Donna McAuliffe, School of Allied Health, Sport and Social Work, Griffith University, Australia
Assisted dying is an issue that draws out some of the greatest philosophical questions that have been debated through history, dating from ancient Greek and Roman physicians and philosophers, through to the Hippocratic Oath and the do no harm mandates of medicine, and to the religious doctrines that have long condemned suicide and purported suffering to be something endured for a divine purpose. The entanglement of positions around autonomy and choice, with positions around sanctity of life have resulted in polarised views that have seen shifts and changes in laws and policies around the world. More recently, attention has been paid to the cultural considerations of assisted dying, where racial, ethnic and diverse backgrounds present even more complex reasoning for acceptance or denial of this choice (Bloomer et al., 2024).
Understanding terminology in this contested space is important, given the historical alignments with suicide defined as death by one’s own hand, and the intentional taking of life without consent which is murder or homicide. The most commonly used term across the ages has been euthanasia, also known as mercy killing. Voluntary (active) euthanasia is where a person consents to have their life ended and is assisted by another to achieve this, whereas non-voluntary euthanasia is where a person who cannot give consent has their life ended by another (for example an infant who cannot give consent). Passive euthanasia is the withholding of treatment that results in death. Involuntary euthanasia is the taking of life of a person who does not want to die and does not give consent. This is what would commonly be known as murder. Physician assisted suicide (PAS) is the taking of life by a medical intervention facilitated by a physician, whereas assisted suicide is a person taking their own life aided by another person, generally a physician, who provides the means for self-administration of a lethal drug.
Shifts in terminology to distance assisted dying from suicide have been common in more recent years, with Canada using the terminology of medical assistance in dying (MAiD), and Australia adopting voluntary assisted dying (VAD). Death by suicide carries with it a high degree of stigma, and efforts are now made to distinguish assisted dying from suicide by use of alternate terminology. The core tenets of assisted dying are those of consent, capacity for autonomous decisions, freedom from coercion, and stipulations around terminal illness and unbearable suffering that will result in death within a determined time. Euthanasia and assisted dying are legal in countries such as Belgium, the Netherlands, Canada, New Zealand, parts of the US, Australia, Columbia, Ecuador, Luxembourg, Spain, Portugal and Austria. Many other countries such as the UK, France, Italy, and Germany are locked in debate about assisted dying provisions, and the US and UK have seen a marked increase in the public acceptance of assisted dying. Despite the evidence that assisted dying is more accepted as a viable end-of-life choice, there is still resistance in many countries to having this enshrined in law. The so-called ‘slippery slope arguments’ are commonly cited as examples of social morals being placed in an inevitable downhill trajectory where a start point of terminal illness and intractable suffering moves to a society that deems those of greater burden or lesser productivity eligible over time for these measures. Advances in predictive disability screening also provide people with information about what their lives may become should they develop a degenerative condition, and there is the question of whether people who tire of life due to social conditions like poverty or homelessness may make a case for euthanasia on the basis of burden or loss of status.
Social workers play an important role in end-of-life care across many health and social services, and the involvement of social workers in palliative care is long established. The support that social workers provide in their assessment of psychosocial needs of the dying and their families and significant others is consistent with the profession’s values of respect, autonomy, human rights, and dignity (Johns et al., 2019). Palliative care is a person- and family-centred treatment that aims to provide a holistic framework for supporting a person with a life-limiting illness to live with as much comfort as possible, including relief from pain and provision of emotional, spiritual and psychological support. It is not designed to hasten death.
Assisted dying, where this is a legal option, is therefore not a part of the palliative care regime, and controversy exists because good palliative care should mean that a person’s life does not deteriorate to a position of unbearable pain and suffering that would warrant an assisted death (Gerson et al., 2020). For palliative care social workers, assisted dying may not always sit comfortably as an option, which can create the ethical dilemma of honouring a dying person’s autonomy for an assisted death against the valuing of quality palliative care provision. Social workers, as with all health professionals, will have their own values and beliefs about assisted dying and these may be driven by religion, culture, and personal experiences, and may at times lead to the exercise of conscientious objection to involvement in an assisted dying request. If a social worker is unable to reconcile their own personal values and beliefs to assist a dying person to exercise their option for an assisted death, they have an ethical responsibility to ensure that their own position does not adversely impact the dying person’s choices. There are some countries that have provided comprehensive guidance for social workers on working in palliative care and end-of-life, and professional social work practice standards in this area have been developing over the past decade. However, these standards have not yet advanced to the inclusion of assisted dying. It is likely that as assisted dying continues to become legalised, more research will be conducted to provide an evidence base for practice in this emerging field.
It is important that attention is given to the need for families to be involved in consultations and processes leading up to an assisted death in a way that respects care for them as well as for the dying person. The level of social acceptability of assisted dying, and the legal provisions that protect loved ones from potential prosecution should they assist a death, are important predictors of how well families will manage bereavement (Gamondi et al., 2019). Boven et al. (2023) described the importance of a serene atmosphere to assist a dying person and their relatives and family to better manage the bereavement process both before and after death. Social workers play an integral role in shaping such an atmosphere through their support of rituals before death, decision-making processes about practical arrangements, discussions of the spiritual aspects of dying, provision of information and resources for further support for children and others impacted by the loss. Social workers are invaluable members of interdisciplinary teams of health professionals where their skills in psychosocial assessment ensure that the broader life of the dying person is kept in focus. Returning to the differentiation between assisted dying and suicide, it has been found that relatives can experience feelings of judgement if a loved one’s death by assisted dying is referred to as a suicide (Srinivasan, 2019). Social workers can therefore assist bereavement and grieving by focusing on the dying person’s expressed wishes to die with dignity in an uncoerced and voluntary manner, with assistance at a time and place of their choosing, rather than taint the memories with the stigma of suicide.
While assisted dying has largely been legalised within parameters of terminal illness and suffering that cannot be alleviated, there are increasing debates about the extension for people suffering serious, treatment-resistant mental illness, different forms of disability, and those in early stages of dementia or Alzheimer’s disease who will inevitably lose the capacity to consent as their conditions progress. Questions of how to define intolerable suffering and ensure decision-making capacity are critical in these impending debates (Trachsel & Jox, 2022). There are many strong and vocal advocacy groups both for and against assisted dying and these will no doubt continue to have significant influence on how assisted dying is managed, and the standards and definitions that are applied. Social work as a profession upholds values of autonomy, self-determination, respect for persons, professional integrity, social justice and human rights. The multitude of issues raised by assisted dying fall within the domain of social workers who contribute valuable knowledge and skills to assist people, their families and communities to support those nearing end-of-life with compassion and care.
References
Bloomer, M., Saffer, L., Hewitt, J., Johns, L., McAuliffe, D., & Bonner, A. (2024). Maybe for unbearable suffering: Diverse racial, ethnic and cultural perspectives on assisted dying. A scoping review. Palliative Medicine. https://doi.org/10.1177/02692163241268449.
Boven, C., Dillen L., Dierickx, S., Van den Block, L., Piers, R., Van Den Noortgate, N., Van Humbeeck, L. (2023). Relatives’ experiences of being involved in assisted dying: A qualitative study. Qualitative Health Research, 33(13), 1154–1164.
Gamondi, C., Fusi-Schmidhauser, T., Oriani, A., Payne, S., & Preston, N. (2019). Family members’ experiences of assisted dying: A systematic literature review with thematic synthesis. Palliative Medicine, 33(8) 1091–1106.
Gerson, S., Koksvik, G., Richards, N., Materstvedt, L., & Clark, D. (2020). The relationship of palliative care with assisted dying where assisted dying is lawful: A systematic scoping review of the literature. Journal of Pain and Symptom Management, 59(6), 1287–1303.
Johns, L., McAuliffe, D., & Dorsett, P. (2019). Psychosocial care provision for terminally ill clients in rural Australian communities: The role of social work. Rural and Remote Health, 19(3), 1–8.
Srinivasan, E. G. (2019). Bereavement and the Oregon Death with Dignity Act: How does assisted death impact grief? Death Studies, 43(10), 647–655.
Trachsel, M., & Jox, R. (2022). Suffering is not enough: Assisted dying for people with mental illness. Bioethics, 36(5), 519–524.
