To Britain on Legalizing Assisted Dying: Proceed With Caution

In November, the British Parliament advanced a bill that would be making assisted dying legal under certain circumstances. As part of our review of the past year’s biggest events, Joel Zivot, MD, MA, JM, analyzes this development in the context of assisted-dying laws in other countries, with a particular focus on Canada’s liberal approach. His ultimate message to Britain: it’s a slippery slope, so take care in crafting the law.

On November 29, British members of parliament voted to advance a bill — the Terminally Ill Adults Bill — in favor of legalizing assisted dying for ill adults with no more than 6 months to live in England and Wales. Two doctors and a judge would need to give their approval, and the fatal drugs would have to be self-administered. Next, the legislation will be debated and scrutinized in parliamentary committees and could be subject to amendments.

While the bill was ultimately modeled after assisted-dying laws in Oregon, my sources in the U.K. tell me that in the lead-up to the vote, some British assisted-dying advocates first sought comparisons to the Canadian experience in a program known as Medical Assistance in Dying (MAID). The Canadian Supreme Court decision established the legal origin of MAID, which was handed down in February 2015, in the case Carter v. Canada. This decision decriminalized assisting in dying.

For now, British assisted dying intends to pattern itself after the Oregon model as outlined in the state’s Death with Dignity Act. Oregon assisted dying has itself come under scrutiny, including concerns about complications. However, if Britain, a U.S. state, or any other country were to pivot and follow the Canadian model, I fear the consequences would be even worse.

MAID in Canada as a Reason for Prudence

In the aftermath of the Carter decision, MAID has accelerated and expanded at a pace scarcely imaginable. In 2016, the country had 1,018 MAID deaths. By 2023, that number increased more than 15-fold to 15,343, for a total of more than 60,000 Canadian deaths by MAID since the passage of the legislation. That number continues to grow every year. Canada’s MAID program is the fastest-growing assisted-dying program in the world. Since its passage, the law was expanded and now, death does not need to be foreseeable. MAID is available for any grievous and irremediable medical condition. MAID is not currently available for mental health reasons, but there has been discussion of this possibility.

MAID eligibility can occur rapidly in some cases, and very few MAID requests are denied. However, wait times to see a doctor for traditional medical care can be significantly prolonged: a Canadian citizen might wait 4 months to see a psychiatrist in some parts of Canada, but in other regions, that wait can be several years. Some groups believe that MAID should be available to children under certain circumstances. MAID has also been incentivized by offering it as a pathway for organ donation, a violation of the ethical principle of the dead donor rule. MAID has been requested and granted to prisoners facing lengthy prison sentences (although the death penalty has been eliminated in Canada since December 1998).

In Canada, the majority of assisted suicide is done via an injection of substantial dosages of the anesthetic agents propofol, midazolam, and the paralytic rocuronium. Propofol and midazolam are likely not the cause of death. Instead, it is most likely the rocuronium, leading to death by muscle paralysis. Once paralyzed, MAID deaths will appear outwardly calm and peaceful. However, this is essentially death by asphyxiation. The U.S. death penalty commonly uses an intravenous cocktail known as lethal injection. This cocktail is strikingly similar to Canadian MAID. Studies show lethal injection can cause rapid accumulation of fluid in the lungs — prisoners feel they are drowning as they die. Far from dignified, death by MAID may be highly distressing.

Enabling Death

Because of these grizzly facts, British enthusiasm for assisted suicide needs to be explained. I believe a demand to die should be concerning for any society. Over two-thirds of Britain’s population (68%) say the country is in decline. This marks a sharp increase from 48% in 2021. Meanwhile, British satisfaction with the National Health Service is low — only 24% of the public is satisfied, the lowest level since this survey began in 1983. And a recent poll in Britain found that two-thirds of respondents said assisted dying should be allowed under certain conditions.

In usual medical practice, when confronted with a patient threatening suicide, the doctor’s default is to stop it. Some people will persist and may choose by their hand to take their life. Why they do this is personal, but if we make suicide too accessible, it can, in some circumstances, push people over the line.

Before MAID, a Canadian story provided such an example. In 2003, a suicide prevention barrier, the luminous veil, was installed at Toronto’s Bloor Street Viaduct bridge. Once in place, this barrier blocked people from jumping off the bridge. Before this, the Bloor Street Viaduct bridge was the second most common place in North America for suicide by jumping after the notorious killer, the Golden Gate Bridge in San Francisco. After the luminous veil was installed, not only did the suicide rate from the bridge fall to near-zero (only two have taken place from 2003-2020), but the overall rate of bridge-related suicide dropped in Toronto. There was also no change in suicides by other methods.

This finding might mean that when it is harder to commit suicide, people may choose not to. Could the opposite be true, too? When suicide is more available, some people will choose it when, in other circumstances, perhaps they may not. The confluence of misery and means that leads some to suicide cannot be minimized. An effective way to prevent a person from dying by suicide is to restrict that person’s access to the means of ending his or her life. This approach, known as means restriction, is utilized in a complementary fashion with mental health and substance abuse treatment.

Of note, Britain has been a leader in implementing means restriction policies. Poisoning by coal gas was the leading cause of suicide death in Britain before the mandatory switch to natural gas. In Britain, paracetamol (acetaminophen in the U.S.) has been only available in blister packs (with limited pill quantities) since 1998 to reduce the incidence of suicide by intentional overdose.

A Slippery Slope

The prospect of killing people who are lonely, frightened, under-resourced, disabled, or in pain might at least be mitigated by the presence of a caring and committed companion, be that the physician or someone else. Making it easier to commit suicide without fundamentally addressing the real problem is anathema to compassion. British advocates of an assisted-suicide option for the terminally ill argue that it may offer a benefit for some. However, I worry that significant risks remain for vulnerable populations, and without great precaution, assisted-suicide laws can become more relaxed and broader over time.

The job of medicine is to protect vulnerable patients. The prospect of euthanizing anyone prematurely undermines public trust and degrades the medical profession. Also, the technique used in Canada may cause death in a fashion more sinister than acknowledged.

As Britain considers and debates its assisted-dying bill, it must do so cautiously. Advancing age and illness addle us all. A functioning civil society is meant to protect us when we cannot protect ourselves. Unchecked, assisted suicide risks sending the message that the sick are less valued people, better off dead than alive.

If you or someone you know may be experiencing a mental health crisis, contact the 988 Suicide & Crisis Lifeline by dialing or texting “988.”

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