Assisted Dying: For Whom?

May 20, 2016

In the United States, there continues to be intense debate over whether assisted dying should be legalized— for anybody. By contrast, in some European countries, as well as in Canada, the debate is no longer over whether it should be legalized. Instead, the debate now focuses on who should be entitled to assistance in dying.
Last week, I was in Amsterdam attending “Euthanasia 2016,” a perhaps less than felicitously named multi-day conference on assisted dying, which featured presentations from physicians, scientists, lawyers, scholars, and even the occasional philosopher, from a number of different countries. One of the principal issues discussed was which categories of persons should be eligible for legal assistance in dying.
In the United States, assisted dying for the terminally ill is now legal in four jurisdictions by statute: Oregon, Washington, Vermont, and California. All these jurisdictions have adopted the “Oregon model” whereby under certain conditions physicians may prescribe a lethal dose of medication for terminally ill patients. (The conditions are one what might expect: the patient must be competent, the patient must make repeated requests for assistance in dying, there must be a diagnosis of a terminal illness which will bring about death in six months, this diagnosis must be confirmed by a second physician, etc.) Similarly, in those jurisdictions where assisted dying legislation has been proposed recently, such as Maryland, New York, and New Jersey, the proposed legislation follows the Oregon model. There’s been no significant legislative effort to extend assistance in dying to individuals who are not terminally ill but who may be suffering from incurable conditions.
For many in Belgium and the Netherlands, this restriction of assistance in dying to the terminally ill is regarded as unjustified. Both of these countries allow assisted dying when a person has unbearable suffering and the patient’s condition is untreatable. (There are some procedural differences between the two countries in how requests for assisted dying are reviewed and approved.) There is no requirement that the patient be terminally ill. Moreover, the patient’s suffering can be psychological as well as physical. In other words, patients with treatment resistant depression may receive assistance in dying. A few dozen have.
Another not insignificant difference between the United States and the Low Countries is that euthanasia is allowed in Belgium and the Netherlands— indeed, it’s far more common than assisted suicide. In other words, the physician can inject the patient with the lethal medication, whereas in the United States the patient must ingest the prescribed medication.
The debate over which categories of patients should be eligible for assisted dying is playing out right now in the U.S.’s neighbor to the north. In February, 2015, the Canadian Supreme Court ruled that Canada must allow patients with grievous and irremediable medical conditions that cause enduring and intolerable suffering to receive physician assistance in dying. The court directed the Canadian Parliament to draft appropriate legislation. The wording of the court’s decision suggested to many that assisted dying would not be limited to terminally ill patients, yet the bill currently under consideration in the Canadian House of Commons appears to restrict assisted dying to the terminally ill—the bill states that the patient’s death must be “reasonably foreseeable.” Moreover, it does not allow assisted dying for patients who are suffering due to psychiatric conditions. This has sparked outrage from some advocates of assisted dying and a scolding from a provincial court. Meanwhile, a final vote on the legislation has been delayed for various reasons.
So we have these possible categories of eligible patients, each one increasingly broader: the terminally ill; those suffering from incurable physical conditions; those suffering from any incurable conditions, including psychological ones. (And there’s a whole other debate about whether minors should be eligible.)
Moreover, at the Amsterdam conference, a couple of sessions were devoted to discussing whether those who are merely “weary of life” should be able to request euthanasia, that is, people who may not have incurable medical conditions, beyond the usual limitations of old age.
So where should we draw the line? Well, I’m not going to tell you here. This blog post is just to present the issue. I’m not being coy. I need to give further, careful consideration to this issue. I’ve long been an advocate for assisted dying for the terminally ill. I’ve also argued for assisted dying for those with disabling physical conditions (quadriplegia, advanced ALS, and so forth) that make it exceedingly difficult if not impossible for them to end their lives without assistance. In such cases, besides the usual autonomy-based arguments, we have the additional consideration that denying assistance is effectively compelling these individuals to stay alive. Their lives will have been appropriated by the state. But can we say the same for an individual who retains physical capacity but who is tired of living? Most humanists would not dispute the right of such individuals to end their lives. But are we required to provide them with assistance? And in such cases, who would make the determination that someone is truly “weary of life”? A psychologist —or a philosopher? 
Opponents of any form of assisted dying have often argued that once we allow assisted dying for even a limited, reasonably well-defined group, such as the terminally ill, we’ve placed ourselves on the slippery slope to euthanasia on demand and perhaps non-voluntary euthanasia (that is, euthanasia for those who are incompetent and have never requested it, but who, in the physician’s opinion, are suffering.) Does the expansion of those eligible for assisted dying beyond the terminally ill confirm the existence of this slope?
Obviously, most proponents of assisted dying for those who are not terminally ill would dispute that claim. They would argue that whereas there is a clear distinction between euthanasia on demand and euthanasia for those who are suffering, there is no logical distinction between the terminally ill and those suffering from incurable conditions (except that those in the latter group may have to endure suffering longer) and the distinction between physical and so-called psychological suffering just reflects our limited understanding of psychological illnesses. In the final analysis, unless we believe in souls, everything is physical.  (For a forceful argument in favor of assisted dying for those with treatment resistant depression, see this article.)
As indicated, I haven’t resolved these questions myself. I will be writing an article for Free Inquiry on this topic in the coming months, and in the meantime, I am going to do some research and think about these important questions. I invite you to do the same.


#1 David Koepsell (Guest) on Friday May 20, 2016 at 7:06am

Ron, thanks for beginning to tackle this. My own interest sparks from the recent decision in The Netherlands to use medical euthanasia on a sexual abuse survivor and anorexic patient with “untreatable PTSD.” The slope seems to exist, and conflict with standard medical ethics, if we rely on poorly understood mental disorders where there is no medical consensus as reliable indicators of who will suffer forever. Imagine going for mental health help, describing deep depression and being prescribed death as a possible cure. In any case, maybe we can collaborate or do a point/counterpoint for the FI issue.

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