Intended for healthcare professionals

Observations Ethics Man

Paving the way for assisted suicide

BMJ 2008; 337 doi: (Published 11 December 2008) Cite this as: BMJ 2008;337:a3010
  1. Daniel K Sokol, lecturer in medical ethics and law, St George’s, University of London
  1. daniel.sokol{at}

    Sky Television’s documentary showing an assisted suicide has provoked a storm in UK tabloids, but the medical ethicist Daniel K Sokol says it has reinforced his belief in the moral permissibility of helping people die in exceptional circumstances

    On 10 December a controversial documentary showed the suicide of Craig Ewert, a 59 year old man with motor neurone disease (Sky Real Lives, 9 pm). We see Craig in an apartment in Zurich, surrounded by his wife and a social worker, switch off his time controlled ventilator. Unable to press the switch with his fingers, he does so with his teeth. The social worker hands him a potion of sodium pentobarbital. “Mr Ewert,” he says, “if you drink this you’re going to die.” Craig sucks the liquid through a straw and grimaces. He asks for apple juice to wash away the unpleasant taste. At his request, the first movement of Beethoven’s ninth symphony resounds around the room. “Thank you,” he says after finishing the cocktail. The camera is fixed on Craig. Gradually his eyes close. He falls asleep.

    The documentary, Right to Die?, follows two couples in their search for a peaceful death with the aid of the Swiss group Dignitas: Craig and Mary Ewert and George and Betty Coumbias. Unlike Craig, septuagenarian George was not terminally ill, nor in a wheelchair. He had had a series of heart attacks and lamented his inability to play tennis or golf or have sex. He wanted to die while still in relatively good health. His wife, although healthy, could not contemplate a life without him and wanted to die with her husband. Although they loved their two adult children, they loved each other more and wanted to leave this world together. The director of Dignitas, the human rights lawyer Ludwig Minelli, agreed to refer them to a doctor, a 75 year old retired surgeon. He rejected their request for a lethal prescription.

    The two couples engender quite different responses in the viewer (we know that Craig and Mary would give everything for the kind of life that George and Betty wanted to end), and the film’s brilliance lies in the juxtaposition of the stories and the neutrality of the commentary, neither moralising nor facile in its approach to the issue. Although I don’t think the programme presented new arguments for or against the practice of assisted suicide, the lived experiences of the couples did help me clarify my own views about it.

    As an academic medical ethicist I am strongly tempted to offer a noncommittal analysis. Oh, aren’t these heart wrenching cases? Isn’t assisted suicide a terribly difficult, multifaceted issue? Aren’t the arguments for and against so evenly balanced? At the risk of drowning in an ocean of hate mail, let me show my cards: I believe that assisted suicide is not morally wrong and that, with appropriate safeguards, it should be decriminalised in the United Kingdom. John Zaritsky’s documentary has reinforced my belief in the moral permissibility of helping people die in exceptional circumstances.

    Of course, good palliative care can alleviate most types of pain; of course, assisted suicide must be a last resort after all reasonable alternatives have been considered; of course, procedural safeguards must be in place to avoid abuse and exploitation; of course, medicine is principally concerned with saving or prolonging life and not helping patients to die. But assisted suicide can, under some conditions, be consistent with all of these. Palliative care is powerless in rare cases (and targets the physical pain, not the existential anguish); all alternatives may have been exhausted; procedures may be robust enough to indicate autonomous choice and unbearable suffering; and death can be a benefit rather than a harm to the suffering patient.

    Although the documentary deepened my conviction in the moral rightness of individual acts of assisted suicide (on the basis of the twin ethical principles of respect for autonomy and beneficence), it raised serious concerns about the public policy allowing such acts to be performed. The footage did not inspire confidence in the current procedures for assisted suicide in Switzerland, exposing them as worryingly slack. Candidates for assisted suicide are not always assessed by clinicians with the required professional expertise. A retired surgeon may not be the most appropriate person to assess the competence and suitability of candidates, and the danger is that rejected candidates will fish around for someone who will satisfy their request. I would not advocate such a system in Britain, much preferring the more demanding criteria of Oregon’s Death with Dignity Act. Based on my sole viewing of the documentary, I thought the Dignitas experience seemed uncomfortably clandestine and amateurish.

    Zaritsky’s film is difficult to watch. The camera is unflinching, dwelling at length on the protagonists to capture the suffering etched in their faces. We are invited to transcend the boundary from public to private, seeing Mary shave and bathe Craig and following them both into the living room—or dying room—of the austere Zurich apartment where Craig bids his final farewell. Some of the shots were reminiscent of scenes from Julian Schnabel’s film The Diving Bell and the Butterfly, which follows the life of a man with locked-in syndrome. Only the stone hearted will not feel moved by Craig and Mary’s courage in the face of barely imaginable hardships. We must hope that such ills will not befall us and, should they do so, that we can confront them with equal courage.

    Shortly before his death Craig composed an email message to his adult children in the United States. He wrote: “This is a journey that we all must make at some time. I would hope that this is not a cause of major distress to those who love me, and I expect that my dear sweet wife will have the greatest loss, as we have been together for 37 years in the deepest intimacy.”

    If I am unlucky enough to be in a situation where the final stretch is long and bumpy, I hope that we will by then have built a new road that is smooth and direct. I’m in no rush to complete the journey, but I would much prefer we started building this new road now. Oregon, with its Death with Dignity Act, Lord Joffe, with his bill in the House of Lords, and now Craig and Mary, with their story—all have helped to pave the way. We must not be afraid to complete it.


    Cite this as: BMJ 2008;337:a3010