The battle over assisted suicide and euthanasia is not over; advocates of assisted suicide are not resting. While earnest and engaged Americans are focused on the economy, an upcoming presidential primary, and impending Supreme Court battles over the health insurance mandate and same-sex marriage, the culture of death continues to advance largely unnoticed along a front that some had supposed was dormant. Now, from the Bay State, comes news that advocates for assisted suicide have succeeded in bringing before Massachusetts voters a ballot initiative that would permit doctors to help their ill patients kill themselves. The initiative will appear next year. If it succeeds, Massachusetts would join Oregon and Washington in legalizing assisted suicide. Montana remains in limbo after the state high court called into question the enforceability of Montana’s prohibition against assisting suicide, but the legislature earlier this year declined to legalize the practice expressly.
People quite naturally recognize that life is better than death, that the deliberate destruction of life is an evil to be avoided, and that the state has a role to play in preventing suicides. It follows logically from these uncontested (and incontestable) observations that state laws prohibiting euthanasia and assisted suicide are just and efficacious. But, like magicians who use distractions to remove the important object from view, proponents of legalized death have shrouded the inviolability of human life in a mist of confusion. Exposing their ploys is the first step in defeating their efforts to advance the culture of death. Below are three arguments that are likely to be advanced for legalization in Massachusetts. All three are designed to distract and to deceive.
The Alleviation-of-Suffering Ploy
In public, proponents of assisted suicide most commonly characterize assisted suicide as the only hope of relief for “suffering patients” who are afflicted with serious illnesses. This plea is of course designed to appeal to voters’ (rightful, natural) sense of compassion for those unfortunate souls in whose shoes none of us would choose to walk. None of us likes to contemplate what it would be like to be told by a doctor that one has just a few months to live, and that one’s most prominent experience during those final months will be unrelenting pain. And we cannot bring ourselves to judge our neighbor who is forced to face such grim prospects. Who are we to tell the terminally ill patient that she must not end her life a few weeks early, and that she may not avoid the suffering and indignity that attend such horrible illnesses?
Thus, cleverly, assisted suicide proponents use voters’ natural aversion to death and suffering to build support for legalized death. To be against suffering is to be against laws that unnecessarily prolong a life of suffering, the argument runs. To celebrate life is to celebrate what is good and enjoyable in life, not to burden the terminally ill with a dark and unendurable coda.
This is an effective ploy, but it rests upon a bold deception. Assisted suicide is neither necessary, nor actually used, for the alleviation of pain. Indeed, the data show a wide gulf between the public justifications for assisted suicide and its actual use in practice. Oregon was the first state to legalize assisted suicide, implementing its program in 1997. The state’s annual reports consistently reveal that, of those who seek and obtain assistance in suicide, only a small fraction cite “inadequate pain control or concern about it” as a reason for their choice. Indeed, hauntingly, more patients are worried about being a “burden on family, friends/caregivers” than are concerned about pain.
Even these data do not tell the whole story; Oregon lumps those who are in pain with those who are merely concerned that they might be in pain at a future date. But few terminally ill patients need to resort to suicide in order to alleviate actual pain. Tragically, legalization in Oregon appears to have decreased patient access to palliative care. Of the initial 142 cases of assisted suicide in Oregon, only 13% were referred for palliative care consultations, and studies reveal that the quality of palliative care in Oregon has declined since assisted suicide became legal.
A much more common motivation than pain management appears to be simple clinical depression. In 2006, the Royal College of Physicians released a statement revealing that patients who want to die will change their minds—will choose life—after they are treated for depression in 98% to 99% of cases. Two researchers writing in the Michigan Law Review also concluded that when patients are treated by physicians who listen to them, treat their depression, and manage their pain, “their wish to die usually disappears.” In light of these facts, it is striking that only one of the sixty-five assisted suicide patients in Oregon in 2010 was referred for psychiatric evaluation. In 2009, none was referred.
The Unnecessary Prolongation Ploy
A second favorite ploy, related to the first, is to conflate prohibitions against assisted suicide with extreme measures to keep people alive. Though legalization proponents trade on fears of being artificially sustained after one’s time has come, prohibiting assisted suicide is not the same as forcing people to live beyond their time. To affirm that life is always worth defending from attempts to destroy it is not to claim that one should always make efforts to lengthen life.
Nor does respect for human life entail that the terminally ill must bear up stoically under extreme pain. Showing respect for all persons regardless of their condition or circumstances means providing needed medical care, including palliative care, when the terminally ill are in their final weeks and hours. That some forms of palliative care hasten impending death is not a reason to condemn its administration. The purpose of administering palliative care is not to kill but to relieve pain. The physician who administers palliative care is no more culpable than the physician who attempts to save a life by performing a risky surgery.
Medical practice involves risk and, sometimes, death. The line that we must ask a physician not to cross is the line at which he adopts the patient’s death as his purpose. That action is inherently different from performing a risky medical procedure; it makes the physician a different kind of person, one who is unfit to practice medicine and who harms himself as well as others.
The Personal Autonomy Ploy
The most common motivation for assisted suicide patients is a desire for personal autonomy, to control the time and manner of one’s own death. In Oregon, this is the most commonly cited concern of assisted suicide patients, and many scholarly advocates of assisted suicide admit that this is the real justification for legalization. The desire for control is understandable, but suicide is a means of control that causes real harm not just to the person who destroys his own life but also to all those with whom he is in community.
Proponents of legalization invoke a radical conception of personal autonomy. The idea is that each individual person makes the value of her own life by choice. When an individual ceases to value her own life, when she no longer prizes those treasures that life enables her to enjoy, she ought to be free to end her life.
People do not make their lives valuable merely by choosing to live. If this were the case, then the lives of small children and senile adults would have no value and would be unworthy of protection in law. As a matter of fact, myriad laws protect human life at various stages of human development, even in states—Oregon and Washington—that permit assisted suicide for the terminally ill. These laws do not discriminate against the very young or the very old, or against those who ascribe the least value to their own lives. States invest resources in suicide prevention and privilege citizens to prevent suicidal acts, by force if necessary. None of these laws provides for weighing the instrumental value of the life being saved.
So even in states that permit assisted suicide, the law reflects our understanding that life has value, regardless of the conditions in which it is lived. Laws preventing suicide preserve the communities of which the suicidal person is a part. The personal autonomy ploy rests upon the deception that suicide affects only the one who commits it, and that this individual alone should have a say in the matter. But suicides are not purely autonomous acts. Just as the family and neighbors of each person recognize the intrinsic value of that person, the family and friends of a suicide realize the irremediable loss that suicide causes.
Suicide should not be inflicted upon anyone. To assist its commission is to do violence to the very fabric of civil society. For the sake of doctors, their sick patients, and the communities in which doctors and patients live, Massachusetts and Montana should strengthen their legal commitments to protect the sick and suffering.
Adam MacLeod is an Associate Professor at Faulkner University’s Thomas Goode Jones School of Law.