This paper considers whether assisted suicide and euthanasia (AS/E) is an area for medical regulation or whether there is a better alternative regulatory mechanism to govern it. Drawing from empirical evidence across a range of jurisdictions where it is legalized, the paper argues that there are at least four good reasons to consider demedicalizing AS/E: (1) pragmatic ethical issues of infrastructural weakness in AS/E service provision in already overstretched healthcare systems globally; (2) challenges of medicalization; (3) regulatory complexities concerning medical law (including pharmaceutical law) and criminal law; (4) the risk that AS/E becomes more easily susceptible to healthcare economics. The paper suggests several recommendations concerning a possible “demedicalized model.”

An exploration of the ethical issues surrounding assisted dying, in the form of a dialogue.

With assisted dying becoming increasingly available to people suffering from somatic diseases, the question arises whether those suffering from mental illnesses should also have access. At the heart of this difficult and complex matter are values such as equality and parity of esteem. These issues require humane deliberation.

The UK is currently considering making assisted dying available to patients who are terminally ill. We discuss ethical and practical aspects of this complex issue and outline the potential role of psychiatry. We set out the challenges of implementation of legislation, and potential unintended consequences including the impact on health inequalities.

Introduction: There have been 3714 medically assisted deaths recorded in Canada so far, with more than half of those deaths occurring outside the hospital – whether this has had any impact on emergency medicine has not yet been documented. This survey sought to find out Canadian emergency physicians’ (EPs) attitudes and experiences with medical assistance in dying (MAID). Methods: An electronic survey was distributed to CAEP members using a modified Dillman technique. The primary outcome was defined as the proportion of EPs in favour of MAID. Secondary outcomes included experience with suicide in the setting of terminal illness, their experience and opinion on referring patients for MAID from the ED, their experience with complications of MAID, and their response to hypothetical cases of complications from MAID. Nominal variables were analyzed and reported as percentages for each relevant answer. Answers submitted as free-form text were coded into themes by the author and reported based on these themes. Results: There were 303 completed surveys. EPs were largely in support of MAID (80.5%), and would be willing to refer patients for assessment from the ED (83.2%), however fewer (58.3%) knew how to do so. 37.1% of EPs had been asked for a referral for MAID assessment, but only 12.5% had made a referral. While only 1% of EPs reported having seen patients present with complications from MAID (failed IVs in the community), 5.0% had seen patients present with suicide or self-harm attempts after being told they were ineligible for MAID by another provider. Conclusion: This is the first study to examine the impact of MAID on emergency medicine in Canada, and it demonstrates that patients are both requesting referrals through the ED and, in rare cases, requiring medical attention for complications. This has implications for both increasing awareness of MAID referral processes for EPs, as well as for the prevention and treatment of complications of MAID in the community.

Complicity in an immoral, and even criminal, activity, such as robbery or murder, is itself regarded as involving responsibility for those acts. What should the position be of health professionals who are expected to participate in actions that they believe are morally wrong? Professional responsibilities may clash with private conscience. Even referring a patient to someone else, when what is in question may be assisted suicide, or euthanasia, seems to involve some complicity. This is a live issue in Canada, but similar dilemmas occur elsewhere. Physicians and others should not be coerced into involvement of any kind in what they regard as wrong. Such coercion goes against the very principles of liberal democracy. Conscience matters. Reasonable accommodation should be given to those whose moral judgment may be at variance with prevailing professional norms. Moral questions should still be given weight within medicine, and disagreements respected. Dedication to the promotion of human welfare should be paramount, but it should be recognized that there may be different visions of what such welfare consists of.

The specialty of psychiatry has a long-standing, virtually monolithic view that a desire to die, even a desire for a hastened death among the terminally ill, is a manifestation of mental illness. Recently, psychiatry has made significant inroads into hospice and palliative care, and in doing so brings with it the conviction that dying patients who seek to end their suffering by asserting control over the time and manner of their inevitable death should be provided with psychotherapeutic measures rather than having their expressed wishes respected as though their desire for an earlier death were the rational choice of someone with decisional capacity. This article reviews and critiques this approach from the perspective of recent clinical data indicating that patients who secure and utilize a lethal prescription are generally exercising an autonomous choice unencumbered by clinical depression or other forms of incapacitating mental illness.

This article challenges the idea that there could be a convincing secular version of the principle that human life is sacred, and explores the significance this has for the law. A number of secular justifications for the claim that there is something intrinsically, as opposed to instrumentally, valuable about human life have been mooted, most eloquently by Ronald Dworkin. While secular explanations for the sanctity of human life are undeniably attractive, this article will maintain that they do not have logic on their side. Having argued that the ‘sanctity principle’ makes sense only as an article of religious faith, the implications this has for the law are explored. In relation to end-of-life decision-making, the sanctity principle has been invoked to justify a sharp line between deliberately ending life and failing to prolong it. This article will conclude by arguing that a rejection of the sanctity principle might, in certain circumstances, cause us to focus instead on the extent to which death harms someone.