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Why Physician-Assisted Suicide is Not Good Enough

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The political position in favor of a general right to suicide has few advocates; in terms of numbers, it is a rather extreme position. Much more common – common enough to be the majority in a few states – is support for a limited right to suicide for terminally ill people, with physicians as gatekeepers for that right.

I have often written on why restricting suicide rights to terminally ill people makes no ethical sense. But there is another major problem with “Death With Dignity” laws like that of Oregon and Washington: physicians are the gatekeepers to the right to suicide, taking control of death away from the individual. “Patients” must depend on physicians in order to be allowed to die. And enough physicians are refusing to “assist” that the right to suicide is empty of practical meaning.

It has been months since Washington’s Death With Dignity law passed, which allows a terminally ill person to access a prescription for a lethal drug. But the scheme requires the cooperation of doctors; and in areas outside Washington’s big cities, doctors simply aren’t cooperating, reports Kim Murphy in the Los Angeles Times (“In rural Washington state, law allows assisted suicide, but most doctors don’t,” May 7, 2009).

Personally affected by this injustice was Stephen Wallace, a victim of terminal pancreatic cancer. Wallace was unable to find a single physician in his area willing to make the lethal prescription at his request. From the article (emphasis mine throughout):

Cancer of the pancreas has a cruel reputation, delivering what some say is the most intense pain humans can imagine. It killed Wallace on April 8.

“It was very hard to watch my father die that way,” said Tricia Crnkovich, who took turns with her brothers and sisters in Wallace’s small bedroom as he shrank from 250 pounds to 60, losing most of the weight in the two months before he died. “I’ll tell you, if I ever get cancer,” she said, “I don’t want to put my kids through that.”

Wallace’s treatment at the hands of medical professionals was appalling. Even beyond the fact that his request to die was ignored, his pain was not being adequately managed because of “concerns” of his nurses.

. . . . Crnkovich said her father had been given strong medications when he went home from the hospital, but that his nurses had resisted increasing the dosage as his pain grew more intense.

Soon Wallace’s mental state began to deteriorate. Because the assisted-suicide law requires a 15-day waiting period between the first oral and the first written requests for lethal medication, and an additional 48 hours before the prescription can be written, he no longer qualified.

“He couldn’t talk for the last eight days,” son Steve Wallace said. “He was not in contact with reality. I’d come in there, and he’d call me somebody else.”

Mr. Wallace’s nightmare had come true. He had, the article states, watched his wife die of cancer, in miserable and unrelieved pain; he did not want to die like that.

Near the end, Steve and Ginny could hardly stand to be in the house because his father was in so much pain. By the time the doctor said his medication should be increased despite the nurses’ concerns, it was too late.

“He was just moaning and screaming, and it got really bad on Friday,” Ginny said. “By Monday when we left, he was just screaming at the top of his lungs.”

Meanwhile, major hospitals in Washington are refusing patients’ right to die as a matter of policy, making the extremely limited right to “Death With Dignity” even more meaningless. From the Seattle Times:

Olympia area hospitals won’t offer assisted suicide services

OLYMPIA — Providence St. Peter Hospital and Capital Medical Center officials said Thursday that the hospitals will not participate in physician-assisted suicide under the state’s new Death with Dignity law, but instead will refer terminally ill patients to their primary doctors.

Providence Health & Services spokeswoman Karina Jennings said Thursday that the same standard applies for all of its medical facilities and nursing homes in Washington and Oregon. The key reason: Providence is a Catholic health care organization, and physician-assisted suicide is “not a path conducive to our values,” she said.

“We don’t believe that health care providers should be put in the position of taking someone’s life,” Jennings said.

Because of its extensive involvement in health care, the Catholic church is able to impose its values on millions of non-Catholics – and Washington’s law does nothing to prevent this. We have already seen the morally repugnant position of the Catholic Church on assisted suicide and suffering: suffering is good for you. Says the Most Rev. Carlos Sevilla:

Initiative 1000 is an attack on our most fundamental beliefs and teaching, and placing it on the November ballot would contradict our proclamation of the gospel of life . . . Pain and suffering and illness are important parts of our faith experience. [Emphasis mine.]

He would probably be so bold as to say to Stephen Wallace’s children that screaming at the top of his lungs in pain as he died was an important part of Wallace’s faith experience. Which might have come as a surprise to Wallace.

The ethical arguments about physician-assisted suicide often focus on physicians’ autonomy, emphasizing the right of a physician to avoid helping someone commit suicide (or, as hospital spokeswoman Karina Jennings misleadingly puts it above, “taking someone’s life”). But the physician’s “right” must be considered against the background of “rights” that have, in our system, been taken away from the patient and given to the physician. Perhaps a physician shouldn’t have to assist in a suicide; but the patient will not be able to help himself and exercise his own autonomy without the physician’s action, because of the drug prohibition. The only comfortable sort of suicide – a suicide by overdose of fast-acting barbiturates – is only “assisted suicide” in that competent adults are generally prohibited from accessing the necessary drugs. Given our existing laws, it is either naive or cruel to refuse physician “assistance” (drug provision) to a would-be suicide.

At any rate, suicide should not be a medical matter. Physicians should not be the gatekeepers of suicide rights – it is unfair to physicians and unfair to people who want to die. The choice to die, and the responsibility for the act, should fall on the individual, not on his physician. From Thomas Szasz, in Fatal Freedom: The Ethics and Politics of Suicide:

Although performing an abortion and developing effective methods of birth control entail the use of medical knowledge and skill, abortion and contraception are not medical matters. The same is true for suicide. Although killing oneself with a drug entails the use of medical knowledge and requires access to the necessary substance, suicide is not a medical matter. We ought to deal with death control the same way we have dealt with birth control: by removing it from the purview of Medicine and the State, by repealing all medical and legal interference with the act. [Bolded emphasis mine; italics in original; citations omitted.]

Written by Sister Y

May 10, 2009 at 3:03 am

States Coerce Their Citizens By Prosecuting Their Doctors

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In the UK, Dr. Iain Kerr, a family physician, was suspended from his practice for six months for prescribing 30 tablets of the sleeping pill sodium amytal to an elderly, ill adult patient at her request.

The patient did not use the pills to die, but disposed of them when she found out Dr. Kerr was being investigated for acceding to her request. She later committed suicide using a much less reliable drug cocktail consisting of Temazepam, antihistamines and painkillers.

Dr. Kerr told the General Medical Counsel:

I think when dealing with someone holding a rational view of the circumstances in which they want to end their life, it was my duty to at least consider whether he or she had a reasonable opinion and that it was my duty to assist if I thought I agreed with that patient’s assessment.

Prosecuting physicians who risk sanctions to respect the choices of their patients and treat them as rational adults is yet another way in which governments act coercively to prevent suicides, without addressing the suffering that causes suicides in any way.

It is unfortunate that the General Medical Counsel felt the need to sanction Dr. Kerr for his act. But he may stand before any man or god, confident that his action was the morally correct one and the one most respectful of humanity.

Written by Sister Y

July 25, 2008 at 1:19 am

Life Rights and Death Rights

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Many of us consider the right to choose to die to be an important liberty interest. The right to die is often seen as an important counterpart to the right to choose to continue to live. Those in favor of maximizing choice may prefer a society that offers both rights, even if they could not personally imagine wanting to exercise the right to die.

Felicia Ackerman, in her essay “Assisted Suicide, Terminal Illness, Severe Disability, and the Double Standard,” points out there may be another right that is cut off merely by having the option to die, namely, the right to live without explicitly choosing to live:

. . . even on the nonpaternalistic assumption that patients will always make the right decision, they may be made worse off simply by having the option of physician-assisted suicide. The presence of this option may cause families to treat patients differently, and in any case, this option deprives patients of the option of staying alive without explicitly choosing to do so and being seen as choosing to do so, and thus without having to justify their decisions to stay alive. (Bolded emphasis mine, italicized emphasis Ackerman’s; Ackerman attributes this line of thinking to J. David Velleman’s Against the Right to Die.)

The concern for losing the right to live-without-choosing is interesting; I argue that what Ackerman and Velleman miss is a symmetrical concern for the right to die-without-choosing. Perhaps this right isn’t often discussed because most people, fortunately, have not been in the position to notice that they lack such a right. But the suffering, particularly would-be suicides, who feel that life is worth living yet do not commit suicide for various practical or moral reasons, often wish that death would take them in their sleep, without requiring them to be an agent of their death.

Really there are four rights in question, two “life rights” and two “death rights”:

  1. The right to live without explicitly choosing to live
  2. The right to (choose to) live
  3. The right to (choose to) die
  4. The right to die (or not exist) without explicitly choosing to die

In the absence of physician-assisted suicide, Life Right 1, the Velleman right, is generally the only right available. Widely-available physician-assisted suicide, implemented in a way which would remove the barriers to suicide I have earlier identified, would ensure that Life Right 2 and Death Right 3 are available. Again, those who favor the maximization of rights cannot rely on the idea that forbidding death also preserves “a right,” since it preserves that right at the expense of two very important rights.

Almost never is Death Right 4 actually available. The right not to exist without explicitly so choosing is, of course, available to the lucky never-born. It might be available to those with a very different life than ours – post-biological beings, for instance, might someday achieve something like Death Right 4. Most disturbing to those who value Life Right 1, though, is that Death Right 4 is available in cases where another person, or a natural process, kills someone at a time when he has not explicitly requested to be killed. This is the fervent desire of most suicides, I suspect; but we are denied this right because we are saddled, very much against our will, with Life Rights 1 and 2.

It seems to me that the denial of important death rights to those who wish to die must be considered equally with the consideration of life rights for those who wish to continue to live. I can imagine two justifications for considering life rights as more important than death rights, neither of which I find particularly moving; I am interested to know if anyone else has ideas that would justify seeing life rights as more important than death rights.

First, the life rights might be seen as creating a more revocable situation, and preserving more freedoms (if I continue to live, I can always choose to die or to live; but if I die, I cannot choose anything). However, forcing life really does not preserve choice. If we force life, we deny the death options, preserving only the life “options,” which does not really maximize freedom. Being forced to preserve all one’s options, and never allowed to make choices that remove options, is hardly freedom.

Second, the life rights might be more protected because more people prefer life to death. But, in addition to the fact that majority preference is not much of a reason, many freedoms are guaranteed very much in spite of being unpopular choices. Refusing life-saving medical assistance (separate from the suicide cases) is certainly an unpopular choice, but one it is seen to be important to have available.

I feel that a greater recognition of death rights, and of the fact that at least one of the death rights is necessarily violated as a condition of existence, is important for questions of suicide and antinatalism. In fact, Velleman’s examples where having an additional option puts one in a worse position could serve equally well as examples in favor of antinatalism. (I hope to specifically address his negotiation example and his invitation example in a future post.) Once born, we might, in a just society, possess the right to choose to live or to die; but we lack the choice to not exist without explicitly choosing to die, making us worse off in the case that we would prefer never to have existed. Many of us dearly wish for Death Right 4, but nevertheless are either stuck with Life Right 1 or choose Life Right 2.

Basically, I see Velleman as in a bit of a bind – if he’s right, and options often make us worse off, and offering an option is a morally suspect act, then that is a strong argument in favor of antinatalism, which weakens it as an argument against having a choice to die. If Velleman is wrong, on the other hand, then he merely fails to provide an argument against the suicide option.

My position is, if the right to assisted suicide is wrong, because it harms some who would be better off if they didn’t have the option to die (my synopsis of Velleman’s argument), then birth must also be wrong, because it harms some who would be better off if they hadn’t been given the option to live. It’s a good short article if people want to read it (I’ve linked to it above, in the block quote – it’s a PDF). He says, “I argue that we must not harm others by giving them choices, not that we must withhold the choices from them lest they harm themselves.”

Interestingly, along the same vein, perhaps the Velleman piece could be read equally well as an argument against the right to contraception, as much against the right to suicide or in favor of antinatalism, depending on whether the reproductive interest is seen as essential.