask a doctor to end their life”.</em> </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/166447/original/file-20170424-24654-dvl85e.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/166447/original/file-20170424-24654-dvl85e.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/166447/original/file-20170424-24654-dvl85e.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=238&fit=crop&dpr=1 600w, https://images.theconversation.com/files/166447/original/file-20170424-24654-dvl85e.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=238&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/166447/original/file-20170424-24654-dvl85e.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=238&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/166447/original/file-20170424-24654-dvl85e.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=299&fit=crop&dpr=1 754w, https://images.theconversation.com/files/166447/original/file-20170424-24654-dvl85e.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=299&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/166447/original/file-20170424-24654-dvl85e.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=299&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><a class="source" href="http://www.ncls.org.au/default.aspx?sitemapid=7207">NCLS Research.</a></span>
</figcaption>
</figure>
<p>The question asked in this survey is a good one, and it isn’t leading. However, there is insufficient information in the report about how the data was collected to judge its validity. </p>
<p>For example, even if the results were supposed to be anonymous, information about respondents’ gender and age was collected. The surveys were collected and returned to NCLS Research by the individual churches, and church leaders were provided with the survey results relating to their parishioners. It’s possible respondents moderated their answers under those circumstances, which does cast doubt on the credibility of the survey. </p>
<p>Nevertheless, it’s reasonable to say that while higher percentages of people in the wider community who identify with specific religions express support for assisted dying, there appears to be much lower support among regular churchgoers.</p>
<h2>Verdict</h2>
<p>Nikki Gemmell’s statement that 80% of Australians and up to 70% of Catholics and Anglicans support euthanasia laws is backed up by a number of surveys – but not all. Public support can drop significantly depending on the questions asked, how the survey was conducted and who conducted it.</p>
<p>Support for voluntary euthanasia is generally higher when the question asks about patients with “unrelievable suffering” who have “absolutely no chance of recovering”. Support falls when patients do not have a terminal illness. </p>
<p>Academic research conducted between 1995 and 2002 found that a majority of Australians supported legislation allowing voluntary euthanasia. There has been surprisingly little academic research on this question since then. <strong>– Colleen Cartwright</strong></p>
<h2>Review</h2>
<p>The article is balanced and generally presents an accurate summary of the spread of opinion on assisted death.</p>
<p>The author’s comments on leading questions and on questions that specify “unrelievable suffering” are well supported by the literature.</p>
<p>It’s worth adding that “assistance” might be thought by some respondents to include stopping treatment, something that is already legal. Five of the 10 surveys in the table Nikki Gemmell provided did not specify either “suicide” or a “lethal injection”. Of course, the other five surveys showed similarly high levels of support for assisted dying.</p>
<p>A related issue is that support might be lower if a model of assisted death is specified. The Ipsos study reported 73% approval for unspecified assistance, 64% support for a doctor “administering life-ending medication” and 55% support for a doctor “prescribing life-ending medication that the patient could take”. <strong>– Charles Douglas</strong></p>
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<p>Thank you to everyone who requested this FactCheck by tweeting with the hashtags #FactCheck #QandA. </p>
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<p><em>Update: This FactCheck was updated on May 9, 2017 to add more detail about how the National Church Life Survey was conducted.</em></p>
<hr>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/162128/original/image-20170323-13486-72k52f.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/162128/original/image-20170323-13486-72k52f.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/162128/original/image-20170323-13486-72k52f.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/162128/original/image-20170323-13486-72k52f.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/162128/original/image-20170323-13486-72k52f.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/162128/original/image-20170323-13486-72k52f.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/162128/original/image-20170323-13486-72k52f.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/162128/original/image-20170323-13486-72k52f.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The Conversation FactCheck is accredited by the International Fact-Checking Network.</span>
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</figure>
<p><em>The Conversation’s FactCheck unit is the first fact-checking team in Australia and one of of the first worldwide to be accredited by the International Fact-Checking Network, an alliance of fact-checkers hosted at the Poynter Institute in the US. <a href="https://theconversation.com/the-conversations-factcheck-granted-accreditation-by-international-fact-checking-network-at-poynter-74363">Read more here</a>.</em></p>
<p><em>Have you seen a “fact” worth checking? The Conversation’s FactCheck asks academic experts to test claims and see how true they are. We then ask a second academic to review an anonymous copy of the article. You can request a check at <a href="mailto:checkit@theconversation.edu.au">checkit@theconversation.edu.au</a>. Please include the statement you would like us to check, the date it was made, and a link if possible.</em></p>
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<p><em>If this article has raised issues for you or if you’re concerned about someone you know, call Lifeline on 13 11 14.</em></p><img src="https://counter.theconversation.com/content/76079/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Colleen Cartwright previously received government funding for research through the University of Queensland and Southern Cross University.</span></em></p><p class="fine-print"><em><span>Charles Douglas has received internal research funding from the University of Newcastle to conduct research into attitudes to assisted death.</span></em></p>During a discussion on Q&A, author Nikki Gemmell said 80% of Australians and up to 70% of Catholics and Anglicans support euthanasia laws. Is that right?Colleen Cartwright, Emeritus professor, Southern Cross UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/737552017-03-03T04:53:30Z2017-03-03T04:53:30ZIn places where it’s legal, how many people are ending their lives using euthanasia?<figure><img src="https://images.theconversation.com/files/159231/original/image-20170303-24331-15wkfi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">One paper reported that between 0.3% to 4.6% of all deaths are reported as euthanasia or physician-assisted suicide in jurisdictions where they are legal.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/126396110@N06/26137241265/in/photolist-FPEcdM-p44dbM-oDVwym-yjqsr-9yLRbh-xd3QZC-wxB2qJ-xvfSQt-xcZGPN-xd7PWP-xv9Fz4-ozjqCb-5xYYyD-s3inR-9BG9eQ-cQay4s-puzqPc-6HNRj7-qRKw1f-kowQG9-2V2uSq-pdnpsG-74taDB-74sJAK-8GggAp-EnGPHB-EnGPFn-aBq5BW-55PvFX-bgc1KX-8bdRFs-q7Gre-74x5z3-bsvp45-4yk6nn-pdVvm4-2A3qv6-53Z5nP-oUoibY-oDW3YX-6h6rZp-6hC8ZU-puydo2-pdnC1X-9gUcFY-DwyaEF-crVdu9-Aj6No-5J6uam-9gR6hF">Flickr/Alberto Biscalchin</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span></figcaption></figure><p>The Victorian Parliament will consider a bill to <a href="http://www.theage.com.au/victoria/victorian-parliament-to-vote-on-assisted-dying-laws-next-year-20161208-gt6t0w.html">legalise euthanasia</a> in the second half of 2017. That follows the South Australian Parliament’s decision to <a href="http://www.abc.net.au/news/2016-11-16/voluntary-euthanasia-debate-in-south-australia-goes-to-committee/8031776">knock back</a> a voluntary euthanasia bill late last year, and the issue has also cropped up in <a href="http://www.abc.net.au/news/2017-02-24/wa-election-barnett-mcgowan-christian-safe-schools-euthanasia/8298754">the run-up</a> to the March 11 Western Australian election.</p>
<p>With the issue back in the headlines, federal Labor’s justice spokesperson, Clare O'Neil, told <a href="http://www.abc.net.au/tv/qanda/txt/s4615749.htm">Q&A</a> that in countries where the practice is legal, “very, very small” numbers of people use the laws.</p>
<p>Whether or not you agree with O'Neil’s statement depends largely on your interpretation of the subjective term “very, very small”, but there is a growing body of data available on how many people are using euthanasia or assisted dying laws in <a href="https://www.ncbi.nlm.nih.gov/pubmed/27380345">places</a> such as the Netherlands, Belgium, Luxembourg, Colombia, Canada and some US states.</p>
<h2>Assisted dying, assisted suicide and euthanasia</h2>
<p>Many people use the terms “assisted dying”, “assisted suicide” and “euthanasia” interchangeably. But, technically, these phrases can have different meanings.</p>
<p>Assisted dying (sometimes also assisted death) is where the patient himself or herself ultimately takes the medication. Euthanasia, by contrast, is usually where the doctor administers the medication to the patient. </p>
<p>Assisted suicide includes people who are not terminally ill, but who are being helped to commit suicide, whereas assisted dying refers to people who are already dying. Some reports do not, however, distinguish between assisted dying and assisted suicide, and I will not distinguish them here.</p>
<p>In some jurisdictions, the word “euthanasia” is used to refer to both assisted dying/suicide (where the patient himself or herself takes the medication) and to euthanasia (where the doctor administers the medication to the patient). So “euthanasia” can sometimes be used as a broad term to cover a range of actions.</p>
<h2>Euthanasia and assisted suicide rates around the world</h2>
<p>According to a peer-reviewed <a href="https://www.ncbi.nlm.nih.gov/pubmed/27380345">paper</a> published last year in the respected journal JAMA:</p>
<blockquote>
<p>Between 0.3% to 4.6% of all deaths are reported as euthanasia or physician-assisted suicide in jurisdictions where they are legal. The frequency of these deaths increased after legalization … Euthanasia and physician-assisted suicide are increasingly being legalized, remain relatively rare, and primarily involve patients with cancer. Existing data do not indicate widespread abuse of these practices.</p>
</blockquote>
<p>The authors of that paper said that 35,598 people died in Oregon in 2015. Of these deaths, 132, or 0.39%, were reported as physician-assisted suicides. The same paper said that in Washington in 2015 there were 166 reported cases of physician-assisted suicide (equating to 0.32% of all deaths in Washington in that year).</p>
<p>Interestingly, the same paper noted that US data show that:</p>
<blockquote>
<p>pain is not the main motivation for PAS (physician-assisted suicide)… The dominant motives are loss of autonomy and dignity and being less able to enjoy life’s activities.</p>
</blockquote>
<p>The authors said that in officially reported Belgian cases, pain was the reason for euthanasia in about half of cases. Loss of dignity is mentioned as a reason for 61% of cases in the Netherlands and 52% in Belgium.</p>
<p>A 2016 Victorian parliamentary <a href="http://www.parliament.vic.gov.au/file_uploads/LSIC_pF3XBb2L.pdf">report</a> has quoted from the UK Commission on Assisted Dying, which in turn referenced the work of John Griffiths, Heleen Weyers and Maurice Adams in their book <a href="https://books.google.com.au/books/about/Euthanasia_and_Law_in_Europe.html?id=x6YEQgAACAAJ">Euthanasia and Law in Europe</a>. The commission said:</p>
<blockquote>
<p>There are no official data in Switzerland on the numbers of assisted suicides that take place each year, as the rate of assisted suicide is not collected centrally. Griffiths et al observe that there are approximately 62,000 deaths in Switzerland each year and academic studies suggest that between 0.3% and 0.4% of these are assisted suicides. This figure increases to 0.5% of all deaths if suicide tourism is included (assisted suicides that involve non‑Swiss nationals).</p>
</blockquote>
<p>Around 3.7% of deaths in the Netherlands in 2015 were due to euthanasia. The Netherlands’ regional euthanasia review committees <a href="https://www.euthanasiecommissie.nl/uitspraken/jaarverslagen/2015/april/26/jaarverslag-2015">reported</a> that there were 5,516 deaths due to euthanasia in 2015. That is out of a <a href="https://www.statista.com/statistics/520011/total-number-of-deaths-in-the-netherlands/">total</a> of around 147,000 - 148,000 <a href="https://www.cbs.nl/en-gb/news/2016/04/population-growth-fuelled-by-immigration">deaths in the Netherlands</a> that year.</p>
<p>This figure represents an increase of 4% of deaths due to euthanasia <a href="https://www.euthanasiecommissie.nl/uitspraken/jaarverslagen/2015/april/26/jaarverslag-2015">compared to 2014</a>.</p>
<p>A 2012 <a href="https://www.ncbi.nlm.nih.gov/pubmed/22789501">paper</a> published in The Lancet reported on the results of nationwide surveys on euthanasia in the Netherlands in 1995, 2001, 2005 and 2010. The researchers said:</p>
<blockquote>
<p>In 2002, the euthanasia act came into effect in the Netherlands, which was followed by a slight decrease in the euthanasia frequency … In 2010, of all deaths in the Netherlands, 2.8% were the result of euthanasia. This rate is higher than the 1.7% in 2005, but comparable with those in 2001 and 1995.</p>
</blockquote>
<p>Another Netherlands-based <a href="http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2426428">study</a> published in the journal JAMA Internal Medicine reported in 2015 that: </p>
<blockquote>
<p>Certainly, not all requests are granted; studies conducted between 1990 and 2011 report rates of granting requests between 32% and 45%.</p>
</blockquote>
<p>A 2015 <a href="http://www.nejm.org/doi/citedby/10.1056/NEJMc1414527#t=citedby">paper</a> in the New England Journal of Medicine about euthanasia rates in the Flanders region of Belgium (the northern half of the country) noted:</p>
<blockquote>
<p>The rate of euthanasia increased significantly between 2007 and 2013, from 1.9% to 4.6% of deaths.</p>
</blockquote>
<h2>Filling in the bigger picture</h2>
<p>It can be hard to put these rates in context, but what is clear is that euthanasia is by no means a leading cause of death in countries where it is legal. For example, <a href="http://statbel.fgov.be/en/binaries/PRESS%20RELEASE%20Causes%20of%20death%202012_tcm327-267267.pdf">Statistics Belgium</a> said that for the year 2012, cardiovascular disease was the most common cause of death (28.8%), and cancer was the second most common cause of death (26%).</p>
<p>And in the Netherlands – where <a href="https://www.euthanasiecommissie.nl/uitspraken/jaarverslagen/2015/april/26/jaarverslag-2015">5,516</a> of deaths were due to euthanasia in 2015 – more than <a href="https://www.cbs.nl/en-gb/news/2015/38/number-of-dementia-related-deaths-increased-to-12-5-thousand">12,000</a> Dutch people died from the effects of dementia in 2014, approximately 10,000 Dutch people died from lung cancer and nearly 9,000 died from a heart attack. In <a href="https://www.cbs.nl/en-gb/news/2014/50/most-people-die-of-cancer-and-cardiovascular-disease">2013</a>, 30% (about 42,000) of Dutch deaths were from cancer and 27% (about 38,000) of Dutch deaths were from cardiovascular disease.</p>
<hr>
<p><em>If this article has raised issues for you or if you’re concerned about someone you know, call Lifeline on 13 11 14.</em></p><img src="https://counter.theconversation.com/content/73755/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew McGee 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>There is a growing body of evidence available on how many people are using euthanasia and assisted dying laws in places where it is legal.Andrew McGee, Senior Lecturer, Faculty of Law, Queensland University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/733622017-02-27T21:57:00Z2017-02-27T21:57:00ZRuling on assisted dying drug Nembutal sets important precedent<p>Just before Christmas 2016, the Victorian Civil and Administrative Tribunal (VCAT) handed down a historic <a href="https://www.vcat.vic.gov.au/sites/default/files/resources/Syme%20v%20Medical%20Board%20of%20Australia%20%28Review%20and%20Regulation%29%20%5B2016%5D%20VCAT%202150.pdf">judgement</a> in a case brought by the veteran advocate for assisted dying, <a href="http://www.abc.net.au/austory/content/2015/s4384763.htm">Dr Rodney Syme</a>.</p>
<p>This followed a decision, which was then referred to its immediate action committee by the <a href="http://www.medicalboard.gov.au/">Medical Board of Australia</a>, to prevent Syme from “engaging in the provision of any form of medical care, or any professional conduct in his capacity as a medical practitioner that has the primary purpose of ending a person’s life”.</p>
<p>Syme appealed to VCAT where a panel comprising a judge and two medical practitioners overruled the Medical Board. The panel declared Syme could continue to supply the rapidly acting drug Nembutal (generic names pentobarbital or pentobarbitone) to patients he assessed would get significant psychological or existential relief from it.</p>
<h2>Background to the case</h2>
<p>Police interviewed Syme three times between 2005 and 2014 about his medical practice with a particular patient. Their interest was in whether he had committed the offences of inciting suicide, and aiding and abetting suicide.</p>
<p>As Syme was prepared to have his actions tested in a court, he admitted in 2014 he had provided Nembutal to patients who had approached him about assistance with their terminal illnesses.</p>
<p>Syme told me that, despite his admissions about having provided Nembutal to the patient, the police told him that a “lack of evidence” in this case would not result in his prosecution. He formed the view that there was a “benign conspiracy” by the police to not intervene in matters of doctor-patient end-of-life care unless a “serious complaint” had been made. An example might be if there were questions surrounding lack of consent or sentience in a patient supplied with the drug. He subsequently told VCAT he had provided Nembutal to more than 100 people.</p>
<p>In November 2015 Syme was a panellist, along with fellow advocate Andrew Denton and others, on <a href="http://www.abc.net.au/tv/qanda/txt/s4325242.htm">ABC’s Q&A</a> where he very publicly repeated an account of his actions. After the program, Bernard Erica, a man dying of tongue cancer, contacted him for advice.</p>
<h2>Reported to the Medical Board</h2>
<p>In January 2016, a doctor who had been treating Erica reported Syme’s contact with Erica to the Medical Board, which convened a hearing to consider whether it should take action. It ruled that Syme posed a serious risk to persons generally and to this patient in particular.</p>
<p>It upheld its decision on further investigation, causing Syme to appeal to VCAT in an attempt to overturn the Medical Board’s ruling.</p>
<p>The core of Syme’s appeal, <a href="https://www.vcat.vic.gov.au/sites/default/files/resources/Syme%20v%20Medical%20Board%20of%20Australia%20%28Review%20and%20Regulation%29%20%5B2016%5D%20VCAT%202150.pdf">which VCAT agreed with</a>, was his:</p>
<blockquote>
<p>… practice is a form of palliative care that is directed to the palliation of the psychological and emotional suffering experienced by some patients in the end stages of terminal disease. In particular, a sense of having control over the end of one’s life is one of the most powerful tools for the relief of that psychological and existential suffering. Dr Syme’s practice therefore is directed to providing support, including information and advice, which gives that sense of control to patients.</p>
</blockquote>
<p>VCAT accepted that Syme’s primary purpose in providing Nembutal was therefore palliative care in the form of psychological relief to the dying patient who may or may not decide to eventually take the drug. The primary purpose was not to assist such patients to end their own lives, however likely this might be. However, significantly, VCAT concluded that the provision of Nembutal to provide psychological relief could have the “double effect” of ending a patient’s life.</p>
<h2>Illegal to supply Nembutal in Australia</h2>
<p>So how does an Australian doctor get Nembutal to give those patients who request psychological relief in the form of life-ending drugs to provide comfort about what may lie ahead? Here, a significant barrier emerges. Under <a href="https://www.vcat.vic.gov.au/sites/default/files/resources/Syme%20v%20Medical%20Board%20of%20Australia%20%28Review%20and%20Regulation%29%20%5B2016%5D%20VCAT%202150.pdf">cross-examination</a> during the VCAT hearing:</p>
<blockquote>
<p>Dr Syme agreed that certain barbiturates, including Nembutal, cannot be prescribed or legally obtained, by a medical practitioner and that it is probably illegal to give Nembutal to another person.</p>
</blockquote>
<p>It is illegal to dispense Nembutal in Australia unless a doctor obtains permission via the <a href="https://www.tga.gov.au/form/special-access-scheme">Special Access Scheme</a> administered by Australia’s drug regulator, the Therapeutic Goods Administration (TGA).</p>
<p>Once the TGA grants approval, the applicant (who must be a medical practitioner) then needs a permit to import it. No information has been released about whether this scheme has ever seen a request approved for Nembutal to be given to a dying patient.</p>
<p>However, here VCAT <a href="https://www.vcat.vic.gov.au/sites/default/files/resources/Syme%20v%20Medical%20Board%20of%20Australia%20%28Review%20and%20Regulation%29%20%5B2016%5D%20VCAT%202150.pdf">declared</a>:</p>
<blockquote>
<p>It should be emphasized that the Tribunal is not concerned in this application with the illegality or otherwise of Dr Syme’s conduct in obtaining the drug Nembutal or giving it to a patient. However, the Tribunal notes that Dr Syme’s conduct in this respect could hardly have been more public and there is no evidence before the Tribunal that he has ever been investigated, charged or prosecuted for any related breach of the law.</p>
</blockquote>
<p>It would seem that, like the police who had interviewed him, VCAT had joined the benign conspiracy that recognises Nembutal can be accessed but that no draconian action will be taken against individuals who manage to get hold of it.</p>
<p>There are three main ways that Nembutal now finds its way into the hands of those planning to end their life in Australia, and to doctors willing to assist in providing it for them.</p>
<h2>Ordering online</h2>
<p>Suppliers from overseas are readily found on the internet, as are many useful comments from those who have attempted both successfully and unsuccessfully to import the drug by mail order.</p>
<p>Dangers include being ripped-off when the drugs are never sent; being sent tablets that are not pentobarbitone; and having the import intercepted by customs with the possibility of fines of up to <a href="https://www.border.gov.au/Importingandbuyinggoodsfromoverseas/Documents/importingbarbiturates.pdf">A$825,000 and/or imprisonment</a>.</p>
<h2>Bringing through customs</h2>
<p>Similar risks apply to carrying the drug in through customs at airports. Annual reports from the Department of Border Protection and Immigration do not provide data on seizures of pentobarbitone. </p>
<p>Perhaps the most relevant reported data on illegal imports of pharmaceutical drugs are from 2014-15 where 7,067 intercepts of steroids and hormones were made from mail and just 314 via customs hall arrivals (<a href="https://www.border.gov.au/ReportsandPublications/Documents/annual-reports/ACBPS-Annual-report-2014-15.pdf">see p 68</a>). To put this latter figure in perspective, there were 19.13 million air and sea passenger and crew who arrived in Australian in the 2015-16 financial year (see <a href="https://www.border.gov.au/ReportsandPublications/Documents/annual-reports/ACBPS-Annual-report-2014-15.pdf">page 43</a>).</p>
<p>Syme, who has spent some 25 years gathering intelligence about the issue, is aware of importers of commercial quantities who have been prosecuted, but is unaware of cases of prosecution for possession of small quantities enough for personal use. Here, discovered drugs are confiscated, with fines said to be typically A$500-700.</p>
<h2>Diversion from veterinary sources</h2>
<p>Vets use Nembutal daily for both anaesthesia and euthanasia of sick and dying domestic, agricultural and wild animals, such as those injured by vehicles. The TGA provides a <a href="https://www.tga.gov.au/book-page/22-pentobarbital">detailed history</a> of the scheduling of pentobarbitone in Australia, starting from 1955. Its most recent decision from November 2016 is described, when a proposal to tighten the scheduling was rejected. There was concern about suicides by veterinary staff with easy access to the drug.</p>
<p>Central to this decision was the concern that a higher level of restriction would greatly compromise animal welfare; red tape frustrated ease of access to the large quantities of the drug required particularly by those vets with rural practices. Importantly, the TGA noted that the variable dose requirements for euthanasia of different sized animals would always make skimming of pentobarbitone for human voluntary euthanasia purposes possible, regardless of any regulatory schedule.</p>
<p>Because each of these three access routes are illegal, no reliable data exist about how much Nembutal today sits inside Australian houses.</p>
<p>A long-time medical friend told me many years ago that she had a supply of the needed drug in her home safe that she planned to use if she decided her remaining life was not worth living should she develop a fatal disease. Several years after she developed a degenerative disease that would eventually lead to her death, she took her own life as planned. She was surrounded by her family during her final, fully conscious day. She took the drugs on going to bed and her partner woke to find her dead next to him at 4am. He told me “she went the way she always wanted to”.</p>
<h2>Community support</h2>
<p>With surveys like <a href="http://www.abc.net.au/news/2015-03-15/nsw-voters-support-euthanasia,-vote-compass-finds/6313864">this one</a> repeatedly showing that very large proportions of the community support assisted suicide for the terminally ill who wish to end their lives at a time of their choosing, it is likely that those accessing the drug will increase, particularly as the population ages. </p>
<p>Many people imagine such a scenario for themselves, so acquiring the drug is likely to become more common if customs continue to turn a blind eye. Legislative reform may soon put an end to people needing to break the law to make this happen.</p>
<p>VCAT’s decision is of immense importance. Its decisions can be cited in evidence and so may be used as legal precedents. VCAT accepted Syme’s defence (that his supply of Nembutal to dying patients was a legitimate and important part of palliative care). This means that other doctors around Australia may seek and perhaps succeed in using a similar argument should they be questioned by disciplinary authorities like the Medical Board or the police.</p>
<p>Those with terminal illnesses wanting the right to end their own life using Nembutal have a lot for which to thank Rodney Syme.</p>
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<p><em>If this article has raised issues for you or if you’re concerned about someone you know, call Lifeline on 13 11 14 or beyondblue on 1300 22 4636.</em></p><img src="https://counter.theconversation.com/content/73362/count.gif" alt="The Conversation" width="1" height="1" />
<h4 class="border">Disclosure</h4><p class="fine-print"><em><span>Simon Chapman AO is an ambassador for Dying with Dignity. In 1995 he edited (and wrote a contribution to) Chapman S, Leeder S (eds.) The Last Right? Australians Take Sides on the Right to Die. Sydney:Mandarin, 1995 (see <a href="http://ses.library.usyd.edu.au//bitstream/2123/10762/2/TheLastRight.pdf">http://ses.library.usyd.edu.au//bitstream/2123/10762/2/TheLastRight.pdf</a>)</span></em></p>A Victorian legal precedent of how Nembutal can be used during palliative care provides more options for doctors to help their dying patients.Simon Chapman, Emeritus Professor in Public Health, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/690502016-12-02T05:13:17Z2016-12-02T05:13:17ZSouth Australia’s reasons for voting down euthanasia go against the evidence<figure><img src="https://images.theconversation.com/files/148365/original/image-20161202-25685-1bwyyc3.png?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The last four years have witnessed a sea-change in the debate on the adequacy of safeguards in protecting the vulnerable.</span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p>South Australia <a href="https://www.legislation.sa.gov.au/LZ/B/CURRENT/DEATH%20WITH%20DIGNITY%20BILL%202016_DR%20DUNCAN%20MCFETRIDGE%20MP/B_AS%20INTRODUCED%20IN%20HA/DEATH%20WITH%20DIGNITY%20BILL%202016.UN.PDF">recently voted against</a> legalising voluntary active euthanasia. The legislation failed by one vote. It was the latest of <a href="https://eprints.qut.edu.au/95429/1/Failed%20Voluntary%20Euthanasia%20Law%20Reform%20UNSWLJ.pdf">more than 50 legislative attempts</a> in Australian parliaments to change the law in this area. </p>
<p>Reform attempts are likely to continue. A bill may be released soon in Victoria following a recommendation by the <a href="http://www.parliament.vic.gov.au/lsic/inquiry/402">Legal and Social Issues Committee</a>. So we should examine why the South Australian bill did not pass to see if lessons can be learned for future bills. The key concern during the debate in South Australia was adequacy of safeguards. </p>
<p>The term “voluntary euthanasia”, both in the bill and in this article, includes assisted suicide. There are some differences; in voluntary euthanasia, the doctor administers the fatal medicine whereas, in assisted suicide, the patient administers it herself.</p>
<h2>The vulnerable are protected</h2>
<p>One major concern was if we legalise voluntary euthanasia for people who are competent and make the decision voluntarily, how can we protect those who are not and do not? “Competence” means the person requesting voluntary euthanasia must fully understand the decision. A decision is “voluntary” if it is not the result of coercion or made under the undue influence of others. </p>
<p>One safeguard for this is requiring two independent doctors to agree the patient is competent and the decision is voluntary. A second is requiring a minimum period of time to pass between the request and its fulfilment – to ensure the decision is unwavering. These are standard safeguards in legislation all over the world where euthanasia is legal (Canada, California, Oregon, Vermont, Washington, Netherlands, Belgium), and they appeared in the South Australian Bill. </p>
<p>The last four years have witnessed a sea-change in the debate on the adequacy of safeguards in protecting the vulnerable. Because euthanasia is legal in many parts of the world, we now have evidence that can show us whether safeguards are reliable. And it shows they are.</p>
<p>In a <a href="https://scc-csc.lexum.com/scc-csc/scc-csc/en/item/14637/index.do">recent Canadian case</a>, these concerns were examined at length and expert witnesses from all sides of the debate were called to give evidence that was cross-examined in court. The judge concluded the particular concern about the vulnerable was largely unfounded, a conclusion upheld by the Canadian Supreme Court.</p>
<p>An equivalent conclusion was reached by the Victorian Legal and Social Issues Committee. These findings, together with those in <a href="https://www.ncbi.nlm.nih.gov/pubmed/21191121">peer-reviewed academic research</a>, mean the vulnerability concern is no longer credible.</p>
<p>Yet some MPs did raise concerns about this aspect of the safeguards. When we look closely at their comments, it becomes clear they are demanding safeguards be fail-safe. One MP said no safeguard can be “completely fail-safe”, and declared legislation was therefore not workable. </p>
<p>We agree regulation should aim to be fail-safe, but this is to be understood as an ideal we should strive for. A perfect regulatory system is not possible. Would any of our current end-of-life legislation have been enacted if it were required to be fail-safe? For example, we know in rare cases mistakes can be made in the withdrawal of life support. But this is not an argument for making it unlawful.</p>
<p>Instead of unrealistic demands safeguards be “fail-safe” (an impossible standard for regulating human behaviour), we should be examining whether safeguards can be reliable, dependable and trustworthy. The answer to this is “yes” – as the evidence mentioned above shows.</p>
<h2>More change inevitable?</h2>
<p>The second concern raised by MPs about safeguards was the perceived inevitability legislation would be expanded over time, so a broader group of people would have access to euthanasia. Illustrative of many such comments was the following by MP Mitch Williams, who said:</p>
<blockquote>
<p>I have no confidence that the supposed safeguards in the bill before us will stand up […] The reality is that, if we look at the few other jurisdictions around the world where they have opened the gate, we can see quite clearly that the safeguards […] are being slowly watered down.</p>
</blockquote>
<p>First, there is very little evidence of change in those jurisdictions that have passed legislation. For example, 19 years ago the state of Oregon enacted physician assisted suicide for terminally ill people with less than six months to live. The legislation has not changed. </p>
<p>Belgium is one jurisdiction which has <a href="http://www.abc.net.au/news/2016-09-18/euthanasia-17-year-old-first-minor-to-be-granted-belgium/7855620">changed its laws</a> in a limited way in 2014 to allow competent, terminally ill young people to access their regime. But these reforms were preceded by careful debate and resulted in tightly framed laws. This is illustrated by it being some two and half years after these laws were introduced before it was first used – by a competent terminally ill 17 year old.</p>
<p>Second, the assumption a change to any law, by definition, is bad needs to be tackled head-on. This fails to recognise we live in a democracy, and it is open for society, through its elected MPs, to consider change if appropriate. History shows change in this field is extremely rare and when it happens, is very limited.</p>
<p>Voluntary euthanasia is a vexed issue and this includes within the parliament. But the Australian people have a right to careful debate that draws on the significant body of evidence that exists on this topic. All MPs need to engage with this evidence and consider how it impacts the arguments being raised when bills are being considered.</p><img src="https://counter.theconversation.com/content/69050/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A bill may be released soon in Victoria so we should examine why the South Australian bill did not pass to see if any lessons can be learned for future bills.Andrew McGee, Senior Lecturer, Faculty of Law, Queensland University of TechnologyBen White, Professor of Law and Director, Australian Centre for Health Law Research, Queensland University of TechnologyLindy Willmott, Professor of Law, Queensland University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/691722016-11-21T16:17:07Z2016-11-21T16:17:07ZAssisted Suicide: a musical that asks us to think critically about the portrayal of euthanasia<figure><img src="https://images.theconversation.com/files/147006/original/image-20161122-21709-ife1ni.jpg?ixlib=rb-1.1.0&rect=0%2C332%2C1997%2C1901&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Assisted Suicide: The Musical.</span> <span class="attribution"><span class="source">Unity Theatre</span></span></figcaption></figure><p>Earlier this month, Colorado voters approved a ballot that made it the fifth state to <a href="http://www.denverpost.com/2016/11/08/colorado-aid-in-dying-proposition-106-election-results/">legalise physician-assisted suicide</a> (excluding Montana, which allows it via court ruling). Discussions around this issue are understandably fraught. </p>
<p>At a time when legalisation is becoming more common, it’s now even more important that we consider how the debate around assisted dying is framed. Not only the news – but also documentaries and fictional entertainment such as novels and films contribute towards the public understanding of euthanasia. And in the main, such fictional depictions and documentaries are largely in support of assisted suicide. Unless handled carefully, such media could work to stifle the debate.</p>
<p>A musical attempting to highlight this dynamic was staged this weekend at Liverpool’s Unity Theatre as part of <a href="http://www.dadafest.co.uk/">DaDa Fest</a> – an arts festival which delivers events based around disability. <a href="http://www.southbankcentre.co.uk/whatson/assisted-suicide-the-musical-97416">Assisted Suicide: The Musical</a> is described by its creator, Liz Carr, as “a TED talk with show tunes”.</p>
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<p>Carr is a well-known disability activist, comedian and actress, who has spent a lot of time campaigning against the legalisation of assisted dying. The musical finds Carr, alongside a small cast of actors, singing a collection of catchy tunes which draw attention to various issues surrounding the debate, including the <a href="http://meloukhia.net/2012/04/choices_do_not_occur_in_a_vacuum/">contested notion of choice</a> and the <a href="https://www.theguardian.com/commentisfree/2016/nov/17/government-punish-us-disabled-disability-cuts">various social barriers</a> faced by those living with disabilities.</p>
<p>The musical is refreshing for many reasons – not least because it addresses the bias of creative work exploring this contentious issue. As <a href="https://www.theguardian.com/commentisfree/2016/sep/09/legalising-assisted-dying-dangerous-for-disabled-not-compassionate">Carr points out</a>, it’s very rare to see people with disabilities being shown to lead happy and fulfilling lives. It’s the stories in which individuals request to end their life that receive most attention.</p>
<h2>Setting agendas</h2>
<p>A film released this year called <a href="http://www.imdb.com/title/tt2674426/">Me Before You</a> played a large role in highlighting this bias. Carr and other campaigners from the group <a href="http://notdeadyetuk.org/">Not Dead Yet</a> protested against what they saw as the film’s romanticisation of euthanasia at its premiere in June of this year. </p>
<p>Based on a 2012 novel by Jojo Moyes, Me Before You tells the story of Will, a young man who is left quadriplegic after being hit by a motorcycle. On realising that his paralysis is permanent, Will requests to travel to Switzerland where he can be helped to end his life. Much of the novel is concerned with the romance that develops between Will and his carer, Louisa. Despite their feelings for one another, Will maintains that he will not change his mind about ending his life. Louisa struggles to understand how their relationship is not enough for him to want to live.</p>
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<p>Criticism of Me Before You was certainly justified – the film doesn’t do enough to criticise the social barriers Will faces nor does it delve into the mental health side of things. And yet there are individuals living with disabilities who are <a href="https://www.theguardian.com/commentisfree/2016/jun/06/why-should-not-be-allowed-to-choose-when-we-die?CMP=share_btn_tw">not wholly disappointed</a> with the way in which the film raised the issue of assisted suicide. The dialogue which emerged in response to Me Before You raised questions over the way entertainment explores these issues and its role as a means of engaging the public with the ethical debates around euthanasia.</p>
<p>Documentaries also have an important role in setting the agenda of these debates. Assisted Suicide: The Musical pokes fun at these, too. Carr believes such documentaries are intended to pull at audiences’ heartstrings by showing disabled people as pitiable – and euthanasia as a suitably compassionate response. No specific examples are mentioned but documentaries such as the BBC’s <a href="https://youtu.be/-K7ka6NDnpU">How to Die</a> and Terry Pratchett’s <a href="https://youtu.be/xsvwhuOSApI">Choosing to Die</a> undoubtedly fit the bill here. </p>
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<p>Once again, the issue is representation. It’s not so much that these portrayals are maliciously insincere, only that so few documentaries consider how disabled individuals should be assisted to live, not simply to die.</p>
<h2>Better alternatives?</h2>
<p>There do exist books and films which are, at least to my mind, more adept at handling the topic of euthanasia and disability.</p>
<p><a href="http://www.imdb.com/title/tt1198156/">You’re Not You</a> is both a novel and a film which centres on the life of Kate, a classical pianist who is diagnosed with ALS. Kate employs a carer – Bec, a college student desperate for money, who applies for the job despite a lack of experience. The narrative ends with Kate being taken off life support. Or there’s the 2011 French film <a href="https://youtu.be/34WIbmXkewU">The Intouchables</a>, loosely based on a true story in which a wealthy aristocrat hires a young man from the projects to be his caregiver. The film ends with Philippe marrying the love of his life.</p>
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<p>The difference with these narratives is their capacity to reflect nuance – to show the characters as indecisive, to show the realities of their condition while also showing them enjoying life. The key point here is uncertainty. Disability rights groups who reject physician-assisted suicide focus on the idea that it’s understandable to want to end one’s life but also that this is never permanent, just a phase.</p>
<p>Whether you agree with this perspective or not, the <a href="http://blogs.wsj.com/speakeasy/2015/09/28/with-after-you-jojo-moyes-returns-to-the-world-of-bestseller-me-before-you/">high book sales</a> of Me Before You and Carr’s sold-out musical demonstrate that the arts are a prominent platform for engaging people with social and bio-ethical issues. They may not always be successful in terms of appropriate representation, but they still promote reflection on how they participate in and frame these discussions.</p>
<p>And such reflection is to be promoted. It encourages future books, plays, films and documentaries to acknowledge the complexity of this issue and avoid attempting to provide a blueprint that must be followed in order to achieve clearly defined positive or moral outcomes.</p><img src="https://counter.theconversation.com/content/69172/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Morven Cook receives funding from University of Liverpool Centre for Humanities and Social Science of Health, Medicine and Technology. </span></em></p>There’s a problematic bias in the way that assisted suicide is portrayed in the media.Morven Cook, PhD Candidate, University of LiverpoolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/675742016-10-25T16:01:38Z2016-10-25T16:01:38ZWe have a right to die with dignity. The medical profession has a duty to assist<figure><img src="https://images.theconversation.com/files/142938/original/image-20161024-28373-yl7mbk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Desmond Tutu said on his 85th birthday early in October 2016 that he wanted the right to end his life through assisted dying.</span> <span class="attribution"><span class="source">Mike Hutchings/Reuters</span></span></figcaption></figure><p>Euthanasia represents one of the oldest issues in medical ethics. It is forbidden in the original Hippocratic Oath, and has consistently been opposed by most religious traditions since antiquity – other than, incidentally, abortion, which has only been formally banned by the Catholic Church since the middle of the 19th century.</p>
<p>Euthanasia is a wide topic with many dimensions. I will limit myself in this article to the issue of assisted death, which seems to me to be one of the most pressing issues of our time. </p>
<p>Desmond Tutu, emeritus archbishop of Cape Town, raised it again on his 85th birthday in <a href="https://www.washingtonpost.com/opinions/global-opinions/archbishop-desmond-tutu-when-my-time-comes-i-want-the-option-of-an-assisted-death/2016/10/06/97c804f2-8a81-11e6-b24f-a7f89eb68887_story.html?utm_term=.0bec1c5c4323">an article</a> in the Washington Post. He wrote:</p>
<blockquote>
<p>I have prepared for my death and have made it clear that I do not wish to be kept alive at all costs. I hope I am treated with compassion and allowed to pass onto the next phase of life’s journey in the manner of my choice.</p>
</blockquote>
<p>Assisted death can take the form of <a href="http://www.tandfonline.com/doi/abs/10.3109/07853899908998793">physician assisted suicide (PAS)</a>. Here a suffering and terminal patient is assisted by a physician to gain access to a lethal substance which the patient himself or herself takes or administers. If incapable of doing so, the physician – on request of the patient – administers the lethal substance which terminates the patient’s life. </p>
<p>The latter procedure is also referred to as <a href="http://safampract.co.za/index.php/safpj/article/viewFile/3735/4468">“voluntary active euthanasia”</a> (VAE). I will not deal with the issue of involuntary euthanasia –where the suffering patient’s life is terminated without their explicit consent -– a procedure which, to my mind, is ethically much more problematic.</p>
<h2>Passive form of euthanasia</h2>
<p>The term “voluntary active euthanasia” suggests that there also is a passive form of euthanasia. It is passive in the sense that nothing is “actively” done to kill the patient, but that nothing is done to deter the process of dying either, and that the termination of life-support which is clearly futile, is permitted. </p>
<p>However, the moral significance of the distinction between “active” and “passive” euthanasia is increasingly questioned by ethicists. The reason simply is the credibility of arguing that administering a lethal agent is “active”, but terminating life support (for example switching off a ventilator) is “passive”. Both clearly are observable and describable actions, and both are the direct causes of the patient’s death.</p>
<p>There are a number of reasons for the opposition to physician assisted suicide or voluntary active euthanasia. The value bestowed on human life in all religious traditions and almost all cultures, such as the prohibition on murder is so pervasive that it is an element of common, and not statutory, law.</p>
<p>Objections from the medical profession to being seen or utilised as “killers” rather than saviours of human life, as well as the sometimes well-founded fear of the possible abuse of physician assisted suicide or voluntary active euthanasia, is a further reason. The main victims of such possible abuse could well be the most vulnerable and indigent members of society: the poor, the disabled and the like. Those who cannot pay for prolonged accommodation in expensive health care facilities and intensive care units.</p>
<h2>Death with dignity</h2>
<p>In support of physician assisted suicide or voluntary active euthanasia, the argument is often made that, as people have the right to live with dignity, they also have the right to die with dignity. Some medical conditions are simply so painful and unnecessarily prolonged that the capability of the medical profession to alleviate suffering by means of palliative care is surpassed.</p>
<p>Intractable terminal suffering robs the victims of most of their dignity. In addition, medical science and practice is currently capable of an unprecedented prolongation of human life. It can be a prolongation that too often results in a concomitant prolongation of unnecessary and pointless suffering. </p>
<p>Enormous pressure is placed upon both families and the health care system to spend time and very costly resources on patients that have little or no chance of recovery and are irrevocably destined to die. It is, so the argument goes, not inhumane or irreverent to assist such patients – particularly if they clearly and repeatedly so request – to bring their lives to an end.</p>
<p>I am personally much more in favour of the pro-PAS and pro-VAE positions, although the arguments against do raise issues that need to be addressed. Most of those issues (for example the danger of the exploitation of vulnerable patients) I believe, can be satisfactorily dealt with by regulation.</p>
<h2>Argument in favour of assisted suicide</h2>
<p>The most compelling argument in favour of physician assisted suicide or voluntary active euthanasia is the argument in support of committing suicide in a democracy. The right to commit suicide is, as far as I am concerned, simply one of the prices we have to be willing to pay as citizens of a democracy. </p>
<p>We do not have the right, and we play no discernible role, in coming into existence. But we do have the right to decide how long we remain in existence.
The fact that we have the right to suicide, does not mean that it is always (morally) right to execute that right. </p>
<p>It is hard to deny the right of an 85-year-old with terminal cancer of the pancreas and almost no family and friends left, to commit suicide or ask for assisted death. In this case, he or she both has the right, and will be in the right if exercising that right.</p>
<p>Compare that with the situation of a 40-year-old man, a husband and father of three young children, who has embezzled company funds and now has to face the music in court. He, also, has the right to commit suicide. But, I would argue, it would not be morally right for him to do so, given the dire consequences for his family. To have a right, does not imply that it is always right to execute that right.</p>
<p>My argument in favour of physician assisted suicide or voluntary active euthanasia is thus grounded in the right to suicide, which I think is fundamental to a democracy. </p>
<p>Take the case of a competent person who is terminally ill, who will die within the next six months and has no prospect of relief or cure. This person suffers intolerably and/or intractably, often because of an irreversible dependence on life-support. This patient repeatedly, say at least twice a week, requests that his/her life be terminated. I am convinced that to perform physician assisted suicide or voluntary active euthanasia in this situation is not only the humane and respectful, but the morally justified way to go. </p>
<p>The primary task of the medical profession is not to prolong life or to promote health, but to relieve suffering. We have a right to die with dignity, and the medical profession has a duty to assist in that regard.</p><img src="https://counter.theconversation.com/content/67574/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anton van Niekerk is director of the Centre for Applied Ethics and Head of the Unit for Bioethics in that Centre. The Unit receives an annual contribution from Mediclinic, but that is not for the exclusive use of Anton van Niekerk.</span></em></p>Proponents of assisted suicide, such as emeritus archbishop Desmond Tutu, argue that as people have the right to live with dignity, they also have the right to die with dignity.Anton van Niekerk, Distinguished Professor of Philosophy and Director: Centre for Applied Ethics, Stellenbosch UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/648992016-09-08T20:45:27Z2016-09-08T20:45:27ZSteady rise in suicides will only drop if social ills are tackled<figure><img src="https://images.theconversation.com/files/136904/original/image-20160907-25231-ldgvi0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Suicide rates <a href="http://apps.who.int/iris/bitstream/10665/131056/1/9789241564779_eng.pdf?ua=1&ua=1">continue to rise</a> across both the developed and the developing worlds. This is despite many countries implementing suicide prevention programmes in line with the World Health Organisation’s guidelines.</p>
<p>Suicide rates have increased by 60% over the <a href="http://www.befrienders.org/suicide-statistics">past 45 years</a>. Globally there are 16 suicides for every 100 000 people. And for every suicide that takes place, there are about 20 attempted suicides.</p>
<p>According to the World Health Organisation there are <a href="http://www.who.int/mediacentre/news/releases/2014/suicide-prevention-report/en/">800 000 suicides</a> a year globally. This is expected to rise to 1.53 million by 2020. About 75% of the world’s suicides take place in <a href="http://www.who.int/mediacentre/news/releases/2014/suicide-prevention-report/en/">low and middle income countries</a>. </p>
<p>The research also shows that <a href="http://www.sciencedirect.com/science/article/pii/1047279794900620">men typically have a higher risk than women</a> for completing suicide but more women attempt suicide than men. </p>
<p><a href="http://jmh.sagepub.com/content/10/4/338.full.pdf+html">Our research</a> shows that in South Africa young men are more likely to than ever before to engage in suicidal behaviour because they cannot live up to the expectations placed on them as well as how society views men. </p>
<p>Despite decades of research, preventing suicides remain a problem. The main challenge is that suicide prevention programmes are typically bio-medical and focus primarily on identifying people at risk and promoting access to psychiatric care. </p>
<p>These approaches are often grounded in the assumption that suicidal behaviour is a symptom of psychopathology (mental disorders) and that people who want to die need psychiatric care. </p>
<p>But medicalising suicide ignores the socio-cultural context in which suicides occur. Our <a href="http://jmh.sagepub.com/content/10/4/338.full.pdf+html">research</a> has shown that suicidal behaviour has a social, economic and cultural context. And unless these factors are considered alongside psychiatric care, steadily increasing suicide rates will not be curbed.</p>
<p>A growing body of research is helping policymakers understand that suicidal behaviour – like any other form of human behaviour – has a social, economic and cultural context. These situational factors are as much potential precipitants of suicidal desires as are bio-medical and psychiatric factors. </p>
<h2>Pressures on men</h2>
<p>Our <a href="http://sap.sagepub.com/content/early/2016/08/23/0081246316665990.abstract">research</a> suggests that dominant models of masculinity and restrictive gender norms in South Africa have contributed to some <a href="http://jmh.sagepub.com/content/10/4/338.full.pdf+html">young men’s suicidality</a>. </p>
<p>The perception, according to <a href="http://jmh.sagepub.com/content/10/4/338.full.pdf+html">our research</a>, is that men have to behave in a certain way: they have to have power, be achievers and be in control. And those who cannot either risk being an “outsider” who is stigmatised or opt for suicide as a viable way out.</p>
<p>Interviewed participants saw suicide as a legitimate way for men to deal with conflicted feelings of shame, loss, or vulnerability particularly when these
feelings were elicited by the experience of not living up to societal expectations. </p>
<p>In South Africa suicide accounts for 9.6% of all unnatural deaths. There is about one suicide every hour. <a href="http://sap.sagepub.com/content/43/2/238.short">Data</a> suggests that 80% of suicides in South Africa are males and that suicide rates are highest among those between the ages of 15 and 29. </p>
<p>Our interviewees indicated that clear and rigid social norms dictated and regulated the behaviour of young men in South Africa. They were acutely aware of the perceived gender norms and what the societal expectations were around these. Failure to conform to these norms precipitated feelings of shame and guilt, social exclusion, impotence and isolation. </p>
<p>As a result, suicide was a “logical solution”, allowing these young men to re-empower themselves and escape difficult feelings associated with being isolated or shunned by society. </p>
<p>Although they conformed to the dominant ideals of masculinity which make it difficult to access support or express fear, pain, and vulnerability, not conforming liberated them. It meant they were allowed to express emotions and
access support. </p>
<p>But they were aware that a stance like this would make them socially disconnected, and put them at risk of being stigmatised.</p>
<p>Our research suggest that these socio-cultural ideas about manhood may prevent young men from accessing care, communicating their distress or forming protective authentic relationships. </p>
<p>Socio-cultural factors are not the only factors that contribute to suicide. <a href="http://www.sciencedirect.com/science/article/pii/S2215036616300669">Ongoing research</a> has highlighted the role of economic factors such as poverty, unemployment and hunger in the aetiology of suicide. When people experience economic adversity it can lead to feelings of entrapment, hopelessness and helplessness. This, in turn, gives rise to suicidal thoughts and feelings. </p>
<p>The epidemic of <a href="http://archiv.ub.uni-heidelberg.de/volltextserver/16937/">peasant farmer suicides</a> in India following crop failures is an example of this.</p>
<h2>A new approach</h2>
<p>There is no substitute for good psychiatric care for people who exhibit symptoms of psychopathology like mood disturbances and psychosis. Accessible, affordable and effective psychiatric care is essential for suicide prevention in these cases. </p>
<p>But to make serious advances in suicide prevention, holistic interventions must be developed that move beyond bio-medical and psychiatric explanations of suicidal phenomena. </p>
<p>Such approaches might include systemic interventions to address the economic and socio-cultural factors that contribute to suicide. It would also provide effective integrated person-centered care, which includes psycho-social services at a primary health care level and address gender norms and attitudes towards suicide and help seeking.</p><img src="https://counter.theconversation.com/content/64899/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jason Bantjes receives funding from the South African National Research Foundation and the South Africa Medical Research Counciil.</span></em></p>Each suicide has a social, economic and cultural context. And unless these factors are considered alongside psychiatric care, steadily increasing suicide rates will not be curbed.Jason Bantjes, Lecturer in the Psychology Department, Stellenbosch UniversityLicensed 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">
<figcaption>
<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>
</figcaption>
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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>
<figure class="align-center ">
<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.