David Oliver: If assisted dying is legalised, can we safeguard against misuse?

Dear Editor,

Legalisation of assisted suicide would not only leave the most vulnerable in society open to coercion, but would also lead to significant moral injury among staff including junior doctors.

Mental capacity assessments

The Mental Capacity Act 2005 provides a statutory framework to respond to people who are deemed unable to make particular decisions for themselves. Some assessments of capacity, however, are complex. There are multiple hidden factors at play including the values of the system in which the assessment is taking place and of the assessor, both leading to bias (conscious or unconscious).[1]

In US states that have legalised assisted suicide, capacity assessment is recommended if in the opinion of the attending physician there is a question about capacity or a possible underlying psychiatric condition. However, no training in capacity assessment is required for the determination of eligibility for assisted suicide. In Oregon, in the first three years after legalisation, 28% of cases were referred to psychiatrists, but this had gone down to 5% by 2003 and to 1% in recent years. [2, 3, 4, 5]

If assisted suicide were to be legalised in England and Wales, it is likely that psychiatrists would be asked to assess mental capacity. Participating in such an assessment could be seen as suicide promotion, rather than suicide prevention which accords with the longstanding ethos of psychiatry. [6] Mental capacity assessments would not serve as a safeguard for those requesting assisted suicide. In fact, they would leave the most vulnerable in society open to coercion.

Moral distress

In Ontario, the medical profession’s regulatory college introduced an obligation to provide an effective referral when a person requests assisted suicide.[7] Physicians who decline to refer a patient can face disciplinary action, including the loss of their license to practise. In fact, the Court of Appeal for Ontario has ruled that true conscientious objection is not only unethical but is also illegal.[8] In Canada, some doctors are refusing to become the “Most Responsible Physician” (MRP) as they do not want to participate in the procedure. These clinicians are left with the ethical dilemma of either being the MRP and cooperating in a procedure they deem to be immoral or refusing to approve assisted suicide and being accused of obstructing patient access.[9] There have even been reports of professionals who are so afraid to speak up about their opposition to assisted suicide that they decide to communicate to colleagues in code using alternative email addresses.[8] It is a similar story in Belgium, where doctors who discuss palliative care as an option with those requesting assisted suicide are now seen as obstructing access.[11]

Junior doctors who wish to conscientiously object to assisted suicide face unique challenges. These junior doctors are likely to experience significant moral injury owing to the nature of the medical hierarchy and the structure of their work. In the Australian state of Victoria, where assisted suicide was legalised in 2019, junior doctors cannot participate in assisted suicide in any formal role. However, junior doctors are likely to be more involved in the day-to-day care of people requesting assisted suicide. Also, some of the tasks related to assisted suicide which junior doctors are asked to perform in Victoria are not clearly specified as tasks in which one can legally refuse to participate. Junior doctors must participate or risk jeopardising their careers.[12]

Conclusion

Assisted suicide is based on a flawed view of autonomy;[13] it is never an isolated act but is always deeply relational involving family, friends and healthcare professionals. Legalisation of assisted suicide would lead to coercion, both overt and covert, of individuals nearing death.

References
1. Greener, H., Poole, M., Emmett, C., Bond, J., Louw, S.J. and Hughes, J.C. (2012). Value judgements and conceptual tensions: decision-making in relation to hospital discharge for people with dementia. Clinical Ethics, 7(4), 166-174. https://doi.org/10.1258/ce.2012.012028
2. Hedberg K, New G. Oregon’s death with dignity act: 20 years of experience to inform the debate. Ann Intern Med. 2017;167:579-583. doi:10.7326/M17-2300. Oregon's Death With Dignity Act: 20 Years of Experience to Inform the Debate (acpjournals.org)
3. Oregon Death with Dignity Act. Data summary 2016. Public Health Division, Center for Health Statistics. February 15, 2019. Oregon Death with Dignity Act Data Summary 2016
4. Oregon Death with Dignity Act. Data summary 2018. Public Health Division, Center for Health Statistics. February 10, 2017. year21.pdf (oregon.gov)
5. Oregon Death with Dignity Act. Data summary 2022. Public Health Division, Center for Health Statistics. March 8, 2023. DWDA 2022 Data Summary Report (oregon.gov)
6. Maher, J. (2025) Physician-assisted suicide for psychiatric disorders: pros and con(sequences). In: The Reality of Assisted Dying: Understanding the Issues (edited by J.C. Hughes and I.G. Finlay), Maidenhead: Open University Press; pp. 102-107.
7. Coelho R, Lemmens T, Gaind K, Maher J. Normalising Death as “Treatment” in Canada: Whose Suicides do we prevent , and Whose do we Abet (2022) 70(3) WMJ 27-35. ssrn-4295456.pdf
8. Court of Appeal for Ontario. Christian Medical and Dental Society of Canada v. College of Physicians and Surgeons of Ontario, 2019 ONCA 393. Christian Medical and Dental Society of Canada v. College of Physicians and Surgeons of Ontario, 2019 ONCA 393 (ontariocourts.ca)
9. Herx L, Cottle M, Scott J. The “Normalisation” of Euthanasia in Canada: the Cautionary Tale Continues (2020) 66 WMJ. wmj_2_2020_WEB.pdf (wma.net)
10. Legislative Assembly of Ontario. Second Session, 41st Parliament. Official Report of Debates (Hansard). Thursday 23 March 2017. Standing Committee on Finance and Economic Affairs. Medical Assistance in Dying Statute Law Amendment Act, 2017. F016 - Thu 23 Mar 2017 / Jeu 23 mar 2017 (ola.org)
11. Devos T (Ed). Euthanasia: Searching for the Full Story. Springer Nature., Switzerland. 2021. 978-3-030-56795-8.pdf
12. Mcdougall R, White B, Ko D, Keogh L, Willmott L. Junior doctors and conscientious objection to voluntary assisted dying: ethical complexity in practice. J Med Ethics2022; 48:517-521. medethics-2020-107125.pdf (nih.gov)
13. O’Neill, O. (2025) Autonomy and assisted suicide. In: The Reality of Assisted Dying: Understanding the Issues (edited by J.C. Hughes and I.G. Finlay), Maidenhead: Open University Press; pp. 172-177.