Why I’ve changed my views on assisted dyingBMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j3566 (Published 03 August 2017) Cite this as: BMJ 2017;358:j3566
All rapid responses
Sir or Madam
David Nicholl's recent article describing his conversion to a pro-euthanasia viewpoint following the death by euthanasia in Belgium of a dear friend, suggests rather less an intellectual conversion than a profound emotional reaction. His presentation of the usual run of arguments in favour of euthanasia/assisted suicide (EAS) does not seem based on any great familiarity with the literature. Nor does his article suggest that he is aware of recent doubts voiced by prominent pro-euthanasia figures in both the Low Countries  and in Canada about the direction and conduct of the euthanasia experiments underway in their countries.
The fact a practice is legal is no testimony whatever to its moral acceptability. The example of racism might make the matter clearer. Would he accept that the existence of apartheid laws in a given country is no criterion of the acceptability of racism, even if he could find many people there who could see nothing wrong with such laws? So too, while 'safeguards' are routinely invoked by the proponents of EAS to placate a populace before the introduction of legally protected medical killing, the reality remains, as described by Callahan and White, a "regulatory Potemkin village", where "an elaborate regulatory facade [conceals] a poverty of potential for actual enforcement". Whenever EAS exceeds the safeguards of the law, it is the law that changes to accommodate the practice, while the practitioner escapes without censure. This was graphically illustrated in a recent case in the Netherlands where an elderly woman who changed her mind about ending her life was first slipped sedatives in her coffee to prevent resistance, and when this failed, was held down by relatives to allow the doctor to kill her.
Nor is the situation any better in Belgium. The European Institute of Bioethics (EIB) reported in 2012  that the Commission charged with regulating euthanasia failed to uphold the law in any case in which the legal safeguards were exceeded, regularly signing off on deaths despite flagrant breaches of supposed safeguards. It has also stated that it is illusory to expect doctors to denounce their own failings. The Oregon Department of Human Services has previously expressed similar views. Why should Nicholl believe otherwise?
And so the scope of the law is extended and extended. Henry Hendin, Professor of Psychiatry at New York Medical College and an authority on Dutch euthanasia has noted: "the Netherlands has moved from considering assisted suicide to giving legal sanction to both physician-assisted suicide and euthanasia; from euthanasia for terminally ill patients to euthanasia for psychological distress; and from voluntary euthanasia to nonvoluntary and involuntary euthanasia". Flouting of the law, directing euthanasia more and more at the manifestly treatable and the essentially healthy, continues apace. Even those lacking capacity, not excluding children, are targeted. The argument that legalising EAS permits regulation of concealed non-legal euthanasia is simply delusional; non-voluntary and involuntary euthanasia remain widespread in both Belgium and the Netherlands  . And if cases of death by deliberate withdrawal of fluids and nutrition are included, these far exceed the numbers of cases of voluntary euthanasia under the law. Or rather supposedly "voluntary", since the true "voluntariness" of many deaths is in great doubt; Victor Lamme, Professor of Cognitive Neuroscience at the University of Amsterdam writes that the "normalisation" of euthanasia means that it is seen as an acceptable solution to the problem of the elderly who are felt to have outstayed their welcome, or who feel they are a burden to their families. Some might label this burgeoning or metastasising of indications, noted by Hendin earlier, a "slippery slope".
On 16 June 2017, Boudewijn Chabot, described by some as the 'patron saint' of Dutch euthanasia, with over 220 colleagues, wrote to a national newspaper decrying the unchecked and rapidly rising use of the euthanasia law against the psychiatrically ill and the demented. Chabot and his colleagues state plainly that "euthanasia practice is running amok.....I don't see how we can get the genie back in the bottle". Chabot and his colleagues are not alone in their concerns. In 2015, 65 Belgian psychiatrists, clinical psychologists and others, wrote to a Flemish newspaper to request that the option of euthanasia solely on the basis of "psychological suffering" be removed from the legislation, since they argued, it was promoting the "trivialisation" of euthanasia; and being wholly subjective and incapable of objective verification was through its promotion of 'death as therapy', undermining the entire field of mental health.
The numbers of euthanasia cases published in official statistics are often a gross underestimate of the tally of medically intended deaths of patients not least because a form of semantic hide-and-seek is used to define"euthanasia", ensuring that only a small subset of such deaths, which meet the arbitrary legal definition, are counted. Many killings are not reported at all. Deliberately inflicted death by dehydration and starvation under sedative cover are not for instance covered by the legal definition used in the Netherlands. Therefore, so the circular argument runs, they are not "euthanasia". It is "Alice in Wonderland" meets the morphine syringe driver. Far from protecting patients, legalising EAS merely provides legal cover for the clinicians who adopt these practices.
Experience in the USA suggests that once EAS is on the statute books, payers like insurance companies and state health departments are increasingly disposed to prefer it as a cheaper alternative to curative care. Multiple well-documented cases exist . This is coming very close to being "forced to opt for assisted suicide", something Nicholl seems not to have noticed. Not yet at the stage of being pinned to the floor to be killed, but not far off. Give it a few years. Nicholl demands that society accommodate what he calls a small but important minority, yet it is unarguable that legalising EAS seriously endangers the much larger and no less important proportion of people in society who have no wish to have their lives ended prematurely.
1 Nicholl D. Why I've changed my views on assisted dying. BMJ 2017;358:j3566 doi: 10.1136/bmj.j3566
2 Cook M. A Dutch euthanasia pioneer surveys the wreckage and despairs. https://www.bioedge.org/tools/newsletter_/#belge (accessed 25.7.17)
3 Mainwaring D. Merchants Of Death: Dutch Euthanasia Troubles Even Assisted-Death Doctors. https://www.technocracy.news/index.php/2017/07/06/httpswww-lifesitenews-... (accessed 14.8.17)
4 Somerville M. The euthanasia slippery slope: a failure of memory and imagination. https://www.mercatornet.com/careful/view/the-euthanasia-slippery-slope-a... (accessed 14.8.17)
5 Callahan D & White M. The legalization of Physician-Assisted Suicide: Creating a Regulatory Potemkin Village. References for: Mis-selling Euthanasia. http://scholarship.richmond.edu/lawreview/vol30/iss1/3
6 de Diesbach E et al. Euthanasia in Belgium: 10 years on. European Institute of Bioethics. www.ieb-eib.org (accessed c.7.6.13)
7 Hendin H. Seduced by Death:Doctors, Patients and Assisted Suicide. Pub. W W Norton & Co. Revised and updated edition (1998). ISBN-13: 978-0393317916.
8 Inghelbrecht E et al. The role of nurses in physician-assisted deaths in Belgium. CMAJ � June 15, 2010; 182 (9). First published May 17, 2010;doi:10.1503/cmaj.091881 (accessed 5.2.17)
9 Chambaere K et al. Physician-assisted deaths under the euthanasia law in Belgium: a popular based survey. https://www.ncbi.nlm.nih.gov/pubmed/20479044 http://www.cmaj.ca/cgi/content/full/182/9/895maxtoshow=&hits=10&RESULTFO... -18.1.11 (5.2.17)
10 Overledenen naar medische beslissing rond levenseinde;leeftijd, doodsoorzaak (Netherlands Govt.Statistics for Euthanasia). http://statline.cbs.nl/Statweb/publication/?DM=SLNL&PA=81655NED&D1=a&D2=... (accessed 1.9.17)
11 Victor Lamme, "he Practice of Euthanasia Has Landed on A Slippery Slope. Huppakee Gone!" https://trudolemmens.wordpress.com/2016/02 (23.8.2017)
12 Chabot B et al. Worrisome Culture Shift in the Context of Self-Selected Death. https://trudolemmens.wordpress.com/2017/06/19/the-euthanasia-genie-is-ou... (23.8.17)
13 Bazan A, van der Vijver G, Lemmens W et al. Remove euthanasia on the basis of Purely Psychological Suffering from the Legislation. https://trudolemmens.wordpress.com/2015/12/09/translation-of-an-open-let... (accessed 26.7.17)
14 Rotunda RD. The way of death in the Netherlands, Oregon, and, Perhaps, California. https://verdict.justia.com/2015/04/27/the-way-of-death-in-the-netherland...
15 B. Richardson, �Assisted-suicide law prompts insurance company to deny coverage to terminally ill California woman,� The Washington Times, Oct. 20, 2016, at
http://www.washingtontimes.com/news/2016/oct/20/assisted-suicide-law-pro... ; Id., (28.6.2017)
16 �Insurance companies denied treatment to patients, offered to pay for assisted suicide, doctor claims,� The Washington Times, May 31, 2017, at http://www.washingtontimes.com/news/2017/may/31/insurance-companies-deni... . (28.6.2017)
Competing interests: No competing interests
While several other respondents have voiced concerns about euthanasia being forced upon unwilling people and health professionals, Dr Wiesenfeldt's rapid response is the first that sailed close to invoking Godwin's rule, except in this case there are probably real and direct historical reasons why this is mentioned due to his place of work.
It is important that readers should be able to differentiate between physician-assisted dying/suicide and euthanasia (since many casual commentators may lump them together):
"Physician-assisted suicide refers to the physician providing the means for death, most often with a presciption. The patient, not the physician, will ultimately administer the lethal medication. Euthanasia generally means that the physician would act directly, for instance by giving a lethal injection, to end the patient's life."
Therefore the legal existence of assisted suicide does not automatically mean euthanasia law is legal
However it is certainly notable that a health professional from Germany expressed no confidence of his fellow citizens to follow the rule of law; it is perhaps too much of an irony that the 3 EU states with both assisted dying and euthanasia laws (2 with more than 15 years experience) are all direct neighbours of this nation. As of interest, Germany did pass laws in 2015 to allow non-commercialised physician-assisted suicide, but not allow euthanasia )as in the definition above).
Maybe there is still much to learn from the medico-legal system (with their fail-safe mechanism in place) in Netherlands, Belgium and Luxembourg?
I neither endorse or oppose the idea of assisted dying, it is, in my opinion, a personal issue complicated by the legal framework of the land.
I do however promote clear understanding of issues and concerns involved by encouraging people to share common terms of reference in this highly emotional and personal discussion.
Competing interests: No competing interests
I read David Nicholls’ piece on assisted dying with sympathy. Nonetheless, I haven’t changed my mind on assisted dying, and the UK should not change its law on the matter. The UK is leaving the EU, with its commitment to human rights. The Conservative Party has pledged to repeal the Human Rights Act and replace it with a British Bill of Rights. Theresa May has said she would like Britain to withdraw from the European Convention on Human Rights. We are potentially removing the legal underpinning of many of our rights. At the same time we have:
an increasing elderly population,
an NHS struggling for funds, and quite possibly going to be replaced by private care too expensive for the vast majority of the elderly
a younger generation who feel they have been unfairly treated by the older generation over student loans and Brexit, and who face extreme difficulty in getting on the property ladder
a growing right wing movement
All this suggests that vulnerable elderly could be seriously at risk if assisted dying was introduced. Do we seriously want to step towards euthanasia in our current circumstances?
Competing interests: I am 60 and after life as a part-time salaried GP have less financial security than most retired doctors. I am involved in the pro-EU movement.
Assisted dying – the dilemma
Supporters of assisted dying emphasise the relief of suffering, individual autonomy and the patient’s right to be free from paternalistic state intrusion. They also suggest that assisted dying under controlled and restricted conditions is preferable to acceding to secret and unregulated activity. Opponents however, stress that it would represent a profound change in social values with serious unintended consequences and any gains would not be worth the risks involved (1).
The recent unsuccessful attempt to legalise assisted dying in the UK highlights the concern of most doctors that they would become social agents in the direct action to end life (2). Perhaps if more attention was paid to the experience of dying patients and the views of their relatives and carers (3) doctors would be better equipped to provide optimal end of life care and assisted dying would no longer be such a contentious issue (4).
1. Buckman J.G, Alcser K.H, Doukas D.J, et al. Attitudes of Michigan Physicians and the Public toward legalising Physician-
Assisted Suicide and Voluntary Euthanasia. N Eng l J Med, 1996, 334: 303-309.
2. McEvoy P. Euthanasia, ethics and the Gordian knot. Is the Hippocratic Code obsolete? Br J Gen Pract, 2015; DOI:
3. Leadership Alliance for the Care of Dying People. One chance to get it right: improving people’s experience of care in the
last few days and hours of life. London: Department of Health, 2014.
right.pdf. Accessed 6th October 2016
4. Hamilton I.J. Assisted dying in countries where it has been legalised and the recent debate in the UK. Nurs Palliat Care,
2016; DOI: 10.15161/NPC.10000133.
Competing interests: No competing interests
Dr Nicholl has found the courage to publish his thoughts on assisted dying after a very touching experience, losing a close friend after many years of struggle against a rare, incurable diesease. I think most of us after years of practice can easily imagine a situation, in which they for themselves, or for somebody close to them, might take steps to get a good supply of barbiturates. Still, this is a personal decision, not a professional duty or medical treatment. Some countries, we learned, have recently decided to provide euthanasia or assisted suicide within health care.
However, the major cocern that needs to be adressed, at least in Germany with her history of medical mass murder under Nazi rule, is the fear of a slippery slope towards euthanasia as something like a "routine service" (*) provided to anybody requesting it in terminal distress and with some ability to give consent, be it by proxy. There will be many frail, demented, weak, mostly elederly people around in the next decades. Should they too be offered the opportunity to get killed by a doctor, when pain, breathlessness or delirium get out of hand ?
I agree that assisted suicide in exceptional cases should not be prosecuted under criminal law. But to label assisted dying an "option" in terminal care is, in my view, a transgression.
* Madeline Li, M.D., Ph.D., Sarah Watt, Marnie Escaf, H.B.B.A., M.H.A., Michael Gardam, M.D., Ann Heesters, M.A., Gerald O’Leary, M.B., and Gary Rodin, M.D; Medical Assistance in Dying — Implementing a Hospital-Based Program in Canada; N Engl J Med 2017; 376:2082-2088.
Competing interests: Employee of a catholic hospital trust
Dr Pablo's rapid response stated:
"Why do we need a law of euthanasia? Fabienne Vanheuverbeke committed suicide with the help of a doctor (1) but she could have done so without his help and without having to involve the medical profession.
To introduce assisted suicide, it would be better to contract trained executioners, without involving doctors. Our profession is not meant to kill but to help die. We doctors value human life with functional limitations, and we do know that loss of functional autonomy does not lead to loss of dignity"
Dr Pablo may not realise that for those people who advocate for a law for assisted dying, do so to:
1. Ensure that the process of dying in comfort is assisted by professionals who have medical expertise in symptom relief and drugs, to minimise any risk of the process being botched and inevidently causing unintentional pain and suffering of the person dying and their loved ones. In such a sensitive time, only health professionals who can prescribe and dispense medicine to keep people comfortable is in the best position to look after those who are dying, whether it is facilitated or not..
2. Ensure that people who assisted in persons dying, professionals and otherwise, will not be persecuted by the police, judicial system or frivolous lawsuits by someone who claims to advocate for the departed.
3. Ensure that there is an option for people to retain their own autonomy over their properties including their bodies. While some can claim that loss of functional autonomy does not lead to loss of dignity, there will be plenty others who will think otherwise. Perhaps other readers should be aware that the quote extracted by Dr Pablo attributed to a published reference (1) is actually a personal opinion by Dr Krahn, and not a conclusion from any research study.
"Paradoxically, while the APHA* vote supported aid in dying, my personal values were clarified as lying in the other direction. Through this intensely emotional process, I gained greater comfort with my own mortality and the self-knowledge that, for me, loss of my functional autonomy does not need to lead to loss of dignity or hastening of my own death."
*American Public Health Association
Perhaps Dr Pablo did not intend for his opinions to be misleading; afterall, I for one would not know where to start looking for contract killers in Spain or any other country.
1. Krahn GL. Reflections on the debate on disability and aid in dying. Disabil Health J. 2010 Jan;3(1):51-5.
Competing interests: No competing interests
Dr. David Nicholl's views on assisted dying and his change of opinion about euthanasia is as relevant as that of most of his opposing colleagues (1). It is significant that palliative care doctors, who treat terminally ill patients, are against euthanasia (2)
Why do we need a law of euthanasia? Fabienne Vanheuverbeke committed suicide with the help of a doctor (1) but she could have done so without his help and without having to involve the medical profession.
To introduce assisted suicide, it would be better to contract trained executioners, without involving doctors. Our profession is not meant to kill but to help die. We doctors value human life with functional limitations, and we do know that loss of functional autonomy does not lead to loss of dignity (3).
(1). David Nicholl. Why I’ve changed my views on assisted dying? BMJ 2017;358:j3566
(2). Bridge D. Palliative care, euthanasia and physician assisted suicide. MJA Insights 2017: 10 / 20 March 2017. Accesed in https://www.doctorportal.com.au/mjainsight/2017/10/palliative-care-eutha...
(3). Krahn GL. Reflections on the debate on disability and aid in dying. Disabil Health J. 2010 Jan;3(1):51-5.
Competing interests: No competing interests