(10-Minute Read) Before reading this Article it would be a nice idea to skim a brief history of assisted suicide– Here.
FYI: This post includes links to definitions of some technical Philosophy vocab. The links will open in a new window so you do not have to lose your reading place in order to view them. Feel free to ignore them if you’d like, they’re not necessary for this piece to be engaging.
Physician Assisted Suicide (PAS) remains illegal in 46 states, while 41 of those states have gone as far as to make it a crime to assist in the death of an individual. However, recent legislations are calling for a reformation to protect the autonomy of those who are classified as terminally ill. Currently, Oregon, Washington, Vermont and California (effective June of 2016) are the only states that legally allow for patients to choose suicide as a method to end the suffering associated with terminal illness. The specific qualifications of the law require a mentally competent individual to make two requests 15 days apart, and a third written request. Further, the individual’s attending physician(s), who must be willing to prescribe the lethal pills, as well as one family member all must be present at the time of the request. In those states that currently have a ban on PAS, specifically Maryland as of Spring 2016, recent legislative proposals have raised the possibility of the future legalization of physician-assisted suicide. While the MD bill has since been withdrawn due to lack of support (as of March 2nd), other states still seem to be undecided and are contemplating the implications that the legalization of PAS might bring.
Those oppose its legalization argue that physician-assisted suicide should not even be an option, as it is an issue of morality rather than autonomy. Further arguments state that those who are poor or have disabilities might face abuse from the system with the implementation of an inexpensive lethal prescription as an option. Meanwhile, the strongest arguments in favor of physician-assisted suicide attempt to reverse the usurped autonomy of terminally ill individuals while also claiming that individuals should not be forced to live a life with no value.
While, I do question the moral implications of allowing any individual to take his or her own life, especially if actions such as these will lead to the exploitation of those who might just be facing the emotional trauma of illness, I still support the regulated allowance of physician-assisted suicide because it calls for transparency in the process and allows the patient to use the expression of the will.
Ira Byock, Physician and Direction of Palliative Care at Dartmouth-Hitchcock Medial Center, states,
“The admonition against killing other people is the bedrock of civilization. Our earliest ancestors decided to collaborate, protecting and looking after one another as an alternative to competition and individual conflict over resources.”
He commits a genetic fallacy here. In referring to the actions of our ancestors, even those which may have improved our future state of existence, I could also make an argument for the protection of slavery and genocide by stating that those who entered America and enslaved Africans and who murdered Natives, were actually doing good because it allowed for my relatives to eventually enter the US. He is using the origins of certain behaviors to justify decisions of the present day. While in some cases, this might make a good argument, I don’t think it serves as a strong enough reason to argue against physician-assisted suicide. Ira further argues,
“An obligation to protect and care for one another is an integral part of social compacts. Society exists in service of life, liberty and the pursuit of happiness. From its very inception, the profession of medicine has formally prohibited its members from using their special knowledge to cause death or harm to others. This was — and is — a necessary protection so that the power of medicine is not used against vulnerable people.”
By using the past practices of ancestors as a reason to prohibit physician-assisted suicide, Byock is appealing to tradition. Once again, doctors also used electric shock with devastatingly high levels and also performed frontal lobotomies in order to “cure” the mentally ill. By those means, an appeal to tradition would not make much sense here. However, looking at the statement in his argument it seems like Byock might be able to make a valid point. Taking just the first statement, “An obligation to protect and care for one another is an integral part of social compacts,” and forming it into a deductive argument with implied premises and all, it seems to argue:
Society has an obligation to protect and care for one another, and this obligation should be considered part of a social compact. If an action violates society’s obligation to protect and care for one another, then said action is not a part of the social compact. If an action is not part of the social compact, then it should not be legal. If an act leads to the death of an innocent human being, then that human is not being cared for and protected, and it cannot be considered part of the societal compact. Physician-assisted suicide is an act involving the death of an innocent human, it violates society’s obligation to care for and protect one another, and it cannot be considered a part of the social compact. Therefore, Physician-assisted suicide should not be legal.
Making an argument regarding morality requires extensive reasoning which is what Byock seems to be doing. The looming question is whether or not an individual’s autonomy can ever presuppose a possible moral obligation to live? Is there a moral obligation to live despite all circumstances of suffering? I will attempt to explore the answers to these questions a bit later.
Byock also states,”As a palliative medicine specialist, I know from years of experience that it is possible to alleviate pain and other physical suffering and enable patients to die gently.” In contrast, Lewis Cohen a professor of psychiatry at Tufts University School of Medicine, states,
“Medication such as morphine can help the terminally ill manage pain, but it can’t ameliorate their agony at no longer being the same people that they were before the illness…It is time that we confront the taboo of death with dignity and openly debate the legitimacy of our laws around the issue and the actions of groups like Compassion and Choices and the Final Exit Network… I no longer think that these should remain confidential matters ungoverned by legislation without explicit built-in safeguards.”
Cohen makes a strong argument calling for improved safeguards in the dying process. Those who qualify for PAS may feel that they have the right to ask for such an action, but if they are facing psychological issues, should they still follow through with the task? This sort of thing happened when the Final Exit Network helped Jana Van Voorhis, a mentally ill woman, commit suicide by breathing in helium,“In Final Exit Network, decisions about who will be accepted into the group’s Exit Guide program are made not by an individual’s doctor, but by a physician with whom the person, in most cases, has never spoken or met.” Further, the Final Exit Network claims on their website,
We hold that mentally competent adults who suffer from a fatal or irreversible physical illness, from intractable physical pain, or from a constellation of chronic, progressive physical disabilities have a basic human right to choose to end their lives when they judge the quality of their life to be unacceptable.
I would consider the Final Exit Network to be an example of an organization which takes advantage of the law by giving ambiguous reasons for an individual to commit suicide. This is another reason that there needs to be a national, open discussion on PAS— the law needs to be addressed, not hidden. Moreover, safeguards for those with mental suffering need to be addressed. Those who have disabilities and mental illness will be affected by this law more than the general population simply because they have changing views on their qualities of life. In fact, I don’t think that quality of life should be a deciding factor in PAS. The idea of the quality of life is too vague. In addition, this standard for a quality of life places pressure on those who are severely disabled or ill, who may not want to die, but who feel as though they are a burden to family or to society. Even those who only have six months to live may feel pressure to use the suicide prescription. Looking at Oregon 2015 Statistics, only 52 of the 1000 people who were aided in suicide were psychiatrically evaluated. This number needs to change. I think revising these laws with an additional level of psychiatric evaluation for one month would be more beneficial to the patient at the time of his or her death.
One doctor from Peninsula Regional Medical Center pointed out the fact that a substantial amount of money would be saved in the legalization of PAS. However, I don’t think that money should be a deciding factor in dictating the legalization of this kind of law. I think the fact that it’s a lot less expensive to prescribe a patient lethal medication is a reason not to allow PAS. Looking at the 2008 case of Oregon resident, Barbara Wagner gives the exact reasoning behind this possible reason.
The Oregon Health Plan office refused to pay $4,000 per month because it wasn’t within its narrow guidelines of appropriate treatment. But it did offer to pay $50 for lethal prescription drugs to end her life. Wagner told the local newspaper: “To say to someone, ‘we’ll pay for you to die, but not pay for you to live,’ it’s cruel.” Yes, everyone deserves a death with dignity. But physician-assisted suicide—which could put undue pressure on the poor, the lonely, and the excluded—isn’t the way to achieve this. Focusing on expanding access to health care for every American at the end of their lives would be the progressive thing to do.
Now, only using this one case to completely ban any legalization of physician-assisted suicide would be a hasty generalization, but I think the fact that this occurred does show that the law has the potential for at least one detrimental shortcoming. Moreover, California, a state which recently legalized PAS, has 12 million individuals using Medicaid. It is a possibility that this same situation will happen to them if they seek expensive treatment options for any kind of illness classified as terminal. Looking at the overall statistics for those who chose to opt for PAS in Oregon about 30 of 1000 people (3%) were concerned about the inability to pay for treatment. If PAS become a nationally passed law, there should also be a law enacted to give individuals the proper treatment despite its financial burden. A sick person should never feel trapped by lack of money to pay for treatment; if a person possesses the right to end his/her life with dignity, do not allow for the choice to be forced by lack of affordability of treatment.
Further favoring the legalization of PAS are those who acknowledge that PAS already occurs in secrecy. They argue that legalizing PAS will force the issue into transparency and further regulation, thus providing patients with a wider variety of support and options during the period before their death. They believe that an individual who feels that his or her life is not worth living in the conditions that characterize terminal illness should have the ability to end his or her pain as an affirmation of autonomy even in suffering. The argument, although leaning towards an emotional appeal, is strong one. Death is naturally an emotional thing, so to use a complete lack of emotion in discussing the topic might cause a desensitization when regarding the patient’s feelings. States that have legalized PAS allow for patients to choose medically assisted options rather than choosing strange organizations such as The Final Exit Network who are not held to the same rules as hospitals with insurance.
I recently spoke with Dr. Francis Kane of PR Medical Center, who taught medical ethics for 40 years, about the issue of physician suicide. He pointed out the case of Elizabeth Bouvia, a handicapped woman who wanted aid in committing suicide by starving herself. Dr. Kane uses this case as a useful example to argue that autonomy is not a sufficient reason for individuals to allow the assistance of suicide. He states, “The key I think is that the argument is not just about individual rights but about the moral assessment a community makes when it passes a law. And that applies to professions too.” He recognizes that a patient seeking out assistance in suicide requires active participation from the public sphere (medical professionals and acceptance of public law). He additionally marks that there is a difference between actively prescribing lethal medication and allowing a patient to be killed by his or her illness. A patient can deny treatment, but should the patient be able to require the compliance of the public in his or her death by nonnatural causes? Dr. Kane states that it would not be reasonable to require that medical professionals deny their morals in order to uphold a law allowing patient’s to kill themselves with the aid of a physician. In a 1983 essay, he calls this an inescapable horned dilemma. While he continues on to recognize that the doctors and nurses have the ability to deny such an action, he questions the future actions of a court of law if a patient is unable to find a doctor to prescribe the dose, “Would not the courts be forced into mandating, under legal penalties, that these reluctant professionals comply with her wishes?” Dr. Kane also makes an argument by analogy by comparing the legalization of PAS to a possible consideration of allowing individuals to enslave themselves to another person. He points that,
“The universal quality of a right supersedes the individual expression; so, for example, selling oneself into slavery is forbidden, for that would be precisely the alienation of the inalienable right to liberty… If life is valued, then every life must be valued, even one’s own.”
Dr. Kane argues for the notion of a public good that supersedes considerations of autonomy in the case of assisting actions that would lead to the suicide of an individual. Dr. Kane makes a strong point, but I still question whether or not there are cases in which allowing an individual to die 6 months early due to avoidance of suffering can be morally plausible. Further, there are some differences in Dr. Kane’s analogy and the true concept of PAS. Enslaving oneself is an action that can be undone (even if by force of the law). Committing suicide is irreversible, there is no way to bring someone back to life after taking a permanent, death-inducing pill.
However, the individuals who are granted the ability to take a lethal prescription are competent, very ill and suffering. Would it be ethical for us, as a free society, to watch an individual suffer for the sake of our greater good? I am just not sure that I can agree to this. However, if I knew that it was possible to subdue the individual’s pain level, then I would agree that assisted-suicide is not necessary. Once again, though, how can I tell someone that they must sit in a vegetative state while on a morphine drip, and perhaps dozens of other medications, in order to promote the better good of a society which does not have to experience the mental and physical turmoil of terminal illness?
In conclusion, in the cases of terminally ill and competent patients, the individual should possess the right to assistance in ending his/her life. However, I think the current legislation of those states which have already legalized physician-assisted suicide have not made measures strict enough. In order to protect those who may be choosing PAS out of fear, pressure or mental illness, it is imperative that legislators protect all individuals by enacting at least one month of psychiatric evaluation before requesting PAS, a promise of dedicated treatment practices for individuals despite financial and physical circumstances– and finally legislators must pass laws making any unregulated and uncertified organizations, w assist in others’ deaths, criminal offenders.
Author: R.Lederman. May 9, 2016.
Copyright 2016-Present. Please cite author and site in any use of this essay. Thank You.
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Joyce, Jaime. “Kill Me Now.” Thebigroundtable.com. The Big Round Table, 27 Dec. 2013. Web. 2 May 2016.
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Oregon Health Division, comp. “Death with Dignity Act.” SpringerReference (2015): 1-7. Oregon Death With Dignity Act 2015 Data Summary. Oregon Public Health Division, 4 Feb. 2016. Web. 8 May 2016.
Raskin, Guzzone, Kagan, Astle, Currie, Feldman, Gladden, Kelly, King, Madaleno, Manno, and Pinsky. “Richard E. Israel and Roger “Pip” Moyer End–of–Life Option Act.” Comp. Young. Sent Bill 418 404th ser. CF.HB (2016): 1-22. Http://mgaleg.maryland.gov/2016RS/bills/sb/sb0418f.pdf. MD Senate, 1 Feb. 2016. Web. 4 May 2016.
Anderson, Ryan T. “Always Care, Never Kill: How Physician-Assisted Suicide Endangers the Weak, Corrupts Medicine, Compromises the Family, and Violates Human Dignity and Equality.” The Heritage Foundation. Heritage.org, 24 Mar. 2015. Web. 09 May 2016.
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 Breslow, 2012
 Aliferis, 2016
 Senate Bill 418
 Cox, 2015
 Hale, 2016
 Biller-Andorno, 2013
 Benjamin as qtd. in Cazeuax, 2011
 Byock as qtd. by Breslow, 2012
 Cohen as qtd. in Breslow, 2012
 Joyce, 2013
 Argument via Mattlin as qtd. in Breslow, 2012
 Oregon Health Division, 2015
 Oregon 2015 Statistics on Physician-Assisted Suicide
 Hale, 2015
 University of Washington School of Medicine, 2013
 Joyce, 2013
 Kane, 1983
 Kane, 1983