Editor—There is indeed concern that legalising assisted death without enhancing palliative services could result in low thresholds for giving up on palliative care.1 This has been central in the decision not to legalise euthanasia in Switzerland. Even with enhanced palliative services, however, the question of assisted death will remain. In the Swiss debate the importance of palliative care is recognised by all. Disagreements hinge on whether assisted suicide can be acceptable when palliative care fails to relieve suffering sufficiently to make life bearable in the patient's eyes, whether safeguards ensure that assisted suicide is used only as a last resort, and whether doctors should participate in it.
Bosshard and Bury's positions illustrate the difficult question of doctors' participation in assisted suicide. Doctors are likely to receive requests for assisted death. However, this does not mean that they must be directly involved in acts that terminate life. Specific ethical clarification and guidance for doctors are indeed needed as to how best to respond to requests for assisted suicide or euthanasia.
Gardner indicts “modern bioethics” as establishing hierarchies of human worth. This is mistaken. Proponents of assisted suicide argue that respecting each of us as legitimate choosers of our own moral values (as long as we do not harm others) requires that patients be allowed to end their own life if they feel that their life is not worth living. This position may be controversial, but it clearly recognises that all human beings have equal worth. Curtis seems to have misunderstood this also.
Gardner points out that the Dutch guidelines do not prevent the occurrence of life terminating acts without the patient's request. This may be a failure if the intended purpose of these guidelines was to give patients more control over their own death. It seems, however, that this is ambiguous, and that this very ambiguity could be problematic.2
Furthermore, without comparative data, the effects of legal frameworks on the frequency of any life terminating acts are unknown. In a survey of European critical care doctors, a higher proportion reported “deliberate administration of medication to speed death” in France and in Belgium, where euthanasia was illegal, than in the Netherlands.3 Further data on end of life practices in Switzerland would be important in understanding the practical implications of its unique legal situation.
The views expressed here are the authors' own and do not reflect the position of the National Institutes of Health, of the Public Health Service, or of the Department of Health and Human Services.
Competing interests: AM is a member of the Swiss National Advisory Commission on Biomedical Ethics. The views expressed here do not necessarily reflect those of the commission.
References
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