INOT 1995 AUSTRALIA The Northern Territory enacted the world’s first law explicitly authorizing assisted death. He said that mentally competent terminally ill adults who wanted to die could seek help from a doctor, using lethal drugs. The law sparked outrage. Within months, the federal government had overthrown him. Yet today, five of Australia’s six states have assisted dying laws.
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The Economist first advocated for physician-assisted dying in 2015. We argued that freedom should include the right to choose how and when to die, while warning that the practice should be carefully monitored and regulated to prevent abuse. Since then it has become more widely available. Assisted dying is now legal in one form or another in a dozen countries, and the trend looks likely to continue. Last week, New Zealand passed a law on euthanasia for the terminally ill after 65% of voters backed it in a referendum. The same week, the Portuguese parliament passed a broader law. Medical assistance in dying is still illegal in Britain, but the House of Lords is debating a bill to allow it.
The number of people dying this way is increasing, although still small. In the Netherlands, it has increased from around 1,800 in 2003 to almost 7,000 in 2020, or 4% of all deaths. As more countries liberalize, the world total will increase further.
Many people oppose physician-assisted dying on religious grounds: some denominations consider suicide a sin. Others fear that guarantees will prove insufficient or that legalization is a slippery slope. Critics have long predicted that families exhausted by the need to care for sick and elderly loved ones will put undue pressure on them to end their lives, or that cash-strapped states will encourage patients to end their lives. most expensive terminal to hurry and die.
Yet such horrors do not seem to have happened. In places with the longest experience of assisted dying, charities representing the elderly or disabled have not reported any abuse. It is conceivable that some have taken place without being observed, but the scrutiny has been intense and in most countries the authorization to assist someone to die is revoked if there is even a suspicion of coercion. Fears that the poor and marginalized will be rushed to their ends have also proved unfounded. In America, the Netherlands and Switzerland, the overwhelming majority of those who choose assisted death are educated and from the middle class.
Far from being too lax, the rules have often been too restrictive. The Australian state of Victoria, for example, prohibits doctors from mentioning assisted dying to their patients. The aim is to avoid coercion, but the consequence is that many people are unaware that this is an option. In some jurisdictions, only people who have less than six months to live are eligible for assisted dying. So, patients may be terminally ill and in severe pain, but unless a doctor feels the end is very near, they cannot end their own suffering. In some cases, the diagnosis comes too late. In Victoria, in the first six months of 2021, no cases were withdrawn because the patient decided not to proceed, but in 90 cases the patient died before they were relieved. Some countries, like Spain and Colombia, have liberal laws in theory, but in practice health authorities are reluctant to let anyone use them. Last week in Spain, a desperate 83-year-old woman threw herself out a window after her repeated requests for euthanasia were denied.
Canada offers a better model because it gives people more leeway to make their own choices. Anyone whose suffering is unbearable can choose assisted dying. They don’t need to be terminally ill. And, singularly, the question of knowing what constitutes “unbearable” suffering belongs to the patients themselves, provided they are of sound mind. There is a ten day cooling off period, in case they have any doubts. In many cases, just having the option of assisted death gives people a sense of comfort and control. In Oregon, one-third of people who receive the prescribed deadly drug ultimately choose not to take it.
Even as more and more societies accept the principle of physician-assisted dying, difficult questions remain. Some people fear that its availability may cause health services to skimp on palliative care. But this is not ordered. Canada’s bill on assisted dying was explicitly linked to increased funding for palliative and long-term care.
If physician-assisted dying becomes commonplace, will older people in need of 24-hour care feel more social pressure to choose death? Many already worry about being a burden on their children or guardians. Some may feel additional guilt if continuing to live is seen as an individual choice, rather than the blind play of fate. This is a real concern. But the possibility that some may agonize over the advisability of dying should not outweigh the certainty that others will suffer excruciating pain if their freedom to choose is denied.
The most difficult questions arise when an individual’s ability to make an informed choice is in doubt. Some people with mental health problems have thoughts of suicide that come and go. For them, the bar must be very high. Doctors need to make sure they can distinguish between a temporary mental health crisis and a sustained, thoughtful desire to die. If in doubt, they should offer treatment aimed at helping the patient to live.
Free to choose, until the end
Dementia is the most difficult problem of all. A person diagnosed with the disease can make a living will, requesting an assisted death when it becomes serious. But they can change their mind. Such a document should never be used to kill someone against their will, and if those wills are unknowable, they must be allowed to live. Assisted dying should only be reserved for those who can make an informed decision when taking the medication.
No rule in this area is perfect. All should be reviewed in light of new evidence on how they work in practice, or to take into account medical advances. But the general principle – that individuals have the right to choose how they end their lives – is, in our view, a good principle. The evidence from countries that allow physician-assisted dying is that the abuses remain largely hypothetical, while the benefits are real and substantial. It relieves suffering and restores a certain dignity to people at the end of their life. ■
This article appeared in the Leaders section of the print edition under the title “A Final Choice”