In 2008, Debbie Purdy and her lawyer were building a case concerning the prosecution of her husband. She wanted to know whether her spouse, Omar Puente, would be imprisoned if he played any role in her death, but the British Director of Public Prosecutions was being maddeningly unclear on the subject. Finally, in 2009, Parliament’s Law Lords ordered the director to clarify the matter. The change came too late for Purdy, but the guidelines published as a result of her case would provide invaluable information to many other Britons.

Purdy, who had been suffering from progressive multiple sclerosis for almost 20 years, hadn’t been seeking protection from her husband. Quite the contrary — she had been looking for assurance that he would not be prosecuted if he helped her end her life. Multiple sclerosis has no cure, and would put Purdy through an array of terrible symptoms including painful muscle contractions, incontinence, tremors, and paralysis. Her plan had been to travel from her home in England to an assisted-suicide organization in Switzerland, and she wanted to know that Puente would not be punished for taking her. Under British law, those who “aid, abet, counsel, or procure the suicide of another,” face up to 14 years in prison.

Though Purdy’s condition deteriorated during the court proceedings and she never got to make the trip, her case was a landmark in the recent history of suicide tourism. The world’s nations, and even the American states, don’t agree on the legality of assisted suicide. As a result, those living in regions that prohibit the practice are traveling many miles to reach a place where they can die with dignity — and creating ethical and legal complications as they go.

Murky Waters

Euthanasia and assisted suicide have taken place in varying degrees and with questionable legality for centuries. Physician-assisted suicide’s time in the mainstream has been relatively brief, but in a little over a decade the practice has become an intensely debated political and ethical topic.

Helping someone end their life is morally and ethically complicated, and that’s reflected in the vague language of many countries’ laws, which has in turn contributed to confusion and court cases like Purdy’s. Some countries, like the Netherlands, explicitly legalize physician-assisted suicide in situations where certain criteria are fulfilled. Likewise, doctors in five U.S. states are legally permitted to prescribe lethal doses of medicine for patients who intend to end their lives. Belgium, with the world’s most liberal suicide laws, even explicitly permits euthanasia by lethal injection.

The laws of other places are not nearly so clear. In 2015, German lawmakers passed a bill allowing assisted suicide for “altruistic motives” but banning the practice when conducted on a “business” basis. In Switzerland, inciting or assisting suicide for “selfish motives” has been illegal since 1942, implying that doing so is only punishable by law if the helper makes personal gains from the death.

Former German Justice Minister Brigitte Zypries told the Associated Press that the German law “will open an era of great legal uncertainty,” and pointed out that it is unclear when a doctor behaves in “a business fashion.” If Switzerland’s vague law is any indication, however, right-to-die advocates will interpret the law in their favor. Since assisted suicide in non-selfish cases is not clearly regulated, the country has become a hot spot for the practice — not only among terminally ill Swiss citizens, but for anyone around the world hoping to end his life.

A person and their close relatives may have to relocate for the right to die with dignity. Pixabay Public Domain

Destination Death

As the idea of assisted suicide becomes more acceptable around the world, many patients have grown critical of restrictive laws in their states and countries. For those with a progressive or terminal disease, making the effort of campaigning for change with a local government is unappealing — after all, Purdy grew too weak to travel after fighting her legal battle. Instead of dying by assisted suicide, she ended up in hospice care, intermittently refusing to eat until she passed away. For most patients hoping to end their lives, traveling to a region that allows assisted suicide is much easier than changing the law at home. Thus suicide tourism was born.

The phenomenon has only grown and will continue to do so unabated, according to one team of Swiss researchers. They found that, between 2008 and 2012, 611 visitors came to Switzerland for the sole purpose of ending their lives. These people came from 31 different countries, but most hailed from Germany and the United Kingdom. The study authors write that “in the UK, at least, ‘going to Switzerland’ has become a euphemism for assisted suicide.”

Suicide tourism is not confined to Europe. The widely publicized case of Brittany Maynard, a 29-year-old with terminal brain cancer, brought assisted suicide into the public sphere in the United States, causing an eruption of debate over the right to die and the hassles the current patchwork of state laws produces. Maynard, a resident of California, was forced to uproot her family to go through with her plan to “die with dignity.”

“I met the criteria for death with dignity in Oregon, but establishing residence in the state to make use of the law required a monumental number of changes,” she wrote. “I had to find new physicians, establish residency in Portland, search for a new home, obtain a new driver’s license, change my voter registration, and enlist people to take care of our animals, and my husband, Dan, had to take a leave of absence from his job.”

Maynard noted that most families do not have to resources or flexibility to make such extensive changes.

A Weighty Responsibility

In many cases, it seems countries like Switzerland and states like Oregon are providing a humane service to the terminally ill and their families, one unavailable to them had they stayed home. Some countries want no part of that, however.

Canada, for example, has introduced an assisted suicide law that specifically limits the practice to citizens and residents, excluding foreigners. It can be difficult to understand why a country would withhold medical care, but the tough ethical questions aimed at countries with liberal assisted suicide and euthanasia laws can be hard to handle.

Lawmakers must determine how severe a person’s condition must be before they can legally seek assisted suicide. Most associate the practice with terminal illness, but not all cases concern such an ailment. Comparing their findings to those in two earlier studies, the authors of the Swiss suicide tourism study said their research showed that doctors diagnosed an increasing proportion of neurological and rheumatic diseases among suicide tourists.

“This implies that non-fatal diseases are increasing among the suicide tourists and probably also among Swiss residents,” they wrote.

Liberal euthanasia and assisted suicide laws such as those in Belgium and lack of precise regulation have opened the option to many non-terminal patients. Such laws allow patients with rheumatoid arthritis, osteoporosis, and mental health problems to take their own lives. Nathan Verhelst, a transgender Belgian man, chose to end his life in 2013 after failed sex reassignment surgery, citing psychological suffering. Belgian twins Eddy and Marc Verbessem had been born deaf and were slowly losing their sight as well. They chose to die in January 2013.

Time is an important factor for the terminally ill, but should others be permitted to end their lives as well? Pixabay Public Domain

Who Has the Right to Dignity?

As assisted suicide becomes more common, an increasing number of cases will test the line between the humane and the unacceptable — a category that usually includes traditional, unassisted suicides. People are at a much higher risk for self-harm when suffering from mental illnesses such as schizophrenia, bipolar disorder, and depression, for example, and the latter commonly afflicts those with serious, chronic illnesses. In an editorial concerning physician-assisted suicide, Dr. Morton Tavel, a clinical professor emeritus at the Indiana University School of Medicine, addressed the fine line doctors walk when navigating the law and individual cases.

“Although such laws are humane and sensible, they can be abused and result in wrongful deaths,” he wrote. “We physicians commonly encounter severely depressed patients without life-threatening physical maladies, who, on their own, might opt to commit suicide. … Obviously, in such cases a caregiver’s assistance in suicide would represent a serious disservice.”

Tavel elaborated for Medical Daily, explaining that most physicians would be able to recognize a depression so severe it is disproportionate to a patient’s physical disease, and that they should ask for a psychiatric evaluation in those cases.

“Treatment for the depression with psychotherapy, combined with drug treatment, may allow a patient to return to a satisfactory and prolonged survival,” he said. “If such an outcome seems possible, then assisting one in suicide would be unwise at best.”

Tavel said a patient’s personal physician is the one most qualified to judge their physical and mental state and to request assisted suicide. Ideally, all local jurisdictions would have laws permitting physician-assisted suicide for this reason, but many do not. Tavel supported the idea of applicants traveling to places with more permissive laws, but on the condition that “medical professionals at the receiving destinations are supplied with sufficiently detailed local analyses of the situations” of the patients. “Only then should they be allowed to proceed with ending life in this fashion,” he concluded.

Like Tavel, Maynard’s widower Dan Diaz supports the right to travel for death with dignity, and has become an advocate for allowing the practice in more states. He told the Cleveland Plain Dealer he hopes to debunk misconceptions about patients seeking the right to die. A person who participates in a medical-aid-in-dying program hasn’t necessarily given up hope, he said, and may not be planning to take his life in the near future. Just having the lethal dose of barbiturates in her possession lessened Brittany’s fear of suffering.

“When you have cancer, you fight,” he said. “Having this medication changed nothing about our ability to fight. The strength of this [right to die] legislation is that it provides the [patient] peace of mind. … Brittany had taken the control back from the tumor.”

The governments and populations of many regions remain opposed to physician-assisted suicide, and will likely remain so for years. Which means suicide tourism is here to stay — regardless of whether it is ethical and responsible.