Assisted dying: law and practice around the worldBMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h4481 (Published 19 August 2015) Cite this as: BMJ 2015;351:h4481
All rapid responses
It is a pity that the report about Switzerland is limited and unbalanced. Less space is devoted to the Swiss experience than any other country despite the fact that Switzerland has a longer experience of assisted suicide than any other jurisdiction. The authors have no doubt read and been impressed by newspaper accounts of foreign nationals coming to Switzerland for assisted suicide but they make hardly any effort to present the situation as it applies to residents of Switzerland. Not a single reference to a Swiss source is made, except for one on assisted suicide "tourism", of no relevance to the situation within Switzerland. A cursory search would have given access to statistics published by the Swiss Office of Public Health, to the criteria applied by EXIT ADMD for accepting requests for assisted suicide, to guidelines issued by the Swiss Academy of Medical Sciences and to articles about doctors' attitudes and public opinion. There is also informative material on the HUDOC website of the Council of Europe on the case law of the European Court of Human Rights relating to Switzerland.
I found the half column devoted to the situation in Colombia very interesting, even if, so far, only four patients have had assisted deaths. A little more diligent research and a few more lines on Switzerland could have helped readers of the Journal to benefit from the Swiss experience and judge whether, after more than twenty years of assisted suicide, we are slithering down the slippery slope or are reassured that a small minority of suffering patients are able to take charge of their destiny and die with dignity.
Competing interests: I have written a letter, published in the BMJ a couple of years ago, stating that I find it reassuring to live in a country where assisted suicide is legally available.
We urge the BMJ authors (Assisted dying: law and practice around the world Owen Dyer, Caroline White, Aser García Rada. 351:doi 10.1136/bmj.h4481) to disclose the reference to the claim, which appears unsubstantiated, that ‘unassisted health related suicides’ have reduced in Oregon. Oregon now is always among the top ten states in the US having the highest rate of suicides in the US.
In fact, Oregon had the 2nd highest suicide rate in the country between 1999-2010. 1 Further, the rate of suicide in Oregon has been rising,2 not falling. A Center for Disease Control report shows Oregon saw a 49.3 percent increase in suicides among men and women aged 35-64 from 1999-2010, compared to 28 percent nationally. 3
Despite having suicide rates among the highest in the nation, the Oregon Health Authority has abandoned efforts to help despairing adults. It will, however, pay to help adults commit suicide. 4 Such data support concerns of suicide contagion in Oregon.
In addition, another major problem with Oregon's assisted suicide law is that its implementation occurs to a large extent behind closed doors. There is no investigative machinery in place to conduct post-event scrutiny. We do not know how the doctors who agree to consider requests for assisted suicide undertake this task. Are they making careful and painstaking inquiries to satisfy themselves that the people who ask for lethal drugs really do meet the criteria specified in the law? Or are they just ticking boxes?
When the people who have received lethal drugs come to take them, it is not possible to verify whether or not there has been any pressure on them; Oregon’s law contains no requirement for witnessing ingestion. What is needed is greater transparency.
Competing interests: No competing interests
The scenario the bill is addressing is someone in the very last stages of life who wants to be spared the final indignities and to spare their family the burden of their final indignities.
How come the pressure for this is not coming from the slums of Calcutta or Cape Town where people suffer on a daily basis from oppression, violence, rape, disease etc but from people who by and large have been able to secure a good and well provided for existence?
One leading medical advocate of assisted dying has told me that what people ‘feared’ was not the pain of the end, but the indignity.
The message of the Old Testament Book of Job is that there is a lot we do not know about life and why things happen. The message of the scripture is “The Lord gave and the Lord takes away. Blessed be the name of the Lord.”
The heart of the issue seems to be the unwillingness of people used to a well provided for life, and their families, to come to terms with the loss of independence, the experience of helplessness and its indignities. This is strange since we come into the world as helpless babes and may need to exit in a similar fashion.
Christopher Sugden Ph.D
Competing interests: No competing interests
Assisted dying: Islamic View
To The Editor
We read with interest the article “Assisted dying: law and practice around the world” by Dyer O et al. Muslims form the world's second largest religious group with a population of 1.57 billion Muslims, accounting for almost a quarter of the world population. Recent data showed that the total number of Muslims in the European Union and USA exceeds 25 million. The number of Muslim physicians in USA alone is around 50,000.1 Physicians treating Muslim patients at their end-of-life are often ethically challenged when making decisions, and they seriously search for religious guidance in these matters.
Human beings are considered to be responsible stewards of their bodies, which are viewed as gifts from God. The sanctity of human life is affirmed in the Qur’an. The Qur’an says: “…One who has killed a person except in lieu of murder or mischief on earth; it would be as he slew the whole mankind and whoever saves the life of a human being, it is as if he has saved the life of all mankind …” (Qur’an 5:32). Preservation of life is one of the five basic purposes of the Islamic law (Sharia’h). Life is given by God and cannot be taken away except by Him or with His permission.2
Islam and the Islamic law clearly prohibit euthanasia in all circumstances. However, the wishes of a patient not to have his dying prolonged artificially in the presence of hopeless prognosis are well preserved. Such wishes may be declared in accepted standing Do Not Resuscitate (DNR) orders in certain hopeless medical conditions.3
The physician therefore, has no right to terminate any human life under his care. Thus, killing a person to ease his suffering even though it is at the request of the person will be inconsistent with Islamic law, regardless of the different names given to the procedure, such as, active voluntary euthanasia, assisted suicide, or mercy killing. The Islamic World League held in Jeddah in May 1992 declared a strong rejection against the so-called euthanasia under all circumstances. Terminally ill patients should receive the appropriate palliative medication, utilizing all measures provided, and doctors should do their best to support their patients morally and physically, irrespective of whether these measures are curative or not. 2 The Islamic Medical Association of North America (IMANA) is absolutely opposed to euthanasia and assisted suicide in terminally ill patients by healthcare providers or patients’ relatives.4 Besides, the Laws in Islamic and Arab Countries criminalize euthanasia. In summary and according to Islam, no one is authorized deliberately to end life, whether one’s own or that of another human being. Withdrawal of food and drink to hasten death is therefore not allowed and is considered as a murder crime. 5 Saving life is encouraged, and reducing suffering with analgesia is however acceptable, even if, in the process, death is hastened.
Hassan Chamsi-Pasha, FRCP, FACC. Cardiac department, King Fahd Armed Forces Hospital, Jeddah, Saudi-Arabia. ( firstname.lastname@example.org)
Mohammed Ali Albar, MD, FRCP. Medical ethics department, International Medical center, Jeddah, Saudi-Arabia.
1. Abu-Ras, W, LD Laird, and F Sensai.. A Window Into American Muslim Physicians: Civic Engagement and Community Participation, their diversity, contributions & Challenges. Washington DC: Institute for Social Policy and Understanding. 2012.
2. Al-Bar MA, Chamsi-Pasha H. Contemporary Bioethics: Islamic Perspective. Springer.2015.(Open access), http://link.springer.com/book/10.1007/978-3-319-18428-9
3. Takrouri MS, Halwani TM. An Islamic medical and legal prospective of do not
resuscitate order in critical care medicine. Internet J Health 7 [Electronic Version],2008.
4. Islamic medical Association of North America (IMANA). IMANA Ethics Committee. Islamic medical ethics: the IMANA perspective. J Islamic Med Assoc , 2005;37:33–42
5. Misha’l AA. Commentary. End of life medical interventions. Federation of Islamic Medical Association (FIMA). FIMA Book 2005-2006. http://fimaweb.net/main/fimayearbook/FIMA%20Year%20Book%202006.pdf
Competing interests: No competing interests
It is difficult to provide a balanced and reliable account of a controversial subject, and in general Dyer, White and García Rada have done an admirable job in presenting the main outlines of law and practice in relation to assisted suicide and euthanasia. It is unfortunate therefore that the definitions of terms were taken from the website of a campaigning organisation and that the definitions provided were both contentious and problematic.
According the definition provided, “assisted dying” only refers to “prescribing life ending drugs for terminally ill, mentally competent adults to administer themselves” and not to euthanasia or to assisting the suicide of someone who is not terminally ill. However this definition is arbitrary as there is nothing in the connotation of the words “assisted” or “dying” that restricts the meaning in this way. In fact the organisation that currently proposes this definition only ten years ago supported a bill that defined “assisted dying” to mean “the attending physician, at the patient’s request, either providing the patient with the means to end the patient’s life or if the patient is physically unable to do so ending the patient’s life”.
There is no stable consensus as to the meaning of “assisted dying” and indeed in the very title of the article, Dyer, White and García Rada use “assisted dying” to cover discussion of law and practice in the Netherlands and Switzerland as well as Oregon and Washington. The phrase is regularly employed in this broad sense in articles in the BMJ; for example, an article entitled “More people opt to use assisted dying laws for greater variety of reasons” has as its focus laws on euthanasia and assisted suicide in the Netherlands and Belgium, just as a reader might expect.
In relation to “assisted suicide”, the definition provided stipulates that this phrase implies “giving assistance to die to disabled and other people who are not dying”. But there is nothing about the phrase “assisted suicide” that requires it to be applied to such persons. There is no logical contradiction in proposing that a law permit assisted suicide specifically for terminally ill, mentally competent adults. Indeed the Assisted Suicide (Scotland) Bill rejected by the Scottish Parliament earlier this year used the phrase in exactly that sense.
The phrase “assisted suicide” requires further specification (what kind of assistance? By whom? Under what conditions?), but it has at least the advantage over “assisted dying” that it clearly excludes euthanasia. Given that euthanasia is associated with significantly higher rates of death and, at least in the case of Belgium, with widespread ending of life without request, then it would seem highly problematic to use a term that can be ambiguous between assisted suicide and euthanasia.
In offering the definition the authors suggest that it is only opponents of the Assisted Dying Bill in England and Wales (or similar legislation) who use the term “assisted suicide” to cover the provision of life ending drugs for terminally ill adults. This is inaccurate. The Society for Old Age Rational Suicide, while campaigning for a much more extensive law, supports the Assisted Dying Bill as far as it goes, which they categorise as the “more limited objective of only legalizing doctor-assisted suicide for the ‘terminally ill’.” Similarly, Mary Warnock, a well-known supporter of the Assisted Dying Bill, has stated that she “prefer[s] the terms ‘euthanasia’ and ‘assisted suicide’ - not sanitising these words with euphemisms like ‘assisted dying’”. In the same vein, the philosopher Gerald Dworkin, another longstanding advocate of laws such as Oregon’s Death With Dignity Act, expresses his preference for the term “physician assisted suicide” and regrets that the term “is now politically incorrect, for tactical reasons”.
An approximate comparison of the relative popularity of the terms “assisted suicide” and “assisted dying” can be gleaned from a search of Medline. If one starts from the date on which the Oregon law was enacted (27 October 1997) one finds 348 instances of the term “assisted dying” in the title or abstract but 1685 instances of the term “assisted suicide”. These do not map against support for or opposition to physician assisted suicide for the terminally ill.
A less contentious source providing more well-established and less problematic definitions might have been the NHS choices website. This defines euthanasia as “the act of deliberately ending a person's life to relieve suffering” and assisted suicide as “the act of deliberately assisting or encouraging another person to kill themselves”. The Assisted Dying Bill, if passed, would indeed legalise a form of assisted suicide – it would legalise “physician assisted suicide for terminally ill people in England and Wales”.
 O. Dyer, C. White, A. García Rada. Assisted dying: law and practice around the world BMJ 2015;351:h4481 http://www.bmj.com/content/351/bmj.h4481
 Campaign for Dignity in Dying. www.dignityindying.org.uk/assisted-dying/
 Assisted Dying for the Terminally Ill Bill [HL] 2003-04 http://www.publications.parliament.uk/pa/ld200304/ldbills/017/04017.1-4....
 I. Torjesen. More people opt to use assisted dying laws for greater variety of reasons BMJ 2015;351:h4332 http://www.bmj.com/content/351/bmj.h4332
 Assisted Suicide (Scotland) Bill http://www.scottish.parliament.uk/parliamentarybusiness/Bills/69604.aspx
 C. Gamondi, G.D. Borasio, C. Limoni, N. Preston, S. Payne. Legalisation of assisted suicide: a safeguard to euthanasia? Lancet, 2014;384(9938), 127
 R. Cohen-Almagor. First do no harm: intentionally shortening lives of patients without their explicit request in Belgium. Journal of Medical Ethics (2015): medethics-2014.
 D.A. Jones. Assisted Suicide and Euthanasia: A Guide to the Evidence http://www.bioethics.org.uk/evidenceguide.html
 SOARS Newsletter April 2015 Issue 11, page 1 http://soars.org.uk/Newsletter/SOARS-newsletter-11-Apr-2015.pdf
 C. Brewer, M. Irwin (eds) 2015. I’ll See Myself Out, Thank You. Newbold on Stour: Skyscraper, p.130.
Competing interests: Director of the Anscombe Bieothics Centre
The BMJ readers are all familiar with the medical term "primum non nocere" and this has served the medical world well for centuries. It has been and still is a foundation for best practice. When such a key stone is removed the medical world is undermined and a relativistic free for all ensues. The basis of medical practice is then left to the opinion of case law and what one particular judge or tribunal decides. The new medical vocabulary risks being changed to "primum nocere" since this is the very goal of all assisted deaths.
The evidence from juristictions where induced death has been decriminalised clearly shows that all forms of assisted dying including suicide exponentially escalate.1. The solid basis of medical practice and the safeguarding of the very vulnerable is what is at stake.
1. Anscombe Bioethics Centre. Assisted Suicide and Euthanasia. Guide to the evidence. 2015. Eight reasons not to legalise assisted suicide. 2015.
Competing interests: I have written "Mind and Belief V" which is very transparently pro life.