EAS Undermines Patient Dignity

A key argument in favour of legalising assisted suicide is that it is necessary to secure ‘dignity in dying’, by providing painfree and peaceful deaths. The causing of death by ingestion of drugs is an unnatural act however, and as might be expected can lead to the opposite of what is intended: undignified and painful deaths.

The latest annual statistical report from Oregon reports that between 1997-2020, 68.8% of lethal drugs used in Oregon assisted suicide have been barbiturates such as secobarbital, phenobarbital, and pentobarbital. This is the same means by which criminals on death row in the U.S. are killed in ‘lethal injection’ executions, and works by inducing unconsciousness, followed by respiratory arrest and consequent asphyxiation. This has been called ‘cruel and unusual’ due to testimony that

the majority of those injected with pentobarbital suffer flash pulmonary edema, which can lead to a sensation akin to drowning and “extreme pain, terror, and panic”’.

Pulmonary edema is when fluid collects in the air sacs in the lungs, making it difficult to breathe, which can even lead to death by a kind of internal suffocation. This experience in U.S. executions has been described recently in an article in the Spectator by the Canadian physician Dr Joel Zivot, an associate professor of anaesthesiology and surgery at the Emory School of Medicine in Georgia, and who has acted as an expert witness against the use of lethal injection as capital punishment in the United States. He described the autopsy of one death row inmate killed by pentobarbital lethal injection, Marcus Wellons, which

revealed that his lungs were profoundly congested with fluid, meaning they were around twice the normal weight of healthy lungs… Wellons had drowned in his secretions… drowning in this manner is both prolonged and painful”.

Dr Zivot concludes that he is:

quite certain that assisted suicide is not painless or peaceful or dignified. In fact, in the majority of cases, it is a very painful death”, and that “[a]dvocates of assisted dying owe a duty to the public to be truthful about the details of killing and dying. People who want to die deserve to know that they may end up drowning, not just falling asleep”.

Other research suggests that signs of pulmonary edema occur in 84% of cases studied. There is a suggestion that the reason for the buildup of fluid in the lungs of those who die by lethal injection may be due to the fact that large amounts of drugs are being given intravenously over a short time frame rather than taken orally and that this damages the lungs. In Canada, intravenous delivery of Medical Assistance in Dying (MAiD) occurs in nearly all euthanasia deaths which raises the question of how many of the 21,589 Canadians who died by euthanasia in Canada between 2016 and 2020 (most likely over 28,000 if the 2021 deaths to date are included) also experienced pulmonary edema, or the ‘drowning’ effect, identified by Dr Zivot in his death row examples. Evidently there is a need for more research.

In a subsequent debate with Dr Zivot during a Spectator podcast on 16th September 2021 Dr Jacky Davis, Chair of Healthcare Professionals for Assisted Dying (HPAD) and a Board Member of Dignity in Dying (both UK pressure groups for assisted suicide), said she had been unaware of this issue previously and acknowledged that Dr Zivot may be right in his findings. She urged Dr Zivot or others to conduct more research on this issue before releasing this information to the public. Whether or not the doctors, healthcare providers or legal authorities involved in administering or scrutinising assisted suicide and euthanasia deaths in the USA and Canada will be willing or interested to investigate this matter further remains open to question. What is clear, however, is that rather than rushing into changing the law to follow their North American counterparts in legalising assisted suicide or euthanasia, British parliamentarians should take a much more cautious approach.


Worse Alternatives

Substitutes for barbiturates fare no better in the potential for causing suffering in a patient’s last hours of life. These have been developed in American assisted suicide practice, as barbiturates have become increasingly unavailable. Individual countries (including the entire EU) have introduced export bans on drugs used in lethal injection executions, whilst pharmaceutical companies and pharmacies have stopped supplying pentobarbital for human use to, and within, the United States. Secobarbital, under the brand name Seconal, rose drastically in price due to restricted supply and opportunistic price gouging. One month after California began to license assisted suicide in 2016, Valeant Pharmaceuticals (now Bausch Health) bought the manufacturing rights, such that a lethal dose which once cost $200 in 2009 began to cost $3,000 or more.

This has led to experiments with cheaper drug cocktails to bring about assisted suicide. Initially, doctors in Washington state experimented in the mid 2010s with a mixture of phenobarbital, chloral hydrate, and morphine sulfate, which were easily accessible and a lethal dose of which cost around $500. This combination caused “profound burning” in the mouths of patients presenting for assisted suicide however, and so a new combination of diazepam, digoxin, morphine and propranolol (‘DDMP’) was developed: “diazepam and morphine – meant to sedate the person and depress their respiratory drive – and digoxin and propranolol to stop the heart”. In 2016, this cost between $300 and $600.

The journalist Anita Hannig reports that,

After the first 30 deaths, the group increased the individual doses and named the new formula DDMP2, which cost around $750. On average, patients who ingested DDMP2 took much longer to die than those who could still afford Seconal. Until the end of 2019, the mean time to death for DDMP2 was over four hours in Oregon, and one death lasted as long as 47 hours. But Seconal had moved out of reach for many, and in 2018 fewer and fewer pharmacies were stocking it, knowing the current batch was set to expire by the end of the year. Since then, Seconal has become unavailable, forcing physicians across the country to rely exclusively on DDMP2”.

One Californian assisted suicide practitioner, Dr Lonny Shavelson, has reportedly “fine-tuned the [DDMP2] protocol, swapping the propranolol out for amitriptyline, an anti-depressant that can cause a fatal change in heart rhythm at high doses. With this change, 90 percent of his patients have died in under two hours”. This is long enough to cause grave concern, but Hannig gives a real life example of the use of Shavelson’s protocol of DDMP2 in the account of ‘Jeff’, an Oregonian man in his late 50s, who suffering kidney failure was attempting to procure assisted suicide, as related by his social worker ‘Ada’. This ended:

Jeff drank the lethal cocktail through a straw. Within 20 minutes he was asleep. Twelve hours later, Ada saw a shadow out of the corner of her eye and looked over. Jeff was sitting up and awake. Then, he started vomiting profusely…  After he awoke, scared and confused, Jeff was admitted to the hospital. When Ada visited Jeff the next day, she found him in the “comfort care” ward. Nurses had given him a mild tranquiliser to help with his nausea and vomiting. Over the next four days he declined rapidly. Ada was with Jeff when he died. As he lay flailing in his hospital bed, yanking at the sheets, she held his hand. “He didn’t die peacefully”, she said, her voice almost breaking. “It was a terrible death”.

Accounts like this illustrate how the introduction of assisted suicide into clinical practice, rather than leading to ‘dignified’ deaths, can instead create horribly undignified, drawn out, and painful ones. Given that no drug or protocol used in assisted suicide practice in overseas jurisdictions has undergone medical trials, and can often involve highly distressing complications, Jersey doctors would be effectively experimenting on their patients in the development of assisted suicide in Britain. No specific drugs or technique is prescribed in the Proposition before the States Assembly, and so no evaluation can even begin to be made of what the potential results would be on patients.


Indignity in Dying

Even without the dangers within lethal drugs themselves of causing intense suffering to patients, the risk of patient mismanagement of assisted suicide is not inconsiderable. Of the 75,297 deaths that have come about in the Netherlands due to ‘assisted dying’ in the Netherlands since 2002, 3,477 have been assisted suicides. A further 567 have been recorded as ‘joint’ assisted suicide-euthanasias. What this indicates is that the patient has tried to commit assisted suicide, but has failed the procedure, and needed a doctor to ‘finish’ their death with a coup de grace. Under Baroness Meacher’s Bill in England and Wales, for example, one question that needs answering is what the ‘assisting health professional’ present at an assisted suicide would do in the case of ‘failing’ suicide using dangerous drugs.

Both the risks of patient failure or the pain caused by lethal drugs themselves raise serious and concerning questions about the kind of drugs that would be used if assisted suicide were introduced into UK medicine, and the potentially harrowing deaths patients would consequently experience.

Even without the personal indignity of allowing psychological pressure on vulnerable patients, EAS carries the serious danger of physical indignity through painful deaths.