Getting our definitions right in the debate over assisted suicide and euthanasia
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.[1] It is unfortunate therefore that the definitions of terms were taken from the website of a campaigning organisation[2] 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”[1] 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”.[3]
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”[4] 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”.[1] 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[5] 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[6] and, at least in the case of Belgium, with widespread ending of life without request,[7][8] 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’.”[9] 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’”.[10] 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”.[11]
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”[12] and assisted suicide as “the act of deliberately assisting or encouraging another person to kill themselves”.[12] 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”.[4]
[6] C. Gamondi, G.D. Borasio, C. Limoni, N. Preston, S. Payne. Legalisation of assisted suicide: a safeguard to euthanasia? Lancet, 2014;384(9938), 127
[7] 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.
Rapid Response:
Getting our definitions right in the debate over assisted suicide and euthanasia
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.[1] It is unfortunate therefore that the definitions of terms were taken from the website of a campaigning organisation[2] 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”[1] 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”.[3]
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”[4] 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”.[1] 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[5] 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[6] and, at least in the case of Belgium, with widespread ending of life without request,[7][8] 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’.”[9] 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’”.[10] 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”.[11]
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”[12] and assisted suicide as “the act of deliberately assisting or encouraging another person to kill themselves”.[12] 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”.[4]
[1] 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
[2] Campaign for Dignity in Dying. www.dignityindying.org.uk/assisted-dying/
[3] Assisted Dying for the Terminally Ill Bill [HL] 2003-04 http://www.publications.parliament.uk/pa/ld200304/ldbills/017/04017.1-4....
[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
[5] Assisted Suicide (Scotland) Bill http://www.scottish.parliament.uk/parliamentarybusiness/Bills/69604.aspx
[6] C. Gamondi, G.D. Borasio, C. Limoni, N. Preston, S. Payne. Legalisation of assisted suicide: a safeguard to euthanasia? Lancet, 2014;384(9938), 127
[7] 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.
[8] D.A. Jones. Assisted Suicide and Euthanasia: A Guide to the Evidence http://www.bioethics.org.uk/evidenceguide.html
[9] SOARS Newsletter April 2015 Issue 11, page 1 http://soars.org.uk/Newsletter/SOARS-newsletter-11-Apr-2015.pdf
[10] C. Brewer, M. Irwin (eds) 2015. I’ll See Myself Out, Thank You. Newbold on Stour: Skyscraper, p.130.
[11] http://www.3quarksdaily.com/3quarksdaily/2015/06/california-dying.html
[12] http://www.nhs.uk/conditions/euthanasiaandassistedsuicide/pages/introduc...
Competing interests: Director of the Anscombe Bieothics Centre