Assisted dying: We need to talk about suicide

The push to legalise assisted suicide in the United Kingdom has relied largely on euphemisms, argues Dr Jonathan Blackwell. It’s time to call things by their real name.

I cannot forget a Sunday night from when I was 17. Waiting on the platform at Wandsworth Common in South London, laughing, joking, waiting for the train. And then it hit us. Adam was dead, he had thrown himself off the heights of Beachy Head.

Suicide is defined in the Oxford English Dictionary as ‘The action of killing yourself deliberately’. Its definition is unequivocal yet the act of suicide breeds endless questions. Why? What could I have done? Why couldn’t they have lived for me? How could they feel so unloved?

The latest question is – what is the best phrase to describe ‘The action of killing yourself deliberately… with the legal assistance of one’s doctor’?

Kim Leadbeater’s Terminally Ill Adults Bill, a document over 47,000 words long, whose purpose is to legalise exactly this act, mentions the word ‘suicide’ just four times – where it modifies the 1961 Suicide Act. The avoidance of the word ‘suicide’ is even more conspicuous in Liam McArthur’s Assisted Dying For Terminally Ill Adults (Scotland) Bill, as it is not mentioned even once.

As these two pieces of legislation progress through Westminster and Holyrood there has been heated debate about whether the term ‘Assisted Dying’ or ‘Assisted Suicide’ is more appropriate. In other jurisdictions a variety of nomenclature are used including ‘Medical Assistance in Dying’ in Canada, ‘Death with Dignity’ in Oregon, and ‘Assisted Suicide’ (hulp bij zelfdoding) in the Netherlands. The American Medical Association prefers ‘Physician-Assisted Suicide’ as it ‘describes the practice with greatest precision’.

Proponents of the bills have denounced the use of the word ‘suicide’, with Kim Leadbeater claiming terminally ill people choosing to end their lives are not ‘suicidal’ and ‘want to live’. Such linguistic contortions might be expected from a politician but as clinicians we are perhaps just as guilty.

Kathryn Mannix’s With the End in Mind details how we have lost the vocabulary to describe death, relying on euphemisms to shield ourselves from its painful reality.

Unfortunately, while euphemisms may soften the blow, they can also obscure the truth — sometimes with tragic consequences.

I was reminded of this recently after one of my patients died. When I met with his mother, devastated by her son’s death, what struck me most was how our communication with her during his final days had fallen short. 

It became painfully clear that the language we had used had not prepared her for what was coming. I had told my patient he was dying. He understood. My team had told his mother “this will be his final admission to hospital” and she heard he would be cured. Such misunderstandings are common and tragic and ultimately very painful.

Great efforts have been made to reclaim the language of death but I fear we are simultaneously losing the language to describe suicide. The phrase ‘assisted dying’ creates confusion and is poorly understood. A UK poll found just 43% of respondents thought ‘assisted dying’ involved the provision of lethal drugs to end somebody’s life. The majority believed the term meant withdrawing life-prolonging treatment or providing hospice-type care.

Much of the discourse has centred on autonomy. Laudable. But autonomy is only respected when people are given the facts.

Without accurate information, informed consent cannot exist. The starting point must be to use plain and honest language. Adam, who jumped off Beachy Head, did not die from ‘unassisted dying’. It was suicide and what is being proposed in England, Wales, and Scotland is ‘assisted suicide’.

The dictionary is currently being rewritten in order to distance ‘assisted dying’ from the stigma of suicide. But taboos do not reduce stigma. In the long run they perpetuate it and I feel deeply uncomfortable with the suggestion assisted dying is morally distinct from suicide because the people who might avail themselves of it are terminally ill and suffering. 

There has never been a person who killed themselves who was not suffering intensely and in need of love and support. I am sure Adam was. The problem with suicide is not that it is somehow shameful, I reject that entirely. Yet suicide is always a shame. Life lost. Opportunities lost. The chance to recover from devastating news – lost. Time with loved ones – lost. Those long unspoken words of reconciliation or declarations of love – lost.

Rebranding assisted suicide with the euphemism assisted dying may be well intentioned, wanting to spare patients any shame in choosing such a path. But the truth it obscures, as I have learned from painful personal experience, is that suicide is a fundamentally destructive act and many of us who are left behind will never fully heal. Legalisation, societal approval, friendly doctors, and clean and private rooms will not change that one iota.

I hope neither bill passes but if they do I hope we can at least be honest with our patients about what is really on offer.

This is a very slightly edited post which first appeared on the Blog Forum of the BMJ website. For the original post, see here. It is re-published in Adamah Media with the author’s permission.

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