In the article “Is Assisted Dying Really a Matter for Medical Regulation,” Dvorak provides four arguments for the demedicalization of assisted dying in areas of the world where it is currently legal.Reference Hardes Dvorak ¹ These arguments are (1) pragmatic ethical issues of infrastructural weakness in assisted suicide/euthanasia (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; and (4) the risk that assisted dying becomes more easily susceptible to healthcare economics.

The question of whether or not assisted dying should involve the medical profession, i.e., medicalization, is somewhat rhetorical as even in the model “demedicalized” society, medical professionals are still integral to the process. In the Swiss model of assisted dying, non-medical volunteers for right-to-die organizations directly assist those wishing to accelerate their deaths by removing the medical profession from the “final act.” This model, currently achieved in a singular nation that at present enjoys the socio-political support of its citizens, is unevenly practicedReference Bartsch ² and does not fully exclude the medical profession. Medical professionals are still required to assess decisional capacity and prescribe medication as part of the process.Reference Andorno ³

History has repeatedly shown that which is supported today may be criminalized tomorrow, and vice versa. Although assisted dying has been practiced since the dawn of time, it became formally organized in the UK in the 1930s and in the US by the Hemlock Society in 1980 as a compassionate response to those suffering from incurable medical conditions and whose lives were reduced to trying to escape the pain and suffering of their remaining days.Reference Emanuel ⁴ As a result, the medical profession has always been instrumental in ascertaining that medical futility correlated with the “patient’s” own futility,Reference Quill ⁵ and in essence, assured society of the soundness of the decision. Even when the legal system is involved in the assisted dying decision-making process, key testimony is sought from medical experts on the terminal nature of the condition(s) in question. To remove medical expertise from the approval process may well have the unfortunate consequence of elevating superfluous and subjective issues, potentially inserting greater bias than already exists. In other words, as Dvorak noted that a majority of health professionals are against assisted dying, it is more than likely that volunteers for an assisted dying service will likely be overwhelmingly biased towards assisted dying. These may inadvertently reduce the guardrails we advocate for with assisted dying and allow the so-called “bracket creep” to occur.

Surveys show that there is some resistance to assisted dying within the medical profession, specifically within the specialties most likely to be involved in conversations with patients requesting assisted dying (geriatrics, palliative care, family practice). Despite the number of reluctant and conscientious objectors, the numbers of medical personnel willing to assist with assisted dying may well be sufficient to meet the demands of society. In assisted dying, as with any other medical procedure, the reaction to an insufficient number of trained medical providers is to provide avenues for additional training, not to move the procedure outside the medical purview. Multiple options to ensure access to a qualified medical professional exist, particularly since many jurisdictions have allowed telehealth consultations for these discussions and, in some cases, during the administration of the medications. Rather than removing the medical profession from the approval process for assisted dying, there should be a transparent process under medical supervision to objectify the qualifying conditions for assisted dying, one that incorporates community and professional stakeholders.

Maintaining the medical profession in assisted dying also helps guard against “bracket creep,” in which the practice spreads from addressing medical conditions to otherwise “‘normal’ areas of life.” For example, there have been individual cases in which people with nonmedical issues have become eligible for assisted dying, such as some treatable mental illnesses, or being old and “tired of life.” None of these conditions should ever be allowed to qualify for assisted dying and were only permitted due to poorly informed decisions by some courts. The possibility that non-medicalization could increase “bracket creep” and allow otherwise healthy people who simply do not want to live any longer or who have socioeconomic conditions that lead them to wanting to end their lives portends increased marginalization and mistreatment of vulnerable people. It could also lead society to reverse its overwhelming support for the right for assisted dying for those in medical need of this option.

Another argument for non-medicalization is that non-medics are best suited to perform assisted dying because medical professionals fear the judgement of their peers as well as lack sufficient time and remuneration for this service. The former argument does not warrant much discourse as committed physicians have embraced and provided care in controversial areas, such as abortion, oftentimes practicing despite imposed legal limits, not to mention fear of judgement from their peers. In the Swiss model, the non-medics are presumed to be free from the aforementioned concerns. Although volunteers may not be paid for their time, it is unreasonable to assume that physicians will only perform procedures associated with high remuneration. Physicians are motivated by multiple factors, not the least of which is the duty to provide care for patients. Primary care, palliative care, and geriatrics are not typically fields associated with high reimbursement in North America. Physicians who self-select into these specialties are unlikely to be motivated solely or mostly by financial rewards.Reference Kayser ⁶

We recognize the positive roles the medical profession plays in assisted dying, not only as gatekeepers, but also to reassure society that assisted dying is like any other treatment for any other medical condition. For example, the involvement of the medical profession has led to the publication of medical eligibility criteria. These criteria currently serve the purpose of preventing “bracket creep” of nonterminal conditions and, crucially, are not insurmountable and immotile barriers, as exceptions may be obtained via an expedited review process, something that commonly occurs for procedures and treatments other than assisted dying. As with all relatively new processes, there is a necessary period of growth, change, and improvement based on feedback. Ultimately, such a process could develop ways of reducing bureaucratic red tape by, for example, organizing physician-led committees that create preestablished conditions for qualification and a rapid system for an ad hoc assessment of special cases. If it is determined that the original list of medical conditions permitted for assisted dying was limited, then there should be a systematic review and feedback mechanism.

It is important to stress that decision making for assisted dying should not be left to individual doctors, because it would be far too easy to “doctor shop” and find a willing provider. Instead, medical oversight and standardization are the answers to a just and equitable assisted dying program and should become the model for all jurisdictions, rather than the Swiss model. Similar to other controversial cases such as abortion, adherence to clear guidelines could remove much of the individualized morally stressful decision-making and could reduce the involvement of courts, which are ill-equipped to decide cases without established guidelines from subject-matter experts.

Demedicalization will never reduce the regulatory complexities around assisted dying but, instead, could likely increase them if “non-medics” are at the helm. Furthermore, assisted dying will not be any less susceptible to healthcare economics without medics. In both socialized and fee-for-service medical systems, the economics are not affected by the few cases of assisted dying that may or may not be covered. Those seeking assisted dying need the subject matter expertise of medical professionals to inform and reassure patients and families. Although this may add some inefficiencies to the process, it also provides the necessary safeguards through checks and balances to ensure a morally just process.