Observations

Assisted dying is not the same as euthanasia

BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g3532 (Published 28 May 2014) Cite this as: BMJ 2014;348:g3532

Re: Assisted dying is not the same as euthanasia

Dr Tallis has listed various criticisms of a publication by ‘the campaigning group Care Not Killing’.[1] These merit a response within the same careful spirit.

It should first be duly acknowledged that ‘no attempts are being made to introduce euthanasia through parliament in England and Wales’.[1] Lord Falconer’s Assisted Dying Bill would legalize not euthanasia but a form of assisted suicide, specifically physician assisted suicide for terminally ill competent adults. Nevertheless it does not follow that other forms of physician assisted dying are irrelevant to the current debate.

In this respect it is misleading to say that ‘to interchange the terms euthanasia and assisting dying is, to put it simply, wrong’.[1] While the proposed Bill, and the campaign currently supported by Dignity in Dying,[3] both define ‘assisted dying’ in this restricted sense, this usage is far from universal. It is not even followed consistently by Dignity in Dying. An earlier Bill supported by Dignity in Dying (which was then known as the Voluntary Euthanasia Society) defined ‘assisted dying’ as ‘the attending physician, at the patient’s request, either providing the patient with the means to end his life or ending the patient’s life’[2], i.e. as covering both physician assisted suicide and euthanasia.

On the current website of Dignity in Dying it does indeed state that ‘assisted dying is not the same as assisted suicide, voluntary euthanasia or euthanasia’.[3] However, on the same website under the heading ‘Assisted dying overseas’ it states that ‘a number of countries have passed laws to provide terminally ill people with the choice of an assisted death’ and lists the Netherlands, Belgium, Luxembourg and Switzerland, explicitly including ‘voluntary euthanasia’.[4]

With so few jurisdictions having legislated for ‘assisted dying’ in some form or other it seems irresponsible not to consider evidence from all those countries, i.e. from Belgium, the Netherlands and Switzerland, as well as that handful of States in the United States that have legalised physician assisted suicide. By excluding the Benelux countries and Switzerland Tallis excludes a wealth of research into the wider impact of this kind of legislation. Some of these effects will of course reflect particular circumstances in those countries, and some may reflect differences in the legislation, but surely some aspects will be similar and relevant, or else why are these countries listed even on Dignity in Dying’s own website as ‘countries [that] have passed laws to provide terminally ill people with the choice of an assisted death’?

Confining ourselves to data from Oregon, it is not accurate to say that ‘the figures have remained reasonably steady over the past six years and actually went down last year’.[1] Readers should consult the figures themselves to confirm that, while annual figures have not risen every year, there is a readily discernible upward trajectory.[5] Thus in the sixteen years for which the law has been in effect, the number of lethal prescriptions rose on thirteen occasions and only decreased in one year (in 2004). The figures for actual deaths are more variable but the underlying trend can be seen by taking averages for every four years: 1998-2001: 22.75 deaths; 2002-2005: 38.75 deaths, 2006-2009: 53.5 deaths, 2010-2013: 73 deaths. It should also be noticed that while Tallis states that the number ‘actually went down last year’[1] he is referring to uncorrected figures from January 2014 (the figure carries a note to this effect in the official report) with 31 cases as yet to be resolved.[5] Lastly while the numbers may appear reassuringly small, only ‘0.25% of all deaths in Oregon’,[1] this would be the equivalent of more than 1,200 assisted suicides in England and Wales.

Dr Tallis also states that ‘under the current legal system many terminally ill people are committing suicide or attempting to commit suicide… people will continue to die in an unregulated and unprotected manner’.[1] From this he concludes that ‘under an assisted dying law no more people would die but fewer people would suffer’.[1] This conclusion is not supported by evidence from Oregon. The State of Oregon has long had a high rate of suicide (significantly higher than the average in United States or in the United Kingdom) and this rate is particularly high in the over 65s, i.e. within the group most likely to seek physician assisted suicide.[6] However, the introduction of the Death with Dignity Act did not lead to a reduction in these ‘unregulated and unprotected’ suicides. Indeed they have increased over this period by a staggering 32% (from 1.9% of all deaths to 2.2% of all deaths).[7][8] This is roughly double the suicide rate in the United Kingdom. The rise in suicides subsequent to the new law does not necessarily indicate that the law caused a shift in the acceptability of suicide, but still less does it lend credence to Tallis’s claim that ‘no more would die’.[1] In Oregon more are dying by suicide: both by physician-assisted suicide and by non-physician-assisted suicide.

Before considering what all acknowledge to be a radical change in the law, parliamentarians should consider all available evidence from countries which have legalised ‘assisted dying’ in some form or other. This will include worrying data from Oregon but also the even more dramatic evidence from Switzerland and from the Netherlands and Belgium. People may also ask themselves why it might be that the campaigning organisation formerly known as the Voluntary Euthanasia Society is so keen that people do not even consider the experience of countries who have embraced its formerly-eponymous goal.

[1] Tallis, R. Assisted Dying is Not the Same As Euthanasia. BMJ 2014;348:21. http://www.bmj.com/content/348/bmj.g3532

[2] Patient (Assisted Dying) Bill [HL] HL Bill 37, section 1(2)

[3] http://www.dignityindying.org.uk/assisted-dying/

[4] http://www.dignityindying.org.uk/assisted-dying/assisted-dying-overseas/

[5] Death with Dignity Act Annual Reports Year 16 – 2013 http://public.health.oregon.gov/ProviderPartnerResources/EvaluationResea...

[6] Oregon Older Adult Suicide Prevention Plan: A Call to Action Oregon Department of Human Services, March 2006
http://public.health.oregon.gov/PreventionWellness/SafeLiving/SuicidePre...

[7] Oregon Resident Deaths by Manner of Death and County of Residence, 1998 Final Data
http://public.health.oregon.gov/BirthDeathCertificates/VitalStatistics/F...

[8] Oregon Resident Deaths by Manner of Death and County of Residence, 2012 Final Data
http://public.health.oregon.gov/BirthDeathCertificates/VitalStatistics/d...

Competing interests: Member, Care Not Killing

06 June 2014
David A Jones
Director
Anscombe Bioethics Centre
17 Beaumont Street, Oxford OX1 2NA