Quebec legalises assisted-death: should other states follow?

Last month Quebec legalised assisted-death. The new law allows ‘medical aid in dying’ for adults at the end of life who suffer “constant and unbearable physical or psychological pain” as a result of a “serious and incurable illness”. The passage of this law makes Quebec the first jurisdiction in Canada to allow assisted-death or euthanasia.

The Bill follows successful legalisation of assisted-dying just south of Quebec last year in the American state of Vermont. Jurisdictions in which the practice is now legal include the Netherlands, Switzerland, Belgium, Luxembourg, Washington, Montana and Oregon.

Surprisingly, the arguments for and against assisted-death and euthanasia haven’t been discussed all that frequently on this blog. So this post will consider: would legalising assisted-death (patient administered) or voluntary euthanasia (physician administered) provide a compassionate exit to those facing decline and suffering and the means to live and die by our own lights, or involve a repugnant devaluation of human life that would put the vulnerable at risk?

Two arguments for legalisation

Perhaps the two strongest arguments in favour of legalisation relate to autonomy and beneficence (well-being).

The principle of autonomy entails that we should generally be able to do what we want with our bodies. This fits with the key tenet of liberal political thought – that an individual’s freedom should only be curtailed where it would cause harm to others. The principle is central to medical practice; consent, for example, is generally required for medical procedures (without consent, a medical procedure would generally constitute an unlawful battery). Similarly, patients have a legally protected right to have treatment withdrawn if they wish. A competent patient sustained by a respirator or artificial feeding may have this support removed if they wish, even if it would inevitably result in their death. The argument from autonomy suggests that, given we have these rights – which may well result in death – we should have an analogous right to assistance to end our lives more directly, at least in some circumstances.

The principle of beneficence requires us to consider the well-being of others. It motivates much of palliative care – the key aim being to reduce the suffering of those who face an imminent death. The beneficence argument for assisted-dying or euthanasia recognises the fact that some forms of suffering are unable to be relieved by even the best end-of-life care. For example, although modern drugs are very effective at relieving physical pain, it is much harder to relieve psychological or ‘existential’ suffering that can arise as a result of no longer being able to engage in activities one considers meaningful (as a result of being bedridden, for example), from a loss of independence or control (e.g. being unable to feed or bathe oneself), or even from a loss of subjective dignity (perhaps as a result of incontinence). Additionally, patients may consider that their well-being would be enhanced by the possibility of assisted-death or euthanasia because they would be assured of a peaceful and speedy exit should their suffering become intolerable and have control over the timing and circumstances of their death (for instance, by being able to ensure that their family members are present).

The principles of autonomy and beneficence provide strong prima facie reasons for legalisation. Are there nonetheless powerful countervailing arguments?

Arguments against legalisation

One argument opposed to legalisation posits that euthanasia improperly devalues life. If murder is considered wrong, why isn’t euthanasia?

One way to address this argument is to ask what it is that generally makes death regrettable and consider whether these factors also apply in cases of assisted-death or euthanasia. For example, most people want to continue to live, and death deprives them of positive future experiences. Additionally, death can cause grief to friends and family. In the case of assisted-death or euthanasia, however, a person has judged that their life is no longer valuable to them – that the possible future good experiences will not outweigh the bad. Their family may still be upset – just as they would be if they died of natural causes – but they may also be relieved that life was ended in a way that minimised suffering and gave their loved one some control. Is death in these circumstances still wrong, then?

The devaluation of life argument may be more powerful if it can tie the value of life to something other than the value placed upon it by the person experiencing it. But this raises the question: whose life is it anyway? Some religious moralists argue that life is a gift from God, and that we have no right to end it when we choose, regardless of how much suffering we may endure or how few positive experiences are left for us. This is often described as a belief in the ‘sanctity of human life’. Unfortunately, however, this won’t strike those who don’t share certain faith commitments as very convincing. And legislators in societies composed of individuals with a multitude of religious beliefs, and none, should not enact any one set of religious values into law without arguments that can be justified in non-religious terms.

A second objection relates to the role of medical professionals. Allowing doctors to kill their patients (or provide them with the means), it is said, would be antithetical to their role as ‘healers’ and may undermine the trust of patients. Firstly, however, it’s important to note that not all medical practice involves healing. Palliative care is a case in point. Good medical practice regularly involves the relief of suffering, and particularly at the end of life this may sometimes only be able to be achieved, to the patient’s satisfaction, through the ending of life. The issue of trust is of course important, but it is equally plausible that legalisation could increase trust from the point of view of patients, through their knowledge that medical professionals could help them end their lives if their suffering became unbearable. The empirical evidence here is key. In jurisdictions which have legalised assisted death or euthanasia there is no evidence of any sizeable decline in trust of medical professionals. In the Netherlands, for example, which has the longest history of assisted-dying and euthanasia, GfK’s Trust in Professions 2014 survey reveals 88% of the public either ‘completely’ or ‘generally’ trust doctors and physicians, comparable to other developed Western countries. (The figure for Australia is 90%; for Belgium – which also has assisted-dying and euthanasia – it is 93%).

Perhaps the most common objection to legalisation has to do with the risk of abuse and protection of the vulnerable. It is common to hear of an inevitable ‘slippery slope’ that has catastrophic consequences at the bottom, perhaps involving the deaths of those who didn’t really want to die. Given the extensive empirical literature that has now been amassed from overseas, we can look to the evidence in assessing the likelihood of these negative outcomes. The next section will do just that.

The experience of other jurisdictions

Worldwide, there are now at least eight jurisdictions in which assisted-death or euthanasia is legal. The trend seems to be firmly on the side of legalisation, and the only jurisdiction in which legalisation was removed was in the Northern Territory in 1997, as a result of the Australian Parliament using its constitutional power to do so. This in itself is telling – that in the jurisdictions which have legalised assisted-dying or euthanasia (all democracies that are responsive to public opinion), calls for removal have been minimal. As mentioned earlier, the Netherlands has the longest history with these practices. The current law has overwhelming public support there, reportedly around 92%. This should at least make us sceptical of the claim that assisted-death or euthanasia has been a disaster in practice.

The legal jurisdictions usually have numerous safeguards to ensure that the schemes are not abused. The requirements vary, but examples of safeguards employed include that the patient be suffering unbearably from an incurable disease or be terminal (assessed as having less than one year of life remaining), be competent to make a request and do so voluntarily and repeatedly, be informed of alternative care options and required to wait through a ‘cooling off’ period, and be required to make their request in writing if possible. Often compliance with these requirements is assessed by multiple medical professionals. Some jurisdictions require post-facto review by a board to check whether the rules have been complied with. Some also provide for an independent body to publish reports on the operation of the law.

With respect to the patients who tend to avail themselves of these schemes, roughly 80% have been diagnosed with end-stage cancer (e.g. 84% in the Netherlands, 78.5% in Belgium). The data tends to show roughly equal gender balance (in the Netherlands 51% of total deaths have been men and 49% women) and indicates that patients are more often both economically better off and more highly educated than the average citizen. According to Battin and colleagues, who review the empirical literature from both the Netherlands and Oregon (the jurisdictions that have been studied most extensively), there is “no evidence to justify the grave and important concern often expressed about the potential for abuse – namely, the fear that legalised physician-assisted dying will target the vulnerable or pose the greatest risk to people in vulnerable groups.”

In recent years there have been a number of comprehensive reviews of the worldwide empirical evidence from a public policy perspective. A report from the Royal Society of Canada (November 2011) concludes that “Despite the fears of opponents, it is … clear that that the much-feared slippery slope has not emerged following decriminalization, at least not in those jurisdictions for which evidence is available.” The Commission on Assisted Dying in the UK (January 2012) likewise note that, on the basis of the expert evidence they reviewed, “it is not vulnerable people who lack capacity or who are experiencing pressure from others who are actually having assisted deaths.” And a Select Committee of Quebec’s Assemblee Nationale (March 2012) state in their report – which informed the recent legalisation there – that, “we did not observe any abuse associated with the feared slippery slope.” All of these reports have recommended legalisation of assisted-dying or euthanasia.

Conclusion

It’s high time for the public debate on this issue to be reinvigorated and reform pushed. There is a strong moral case for legalising assisted-death and euthanasia on the grounds of both respect for autonomy and beneficence. The case has not been rebutted by compelling moral reasons. The empirical evidence from overseas indicates that a successful scheme that operates without unwelcome consequences is achievable.