The push for legalized physician-assisted suicide (PAS) in the United States continues to gain traction, with the state of Hawaii becoming the seventh state in the union to sanction assisted death via physician-prescribed, life-ending medication. The Aloha State joins an ever-growing cohort of PAS-friendly states, including Oregon, California, Colorado, Montana, Vermont, and Washington. After a controversial vote in 2016, our nation’s capital also implemented its own assisted suicide legislation in July 2017.

Fortunately, a few barriers have recently popped up on the downhill slide toward assisted death for all: the American Medical Association reaffirmed its position opposing PAS, and a judge in California overturned that state’s assisted suicide law. But we are a long way from witnessing a sea change in public and professional sentiment toward PAS. A growing number of state-level medical associations are ending their traditional opposition to PAS, the California decision will most assuredly face legal challenges in court (reportedly, the law was supported by 76 percent of Californians), and the movement continues to gain ground internationally as countries like Spain and Finland consider implementing PAS and euthanasia laws.

One of the most active and vocal groups leading the push for legalized PAS in the United States is an organization called “Compassion and Choices.” Overwhelmingly, the campaign waged by PAS interest groups like Compassion and Choices is fueled by promises of ensuring personal autonomy (“choices”) and easing of suffering (“compassion”) at the end of life. But the very arguments used to promote PAS in the United States and around the globe raise the question of why physician involvement is necessary at all when one wants to end one’s life. In fact, a disturbing movement of pro-suicide organizations is growing around the globe. These organizations promise a way out without the (minimal) red tape imposed by PAS and euthanasia “safeguards” that exist where those practices are already legal.

The “Last Wish Cooperative”

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One such organization is the Dutch Coöperatie Laatste Wil (CLW) (“Last Wish Cooperative,” in English). The bioethics newsletter BioEdge reports that

The Dutch Public Prosecutor has opened a criminal investigation into the Last Wish Cooperative (Coöperatie Laatste Wil), which claims to distribute a deadly powder to people who want to commit suicide. Despite the notoriety of Dutch end-of-life legislation, assisted suicide without the help of a doctor is strictly illegal. But after a 19-year-old girl killed herself with a lethal powder last month, public attention has focused on CLW’s activities, even though it appears that she did not obtain the substance through CLW. CLW announced last September that it would make available a suicide agent, which it called “X,” to its members. Therefore the public prosecutor suspects that CLW members are “participating in an organization that aims to commit crimes.”

Whether or not the Dutch Last Wish Cooperative (CLW) is responsible for the 19-year-old girl’s death remains to be seen. What is obvious, however, is that CLW is nothing more than a glorified suicide cult. Its members see the involvement of doctors in end-of-life decision-making as not only unnecessary, but an infringement on personal autonomy. CLW’s website states that “Cooperative Last Wish accommodates people who favor the concept of assisted suicide and self-euthanasia without intervention or doctors and want to make early preparation by joining with others who share their views.”

The reality is that the arguments presented by assisted death advocates—whether they are promoting euthanasia or PAS (for the purposes of this essay, the difference between the two acts is not morally significant)—pave the way for suicide cults like the Dutch CLW. By grounding a legal right to PAS in personal autonomy and misbegotten conceptions of compassion and dignity, even if they advocate that the right only be exercised under the jurisdiction and protections of the medical establishment, PAS advocates around the world all but ensure the explosion of suicide cults in every country where their campaign of death is waged.

Autonomy as Our Greatest Good

Preservation of personal autonomy is among the greatest goods sought by PAS promoters and seekers. Studies show that maintaining autonomy (often described as “choice”) and a “sense of self” at the end of life are among the top reasons patients with terminal illnesses desire to end their lives with the help of physician-prescribed lethal agents. This key fact is not lost on groups like Compassion and Choices, which is precisely why they use the language of “choice” to promote their cause.

As I’ve written before at Public Discourse, the “Cult of Autonomy” in our country makes Americans particularly receptive to the idea of PAS when it is presented as a means of preserving autonomy. Vulnerable patients facing poorly controlled or uncontrolled pain, uncertain prognoses, or the fear of being a burden to others may be particularly attracted to the false promises of the PAS movement, seeking to make one final (and fatal) decision “on their own terms.” In a world where we no longer accept the existence of objective truth, we each create our own “truths,” making us our own gods. It is little wonder that under these circumstances, the impulse to preserve the illusion that we are all the true “masters of our fate” is so diabolically strong that we would rather end our own lives than have our perception of control wrested from us.

Set aside the logical inconsistencies in the idea that killing oneself—an act that permanently destroys one’s ability to make autonomous choices—is truly the ultimate act of autonomy that advocates assure us it is. Even so, it should be obvious that this enshrinement of autonomy as the greatest of goods raises the question of why physician involvement is necessary for anyone—terminally ill or otherwise—to end his or her own life. If preservation of autonomy is our greatest good, then nothing and no one should stand in the way of our exercise of that autonomy.

Suicide-promotion groups like the Dutch CLW therefore recognize that submitting to the expertise and evaluation of a physician or bureaucratic review board constrains a person’s ability to act autonomously. Sanctioned suicide outside the constraints of the medical establishment is simply the next logical step.

Preserving Autonomy While Ending Suffering: A Discordant Message

While other countries have made the dystopian leap to allow non-terminally ill individuals (and even children) to end their own lives, in the United States, PAS advocates seek only to end the lives of the terminally ill—at least for now. American PAS proponents specifically appeal to those with diseases such as terminal cancers with the twofold false promise of a way to “regain” control at the end of one’s life and a way to end suffering on one’s “own terms.” American PAS advocates frame the suffering that these kinds of patients endure as meaningless, presenting assisted death as the truly “compassionate” choice. But PAS advocates not only misuse the word “compassion” (which is from the Latin “com pati,” which literally means “to suffer with”), but in grounding the right to PAS in an individual’s subjective experience of suffering, they open the door to a slippery slope of abuses that will inevitably lead to a general increase in suicides outside the medical establishment’s jurisdiction.

Indeed, proponents of suicide and opponents of PAS alike should ask how a PAS medical review board could ever adequately assess the degree to which a person experiences suffering. A doctor might employ statistical measures or standardized questionnaires designed to tease out the precise nature of a person’s suffering and then compare it to normative standards. However, to employ such measures and make a yes/no determination on whether the patient should be allowed to kill himself by definition erodes the autonomy of the patient’s decision: it is now no longer the patient’s decision, but a determination made by a third party board of “experts.” Furthermore, to apply normative standards of suffering to an individual case does not capture the individual’s suffering well at all; after all, it applies an objective measure to something that is a purely subjective experience. Even though the downstream effects of suffering can be objectively characterized and subjected to statistical analysis (pain scales, depression ratings, etc.), such measures can never fully capture the patient’s subjective self-view.

Imagine, for example, that Jane Doe suffers from well-controlled diabetes, but the mental, emotional, and physical anguish of living with her disease causes her such suffering that she desires PAS. By every American PAS law currently on the books, she does not qualify for PAS because her disease (in its well-controlled state) is not terminal in nature; a third party has objectively determined that her subjective suffering is not great enough for her to merit PAS. John Smith, however, has a terminal cancer, but for whatever reason (faith in a higher power, excellent family support, etc.) his suffering has not led him to believe that PAS is necessary for himself. John Smith does qualify for PAS by every American PAS law currently in place, should he so choose. In both cases, a third party has made an objective judgement about the highly subjective suffering of both Jane Doe and John Smith, and as a result, the autonomy of each patient has been infringed by the existence of legalized PAS.

From these fictional (albeit very realistic) examples, it is clear that if the right to PAS is based on preserving a person’s autonomy and ending a person’s suffering, then organizations such as the Dutch CLW are correct that third parties (doctors and bureaucrats) should have no role in determining a person’s suitability for suicide. In short, by upholding autonomy and the ending of suffering by any means necessary as the greatest of goods, one is pointed away from supporting physician-assisted suicide, and toward simply supporting suicide.

The Safeguards Cannot Stand

Once PAS is sanctioned as a legally acceptable means of ending one’s life, it is laughable to insist that the practice of suicide must be kept within the safeguards of the medical establishment. Particularly in the face of the abuses seen in every jurisdiction where PAS and euthanasia are legally sanctioned, it is easy to see that the supposed “safeguards” that aim to protect vulnerable populations from being subjected to euthanasia are flimsy at best. In the Netherlands, medical personnel have euthanized the intellectually disabled and have held down an elderly, demented woman and euthanized her against her will. In Belgium, an elderly, demented women with Parkinson’s disease was euthanized at the request of her family, and, reportedly, a thirty-eight-year-old autistic woman was euthanized without proper documentation after she ended a love affair. In Oregon, officials have granted PAS requests to the depressed without first referring them for psychiatric evaluation. And yet no move has been made by the authorities in any of these jurisdictions to halt the practice of PAS or euthanasia in the face of these incredibly serious abuses. Assisted death is seen as a good so great that even heinous abuses of the system enshrining it in law are not enough to make governments question its legality. So, we must ask, if the logic of assisted-suicide proponents is correct, why is the involvement of the medical establishment required at all?

The answer, of course, is that it isn’t.

CLW made this easy jump in logic, and others will soon follow. As long as our culture continues its death march toward assisted suicide for all, more and more people will conclude that everyone has the right to kill himself—by any means necessary.