Will legalised suicide, even when presented as assisted dying, adversely impact on efforts to reduce do-it-yourself suicide?

If it looks like a duck and it quacks, then . . .

On the same day that the Victorian Legislative Council Select Committee Inquiry into end of life choices report was released, the Prime Minister foreshadowed a new inquiry into suicide and its prevention. That evening, the ABC Drive program ran the two news items consecutively. Whether this arrangement was an initiative of a program arranger or was completely fortuitous, is not known but the grouping of the two items failed to elicit any comment from the usually chirpy presenter PK. Nor were any text messages from listeners received by the ABC (or at least none were aired). Perhaps this was an early indication of a general failure to recognise that the term assisted dying had a very well established currency overseas as a polite substitute for assisted suicide. It certainly represented an emphatic acknowledgement of the success of the Select Committee in quarantining the S word from polite conversation.

The Select Committee report was remarkable in a number of respects. Whereas the S word only appeared a handful of times (either when emphasising the potential of assisted dying for preventing do it yourself unassisted suicide or for citing overseas legislation embodying the word), the phrase assisted dying made in excess of 100 appearances in the first 30 pages an achievement of truly Orwellian proportions. Creation of the expression assisted dying represents one of a number of neologisms to shield a variety of communities from the S word. Nomenclature including terms such as Voluntary Euthanasia and Hemlock for organisations formed to promote assisted suicide have given way t others such as Compassion and Choice. An international competition generated such gems as dignicide. Assisted dying had little competition to emerge as a favourite.

A warning of things to come emerged on first reading of the report. The first 7 Chapters generated 48 recommendations to improve end of life care. The eighth yielded the only recommendation (number 49) to have received the Premiers immediate endorsement, namely the legalisation of assisted suicide (aka assisted dying). On a second reading of the report, undue cynicism is not required to recognise the first 7 chapters as an entre for the main course. Whereas original advocacy for assisted suicide usually presented it as a solution if available palliative care was not adequate to relieve a patients distress, more recent efforts, including the Victorian report, cast it as an alternative to offering palliative care at all.

The 13 months following release of the Select Committees report have been notable for the deafening silence among Australian suicide prevention organisations. The reason(s) for this silence are not readily apparent. Perhaps a number exist, varying between such organisations. Whether there has been confidential discussion within the suicide prevention sector remains unknown. Perhaps the likeliest explanation for lack of any comment is apprehension that, were the community to equate assisted dying with suicide, there might arise some confusion in distinguishing between good suicide (OK according to the Victorian Government) and bad suicide which the suicide prevention sector seeks to discourage.

Reading of the chairs foreword to the Select Committee report could leave the impression that he lacked familiarity with features of the current status of bad suicide in the community he was elected to represent. So, for openers, he asserted that: We are living longer, fewer young people die and we have an expectation, sometimes falsely, that appropriate medical intervention can cure virtually all serious conditions. Could have been better chosen when introducing a document crafted to achieve legitimacy for good suicide; A moments reflection could have prompted him to recall that the commonest cause of death of young Australians now is youve guessed it suicide. Motor vehicle accidents are now running a distant second. (The gap between winner and runner up may be rather greater than figures suggest Single vehicle, single occupant fatal MVAs are sometimes suicidally motivated).

Assessment of the influence of legitimising assisted suicide upon the frequency of its do-it-yourself equivalent is difficult to assess and disputed. There is no question that suicide (that is the bad variety) has a ripple effect and the worthwhile efforts of prevention campaigns to minimise publication of case details attests to this. As an aside, it is interesting that the most recently enacted Canadian legislation to permit euthanasia, as does its predecessor in Oregon relating to assisting at suicide, prohibits any indication of the cause of death as being suicide. Causation shall be recorded as the medical condition justifying the event (in hindsight, this may be embarrassing in the recent Canadian case of a patient whose euthanasia was approved by a court on the grounds of osteoarthritis). Perhaps it would not be reading too much into this mandated requirement to falsify death certificates

to infer that the legislative drafters sought to avert any possibility that published information on good suicide might inspire some of the bad variant?

The ripple effect of suicide is especially evident when the frequency of suicides within different identifiable groups is compared. Considerably augmented rates have been recorded among gaoled prisoners during the first month after release and among military personnel during the period after return from active service. The latter is currently the focus of government initiated review. Whilst considerable attention has been directed to suicide of prisoners in custody, Im unaware of any action initiated to forestall suicide in released prisoners.

The most publicised, and in many ways the most concerning instance of the ripple effect in an identifiable group is that in Australian Indigenous communities. A series of suicides in young indigenous people in the Kimberley is currently the subject of a major coronial inquiry. In this instance, Australia is certainly not unique. It is of interest to recall the handling of this sensitive issue by those responsible for the Canadian parliamentary legislation. Groups of suicides among First Nations and Inuit communities have been subject to considerable publicity extending beyond Canada. The manner in which this potential obstacle to the passage of euthanasia legislation was handled by placating Indigenous MPs came into the media some months after the event.

If interested in the question of coexistence of good and bad suicide within a jurisdiction, and especially of the status of prevention of the latter in such a situation, try googling suicide prevention together with Belgium or Netherlands. The results wont detain you for too long.

Some comparison of attitudes towards suicide among young people in the Netherlands and Australia is interesting. Whilst identification of Australian students at risk of suicide and intervention strategies is a priority, their Dutch equivalents have the opportunity to participate in Caf Door Normaal, (Caf Euthanasia Dead Normal) an initiative undertake by the junior offshoot of the NVVE

The viability of an active suicide prevention program alongside an active system permitting good suicide must be questionable.

Peter McCullagh is a graduate of the University of Melbourne (MD), Oxford University (D Phil) and a member of the Royal College of Physicians (MRCP Lond.). He was a member of the John Curtin School of Medicine, ANU for 35 years undertaking research on the manner in which the immune system learns to recognise self during fetal life and the implications of this process for autoimmune diseases and transplantation in adult life. Apart from immunological research articles, he has had 4 books published 3 of which deal with bioethical issues.

Good Suicide v Bad Suicide was previously published on http**// thefreedomproject.com/**