End-of-Life Issues and Care:Arguments in Support of and Opposition to Assisted Suicide

By Tom Smith, Ph.D.

 

As we have seen, the term “Hastened Death” can have a variety of meanings. The term “Assisted Suicide”, however, has a much more straightforward definition. Most simply, it can be understood to mean the professional (usually) consultation and assistance to determine the effective means and to obtain those means to end one’s life. It does not necessarily mean that the person seeking such consultation, assistance or means is terminally ill or facing imminent death. Withholding or withdrawing medical treatment, food or fluids is not legally considered to be either euthanasia or assisted suicide. Additionally, the administration of drugs to relieve suffering and provide comfort; e.g., morphine, that may result in death is also not considered euthanasia or assisted suicide, as the intent is to relieve the suffering of the individual.

Assisted suicide necessarily involves a discussion of suicide itself that considers the legality, morality and ethics of taking one’s own life. Such a complex and protracted discussion is outside of the scope of this paper and may be considered some other time. Nevertheless, in the present context, let us begin with some examples of assisted suicide, and the arguments for and against such action.

What comes to most people’s minds when thinking of assisted suicide is the infamous Doctor Kevorkian with his van administering lethal drugs from his “death machine” to terminally ill people; or, organizations such as “Final Exit”, “Death with Dignity”, “Compassion and Choices”, the “Hemlock Society” and other groups in the United Kingdom, the Netherlands and the United States. Some of these groups have consolidated themselves into more powerful blocks. However, in a most interesting turn of events, the Associated Press reported in July of 2008 of a woman in Wuerzburg, Germany who was counseled by a physician who told her just the right formula of lethal drugs to commit suicide painlessly and he set up a camera to film the death. What is striking in this case was that the 79 year old woman was not in chronic pain or suffering from a terminal illness. She simply did not want to move into a nursing home! Suicide and assisted suicide is not illegal in Germany, but this was scandalously reminiscent of the killing of the Nazi programs that killed mentally ill and disabled people. The Germans were shaken. In her note to the doctor, the woman wrote that she planned her death “smilingly and systematically” and “should the manner of my death help you in your fight, my life goal – the freedom to die in dignity – will be achieved”.

The above situation seriously complicates the principled arguments for and against assisted suicide. There are ethical and moral arguments, legal arguments, medical arguments, and arguments about the efficacy of the means and that a conventional acceptance of assisted suicide may lead to killing of select populations.

Arguments for Assisted Suicide

Among the most vigorous arguments for assisted suicide, sometimes called “self-deliverance”, are ethical and moral stands that include the principles of self-determination to control all aspects of one’s death that places the quality of life above the sanctity of life. Reference the German woman. People argue that they do not want to go on living if their quality of life were severely impacted, their sense of dignity jeopardized or that they had to suffer uncontrollable pain from a terminal illness. Also included in these arguments is the principle of autonomy. People have the right to make decisions and conduct their lives as they wish; this includes the right to determine the course of their dying as much as possible.

It is argued that as long as the person is competent and has the capacity to make a rational decision and can judge their situation appropriately and accurately, they should not be denied help in assisted suicide. It is not euthanasia for the purpose of genocide if the assisted suicide is based on the principles of dignity, honor and respect and is chosen and not imposed.

Legal arguments, under the above circumstances, specify in the facts for consideration that it would be in the best interest of dying patients to be able to regulate practices that are now commonly, but covertly used for assisted suicide. This would also protect professionals who currently and illegally provide such service out of compassion.

Physicians who refuse to assist the competent terminally ill may lead the patient to believe that they are being abandoned by their doctors. It is argued that there is no violation of the Hippocratic Oath to “first, do no harm” because the original oath prohibited abortions, surgery and taking teaching fees and these have been changed to fit the realities of modern society; moreover, it is not the physician who administers the lethal dose; the patient takes that responsibility and action. Finally, the Oath mandates that the physician relieves suffering and assisted suicide may be the only way the suffering can be brought to an end.

One of the greatest fears surrounding assisted suicide is that vulnerable people will not be protected from abuse; e.g., by administrations that want to free up resources or family members who want to keep the patients assets from being spent, thus leaving an inheritance. It is argued that appropriate regulation and oversight by professional and legislative bodies that include diagnosis, prognosis, treatment options, alternative means to relieve suffering, competency and professional and public education will prevent abuse of assisted suicide for other reasons other than relieving the patient of unacceptable suffering. Besides, there does not appear to be any abuse of accepted end-of-life interventions such as withdrawing treatment; e.g., chemotherapy, or terminal sedation. Finally, by having mental health practitioners and social workers involved in end-of-life decisions, possible abuse by family or the system or comorbid emotional or psychological problems can be identified.

Arguments Against Assisted Suicide

Moral and ethical arguments against assisted suicide emphasize the principle of protecting the vulnerable; viz, the socially and economically disadvantaged. Think “poor people”, the uneducated and stigmatized groups (Hitler marginalized homosexuals, the developmentally and physically disabled, the emotionally disturbed and Gypsies in addition to the Jews) as well as people who are simply too old. This is of great concern considering the ever increasing incidence of Alzheimer’s Disease which will grow evermore as the “Baby Boomers” age and become an increasing burden on the system. The pressure to accept assisted suicide may not be explicit because these marginalized groups may have internalized a sense that they are not entitled to care, resources and services. This is of particular concern in the United States where health care is bought and sold, controlled by insurance companies and not understood or accepted as a social right.

Considering the above point of view, the “rights and independence of the individual” dissolve as the doctors, health care administrations and insurance companies begin making decisions that are based on monetary concerns or the rationing of care under the “managed care” model. Many people may simply feel that they do not have the choice to live.

A seminal argument against assisted suicide is derived from the principle that life is sacred, must be respected and that any kind of killing is wrong, even if a person wants to die. We do not let people kill themselves. If we can, we stop them. Hitler did not think life sacred.

Legal arguments are concerned about criminal and civil suits. Did the doctor kill the patient? Was there a diagnostic error? Was there an error in prognosis? Can legal procedures be enforced as decisions are rapidly made? Art Buchwald, the famous American humorist was sent home to die after he refused kidney dialysis. He lived for almost a year.

Medical arguments against assisted suicide are legion: The possibility of misdiagnosis, availability of new treatments, incorrect prognosis (Art Buchwald), improved palliative care, aggressive treatment of pain, the value of social support and hospice care cannot be overestimated. If assisted suicide were readily available, not only the patient, but also the health care providers might take the easy way out to avoid being a burden on the part of the patient or on the part of the health care system, costly, but appropriate, medical or palliative treatment.

The American Medical Association and the California Medical Association are adamantly opposed to physician assisted suicide, voicing the view that it is incompatible with the physicians role as healer and that the people, the society may lose trust in doctors and begin to fear that they may want to kill them rather than heal them. Nevertheless, many doctors feel that these organizations’ decision-making processes have been sidetracked by misinformation and paternalism and that evidenced-based, logical debate and sound medical judgment have been lacking.

Safeguards may not prevent what would be considered fitting and suitable for competent terminally ill patients being applied to the non-terminally ill, those in emotional pain, physical disability (think bedridden) or those who, like the German woman noted above, do not want to go the nursing home. If procedures (mandated reporting, logging of protocols, etc.) can be violated, they will be violated. If there is room for abuse (involuntary euthanasia), there will be abuse.

Let it be said that there is no end of emotional debate by politicians, jurists, the medical world, religious leaders and the terminally ill themselves on whether death should ever be a planned event.

Legally Assisted Suicide in Oregon and the Netherlands

Oregon

Currently, Oregon is the only state in the U.S. where and adult who is capable and resident of the state and who has been determined by the attending and consulting physician to be suffering from terminal disease and has repeatedly and voluntarily expressed a wish to die, may legally make a written request for medication for the purpose of ending one’s life in a humane dignified manner. This law was enacted in 1994. In November 2008, Washington state will be voting on whether to legalize assisted suicide. California rejected a bill in 2007, but is not far behind and will try again to get a measure passed.

There are many safeguards in the Oregon Death With Dignity Act and it contains revised statutes after it was made law. Even though many have taken advantage of the Act, many choose not to end their lives after acquiring the means to do it. Many more people choose to die a natural death. It seems that those who do take advantage of the Act want a sort of “insurance policy” that they can end it if they want.

Statistics in Oregon are rigorously compiled. In the first nine years of the law, a report showed that about 60% of those who legally got lethal drugs used them. A total of 292 died by taking lethal medications. The median age was 70 and most were Caucasian with a college education and lived in urban areas. The primary factor involved in these deaths was the desire of the person to exercise autonomy and control over their death. Economic concerns or pain were not an issue. This finding seems to discount the concern that the socially and economically disadvantaged would be adversely impacted.

Advocates and opponents of assisted suicide interpret these findings differently. Advocates say that personal autonomy and a sense of control are strong values that must be respected. Opponents argue that if those people had more social support, understanding caregivers and better services they may not have chosen to end their lives. Moreover, there are some methodological concerns regarding the research and many feel that the research that has been done is not adequate.

Netherlands

Policies and practices regarding assisted suicide and euthanasia are different in the Netherlands than they are in Oregon. Because of cultural differences, smaller population and their health care system that stresses long term relationship with the “family doctor”, it is difficult to generalize from the Netherlands policy and practice to the situation in the United States. Be that as it may, some value can be gained by considering their experience.

Firstly, medical guidelines were met. Also, patients were mentally competent adults who were suffering without alternatives and who requested assisted suicide or euthanasia voluntarily, consistently, and repeatedly over a reasonable time. The requests were documented. Moreover, the patients were suffering intolerably with no prospect of relief and the primary doctors consulted with another physician not involved in the case. However, some physicians admit causing death without an explicit request.

Opponents argue that the Netherlands has fallen far down the “slippery slope” of wanton killing of those who are no longer valued by society. Proponents counter by pointing out that there has been a cautious use of euthanasia and assisted suicide. A study in 1995 concluded there was little evidence of a slippery slope occurring. Dutch doctors seemed to “continue to practice physician-assisted dying only reluctantly and under compelling circumstances”. However, critics in the United States have noted that in the past twenty years the Netherlands has moved from simply considering assisted suicide “to giving legal sanction to both physician assisted suicide and euthanasia; from euthanasia for terminally ill patients to euthanasia for those who are chronically ill; from euthanasia for physical illness to euthanasia for psychological distress; and from voluntary euthanasia to non-voluntary and involuntary euthanasia”.

Additionally, there is widespread realization of the involuntary euthanasia of severely disabled newborns, children and teens with severe brain damage or mental retardation and other incompetent patients that has been taking place in Holland. In 2004, Dutch doctors were explaining that euthanasia of infants (infanticide) was a necessary part of pediatric care. A boundary was moved that changed the whole conversation about this difficult subject. Even in the United Kingdom, the British Medical Association’s ethics committee in May 2006 recommended that doctors end the lives of some patients “swiftly, humanely and without guilt”. What is disconcerting is that this type of debate has now become respectable.

The current situation in the developed world is this: Euthanasia is a medical treatment in the Netherlands and Belgium and assisted suicide is a medical treatment in the Netherlands, Belgium and Oregon. In those places both acts are considered to be private and personal, but legislation has to do with medicine, ethics, public policy, families, children and the law. Currently, the legalization of euthanasia and assisted suicide is being considered in Great Britain, Canada, California, Vermont, Hawaii and will be voted on in November 2008 in Washington state.

Put simply, proponents and opponents of assisted suicide agree that there are costs and benefits to permitting versus banning the practice; however they differ in their assessment of these relative costs and benefits. Informed, rational people do indeed arrive at different conclusions when analyzing the data regarding assisted suicide. This is a result of differing philosophical, ethical and moral outlooks, value systems and personal and professional experience. To repeat: Let it be said that there is no end of emotional debate by politicians, jurists, the medical world, religious leaders and the terminally ill themselves on whether death should ever be a planned event.

References

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Task Force to Improve the Care of Terminally-Ill Oregonians (1998). The Oregon Death with Dignity Act: A guide book for health care providers. Portland, OR: Center for Ethics in Health Care, Oregon Health Sciences University.

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The Oregon Death with Dignity Act: Oregon Revised Statutes.
https://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Pages/faqs.aspx
FAQ about the Death with Dignity Act