An autonomy-based approach to assisted suicide: a way to avoid the expressivist objection against assisted dying laws

Braun, E.

Journal of Medical Ethics 

2023;49:497-501

Abstract

In several jurisdictions, irremediable suffering from a medical condition is a legal requirement for access to assisted dying. According to the expressivist objection, allowing assisted dying for a specific group of persons, such as those with irremediable medical conditions, expresses the judgment that their lives are not worth living. While the expressivist objection has often been used to argue that assisted dying should not be legalised, I show that there is an alternative solution available to its proponents. An autonomy-based approach to assisted suicide regards the provision of assisted suicide (but not euthanasia) as justified when it is autonomously requested by a person, irrespective of whether this is in her best interests. Such an approach has been put forward by a recent judgment of the German Federal Constitutional Court, which understands assisted suicide as an expression of the person’s right to a self-determined death. It does not allow for beneficence-based restrictions regarding the person’s suffering or medical diagnosis and therefore avoids the expressivist objection. I argue that on an autonomy-based approach, assisted suicide should not be understood as a medical procedure but rather as the person’s autonomous action.

Conclusion

Assuming that the expressivist argument is valid, it only applies to (partly) beneficence-based approaches to assisted dying that require irremediable suffering. An autonomy-based approach to assisted suicide, as put forward by the German Federal Constitutional Court, avoids the expressivist objection. It understands

assisted suicide as an act justified by autonomy and does not imply objective judgments of whether the person’s life is worth living. I have argued that on an autonomy-based approach, assisted suicide should not be understood as a medical intervention but rather as an autonomous action that does not invoke

traditional medical principles such as beneficence.

A pdf is here.

Said differently: 

The article argues that an autonomy-based approach to assisted suicide can avoid the expressivist objection against assisted dying laws. The expressivist objection is the claim that assisted dying laws send the message that suicide is a good thing, which could lead to more people committing suicide. The author argues that this objection is not valid because autonomy is a fundamental value that should be respected, even if it means allowing people to die.  (Autonomy > beneficence)

Assisted-Suicide Fight Moves to Colorado

Dan French
The Wall Street Journal
Originally posted October 16, 2016

The latest front in the battle over doctor-assisted suicide is unfolding in Colorado, where voters will consider a ballot measure next month that would permit physicians to aid terminally ill patients in dying.

Proposition 106 would allow adults who have six months or less to live, and are mentally competent, to take medication prescribed by a doctor to end their lives.

If it passes, Colorado would be the fifth state to have a law that allows the practice, according to the National Conference of State Legislatures.

Oregon—which is the model for Colorado’s proposal— along with Vermont and Washington have enacted similar measures. California’s law permitting doctor-assisted suicide took effect in June after it passed the state legislature last year.

In a sixth state, Montana, the state supreme court ruled that doctors who provide “aid in dying” are allowed to use a terminally ill patient’s consent as a defense in court if they are charged with homicide.

The article is here.

Suicide tourism: a pilot study on the Swiss phenomenon

By S. Gauthier, J. Mausbach, T. Reisch, and C. Bartsch
J Med Ethics doi:10.1136/medethics-2014-102091

Abstract

While assisted suicide (AS) is strictly restricted in many countries, it is not clearly regulated by law in Switzerland. This imbalance leads to an influx of people—‘suicide tourists’—coming to Switzerland, mainly to the Canton of Zurich, for the sole purpose of committing suicide. Political debate regarding ‘suicide tourism’ is taking place in many countries. Swiss medicolegal experts are confronted with these cases almost daily, which prompted our scientific investigation of the phenomenon. The present study has three aims: (1) to determine selected details about AS in the study group (age, gender and country of residence of the suicide tourists, the organisation involved, the ingested substance leading to death and any diseases that were the main reason for AS); (2) to find out the countries from which suicide tourists come and to review existing laws in the top three in order to test the hypothesis that suicide tourism leads to the amendment of existing regulations in foreign countries; and (3) to compare our results with those of earlier studies in Zurich. We did a retrospective data analysis of the Zurich Institute of Legal Medicine database on AS of non-Swiss residents in the last 5 years (2008–2012), and internet research for current legislation and political debate in the three foreign countries most concerned. We analysed 611 cases from 31 countries all over the world. Non-terminal conditions such as neurological and rheumatic diseases are increasing among suicide tourists. The unique phenomenon of suicide tourism in Switzerland may indeed result in the amendment or supplementary guidelines to existing regulations in foreign countries.

The entire story is here.

The Role of and Challenges for Psychologists in Physician Assisted Suicide

Shara M. Johnson, Robert J. Cramer, Mary Alice Conroy, and Brett O. Gardner
Death Studies, 38: 582–588, 2014
Copyright © Taylor & Francis Group, LLC
ISSN: 0748-1187 print/1091-7683 online
DOI: 10.1080/07481187.2013.820228

Abstract

Physician assisted suicide (PAS) poses complex legal and ethical dilemmas for practicing psychologists. Since the passage of the Oregon Death with Dignity Act in 1997, Montana and Washington have passed similar legislation. Despite the law requiring competence evaluations by medical and psychological professionals, existing psycholegal literature inadequately addresses the role of psychologists in the PAS process. This article reviews legal statutes and analyzes ethical dilemmas psychologists may face if involved. We consider competence both generally and in the context of PAS. Suggestions are made for psychologists completing competence assessments and future directions to improve competence assessments for PAS are provided.

The entire article is here.

Vermont Legalizes Assisted Suicide

By Wilson Ring
The Associated Press
Originally published May 20, 2013

After years of debate, Vermont became the fourth state in the country Monday to allow doctors to prescribe lethal doses of medicine to terminally ill patients seeking to end their lives.

Gov. Peter Shumlin signed the bill into law at a Statehouse ceremony even as opponents vowed to push for its repeal.

The End of Life Choices law was effective immediately, although it could be weeks before the state Health Department develops regulations in accordance with the new measure.

Vermont Health Commissioner Dr. Harry Chen said he expects doctors to write between 10 and 20 lethal prescriptions a year, with a smaller number of patients actually using the drugs.

He based his figures on the experience in Oregon, the first state to legalize assisted suicide in 1997. Washington state and Montana followed later, with Montana's coming by way of a court order.

The entire story is here.

Physician-Assisted Suicide Program Wins Praise

By John Gever
Medscape News
Originally published April 10, 2013

Patients, their families, and physicians have been satisfied with a "death with dignity" physician-assisted suicide program made available to terminal cancer patients at a Seattle clinic, clinicians there reported.

Among 114 patients who asked about the program at the Seattle Cancer Care Alliance, the outpatient clinic for the city's major cancer treatment centers, 40 passed screening examinations and ultimately received lethal prescriptions for secobarbital, although only 24 actually took the drug, according to Elizabeth Trice Loggers, MD, PhD, and colleagues at the clinic and its affiliated centers.

"Patients, caregivers, and family members have frequently expressed gratitude after the patient obtained the prescription, regardless of whether it was ever filled or ingested, typically referencing an important sense of control in an uncertain situation," the authors wrote in the April 11 issue of the New England Journal of Medicine.

The entire story is here.

The primary source is here.

Physician-Assisted Suicide Program Rarely Used, Study Finds

By Serena Gordon
HealthDay Reporter
Originally published April 10, 2013
Physician-assisted suicide laws can raise controversy and concern with their passage, but a new study from Washington state suggests many of those fears may be unfounded.


Washington's Death With Dignity Act hasn't lead to scores of terminally ill people seeking lethal prescriptions, the researchers report: Almost three years after the law was enacted, just 255 people had obtained a lethal prescription from a physician.

Of those 255 prescriptions, 40 were written for terminal cancer patients at the Seattle Cancer Care Alliance. And, in the new study, doctors there found that only 60 percent (24 people) of their patients chose to use their prescription to hasten their death.

"Most Americans say that they want to die at home with family members around, not in pain and with their mental faculties as in tact as possible. But, not everyone is achieving that kind of good death. For the rare number of people using the Death With Dignity program, we are reassured by the high numbers of people who use palliative or hospice care and who talk with their families about this decision," said study author Dr. Elizabeth Trice Loggers, medical director of palliative care at the Seattle Cancer Care Alliance.

The entire story is here.

Vermont Senate approves amended death with dignity bill

By Dave Gram
The Associated Press
Originally published February 13, 2013

The Vermont Senate on Wednesday gave preliminary approval to an amended bill allowing doctors to prescribe a lethal dose of medication to terminally ill patients.

But even some backers of the measure, which passed 21-9, called the amended version a travesty. And other long-time backers of what they call ‘‘death with dignity’’ or ‘‘end-of-life choices,’’ along with opponents of physician-assisted suicide, were so angry about the amendment that they voted against it.

‘‘I will be voting yes for this bill, as much as I detest it,’’ said Sen. Claire Ayer, D-Addison and chairwoman of the Senate Health and Welfare Committee.

She said she hoped much of the original language — which mirrored Oregon’s first-in-the-nation Death With Dignity Act — would be restored when the measure moves to the House.

‘‘I want to be on that conference committee,’’ Ayer said, referring to the six-member panel of lawmakers who work out the differences between the House and Senate bills after they have cleared both chambers.

The entire story is here.

Assisted Suicide on Legal Agenda in Several States

By Susan Haigh
Associated Press
Originally posted February 8, 2013

A push for the legalization of physician-assisted suicide is under way in a half-dozen states where proponents say they see strong support for allowing doctors to prescribe mentally competent, dying individuals with the medications needed to end their own lives.

The large number of baby boomers facing end-of-life issues themselves is seen to have made the issue more prominent in recent years. Groups such as Compassion & Choices, a national end-of-life advocacy organization, have been working to advance the cause.

Advocates received a boost from last year's ballot question in Massachusetts on whether to allow physicians to help the terminally ill die. Although the vote failed, it helped to spark a national discussion, said Mickey MacIntyre, chief program officer for Compassion & Choices.

"The Massachusetts initiative lifted the consciousness of the nation and in particular the Northeast region to this issue that there are other alternatives patients and their families should have an opportunity to access," MacIntyre said.

Bills legalizing assisted suicide are being considered in Connecticut, Vermont, New Jersey, Kansas and Hawaii — and in Massachusetts, where proponents decided to resume their efforts after the public vote, according to the National Conference of State Legislatures, which tracks legislative trends. There are also bills related to the issue under consideration in New Hampshire, New York, Arizona and Montana.

In Connecticut, which has banned the practice since 1969, a group of lawmakers said Tuesday that the legislature's first public hearing on the subject would probably be held this month. At least two bills on the issue have so far been proposed in this year's session of the Connecticut legislature.

The entire story is here.

Backers of Mass. assisted suicide measure concede

ASSOCIATED PRESS  
Originally published NOVEMBER 07, 2012


Supporters of a ballot question legalizing physician-assisted suicide for the terminally ill in Massachusetts have conceded defeat, even though the vote is too close to call.

A spokesman for the Death With Dignity Act campaign said in a statement early Wednesday that ‘‘regrettably, we fell short.’’

The entire story is here.

Suicide by Choice? Not So Fast

By Ben Mattlin
The New York Times - Opinion Pages
Originally published October 31, 2012

NEXT week, voters in Massachusetts will decide whether to adopt an assisted-suicide law. As a good pro-choice liberal, I ought to support the effort. But as a lifelong disabled person, I cannot.

There are solid arguments in favor. No one will be coerced into taking a poison pill, supporters insist. The “right to die” will apply only to those with six months to live or less. Doctors will take into account the possibility of depression. There is no slippery slope.

Fair enough, but I remain skeptical. There’s been scant evidence of abuse so far in Oregon, Washington and Montana, the three states where physician-assisted death is already legal, but abuse — whether spousal, child or elder — is notoriously underreported, and evidence is difficult to come by. What’s more, Massachusetts registered nearly 20,000 cases of elder abuse in 2010 alone.

The entire article is here.

Dutch Euthanasia Rates Unchanged After Legalization

By Robert Preidt
MedicineNet.com
Originally published July 10, 2012

The rates of euthanasia and assisted suicide in the Netherlands in 2010 were comparable to the rates before the practices became legal in 2002, a new study finds.

(cut)

Researchers analyzed the Netherlands' death-registry data and found that the total number of euthanasia and assisted-suicide deaths in 2010 was 4,050, slightly less than 3 percent of all deaths.

The rates of euthanasia and assisted suicide in the Netherlands decreased between 2002 and 2005, but increased between 2005 and 2010. The increase was due largely to a rise in the number of patients requesting to end their lives, the researchers said.

The entire story is here.

The research from The Lancet is here.

Massachusetts Debates ‘Death With Dignity’

By Paula Span
The New Old Age Blog: Caring and Coping
The New York Times
Originally published May 29, 2012

Consider this an update. Last fall, when I talked with some of the 350 volunteers circulating petitions, they sounded confident about collecting 70,000 certified signatures by the end of the year. They more than succeeded, which meant the state legislature had until May 1 to act. It didn’t — to no one’s surprise — so volunteers for the organization backing the referendum, Dignity 2012, have headed back out with their clipboards.

If they can gather another 11,000 signatures by July 2, the public will decide whether the state’s physicians can lawfully prescribe medications with which terminally ill patients can end their lives. (You can read the exact language here.)

Oregon enacted essentially the same law allowing self-administration of lethal drugs in 1997, and Washington in 2009. Though their adversaries often used “slippery slope” arguments, the number of residents who have taken advantage of the laws remains quite small. After meeting all the requirements and undergoing the mandated waiting periods, 114 people received lethal prescriptions last year in Oregon and 103 in Washington. In both states, about a third of those who qualified ultimately decided not to use the drugs.
But the controversy was intense in those states, with contentious public debate and expensive media campaigns, and it will be this round, too. In both camps, fund-raising has already begun.

“It has potent national implications,” the Rev. J. Brian Hehir, secretary for health care and social services at the Roman Catholic Archdiocese of Boston, said of the referendum. “We are talking about fundamental human values, deeply personal choices.”

The entire blog entry is here.

Georgia Court Overturns Assisted Suicide Restrictions

Court Finds that Law Banning People from Advertisng Suicide Violated Free Speech Rights

By Greg Bluestein

Associated Press

Georgia's top court struck down a state law that restricted assisted suicides, siding on Monday with four members of a suicide group who said the law violated their free speech rights.

The Georgia Supreme Court's unanimous ruling found that the law violates the free speech clauses of the U.S. and Georgia constitution. It means that four members of the Final Exit Network who were charged in February 2009 with helping a 58-year-old cancer-stricken man die won't have to stand trial, defense attorneys said.

Georgia law doesn't expressly forbid assisted suicide. But lawmakers in 1994 adopted a law that bans people from publicly advertising suicide, hoping to prevent assisted suicide from the likes of Dr. Jack Kevorkian, the late physician who sparked the national right-to-die debate.

The law makes it a felony for anyone who "publicly advertises, offers or holds himself out as offering that he or she will intentionally and actively assist another person in the commission of suicide and commits any overt act to further that purpose."

The court's opinion, written by Justice Hugh Thompson, found that lawmakers could have imposed a ban on all assisted suicides with no restriction of free speech, or sought to prohibit all offers to assist in suicide that were followed by the act. But lawmakers decided to do neither, he said.

"The State has failed to provide any explanation or evidence as to why a public advertisement or offer to assist in an otherwise legal activity is sufficiently problematic to justify an intrusion on protected speech rights," the ruling said.

State attorneys said they were reviewing the order. The network's members said they were thrilled with the decision.

'Turned out to be a boondoggle'

"This was politically motivated and ideologically driven as opposed to being, in any way, motivated by sound legal practice," said Ted Goodwin, the group's former president and one of the four defendants. "I'm just sorry that as many people have been put through what they've been put through in what turned out to be a boondoggle."

The challenge was brought by four members of the network who were arrested in February 2009 after John Celmer's death at his north Georgia home. They were arrested after an eight-month investigation by state authorities, in which an undercover agent posing as someone seeking to commit suicide infiltrated the group. Prosecutors say group members helped Celmer use an "exit hood" connected to a helium tank to kill himself.

The entire story is here.

Assisted suicide should be legal, says major report to parliament

MPs told that people with a terminal illness could be safely offered the choice to end their own lives

By Esther Addley

The Guardian

Originally published Wednesday 4 January 2012

MPs should consider changing the law on assisted suicide to allow some terminally ill people to end their lives at home with the help of their doctor, a major report into the subject has concluded.

The Commission on Assisted Dying, chaired by the former lord chancellor Lord Falconer, says a choice to end their own lives could be safely offered to some people with terminal illnesses, provided stringent safeguards were observed.

Describing the current law on assisted dying as "inadequate and incoherent", the commission will today outline a legal framework that would permit only those who had been diagnosed with less than a year to live to seek an assisted suicide, and then only if they met strict eligibility criteria. These would include:

• Two independent doctors were satisfied with the diagnosis.
• The person was aware of all the social and medical help available.
• They were making the decision voluntarily and with no sense of being pressurised by others or feeling "a burden".
• They were not acting under the influence of a mental illness, and were capable of taking the medication themselves, without help.

The 400-page report follows a year of investigation by the commission, whose members also include the former Metropolitan police commissioner Lord Blair, a former president of the General Medical Council, a leading consultant in disability equality, an Anglican priest, and medical, mental health, palliative care and social care specialists.

The rest of the story is here.

Assisted suicide could be 'legalised' in groundbreaking case

Sarah Boseley, Health Editor

guardian.co.uk

A 46-year-old-man who wants to die after a stroke that left him almost completely paralysed is bringing a groundbreaking legal action that could effectively lead to the legalisation of assisted suicide in the UK.

Martin, as he has agreed to be called to preserve his anonymity and that of his family, was a fit and active man who enjoyed rugby, cars and socialising with friends in the pub before suffering a brainstem stroke three years ago. Now requiring round-the-clock care, his mobility is limited to moving his eyes and small movements of his head. He communicates by staring at letters on a computer screen which the machine recognises and forms into words spoken by a digitised voice.

Martin has been asking to die since six months after the stroke but says he has no one willing to assist him and cannot on his own organise a trip to the Swiss clinic Dignitas, where he could end his life legally. His wife, who chooses to be known as Felicity, says she will be with him if he dies but will not help bring about his death.

Human rights lawyers at the firm Leigh Day in London have taken the first step in an action on Martin's behalf that, if successful, could have massive implications. One possibility is that the case could lead to a court ruling that Martin has the right to help not only from a paid professional to assist him get to Switzerland, but also to the services of a palliative care doctor in the UK to ease his death, should he decide to end his life by refusing food and drink.

Such a ruling would dramatically alter the current options for seriously ill and severely disabled people who wish to end their own lives in the UK. "There would be no more planes to Switzerland," said Richard Stein of Leigh Day. "Why would you bother?"

However, Stein added that beginning this legal action would potentially put the lawyers working on it in legal difficulty, since both they and any doctor or psychiatrist who came to examine Martin for the case could be considered to be assisting his suicide, thus exposing them to potential prosecution or disciplinary action from professional bodies.

The rest of the story and the video can be found here.
A prior post on assisted suicide can be found here.

Switzerland: Assisted Suicide Remains Legal

Story from the BBC



The Suicide
Madalina Iordache-Levay



Voters in Zurich, Switzerland, have rejected proposed bans on assisted suicide and "suicide tourism".

Some 85% of the 278,000 votes cast opposed the ban on assisted suicide and 78% opposed outlawing it for foreigners, Zurich authorities said.

About 200 people commit assisted suicide each year in Zurich, including many foreign visitors.

It has been legal in Switzerland since 1941 if performed by a non-physician with no vested interest in the death.

Assistance can be provided only in a passive way, such as by providing drugs. Active assistance - helping a person to take or administer a product - is prohibited.

'Last resort'

While opinion polls indicated that most Swiss were in favour of assisted suicide, they had also suggested that many were against what has become known as suicide tourism.

Many citizens from Germany, France and other nations come to die in Switzerland because the practice remains illegal abroad.

One local organisation, Dignitas, says it has helped more than 1,000 foreigners to take their own lives.
Another group, Exit, will only help those who are permanently resident in the country - saying the process takes time, and much counselling for both patients and relatives.
 
Its vice-president, Bernhard Sutter, said the result showed Swiss voters believed in "self-determination at the end of life".

The referendum had offered a proposal to limit suicide tourism, by imposing a residency requirement of at least one year in the Zurich area in order to qualify for the service.

It was backed by two conservative political parties, the Evangelical People's Party and the Federal Democratic Union.

But the major parties of the left and right, including the Swiss People's Party and the Social Democratic Party, had called on their supporters to vote against both motions.

The BBC's Imogen Foulkes, in Geneva, says the size of the vote against a ban on assisted suicide reflects the widely held belief among the Swiss that is their individual right to decide when and how to die.
Their rejection of the proposal to limit assisted suicide to those living in Zurich shows that concerns about suicide tourism carry less weight with voters than their conviction that the right to die is universal, our correspondent says.

But the debate in Switzerland will continue, she adds. Polls show voters do want clearer national legislation setting out conditions under which assisted suicide is permitted.

The Swiss government is planning to revise the country's federal laws on assisted suicide.

It has said it is looking to make sure it was used only as a last resort by the terminally ill, and to limit suicide tourism.

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Blogger Note: Many ethical issues are found in this story.