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Living in the Epilogue: Social Policy as Palliative Care

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“A self is a machine for making you concerned about your organism.”
— Antonio Damasio


The Story as a Cognitive Bias

The essence of consciousness, says Antonio Damasio, is the internal narrative – the story one tells oneself about oneself. The ability to create this narrative – to conceive of oneself, to project oneself into the past and the future, to connect events meaningfully – has proven to be a very effective evolutionary strategy to ensure that an organism acts to promote its own ends.

Our evolutionary history ensures that we think in stories. They are so central to our thinking that it is hard to think about them. An old fish said to a couple of young fish, “Morning, boys! The water’s fine today!” and swam off. One young fish turned to the other young fish and asked, “what’s water?” Thus it is with humans and stories.

Stories are extremely useful; as information-hungry, social creatures, we are as pleased to hear stories as dogs are to sniff the pee stains of other dogs. We love stories. We are stories. We think and remember in the form of stories. As Roger Schank puts it (in Tell Me a Story: A New Look at Real and Artificial Memory), “In the end all we have, machine or human, are stories and methods of finding and using those stories.”

But stories are not real. They are constructs that we apply to the universe, but there is no story out in the universe. There is no “gist” or “point” to the universe, as stories have gists and points. We construct meaning to serve our evolutionarily-determined ends, and this is, I think, the most central of all the cognitive biases.
<!–conflict
causation (story v. narrative)
events follow each other in time
a protagonist pursues his goals
we empathize with the protagonist
conflict followed by resolution – structure/pattern of events
characters affect each other
not just what stories we are attracted to (what makes stories “interesting”) – but the very form of the story itself
positions in time of the story have different emotional connotations–>
Living in the Epilogue

My name is Sarah. I’m 32 and I live in Los Angeles. Since I was a small child, I have wanted to die. But here I am.

I keep two bottles labeled “Poison” on the shelf next to my bed. They are filled with an alcohol extract of several pounds of macerated immature Conium maculatum seed pods, the part of the plant that is highest in toxic alkaloids. I feel much better having it there. My hope is that someday I’ll get drunk and upset and drink it down without even thinking about it. I think it will work; my only worry is a couple of papers that point to extreme pain while dying and possible kidney problems if one survives. (Also, the stuff smells like the Grim Reaper’s boiled turd smeared on a rat with gangrene.) Still, here I am.

A few years ago, I wanted to die all the time, every minute. I suffered intensely, and the main project of my life was to get through time. I researched suicide methods, made repeated attempts, but always failed, and was left with the conviction that suicide is extremely difficult without barbiturates, which I could not (and remain unable to) get. At some point, I changed my focus from trying to end my life to trying to make what years I am forced to endure less miserable. In the language of illness, I put myself in hospice and gave myself palliative care.

I tried many therapies, including a six-month attempt at alcoholism. Many of my experimental palliative care therapies (including this) failed, but a few were extremely successful at making me not suffer all the time. I stopped trying to be in monogamous relationships. I take a couple of prescription SSRIs. I exercise in a rather extreme fashion. I see a therapist. I smoke marijuana and have riotous group sex with my boyfriends and girlfriends. I go to lectures and watch experimental animation at the independent movie theater. I write essays on my couch with my books all around me and Shehnai music playing.

I suspect that I have more fun that most people in the world. Life remains an irritation, but for me, it is not the constant grind of pain and humiliation that it must be for millions of people. In many ways, my very suicidality makes life more pleasant for me, since I utterly lack the fear of death and all the cringing urgency that fear engenders.

But there is something missing. Here is the problem, if it is a problem: I am not in a story.

Living outside of any story – living without hope for the future, without the belief that one is part of a narrative – is confusing. It’s hard to get anything done when nothing has a point. For any not-immediately-pleasurable action (or inaction) I contemplate – getting up in the morning, vacuuming, answering the phone, spending an entire day sober – there is no readily-available answer to the ever-present question in my mind, “why?” At least, there is no long-term “why.”

Do I wish I were in a story again? Ultimately, no. Even if it were possible to imagine myself as a character in some narrative about to unfold, I don’t really want to. This would be sacrificing truth for comfort – and questionable comfort at that.

I spoke about this with my closest friend, and he suggested that I have had a story, and now I’m living in the “ever after” part. I am, for all relevant purposes, living in my own epilogue. This is also, I think, the status of people with terminal illness who are about to die: their story is essentially over. This is even true if you believe in magical sky friends and heaven and all that.

There Are No Stories In Heaven

There are no stories in heaven; heaven is all epilogue. It functions as a bookend on our stories; we may even call it the “hereafter,” as in “happily ever after.” There can be no conflict in heaven, so there can be no stories, either.

Aristotle scholar Martha Nussbaum explores how crappy it is for humans to live outside of a story, even in heaven, in her essay “Transcending Humanity.” Here, she considers Odysseus’ choice to give up eternal youth and pleasure with Calypso in order to return to his wife and the certainty of inevitable death. She says,

What, in the face of the recognized human attachment to transcendence, could justify such a choice? Odysseus has little to say. But what he does say makes it perfectly clear that they key is not any surpassing beauty in Penelope herself. He freely grants that from this point of view Calypso will be found superior. And he points to no superiority in Penelope that could counterbalance Calypso’s divine excellence. So he is not, it seems, choosing a glorious prize in spite of the fact that he has to face death to get it; that is not at all how he sees the issue. He is choosing the whole human package: mortal life, dangerous voyage, imperfect mortal aging woman. He is choosing, quite simply, what is his: his own history, the form of a human life and the possibilities of excellence, love, and achievement that inhabit that form. What, then, can he say to make that choice intelligible, once the alternative of divinity and agelessness is on the scene?

And yet, to readers of the poem from ancient to modern times, Odysseus’ choice does seem intelligible, and also admirable — the only choice we would have our hero make.

Odysseus’ choice is perfectly understandable because the alternative is so . . . boring. Without the possibility of loss, nothing is interesting. Without limitation, there is no possibility for excellence, which is, in the Aristotelian view at least, the purpose of a human being:

We don’t quite know what it would be for this hero, known for his courage, craft, resourcefulness, and loyal love to enter into a life in which courage would atrophy, in which cunning and resourcefulness would have little point, since the risks with which they grapple would be removed, and in which love, insofar as it appears at all, would be very different in shape from the love that connects man to wife and child in the human world of the poem.

And:

The Greeks, no less than contemporary Americans, praise outstanding athletic performance as a wonderful instance of human excellence. . . . But clearly, such achievement has point and value only relatively to the context of the human body, which imposes certain species-specific limits and creates certain possibilities of movement rather than others. . . . But if this means that even races or contests between different animal species will usually seem pointless and odd, it means all the more that there will be no athletic excellence at all, and no meaningful concept of athletic excellence, in the life of a being that is, by nature, capable of anything and physically unlimited. . . . What would such achievement be, in a being for whom it is all easy? What would be the rules of the game? [Bolded emphasis mine.]

But the real appeal of Penelope, and of the mortal world, compared to heaven, is the possibility of stories. We root for Odysseus to choose Penelope over immortality, says Nussbaum, because of

this more general uneasiness about the shapelessness of the life Calypso offers: pleasure and kindliness and on and on, with no risks, no possibility of sacrifice, no grief, no children. All we need to do to see this is to compare accounts of lovemaking. Odysseus and Calypso “withdrew, and in a recess of the arching cavern they took their pleasure in love, and did not leave one another’s side.” That’s the end of that; the poet can say no more; for they have nothing to talk about, since they have done nothing and nothing has happened to them. As for the human husband and wife:

The two in their room enjoyed the delights of love, then pleased one another with recounting what had befallen each. The queen told how much she had suffered in these halls, seeing always there the pernicious multitude of suitors who in wooing her had slaughtered so many beasts, fat sheep and oxen, and drawn so much wine from the great jars. The king told of the harm he had done to others and the misery he had endured himself. Penelope listened to him enraptured, and sleep did not fall upon her eyelids till he had told his tale to the end. [Oddyssey, V.226-27, XXIII.300-09, W. Shewring transl.]

It’s perfectly plain that the human pair are, at least from the viewpoint of the human reader, more interesting and more erotic. A sexuality divorced from conversation, from storytelling, from risk and adventure and the sharing of risk and adventure, seems extremely boring; and we feel that it is a great tribute to the goddess’s beauty that Odysseus retains his interest in her, after so much time.

Life is quite unbearable, for a human, without the “risk and adventure” of a story-bound life. What we are looking for when we look for the “meaning of life” is the greater story. The unfortunate truth, suggested by science and vehemently denied by religion, is that there is no greater story. We may make up stories and allow them to shape our perceptions, but ultimately there is no story. We are all living in the epilogue of reality, or rather worse, because there never was a story. For many of us, our personal stories have run out – and it’s extremely difficult to push oneself into a new story once you see that all stories are vanity. It is like the difficulty of staying in a dream once one realizes one is dreaming.

The Cheery and the Damned

Why are drugs, prostitution, gambling and suicide illegal, when they clearly give so much relief to suffering people? I think it is because, at a societal level, we are deluded into thinking that happiness is possible, maybe even easy or likely, without these things. I have called this cheery social policy.

The fundamental problem with this sort of cheeriness is the assumption that a good life – a pleasant life – is relatively easy to achieve. Cheery people are able to hold such a belief because they are able to ignore – and perhaps can’t even conceive of – the suffering of a significant minority of the population. A good life is not easily achieved for many of us.

There is a majority belief that we need not use extraordinary means to achieve a happy and meaningful life. Behaviors that deviants engage in, perhaps in pursuit of a tolerable life – weird sex with lots of people, say, or using steroids or marijuana or LSD or benzodiazepines – strike cheery people as perplexing and frightening. For a cheery person, these behaviors are wholly unnecessary – life is perfectly tolerable without them. And they increase the risk of harm! Who wants harm?

What the cheery cannot imagine is the importance, the function of these behaviors, and others like them – the pursuit of the interesting, and the temporary suspension of the intolerability of existence, which intolerability (for many) the cheery do not even perceive, and therefore do not properly weight as a problem.

Jason Roy’s “Explanations for drug war” makes this point with respect to the drug prohibition. He quotes John Gray’s Straw Dogs:

Drug use is a tacit admission of a forbidden truth. For most people happiness is beyond reach. Fulfillment is found not in daily life but escaping from it. Since happiness is unavailable, the mass of mankind seeks pleasure.

Religious cultures could admit that earthly life was hard, for they promised another in which all tears would be wiped away. Their humanist successors affirm something still more incredible — that in future, even the near future, everyone can be happy. Socieities founded on a faith in progress cannot admit the normal unhappiness of human life. As a result, they are bound to wage war on those who seek an artificial happiness in drugs.

But it is not necessarily the case that prohibitionists think that life is great. It’s that they think it is meaningful – that we are in a story, and it’s worth participating in, win or lose.

The idea that life is inherently worthwhile, and happiness easy to achieve, underlies many social policies, including prohibitions (legal or moral) on suicide, abortion, nonmarital sex, drugs, gambling, and even eating fatty food.

On the other hand, if life were not inherently worthwhile, suicide would be understandable, and bringing a new life into the world would not be an unqualified good, but an uneasy question mark. Sex, drugs, and fun would be appropriate ways to treat oneself for the unwanted condition of life.

Palliative Care: A Double Standard for People in the Epilogue

The terminally ill are at the end of their story. If you’re going to die anyway, what does it matter what you do? Take ecstasy. Go skydiving. Fuck a prostitute. Kill yourself. Who cares?

There is a sense that, once you’re terminally ill and an official short-timer in life, what you do ceases to really matter. This is, I think, at the heart of the double standard our society imposes with regard to suicide and the other activities mentioned above. If you’re young and healthy, you have an obligation to stay alive and be sober and responsible. But if you’re toast anyway, anything goes. For the dying, we can conceive of allowing them pleasure as mercy. But we are not so eager to offer mercy to healthy people. That is because we mistakenly believe in the concept of health.

Toward Social Policy as Palliative Care

We are all terminally ill. Not one of us is going to survive. And our stories are delusions. Each one of us lives in The Matrix – a story-dream created by our minds. Happiness is not easy; meaning is elusive. Young, healthy people who find themselves miserable, or find that they no longer inhabit a story, have even more need of the kind of “palliative care” that we offer to terminally ill people, simply because young people have so much more time to get through. Eighty years! Ninety years! A hundred years of epilogue ahead of us. It’s crushingly boring to ponder. As Martha Nussbaum says,

When Calypso speaks of “calm possession of this domain,” our hearts sink; for there’s no story in that. . . . Stories have shaped and continue to shape the readers’ desires, giving them a preference for onward movement over stasis, for risk over self-sufficiency, for the human form of time over divine timelessness. They play upon and nourish the emotions — fear, anticipation, grief, hope — that presuppose the form of life of a being both needy and resourceful, both active and finite — and that seem to have their point and function only within the context of such a life.

Regarding antinatalism, someone recently asked me if it was my belief that the bad outweighed the good, or whether I thought they weren’t even comparable. I believe the latter. Ray Brassier, in his introduction to Thomas Ligotti’s excellent The Conspiracy Against the Human Race, puts it thus:

The optimist fixes the exchange rate between joy and woe, thereby determining the value of life. The pessimist, who refuses the principle of exchange and the injunction to keep investing in the future no matter how worthless life’s currency in the present, is stigmatized as an unreliable investor.

This is the view from hell. Hell is not the state of experiencing a great deal of suffering with no pleasure to “balance it out.” Hell is popping out of the notion of meaning altogether. And this Hell is the meta-condition that we are all in, whether we perceive it or not.

Memento mori

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Written by Sister Y

December 8, 2010 at 9:54 pm

"I regard this as justice"

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June Hartley of Lodi, California, was charged with “assisting a suicide” and “causing injury leading to death” for helping her brother to commit suicide. She recently pleaded guilty to a lesser charge of “being an accessory to a crime.” (I thought suicide was not illegal?)

Her brother, blues musician Jimmy Hartley, had suffered a series of strokes which left him bound to a wheelchair and in constant neuropathic pain. Prior to his death, at age 45, he had begged others to help him end his life.

Both Hartley’s lawyer, Randy Thomas, and the prosecutor in the case, Sherri Adams, expressed approval of the plea agreement.

“I regard this as justice,” Thomas said. “It sent two messages: The district attorney had an acknowledgement [sic] that the law was broken but also that it was a unique situation involving mercy.”

The prosecutor, Deputy District Attorney Sherri Adams, said the plea agreement was just. Adams said the District Attorney’s Office must scrutinize cases of assisted suicide, which are illegal in California, to prevent malicious killings that are masked as merciful.

Hartley’s actions, Adams said, were a genuine act of mercy.

“This case did not involve any ill will,” Adams said. “The defendant violated the law out of love and support for her own brother.” [Emphasis mine.]

Both Hartley’s attorney and the prosecutor seem to agree that this is the correct outcome for a case of assisted suicide.[1] Adams and Thomas recognize two kinds of harm:

  1. The harm of living in misery and not being able to die (hence the recognition that the act of helping a person to die can be merciful or compassionate, and that such a person should not be punished);
  2. The harm of a “malicious killing” (presumably a murder, but perhaps something else is meant) going unpunished.

The statement that the outcome in Hartley’s case is “justice” indicates that the correct balance has been struck between the two kinds of harm.

In fact, in this case the first interest – the right to choose death over suffering – is almost completely sacrificed at the expense of the second – punishing “malicious” killers. James Hartley’s interests, and those of people like him, are ignored. Adams is concerned with “malicious” killers disguising their work as assisted suicide. But what about all the people suffering in misery, who have a longstanding wish to die, but cannot die because anyone assisting them will face prosecution? The idea that June Hartley’s actions were “merciful” concedes that her brother had an interest in dying. Prosecuting people who assist suicides does nothing to protect that interest.

Also, as I have previously argued, prosecuting assisted suicides is an extremely poor way (in practical terms) to prevent malicious killings from being disguised as suicides. In Oregon and Washington, for example, it would be extremely difficult to make a murder look like an assisted suicide, at least a murder of a person ill enough to qualify for suicide assistance from a doctor. Since a comfortable means of assisted suicide is legal, with many safeguards to ensure that it is the true wish of the decedent, an “assisted suicide” by any other means would be unlikely and extremely suspicious. I assert that assisted suicide in Oregon and Washington is much harder to fake than in California – and, of course, the right to die is protected better there, as well. Both interests recognized by Adams and Thomas are poorly protected by the solution they claim is “justice.”

Elsewhere on the web, TGGP rips apart Frontier Psychiatrist‘s definition of rationality, in the context of suicide (“Life is a disease, so cut the bullshit please.”). Rationality in this context means that a decision is “characterized by reason or ‘makes sense’ to others,” FP claims. I manage to comment in both places without rolling my eyes or sighing deeply.

And Bryan Caplan wonders why so few terminally ill people kill themselves.


1. The term “mercy killing” is often used in cases such as Hartley’s. I think this term is misleading: “killing” implies that one person caused another person’s death – such as by smothering or shooting the person – without his permission. In Hartley’s case, she merely helped her brother achieve his own aim of dying. Helping someone to commit suicide who has a longstanding wish to die is not properly considered a killing.

Written by Sister Y

June 4, 2009 at 1:49 am

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

What Distinguishes "Assisted" Suicide From Regular Suicide?

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“Assisted suicide,” in the popular use of the term, can probably be distinguished from garden-variety “suicide” in two ways:

  1. Assisted suicide requires the assistance of some third party to carry out the act.
  2. Usually, “assisted suicide” connotes suicide by a person who is terminally ill.

I wish to challenge the accuracy and importance of the first distinction, and to examine how it interacts with the second distinction.

Assisted suicide, by definition, requires the assistance of another person. It conjures images of doctors injecting a lethal drug into a patient at the patient’s request. But that is now how it often works in practice. Oregon’s law is considered an “assisted suicide” law, but the “assistance” consists only in a physician writing a prescription for a lethal dose of Nembutal – not in helping to administer the drug. But is this really assistance?

The purported “assistance” going on in this type of “assisted suicide” is merely an artifact of our particular system of drug prohibition. We consider suicide by gunshot to be a suicide, rather than an assisted suicide; but why not call it an “assisted suicide,” since the procedure for buying a gun requires the assistance of others? I think we would not call it an assisted suicide in the latter case. The distinction seems to be that, “assisted suicide” requires that the person providing assistance do so knowing the suicidal purpose of the person who is assisted. But the only reason the person wishing to commit suicide needs to let the doctor intrude on his personal life in this way is that he cannot obtain the drug in any other way. We too easily accept our drug prohibition as a given, when in fact it is a policy decision. There is not so much difference between “assisted suicide” and plain old suicide, except that in the former case, another person has been made privy to the suicidal person’s private decision, often because the state requires the intrusion.

“Assisted suicide” in the form of a prescription is necessary, in most cases, merely because proper drugs are not available through other means. It is not “assisted suicide” any more than divorce with the help of a judge is “assisted divorce.” But, in some cases, the physical inability to kill oneself is the circumstance that requires “assistance.” This circumstance is especially likely in cases of people who are terminally ill. Here again, the “assistance” required may be for legal or practical reasons. If proper drugs are not available for legal reasons, the person who wishes to die may have to send a relative in place of himself overseas to seek out the necessary drugs. Or, the person who wishes to die may actually need physical assistance in dying, such as an injection, or assistance holding the cup if the drugs are taken by mouth.

I suspect that many people who oppose “assisted suicide” are concerned about the act of assisting someone to die in this latter sense. They fear that, rather than willingly choosing to die to end their own suffering, people may be put to death because they are disabled or inconvenient or expensive to provide for. To its credit, the Oregon law specifically requires a personal request, as well as an assessment of legal “capability” and many other safeguards, to prevent murders from disguising themselves as assisted suicides. I think the fears mentioned above should be taken seriously, and in this limited circumstance, I approve of the restrictions.

But these restrictions are not necessary when it comes to people who are fully competent and need no physical assistance in taking their own lives. 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. Lift or even relax the barbiturate prohibition, and forced life becomes chosen life. There is no compassionate reason for forcing capable, suicidal adults to choose between shooting themselves in the head, cutting their arteries, hanging themselves, or living a life of unbearable misery and indefinite duration.

Written by Sister Y

July 3, 2008 at 11:41 pm

Oregon’s Law

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Oregon’s Death With Dignity Act succeeds in many ways. The Act respects patient autonomy, from its definition of “capable” to mean that

in the opinion of a court or in the opinion of the patient’s attending physician or consulting physician, psychiatrist or psychologist, a patient has the ability to make and communicate health care decisions to health care providers, including communication through persons familiar with the patient’s manner of communicating if those persons are available.

to the way it allows patients to decide for themselves whether to notify family members and when – even if – to self-administer the lethal prescription, once requested. (Some people who request suicide assistance don’t use it until months or years after it has been provided.)

Oregon’s law is wrong, however, in limiting access to death to those with terminal illnesses. Although this flawed version is certainly the only version of the law that would have had a chance of being enacted, the fact remains that it is wrong.

First, restricting access to comfortable means of death to those with a terminal illness is actually demeaning to people with terminal illnesses. The idea that human dignity somehow requires that one be able to walk and talk and control one’s bodily functions is demeaning and wrong, as Felicia Ackerman (see Readings) and disability advocates point out. A terminally ill person must decide for him or herself whether to request suicide assistance; it is not the right decision for everyone. But what possible justification could there be for limiting this right to terminally ill people, except that their lives are somehow less valuable than those lives that will (probably) continue on for many years? The designation “Death With Dignity Act,” of course, hints at the demeaning implication of the limit: some deaths are dignified, other are not. The state will decide for you whether you are undignified enough to be allowed to die peacefully. (The Oregon law does not allow assisted suicide to be provided to non-terminally-ill disabled or merely old people, but the implications of the restriction to terminally ill people are clear enough.)

Second, the Oregon law’s restriction against suicide assistance to non-terminally-ill people is wrong because suicide is an important right for everyone, not merely the terminally ill. In fact, if anything, the right is more important for those who are not terminally ill, because their time of suffering will most likely be much longer than those who will die soon naturally. And, as pointed out by Velleman, terminally ill people are much more likely to be harmed by having the option to die than healthy people are, because they are more likely to be dependent on the care of others and therefore to feel themselves to be a burden. A more sensible restriction might be to allow suicide assistance only to non-terminally-ill people! I am not, of course, in favor of this restriction, but it makes more philosophical sense than Oregon’s law, which makes political sense, if anything.

Meanwhile, Switzerland recently extended suicide rights to those with incurable mental illnesses. Jacob Appel, writing in the Hasting Center Report, explains the basic ethical issues:

Another set of objections are from those who support a basic right to assisted suicide in certain situations, such as those of terminal disease, but do not wish to extend it to cases of severe and incurable mental illness. This resistance may be inevitable, considering the increased emphasis that contemporary psychiatry places on suicide prevention, but the principles favoring legal assisted suicide lead logically to the extension of these rights to some mentally ill patients.

At the core of the argument supporting assisted suicide are the twin goals of maximizing individual autonomy and minimizing human suffering. Patients, advocates believe, should be able to control the decision of when to end their own lives, and they should be able to avoid unwanted distress, both physical and psychological. While these two principles might explain why a victim of amyotrophic lateral sclerosis or cancer would choose assisted suicide, they apply equally well in many cases of purely psychological disease: a victim of repeated bouts of severe depression, particularly in cases where treatment has consistently proven ineffective, rationally might prefer dignified death over future suffering. [Hastings Cent Rep. 2007;37(3):21-23. Via Medscape. Emphasis mine.]

Written by Sister Y

June 24, 2008 at 3:40 am