Assumption 1: The primacy of patient autonomy

Patient autonomy, the right to make self-governing choices, is often quoted as the rationale for why VAD is warranted (NSW Ministry of Health 2023). However, it is well recognized that this principle is not absolute in healthcare. For example, if a patient with a headache in ED demands an MRI, we do not automatically acquiesce, i.e. we recognize that there are limits to what an autonomous individual can request and that autonomy should not be confused with independence (Quill and Brody Reference Quill and Brody1996). Professional medical ethics demands that the doctor use their expertise to guide patients in their medical decision-making, which includes engaging with the reasons underlying a patient’s choice and judging capacity (Medical Board AHPRA 2020). A patient’s request for VAD is known to be a call for help in the first instance (Chochinov Reference Chochinov2004). The will to live, and conversely to die, is known to vary over time (Chochinov et al. Reference Chochinov, Tataryn, Clinch and Dudgeon1999) and with intercurrent conditions, e.g. depression (Breitbart et al. Reference Breitbart, Rosenfeld, Gibson, Kramer, Li, Tomarken, Nelson, Pessin, Esch, Galietta, Garcia, Brechtl and Schuster2010).

Assumption 2: A VAD choice only concerns the individual

Our modern society focuses on the primacy of the individual but Christian Ntizimira, a Rwandan palliative care physician, makes the point that in his culture, the individual is seen as part of their social community; “When you are well, you belong to yourself. But when you are sick, you belong to your family.” (Ntizimira Reference Ntizimira2023) Seeing the person in isolation ignores the relational aspects of human living. VAD carries not only a documented risk of moral injury to the health care team, but also a more complicated grief and an erosion of community for those left behind (Kelly et al. Reference Kelly, Handley, Kissane, Vamos and Attia2020). The sum of individual acts also shifts the tide of sentiment in the community regarding which lives are worth living. This “slippery slope” can be seen in the Netherlands: while assisted dying was initially highly restricted to adults with life-limiting physical conditions, over time the indications have expanded to mental suffering, to those with longer time frames, and to children (Lemmens Reference Lemmens2018), and, in Canada, to those without a terminal diagnosis at all (Gaind Reference Gaind2023).

Assumption 3: VAD is the only way to retain dignity in dying

VAD is often couched in the language of “dying with dignity.” However, research has shown that what really preserves patient dignity at the end of life is treating them with respect as an individual and upholding their values (Best Reference Best, MacLeod and Van2019). There is often a fear of dependency, i.e. not wanting to be a “burden” on others (Monforte-Royo et al. Reference Monforte-Royo, Villavicencio-Chávez, Tomás-Sábado and Balaguer2011). However, theologian Stanley Hauerwas makes the point that “there is nothing wrong with being a burden!” How we care for those who can no longer care for themselves (e.g. the elderly and the disabled) is one of the ways in which we celebrate the dignity of that person’s life (Hauerwas and Bondi Reference Hauerwas and Bondi1976).

On a societal level, Fernandes also warns that judging people as “not of use” was part of the rationale used by physicians during the Nazi regime to justify euthanasia; this label can just as easily be applied by patients to themselves, undermining their own dignity (Fernandes Reference Fernandes, Rubenfeld and Sulmasy2020).

Assumption 4: We have a right to die

VAD advocates often appeal to an individual’s “right” to die, referring to the desire to choose the timing and manner of one’s death but for much of the western medicine’s history, life was seen as a gift from the Creator, and hence the responsibility was to steward this gift wisely and to use the time well. Theologian Stanley Hauerwas puts it this way: “We should view time not as something to be lived through, not life as an end in itself, but rather see life as the gift of time enough for love” (Hauerwas and Bondi Reference Hauerwas and Bondi1976). It is not life that is a burden but suffering, and medical care has a responsibility to come alongside and support the patient to live as well as possible (Chochinov Reference Chochinov2013).

Experience from overseas indicates that those opting for assisted dying tend to be more educated, more affluent and are essentially seeking more control (Goroncy Reference Goroncy2019). Karen Hitchcock, a physician and author, states it this way:

This desire for control may spring out of our fear of death, for we seek to control what we fear. Monica Renz, at St-Gallen Hospice in Switzerland, makes the point that our role as physicians is to help our patients face this fear and recognize that none of us are in control of life, much less of death. In helping them reach this acceptance, we affirm that growth and maturation occur throughout life, right up to the point of death (Renz Reference Renz2015).

Another caveat is that the “right to die” risks becoming the “duty to die”; given the power imbalances between patients at the end of life and their families/carers/clinicians, there can be subtle pressure to end one’s life quickly when one is becoming a “burden” (Meier Reference Meier, Rubenfeld and Sulmasy2020).

Assumption 5: Suffering and pain are completely avoidable

While a common argument for VAD is that it is necessary for ending unrelieved pain, physical pain is an uncommon reason for requesting hastened death (Monforte-Royo et al. Reference Monforte-Royo, Villavicencio-Chávez, Tomás-Sábado and Balaguer2011). Furthermore, VAD requests for anticipated suffering are more common than requests on the basis of current suffering. Early referral of patients to palliative care can alleviate many of the patient’s concerns. Furthermore, modern medicine has perpetuated this idea of freedom from illness and from the limitations of aging, with physicians often persisting with futile treatments right up to the time of death rather than discussing the need to prepare for death (Angus et al. Reference Angus, Barnato, Linde-Zwirble, Weissfeld, Watson, Rickert and Rubenfeld2004).

The observation that patients at the end of life can reach a peaceful death following engagement with, rather than escape from, existential struggles is one of the reasons why the majority of palliative care societies worldwide are opposed to practices hastening death (Roy and Rapin Reference Roy and Rapin1994). Moreover, legalization of VAD has had a negative impact on palliative care resourcing, and we need to continue to advocate for high quality palliative care provision (Jones Reference Jones2024).

Assumption 6: We don’t let animals suffer like this

A common refrain in the lay press is that if we put down animals in pain, we should be able to do the same to humans. This is contrary to the idea of the value and dignity of the individual human not only in the Judeo-Christian tradition but also Muslim, Hindu and Buddhist traditions (Grove et al. Reference Grove, Lovell and Best2022). This view also downplays the emotional toll, moral distress, cognitive dissonance, and burnout experienced by a majority of the veterinarians who carry out animal euthanasia; the comparison should raise warning bells rather than support for this option (Cooney and Kipperman Reference Cooney and Kipperman2023).