In a similar way there are excellent reasons why civilized countriesrestrict private people’s access to guns. But if the state allows access insome cases, for example for shooting sports or hunting, it does notfacilitate these activities, it only abstains from hindering or thwartingthem. The default is unlimited access; access is only limited for someacknowledged reasons, to the extent that these reasons require. If theydon’t apply, access is free again. One cannota prioriexclude the possi-bility that these reasons require access to be blocked altogether, butthis has to shown.

In Oregon, as in the other American states that legally permitassisted suicide,8on the other hand, all the doctor does, after havingascertained that the patient has voluntarily expressed his wish to die, iscapable of making and expressing health care decisions, and cannot rea-sonably be expected to live longer than six months, is to give the patienta prescription for a lethal drug. When the patient has acquired the medi-cation, it is his own responsibility to procure his own death in a safe andeffective way. If something goes wrong, the doctor is not to blame. Shecan be present if she wishes, but is so only in 28% of cases.9More oftena volunteer from a right-to-die society, usuallyCompassion and Choices,will be present. The patient can decide not to use the drugs, and in aboutone third of the cases actually decides not to.10In the Netherlands andBelgium the doctor would not even be allowed to leave the patient alonewith the drugs. He may go to the next room, but must be continuouslyavailable to intervene if the drugs are not sufficiently effective.11

is lifting a blockade when the acknowledged rationale for the blockadedoesn’t apply. In a‘state of nature’people would have unlimited access.Then the state comes along, limiting access, for whatever reason. If thestate then makes an exception for people who have chosen deathwithout undue pressure and after ample consideration, it only stopsinterfering with their freedom. It stands out of the way.

So, even when a case in Oregon and a Dutch case are both classifiedas‘physician-assisted suicide’, the cases are fundamentally different.12This difference has a normative meaning. Pentobarbital and similarlethal pharmaca are not freely available on the market. There areobvious reasons for limiting the access to such drugs: they can be usedimpulsively, to commit suicides that cannot be regarded to be well-considered, or fully voluntary. In addition they can be used for killingothers. When a patient approaches a doctor in Oregon, the doctorascertains whether these risks are absent, or minimal, and, if they are,opens the access to the drugs. That is not really a form of assistance, i

To summarize: a right to determine the time and manner of yourown death can only be meaningful if you have access to humanemeans of ending your life. That access can only be limited in order toensure that it is given to people who satisfy its conditions of eligibility,to prevent harm to others, or, perhaps, to protect human dignity. Thesereasons cannot justify a blanket prohibition

AUTHOR BIOGRAPHYGOVERT DENHARTOGHis professor emeritus of ethics in the University ofAmsterdam, Department of Philosophy. He has published widely in theareas of moral, political and legal philosophy, recently concentrating onbioethical issues, in particular concerning life and death

How to cite this article: den Hartogh G. Two kinds ofphysician-assisted death.Bioethics. 2017;31:666–673.

40This has been denied by the Supreme Court, inNicklinson v Ministry ofJustice, [2014] UKSC 38 [2014] 3 W.L.R. 200 (majority view). InR(Purdy)vDirector of Public Prosecutions[2009] UKHL 45, [2010]AC 345, the Houseof Lords already stated that a blanket prohibition of assistance would notbe in accordance with the European Convention, article 8(2), in the absenceof an offence–specific prosecution policy, which the DPP then duly pro-vided. See Lewis, P. (2011). Informal legal change on assisted suicide: thepolicy for prosecutors.Legal Studies,31, 119–134.41Unless one believes that the request itself is a reason for doubting theperson’s competence. In theHeringa-case that will shortly be decided bythe Dutch Supreme Court, neither the prosecution nor the courts doubtedthat Mrs. Heringa had decided to end her life in a fully voluntary and well-considered way. In its decision of 15 Dec. 2015 to dismiss a case againstthe president of the Verein Sterbehilfe Deutschland, Roger Kusch, theHamburger Landgericht made a similar assessment of the decision of thetwo women who had acquired lethal drugs from Kusch.42It has been pointed out to me that the ECHR follows some such (ratherperverse) argument inABC v. Ireland(16 dec. 2010, nr. 25579/05): becauseIrish women can go to another country in order to get an abortion, the Irishprohibition of abortion creates a‘fair balance’between the right to self-determination of women and the protected right to life of the unborn.43See footnote 6.44One reason is that it is almost impossible for people to calmly attack theirown body, Joiner, Th. (2011).Myths about suicide. Cambridge Mass.:Harvard University Press

33See e.g. Griffin, J. (2008).On human rights(Chapter 12). New York:Oxford University Press.34See Bosshard in Lewy,op. cit.note 9; Griffiths et al.,op. cit.note 11.35Positionspapier Foederatio Medicorum Helveticorum. (2008).Suizidbei-hilfe ist nicht gleich Sterbehilfe. Bern.36As regards psychiatric patients, this requirement has been lifted by a deci-sion from 2006 of theSchweizerische Bundesgericht, BGE 133 I 58.37Guidelines of theSchweizerische Akademie der Medizinischen Wissenschaf-ten, 25 Nov. 2004, adopted by the medical associationFMHand quoted inECrtHR,Haas v Switzerland(20 Jan. 2011, nr. 31322/07). These guidelineshave been enforced by several court decisions, resulting in the accused psy-chiatrist losing his licence to prescribe controlled substances. Black, I.(2012). Suicide assistance for mentally disordered individuals in Switzerlandand the state’s positive obligation to facilitate dignified suicide.Medical LawReview20, 157–166.38The Court here cites its decision inPretty v the UK(April 29, 2002, nr.2346/02), but in that decision the Court had only said it was’not to be pre-pared to exclude’that the fact that the applicant was prevented by lawfrom exercising her choice for death constituted an interference with herright to respect for private life. A right to end one’s life is not generally rec-ognized in the USA, that it can be drived from the Constitution has beenrejected by the Supreme Court inVacco v. Quill, 521 U.S. 793 (1997), butits recognition seems to be presupposed in theDeath with Dignityacts.39This argument is repeated inGross v Switzerland(14 May 2013, nr.67810/10) and inNicklinson and Lamb v. the UK(July 16, 2015, nrs 2478/15 and 1787/15).

28On its website the organization of Flemish consultants LEIF subscribes toboth assumptions. They seem also to be implied by the wording of theCanadian Bill C-14. The Dutch Regional Euthanasia Review Committeesreject both, see theirCode of Practice2015, p. 14–6. For a recent case inwhich the committee accordingly judged that the requirements of due carehad not been met, see Oordeel (2016), 21 on the website of the commit-tees. An earlier case, however, in which the committee made a similar judg-ment, has been dismissed by the Public Prosecutor on grounds implying a‘Belgian’interpretation of the requirements.29Adams in Griffiths et al.,op. cit.note 11, p. 323.30I am indebted to Dr. Linda Ganzini for informing me about this possibilityin correspondence.31In Belgium this argument has occasionally been used, for example by theCourt of Arbitration (Arbittragehof) in its decision of January 14 2004,quoted by Nys HFL (2007). Euthanasie: de toekomst van het Belgischemodel.Tijdschrift voor Gezondheidsrecht, 31,149–152.32The recent Canadian Bill C-14 does not fit this pattern in any way.

20Two examples: Rawls, J., Thomson, J. J., Nozick, R., Dworkin, R., & Nagel,T. (1988). Assisted suicide: The philosophers’brief,New York Review ofBooks,44(5), 27; and the decision of the English Supreme Court inNicklin-son v Ministry of Justice(25 June 2014, UKSC 38).21It is for example arguable that professional positive duties of care are ona par with negative ones in terms of urgency.22See Section 5, first paragraph.23Schoonheim-case, HR 27 November 1984, NJ 1985/106, translated inGriffiths, J., Bood, A., Weyers, H. (1998).Euthanasia and law in the Nether-lands. Amsterdam: Amsterdam University Press.24Chabot-case, HR 21 juni 1994, NJ 1994/656, translated inop. cit.note 9,pp. 329–338.25For a more extensive structural analysis, see Griffiths, et al.,op. cit.note11, pp. 48–50; for a historical argument, taking into account the parliamen-tary debate about the law, see Pans, E. (2006).De Normatieve Grondslagenvan het Nederlandse Euthanasierecht(Chapter 2). Nijmegen: Wolf Legal Pub-lishers; De Haan, J. (2002). The ethics of euthanasia: Advocates’perspec-tives,Bioethics,16,154–172, gives a somewhat different analysis, butdoesn’t dispute the essential role of the principle of mercy.26Adams in Lewy,op. cit.note 9; Griffiths et al.,op. cit.note 11, pp. 259–273.27Adams in Griffiths et al.,op. cit.note 11.

13The Benelux laws require her to have exercised those capacities in thepresent case: her decision itself must be well-considered.14Van Holsteyn, J., & Trappenburg, M. (1995).Het laatste oordeel: meningenover nieuwe vormen van euthanasie. Baarn: Ambo, summarized inop. cit.note 11, p. 26; Van Delden, J., van der Heide, A., van de Vathorst, S.,Weyers, H., van Tol, D. G. Eds., (2011).Kennis en opvattingen van publiek enprofessionals over medische besluitvorming rond het einde van het leven: hetKOPPEL-onderzoek, Den Haag: ZonMw, ch. 2–4, in particular pp. 31, 54. Asthese studies show, most people nevertheless are in global agreement withthe legal requirements of due care (to the extent they know them), orwould even prefer stricter requirements, in particular as regards lifeexpectancy.15Whether amputation of healthy limbs can be lawful in a case of BodyIntegrity Identity Disorder is in many countries unclear or disputed, but if itis, this is because a medical indication is recognized for the amputation, inan appropriately wide sense of that term.16For the limited role of Volenti in American criminal law see Bergelson, V.(2010). Consent to Harm. In F. G. Miller, A. Wertheimer (Eds.),The ethics ofconsent: Theory and practice. New York: Oxford University Press.17Lewis, P. (2012). The medical exception,Current legal problems,65,355–376, in particular pp. 357–359 on patient-focused public policyjustifications.18Feinberg, J. (1986).Harm to self(pp. 9–10). New York: Oxford UniversityPress. As a referee points out, the term had been used before by Kleinig, J.(1983).Paternalism(p. 11). Manchester: Manchester University Press.19Exceptions include Bergelson,op. cit.note 16; Schramme, Th. (2008).Should we prevent non-therapeutic mutilation and extreme body modifica-tion?Bioethics, 22,8–15; Schramme, Th. (2015). Preventing assistance todie: Assessing indirect paternalism regarding voluntary active euthanasiaand assisted suicide. In M. Cholbi, J. Varelius (Eds.).New directions in theethics of assisted suicide and euthanasia(pp.27–40). Berlin: Springer;Simester, A. P., & von Hirsch, A. (2014).Crimes, harms, and wrongs: On theprinciples of criminalization(pp. 151–186). Oxford and Portland Oregon:Hart Publishing.

2e.g. England and Wales (Lord Falconer’s Assisted Dying Bill, rejected bythe House of Commons September 2015); Scotland (Assisted Suicide Bill,introduced by Margo MacDonald Nov. 2013, rejected May 2015); SouthAfrica (Ruling of the Gauteng North High Court in the case of Stransham-Ford, 29 April 2015, set aside by the Supreme Court of Appeal, 6 Decem-ber 2016); and many American states, Retrieved from: http://www.death-withdignity.org/advocates/national). Canada’s recent Bill C-14, assented toon June 17 2016, uses the term‘medical assistance in dying’that coversboth euthanasia and suicide assistance.3In Belgium, the law of 2002 formally only permits euthanasia, but the Fed-eral Control and Evaluation Commission stated in its first biennial report(2004) that it considered assistance in suicide to fall within the definition ofeuthanasia.4In 2015 the Dutch Review Committees received 5277 reports of euthana-sia, 208 reports of assisted suicide, and 31 reports of a combination of bothactions, Regionale Toetsingscommissies Euthanasie,Jaarverslag 2015.Ofthe 1807 reports received by the Belgian Commission in 2013, no morethan 12 concerned suicide assistance, Federale Controle- en Evaluaticom-missie Euthanasie,Zesde Verslag aan de Wetgevende Kamers (2012–2013).5The reasons mentioned by doctors in research are only practical ones,Kouwenhoven, P. S. C., van Thiel, G. J. M. W., Raijmakers, N. J. H., Rietjens,J. C., van der Heide. A., & van Delden, J. J. M. (2014). Euthanasia orphysican-assisted suicide? A survey from the Netherlands.European Journalof General Practice,20(1), 25–31. In particular the intake of barbiturates issometimes considered less safe because they can be disgorged. Between1998 and 2014 this is known to have happened in Oregon in 24 cases (of556 cases of suicide assistance on which relevant information was avail-able), Oregon Report DWDA 2015. However, by now Dutch and Belgiandoctors can rely on professional guidelines, and, for example, prevent vom-iting by the use of anti-emetics. See Emanuel, E. J., Onwuteaka-Philipsen, B.D., Urwin, J. W., & Cohen, J. (2016). Attitudes and practices of eruthanasiaand physician-assisted suicide in the United States, Canada, and Europe.JAMA,316(1), 79–90, for a survey of the known data on possible complica-tions, from Oregon and the Netherlands.6As understood by most Dutch doctors, see Kouwenhoven et al.,op. cit.note5. Paradoxically, as the authors say, the choice for suicide assistance is pre-dominantly a physician’s one. Most patients prefer to be killed by doctorsrather than killing themselves.7“Suppose a physician supplied a lethal dose to a patient with the knowl-edge and intent that the patient will wrongfully administer it to another.We would have no difficulty in morality or the law recognizing this as acase of joint action to kill for which both are responsible.”Brock, D. W.,(1992). Voluntary active euthanasia.Hastings Center Report,March-April,10–22.8Oregon (Death with Dignity Act 1994),Washington (Death with Dignity Act2008), Vermont (Patient Choice and Control of End of Life Act2013), Califor-nia (End-of-Life Option Act, signed by governor Brown 5 Oct. 2015). InBaxter v. Montana(Dec. 6, 2009) a trial court allowed a defence of consentfor a person charged with assisting in a suicide, but an Oregon-style Deathwith Dignity statute failed in the Senate on April 15, 2013. To my knowl-edge all proposed bills referred to in footnote 2 are of the same kind.9Lewy, G. (2011).Assisted death in Europe and America: Four regimes andtheir lessons(p. 139). New York: Oxford University Press.10Ibid: 134.11Griffiths, J., Weyers, H., & Adams, M. (2008).Euthanasia and Law inEurope(pp. 100–101). Oxford: Hart.12In theRapport de la Mission presidentielle de reflexion sur la fin de vie(rap-port Sicard) published on 18 Dec. 2012, it is proposed to legalize“uneforme de suicide assiste, pratique qui consisteadelivrer sur ordonnancedes produits letaux, sous certaines conditions, et que le patient choisit final-ement d’utiliser ou non.”

n such a close cooperativescheme, why does it matter who is performing the last action of thewhole series? The most one could say is that, if the last action is thepatient’s, that underlines that it is his autonomous choice that isexecuted, but that is only a matter of symbolic meanings.6In eithercase, if death follows, doctor and patient will be jointly responsibleforthatoutcome.7

1Ending someone’s life on his explicit request, see the Benelux definition,Rapport van de Staatscommissie Euthanasie, deel 1: Advies, Den Haag (1985),or in his presumed welfare interests, see Keown, J. (2002).Euthanasia,Ethics and Public Policy: an Argument against Legalisation. Cambridge: Cam-bridge University Press, 10: or from the belief that he is better off dead, seeMcMahan, J. (2002).The ethics of killing: Problems at the margins of life(p. 456). Oxford: Oxford University Press, or in order to benefit him

I argue that the concept‘physician-assisted suicide’covers two procedures that should be distin-guished: giving someone access to humane means to end his own life, and taking co-responsibilityfor the safe and effective execution of that plan. In the first section I explain the distinction, in thefollowing sections I show why it is important. To begin with I argue that we should expect thelaws that permit these two kinds of‘assistance’to be different in their justificatory structure. Lawsthat permit giving access only presuppose that the right to self-determination implies a right to sui-cide, but laws that permit doctors to take co-responsibility may have to appeal to a principle ofmercy or beneficence. Actually this difference in justificatory structure can to some extent befound in existing regulatory systems, though far from consistently. Finally I argue that if one recog-nizes a right to suicide, as Oregon and other American states implicitly do, and as the EuropeanCourt of Human Rights has recently done explicitly, one is committed to permit the first kind of‘assistance’under some conditions

In both cases the doctor acts on the ini-tiative of the patient. That is confirmed by the fact that beforeadministering the lethal drugs in whatever way, she will always askthe patient whether he still wants to go on. In both cases the willingcooperation of the patient is needed through the whole process.And in both cases the proceedings are under the final control of thedoctor, because she has the responsibility to ensure that deathoccurs, safely, relatively quickly and painlessly. She acts and tellsthe patient how to act effectively. Even if the plan is that thepatient drinks something, if he cannot hold the drink she will use analternative way of ensuring his death.

This is understandable

kind of physician-assisted death only suicide assistance is allowed;in jurisdictions that forbid both, the maximum penalty for suicideassistance is usually lower than for euthanasia; and in most jurisdic-tions in which some form of legalization is considered, it is onlyassistance that is debated.2Until now only the Netherlands, Bel-gium, Luxemburg, Colombia and Canada also allow euthanasia.3Inthe Benelux-countries physicians generally prefer euthanasia toassisting in suicide.4The reasons for this preference are not fullyclear,5but whatisclear is that these doctors don’trecognizethedistinction to have the fundamental importance attributed to itelsewhere.

Many authors consider the distinction–helpingsomeone to kill himself or killing him–to be of fundamental moralimportance. In most of the jurisdictions that legally permit some

n the literature about physician-assisted death a conceptual dis-tinction is usually made between assisted suicide and euthanasia (orvoluntary euthanasia, depending on the definition of euthanasiaone prefers).1

That argument obviously only applies to states that recognizeindividual human rights, including a right to self-determination tobegin with. Moreover, I do not argue that the right to self-determination actually implies a right to suicide. Nor do I argue thatthe principle of beneficence actually justifies taking co-responsibility. In these respects my argument is merely a condi-tional one. Its aim is to elucidate the normative logic of differentregulatory systems.

Actually, as I show inSection 3, this difference in justificatory structure can to some extentbe found in existing regulatory systems, though far from consistently.In Section 4, finally, I argue that if one recognizes a right to suicide, asOregon and other American states do implicitly, and as the EuropeanCourt of Human Rights has done explicitly, one is committed to permitthe first kind of‘assistance’under some conditions.

n Section1 I explain the dis-tinction, in the following sections I try to show why it is important,more important than the usual distinction between physician-assistedsuicide and euthanasia. In Section 2 I argue that we should expect thelaws that permit these two kinds of‘assistance’to be different in theirjustificatory structure.

Laws that permit giving access need to presup-pose only that the right to self-determination implies a right to suicide,but laws that permit doctors to take co-responsibility may have toappeal to a principle of mercy or beneficence

WHAT IS IMPLIED IN A RIGHT TOSUICIDE?

ACTUAL REGULATIONS

HE RELEVANCE OF THE DISTINCTIONTO THE JUSTIFICATION OF LEGAL REGIMES

A FUNDAMENTAL DISTINCTION

I want to argue that the concept‘physician-assisted suicide’covers twoprocedures that should be distinguished: giving someone access tohumane means to end his own life, and taking co-responsibility for thesafe and effective execution of that plan.

negative and positive rights,

indirect paternalism

suicide

unbearable suffering

hysician-assisted death, p-assistedsuicide

euthanasia

‘physician-assisted suicide’

physician-assisted death

Two kinds

One might also argue that fewer people will die if these acts are distinguished. This position rests on evidence put forward by David Jones and David Paton that demonstrates that sui-cide rates increase in states in which medically assisted dying is legal-ized,66 which some have argued may be the result of social contagion.67 As Dugdale and Callahan argue, “There is, in short, a striking conflict between suicide prevention efforts and legal AD.”68 The deaths contributing to the suicide rates in Jones and Paton’s analysis, however, include medically assisted deaths as well as suicides. This means that more individuals are dying as a result of either medi-cally assisted dying or suicides, which could also mean that more “good” deaths are taking place. Individuals who seek to end their lives generally prefer to do so in a supportive setting rather than through suicide. A quali-tative analysis of people who request-ed assistance in dying in Belgium for psychological suffering found that “suicide in general was considered as painful, horrific and humiliating, but still evaluated as a possibility by patients whose euthanasia requests could not be granted. However, dying in a caring environment, surrounded by loved ones, was very much the pre-ferred option.”69

Legislation. Many proponents of legalizing the practice of medically assisted dying will argue that efforts toward this will more likely succeed if the two acts are clearly distinguished in the public eye. Evidence support-ing this claim can be found in the re-sults of a Gallup poll conducted in the United States in 2013. The poll found that while 70 percent of Americans say they support the practice when it is described as ending the patient’s life by a painless means, only 51 per-cent support it when it is described as assisting the patient to commit sui-cide.64 However, the importance of the word “suicide” appears to be de-creasing; the difference in responses between the two questions dropped from 19 percent in 2013 to 6 per-cent in 2017.65 Of course, those op-posed to legalizing medically assisted dying will argue that the similarities between it and suicide ought to be emphasized. Since the ethical permis-sibility of the practice is not the focus of this article, I will not discuss these arguments further.

umber of (good?) deaths.

It is also well established that sui-cides affect families in more negative ways than do deaths that are medi-cally assisted and that the latter some-times lead to better psychological outcomes in family members than do deaths by natural causes.70 If it is the case that individuals who would oth-erwise die by suicide are ending their lives through medical assistance, then this seems like a positive result. As re-ported by Lieve Thienpont et al. with

Taking the discussion above into account, we are left with little clarity with regard to the question of whether suicide and medically assist-ed death are fundamentally different. As we have seen, differences in mo-rality, impulsiveness, and capacity are not as clear-cut as many seeking to distinguish the two acts make them out to be. Similarly, a desire to die is present in both cases, as is a form of existential suffering that contributes to this desire. Differences do appear in relation to the kinds of reasons giv-en for the decision to end one’s life, and these are most pronounced when suicides in young people are com-pared to medically assisted dying in older persons who are terminally ill. Additionally, the ability to determine medical futility is often perceived as greater in cases of requests for medi-cal assistance in dying than in cases of suicidality, and the degree of hope associated with physical suffering from terminal or other serious illness is generally less than that associated with psychological suffering. Given all this, it is not clear whether we ought to emphasize the similarities between suicide and medically assisted death for various reasons—drawing together the nar-ratives of individuals who have lost hope and desire to end a life they deem unlivable—or whether we ought to emphasize differences, plac-ing a distance between those who wish to die because of psychological suffering and those who wish to die because of a physical condition. If there is no clear answer to the ques-tion of whether suicide and medically assisted death are fundamentally dif-ferent, might there be other reasons for calling them by different names? Or, in fact, should they be called by the same name, that is, “suicide”?

Additional evidence from Belgium suggests that collapsing the distinc-tion between those who wish to end their life as a result of psychological suffering and those who wish to on account of physical suffering could, somewhat surprisingly, lead to a re-duction in suicide. As mentioned above, out of a sample of forty-eight who were granted permission for eu-thanasia as a result of psychological suffering, thirty-five carried it out, and two committed suicide. The re-maining eleven, however, postponed or canceled the procedure after re-ceiving permission, and eight of these individuals “explained (by phone or mail) that knowing they had the op-tion to proceed with euthanasia gave them sufficient peace of mind to con-tinue their lives.”72 In this case, nearly 17 percent of those who had been approved for euthanasia for psycho-logical suffering found the process of requesting the procedure comforting enough that they no longer desired it. Other research found that up to 50 percent of individuals who were not yet approved but had made an initial request then put their request “on hold” after it was taken seriously.73This offers additional evidence for the appropriateness of retaining hope in cases of psychological suffering. It also suggests that the very act of rec-ognizing an individual’s hopelessness or permitting those who are suffering to give up in a way that is condoned by society may induce enough hope to end their desire to die.

Stigma

A related argument holds that there will be less stigma attached to medically assisted dying if it is dis-tanced from suicide. Louise Shaefer, who sought out medical assistance in dying when diagnosed with a ter-minal illness, argued in a letter to a local newspaper that “[p]ortraying me as suicidal is disrespectful and hurtful to me and my loved ones. It adds insult to injury by dismissing all that I have already endured.”74This suggests that placing more dis-tance between these two acts may contribute to more dignified treat-ment of those seeking to end their life through medically assisted means.

However, the push away from char-acterizing medically assisted dying as medically assisted “suicide” may lead to an increase in stigma in the other direction. Many of the attempts to distance the two acts describe suicide quite harshly (for example, as “a des-perate act by a despondent, mentally unbalanced person”75), contributing to a view of suicide as selfish and immoral. These characterizations of suicide in the context of discussions of medically assisted dying are often surprising, given the importance usu-ally placed on dignity, empathy for suffering, and supporting one’s au-tonomy. As pointed out by Kelly and McLoughlin, there is at times a “dis-criminatory” tone in discussions of the difference between psychological and physical suffering; this tone can be quite pronounced in discussions of the distinction between suicide and medically assisted dying.7

To portray suicide in this way also appears to undo much of the work of campaigns to prevent it. Despite the fact that someone dies every forty seconds as a result of suicide, the act is rarely discussed.77 One survivor de-scribes the difficulty of even having a conversation about it: The betrayal I felt after the at-tempt, facing stigma and a lack of education from my family, could have been prevented. We could have made safety contracts, shared information, and worked together. I should have sought help and psychoeducation. Instead my par-ents covered their ears and I didn’t speak, until it became a trauma for all of us.78

Historically, people have believed that it was too dangerous to offer peer-to-peer support groups fo-cused on the topic of suicide with-out a clinician present. There are many myths and fears around this sort of group and around suicide in general. However, as a com-munity we have found strength in coming together to talk about many “taboo” topics and to sup-port one another in our times of greatest distress. Our collective wisdom and individual stories have taught us that the space to come together in this way can be powerful and healing.79

here is no clear justification for emphasizing either the differences or similarities between suicide and medically assisted dying.

Many organizations involved with suicide prevention have come to recognize that giving space to talk to those who want to die might be an important aspect of prevention.

As Kirker conveys, Alternatives to Suicide80 is a space run by individu-als who have themselves been faced with the desire to end their lives.

These individuals were motivated to create a setting in which it is permis-sible to speak about this desire, with-out the risk of being hospitalized or treated against one’s will, which often prevents individuals from speaking about their suicidal thoughts or in-tentions. In line with this, some evi-dence suggests that suicidal ideation can form a symbolic rock bottom that can help individuals to cope as well as to seek help,81 implying that allowing individuals to talk about such ide-ation may support well-being

Other projects recognize the importance of allowing individuals to tell stories of suicide attempts in order to share with others their experiences of want-ing to die and how they moved be-yond this desire.82 Behind both these endeavors is a desire to overcome silence about suicide and to create spaces in which individuals who have thought about or are thinking about ending their lives are able to share their experiences and access the sup-port they need. Further stigmatizing the act—which arguably is the result of some attempts to distance medi-cally assisted dying from suicide—is not likely to contribute positively to this endeavor.

If, however, proponents of medi-cally assisted dying acknowledged the parallels between it and suicide, even welcomed the term “physician-assisted suicide,” the results might be quite different. Some of the con-clusions drawn within the move-ment—that having control over one’s death can sometimes lead to a better death, that there are rational reasons that an individual might wish to end their life, and that creating space to talk about the desire to die can help others cope—could be extended to discussions related to preventing sui-cide, perhaps reducing stigma in the process

Given the arguments on either side, there is no clear justification for emphasizing either the differ-ences or similarities between suicide and medically assisted dying, and more evidence about the impact of representing them as either dissimi-lar or alike should be sought. In the meantime, however, it is worth tak-ing caution with regard to the harms that might be introduced in attempts to distance suicide from medically assisted dying, particularly with ref-erence to exacerbating stigma sur-rounding suicide and undoing the work of those seeking to prevent it by opening up a space to talk about the desire to end one’s life.

I have offered a critical evalua-tion of the argument that underlies the growing push away from using the term “physician-assisted suicide” when discussing medically assisted dying in the United States. In an anal-ysis of whether there is a fundamental difference between the acts of suicide and medically assisted dying, I argued that many of the features thought to distinguish them are not consistently present in either case, but that there are some themes that arise in one case more often than the other. In light of this, I have examined other reasons that one might give for emphasizing the similarities or differences between suicide and medically assisted dying, and have argued that there is no clear justification for either emphasis, but that more harm may be done by em-phasizing their differences.

Rather than resting the determi-nation of hopelessness on either the individual who is suffering or the cli-nician, it seems more reasonable, and better aligned with the requirements underlying access to medically assist-ed dying more generally, for both to be involved. In Belgium, the patient and physician must agree that there are no reasonable alternatives left to end the patient’s unbearable psycho-logical suffering.62 In line with this, a collaborative group of psychiatrists in Canada recommends an “intersubjec-tive exploration of suffering” between the patient and the practitioner to determine whether the psychologi-cal suffering of an individual justifies medically assisted dying.63

of hopelessness to justify medically assisted dying, the individual’s per-spective is the one that matters. Graham Clayton, father of Adam Maier-Clayton, who took his own life as a result of psychological suffering, thought that these cases ought to be treated the same as cases of terminal illness, that patients ought to be able to make that decision for themselves. “When you know that you’re in such a dire situation and the science hasn’t been done,” Clayton asserted, “it should be your call when you’ve had enough.”60 For those who see psy-chological suffering as a poor basis for being granted medical assistance in dying, the clinician’s perspective is central to determinations of hope; judgments of capacity often enter the picture as well.61

The second question, that of who ought to decide when there is enough hopelessness to justify ending a life, is perhaps more fundamental. For many who see psychological suffering as able to contain a sufficient degree

It may be that determinations of hopelessness are more difficult to make in cases that involve psycho-logical suffering rather than physical suffering and, because of our expo-sure to stories of recovery in relation to psychological suffering, we col-lectively attribute a baseline level of hope to these cases that is not pres-ent in cases of terminal illness, where futility seems more clear-cut. Futility is not difficult to determine only in psychiatry, however; there is always one more combination of chemo-therapy and radiation to try. When a terminally ill patient is deemed to have capacity, though, it is taken as a given that the patient gets to decide when enough is enough. Supporters of medically assisted dying take this further, arguing that not only should those who are terminally ill be able to choose when to stop treatment, but that they should also be able to choose when to die. This raises the question of whether this choice should also be extended to those who are suffer-ing psychologically. As Andre Picard has argued, “Faint hope [as seen by a third party] is not a reasonable jus-tification for denying assisted death, whether a person suffers from cancer or refractory mental illness.”59

Countries that permit medically assisted dying respond to the first question in significantly different ways. While discussion has been tak-ing place for years in the Netherlands over whether to legalize euthanasia for those who are tired of life—suggest-ing a rather low threshold for what falls into the domain of sufficiently hopeless—in the United States, ev-ery state that has legalized medically assisted dying to date requires that natural death is foreseeable within the next six months.58 This suggests that there is little agreement on the appro-priate amount of hopelessness to re-quire before permitting one medical assistance in dying.

Do these differences in hope justify differential treatment of psychologi-cal suffering and physical suffering in requests for medical assistance in dying? Two important questions are embedded in this one: How much is enough hopelessness to justify an individual’s request for a medically assisted death?57 And whose hope should provide justification for either the approval or denial of such a re-quest?

Why do we feel so different with respect to the hopefulness appropri-ate in these two cases? First, the no-tion of futility is not clearly defined in the realm of psychological suf-fering. It is “essentially impossible to describe any psychiatric illness as incurable,” write Brendan Kelly and Declan McLoughlin, so there is no easy way to determine which cases should be deemed hopeless.55Similarly, narratives abound of survi-vors of suicide who are grateful to be alive, reinforcing the notion that it is always wrong to allow a person who is suffering psychologically to end their life by suicide or to be assisted in dy-ing. As one survivor describes his sui-cide attempt, “That was a thing that happened and I’m better now because of it.”56 No parallel narratives are heard from those who are terminally ill and request medical assistance in dying, for, of course, these individu-als die soon after their request, either through its fulfillment or as a result of their medical condition.

he seeming difference in hope between cases of suicidality and cas-es of requests for medically assisted death is one that tugs at heartstrings when medically assisted death for those who are suffering psychologi-cally is mentioned. The idea of per-mitting medically assisted dying for those who are suffering psychologi-cally often seems to mean letting go of any hope for those who need it most. As expressed by Mark Henick, “If we were to offer assisted dying to people who have mental-health dis-orders, I feel like we’d be giving up on them.”54 Again, this distinction comes down to intuitions regarding hope as it relates to physical and psy-chological suffering.

ne candidate for this something more is hope. While those ar-guing that there is a fundamental difference between suicide and medi-cally assisted dying do not focus on differences in hope, it may be the most plausible candidate. Suicides are frequently characterized as tragic and preventable, while medically as-sisted deaths are often seen as pro-moting dignity and the fulfillment of an individual’s wishes. A significant part of these different reactions rests on the degree of hope that seems ap-propriate in either context: a suicide feels tragic because there was still so much to hope for in an individual’s life, while a medically assisted death for someone who is terminally ill only shortens a life in which all hope was already lost.

January-February 2020HASTINGS CENTER REPORT37as a result of psychological suffering is to beg the question. One must make the case that there is something more that contributes to the legitimacy of one of these acts over the other.

s recognized by this court, to insist that wanting to die as a result of physical suffering is more legitimate than wanting to die

In 1994, the Dutch Supreme Court argued that they should not, ruling (according to commentators) that “the seriousness of the suffering of the patient does not depend on the cause of the suf-fering,” thereby rejecting a distinc-tion between physical (or somatic) suffering and psychological or mental suffering as the basis for demarcating legitimate and illegitimate requests for euthanasia.53

Do these different themes of suf-fering lead to differences in its se-riousness or in the way we should respond to it?

From a higher, more abstract level, a kind of existential pain (sometimes called “psychache”) appears to be central to the experiences leading to the decision to seek to end one’s life in both contexts. At a lower, more detailed level, both similar and dif-ferent themes arise, particularly in comparisons of young people who have attempted suicide and individu-als seeking medical assistance in dy-ing when terminally ill. In the latter case, the deterioration of one’s physi-cal health leads individuals to feel the future is not worth living for, while in cases of suicide, it is the accumulation of trauma and psychological suffering that leads individuals to feel the fu-ture is not worth living for.

What should we make of this?

These quotations, the first from an individual who attempted suicide and the second from an individual dying from AIDS, highlight the im-portance that many place on the no-tion of burdening others, whether in the context of suicide or of medically assisted dying.

Sometimes the similarities are quite striking, as can be seen from these two quotations:Death made the most sense to me. I did not see it as “copping out” or “taking the easy way out.” The decision weighed on me heavily but I saw it as the kindest thing I could do for the people I loved and who possibly still love me. I was tormenting them, and I was tormented. I saw leaving as a way of giving them peace.51I’m inconveniencing, I’m still inconveniencing other people who look after me and stuff like that. I don’t want to be like that. I wouldn’t enjoy it, I wouldn’t, I wouldn’t. No, I’d rather die.52

A significant number of themes are common across the contexts of medi-cally assisted dying and suicide. These include the central place of loss, lone-liness, hopelessness, the experience of burdening others, a dissolution of one’s identity, a lack of control, and feeling that one has no future pros-pects.5

Like those who request medical assistance in dying, those who choose to die by suicide would not make such a choice if they were not in the circumstances that they are in.

ered or attempted to engage in these acts, and not only from the perspec-tive of outsiders. The value of these perspectives will, I hope, become clearer in the discussion that follows.

Moreover, the perspectives of those who have sought to end their lives seem important for the ques-tion at hand. If the acts of suicide and medically assisted dying are funda-mentally different, it seems that such difference must be visible from the perspective of those who have consid-

as well as with a broader recog-nition of the need for patient voices in discussions of medically assisted dying.11

A brief note on my methodology before diving in: while I draw on vari-ous forms of data, I have intention-ally sought out qualitative as well as quantitative research regarding sui-cide and medically assisted dying. By doing so, I hope in part to align this project with the growing recognition within suicidology of the importance of including the voices of those who have attempted or considered sui-cide,10 as well as with a broader recog-nition of the need for patient voices in discussions of medically assisted dying.11

Throughout the paper, “medically assisted dying” will refer to the act as practiced in the legal context of the United States, in which all eligible patients have a terminal condition.

Morality

Before we do so, we need more evidence either that the two acts are fundamentally different or that em-phasizing differences between them is unlikely to do more harm than good. As will be demonstrated below, both these points are far from clear

Arguments that suicide and medi-cally assisted dying are different do not usually explicitly cite morality, but a moral difference is often im-plied. Butler, in her blog post, names this difference explicitly: “‘Suicide’ is like ‘homosexual.

It’s not inac-curate, exactly, but the associations are clinical, judgmental, legalistic, even freighted with the notion of sin. Catholic theologians have writ-ten treatises against it. ‘Committing’ suicide is illegal, like committing a burglary.”12

“Suicide” will refer to cases of indi-viduals choosing to end their lives without medical assistance. I will also discuss cases in which medical as-sistance in dying is granted to those with psychiatric conditions who wish to end their lives. I will call this “euthanasia for psychological suffer-ing,” which is how it is referred to in the Netherlands, Belgium, and Switzerland, where it is legal; this will also help to differentiate it from cases of medical assistance in dying as prac-ticed in the United States.

Attempting suicide is not actu-ally considered a crime in most of the United States, and in most states, assisted suicide is equivalent to man-slaughter. What Butler describes here is the moral stigma associated with suicide, and the goal of distancing medically assisted dying from suicide is precisely to free it of such associa-tions.

Finally, in light of my analyses, I argue that we should be cautious before we conclude that medically as-sisted dying should not be called “sui-cide.”

These associations stem from a history in the West in which law and religion were more closely inter-twined. The act of suicide was con-sidered immoral because it involved making on one’s own a decision be-lieved to belong to God; the act was regarded as violating the sanctity of life.

This is a serious argument, but it does not provide a viable candidate for a fundamental difference between medically assisted dying and sui-cide. It applies, after all, to instances of both.1

Ultimately, what we say about the morality of the two acts is the conclusion, not a premise, of an argument about their differences. If it were the case that the fundamen-tal difference is one of morality, then there would have to be some other difference that could underlie the re-spective morality and immorality of suicide by one’s own hand with the permission of a medical doctor and suicide by one’s own hand without the permission of a medical doctor.

I then consider whether the conclusion—that the two acts should not be called by the same name—follows from the premises. I ask what else might justify the conclusion that suicide and medi-cally assisted dying ought to be called by different names, and I examine possible justifications for accepting this premise, as well as what justifi-cations might exist for emphasizing the similarities between these two acts.

I consider some of the reasons commonly given for holding that suicide and medical-ly assisted dying differ fundamental-ly: moral justifiability, impulsiveness, capacity, or the reasons underlying the decision to end one’s life.9

Impulsiveness

Another fundamental difference suggested by those seeking to characterize the gap between sui-cide and medically assisted dying is the purported impulsiveness of the former. Death with Dignity defines suicide as generally occurring “as the result of an individual’s self-destruc-tive impulse,”14 while others have described it as involving a “desper-ate, impulsive choice.”15 In contrast, medically assisted dying has been characterized as a choice that results from “exhaustive reflection and con-templation.”1

Data suggests, however, that less than a quarter of suicide attempts are impulsive (defined as taking place within five minutes of the decision to attempt).17

Ideation and plan-ning are known to be some of the best predictors of suicide attempts and suicide completion, suggest-ing that impulsiveness is far from a necessary feature of the act. The im-portance of planning is highlighted in theories proposed in suicidology such as the suicide continuum (from fleeting ideation to completed sui-cide) and the “Ideation-to-Action” framework.18

Evidence for the im-portance of planning was also found in a survey of high school students; researchers reported that nearly 80 percent of those who had “seriously considered” suicide had made a plan and that those who had made a plan were significantly more likely to have attempted suicide.19 Similarly, in a review of qualitative studies of sui-cide, Richard Lakeman and Mary Fitzgerald found that most individu-als who had attempted suicide were inclined to characterize their own at-tempt as a choice rather than as an impulse.

The authors describe how “fantasizing or choosing the time, place and method of one’s own death may reinforce to the person that they at least have some power, an option or escape. Knowing that there is a possible escape may make it easier to go on or to endure suffering.”20

Likewise, planning is central to the experience of those who seek medical assistance in dying, especially because it is legally required; a wait-ing period of at least fifteen days is required in between two mandatory requests. The importance of planning also extends to cases of euthanasia for psychological suffering.

In an analysis of requests for eu-thanasia as a result of unbearable psychological suffering in Belgium, out of forty-eight requests that were approved, only two people died by suicide before the waiting period was complete, and thirty-five were medically assisted in death after the waiting period. Although, legally, pa-tients in Belgium must wait at least one month after their initial request before ending their lives, the average wait in this sample was nearly nine months.21

his suggests that these individuals, who would have been able to end their lives only by suicide had they lived in almost any other nation, did not impulsively decide to die through medical assistance.

Furthermore, the authors of a quali-tative analysis of the same population remarked on the significance of how much planning took place in advance of these deaths. They reported that those eligible for euthanasia partook in “advance preparation of all kinds of financial and practical arrangements, from the preparation of a warm and serene atmosphere in which the act of euthanasia would take place at home, to making sure that the act of eutha-nasia would not take place near or during holiday seasons.”22

Capacity

Capacity is frequently suggested as a factor that distinguishes those who aim to end their lives by sui-cide and those who aim to end their lives with the help of a physician.

A statement issued by the American Public Health Association holds that “[p]rofound psychological differ-ences distinguish suicide from ac-

tions under DDA [the Oregon Death with Dignity Act].”23 Quoting Rhea Farberman, the American Psychological Association asserts, “It is important to remember that the reasoning on which a terminally ill person (whose judgments are not impaired by mental disorders) bases a decision to end his or her life is fun-damentally different from the reason-ing a clinically depressed person uses to justify suicide.”24

Similarly, the American Association of Suicidology suggests that the “conventionally sui-cidal person may be unable to assess his or her situation clearly or objec-tively.”25

There is undoubtedly a high cor-relation between the presence of mental disorders and suicide.26 This is not surprising, given that suicidal-ity is part of the diagnostic criteria for depression, which suggests that we should be cautious about circularity in these definitions.27

Some criticize jumping from correlation to causation in trying to understand what leads to suicide. Scott Fitzpatrick describes how “survivors of suicide attempts, like users and survivors of psychia-try, have typically rejected a narrow framing of suicide as the outcome of mental illness, instead situating their illness within a broader personal life history,” highlighting factors that have contributed to their suffering, such as abuse and bullying.28 Suicide researchers have, in addition, criti-cized the emphasis on “psychiatric antecedents” and the neglect of social and historical factors that are likely to also play causal roles.29

Regardless of whether mental dis-order plays such a role in suicide,30many who seek to distinguish suicide from medically assisted death empha-size that those who attempt suicide lack decisional capacity at the time they make the decision. This raises the question of whether individuals who attempt suicide are unable to understand and appreciate the deci-sion.

Answering this is difficult. Of course, being diagnosed with a men-tal disorder does not necessarily entail a lack of capacity. All those who have been granted euthanasia for psycho-logical suffering in Europe have been deemed to have the capacity to con-sent to the procedure.

ndividuals with diagnoses of mental disorders regularly consent to clinical interven-tions as well as to participation in medical research. Additionally, a tre-mendous range of mental states can be present with a diagnosis of mental disorder. As Adam Meier-Clayton, a proponent of legalizing medically as-sisted dying for those with psychiat-ric diagnoses, pointed out, “There’s a major difference between someone such as myself and someone who is in a psychotic state.

With my deper-sonalization disorder, it’s simply a sensation I experience. It doesn’t af-fect how I make my decisions or how I base my decisions. Simply having a mental illness does not cancel out the ability to give informed consent.”31

At the other end, someone like Maier-Clayton may have a diagnosis of mental disorder but be able to reflect on their long and unbearable suffer-ing and, as a result, desire to end their life.32

At one end of the spectrum of suicides in the presence of mental disorder, someone can experience a delusion that produces a belief that they ought to commit suicide.

Instead, I aim to illuminate some of the considerations that ought to be included in discussions related to medically assisted dying and also to shed light on what the indirect effects of such discussions can be.

Below, I evaluate this knot of problems, starting with an extended evaluation of the premise that suicide and medically assisted dying are fun-damentally different. I do not take a stand for or against the morality or le-gality of suicide or medically assisted dying.

Additionally, it is not entirely clear to what degree mental illness is present in those making requests for medically assisted dying. Evidence suggests that depression is often pres-ent but undetected in those at the end of life,33 while those with terminal di-agnoses who have a desire to hasten death are significantly more likely than those without them to meet the criteria for major depression and ex-hibit symptoms characteristic of the disorder.34 As Lydia Dugdale and Daniel Callahan have pointed out, “Data from Oregon show that only approximately 5% of people electing AD [aid in dying] have been referred for psychiatric evaluation. This is un-settling considering that the majority of patients who elect AD have cancer and that depression is a comorbidity affecting up to 50% of US patients with cancer.”35

Even when evalua-tions do take place, says Farberman, “attempting to determine to what degree, if any, a terminally ill person is experiencing depression or other cognitive impairments is extremely difficult.”36

sychological evaluations can be especially challenging because the will to live often fluctuates sub-stantially among patients who are dying.37 It has even been suggested that anyone in a palliative care set-ting with feelings of meaninglessness and hopelessness should be thought of as experiencing “demoralization syndrome,” which is likely to impair their capacity.38

We can conclude that capacity is unlikely to be a good candidate for the fundamental difference between suicide and medically assisted death that proponents of legalizing the lat-ter claim exists.

Digging deeper into the claim that these acts are different leads to an examination of the difference between two kinds of suffering—suffering from psychological condi-tions and suffering from physical conditions—and therefore leads also toward an examination of whether re-quests for medical assistance in dying by those suffering from psychological conditions and those suffering from physical conditions should be paint-ed with the same brush

Reasons for Wanting to Die

This argument may appear, on the face of it, to be merely about the ap-propriate semantic territory of these two terms. “Suicide” and “medically assisted dying” are often used to sug-gest differences between the experi-ences of people who choose to die on account of psychological suffering and the experiences of individuals with a terminal illness who choose to die.8

Perhaps the most common claim in arguments that suicide is dif-ferent from medically assisted death is that different reasons underlie the decision to end one’s life. These dif-ferences may concern the desire to die or the nature of the suffering that generates this desire to die.

36HASTINGS CENTER REPORTJanuary-February 2020to live. Suicide is described as a choice “to end an otherwise open-ended span of life,”39 whereas “the person with a terminal illness does not neces-sarily want to die; he or she typically wants desperately to live but cannot do so.”4

Desire to die. One distinction that frequently arises in discussions of the gap between suicide and medically as-sisted dying is a difference in the will

Whose hope should provide justification for either the approval or denial of a request for medically assisted death?

and that, as a result, the term “physician-assisted suicide” should be “deleted from use.”7

This is a shaky distinction at best. Of course, anyone making a request for medical assistance in dy-ing (assuming there is no coercion or manipulation) desires to die in one sense; that is precisely what the re-quest is for. What is really being said here is that they wouldn’t make such a choice if they were not in the circum-stances that they are in. However, those who choose to die by suicide would also not make such a choice if they were not in the circumstances that they are in. As Aaron Kheriaty puts it, “Suicidal people do not really want to die. What they want to do is escape what they see to be an intoler-able situation.”41 For this reason, the desire to die does not make for a good distinction between these two acts

The nature of the suffering.

Perhaps the nature of the suffering contributes to different reasons for wanting to die, some of which are more legitimate than others, and this is what underlies the difference be-tween suicide and medically assisted death. This intuition is in play when a contrast is drawn between the sui-cide of a “distraught teenager”42 and medically assisted dying that consists of “participating in an act to short-en the agony of [a patient’s] final hours.”43

t has also been suggested that in requests for medical assistance in dying in the context of terminal illness, individuals are “not killing themselves; cancer is killing them.”44These characterizations seem to sug-gest that some reasons for wanting to die are appropriate, whereas others are not.

This statement outlines fifteen differences between the acts, arguing that, even though there may be significant over-lap between the two, “the practice of physician aid in dying is distinct from the behavior that has been tra-ditionally and ordinarily described as ‘suicide,’ the tragic event our organi-zation works so hard to prevent”6

In an explicit formulation of the argument, the American Association of Suicidology recently published a statement en-titled “‘Suicide’ Is Not the Same as ‘Physician Aid in Dying.’”5

While the emphases of the dis-cussions are not always the same, a similar argument underlies each plea for recognizing the distance between these two acts. This argument has two premises: that suicide and medi-cally assisted dying are fundamentally different and that if they are differ-ent, then they should not be called by the same name.

Research does suggest that some reasons feature more prominently in decisions to request medical as-sistance in dying than in suicide, and vice versa. Those with physical illnesses who request medical as-sistance in dying often speak of the importance of dignity, the fear of having one’s body fall apart, the ex-perience of having seen others die in pain, and the desire to avoid such a fate themselves, while those who have attempted suicide raise such concerns infrequently.45 Topics such as past abuses, betrayals within relationships, substance use, and a desire to seek revenge or attention appear in dis-cussions about individuals who have attempted suicide, and these themes rarely arise in discussions about medi-cally assisted dying.46 However, the themes particular to suicide show up much more frequently in young people, while older persons who have attempted suicide offer reasons that tend to resemble those given in the context of medically assisted dying for the terminally ill.4

Interestingly, pain and symptoms appear to play much less of a role in contributing to terminally ill persons’ decisions to end their lives than one might expect. Research overwhelm-ingly cites existential reasons as the primary motivations for requests for medical assistance in dying.48 Family members who have watched their loved ones end their life with medical assistance concur; they describe “feel-ings of anger, impotence, despera-tion and hopelessness” as the primary contributors to their loved ones’ deci-sions to end their lives.4

and

Degree of Hope

The seeming difference in hope between cases of suicidality and requests for medically assisted death comes down to intuitions regarding hope as it relates to physical and psychological suffering.

Beyond a Fundamental Difference

1. I will primarily use the terms “medical-ly assisted dying” and “medical assistance in dying” in an attempt to remain somewhat neutral throughout this paper, although I will sometimes use the term “euthanasia” when speaking of the European context.2. “Terminology of Assisted Dying,” Death with Dignity, https://www.death-withdignity.org/terminology/, accessed September 13, 2017.3. K. Butler, “Aid in Dying or Assisted Suicide? What to Do When Every Phrase Is Fraught,” Center for Health Journalism Member Blog, October 26, 2015, https://www.centerforhealthjournalism.org/2015/10/23/aid-dying-or-assisted-suicide-what-do-when-neutral-terms-can%E2%80%99t-be-found.4. The push away from using the term “physician-assisted suicide” is not unique, in that much of the politics surrounding the movement to legalize medical aid in dy-ing has come in the form of battles related to terminology (for instance, proponents advocate for “the right to die” and “self-deliverance,” while critics often classify the act as “murder”).5. American Association of Suicidology, “Statement of the American Association of Suicidology: ‘Suicide’ Is Not the Same as ‘Physician Aid in Dying,’” 2017, https://ohiooptions.org/wp-content/uploads/2016/02/AAS-PAD-Statement-Approved-10.30.17-ed-10-30-17.pdf.6. Ibid., 1.7. Ibid., 4. 8. This reflects the debate around medi-cal aid in dying particular to the context of the United States, where this distinc-tion carries a lot of weight. In Belgium, the Netherlands, and Switzerland, where those requesting medical aid in dying are not required to have a terminal illness, the distance between requests for medically assisted deaths as a result of psychological suffering and those related to physical suf-fering is often less apparent. Canada is still debating how this distinction will shake out, as there is ambiguity in the current law where those eligible for medical aid in dying must be suffering from a “griev-ous and irremediable medical condition” and death must be “reasonably foreseeable” (Government of Canada, Bill C-14: An Act to Amend the Criminal Code and to Make Related Amendments to Other Acts [Medical Assistance in Dying], S. C. 2016, c. 3). The analysis within this article is not meant to be specific to a country or region but takes inspiration from current logical debates particular to the United States.9. While the American Association of Suicidology statement argues that there are fifteen features that distinguish suicide and medically assisted death, I do not con-sider all of these because several of the fea-tures highlighted (such as safeguards built into death with dignity laws in the United States) are not universal or have a somewhat accidental relationship to the acts them-selves. 10. H. Hjelmeland and B. L. Knizek, “Why We Need Qualitative Research in Suicidology,” Suicide and Life-Threatening Behavior 40, no. 1 (2010): 74-80; M. Gavin and A. Rogers, “Narratives of Suicide in Psychological Autopsy: Bringing Lay Knowledge Back In,” Journal of Mental Health 15, no. 2 (2009): 135-44. I ac-knowledge that relying on the accounts of those who have survived suicide attempts is inherently limited. As articulated by Scott Fitzpatrick, “Although personal stories of suicide confer certain privileges and ben-efits on survivors of suicide attempts, they also manifest and normalize particular ways of thinking, acting, and communicating that have considerable ethical and political force in shaping the ways suicidal behavior is understood, the ways it is subjectively experienced, and the ways it is responded to” (S. J. Fitzpatrick, “Ethical and Politica

Implications of the Turn to Stories in Suicide Prevention,” Philosophy, Psychiatry, & Psychology 23, no. 3 [2016]: 265-76, at 267.) Of course, there are limitations to re-search that excludes such voices as well.11. Y. Y. W. Mak, G. Elwyn, and I. G. Finlay, “Patients’ Voices Are Needed in Debates on Euthanasia,” BMJ 327 (2003): 213.12. Butler, “Aid in Dying or Assisted Suicide?” 13. See David Hume’s essay “On Suicide” for an extended critique of the stance that suicide is immoral as a result of the sanctity of life (chap. 1 in Essays on Suicide and the Immortality of the Soul [Blackmask Online, 2001]).14. “Glossary of Terms,” Death with Dignity, https://www.deathwithdignity.org/assisted-dyingglossary/, accessed February 6, 2018.15. These words from E. J. Lieberman in Psychiatric News, August 4, 2006, are quoted in “Terminology of Assisted Dying,” Death with Dignity, https://www.deathwithdig-nity.org/terminology/, accessed September 13, 2017. A related difference that has been put forward is that suicide is much more violent than medically assisted dy-ing (American Association of Suicidology, “Statement of the American Association of Suicidology”; D. C. Leven and T. E. Quill, “The Clinical, Ethical and Legislative Case for Medical Aid in Dying in New York,” New York State Bar Association Health Law Journal 22, no. 3 (2017): 27-29. This claim is difficult to evaluate because one’s method of suicide is significantly predicted by the ac-cessibility of different means (C. W. Barber and M. J. Miller, “Reducing a Suicidal Person’s Access to Lethal Means of Suicide,” American Journal of Preventive Medicine 47, no. 3 [2014]: S264-S272; M. Eddleston et al., “Choice of Poison for Intentional Self-Poisoning in Rural Sri Lanka,” Clinical Toxicology 44, no. 3 [2006]: 283-86.) For example, while suicide by firearms account-ed for over 50 percent of cases of suicide in the United States in 2012, in the United Kingdom, where firearms are less prevalent, only 1.8 percent of suicides were caused by firearms in 2011 (“Suicide Statistics,” Lost All Hope, http://lostallhope.com/suicide-statistics, accessed February 6, 2018).16. L. W., “A Terminally Ill Patient’s Right to Die,” Write the World, March 18, 2016, https://writetheworld.com/groups/1/shared/11180/version/26139.17. T. R. Simon et al., “Characteristics of Impulsive Suicide Attempts and Attempters,” Suicide and Life-Threatening Behavior 32 (2001): 49-59. 18. D. E. Klonsky and A. M. May, “The Three-Step Theory (3ST): A New Theory of Suicide Rooted in the ‘Ideation-to-Action’ Framework,” International Journal of Cognitive Therapy 8, no. 2 (2015): 114-29; M. Liotta, C. Mento, and S. Settineri, “Seriousness and Lethality of Attempted Suicide: A Systematic Review,” Aggression and Violent Behavior 21 (2015): 97-109.19. T. R. Simon and A. E. Crosby, “Suicide Planning among High School Students Who Report Attempting Suicide,” Suicide and Life-Threatening Behavior 30, no. 3 (2000): 213-21.20. R. Lakeman and M. Fitzgerald, “How People Live with or Get Over Being Suicidal: A Review of Qualitative Studies,” Journal of Advanced Nursing 64, no. 2 (2008): 114-26, at 123.21. L. Thienpont et al., “Euthanasia Requests, Procedures and Outcomes for 100 Belgian Patients Suffering from Psychiatric Disorders: A Retrospective, Descriptive Study,” BMJ Open 5, no. 7 (2015): doi:10.1136/bmjopen-2014-007454.22. M. Verhofstadt, L. Thienpont, and G. Y. Peters, “When Unbearable Suffering Incites Psychiatric Patients to Request Euthanasia: Qualitative Study,” British Journal of Psychiatry 211, no. 4 (2017): 238-45, at 241. While medically assisted dying is not impulsive in one sense, given that a required waiting period acts as a safeguard to ensure that individuals take the time to consider their decision before ending their lives, the act itself can take place quite im-pulsively once the substance has been ob-tained, particularly in the United States, where a physician is not required to be pres-ent and a final attestation is not required (except in California).23. “Patients’ Rights to Self-Determination at the End of Life,” American Public Health Association, October 28, 2008, https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/29/13/28/pa-tients-rights-to-self-determination-at-the-end-of-life.24. R. K. Farberman, “Terminal Illness and Hastened Death Requests: The Important Role of the Mental Health Professional,” Professional Psychology Research and Practice 28 (1997): 544-47, quoted in Working Group on Assisted Suicide and End of Life Decisions, Report to the Board of Directors (Washington, DC: American Psychological Association, 2000). 25. American Association of Suicidology “Statement of the American Association of Suicidology,” 3. 26. E. Chesney, G. M. Goodwin, and S. Fazel, “Risks of All-Cause and Suicide Mortality in Mental Disorders: A Meta-review,” World Psychiatry 13, no. 2 (2014): 153-60; J. Cavanagh et al., “Psychological Autopsy Studies of Suicide: A Systematic Review,” Psychological Medicine 33, no. 3 (2003): 395-405.27. H. Kincaid, “DSM Applications to Young Children: Are There Really Bipolar and Depressed Two-Year-Olds?,” in Extraordinary Science and Psychiatry: Responses to the Crisis in Mental Health Research, ed. J. Poland and Ş. Tekin (Cambridge, MA: MIT Press, 2017), 267-92.28. Fitzpatrick, “Ethical and Political Implications of the Turn to Stories,” 269.29. Gavin and Rogers, “Narratives of Suicide in Psychological Autopsy,” 135.30. See H. Maung, “Voluntary Euthanasia and Borderline Personality Disorder: Is the Wish to Die Necessarily a Symptom of the Illness?” (unpublished) for a fascinating discussion of whether or not a causal relationship between a psychiatric disorder and the wish to die necessarily ren-ders that wish invalid.31. A. Maier-Clayton, “As a Person with Mental Illness, Here’s Why I Support Medically Assisted Death,” Globe and Mail,May 8, 2016.32. In 2017, after years of advocating for legalizing medical aid in dying in Canada for those suffering psychologically, as he was, Maier-Clayton did in fact end his life by suicide.33. S. A. Irwin, “Psychiatric Issues in Palliative Care: Recognition of Depression in Patients Enrolled in Hospice Care,” Journal of Palliative Medicine 11, no. 2 (2008): 158-63.34. B. Kelly et al., “Factors Associated with the Wish to Hasten Death: A Study of Patients with Terminal Illness,” Psychological Medicine 33, no. 1 (2003): 75-81; K. G. Wilson et al., “Desire for Euthanasia or Physician-Assisted Suicide in Palliative Cancer Care,” Health Psychology 26, no. 3 (2007): 314-23. 35. L. S. Dugdale and D. Callahan, “Assisted Death and the Public Good,” Southern Medical Journal 110, no. 9 (2017): 559-61, citing evidence from D. L. Rosenstein, “Depression and End-of-Life Care for Patients with Cancer,” Dialogues in Clinical Neuroscience 13, no. 1 (2011): 101-8.36. Farberman, “Terminal Illness and Hastened Death Requests,” 545.37. H. M. Chochinov et al., “Will to Live in the Terminally Ill,” Lancet 354 (1999): 816-19.38. D. W. Kissane, “The Contribution of Demoralization to End of Life Decision-Making,” Hastings Center Report 34, no. 4 (2004): 21-31.39. “Terminology of Assisted Dying,” California Death with Dignity, http://cali-forniadeathwithdignity.org/terminology/, accessed September 13, 2017.40. American Association of Suicidology, “Statement of the American Association of Suicidology.”41. S. O’Neill, “‘Assisted Suicide’ or ‘Aid in Dying?’ The Semantic Battle over SB 128,” Southern California Public Radio, 89.3KPCC, https://www.scpr.org/

42HASTINGS CENTER REPORTJanuary-February 2020news/2015/06/04/52187/assisted-suicide-or-aid-in-dying-the-semantic-batt/. There are interesting parallels here between this discussion and past debates surrounding whether the withdrawal of medical treat-ment constitutes suicide (for example, William Bartling’s living will read, “While I have no wish to die, I find intolerable the living conditions forced upon me by my deteriorating lungs, heart and blood ves-sel systems and find intolerable my being continuously connected to this ventilator” [William Francis Bartling et al., Plaintiffs and Appellants, v. Glendale Adventist Medical Center et al., Defendants and Respondents: Court of Appeal, Second District, Division 5, California, 1986]). Thank you to an anonymous reviewer for pointing this out. 42. Butler, “Aid in Dying or Assisted Suicide?”43. “Terminology of Assisted Dying,” California Death with Dignity, http://cali-forniadeathwithdignity.org/terminology/. 44. Ibid.45. M. Dees et al., “Unbearable Suffering of Patients with a Request for Euthanasia or Physician-Assisted Suicide: An Integrative Review,” Psycho-Oncology 19, no. 4 (2010): 339-52; W. Breitbart, B. D. Rosenfeld, and S. D. Passik, “Interest in Physician-Assisted Suicide among Ambulatory HIV-Infected Patients,” American Journal of Psychiatry153, no. 2 (1996): 238-42; A. Chapple et al., “What People Close to Death Say about Euthanasia and Assisted Suicide: A Qualitative Study,” Journal of Medical Ethics32, no. 12 (2006): 706-10. 46. S. J. Cash et al., “Adolescent Suicide Statements on MySpace,” Cyberpsychology, Behavior, and Social Networking 16, no. 3 (2013): 166-74; S. A. Kidd and M. J. Kral, “Suicide and Prostitution among Street Youth: A Qualitative Analysis,” Adolescence 37 (2002): 411-30; Lakeman and Fitzgerald, “How People Live with or Get Over Being Suicidal”; D. H. Rosen, “Suicide Survivors: A Follow-Up Study of Persons Who Survived Jumping from the Golden Gate and San Francisco–Oakland Bay Bridges,” Western Journal of Medicine122, no. 4 (1975): 289-94.47. Lakeman and Fitzgerald, “How People Live with or Get Over Being Suicidal.”48. L. Ganzini, E. R. Goy, and S. K. Dobscha, “Oregonians’ Reasons for Requesting Physician Aid in Dying,” Archives of Internal Medicine 169, no. 5 (2009): 489-92; Dugdale and Callahan, “Assisted Death and the Public Good”; Breitbart, Rosenfeld, and Passik, “Interest in Physician-Assisted Suicide among Ambulatory HIV-Infected Patients.” 49. C. Gamondi, M. Pott, and S. Payne, “Families’ Experiences with Patients Who Died after Assisted Suicide: A Retrospective Interview Study in Southern Switzerland,” Annals of Oncology 24, no. 6 (2013): 1639-44, at 1641.50. J. V. Lavery et al., “Origins of the Desire for Euthanasia and Assisted Suicide in People with HIV-1 or AIDS: A Qualitative Study,” Lancet 358 (2001): 362-67; Dees, “Unbearable Suffering”; Breitbart, Rosenfeld, and Passik, “Interest in Physician-Assisted Suicide among Ambulatory HIV-Infected Patients”; Mak, “Patients’ Voices”; S. Gibson et al., “The Impact of Participating in Suicide Research Online,” Suicide and Life-Threatening Behavior 44, no. 4 (2014): 372-83; Kidd and Kral, “Suicide and Prostitution among Street Youth”; M. J. Player et al., “What Interrupts Suicide Attempts in Men: A Qualitative Study,” PloS One 10, no. 6 (2015): e0128180; M. Elliott, D. E. Naphan, and B. L. Kohlenberg, “Suicidal Behavior during Economic Hard Times,” International Journal of Social Psychiatry61, no. 5 (2014): 492-97; J. K. Chan, H. Kirkpatrick, and J. Brasch, “The Reasons to Go On Living Project: Stories of Recovery after a Suicide Attempt,” Qualitative Research in Psychology 14, no. 3 (2017): 350-73. 51. Chan, Kirkpatrick, and Brasch, “The Reasons to Go On Living Project,” story 56. 52. Lavery et al., “Origins of the Desire for Euthanasia,” 364.53. R. Berghmans, G. Widdershoven, and I. Widdershoven-Heerding, “Physician-Assisted Suicide in Psychiatry and Loss of Hope,” International Journal of Law and Psychiatry 36, no. 5 (2013): 436-43, at 436. 54. M. Henick, “Why People with Mental Illness Shouldn’t Have Access to Medically Assisted Death,” Globe and Mail,May 8, 2016. 55. B. D. Kelly and D. M. McLoughlin. “Euthanasia, Assisted Suicide and Psychiatry: A Pandora’s Box,” British Journal of Psychiatry 181, no. 4 (2002): 278-79, at 279.56. Joey Olszewski, “I Survived a Suicide Attempt,” in D. L. Stage, “Live through This,” https://www.livethroughthis.org/, accessed February 16, 2018.57. This question overlaps significantly with the question of how much is enough suffering to justify approving an individual’s request for a medically assisted death, or at what point is suffering unbearable. I have chosen to frame it in terms of hopeless-ness rather than suffering here because I see hope as a central factor underlying intu-itions regarding the difference between psy-chological and physical suffering, but this discussion overlaps in important ways with questions related to how we define unbear-able suffering. 58. T. Sheldon, “Being ‘Tired of Life’ Is Not Grounds for Euthanasia,” BMJ 326, no. 7380 (2003): 71.59. A. Picard, “The Mentally Ill Must Be Part of the Assisted-Dying Debate,” Globe and Mail, April 17, 2017.60. S. Hughes, “Adam Maier-Clayton’s Controversial Right-to-Die Campaign,” BBC, http://www.bbc.com/news/world-us-canada-40546632, accessed February 8, 2018.61. Kissane, “The Contribution of Demoralization.” 62. Thienpont, “Euthanasia Requests, Procedures and Outcomes.”63. M. Gupta et al., “Exploring the Psychological Suffering of a Person Requesting Medical Assistance in Dying,” Medical Assistance in Dying Research Group, Department of Psychiatry, CHUM Research Centre, August 2017, http://www.cmq.org/pdf/outils-fin-de-vie/exploring-psychological-suffering.pdf?t=1535846400024.64. L. Saad, “U.S. Support for Euthanasia Hinges on How It’s Described,” http://news.gallup.com/poll/162815/support-euthanasia-hinges-described.aspx, accessed February 15, 2018.65. J. Wood and J. McCarthy, “Majority of Americans Remain Supportive of Euthanasia,” http://news.gallup.com/poll/211928/majority-americans-remain-sup-portive-euthanasia.aspx, accessed February 15, 2018.66. D. A. Jones and D. Paton, “How Does Legalization of Physician-Assisted Suicide Affect Rates of Suicide?,” Southern Medical Journal 108, no. 10 (2015): 599-604. 67. A. Kheriaty, “Social Contagion Effects of Physician-Assisted Suicide: Commentary on ‘How Does Legalization of Physician-Assisted Suicide Affect Rates of Suicide?’,” Southern Medical Journal 108, no. 10 (2015): 605-6. 68. Dugdale and Callahan, “Assisted Death and the Public Good,” at 559.69. Verhofstadt, Thienpont, and Peters, “When Unbearable Suffering Incites Psychiatric Patients,” 241.70. L. Ganzini et al., “Mental Health Outcomes of Family Members of Oregonians Who Request Physician Aid in Dying,” Journal of Pain and Symptom Management 38, no. 6 (2009): 807-15; N. B. Swarte et al., “Effects of Euthanasia on the Bereaved Family and Friends: A Cross Sectional Study,” BMJ 327 (2003): 189.71. Thienpont et al., “Euthanasia Requests, Procedures and Outcomes,” 7.72. Ibid., 5. A significantly smaller per-centage of individuals with terminal illness whose requests for medical aid in dying are granted actually take the prescription in order to die; in 2015, only 135 out of 208 individuals (62 percent) who received

he prescription used it to end their lives (Oregon Health Authority, Center for Health Statistics, Public Health Division, Oregon Death with Dignity Act: Data Summary 2016 [Oregon Health Authority, February 10, 2017], at https://www.oregon.gov/oha). Of course, many die as a result of their terminal illness before having a chance to plan their death, which is rarely the case with requests based on psychological suffer-ing.73. M. De Hert et al., “Attitudes of Psychiatric Nurses about the Request for Euthanasia on the Basis of Unbearable Mental Suffering (UMS),” PloS One 10, no. 12 (2015): e0144749.74. L. W., “A Terminally Ill Patient’s Right to Die.”75. O’Neill, “‘Assisted Suicide’ or ‘Aid in Dying?’”76. Kelly and McLoughlin, “Euthanasia, Assisted Suicide and Psychiatry.”77. “Mental Health: Suicide Data,” World Health Organization, 2017, http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/.78. Story 60, Reasons to Go On Living, http://www.thereasons.ca/stories/story_60.php, accessed February 15, 2018.79. J. Kirker, “Talking about Suicide: Alternatives to Suicide,” Linked In, May 5, 2016, https://www.linkedin.com/pulse/talking-suicide-alternatives-joanne-kirker.80. “Alternatives to Suicide,” Western Mass Recovery Learning Community, http://www.westernmassrlc.org/alterna-tives-to-suicide/, accessed February 15, 2019.81. C. Siegel and I. H. Meyer, “Hope and Resilience in Suicide Ideation and Behavior of Gay and Bisexual Men follow-ing Notification of HIV Infection,” AIDS Education and Prevention 11, no. 1 (1999): 53-64.82. Brasch and Kirkpatrick, “Reasons to Go On Living”; “What Happens Now?,” Attempt Survivors, https://attemptsurvi-vors.com/; Stage, “Live through This,” ac-cessed February 15, 2019

Notes

Similar discussions about the dif-ferences between medically assisted dying and suicide can be found in news reports, in academic articles, in blog posts, and on websites that argue in favor of legalizing the for-mer.4

“Suicide” brings to mind a distraught teenager jumping off the Golden Gate Bridge. Is it really fair or accurate to use the same word to describe a 76-year-old with painful and terminal pancre-atic cancer who intentionally shortens his life

January-February 2020HASTINGS CENTER REPORT33(or his dying) by a few weeks or months? These are two very dif-ferent moral, emotional, and legal acts. Both will have repercussions for family members and are not to be taken lightly. But they are not the same.”3

A blog post by Katy Butler offers paradigmatic cases of both suicide and medically assisted dying in order to highlight the distance between them:

Because the person is in the process of dying and seeking the option to hasten an already inevitable and imminent death, the re-quest to hasten a death isn’t equated with suicide. The patient’s primary objective is not to end an otherwise open-ended span of life, but to find dig-nity in an already impending exit from this world. They’re participating in an act to shorten the ago-ny of their final hours, not killing themselves; can-cer (or another common underlying condition) is killing them.2

Physician-assisted suicide, or PAS, is an inaccu-rate, inappropriate, and biased phrase which op-ponents often use to scare people about Death with Dignity laws.

The website of Death with Dignity, one of the largest organizations seeking to legalize medically assisted dying in the United States,

There has been a growing push, particularly among U.S. proponents of legalizing the practice,away from calling it “physician-assisted suicide.”

Those who call for legalizing medically assisted dying often distinguish the practice from suicide.

How Are They Different, and How Are They Similar?

Medically Assisted

Suicide

Dying