The Case for Physician-Assisted Suicide in Ireland

In light of the large public support and recent international trends, it seems more likely to be a matter of when, and not if, there will be legislation

One topic that has received increasing public discussion in recent years is the issue of voluntary physician-assisted suicide (PAS) and euthanasia. PAS and euthanasia are not limited to contemporary societies: the Athenian poet of the 5th century BC Cratinus referred to euthanasia – roughly translated as ‘good death’ – as a fast, gentle, painless death; the Roman Stoic philosopher Seneca thought it was preferable to choose death than to live with excruciating, incurable pain. Christianity, however, viewed voluntary death more negatively. The Catholic Church, for instance, regards suicide as intrinsically wrong. The Christian position on PAS has been the dominant viewpoint for several centuries, but it is no longer universally shared.

The Ethics of PAS 

The UK public healthcare system, the National Health Service (NHS), defines assisted suicide as “the act of deliberately assisting another person to kill themselves.” An example would be a doctor prescribing strong sedatives to a person with a terminal illness, knowing they will use the substance to kill themselves. Euthanasia is defined as “the act of deliberately ending a person's life to relieve suffering.”

Two common arguments in favour of PAS (and euthanasia) are the right to personal autonomy and freedom from suffering. Patients, particularly those who are terminally ill and close to death, have the right to make their own decisions and choices. Autonomy is one of the core principles of healthcare ethics, proponents claim, and denying someone the right to PAS is an excessive form of paternalism.  It would be wrong to end one’s life against her wishes, but not wrong if that was what she, as a competent adult, requested. The second argument is that patients have a right not to endure unnecessary suffering. The pain associated with some illnesses is so great that death is often preferable to continuing to live.    

Another argument is that PAS, as a matter of moral consistency, should be accepted. Suicide is no longer illegal in many societies, for instance, and it is common for patients to refuse or withdraw life-saving treatments. As James Rachels pointed out, there is no serious moral difference, all else being equal, between doing something that causes a death and doing nothing to prevent that death from occurring. Despite the same outcomes, though, one of them is regarded as standard medical practice and the other as a criminal offense.

Opponents of PAS claim that assisting patients to kill themselves is worse than letting them die. PAS directly intends death but letting die merely foresees that outcome but does not necessarily intend it. In the latter case, the doctor foresees death – but wishes that the patient makes a miraculous recovery. In the former case, though, the death of the patient is the intention. This distinction is known as the ‘doctrine of double effect.’ The doctrine is controversial – especially when applied to end-of-life issues – and some philosophers have criticised it for not actually explaining any material distinction of events, aside from the psychological intentions of doctors. The bioethicist John Harris went as far to suggest it is a creative form of sophistry. 

Winston Nesbitt argues, however, there are good reasons to draw a distinction. We have more reason to fear those who would take active steps to end our lives than those who would merely let us die – the latter are no more a threat to us than rocks or trees.  The person who is prepared to kill for personal gain, for instance, does more wrong than the person who is prepared to let someone die for personal gain. However, Helga Kuhse argues that Nesbitt’s distinction can be reversed when the motive is the opposite of personal gain. If we accept that patients can receive a benefit when life-sustaining treatment is withheld or withdrawn, for example, then presumably they can also receive a benefit when PAS is available. According to Kuhse, if we follow Nesbitt’s logic then the doctor who performs PAS, with the intention of benefiting the patient, seems to do more good than the doctor who merely withdraws or withholds treatment.  

Others argue that PAS could result in practices of non-voluntary euthanasia against people with disabilities and other marginalised individuals. If we permit PAS it would be open to widespread abuse that would outweigh any benefits of PAS. Though, empirically speaking, it is not clear that countries that have already legalised PAS have experienced widespread abuse; cases of PAS in Europe and North America appear to be relatively small and those who avail of it tend to be the educated middle classes.

To be sure, a small number of cases were reported in the Netherlands where eligibility criteria for PAS were not met, thus suggesting some level of misuse exists. Though pointing out cases of misuse is not sufficient to say PAS should not be legalised. Misapplications are likely to occur under any legislative system, no matter how robust safeguards are. Besides, levels of abuse – for instance, cases of non-voluntary ending of life – appear to be no higher in jurisdictions where PAS is permitted than in places where it is banned, and often they are lower. On balance, the fear of sliding down a slippery slope seems to overestimate the risks and underestimate the torment and suffering actually felt by terminally ill, suffering patients.

Another objection is that we do not need PAS because high quality palliative care is sufficient. To be sure, relieving pain and valuing the dignity of patients is very important. There are good reasons to improve the quality of palliative care, but this is not an argument against PAS as they do not have to be mutually exclusive. Besides, palliative care may not always be the preferred choice of patients – some individuals care about more than the ability to control pain and suffering, such as dignity and to remain independent.

One response might be that we should not introduce PAS until palliative care reaches a sufficient standard, or that introducing PAS might actually reduce the amount of resources allocated to palliative care. Yet this fear does not appear to be supported by the evidence: one study suggests the Netherlands, Luxembourg, and Belgium all significantly increased their palliative care budgets after PAS was introduced.   

PAS and the Law

Since 1997, the US state of Oregon permits PAS. It grants the prescription of lethal drugs to competent adults with a terminal condition and who have a life expectancy of six months or less. Washington state (in 2009) and Vermont (in 2013) have passed similar laws. Since then eight other US states have followed, including California, Maine and New Mexico. Other jurisdictions that have passed laws permitting PAS include New Zealand, Australia, Spain, Canada, the Netherlands, Belgium, and Luxembourg. In all, PAS is now legalised in over a dozen countries. And several other countries, including Ireland, the UK, France and Italy, have PAS bills in progress or else they are having significant public debates about it.

In Ireland the Criminal Law (Suicide) Act 1993 decriminalised suicide, but made it a criminal offence under Section 2 to assist someone else to take their own life, with the prospect of a 14-year prison term. The first landmark case to challenge the law criminalising PAS was Fleming v Ireland. The plaintiff, Marie Fleming, who was in the final stages of multiple sclerosis and physically incapable of ending her own life, argued that she had the right to PAS and that the legal ban breached her constitutional right. Her request was for assistance in having a peaceful, dignified death in the presence of her family. Her claim was dismissed in a judgement which suggested that “any relaxation of the ban on assisted suicide would be impossible to tailor to individual cases and would be inimical to the public interest in protecting the most vulnerable members of society.”

In the Supreme Court appeal, it was said that “[t]here is no explicit right to commit suicide, or to determine the time of one’s own death, in the Constitution.” However it was suggested that this was an issue for the legislature to examine: “Nothing in this judgment should be taken as necessarily implying that it would not be open to the State, in the event that the Oireachtas were satisfied that measures with appropriate safeguards could be introduced, to legislate to deal with a case such as that of the appellant.”

The government focused on PAS with a report in 2018. Based on the hearings, the Oireachtas Joint Committee on Justice and Equality “believes serious consideration should be given,” and “urges the Houses of the Oireachtas to consider referring the issue to the Citizens’ Assembly for deliberation.” In 2020 a private members’ bill was introduced; however it did not progress as the Dáil committee found that it had a number of serious technical flaws and was not fit for purpose. Yet it did recommend that a Special Oireachtas Committee on Assisted Dying should be established to examine the issue in more detail. That committee discussion is currently in progress and can be viewed here. 

PAS and the Future 

Seeing that there is now serious on-going discussion about PAS in the legislature, and that, according to one poll in 2021, 71% of voters in Ireland are in favour of PAS, it would not be surprising to see legislation passed in the near future. Although it is interesting to note that support for PAS among doctors appears to be considerably lower than the general public: a study in 2021 found that 67% of doctors in Ireland were against the legalisation of PAS and euthanasia, 14% in favour, and 19% undecided. Various professional bodies, including the Royal College of Physicians of Ireland, the College of Psychiatrists of Ireland, and the Irish Palliative Medicine Consultants Association, still officially oppose any legalisation of PAS. Nonetheless, the tide appears to be turning. For instance, the Irish Doctors supporting Medical Assistance in Dying, a group of medical doctors who support choices for people at the end of life, broadly support the right to access PAS. 

What’s more, several medical professional bodies in the UK – such as the British Medical Association, the Royal College of Surgeons, and the Royal College of Physicians – that have historically opposed PAS now take a neutral position on it. It doesn’t seem implausible that medical professional bodies in Ireland, as a result of changing public opinion and trends in other countries, could also change their positions on PAS. 

In light of the large public support and recent international trends, it seems more likely to be a matter of when, and not if, there will be legislation. If this is right, then future discussions will not be about whether or not PAS should be legal, but on what form it should take.