The case against assisted suicide that does not depend on religion

Whenever conservatives oppose assisted suicide, the first reply is usually not an argument. It is a diagnosis: you only believe that because of your religion. That reply has the virtue of letting the speaker skip the debate. It has the vice of being irrelevant, since an argument does not become false because the person making it also goes to church.

So let us run the experiment. Take faith out of the room entirely. No scripture, no sacred-life language, no appeal to a Creator. What is left? I think a good deal, and I think it is stronger than most people on either side expect. This is an argument from law, from evidence, and from the way institutions treat the weak.

The terms

Definitions first, because this debate is usually conducted in euphemisms.

• Assisted suicide means a physician provides a patient with the means to end his own life, typically a lethal prescription the patient takes himself. Supporters usually call it "medical aid in dying."
• Euthanasia means a physician or other person directly administers the lethal agent. Canada's law covers both, under the name "medical assistance in dying."
• Withdrawing or refusing treatment is a different thing, long recognized in law: a patient may decline an intervention, and a physician may honor the refusal. The Supreme Court treated the distinction as well established in Vacco v. Quill (1997), decided the same day as Washington v. Glucksberg. Washington v. Glucksberg and the 9-0 refusal to find a right to assisted suicide tells that case.

I am not making any medical claim in this post. I am not saying what treatment helps whom, and I am not advising any reader about his own situation. I am arguing about law and policy: what a state should authorize.

My thesis in one sentence: a state that authorizes physicians to help end the lives of the sick builds a pressure into the system that falls hardest on the people with the least power, and the record of enacted laws shows that the limits do not hold.

The autonomy argument at its strongest

Fairness requires me to state the other side at its best. Here it is.

A competent adult who is dying has a settled, informed wish to end his suffering on his own terms. The law already lets him refuse treatment, which can bring death sooner. It lets him decline food and drink in some circumstances. It lets him receive sedation to relieve suffering. What principled difference is there, the argument asks, between these things and a prescription he can take himself? The only difference is that the state decides how he may die, and a free person should not have the state intrude on the most private decision of his life.

Add that the safeguards are real. Under Oregon's law as enacted, and under similar statutes in other states, the patient must be an adult, capable of making and communicating decisions, diagnosed with a terminal illness expected to cause death within six months, and must make repeated requests with waiting periods. Two physicians must confirm. If the patient has a disorder affecting judgment, a referral for evaluation is required. Opponents who worry about abuse, the argument concludes, are legislating against a danger that the statute's own limits already address.

I accept that this is a humane argument made in good faith. It comes from the sight of real suffering, and anyone who has watched a loved one decline knows its force. Now the reply.

Premise one: a right to die becomes a duty to explain

Consider the incentives. When a society makes a death available as a medical option, it changes the position of every person who qualifies for it. The option is not neutral. It is a choice that must now be explicitly refused, and a person who refuses it may find he has to give reasons.

Think about an elderly man with an expensive illness and a family who is stretched thin. Before legalization, nobody asks whether he ought to want to live. After legalization, the question hangs in the air, unspoken, in the room. This is a hypothetical, and I label it as one, but it describes a structural feature of the law, not a rare accident. The existence of the option creates a pressure that did not exist when the option was not available.

Evidence for this concern comes from the official reports themselves. Oregon's Health Authority publishes an annual report on the state's Death with Dignity Act, summarizing data from the physicians' reports. Those reports have listed, among the end-of-life concerns patients cite for requesting the prescription, being a burden on family, friends or caregivers; in the early reports, roughly four in ten patients cited it. I will not quote a percentage, because the figure changes every year and I want you to look it up yourself in the current report, which is public. The point is that "feeling like a burden" is in the data, and it is not a reason that autonomy can fully rescue. A request made because one fears being a burden is a request shaped by the people around him.

A society that cares about the vulnerable should be uneasy about building an institution that rewards that feeling with a way out.

Premise two: the pressure falls unequally

Now add money. Health care has costs, and so do long-term care and the support of dying patients. The state, insurers, and families all have financial interests. I am not alleging that any specific person acts from such motives. I am describing a structure: when one option is much cheaper than the others, the others face a standing disadvantage.

Disability-rights organizations have made this argument for decades. Groups such as Not Dead Yet, which was formed in 1996, argue that legalizing assisted suicide sends a message that some lives are not worth living, and that the message lands hardest on disabled and chronically ill people, who already face assumptions from the world around them that their lives are lesser. Their concern is not religious. It comes from the lived experience of people who have been told, by medical professionals and by strangers, that they would be better off dead.

There is a point of consistency here. We spend enormous public effort on suicide prevention: hotlines, campaigns, training for teachers and doctors. The message to a despairing teenager is that his life has worth and that the feeling will pass. A law that tells a sick seventy-year-old something different, that his death is a legitimate medical outcome, creates two classes of people: those whose wish to die is treated as a crisis, and those whose wish to die is treated as a treatment option. The line between them is drawn by illness and age. That is a hard line to defend under the principle of equal worth.

Premise three: the safeguards are in the statute, but the statute can change

Here is the part of the argument that does not rely on prediction. Supporters say the safeguards will hold. The best evidence on that question is what legislatures and courts have actually done, so let us look at the record.

Oregon, 1997. The state's Death with Dignity Act was approved by voters in 1994 and, after a repeal measure was rejected in 1997, took effect that year. Its conditions are narrow, as described above. I will be fair and say that, as to its core limits, the statute has stayed narrow in Oregon: it is for adults with a terminal diagnosis. A critic of my argument can point to Oregon and say the law has held its shape. I grant it, with one footnote: in March 2022 Oregon agreed, in settling a federal lawsuit, to stop enforcing the in-state residency requirement, so the law no longer limits itself to Oregonians.

The Netherlands, 2002. The Dutch statute on termination of life on request and assisted suicide, which took effect in 2002, codified a practice that had developed under court decisions and guidelines. Its criteria include that the patient's suffering be unbearable with no prospect of improvement, and that the request be voluntary and well considered. In the Netherlands the law applies to suffering generally, not only to terminal illness, and it covers euthanasia as well as assisted suicide. That is a wider door than Oregon's, and it was opened by statute.

Canada, 2016 and 2021. This is the most instructive case, because it is recent and the dates are clear. In 2015 the Supreme Court of Canada, in Carter v. Canada, struck down the criminal ban on assisted dying for competent adults with a grievous and irremediable medical condition causing enduring suffering. Parliament responded with a law in June 2016 that allowed medical assistance in dying for people whose natural death had become "reasonably foreseeable." That was the limit.

Then, in 2019, a Quebec court struck down the foreseeability requirement as unconstitutional, and Parliament, rather than defend it, passed a new law in March 2021 that removed it. After March 2021, a person whose death is not reasonably foreseeable could qualify, under a separate track with additional safeguards. The 2021 law also provided that a mental illness alone would be excluded for a temporary period, but the start date for including it has been postponed more than once, most recently to March 17, 2027 by a law of February 2024. You can verify all of this on the website of the Government of Canada, which publishes its annual reports on the law.

Look at the sequence: a court decision in 2015, a limit set by Parliament in 2016, a court challenge to the limit in 2019, a legislative change in 2021. In five years the central safeguard of the law, that death be foreseeable, was removed, after a court held the limit unconstitutional, and Parliament chose to amend the law rather than defend it.

That is the slippery slope. But notice that I have not argued it from speculation. I have argued from enacted law. A critic who says the slope is a fantasy must explain why the Canadian statute looks the way it does.

The slippery-slope objection, answered

The best objection to the previous section is that the slope argument proves too much. "You say the laws expand. But Oregon's law has not. Different countries differ. Canada's experience is the result of its own court system and its own politics. You cannot generalize from one country."

I agree that one country does not prove a law of nature, and I would not claim one. Here is what the record does show.

1. The principle behind the law invites its own extension. If the justification is that a competent person should be able to end his suffering on his own terms, then a limit based on a six-month prognosis, or on foreseeability, is hard to defend on that principle. Why should suffering that will last for years count less than suffering that will last for months? The logic of autonomy has no natural stopping point at a prognosis. A Canadian court noticed this, and the Dutch legislature wrote suffering generally into the statute.
2. The institutions that police the limits are the same institutions that benefit from loosening them. Review boards, physicians and agencies that administer the law are interested parties. That is a structural weakness, not an accusation.
3. Reversal is rare. When a right to a procedure is established, repeal is politically difficult. The path is easier to widen than to narrow.
4. Oregon proves less than it seems. A state may have held its limits for a quarter-century, but that does not tell us whether the pressure I described in premises one and two exists. The limits and the pressure are separate questions.

I do not want to overstate. I am not predicting that every state will follow Canada, and I am not claiming that legalization has produced the results I fear everywhere. I am claiming that the burden of proof lies with those who would give the state the power to authorize a physician to help end a life, and that the record gives reasons for caution.

What a non-religious conservative can say

You will notice that I have not mentioned God. I do not need to, and I would not want the argument to depend on it. Here is the secular core, in plain terms.

The Declaration of Independence says that governments are instituted to secure the rights to life and liberty. A government's first job, on that view, is to protect life, especially the lives of those least able to protect themselves. A policy that makes the death of the sick a state-sanctioned medical option, and that puts the pressure to choose it on people who feel they are a burden, runs against that job.

That principle does not require religion. It requires only the proposition that all people have equal worth, whatever their health. Those who also hold that view for religious reasons are welcome in the argument. Those who hold it on the ground of the Declaration are welcome too. Why 'created equal' is a claim about God and not just about politics takes up the role faith plays in the Founding claim, for those who want to read the other side of the question.

What the alternative looks like

A purely negative case is not enough. If we oppose assisted suicide, we owe the suffering something else. That means supporting hospice and palliative care, which can relieve pain and offer comfort at the end of life. It means helping families with the costs of care and with the burdens of caregiving. It means building the kind of private and community support that How to Give Well, a Family Playbook for Charity That Actually Helps describes. And it means insisting that a society is judged by how it treats those who are dying, not by how efficiently it manages their deaths.

I would add a word about the dying person's dignity. Many who ask for help in dying are afraid of being alone, of being a burden, of pain that goes untreated. These fears deserve a serious response, and the right response is care, presence and the relief of suffering, not a prescription.

The case in brief

1. Assisted suicide differs from refusing treatment, a distinction the Court held to be well established in Vacco v. Quill (1997), and the debate is over what a state should authorize.
2. Autonomy is the strongest argument for legalization, and it deserves respect, but legalization creates pressure on the vulnerable, as the "burden on others" concern in Oregon's own official reports shows.
3. Disability-rights groups argue that the pressure falls unequally and that a law drawing a line by illness and age conflicts with the principle of equal worth.
4. Enacted law shows the limits can change: the Netherlands covers suffering generally under its 2002 law, and Canada's 2016 law, limited to foreseeable death, was widened in 2021.
5. A secular conservative can rest the case on the Declaration's claim that government exists to secure life, and should pair it with real support for hospice, caregivers and the dying.

What you can do: read the latest annual report of the Oregon Health Authority on its Death with Dignity Act, then check whether your own state legislature has a bill on the subject and attend or submit a written comment at its next hearing.