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SAMJ: South African Medical Journal

versión On-line ISSN 2078-5135
versión impresa ISSN 0256-9574

SAMJ, S. Afr. med. j. vol.105 no.7 Pretoria jul. 2015 



Legal assisted suicide in South Africa



To the Editor: Following the Stransham-Ford case in the Pretoria High Court, the South African Medical Association (SAMA) has stated clearly that it does not support the right to die in law, and opposes euthanasia and doctor-assisted suicide in line with the Health Professions Council of South Africa's policies and the World Medical Association's guidelines and codes on the subject. Yet this is an emotive issue, and this letter is written in the hope of clarifying the issues that are at stake in South Africa (SA) for the sake of those who do not agree with SAMA.

Dan Nciyayana, Editor of the SAMJ at the time, wrote an editorial about this in 2012.[1] He concluded that SA is not a safe place for liberalised voluntary euthanasia legislation. His reasons were as follows: 'Euthanasia - a recourse of last resort - can only really be justified in a country with the very best medical care for all, a well-organised and universally accessible palliative care and support system, stable and well-functioning (particularly judicial) institutions, and a strong culture of respect for human life. In SA, with its "severe constraints on health care facilities and the totally inadequate allocation of resources for highly effective medical treatments"[2] [reference 4 in the editorial], there is a real risk of euthanasia becoming a substitute for proper care for the terminally ill and other patients in dire medical straits. Even more damning for SA is the pervasive lack of an ethos of respect for human life. We are an extraordinarily violent society, with over 45 murders committed daily and interpersonal violence the second highest cause of death. Mob justice, police brutality and xenophobia abound. Needless deaths occur regularly in our hospitals through staff neglect and indifference. Health care providers think nothing of downing tools and walking off, abandoning critically ill patients, or of blocking ambulances with critical emergencies from entering health facilities during labour disputes.'

Nciyiyana's words take on fresh meaning when read with those of Prof. Theo Boer, the medical ethicist who was part of the committee that motivated for, and regulated, euthanasia in The Netherlands. In 2007 he wrote: 'There doesn't need to be a "slippery slope" when it comes to euthanasia. A good euthanasia law, in combination with the euthanasia review procedure, provides the warrants for a stable and relatively low number of cases.' Most of his colleagues drew the same conclusion. 'But', he wrote in 2014 in a public appeal to the British House of Lords, 'we were wrong, terribly wrong'.[3] He then describes the rapid escalation in the numbers of assisted suicides, to the point that 'Euthanasia is on the way to become a "default" mode of dying for cancer patients.' He laments that the Dutch Right to Die Society (NVVE) has founded a network of travelling euthanising doctors who have no established relationship with the patients, very limited background information on them, and offer only two options: administer life-ending drugs or send the patient away. 'The NVVE shows no signs of being satisfied even with these developments. They will not rest until a lethal pill is made available to anyone over 70 years who wishes to die. Some slippery slopes are truly slippery.'

There has been a rapid shift in the type of patients being killed in Holland since 2008. In the beginning, euthanasia was offered only to terminally ill patients with severe pain or suffering. Now a rising number of psychiatric patients, especially those who are depressed and those with dementia, and many people who are simply lonely, aged or bereaved, are offered assisted suicide. 'Whereas the law sees assisted suicide and euthanasia as an exception, public opinion is shifting towards considering them rights, with corresponding duties on doctors to act. A law that is now in the making obliges doctors who refuse to administer euthanasia to refer their patients to a "willing" colleague. Not even the Review Committees, despite hard and conscientious work, have been able to halt these developments.'

He ends his article: 'I used to be a supporter of the legislation. But now, with 12 years of experience, I take a different view. At the very least, wait for an honest and intellectually satisfying analysis of the reasons behind the explosive increase in the numbers. Is it because the law should have had better safeguards? Or is it because the mere existence of such a law is an invitation to see assisted suicide and euthanasia as a normality instead of a last resort? Before those questions are answered, don't go there. Once the genie is out of the bottle, it is not likely to ever go back in again.'

The case against legalising assisted dying in SA gets stronger when one reads the responses to the BMJ editorial[4] advocating for it to be made available in the British Isles. For instance, Rob George, Professor of Palliative Care, Cecily Saunders Institute, King's College Hospital, argues that 'the safety of vulnerable people must take priority over the determined wishes of individuals'.[5] 'For me the real question is this: "Which is worse: not to kill people who want to die or to kill people who might want still to live?" In my experience it is impossible to separate those who might want to die from those who believe they ought to die and whose view is pretty well never "settled." No one can be sure that some people, not now at risk, will find themselves [to be] so were the law to change. A full blooded expression of autonomy includes the responsibility at times to restrain oneself on behalf of another. When it comes to having our lives ended, let's keep it that way. Once this line is crossed there is no going back.'

Wager et al.[6] report that although assisted suicide (not by physicians) for altruistic reasons has been legal in Switzerland since 1918, it is only now that the consequences for other family members are being recognised. They report: 'Witnessing the unnatural death of a significant person has a strong impact on the bereaved, which may lead to severe mental health problems at 14 to 24 months post loss.' They observed a 20% incidence of developed or partial post-traumatic stress disorder. Other studies show that such illness is associated with 'suicide contagion',[7] which mostly affects teenagers and young adults.

There is evidence that interventions such as legislating liberal access to abortion in developing countries result in an increase rather than a decrease in maternal deaths, because of the factors detailed by Ncayiyana. [1] It is also relevant to point out that >80% of the SA population do not have a culture based on the idea of autonomous individuality. Our nation has large cultural groups which have a strong sense that the value of the individual is found in community (cf. the Zulu idiom A person is a person because of people'). They do not hold to a Western view of the importance of individual autonomy, and therefore they value security and family/clan decision-making above autonomy. It is very likely that the introduction of medical assisted suicide in these communities in particular will affect their security. Violence is probable should any healthcare provider be considered to have disdained family and ancestor claims and taken the life of a clan member. Deaths from 'suicide contagion' are also likely to be very frequent in such extended families.

When put together, this evidence should warn us to be very careful how we interpret section 12 of the Bill of Rights in the SA Constitution.[8] It is commonly interpreted as favouring the dignity of the individual, but a careful reading shows that it balances two values, that of individual security and that of autonomy and dignity. In our circumstances, it is clear that the value of security trumps that of dignity. SAMA is therefore to be applauded for its stand as it associates itself with the April 2013 Resolution of the 194th WMA Council of the World Medical Association, which states:

  • The World Medical Association reaffirms its strong belief that euthanasia is in conflict with basic ethical principles of medical practice.
  • The World Medical Association strongly encourages all national medical associations and physicians to refrain from participating in euthanasia, even if national law allows it or decriminalises it under certain conditions.

J V Larsen

Howick, KwaZulu-Natal, South Africa



1. Ncayiyana D. Euthanasia: No dignity in death in the absence of an ethos of respect for human life. S Afr Med J 2012;102(6):334.         [ Links ]

2. Benatar SR. Dying and euthanasia. S Afr Med J 1992;82(1):35-38.         [ Links ]

3. Boer T. Assisted dying: Don't go there. Daily Mail (UK), 9 July 2014.         [ Links ]

4. Delmothe T, Snow R, Godlee F. Why assisted dying should become law in England and Wales. BMJ 2014;349:g4349. []        [ Links ]

5. George R. We must not deprive dying people of the most important protection. BMJ 2014;349:g4311 []        [ Links ]

6. Wager B, Muller J, Maecker A. Death by request in Switzerland: Posttraumatic stress disorder and complicated grief after witnessing assisted suicide. Eur Psychiatry 2012;27(7):542-546. []        [ Links ]

7. Velting DM, Gould S. Suicide contagion. In: Maris RW, Silverman MM, Canetto S, eds. Review of Suicidology. New York: Guilford Press, 1977:96-137.         [ Links ]

8. The Constitution of the Republic of South Africa, Act 108 of 1996: Chapter 2: 12.         [ Links ]

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