The Controversy, Legality, and Morality of Assisted Dying

One of the most memorable scenes from Meet Joe Black (1997) is the ironic one with a boardroom associate trying to explain the phrase “Nothing is certain but death and taxes” to Brad Pitt’s character, Death himself.

“What an odd pairing,” came Death’s reply, who was certainly unfamiliar with the mortals’ concept of taxes. We all have to pay taxes and die one day. Those are some of the inevitable things in life that we are all still learning to accept.

As Eric Idle, a former member of the comedy group Monty Python sings “Always look on the bright side of death” (the second and less popular verse of his famous song), we cannot help but let out a wry smile and wonder how some life-loving humans can perceive death light-heartedly.

Most people’s stoic resignation to their eventual exit from this world, as we liken it to paying taxes, is nothing short of having a white elephant in the room. We know it is there, but no one wants to talk about it.   

The changing narratives of death and dying

However, in recent years, as our societies have become increasingly open to discussions and debates on controversial issues on race, gender, and culture, among others, we tend to be more accepting of the narrative of death, a discourse otherwise shunned as macabre and grim.

Some people, young and old, healthy and illness-stricken alike, have planned in the event of their own death – giving instructions to family and loved ones on what to do in cases of fatal mishaps, drawing up wills, and purchasing plots of the burial ground or columbarium spots for their final resting place.

Palliative patients are also weighing in on whether to turn to a medical procedure called assisted dying, also known as euthanasia or physician-assisted suicide (PAS), using lethal drugs administered by a doctor.

Assisted dying has been a controversial and ongoing debate for human rights activists, religious groups, politicians, legislators, medical practitioners, and patients suffering from terminal illnesses and debilitating conditions. This also includes the patients’ families because any decision made will have a direct and significant impact on them.

This topic is often difficult and complex because of the largely opposing views that often divide people into two schools of thought – pro-life or pro-choice.

The legality of assisted dying in countries around the world

Assisted dying is also an illegal practice in many jurisdictions. Under certain circumstances and conditions, it is legal only in countries such as Switzerland (since 1942), Colombia (1997), Belgium (2002), the Netherlands (2002), Luxembourg (2009), Canada (2016, Quebec in 2014), New Zealand (2021), Spain (2021), parts of the United States (US) (Oregon, Washington, Montana, Vermont, California, Colorado, District of Columbia, Hawaii, Maine, and New Jersey) and parts of Australia (Victoria, since 2017 and Western Australia, since 2019).

These specific circumstances include criteria such as having a terminal illness and not having any mental conditions, to only name a few.

In some countries, such as Switzerland, a terminal diagnosis is not a requirement, and people who are seriously ill and wish to end their lives can legally turn to assisted dying under these jurisdictions.

The law allowing a person suffering from a non-terminal illness to end their life by assisted dying was additionally passed in Colombia in January 2022, the first South American country where assisted dying has been legal since 1997.

Germany (2020) and Italy (2022) have legalized assisted dying in principle, but have no legislation and practice regulation in place yet.

Austria has also recently joined the list and legalized ‘assisted suicide’ (‘assistierter Suizid’) in December 2021, both for those who are terminally ill or have a permanent and severe condition. This will be tightly regulated, with each case being assessed by two doctors. Moreover, this new law excludes minors and those with mental health conditions. Do take note though, that ‘active assistance to suicide’ (‘aktive Sterbehilfe’) remains illegal in Austria.

Terminology and meaning – Dying or suicide?

Be aware that in Austria, the German phrases ‘assistierter Suizid’ (legal) and ‘aktive Sterbehilfe’ (illegal) are not to be used synonymously. The same applies to the English terms ‘assisted dying’ and ‘assisted suicide’.

Although both terms have been used interchangeably, especially in media reportage, the meaning and implication can differ from one to the other in the eyes of the law. ‘Assisted dying’ applies to terminally-ill people who will have to meet strict criteria before they can end their life voluntarily.

Intentionally helping another person to kill themselves is known as ‘assisted suicide’, and this can include providing someone with strong sedatives which leads to ending their life. Under Austrian law, anyone who is found to have induced or helped someone to kill themselves faces up to five years in prison.

The representation of assisted dying in films

Films with assisted dying themes were few and far between, but since the beginning of the millennium, this has changed. These films are usually inspired by factual or quasi-factual events, and are endeavors made to introduce a broad philosophical inquiry into the morality of assisted dying or ‘mercy killing’.

They help raise the important questions about who has the right to die, to escape their suffering, and who has the right to assist them.

One of the earliest films is An Act of Murder (1948) in which the protagonist is a judge riding on high moral grounds who finds his views starting to change with thoughts of mercy-killing his wife when she develops terminal brain cancer.

In German cinema, two films Ich Klage An (I Accuse) (1941) and Die Sünderin (The Sinner) (1951) were initially banned due to their controversial impact. The former was banned by the Allied powers of World War II for being Nazi propaganda for a pro-euthanasia campaign while the latter was banned by the Roman Catholic Church for having a prostitute character giving assisted suicide to her lover.

It was not certain if the Catholic Church was appalled by a nude scene in the film or by the subject of assisted dying in general. In any case, both topics of sexual immorality and suicide were, and still are, considered taboos in the Catholic religious practice.

In the last two decades, more films with similar tropes have sprung up. Film is a powerful visual medium, with compelling imagery that etches in our memory. One such image is Javier Bardem’s bedridden quadriplegic character in The Sea Inside (2004) who fought for nearly 30 years to end his life with dignity, based on the true story of Ramon Sempedro.

The efforts of film director Alejandro Amenabar to raise awareness for assisted dying have come to fruition after Spain passed euthanasia laws nearly 20 years after the film was made.

Across the pond, a biopic about Dr. Jack Kevorkian in You Don’t Know Jack (2010) depicts the eponymous character performing controversial activities in PAS. In the film, Al Pacino who plays Dr. Kevorkian advocates assisted dying and introduces his ideas to the public. His family supports his ideology but outside, he faces backlash and public outcries.

The real Dr. Kervokian was tried four times in the US for assisting suicides in the 1990s and was eventually convicted for second-degree homicide. After spending eight years in prison, he continued to pioneer the concept of suicide by working to help people end their own suffering. Dr. Kervokian died a year after the film was released.

In the documentary Right to Die, also known as The Suicide Tourist (2008), and feature film Me Before You (2016), both show Switzerland as the ‘final destination’ for their protagonists, a deemed haven where terminally-ill people and people with debilitating conditions can be freed from their suffering – for good.

Why Switzerland?

Why has Switzerland become the hub of ‘suicide tourism’, and what draws people to make their ultimate trip to this alpine nation?

Assisted dying has remained legal in Switzerland since 1942. Note that the country does not have legislation on assisted dying but instead decriminalizes the practice. This means it is different from countries such as Belgium and the Netherlands where the law considers assisted dying to be ‘medical treatment’. This has allowed a role for non-physicians to carry out the procedure. 

The Swiss law, Article 115 of the Penal Code of Switzerland, however, states that 

“Whoever, from selfish motives, induces another to commit suicide or assists him therein shall be punished, if the suicide was successful or attempted, by confinement in a penitentiary for not more than five years or by imprisonment.”

That points to the fact that some aspects of ‘assisted suicide’ or ‘active euthanasia’ are still illegal (all forms of euthanasia are against the law), but supplying the means for committing suicide is legal, as long as the action which directly causes death is performed by the one wishing to die. 

This means having fewer restrictions surrounding the procedure, hence attracting ‘suicide tourists’ who otherwise cannot legally perform assisted dying or assisted suicide in their own country.

A moral debate

Dignitas, an organization founded near Zurich in 1998, is possibly the household name for those who seek assisted dying. One of its many activities include ‘accompaniment of dying patients and assistance with a self-determined end of life’, as stated on its website. Pegasos is another voluntary assisted dying association with a minimal-bureaucracy approach to the procedure.

Founded only recently in 2019, Pegasos is based in Basel, and also has an office in Melbourne, Australia, where assisted dying was made legal in 2017.

Pegasos made news headlines in March 2022 after two sisters (a doctor and a nurse) from Arizona, US traveled to Switzerland under the guise of a holiday trip, and then chose to die together by assisted suicide in a Pegasos clinic in Liestal. The sisters were said to have health problems but were not terminally ill. They were medically reviewed in Switzerland, and their mental capacity was assessed before the assisted suicide procedure.

This has sparked a controversial debate on whether the US should review its legislation pertaining to assisted dying in states where the procedure is currently illegal.

In 2018, the story of a 104-year-old Australian scientist who traveled to Basel, Switzerland for an assisted death, also made news headlines and fuelled public debates all around the world. News articles that report such ‘suicide tourism’ cases often say little about the functioning of the Swiss model of the right to die. Samuel Blouin sums up this model aptly in his article in The Conversation:

 “Besides the option of palliative care and other social programs, the Swiss model is an invitation to imagine and consider other societal responses to the challenges of suffering and dignity at the end of life.”

Samuel Blouin

Fighters or quitters?

In Me Before You, the resigned quadriplegic protagonist Will whose final wish is to die in Switzerland, said to his contrasting, larger-than-life antagonist Louisa, “You only get one life. It’s actually your duty to live it as fully as possible.” Isn’t it somewhat ironic that an inspirational line should come from someone who, at that point, has completely given up on life itself?

Is Will a fighter, one who bravely confronts death, or a quitter who chooses to run away from pain and suffering? One may argue that death is not for the fainthearted, so Will is surely a hero who chooses his own path and does not end up being a burden to his loved ones. On the other hand, one may argue that Will is quick to give up and quits when his life runs out of fun, and he should have stayed for the good, the bad, and the ugly aspects of life. Whatever decision Will makes, one should consider the complexity of this topic and the impact of the decision from different perspectives.

Whether we believe in the principle of pro-life or pro-choice, the discourse of assisted dying has never been an easy one. It has invited a lot of controversies and criticism over the years and has sparked heated debates among different institutions.

Most of the time, our beliefs and decision-making processes are dictated by a complex set of values that include our cultural background, personal experiences and upbringing, religious beliefs, worldviews, social, economic, and political factors, the stage of life we are at, and the country and region that we live in. It is therefore difficult to try to restrict or liberate someone based on a majority ruling.

Now we may ask ourselves if we would embrace Lance Armstrong’s motto: “Pain is temporary, quitting is forever”. And if we ask ourselves the same question again in 30 years when we get older or are suffering from ailments, will our answer remain the same?

Cover image by Dominik Lange on Unsplash

^{Reviewed by Cosima Rudigier and proofread by Juxhina Malaj}