Suicide, euthanasia and the keys to death’s door

Should anyone be penalised for participating in a suicide, which of itself is not a crime? Should doctors be the guardians of life or should they be as Charon, providing passage between the worlds of life and death? This discussion is back on the books in Britain with the recent debate at the British Medical Association’s (BMA) Annual Representatives Meeting, a court case in the House of Lords, and a decision by the Royal College of Nurses. Read the original post and subscribe to Blue-Genes.net to keep up with the latest news.

Suicide, euthanasia and the keys to death's doorThese to me seem to be the two distinct issues at the heart of the modern right-to-die debate and indeed the two that were debated at this year’s British Medical Association’s (BMA) Annual Representatives Meeting. On the first question, the BMA was ambivalent – it did not support a ‘change in the law’ to decriminalise prosecution of assisted suicide. On the second, there was a resounding ‘Guardians of life!’

The court success of Debbie Purdy in the House of Lords (Law Lords branch, which will be revamped as the Supreme Court in October) shows that the answer to these questions is still muddled in English law. The judge’s decision means that assisted suicide may effectively be legalised in the UK in the near future. A Number 10 Petition has been set up in riposte.

UK law is composed of 1. Case or common law (legal precedents set by court decisions which guide future cases) and 2. Statute Law (Acts of the UK Parliament or devolved nation Parliaments/Assemblies). At present suicide is legal under the UK Suicide Act 1961 but assisting it is not, although people who travel abroad to do it in jurisdictions where it is legal have not been prosecuted. The organisation Dignitas in Switzerland has now assisted somewhere in the hundreds of UK citizens in committing suicide, but no parties have been prosecuted. This is the result of court precedents but no statute upholds this as a freedom.

In usual alarmist style, the Daily Mail has published this article about assisted suicide in Oregon. They focus on one case of an unsuccesful assisted suicide. However, the stronger secular case for the current law, some of which are outlined in this FT letter (and then dismissed), are that it protects against the dangers of coercion into suicide by relatives or friends, a feeling that one is a burden and ‘ought to’ end one’s life, and a general trivialisation of suicide. Family situations are often complex and murky when viewed from the outside and it is easy to imagine that in any assisted suicide determining the extent to which living relatives encouraged or pushed their late relative into committing suicide is difficult in the best of circumstances.

In addition, suicidality often comes hand in hand with severe depression, and can be nothing more than a passing phase. It is likely that a large minority or even a majority of readers will experience depression at least once in their life, and if dealt with sensitively and appropriately it may be that any related death wish goes away in as little as a few months.

This is the reality on the ground for family doctors, the police, social workers, nurses, psychiatrists, palliative medicine doctors and other health workers. Any discussion of assisted suicide and euthanasia is inseparable from this reality; it is weak merely to argue ‘Yes, but if you are of sound mind you should be able to choose to end your own life’, which ignores the broader social context that all deaths happen in. However, ultimately autonomy and the freedom to choose one’s own care is a fundamental principle of liberty and of medical ethics and it is the ideal that we must strive towards.

Those countries where euthanasia or assisted suicide is legal usually have a number of safeguards present, such as requiring the approval of two doctors and/or a panel of experts, or as in Switzerland police inquiries after the fact. In the EU, euthanasia is legal in the whole of Benelux (fun fact – legalisation caused a minor constitutional crisis in Luxembourg when the Grand Duke refused to sign the law). However, in Netherlands, which has administered drugs for euthanasia in 1,000s of cases, the United Nations Human Rights Committee has highlighted concerns that regulation may be too lax.

In summary, in countries where assisted suicide is legal, a fairly large regulatory apparatus is necessary but perhaps not sufficient to prevent abuses. It also seems that there is some correlation between stringency of regulation and number of reported cases.

And what about doctors’ role in all this? Well, repeated votes at the BMA suggest that most doctors (or at least their professional representatives) don’t want to touch assisted suicide with a bargepole. Interestingly however, the Royal College of Nurses recently voted for a ‘neutral’ position. In practice if assisted suicide is decriminalised in the next few months in the UK, nurses and doctors might be able to assist in some way pending review by regulatory bodies such as the General Medical Council.

So even if assisted suicide is decriminalised, it will continue to be a messy and controversial business. Find out more in my next ethics posts as the story unfolds.

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