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To Aryeh, Galia, Noam, and Elad: The light and hope in my life
Acknowledgements
The understanding and conceptualization of the main issues presented in this book took more than 4 years and was supported by the help of many people and organizations to whom and to which I owe many thanks and much appreciation. My initial travel to Switzerland and the research I did there was supported by the Nordmann Fellowship. While in Switzerland I had the opportunity to present my work in progress and reflect on my arguments with the help of many colleagues—most of whom I also interviewed, but other people at the Universities of Fribourg, Lucern, Zurich, Geneva, and many others as well. Other institutions that provided the means to work on parts of my research to which I am also grateful are MOFET Institute, Minerva Center for Interdisciplinary Studies of the End of Life, and Yezreel Valley Academic College.
I would like to acknowledge the help and information I received from all of my interviewees listed in this book and for the academic support which facilitated parts of my research in Europe received especially from Markus Zimmermann, Margot Braizer, Charles Foster, Richard Huxtable, and Jonathan Ives. In addition, I have had extensive communication with various scholars and colleagues on my project whom I would like to thank. These include Raphael Cohen-Almagor, Roberto Andorno, Joachim Cohen, Luc Deliens, Mirko D. Garasic, Simona Giordano, David A. Jones, Shai Lavi, Johan Legemaate, Alexandra Mullock, Agnes van der Heide, Mary Shariff, Silke Schicktanz, and Gila Yakov.
Finally, and as always, I am indebted mostly to my family which shows endless love and support and provided time and emotional and cognitive availability to deal with the issues raised in this book. Special thanks are reserved to my partner Aryeh who not only encouraged me to pursue the writing of this book in times of crisis and personal difficulties but also helped to facilitate this; to my beloved parents, Rina and Adrian, for whom I wish good ageing and prolonged quality of life; and to my beloved children Galia, Noam, and Elad who are the continual light in my life.
Introduction
What would it take for a child to accompany a terminally ill parent to another country to receive aid in dying? What would it mean for the partner of a motor neurone disease sufferer to travel with them to Dignitas? How would a couple suffering from chronic illnesses explain their decision to end their life to their children?
This book examines the phenomenon of ‘suicide tourism’. It is about strong wishes to die and people who are ready to leave their home country in order to receive aid in dying. For this final journey they may pay great sums of money and inadvertently expose their loved ones to risk of criminal charges in order to die legally in unfamiliar surroundings.
There has been a noticeable rise in the number of people seeking aid in dying in recent years, including through suicide tourism. A search on YouTube reveals that there are dozens of documentary films on suicide tourism and on good death—some of which have already attracted more than a million views each. Here and there, you read news stories of more or less familiar people taking the plane, train, or car to meet a stranger who will be with them during their last precious moments. The travel for assisted suicide has become a global practice involving citizens of many Western democracies who, due to local laws prohibiting assisted suicide, are unable to pursue their perhaps most intimate and meaningful goal in their homeland.
The current state of affairs in international politics—with its relatively new trend towards globalization—has strengthened the connection between biomedical ethics and political philosophy, international relations, and global justice. Among some of the most challenging and controversial cases are those concerning euthanasia and assisted suicide.1 Academic papers, as well as general media coverage, have
1 Dan W. Brock, ‘Voluntary active euthanasia’ (2002) 22 The Hastings Center Report 10–22; Kumar Amarasekara and Mirko Bagaric, ‘Moving from Voluntary Euthanasia to Nonvoluntary Euthanasia: Equality and Compassion’ (2004) 17 Ratio Juris 398–423; H.C. Muller-Busch, F.S. Oduncu, S. Woskanjan, and E. Klaschik, ‘Attitudes on Euthanasia, Physician-Assisted Suicide
followed the topic extensively but, somehow, some of the problems related to this debate have been either given insufficient consideration or left to one side altogether.
In this book, I wanted to bring forward a comprehensive analysis that would engage directly with the recent practice of suicide tourism at times also called ‘death tourism’. The analysis is based on intensive and extended research conducted between 2013 and 2018. It includes theoretical discussion of suicide tourism from varied contexts and disciplinary perspectives as well as an exploration of the major findings of my visits and in-depth interviews in Europe. This introduction provides the initial framework necessary for the understanding of this recent trend. Part I begins with an overview of the current state of affairs in the handful of countries that allow assisted suicide and contains a discussion of the recent trends and developments. It then goes on to explain in more detail the specific role that Switzerland—the country to which most people seeking assisted suicide travel to die, when unable to pursue their goal in their country of residence—has within that reality. The investigation gradually moves on to the core problem related to the globalized era in which we live: the freedom of movement that the international community grants to most people between most countries these days (at least theoretically), and its harsh clash with geographically contingent policies and laws. Part I continues with an analysis of the legality of suicide tourism before Part II opens with a consideration of its moral standing. This analysis is complemented with a discussion of the political-philosophical justifications for state intervention in the practice of suicide tourism. Part III sets out the major empirical findings obtained from, mostly, forty-five interviews conducted across Switzerland, France, Germany, the UK, Italy, and Israel to explore more closely the attitudes towards such practices and their effect on public policy and law, especially within countries of origin. By highlighting these considerations and debates, the book will provide an original basis—both useful and necessary—for further discussion on this developing issue.2 and Terminal Sedation: A Survey of the Members of the German Association for Palliative Medicine’ (2004) 7 Medicine, Health Care and Philosophy 333.
2 I am aware that global justice and freedom of movement carry with them many important debates that require in-depth analysis. With this book, I do not expect to find a satisfactory answer for all cases, but I hope at least to contribute to shaping a more coherent account of the
What is suicide tourism?
There are quite a few, relatively recent, forms of tourism that have occurred mainly as a result of the economic disparities between the original and the hosting country or because of their differing respective legal systems.3 Among the more established (though not equally accepted in moral and legal terms) forms—‘medical tourism’,4 ‘sex tourism’,5 ‘abortion tourism’,6 and ‘reproductive tourism’7 there is the more gloomy form of ‘death tourism’,8 9 which encompasses
application of liberal values. For further analysis on the issue, see, for example, Rainer Bauböck, ‘Global Justice: Freedom of Movement and Democratic Citizenship’ (2009) 50(1) European Journal of Sociology 1.
3 I do not want to oversimplify the debate by claiming that all these forms of tourism deserve the same kind of treatment: it is obvious that travelling abroad for the sexual exploitation of children is clearly wrong and can be condemned without much debate. However, it must be noted that the dynamics behind such a ‘market’ are similar in many respects to other forms of tourism considered here. The interconnection between globalization, bodies, the economic gap between regions, and freedom of movement are central issues in ‘sex tourism’ too, and for that reason it is included in the list of modern forms of tourism.
4 Glenn Cohen presents a recent investigation of the main problems related to medical tourism that are equally applicable to this work. Glenn I. Cohen, Patients with Passports: Medical Tourism, Law and Ethics (Oxford University Press, 2015).
5 Nancy Wonders and Raymond Michalowski provide an interesting parallel analysis of ‘sex tourism’, its definition, and its impact in two very distinct contexts. Nancy Wonders and Raymond Michalowski, ‘Bodies, Borders, and Sex Tourism in a Globalized World: A Tale of Two Cities—Amsterdam and Havana’ (November 2001) 48(4) Social Problems 545–71.
6 Seth F. Kreimer, ‘ “But Whoever Treasures Freedom . . .”: The Right to Travel and Extraterritorial Abortions’ (1993) 91(5) Michigan L. Rev. 907–38.
7 Reproductive tourism is probably the one that has more directly considered issues of global justice in relation to its existence and justification. This work can certainly benefit from some of the progress that the discussion has made in the past few years. See among others: Anne Donchin, ‘Reproductive Tourism and the Quest for Global Gender Justice’ (2010) 24(7) Bioethics 323–32; Guido Pennings, ‘Reproductive Tourism as Moral Pluralism in Motion’ (2002) 28(6) JME 337; Lauren Jade Martin, Reproductive Tourism in the United States: Creating Family in the Mother Country (Routledge, 2014).
8 It should be noted that, of all the terms created to describe this phenomenon, ‘death tourism’ is the one that—although extremely accurate—suffers the most from a ‘definition overlap’ with other areas of research, particularly that concerning the kind of tourism related to visiting macabre places such as Auschwitz and Hiroshima. See for example: Brigitte Sion, Death Tourism: Disaster Sites as Recreational Landscape (Seagull Books, 2013).
9 As a definitive terminology has not been agreed upon, other definitions are possible and commonly in use. For example, in his insightful article, Richard Huxtable opted for the definition ‘suicide tourism’. This book follows this definition and discusses it in more detail in the next few chapters. Clearly each definition carries with it some unique undertones, but for reason of space they cannot all be included here. Most notably, however, Huxtable’s work is interesting for taking into account the role of the only individuals who might pay some personal price in cases of ‘death tourism’, namely those accompanying the person into the country. Richard Huxtable, ‘The Suicide Tourist Trap: Compromise Across Boundaries’ (2009) 6 Journal of Bioethical Inquiry 327 (hereafter: ‘Huxtable, Suicide Tourism’).
‘dark tourism’, referring to the act of visiting sites associated with death.10
Since ancient times people have travelled to die outside their country. The idea of the pilgrim or Hajj meeting their end or preparing for their death while engaging in sacred journeys is well documented.11 Modernity has brought about other scenarios, in which people travel to another country to commit suicide. One such example involves people who live outside the city of New York but who travel to the city to make use of, for example, the George Washington Bridge or Empire State Building to commit suicide.12 To use Richard Huxtable’s definition more generally, suicide tourism involves ‘travel by a suicidal individual from one jurisdiction to another, in which s/he will (or is expected to) be assisted in their suicide by some other person/s’.13
Miller and Gonzalez offer four characteristics for death tourism more generally that explain why people seek such services. These characteristics also apply to suicide tourism: (1) the procedures may be illegal in their home countries;14 (2) they wish to take care of unfinished business in their personal life or the business of ending their lives; (3) they seek an ultimate solution—not a medical fix to prolong or improve the quality of life; or (4) they seek the ideal of the ‘death with dignity’, where the deathbed is a notion of a death free from pain and suffering.15
10 Julie S. Tinson, Michael A.J. Saren, and Bridget E. Roth, ‘Exploring the Role of Dark Tourism in the Creation of National Identity of Young Americans’ (2015) 31(7-8) Journal of Marketing Management 856.
11 ERASMUS, ‘Death and Pilgrimage: The Spectre of Death Has Always Loomed over Sacred Journeys’, The Economist (25 September 2015) https://www.economist.com/erasmus/2015/09/ 25/the-spectre-of-death-has-always-loomed-over-sacred-journeys, accessed on 7 June 2018.
12 Sewell Chan, ‘Study Examines “Suicide Tourism” in New York City’ (1 November, 2007) https:// cityroom.blogs.nytimes.com/ 2007/ 11/ 01/ study- examines- suicide- tourism- in- newyork-city/, accessed on 28 May 2018.
13 Huxtable, Suicide Tourism (n 9) at 328. A complementary definition of ‘assisted suicide tourism’ refers to helping the suicidal individual to travel from one jurisdiction to another in order for them to be assisted in their suicide.
14 More generally, travel for services that are illegal in the patient’s home country is called ‘circumvention tourism’ by Glenn Cohen because the person is circumventing the prohibition on accessing that service in her own country. See Glenn Cohen, ‘Circumvention Tourism’ (2012) 97 Cornell L. Rev. 1309.
15 Shondell Miller and Christopher Gonzalez, ‘When Death is the Destination: The Business of Death Tourism Despite Legal and Social Implication’ (2013) 7(3) International Journal of Culture, Tourism, and Hospitality Research 293 at 295. As for the fourth characteristic, the commercial tagline of the Swiss assisted-suicide organization, Dignitas, is ‘Live with Dignity, Die with Dignity’. There also exists a practice of ‘reverse suicide tourism’ by which physicians travel outside their own country to provide aid in dying in countries where assisted suicide is legal when local doctors are unable to provide such aid. The Netherlands was once such a destination.
Moreover, Suzanne Ost highlights three major psycho-emotional needs that suicide tourism corresponds to. First, it makes the assisted death feel less medicalized and less clinical, thereby making it a less tense affair; second, it may reassure the traveller that her relatives approve of her decision, or at least that they are at peace with it; third, it provides the emotional support that relatives provide to the traveller.16 It follows that suicide tourism offers a ‘better death’ for the person involved by having accompanying persons close to the experience of death as much as possible.
As can be deduced from its name, suicide tourism has a unique characteristic: the tourist does not come back home to describe their visit to the country. In fact, the ‘tourist’ does not come back at all. Indeed, the prevailing response of people who participated in the research for this book is repulsion at its title. Following this line of thought, it is argued that travelling to end one’s own life does not constitute a form of medical tourism—or other form of tourism—since that involves selling ‘luxury’ and wellness along with surgery, promoted not only by the healthcare industry but also by the business development and tourism councils.17 Another similar argument holds that travelling for assisted suicide is instead the antithesis of medical and health tourism, offering, as it does, physical and psychological escape without any perceptible rewards, thereby departing from the true recreational and leisure aspects of tourism.18 It also seems that the title ‘suicide tourism’ was first introduced in the media, referring to stories of individuals who travelled to Switzerland for assisted suicide, and was later incorporated in the academic literature review. So why would we be tempted to define this journey as tourism in the first place?
One can argue that there are a few characteristics that make the travel to another country to receive aid in dying, resulting in an act
Rohith Srinivas, ‘Exploring the Potential for American Death Tourism’ (2009) 91 Mich St. J. Med & Law 91 at 104.
16 Suzanne Ost, ‘The De-Medicalization of Assisted Dying: Is a Less Medicalized Model the Way Forward?’ (unpublished paper) http://eprints.lancs.ac.uk/34628/1/Ost_Demedicalisation_ of_Assisted_Death_FINAL.pdf
17 Glenn Cohen, Patients with Passports (Oxford University Press, 2015), pp. 315–18.
18 Gregory Higginbotham, ‘Assisted-Suicide Tourism: Is It Tourism? (2011) 6(2) Turismos: An International Multidisciplinary Journal of Tourism 177.
of suicide, a form of tourism. First, like other forms of tourism, death tourism or suicide tourism is a practice that is limited in time and usually does not repeat itself. Second, such a practice involves and is shaped by market forces. It creates its own demand and supply and is usually associated with monetary exchange. Third, the travel for aid in dying consists of a dimension of exploitation of some kind; one can argue that modern travel from one place to another is a form of exploitation from an environmental perspective as, with its related carbon emissions, it is a threat and represents an ‘unnatural’ exploitation of the territory.19
There are, however, more specific elements of exploitation in suicide tourism. While in medical tourism the tourist exploits the health resources of another country, and in sex tourism the exploitation of women and children is at stake,20 in suicide tourism, the visitor exploits the permissive law of country X as a way of escaping pain and suffering or promoting a wish to die,21 and the companies running the business related to assisted suicide exploit the tourist’s need and desire to accomplish such a goal. There may be other reasons for travel; a shortage of participating physicians who could prescribe the lethal drug even in places where assisted suicide is legal22 or a personal wish to end one’s life at a distance can also serve as motivations for suicide tourism.
A necessary but, in and of itself, insufficient condition for suicide tourism to take place is that assisted suicide be legal within the country to which the death tourist travels. Yet, suicide tourism can also take place within a federal country in which only some of the states or provinces include permissive laws on assisted suicide. The American case is a useful example here.
19 Simon Caney, ‘Cosmopolitan Justice, Rights and Global Climate Change’ (July 2006) XIX(2) Canadian Journal of Law and Jurisprudence 255–78.
20 Karen D. Breckenridge, ‘Justice beyond Borders: A Comparison between Australian and U.S. Child-Sex Tourism’ (2004) 13(2) Pacific Rim Law & Policy Journal 405–38.
21 Although, as argued by Richard Huxtable, tourism could occur between two permissive jurisdictions, or between prohibitive jurisdictions. It is anticipated that such scenarios are less likely in the case of suicide tourism. Huxtable, Suicide Tourism (n 9) at 328.
22 Paula Span, ‘Physician Aid in Dying Gains Acceptance in the US’, New York Times (16 January 2017) https://www.nytimes.com/2017/01/16/health/physician-aid-in-dying.html?smid=pl-share, accessed on 7 June 2018.
Domestic
suicide tourism in the United States
As will be discussed in the following chapters, the states in the US that have a legal option for physician-assisted suicide, even if not as internationally oriented as Switzerland, do represent one form of suicide tourism, that is, intra-state suicide tourism. While allowing, in principle, assisted suicide only to residents of the given states, US citizens from other states can relatively easy overcome this restriction. For example, in Oregon, in little more than 6 months a person can become eligible for residency status by leasing a property.23 In Washington State, the procedure seems even less problematic for those able to afford to buy a property in the state, as this would suffice to ensure residency.24 In Vermont, the definition of ‘Vermont resident’ leaves room even for an international audience, as a driving licence25 could be considered enough to fulfil the requirements of the legislation dealing with the issue.26
Indeed, media reports refer to some stories where terminally ill patients travelled from one US state to one of these other states to receive a prescription for a lethal drug. For example, Brittany Maynard, a 29year-old who suffered from glioblastoma, a deadly form of brain cancer, travelled from San Francisco, California to Oregon to take advantage of Oregon’s Death with Dignity Law. Maynard chose her date of death in advance and died on 1 November 2014 at the home she rented in Portland, surrounded by her friends and family.27 It is believed that her
23 The Oregon Death with Dignity Act, Oregon Revised Statutes, 127.860 §3.10. p.6. Available at: http://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/ DeathwithDignityAct/Documents/statute.pdf.
24 Washington State Department of Health, ‘Death with Dignity Act: Frequently Asked Questions’ https://www.doh.wa.gov/YouandYourFamily/IllnessandDisease/DeathwithDignityAct/ FrequentlyAskedQuestions, accessed on 28 November 2018.
25 It is important to note that the Department of Motor Vehicles in fact states: ‘In order to apply for a Vermont Driver’s License you will need proof that you are . . a Visiting Citizen of a Foreign Country with an authorized duration of stay with at least 30 days remaining’ (emphasis added). Available at: http://dmv.vermont.gov/licenses/drivers/newresidents.
26 No. 39. An act relating to patient choice and control at end of life. Available at: http://www. procon.org/sourcefiles/ACT039_Vermont_Death_with_dignity.pdf.
27 The Brittany Maynard Fund. Available at: http://thebrittanyfund.org/about/; Ashley Collman and Sophie J. Evans, ‘She Was Asleep in Five Minutes and Died in 30: Brittany Maynard’s Widower Describes Cancer-Stricken Wife’s “Peaceful” Final Minutes after Taking Drug to End Her Life’ (MailOnline, 14 January 2015) http://www.dailymail.co.uk/news/article2910111/ It- peaceful- experience- Brittany- Maynard- s- widower- describes- cancer- strickenwife-s-final-moments-taking-drug-end-life.html
case promoted public debate which led, more recently, to legalization of assisted suicide in California.
There is no doubt that this kind of internal suicide tourism underlines the problems of restricting such a practice to a specific group of people based on their geographical location or residency. After all, if we allow a citizen from the state of New York to move freely, start a business, buy a property, and take vacations in any of the other forty-nine states (enjoying the specific advantages—be it the climate or the taxation system—of that state), why should we place restrictions on one’s choice of place to die?
Notably, the fear of intra-state suicide tourism is also present in other contexts, such as Australia and Canada where new assisted-suicide laws have been proposed or passed.28 This worry might be legitimate only if we assume assisted suicide is a negative and unacceptable practice that should be totally prohibited. However, as many polls have started to suggest, public opinion in Europe, for example, is far from having such a straightforward view of the possibility to autonomously decide how and when to put an end to our lives.29 On the contrary, and as the next chapter demonstrates, there appears to be a gradual understanding that the medical advances that can keep us alive for longer do not necessarily represent a standard choice to be made under any circumstances. The principle of being able to make decisions about one’s own life (for good or bad) according to one’s preferences is so much in line with the liberal values of Western democracies that the argument for allowing all citizens of the world to be granted that option sits at the very core of the moral arguments for suicide tourism, as elaborated in Chapter 3 and as exercised,
28 After a period in which the Northern Territory allowed the performance of physicianassisted suicide, Tasmania looked at the option for a long time, but eventually in October 2013 the Bill did not pass with 13 votes against and 11 in favour. The proposal encountered a number of criticisms, with one of the fiercest ones based on the internal migration of elderly people that such a change would bring within Australia. See for example: http://www. lifesitenews.com/ news/ tasmanian- euthanasia- and- assisted- suicide- bill- to- be- debated- thisweek and http://www.news.com.au/national/tasmania-bill-to-make-euthanasia-legal-couldlead-to-8216death-tourism8217/story-fncynjr2-1226729824901. For Canada see Parliament of Canada, Medical Assistance in Dying: A Patient-Centered Approach—Report of the Special Joint Committee on Physician-Assisted Dying (Chairs: Kelvin Kenneth Ogilvie and Robert Oliphant) (Parliament of Canada, 2016) p. 24 and the discussion in Chapter 5.
29 Joachim Cohen, Paul Van Landeghem, Nico Carpentier, and Luc Deliens, ‘Different Trends in Euthanasia Acceptance across Europe: A Study of 13 Western and 10 Central and Eastern European Countries’ (2013) 23(3) European Journal of Public Health 378; Joachim Cohen, PaulVan Landeghem, Nico Carpentier, and Luc Deliens, ‘Public Acceptance of Euthanasia in Europe: A Survey Study in 47 Countries’ (2014) 59(1) International Journal of Public Health 143.
for example, by the Swiss right-to-die organizations discussed in the next chapter.
Suicide tourism and vulnerability
The freedom of movement of people who seek assisted suicide in another federal state or another country, supported by their rights to die with dignity and to promote quality of life, is a crucial element of the relationship between suicide tourism and global justice. As the next chapter observes, some critics argue that organizations such as Dignitas (which offer aid in dying to foreigners) draw in clients in ways that justify moral condemnation and perhaps also some legal restrictions. Others, however, may view their activities and the existence of the opportunity to use their services as a ray of light for all those individuals wishing to choose their life’s path—including its ending.
The political and moral charge made about the distinction between assisted suicide—a practice by which the person ends her own life autonomously and voluntary—and non-voluntary euthanasia—where a person's life is taken from her whether in action or omission by another, usually a physician—is certainly worthy of attention. The same applies to the challenge that such a distinction has received from various other angles, underlining the intrinsic complexity of establishing the existence of such a counter-intuitive choice in individualistic terms.
30
However, it is necessary to point out that certain countries have created several scenarios that need to be addressed by the global community if a convincing policy on the topic is to come about. In 2008, a few reports31 sparked by The Peaceful Pill Handbook by Philip Nitschke32 the founder of Exit International, an Australian organization that aims to help people terminate their lives, and principal supporter of the brief period of legal
30 Byron J. Stoyles and Sorin Costreie, ‘Rethinking Voluntary Euthanasia’ (2013) 38 Journal of Medicine and Philosophy 674.
31 See, for example, Marc Lacey, ‘In Tijuana, a Market for Death in a Bottle’, New York Times (21 July 2008) http://www.nytimes.com/2008/07/21/world/americas/21tijuana.html?pagewanted=all&_ r=1&, accessed on 7 June 2018 (hereafter: ‘Lacey, In Tijuana’).
32 Phillip Nitschke and Fiona Stewart, The Peaceful Pill Handbook (Exit International Publishing Ltd, 2007).
physician-assisted suicide in the Northern Territory—investigated the ease with which citizens from anglophone countries (mainly Australia, but also New Zealand and the US) were able to purchase barbiturates in pet shops in Mexico. These cases involved substances that could cause death within seconds and yet were obtainable without any paperwork to complete or any monitoring system to report to.33 Cases in other parts of the world also raise similar concerns. As discussed in the next chapter, although it would be difficult to receive assisted suicide in Belgium or the Netherlands by travelling to these countries, suicide tourism in these destinations cannot be excluded since there is no formal requirement of residency, and reporting requirements in cases of assisted suicide, at least in Belgium, is believed to be more lenient.34
Interestingly then, it seems that the main distinction between the selling of barbiturates in Mexico and offering aid in dying to foreigners in Switzerland is to be found in the absence or not of clinics and personnel, such as those of Dignitas or LifeCircle in the latter context, namely in the institutionalization of suicide tourism in Switzerland. However, one important aspect that is always raised with regard to euthanasia and assisted suicide should be considered: the potential discrimination against and possible abuse of disabled or particularly vulnerable people. As mentioned, the cocktail of barbiturates available in Mexico does not differ much (if at all) from the services provided through rightto-die organizations in Switzerland. Being part of a recognized—albeit, as this book explores, imperfect—system of assisted suicide, the rightto-die organizations in Switzerland have the power both to alleviate and to exploit the condition of the people requesting assistance with suicide. When the person is a non-resident and has no other alternative to fulfil her wish to die, her dependence on these (few) organizations may be high. This may lead, under some perhaps exceptional circumstances, to more cases of exploitation and in any event it must raise concerns at the policy and legal levels.
33 Susan D. James, ‘Tourists Trek to Mexico for “Death in a Bottle” ’ (ABC News, 31 July 2008) http://abcnews.go.com/Health/MindMoodNews/story?id=5481482, accessed on 7 June 2018; Lacey, In Tijuana (n 31).
In addressing the current global health situation, Salomon Benatar noted in a symposium on global health and the law that,
The most common response to the challenge of protecting health through law is to focus on protecting the rights of vulnerable individuals and to enhance their access to health care. Each one of us is vulnerable or potentially vulnerable because of the fragile, existential nature of the human condition.35
Undeniably, suicide tourism represents a particularly complicated issue to address, as it presents a tension between the two parts of the statement. On the one hand, there are no doubts that potential death tourists are especially vulnerable people, be it for physical, psychological, or social reasons, or a combination of these. On the other hand, however, it is not to be forgotten that it is part of our nature to be fragile, that is vulnerable, limited, mortal. To force upon us a longer life through artificial (i.e. iron lung) or semi-artificial (i.e. medicinal) devices, does not necessarily constitute a more humane and natural way of facing death. While the law attempts to represent the moral views of the majority and in many situations is the result of a political compromise, a legal and just system cannot be justified in its efforts to struggle with one’s wish to die. The respect of such a wish is beyond national borders, civil status, and political affiliation. It requires constant reflection and discussions within and among nations. Analysing the global practice of suicide tourism creates the path to establishing this.
35 Solomon R. Benatar, ‘Global Health, Vulnerable Populations, and Law’ (April 2013) 41(1) Journal of Law, Medicine and Ethics 42.
PART I
LEGAL ASPECTS OF SUICIDE TOURISM
1
The Status of Assisted Suicide
This book discusses the practice of suicide tourism, whereby people travel to countries or states to take advantage of permissive laws on assisted suicide that do not exist in their home countries or states. Assisted suicide is defined as an act where one or more persons, usually a physician, provides knowledge and/or material assistance to another person—most notably by providing instruction about lethal doses of drugs or prescribing such lethal doses—to enable that person to bring about her own death.1
Background
Assisted suicide should be distinguished from euthanasia, by which a person’s death is brought about directly by the actions or omissions of another person. Euthanasia can be passive, for example where life-saving support is withheld from a terminal patient (in terms of it not being renewed), or it can be active, where such support is withdrawn from her (and is deliberately stopped). In either case, there is a causal relationship between the action for which the medical profession is usually responsible and the death of the person; it is the direct killing of the euthanized patient either by the fulfilment of, or by refraining to fulfil, professional obligations to the patient. Whereas assisted suicide requires the actual self-killing of the person herself and so must always be voluntary,
1 The involvement of a physician in this act is usually referred to as physician-assisted suicide. In the literature there exists a debate as to whether the term ‘physician-assisted suicide’ is appropriate for such a practice. Other suggestions include ‘physician-assisted death’ or ‘physician aid in dying’. Ezekiel J. Emanuel, Bregje D. Onwuteaka-Phillipsen, John W. Urwin, and Joachim Cohen, ‘Attitudes and Practices of Euthanasia and Physician-Assisted Suicide in the United States, Canada, and Europe’ (2016) 316(1) JAMA 79 (hereafter: ‘Emanuel et al., Attitudes and Practices’). Some physicians who merely prescribe a lethal drug to a patient do not feel they assist in their dying. Rather, they view themselves as facilitators. See Browne C. Lewis, ‘A Graceful Exit: Redefining Terminal to Expand the Availability of Physician-Facilitated Suicide’ (2012) 91 Oregon L. Rev. 457–94 at 460 (hereafter: ‘Lewis, Graceful Exit’).
