England and Wales may enact a law that permits assisted dying to patients with limited remaining life expectancy. But only if patients can self-assist in their own death.
Photo: Einar Nilsen
On 29 November, the lower house of the Parliament of the United Kingdom, voted for a law to permit assisted dying, under certain conditions: Persons over 18 years of age with an irremediable medical condition and life expectancy of up to six months will be able to make a request for assisted dying. Patients must present their case to two independent doctors, with an interval of at least seven days, and a High Court judge must also rule that the patient fulfils the criteria. A doctor must be present while the patient self-administers the medication, and then certify that the person is dead. Anyone who coerces, pressures or influences another person to make a request for assisted dying may be sentenced to up to 14 years' imprisonment (1, 2, 3) . Euthanasia, i.e. when a doctor (or other healthcare worker) performs the act, will still be prohibited.
According to the British Medical Journal, the proposed law will be the most restrictive of its kind in the world (4) . Some form of assisted dying is permitted in many countries, and around 300 million people have access to such a course of action (4, 5) . In the majority of places, only adults with a terminal illness may have their request for assisted dying approved.
. However, in some countries such as Canada, Belgium and the Netherlands, assisted dying can be approved without natural death being imminent. In the Netherlands and Belgium it can also be approved for children. In Switzerland, where legislation in this field has been liberal since 1942, the law only allows for assisted dying and not for euthanasia. Despite the legislative differences, the group that chooses this way of ending their lives will be fairly homogenous and primarily consist of patients with far-advanced somatic disease and short remaining life expectancy (4) .
Under normal circumstances, taking the life of another person is the greatest of all sins, and considerable resources are used to prevent suicide
The ethical questions surrounding assisted dying are almost inexhaustible. It goes without saying that under normal circumstances, taking the life of another person is the greatest of all sins, and considerable resources are used to prevent suicide. However, quite 'ordinary' questions, such as how to create a just scheme that is not obviously discriminatory, also appear impossible to answer: the proposed law in England and Wales is thus restricted to encompassing assisted dying, not euthanasia. The same applies in many US states and in Switzerland. This seems understandable. Despite everything, facilitating a person to take their own life, as opposed to actively bringing about the death of another person, feels very different—and renders us even more certain that it is the patient him/herself who wishes to die. However, might such a proposed law be discriminatory? Because surely people who for medical reasons cannot administer the medication themselves will be unable to avail themselves of this option? Someone who is dependent on a carer to perform such actions will presumably not be able to do so without making another person a criminal.
Many people fear the slippery slope effect. In Canada, euthanasia and assisted suicide have been on the statute book since 2016, but initially only for patients with an incurable disease where a natural death was 'reasonably foreseeable' (5) . In 2021, the last point was removed and persons with serious mental illness should additionally be granted access to assisted dying. Quite understandably, these individuals feel discriminated against. Their suffering may be (at least) as intolerable as physical suffering, and their illnesses equally difficult to treat. The amendment should have been passed in 2023, but has been postponed for three years. This has led to persons with mental illnesses now taking legal action against the government because they feel discriminated against. Persons with disabilities, who are entitled to request assisted dying, are following suit: In similarly timely fashion, they question a health service that gives them the right to assisted dying, but not the same right to (adequate) assistance to live (5, 6) .
No one wants a country where life is terminated because patients feel they are a burden to their families or society
How can we find the balance between ensuring that everyone knows of the option and preventing some people from feeling pressured—because the issue of pressure is perhaps the greatest fear? No one wants a country where life is terminated because patients feel they are a burden to their families or society. Some states in Australia, as well as New Zealand, have gone so far as to prohibit healthcare personnel from initiating a conversation with a patient about assisted dying. This of course carries the risk of marginalised groups being unaware of what patient rights they actually have (4) .
The proposed legislation in England and Wales has not been finally adopted. It will go through several consultation and voting rounds, and may only come into force in two years' time (1) . If adopted, it is possible that a law will have been passed where justified fear of pressure and the need for stringent restrictions count for more than considerations of fairness and inclusion. It only goes to show the difficult nature of this debate.