Assisted Suicide: Proceed With Caution.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Joel Zivot who is an associate professor of anesthesiology/ surgery at Emory University and a senior fellow at the Emory Center for Ethics wrote an article about the UK assisted suicide debate that was published by Medpage Today on December 26, 2024.

Zivot's article is based on the British assisted suicide debate but his article effectively challenges assisted suicide in general. Zivot writes:

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.

Zivot then comments on the Canadian euthanasia model:

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.

Zivot explains how euthanasia in Canada is done.

In Canada, the majority of euthanasia 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.

The Luminous Veil

Zivot then compares assisted suicide to suicide.

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.

Zivot concludes:

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.

Previous articles related to Dr Joel Zivot (Link to articles)