The reasons so many people support physician-assisted suicide - and why these reasons are not convincing.

AuthorKamisar, Yale

It would be hard to deny that there is a great deal of support in this country--and ever--growing support-for legalizing physician-assisted suicide (PAS). Why is this so? I believe there are a considerable number of reasons. In this article, I shall discuss five common reasons and explain why I do not find any of them convincing.

The Compelling Force of Heartrending Individual Cases

Many people, understandably, are greatly affected by the heart-wrenching facts of individual cases, e.g., a person enduring the last stages of ALS (Lou Gehrig's disease), who gasps: "I want ... I want ... to die." In this regard the media, quite possibly inadvertently, advances the cause of PAS.

A reporter often thinks that the way to provide in-depth coverage of the subject of assisted suicide and euthanasia is to provide a detailed account of a particular person suffering-from a particular disease and asking: "How can we deny this person the active intervention of another to bring about death?" Or "What would you want done if you were in this person's shoes?" But we should not let a compelling individual case blot out more general considerations. The issue is not simply what seems best for the individual who is the focal point of a news story, but what seems best for society as a whole.

Everyone interested in the subject of PAS and active voluntary euthanasia (AYE) has heard emotional stories about people suffering great pain and begging for someone to kill them or help them bring about their death. But people like Kathleen Foley, the Memorial Sloan-Kettering Cancer Center's renowned pain control expert, and Herbert Hendin, the American Suicide Foundation's executive director, can tell very moving stories, too--stories militating against the legalization of PAS and AVE. They can tell us how suicidal ideation and suicide requests commonly dissolve with adequate control of pain and other symptoms or how, for example, after much conversation with a caring physician, a suicidal patient--one who had become convinced that suicide or assisted suicide was his best option--changed his mind, how his desperation subsided, and how he used the remaining months of his life to become closer to his wife and parents.(1)

I can hear the cries of protest now. "Let terminally ill people (and perhaps others as well) obtain assistance in committing suicide if that is what they want. They're not bothering anybody else. Letting them determine the time and manner of their death won't affect anybody else."

But I am afraid it will. "We are not merely a collection of self-determining individuals;" "[w]e are connected to others in many different ways."(2) Therefore, PAS and AVE are social issues and matters of public policy.(3)

Suppose a healthy septuagenarian, who has struggled to overcome the hardships of poverty all his life, wants to assure that his two grandchildren have a better life than he did. So he decides he will sell his heart for $500,000 and arrange to have a trust fund established for his grandchildren. This does not strike me as an irrational or senseless act. But would "society" allow this transaction to take place? I think not. But why not? How can a prohibition against selling one's body parts be reconciled with the view that we have full autonomy over our lives and our bodies?

This article is being written at a time when the firmly established right to refuse or to terminate lifesaving medical treatment is being used as a launching pad for a right to PAS.(4) However, the issue of assisted suicide is ultimately resolved, it will reflect society's views about life and death, as did resolution of the debate over disconnecting the respirator and pulling the feeding tube.

Many want to believe--and loose talk about the "right to die" encourages them to do so--that the termination of life support for dying or seriously ill patients, a considerable number of whom are no longer competent, is merely an exercise of individual autonomy. But "[m]edical technology has forced the law to resolve questions concerning termination of medical treatment ... by making largely social decisions involving our attitudes toward life, and the ways in which society allocates resources best to preserve it and its quality."(5) That many of us prefer to believe that we have simply been deferring to personal autonomy is hardly surprising. On the one hand, confronting questions about the quality of life "worth" preserving is discomfiting, even frightening; on the other hand, individual autonomy is highly prized in our society.(6) But "this model of mere deference to individual wishes does not ring true in many `right to die' cases."(7)

Although I sometimes disagree strongly with Professor Charles Baron, a leading proponent of physician-assisted suicide,(8) I share his view that in many, probably most, persistent vegetative state cases "[w] hat actually drives death decisions ... is an objective test based an the convergence of `best interests' and economic criteria. [But] the extreme discomfort of making death decisions for other. people and our fear of the slippery slope ... lead us to pretend that we are merely complying (however reluctantly) with the wishes of the patient. The result in most states is mere lip service to substituted judgment."(9)

More generally, as Professor Donald Beschle has pointed out:

One way or the other, ... society will label certain types of decisions

about death as `right' and others as `wrong,' some as courageous and noble,

others as at least disappointing, possibly cowardly, or even disgraceful.

These social labels cannot fail to influence subsequent individual choices.

In addition, such attitudes can cause decision makers to interpret the

statements and actions of the individual patient in

ways that are at least problematic.(10)

The "right to die" is a catchy rallying cry, but here as elsewhere we should "turn up [our] collars against windy sloganeering, no matter from which direction it is blown."(11) The right to die focuses on what is only one aspect of a multi-dimensional problem. I think Seth Kreimer put it well when he summarized the "fearsome dilemma" presented by the assisted suicide issue as follows:

Forbidding [assisted suicide] leaves some citizens with the prospect of being

trapped in agony or indignity from which they could be delivered by a death

they desire. But permitting such assistance risks the unwilling or

manipulated death of the most vulnerable members of society, and the erosion

of the normative structure that encourages them, their families, and their

doctors to choose life.(12)

It is noteworthy, I believe, that although some members of the New York Task Force on Life and the Law regarded assisted suicide, and even active voluntary euthanasia, as "ethically acceptable" in exceptional cases,(13) all twenty-four members of the task force concluded that heartbreaking individual cases could not justify significant changes in current law and moral rules.(14) The realities of existing medical practice, observed the task force, "render legislation to legalize assisted suicide and euthanasia vulnerable to error and abuse for all members of society, not only for those who are disadvantaged."(15) "Constructing an ideal or `good' case is not sufficient for public policy," added the task force, "if it bears little relation to prevalent medical practice."(16)

John Arras, a philosopher and bioethicist who served on the task force that issued the aforementioned report on death and dying, recently disclosed that during his work on that project he was one of several members who recognized that in certain rare instances PAS or AVE "might constitute both a positive good and an important exercise of personal autonomy for the individual"--but who nevertheless balked at legalizing these practices "due to fears bearing on the social consequences of liberalization."(17) Professor Arras emphasized that whether we maintain the total prohibition against PAS and AVE or whether we lift the ban for certain groups, "there are bound to be victims."(18) He continued:

The victims of the current policy are easy to identify; they are on

the news, the talk shows, the documentaries, and often on Dr.

Kevorkian's roster of so-called `patients.' The victims of legalization,

by contrast, will be largely hidden from view: they will include the

clinically depressed 80-year-old man who could have lived for

another year of good quality if only he had been treated; the

50-year-old woman who asks for death because doctors in her

financially stretched HMO cannot/will not effectively treat her

unrelenting but mysterious pelvic pain; and perhaps eventually, if we

slide far enough down the slope, the uncommunicative stroke victim

whose distant children deem an earlier death a better death. Unlike

Dr. Kevorkian's `patients,, these victims will not get their pictures in

the paper, but they all will have faces and they will all be cheated of

good months or perhaps even years.(19)

Although Professor Arras and other members of the task force were deeply moved by the sufferings of some patients, they were ultimately convinced that these patients could not be given publicly sanctioned assistance in committing suicide without endangering a much larger number of vulnerable patients. Thus Arras and others who shared his views joined a report that focused not on the alleged immorality of assisted suicide and voluntary euthanasia, but on consequentialist arguments against these practices, such as the well-founded fear--considering "the pervasive failure of our health care system to treat pain and diagnose and treat depression"--that legalizing PAS and physician-administered voluntary euthanasia "would be profoundly dangerous for many individuals who are ill and vulnerable" (especially "those who are elderly, poor, socially disadvantaged, or without access to good medical care").(20)

The Notion That the Only Substantial Objections to Legalizing Assisted Suicide or...

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