I would rather be exposed to the inconveniences attending too much liberty than to those attending too small a degree of it.

– Thomas Jefferson

With the passage and expansion of Canadaā€™s Medical Assistance In Dying law in recent years, the topics of assisted suicide and euthanasia have been in the forefront of the North American popular consciousness in a way that they have not since the trials and eventual conviction of Dr. Jack Kevorkian in the 1990s. Within that context, I have been somewhat surprised at the strong opposition to medical aid in dying laws from some corners of the libertarian community. While valid concerns have been raised that Canadaā€™s provincial single-payer medical care system may be encouraging the option of medical aid in dying as a first resort for patients with expensive chronic illness in order to reduce costs, I still believe that the peaceful termination of oneā€™s life should be an available option for patients. Wherefore, I will endeavor a defense of what I prefer to name ā€œmedical suicide.ā€

To begin with, I would like to define some very important terms in order to make it clear precisely what I am defending, and just as importantly, what I am not. In both a popular and legal context with regard to this topic, different terms may be used to refer to more or less the same thing, or to very different things. ā€œMedical Assistance In Dyingā€ is the term used in Canada to refer to the legal framework that authorizes two different methods of terminating the life of a patient at the patientā€™s request. One such method is the prescription by a physician or nurse practitioner of a fatal dose of a drug, usually a barbiturate, that the patient then self-administers. This type of termination of life is often referred to as ā€œassisted suicideā€ or ā€œphysician-assisted suicide.ā€ Dr. Philip Nitschke and Dr. Fiona Stewart, among others in the ā€œright to dieā€ community, refer to this type of assisted dying as the ā€œpeaceful pillā€ in their book and web platform of the same name. This is also the type of medical assistance in dying that was first authorized in the US state of Oregon, and subsequently adopted by Washington State, California, and others. The ā€œThanatronā€ and ā€œMercitronā€ devices used by Dr. Kevorkian and the ā€œDeliverance Machineā€ used by Dr. Nitschke technically meet this definition, as the administration of the drug (or gas) was initiated by the patient interacting with a computer or mechanical switch, although the Thanatron and Deliverance Machine required an IV to be placed by a clinician. The other method of terminating the life of a patient authorized by Canadaā€™s MAID law is the administration of a fatal dose of a drug by the clinician to the patient, rather than by the patient himself. This type of termination of life is often referred to as ā€œeuthanasia,ā€ and could more accurately be described as ā€œmercy killing.ā€

The moral implications of this difference should be obvious. Providing a lethal dose of a drug to someone that they will subsequently administer to themselves involves a lesser degree (or absence) of culpability in their death compared with actually causing their death yourself by administering the drug to them. Despite this stark distinction, the two are often conflated by imprecise language. Hence, for the sake of precision, I prefer to use the term ā€œmedical suicideā€ when referring to the intentional self-administration by a patient of a lethal drug or substance. This is roughly in keeping with the use of the term ā€œmedical abortionā€ to refer to an abortion induced by drugs, in distinction to surgical abortion. The Greek roots of the word euthanasia translate directly as ā€œgood death,ā€ and the term may be used to describe medical suicide, mercy killing, or even palliative sedation, whereby a terminal patient is given drugs to render them unconscious while their body succumbs to death naturally. You can think of medical suicide as a subset of euthanasia. The key word in this construction is ā€œsuicide,ā€ defined by the American Heritage Dictionary as:

The act or an instance of intentionally killing oneself.

Mercy killing is not suicide. While I do believe that mercy killing can be justified under certain circumstances, the involvement of a third party changes the moral, ethical, and legal calculus. We may posit a defensible justification for voluntary mercy killing from the right to contract and/or the right to free association, but we can derive a justification for suicide, including medical suicide, from the much more tenable right to self-ownership.

The principle of self-ownership is fundamental to liberty, and I am sure it would be an unnecessary waste of time justifying it to this audience. If we guide our public policy and legal ethics from the non-aggression principle, which, as articulated by Murray Rothbard, states that:

No one may threaten or commit violence (ā€œaggressā€) against another manā€™s person or property. Violence may be employed only against the man who commits such violence; that is, only defensively against the aggressive violence of another.

then certainly we may, as individuals, question the wisdom of suicide, either generally or circumstantially, and we may even enlist all our powers of persuasion towards discouraging suicide at an individual or social level, but we can not justify using force to prevent it. If we accept that a man has a right to dispose of his life however he sees fit, so long as he does not impede the equal right of another, then we must at least tolerate his liberty to terminate it. (As an aside, in anticipation of an argument regarding the abortion issue, there is an important distinction in that suicide, by definition, and without controversy, involves only the disposition of oneā€™s own life, whereas people of good faith may disagree about when, if ever, an embryo or fetus becomes an interested party to an abortion.)

So having established that self-ownership must necessarily entail the right to commit suicide, the only valid objection that can be raised with specific reference to medical suicide is the involvement of a third party to provide the fatal substance to the suicidal patient. This objection, however, is only valid to the extent that state drug control, requiring that access to drugs be restricted through a physicianā€™s prescription, is valid. Returning to the non-aggression principle, I cannot find any possible justification for drug control by the state. It would certainly be within the scope of the non-aggression principle for a medical practitioner, drug maker, drug retailer, or the insurer for any one of those entities to restrict access to drugs through market mechanisms, but the likelihood of market mechanisms alone creating a total barrier to access a drug or substance, as we have with state drug control schemes, is infinitesimally small. Without the legal necessity of a medical gatekeeper to access fatal drugs, medical suicide would require no more third-party assistance than any other method. A commercial transaction between the suicidal patient and a drug supplier should impose no more legal liability or moral culpability on the drug supplier than a commercial transaction between a gun supplier or razor blade supplier and a suicidal person would impose on the gun supplier or razor blade supplier. Certainly no libertarian jurisprudence would impose liability under those circumstances, absent fraud. The only unique aspect of medical suicide that requires the participation of a medical professional is state drug control. Like most in the liberty movement, I yearn for the days when such state drug control schemes are relegated to their rightful place on the ash heap of history, but until then, allowing willing medical practitioners to provide lethal drugs to their patients is unobjectionable.

That having been said, the non-aggression principle equally protects the right of an unwilling medical practitioner to withhold his participation in any procedure or treatment, including medical suicide, in accordance with the dictates of his conscience. No person, whether provider or patient, should ever be forced or coerced into providing or obtaining any medical procedure. And here we round back to where we started, with Canadaā€™s MAID law. To the extent that patients are being coerced by their physicians to make use of MAID to terminate their lives rather than continue treatment, thatā€™s a travesty of the law and of medical ethics. But we must be careful to be precise with our language. At what point does a physicianā€™s advice to a patient rise to the level of coercion? It may be the honest medical judgment of a physician that his patient would be better served by palliative care, medical suicide, or mercy killing than continuing treatment, and preventing a physician from broaching the subject with his patient could easily veer into the sort of medical censorship that we observed during the height of COVID misinformation hysteria. So long as a patient remains free to heed or not heed the advice of his physician, as the case still seems to be, the responsibility for his decision to make use of MAID still ultimately rests solely with himself. The thought of the state mandating medical suicide or mercy killing is chilling, and calls to mind the 20th century horrors of eugenics, but restricting the liberty of patients and physicians is a poor solution to that as yet unrealized problem. We must be cautious not to oppose one variety of tyranny by exchanging it for another. As the well-worn C. S. Lewis quotation reminds us:

Of all tyrannies, a tyranny sincerely exercised for the good of its victims may be the most oppressive. It would be better to live under robber barons than under omnipotent moral busybodies. The robber baron’s cruelty may sometimes sleep, his cupidity may at some point be satiated; but those who torment us for our own good will torment us without end for they do so with the approval of their own conscience.

It would, of course, be barbaric to coerce a desperate person to kill himself, but it is no less so to withhold access to drugs that can bring about a peaceful death from a truly desperate person, leaving him to face the wretched inevitability of the forces of nature, or end his life by means of one of the gruesome, painful, and traumatizing methods left to him. I will happily stand at the barricades shoulder to shoulder with those whose quarrel is with a state that prescribes premature death as a solution to its fiscal woes, as well as with those whose quarrel is with a state whose benevolence consists in dictating the terms by which a man may die.