Recently I sat next to a woman at an author’s event in New York City. My guess is that she was a Boomer. She told me she used to be a Republican, but now she’s a Democrat. After learning that I am a medical doctor who has written a book on preparing for death called The Lost Art of Dying, she broached the topic of physician-assisted suicide and euthanasia. Given how ubiquitous these issues have become, we found much to discuss.
To begin, it’s worth distinguishing what is meant by physician-assisted suicide from euthanasia. Assisted suicide refers to the act of doctors providing patients with the means to end their lives. This could include a prescription for lethal drugs. Or it could refer to some other detailed description for how patients might die by suicide. Euthanasia, on the other hand, refers to the direct administration of a lethal substance, usually by a clinician, with the specific intent of ending a life.
Physician-assisted suicide is legal or decriminalized in 10 U.S. states and Washington, DC—geographic areas that represent about 20 percent of the U.S. population. Euthanasia is not legal in the United States. Globally, either physician-assisted suicide or euthanasia (or both) is legal, most notably, in Switzerland, Canada, Belgium, the Netherlands, Luxembourg, parts of Australia, and Colombia. Since 2020, Germany, Spain, Austria, New Zealand, and Tasmania have been added to this list, with varying degrees of legalization.
Arguments in favor of either type of assisted death tend to focus on relief of suffering, compassion, and self-determination. Not distinct from the abortion rhetoric “my body, my choice,” there prevails a sense of “my body, my death, my choice.” Some advocates have suggested that since hospice and palliative care measures are not universally available, it makes sense to be able to control the timing and manner of one’s death.
On the flip side, opponents of legalization worry that killing people instead of providing access to good hospice and palliative care lets governments and health care systems off the hook. With an aging population, they posit, society needs a surge in funding for the care of the elderly and dying—not less. Opponents of assisted death further contend that a right to die will lead to expanded excuses for assisted suicide and euthanasia, that it will de-stigmatize conventional suicide, and that it will lead to abuses of marginalized groups.
In the United States, physician-assisted suicide continues to be very rare. Oregon was the first state to legalize it in 1997. In 2021, only 383 people requested lethal prescriptions and 238 died from ingestion. One safeguard, advocates claim, has been the requirement to self-ingest. As long as patients must be able to crush the lethal drugs, mix the powder into an elixir, and drink it themselves, assisted suicide remains a purely autonomous act.
However, it’s worth noting that there have been attempts to legalize euthanasia in the United States. Just this month a U.S. District Court in California dismissed the Shavelson v. Bonta case in which plaintiffs argued that the self-ingestion provision of California’s assisted suicide law discriminated against those with diseases such as ALS (Lou Gehrig’s) who could not self-administer.
Canada offers a vivid illustration of what happens to a society when both physician-assisted suicide and euthanasia are on offer. First, there is a move away from self-ingestion toward having someone else administer the lethal drug. Canada legalized MAID, or “medical assistance in dying,” in 2016, and since 2019, fewer than 7 people per year have elected assisted suicide. The vast majority choose to be euthanized. Clinicians say they are less comfortable with patient self-ingestion because it is onerous and has potential complications.
Second, as euthanasia becomes normalized, the number of people who choose it will increase. The number of cases has more than tripled in five years, from over 2,800 deaths in 2017 to more than 10,000 in 2021. According to Canada’s July 2022 annual report, the total number of deaths by MAID since legalization is 31,664.
Third, the reasons for ending life expand markedly. Canada’s Supreme Court originally said a person’s death “must be reasonably foreseeable” in order to qualify for MAID. But by 2017, that provision had been eliminated. In March 2021, the law allowed for the euthanasia of anyone with chronic conditions, including disability, regardless of death’s imminence. People have been euthanized for the “suffering” of having housing or medical bills they cannot afford. A military veteran and paralympic athlete was seeking to have a chair lift installed in her home, but instead she was offered MAID. The government had planned to begin permitting euthanasia in March 2023 for the mentally ill—a highly vulnerable population that psychiatrists typically try to prevent from killing themselves—but they recently put this plan on hold.
I shared much of this information with my tablemate at the authors’ event. She found it fascinating. I told her that in 2021, euthanasia and assisted suicide accounted for 3.3% of all deaths in Canada. “But I’ve read that in some parts of Belgium,” I said, “it’s as high as 1 in 7.”
“That sounds about right,” she retorted. “If we want to euthanize people, 1 in 7 sounds about right.”