Assisted dying is not the same as euthanasiaBMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g3532 (Published 28 May 2014) Cite this as: BMJ 2014;348:g3532
All rapid responses
Raymond Tallis is correct when he states (“Assisted dying is not the same as euthanasia”, BMJ 31 May 2014) that Lord Falconer’s bill does not seek to legalise voluntary euthanasia – defined as the administration of lethal drugs to a patient at the patients request. But he himself is guilty of misuse of language when he writes that Lord Falconer’s bill seeks to legalise ‘assisted dying’. There is no such term in law or in the English language. What Lord Falconers bill is seeking to legalise is physician-assisted suicide. The term ‘assisted dying’ is a euphemism, designed to sugar the pill to make it more palatable. It is pure sophistry to suggest as the proponents of a change in the law do, that supplying lethal drug to someone who is terminally ill isn’t assisting suicide because that person is approaching death,. Tallis is right to argue for precision in the use of language, but he and his supporters should perhaps set us an example by ditching the term ‘assisted dying’ and referring instead to assisted suicide.
Tallis writes that Lord Falconer’s bill “contains the provision of referral to a psychiatrist in the case of doubt about capacity".
We would be obliged if he would tell us where we can find this provision: we have searched the bill in vain. The plain fact is that Lord Falconer's bill contains no safeguards, only eligibility criteria plus a suggestion that there might be codes of practice at some point in the future.
Tallis is correct to point out that the death rate from legalised assisted suicide in Oregon has not risen above 0.25 per cent of all deaths. But the overall trend in numbers has been upwards. Moreover - and Tallis could not have known this when he wrote - neighbouring Washington State, which followed Oregon down the assisted suicide road in 2008, has just revealed a 43 per cent rise in deaths from this source between 2012 and 2013.
Tallis gives an airing to the old chestnut that the law as it stands does not protect people because it investigates cases of assisted suicide only after someone has died. He does not explain, however, that the investigation that we have now is just that - an investigation focusing on facts. His 'assisted dying' law would replace that with a series of subjective opinions - about mental state, absence of coercion, settled intent - by doctors who in many cases had never met the patient before.
Dr Derek Willis
On behalf of Association Palliative Medicine Ethics Committee
Competing interests: No competing interests
Forgive me for being a little frustrated when correspondents who wax lyrical about evidence and reasoned argument proceed to get their figures wrong and dismiss counter arguments out of hand as attempts to ‘confuse distinctions’ (which I’m assuming applies to Lianna and I alongside other correspondents). It would also appear that Mr English has unfortunately misquoted mine and Lianna’s comment which reads ‘proposing assisted suicide and not euthanasia’. We were not attempting to ‘confuse distinctions’ but attempting to tackle a complex ethical, moral and legal issue with respect to that complexity.
Also regarding distinctions, the OED defines kill as to ‘cause the death of’. So saying doctors would be killing by participating in PAS is like saying ‘smoking kills’. It’s not untrue but simply referring to a more distal cause than the MI/Lung cancer.
What we were originally trying to communicate is that the Bill as proposed draws distinctions which are not necessarily valid on ethical and legal grounds. Perhaps in aiming for brevity we made ourselves unclear so I will elaborate here.
The first of these problems with the Bill and the original article is the ethical distinction between physician assisted suicide (PAS) and active voluntary euthanasia (AVE). Both the intention and outcome are the same. If a person who wishes to die with the assistance of a physician is their really an ethical difference depending on who administers the medication? Say you had a person unable to swallow due to a neurological condition. If the doctor injects the lethal medication it’s AVE. If the doctor prescribes and draws up the medication, places an IV cannula and gives the syringe to the patient to self-administer it’s PAS. The only difference is who presses the plunger on the syringe. I would argue this does not make for a ‘sharp’ and ‘fundamental’ difference as claimed in the original article but a wafer thin distinction.
Secondly, the criteria applied in the proposed bill are discriminatory. It’s discriminatory on the grounds of disability and life expectancy, which might be considered a special case of ageism. There would surely be a contradiction between Falconers bill, were it to become law, and the Equality Act 2010 which states ‘A person (A) discriminates against another (B) if, because of a protected characteristic, A treats B less favourably than A treats or would treat others’. In the case of Falconers Bill those unable to administer lethal medication to themselves would be being treated ‘less favourably’ by the government, NHS and doctors. The UK already has a precedent for legal challenges on these grounds in the legal action taken by Tony Nicklinson who would not have qualified. After all, we frequently provide invasive assistance to administer medication, food and fluid to patients who are unable to take it themselves. Why would this be any different?
Whilst life expectancy isn’t a protected characteristic in law, how do you draw an ethical distinction between people with predicted life expectancies of 6 and 12 months? If PAS is a good and acceptable way to relieve suffering shouldn’t it be done when a settled decision is made not at some arbitrary line? Moreover, it seems Prof Tallis and other HPAD members believe coercion to be a minor risk. This being the case, it’s hard to see how the 6 month criterion could be justified on the grounds of public safety. It would seem to be in the Bill mostly because of political imperatives not rational argument. The whole terminal illness requirement could even be done away with altogether because the ethical justifications for PAS are based primarily upon autonomy and suffering, things not restricted to the terminally ill. So even though currently it is restricted to PAS for those with a short life expectancy there would be clear grounds for incremental extension of the scope of the Bill if passed.
Turning to the figures, Dr Teed stated rightly that debates should be informed by accurate statistics. As such I will endeavour to be as clear as possible, I apologise that this next paragraph is a little pedantic (the maths, not my spelling or grammar!). I assume the 430% rise in the leaflet is simply rounded from (71/16)x100 = 443.75. If we use the most recent decade for which we have complete figures as Dr Teed suggests, we should use the data from 2002 and 2012 not 2003 and 2013 (as described by David Jones the 2013 figures are provisional with 31 cases pending decisions). One finds that the total number of deaths by PAS in Oregon in 2002 were 38/31082 (0.12%) and in 2012 85/32475 (0.26%). In 2002-2012 73.78% of people who were given a prescription died from it. 122 prescriptions were written in 2013. This would predict a final figure of 90. A rough and ready linear regression of 2002-2012 using year and number of prescriptions (2002 set to year 0) yields an estimate of 81.89 for 2013, model R2 0.947 (using SPSS 20).
Dr Teed’s statement that rates have ‘not even doubled in a decade’, though slightly inaccurate, still demonstrates that even clearly passionate HPAD members cannot support the original claim that PAS rates in Oregon are ‘reasonably steady’ (I doubt that doubling in a decade would be deemed steady for any other cause of death).
Additionally, when considering the evidence for the claim that doctors associations which oppose PAS do not reflect the views of their membership, doesn’t the systematic review in Palliative Medicine in 2012 which concluded that in the majority of studies ‘UK doctors appear to oppose the introduction of AVE and PAS’ warrant consideration? Alternatively why not reference a study by Seale, whose work is probably the basis for the claims AVE is already happening in the UK? Interestingly, in his 2006 paper he found that only 4.6% (3.1-6.1%) of doctors thought laws in the UK interfered with the care of the dying patients they had recently attended and only 2.6% (1.4-3.8%) of doctors thought that a new law would have facilitated better management.
 Oregon Public Health Division. Oregon Resident Deaths by Age Group and County of Residence, 2002 Final. Datahttp://public.health.oregon.gov/BirthDeathCertificates/VitalStatistics/F...
 Oregon Public Health Division. Oregon Resident Deaths by Age Group and County of Residence, 2012 Final. http://public.health.oregon.gov/BirthDeathCertificates/VitalStatistics/d...
McCormack, R., Clifford, M., & Conroy, M. (2012). Attitudes of UK doctors towards euthanasia and physician-assisted suicide: a systematic literature review. Palliative Medicine, 26(1), 23–33.
 Seale, C. (2006). National survey of end-of-life decisions made by UK medical practitioners. Palliative Medicine, 20(1), 3–10.
Competing interests: I am a junior doctor member of CMF
We are sympathetic to the article by Raymond Tallis ‘Assisted dying is not the same as euthanasia’, (Observations BMF 31 May 2014 Volume 348). Living and working in Scotland, we are supporters of the Assisted Suicide (Scotland) Bill and share Prof Tallis’ distaste for the tactics used by opponents of assisted dying.
Care not Killing made a submission to the Scottish Parliament Health and Sport Committee which is considering the underlying principles prior to making recommendations, before MSPs vote as to whether the Bill should progress to stage 2.
One sentence used is ‘Licensing doctors to kill would fundamentally alter the doctor-patient relationship.’ This completely ignores the fact that both Lord Falconer’s Bill and the Scottish Bill make it abundantly clear that no killing will occur. The use of untrue assertions characterises the tactics of some of the opponents.
Doctors for Assisted Suicide is a group of practising and retired GPs and hospital doctors formed to encourage support for the Assisted Suicide (Scotland) Bill in the profession and we will be pleased to have contact from anyone interested in joining.
Doctors for Assisted Suicide
Chair: Charles Warlow
ViceChair: Judy Greenwood
Secretary: Gillian MacDougall
Competing interests: Secretary of Doctors for Assisted Suicide
Amongst a number of factual, practical and ethical issues which Professor Tallis reasonably addresses in his article (Assisted dying is not the same as euthanasia) there is one, in particular, which I feel merits further consideration.
He refers to figures which indicate effectively half those who had an assisted death in Oregon in 2012 said they didn't want to be a burden on family, friends and care givers. He also points out that the three biggest end of life concerns raised by those who had an assisted death were loss of autonomy, less engagement with enjoyable activities and loss of dignity.
Though hinted at, there is no contradiction here: the desire by the suffering individual to minimise the burden, both physical and psychological, upon family and friends is an altruistic and dignified one. As such, this desire to bequeath a "good death" may well represent the final expression of existential autonomy; in turn reducing his or her own suffering.
Richard Clubb (General Practitioner, retired)
Competing interests: Member, Health Professionals for Assisted Dying
I am sure that the journalist as well as the Prof. of Palliative Medicine and Past President of the Royal College of Psychiatrists who contributed to the Care Not Killing insert that has upset Prof Tallis so much, are well aware that assisted dying is not the same as euthanasia.
This does not however mean the two are not linked. Does medication provided in assisted dying to patients to end their lives always work? If not, what should then be done? If a clinician is called upon to administer further lethal drugs to complete what the failed self-administered dose did not achieve, is this not euthanasia?
Competing interests: Member, Care not Killing Alliance
Dr Tallis has listed various criticisms of a publication by ‘the campaigning group Care Not Killing’. 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’. 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’. While the proposed Bill, and the campaign currently supported by Dignity in Dying, 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’, 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’. 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’.
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’. Readers should consult the figures themselves to confirm that, while annual figures have not risen every year, there is a readily discernible upward trajectory. 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’ 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. Lastly while the numbers may appear reassuringly small, only ‘0.25% of all deaths in Oregon’, 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’. From this he concludes that ‘under an assisted dying law no more people would die but fewer people would suffer’. 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. 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). 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’. 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.
 Tallis, R. Assisted Dying is Not the Same As Euthanasia. BMJ 2014;348:21. http://www.bmj.com/content/348/bmj.g3532
 Patient (Assisted Dying) Bill [HL] HL Bill 37, section 1(2)
 Death with Dignity Act Annual Reports Year 16 – 2013 http://public.health.oregon.gov/ProviderPartnerResources/EvaluationResea...
 Oregon Older Adult Suicide Prevention Plan: A Call to Action Oregon Department of Human Services, March 2006
 Oregon Resident Deaths by Manner of Death and County of Residence, 1998 Final Data
 Oregon Resident Deaths by Manner of Death and County of Residence, 2012 Final Data
Competing interests: Member, Care Not Killing
I am a mere junior doctor but I demand evidence based arguments in law and medical practice. I also yield to none regarding patient safety and the vulnerable.
I would like to thank Ray Tallis for highlighting the deliberate confusion by Care Not Killing. I note that so far, no-one has tried to defend the “facts” in the leaflet except to say there has been a small rise in numbers or further confuse distinctions. To continue with correcting “facts”: it would be as ridiculous to portray the rise in numbers as 7000% by picking year 0 as the start point for comparison. In the last decade, the small absolute numbers of assisted deaths as outlined by Prof Tallis has risen from 0.14% to 0.21% of all deaths (let us not forget that in Oregon, 3000 more people are dying than 10 years ago). Not even doubled in a decade. I too shall leave it to the reader to decide if this signifies “a 430% rise”.
This increase is linked (with no evidence) to the vulnerable who “might be” pressured, rather than of respecting autonomy when faced only with a terminal outcome. Yet when it comes to sedating patients and removing non-invasive ventilation with imminent death (and other such inconsistencies in law and practice) we are happy to respect autonomy and mental capacity as good palliative care, with no such calls for these practices to be outlawed due to the impact on the vulnerable.
The fact that there are many (non-hypothetical) people in this country who are currently being coerced (as distinct from pressured) to suffer against their will, is ignored. Dying patients are going to Switzerland or enduring horrifying attempts at ending their own life, with or without help from their loved ones. Then there are the studies that show voluntary euthanasia already happening here in the UK. All of the above without exploration and oversight of capacity or being fully informed regarding care options before a death, but instead when it is already too late.
Care Not Killing advertises itself as a collection of human rights, disabled, medical and faith based groups. This attempts to conceal the fact that nearly 90% of its membership (that are known) are faith-based organisations. Yet, opinion polls show that the faithful are also in support of compassion so I do not for one minute want to claim this is an issue entirely regarding faith, as it is not. However, what this does point towards is that like the medical profession there is an issue of the wider membership's views not being expressed by their respective representative bodies. I welcome constructive dialogue in the debate but demand accuracy within a rational and evidence based discussion.
Competing interests: Member of Healthcare Professionals for Assisted Dying
It is important to appreciate that Lord Falconer's Bill on Assisted Dying is not, as Benjamin Williams suggests,"proposing assisted suicide and euthanasia". Rather it is confined to helping terminally ill patients who are suffering during the last few days or weeks of their life. This is the important distinction between assisted suicide in Switzerland and euthanasia in the Netherlands where the non-terminally ill are included in their laws.
So it is not, as Eugene Breen suggests, designed for someone who is "going through a bad patch". Nor can it be compared to some of the problems encountered with the Liverpool Care Pathway which was a code of practice, whereas the Bill includes upfront safeguards which will be enshrined in law.
Competing interests: Patron Dignity in Dying
"Lotus nobiscum est, hilaris cenavit, et idem
inventus mane est mortuus Andragoras.
Tam subitae mortis causam, Faustina, requiris ?
In somnis medicum viderat Hermocraten" (1).
"Bath'd, supp'd, in glee Andragoras went to bed
Last night; but in the morning was found dead:
Would'st know, Faustinus, what was his disease?
He dreaming saw the quack, Hermocrates" (2).
1. Martial, Epigrams. Book 6.
2. Montaigne (by Cotton), B. ii ch. 37 in Martial, Epigrams. Book 6. Bohn's Classical Library (1897) http://www.tertullian.org/fathers/martial_epigrams_book06.htm
Competing interests: No competing interests
In his opinion article Prof Tallis appears to be doing many of the things of which he accuses the Care not Killing Alliance.
The survey he quotes uses a non-representative sample of volunteer participants commissioned by Dignity in Dying, a fact omitted in the article and the web link provided.
Furthermore, whilst the number of deaths in Oregon are small in absolute terms, saying they are ‘steady’ is misleading. Even excluding the pre-2008 data, as Prof Tallis has, the trend is still clearly upward as the Oregon health authority report demonstrates. Before accusing CNK of uncritical use of surveys with questionable methodology might scrutinise his own data more closely.
Additionally, Prof Tallis hinges his discussion ethical and legal concerns on there being a ‘fundamental’ and ‘sharp’ difference between Falconers Bill and the Benelux system, ignoring major ethical and legal debates. Technically the bill is proposing assisted suicide and not euthanasia, but the difference between these is widely questioned. Indeed, from my understanding of their positions, prominent ethicists like Peter Singer and John Harris (who provide the intellectual muscle for the assisted suicide movement) see no important ethical distinction. Furthermore, any distinction drawn could be challenged as discriminatory on grounds of life expectancy (inverse ageism, if you will) or disability.
Moreover, he dismisses concerns about coercion or abuse, implying that ‘strong and vivacious’ people could not be victims. This is perhaps the most peculiar of the arguments presented, but I will leave it to the reader to decide if collectively these issues constitute ‘misleading falsehoods’.
 Tallis, R. Assisted Dying is Not the Same As Euthanasia. BMJ 2014;348:21. http://www.bmj.com/content/348/bmj.g3532
 YouGov. You Gov/Dignity in Dying survey results. 013. http://d25d2506sfb94s.cloudfront.net/cumulus_uploads/document/tp47zufwiz....
 Yougov. “Assisted dying (disability sample). Disabled Activists for Dignity in Dying 2013. http://www.dadid.org.uk/wp-content/uploads/2013/12/DADiD-poll-2013.pdf
 Oregon Public Health Division. Oregon’s Death with Dignity Act Annual Report. Oregon Health Authority 2013. http://public.health.oregon.gov/ProviderPartnerResources/EvaluationResea...
 Singer, P. Taking Life: Humans. In Practical Ethics (2nd Ed). Cambridge 1993. http://www.utilitarianism.net/singer/by/1993----.htm
 Harris, J. Consent and End of Life Decisions. J Med Ethics 2003;29:10-15. http://jme.bmj.com/content/29/1/10.full
Competing interests: BD Williams is a junior doctor member of the Christian Medical Fellowship. He is not and has never been a staff member nor do his views necessarily reflect those of CMF as an organisation.