Killing Words

A Suicide by Any Other Name Is Still a Suicide

Physician-assisted suicide continues to be in the news. By early 2024, 21 states were debating legislation to either introduce the practice or amend existing legislation.¹ As state legislatures try to enshrine a “right to die” into law, many terms are thrown around, with “euthanasia,” “physician-assisted suicide” (PAS), and “medical aid in dying” (MAiD) being some of the most common. What, if anything, are the differences between these terms? And does the term one uses really matter?

Attempts to Obscure

The first distinction to be made is between euthanasia and PAS. In euthanasia, a doctor administers drugs directly to a patient (often through an injection) with the intent to kill him. In some countries, such as Canada and the Netherlands, this is the dominant practice, but in the U.S., euthanasia remains illegal in all jurisdictions. In PAS, a doctor prescribes a lethal medication for the patient, but the patient must take the medication himself without any assistance. This is the practice that has been legalized in states such as California and Oregon.

With that distinction out of the way, what is the difference between PAS and MAiD? In short, nothing. The two refer to the same thing: a doctor prescribing a lethal medication for a terminally ill patient to take to end his or her own life.

If PAS and MAiD refer to the same thing, does that mean they are interchangeable? Not really. PAS was the term originally used, but MAiD rose to prominence primarily for marketing reasons—it sounds a lot more comforting and avoids reference to suicide.

While this may seem like a subtle distinction, branding such as this has been an important part of the push for PAS in the U.S. When the practice is described accurately, many people are turned away. Calling it “physician-assisted suicide” makes quite clear what is happening—sick persons are ending their own lives with the help of a physician. The phrase “medical aid in dying” masks this fact, and it is completely unclear who provides the aid or what that “aid” even entails. Something as simple as pain relief could reasonably be considered “aid in dying” if the term were not being redefined to mean medically assisting in the patient’s suicide.

In place of a more accurate term, then, proponents of PAS have come to lean on obscurantist terms like MAiD, while also using emotion-laden language, such as “compassion,” “right to die,” and “choice.” For example, the Hemlock Society, one of the leading organizations pushing to expand PAS, was founded in 1980 and took its name from Socrates’s choice to drink hemlock poison for his own execution rather than flee Athens after being condemned to death. The Hemlock Society subsequently changed its name to End-of-Life Choices and then later merged with Compassion in Dying to form Compassion and Choices.² Notice the none-too-subtle shift away from associations with execution and suicide.

Flawed Arguments

Proponents of MAiD, such as Compassion and Choices, contend that a terminally ill patient taking a lethal drug to hasten his death is not really committing suicide. Rather, they say, this should be understood as an entirely different category of death.³ They give numerous arguments for this position and for why their terms should be preferred to PAS, but as we shall see, most of them are shaky at best.

Proponents of the MAiD terminology argue that in jurisdictions where some form of PAS has been legalized, the law does not consider PAS to be suicide on the part of the patient or assistance with a suicide on the part of the physician. This is true, but it doesn’t really help in the debate over which is the better term; it’s a case of merely assuming the conclusion. While the law may make distinctions between what is prosecutable and what is not, pointing to that distinction in a legal code does not tell us whether the two are equivalent in practice. Just because a law uses a term does not mean that term is the best option. Furthermore, it should be noted that laws legalizing PAS have been written by its proponents. Thus, advocates who say that the law makes a distinction between PAS and other forms of suicide are approaching the issue backwards; they are passing a law enshrining a difference and then pointing to the law as evidence that the distinction was there all along.

Another argument put forth by proponents of MAiD is that many medical associations no longer use “suicide” or “assisted suicide” in their policies and position statements, and that some have even adopted policies against suicide terminology.⁴ While what these organizations are doing can be instructive, this, too, fails to answer the question of whether MAiD is the best term. Also, if the words medical associations use should be determinative, it should be noted that the largest medical association in the U.S., the American Medical Association, maintains that PAS is the most precise term and should be preferred over MAiD or “death with dignity.”⁵

Other arguments for preferring “MAiD” deny that a patient who ends his life is really dying by suicide by focusing on the reason for the act.⁶ Since the terminal prognosis is the reason a patient seeks to die, medical assistance in dying is put forth as an act of mercy, allowing patients to avoid suffering from their disease; or it may be cast as an act of empowerment, allowing terminally ill patients to end their lives on their own terms. Advocates point to the fact that most legislation requires screening for depression and other mental illnesses to be certain that suicidality is not the reason for seeking PAS. This, they say, is evidence that PAS and suicide are two different things.

It is usually true that those who make use of PAS would not wish to die if they were not already dying. However, this fact alone does not mean that PAS is essentially different from suicide. In both cases, a person deliberately and artificially shortens his own life. Common warning signs of suicidality include pain, anxiety, hopelessness, and feelings of being a burden. All of these could easily apply to those with a terminal condition.

Those who seek PAS often say that it is not about consciously wanting to die but about gaining control over their death.⁷ This might be true, but that does not change the suicidal nature of what they are doing; it only focuses on the reason for doing it. PAS and suicide are different forms of the same thing—an attempt, stemming from hopelessness and/or a desire to escape or avoid suffering, to control the manner of one’s death. We can and should have great sympathy for those struggling with a terminal diagnosis, but that does not mean we should narrow the definition of suicide.

A final, commonly made argument says that PAS should be treated as a medical procedure and that our language should reflect that. However, just because a doctor is involved does not mean that something is medicine. The goal of medicine should be to work toward the good and the health of the patient. Prescribing a lethal drug is antithetical to those goals.⁸ The American Medical Association’s code of ethics reads: “Physician-assisted suicide is fundamentally incompatible with the physician’s role as healer.”⁹ While it usually arises in the context of end-of-life care, PAS is not a medical procedure and should not be called one. Terms like MAiD confuse the issue and try to lend the credibility of the medical profession to a practice that is hostile to all that medicine stands for.

Compassion, Not Normalization

A related factor worth noting is the association between legalized PAS and suicide rates in general. A 2015 study found that, in states where PAS has been legalized, the rates of non-assisted suicides have also increased.¹⁰ The authors suggest that legalizing PAS may lead to “an increased inclination to suicide” in the rest of society. This should not come as a surprise. When a culture legitimizes people taking their own lives, even for supposedly “good” reasons like gaining control or avoiding suffering, choosing to end life is normalized, and the value of all life is cheapened.

If someone intentionally swallows a bottle of painkillers to end his own life, that is considered a suicide. Should going to a doctor and receiving a drug designed to do just that be considered something different? Intentions matter, but they do not change the nature of taking one’s own life.

Ultimately, many of the reasons proponents prefer terms like MAiD are pragmatic: they want to normalize voluntary termination of life and encourage it as an option for more people while avoiding the stigma of suicide. These are all touted as goods and benefits. However, even some of those who accept the practice recognize that these ends come at the expense of transparency and accuracy. And for those opposed to PAS, reducing stigma and normalizing suicide are not goods at all.

How we talk about the issues of the day matters, and surrendering the definition of suicide to those who want to promote it does not help those with terminal illness. As Matthew Eppinette, executive director of The Center for Bioethics & Human Dignity, recently wrote, “real aid in dying means caring for the dying, not helping them to die.”¹¹ We need to show care and compassion for those facing death and not encourage them to take a physician-assisted escape. They need to know that the final days of life are still worth living, even if that means relinquishing control over the exact timing and manner of their deaths.

—Suicidal thoughts or actions are signs of extreme distress and should not be ignored. Immediate help is available at the National Suicide Prevention Lifeline. Call or text 988.

Notes
1. Thaddeus Mason Pope, “U.S. Bills Regarding Medical Aid in Dying (2024),” ThaddeusPope.com (February 17, 2024).
2. “History of the End-of-Life Choice Movement,” Compassion and Choices, accessed March 12, 2024.
3. “Medical Aid In Dying Is Not Assisted Suicide, Suicide or Euthanasia,” Compassion and Choices, accessed March 12, 2024.
4. Ibid.
5. “Report 2 of the Council on Ethical and Judicial Affairs (2-A-19),” American Medical Association (2019).
6. Anita Hannig, “Medical Aid in Dying Is Still Called ‘Assisted Suicide’; An Anthropologist Explains the Problem with That,” The Conversation (July 6, 2022).
7. Blair Paddock, “Advocates Push for Illinois Legislation That Would Allow Terminally Ill Adults to End Their Own Lives with Medical Assistance,” WTTW (November 13, 2023).
8. Farr Curlin and Christopher Tollefsen, The Way of Medicine: Ethics and the Healing Profession (2021), 170–78.
9. AMA Code of Medical Ethics, “Opinion 5.7: Physician-Assisted Suicide.”
10. David Albert Jones and David Paton, “How Does Legalization of Physician-Assisted Suicide Affect Rates of Suicide?” Southern Medical Journal 108, no. 10 (2015): 599–604.
11. Matthew Eppinette, “Real Aid in Dying Means Caring for the Dying, Not Helping Them to Die,” Newsweek (January 31, 2024).