When Death is Our Physician

It is hard to tell the truth about assisted suicide. Or rather, it's hard to get people to listen. Folks generally are about as eager to delve into the issue of assisted suicide as they are to work out the details of their own funeral. It's a delicate and unnerving subject, involving the ultimate issues of life: the reality of human mortality; fears about illness, disability, and old age; and the loss of loved ones to the dark, dank grave. Thus simply getting people to pay close attention to assisted suicide to grapple with its threat is often a challenging task.

This is even true of people who are religious or prolife, whose faith informs them that death isn't the end but the beginning. In my work as an anti-euthanasia activist, I have often appeared in front of prolife and religious organizations to speak about assisted suicide. More often than not, event organizers tell me that the audience is one-half to two-thirds the size of their audiences for programs about abortion or some other issue of concern to these communities. This has happened so many times now that it is a clear pattern.

I don't take the empty chairs personally. I understand the emotional dynamic at work. Life is difficult and worrisome enough without visiting the painful realm of assisted suicide. It is difficult, even for deeply religious people, to listen, to heed, and to care enough to become involved. But avoidance of the assisted-suicide issue is a luxury that those who believe in the infinite value of all human life can no longer afford, because battles over assisted suicide are being waged and more battles planned throughout the country. Tragically, one major battle has already been lost: Oregon legalized assisted suicide in 1994 and the law went into effect in September 1997. Today in the U.S. a small number of physicians participate actively in their patients' suicide, and it is absolutely legal.

On the bright side, since 1997, when Oregon's voters refused to repeal the state's assisted-suicide law, a broad-based national coalition of diverse groups has formed to oppose the death agenda. Disability-rights activists, advocates for the poor, professional associations in medicine and law, and hospice organizations all of which tend to be liberal and secular have joined with Catholics and other religious people and traditional prolife activists to oppose medicalized killing. And this collaboration has borne fruit. Since 1994 five states (Maryland, Rhode Island, Louisiana, Iowa, and Michigan) have passed laws explicitly making assisted suicide a crime, while Virginia outlawed it as a civil wrong, subjecting anyone who assists in a suicide to civil litigation. In November 1998, Michigan's voters rejected an initiative to legalize suicide by an overwhelming 71 to 29 percent. (That's the same state that put the murderer Jack Kevorkian in prison where he belongs.) National public opinion polls that used to show consistent popular support for assisted suicide in the 70 percent range now generally show support in the mid-to-high 50th percentile. Still, the death tide is powerful and must be contained and further reversed.

The most effective weapons in the pro-assisted-suicide arsenal are fear-mongering, distortion, euphemism, half-truths, and lies, all deployed to the drumbeat of choice. False arguments are gladly spread by the contemporary media, which avoid depth and context, preferring 30-second sound bites, tabloidism, and soap-opera shallowness. The best defense against this propaganda onslaught is to be constantly about the business of spreading truth. After six years in the moral struggle against the medical culture of death, I can state confidently that the more people learn about assisted suicide, the less they support it. The key to victory, then, is education, education, education.

Refusing medical treatment is not the same as assisted suicide

Too many people support assisted suicide because they have watched in horror as loved ones were hooked up to medical machines and kept alive against their desires when they were in the last days of life. The threat of such abuse is fading as the economics of medicine moves inexorably toward managed care in which profits are made from cutting costs rather than providing medical services. Still, for many non-ideological supporters of assisted suicide, being hooked up to machines is the prime concern.

Frequently, in my experience, supporters of assisted suicide turn into opponents once they learn that they have the legal right to refuse unwanted medical treatment even if refusing care will probably lead to their deaths. If a dying person doesn't want a ventilator or kidney dialysis, he doesn't have to have it. If he wants to die at home instead of in a hospital, he can. No one need commit suicide because of fears of falling prey to high-tech medicine.

Declining unwanted medical treatment is the philosophical foundation of the hospice movement which helps dying people die without killing them. In hospice care, machines are out, high-tech medicine is out, surgery other than as an elective procedure to relieve symptoms is out, impersonal medical institutions are out. Nurturing is in. Pain management and symptom control are in, as are spiritual and social services. The goal of a hospice is not to extend life but to help dying people live out their days in comfort and dignity and to care for them in a setting of unconditional love. Hospice care works so well that it is quite common for the dying person to declare that the experience of heading toward death is a blessing. There, then, is true death with dignity and nobody gives anybody a lethal dose of poison.

Pain control is not the same as assisted suicide

Assisted-suicide advocates often try to create a false moral equivalence between the medical control of pain and so-called mercy killing. Their argument goes something like this: Since some people's deaths are hastened by the powerful medications often required for effective palliation, and since such pain control is considered moral and ethical based on the principle of double-effect, then assisted suicide should also be viewed as moral and ethical because the intention of assisted suicide is similarly to alleviate suffering. There's only one problem with this argument. It completely misapplies the principle of double-effect.

Double-effect recognizes that there are occasions when a person may intend to do a good thing while recognizing that a bad thing might occur despite all of his good intentions. Even if the bad outcome then occurs, so long as the original intention was good, then the action is deemed morally acceptable.

In order for the double-effect principle to apply meaning an act that produces a bad result is still considered to be ethical four conditions must be met:

1. The action taken (in this case, treating pain and relieving suffering) is good or morally neutral.
2. The bad effect (in this case, death) may be a risk but it is not intended.
3. The good effect cannot be brought about by means of the bad effect.
4. There is a proportionately grave reason to perform the act (in this case, the alleviation of severe pain) and to risk therein the bad effect.

If properly applied pain control accidentally hastens a patient's death, the palliative act remains ethical because the bad effect death was not intended. On the other hand, assisted suicide intentionally causes death as the means of alleviating suffering. Thus, it fails to measure up to the principle of double-effect and therefore remains an immoral and unethical act.

Pain control, like all medical treatments, whether surgery, chemotherapy, or having a simple medical test, can have unintended lethal side effects. Assisted suicide, on the other hand, has but one intention the death of the patient that should not be confused with its purported motive an end to suffering. Assisted suicide is thus a profound violation of the do no harm values of Hippocratic medicine.

Assisted suicide would not be limited to people who are treminally ill

Legalizing assisted suicide for people who are diagnosed with a terminal illness is wrong. To authorize doctors to dispatch dying people sends the insidious cultural message that the lives of sick and dying people are of little use or value. Kathryn Tucker, an attorney for the assisted-suicide advocacy group Compassion in Dying, once argued in court that the state had little interest in protecting the lives of terminally ill people from suicide because their lives are not viable. On the other hand, most opponents of assisted suicide understand that if we are to value all human life we must treat all people equally. Whether the desire to self-destruct is caused by serious illness, a broken heart, or mental illness, common decency and compassion call for suicide prevention, not the abandonment to death-facilitation.

That being said, most assisted-suicide advocates do not want to limit death-doctor services to people who are terminally ill. Advocates are well aware that popular support for assisted suicide evaporates when the legalization criteria involve chronically ill, elderly, depressed, or disabled people. This presents an acute political problem for them: They want a broad license for medicalized killing but they know they can't promote it openly because they will lose substantial public support.

As a result, advocates resort to using vague and expandable language. In December 1997, shortly after the Oregon law went into effect, the organization called Compassion in Dying of Washington released a fundraising letter. The group had been a key participant in legalizing assisted suicide in Oregon, and was now ready to move its death agenda to the next level, writing to supporters that they needed increased funding because:

We have expanded our mission to include not only terminally ill individuals, but also persons with incurable illnesses which will eventually lead to a terminal diagnosis. The need for increased funding is even more crucial (emphasis added).

Incurable illnesses which will eventually lead to a terminal diagnosis covers a far broader array of maladies than terminal illness, and may include asymptomatic HIV infection, multiple sclerosis, diabetes, emphysema, early-stage cancer, asthma, and many other diseases.

Similarly, on July 27,1998, the Hemlock Society, perhaps the nation's largest assisted-suicide advocacy group, issued a press release calling for the legalization of assisted suicide for people with incurable conditions. The use of the word incurable was intentional. Most people think terminal when they hear incurable, but the terms are not synonyms. Arthritis is incurable but not terminal. Often paraplegia is too. Herpes, too, cannot be cured.

The true agenda of the assisted-suicide movement came into focus in October 1998, when the World Federation of Right to Die Societies an organization consisting of the world's foremost euthanasia advocacy groups issued its Zurich Declaration after its biannual convention. The Declaration urged that people suffering severe and enduring distress [should be eligible] to receive medical help to die (emphasis added). Finally, the actual goal of the assisted-suicide movement is revealed: death on demand for anyone with more than a transitory wish to die.

Guidelines will not protect against abuse

The assisted-suicide movement promises that abuses will be prevented by so-called protective guidelines. But this promise of protection is as empty as the repeated assurances that assisted suicide will be restricted to the terminally ill. One need only look to the experience of the Netherlands to see what scant protection protective guidelines actually provide.

Euthanasia is not, at this writing, technically legal in the Netherlands. But if doctors follow the legal guidelines enacted in the early 1990s by the Parliament, and if they report euthanasia and assisted-suicide deaths to the coroner, they will not be prosecuted. The guidelines require, among other things, repeated requests by the patient, and unbearable suffering for which there are no reasonable alternatives (a guideline that does not exist in Oregon or in most U.S. legalization proposals). The Dutch guidelines also require doctors to obtain a second medical opinion before killing their patients.

In practice, these guidelines are ignored routinely or have been expanded to the point where they are ephemeral. A recent study published in the Journal of Medical Ethics about euthanasia in the Netherlands reveals that the Dutch policy is beyond effective control since 59 percent of doctors do not report euthanasia or assisted suicide to authorities as required by law. Worse, the categories of people who are killed have expanded steadily since euthanasia effectively entered Dutch medical practice. Today in the Netherlands, not only are terminally ill people who ask to be killed euthanized but so are chronically ill people. For example, a pro-euthanasia Dutch documentary, shown in this country on PBS, told the story of a young woman in remission from anorexia. She was so worried about returning to using food for self abuse that she asked her doctor to kill her. He did, without legal consequences. Such well-documented cases of out-of-control euthanasia in the Netherlands abound.

Dutch doctors even kill people who aren't sick but only depressed. There was a prosecution that failed, and it is worth sketching. A psychiatrist assisted in the suicide of a depressed woman after having seen her for only four sessions over a five-week period. The woman had purchased a gravesite for three, had moved into it the caskets of her two dead children, and had an obsessive wish to be buried between them. The psychiatrist obliged. He was prosecuted, but the Dutch Supreme Court despite the doctor's admission that he did not attempt to treat her before helping to kill her validated his act, ruling that suffering is suffering and for purposes of euthanasia it does not matter if it is physical or emotional.

People who can't or don't ask to die are also killed by Dutch doctors. Babies born with disabilities are euthanized at the request of parents based on quality-of-life projections. According to a study published in the July 26, 1997, edition of the British medical journal The Lancet, eight percent of all infants who die in the Netherlands are injected with drugs by their doctors with the explicit aim of hastening death, which amounts to approximately 80 infants killed per year. (According to the study, 45 percent of neonatologists who participated in the study had killed infants, as had 31 percent of pediatricians.)

Many Dutch doctors also practice involuntary euthanasia on adults. According to several studies conducted during the past decade, more than 1,000 persons who do not ask to be euthanized are killed each year by Dutch doctors because the doctor's values dictate that their deaths should be brought about and this number does not include the thousands who are killed each year by intentional overdoses of morphine.

Now, not satisfied with the radical medical killing license already accorded to doctors, the Dutch government recently indicated that it intends to legalize euthanasia formally. If they do remove the few restraints provided by so-called protective guidelines, the consequences will be gruesome.

Assisted suicide is not working well in Oregon

Assisted suicide in Oregon operates in a shroud of state-imposed secrecy. What little we know comes from the press releases of assisted suicide advocacy groups and from a study published in the New England Journal of Medicine which purported to shed light on the law's actual workings. Assisted-suicide advocates claimed that the NEJM report validated their cause. But a close reading reveals that the worries of assisted-suicide opponents are entirely justified.

Fifteen people reportedly committed assisted suicide legally in Oregon in 1998. (The study acknowledges that there is no way to know if this number includes all of the actual assisted suicides. While the law requires doctors to report all assisted suicides, it does not punish doctors who fail to comply.) According to the report, none of the dead patients committed assisted suicide because of intractable pain or suffering that could not be otherwise alleviated. Rather, those who committed the act did so based primarily on fears of future dependency. This represents a dramatic expansion of the types of medical conditions that assisted-suicide advocates had told Oregon's citizens the law would end. These disturbing results demonstrate that assisted suicide, rather than being a rare event resorted to only in cases of extreme medical urgency, will expand steadily, just as it has done in the Netherlands.

Disability-rights advocates point out that allowing assisted suicide based upon fear of needing help going to the toilet or bathing or doing other daily-life activities will involve far more disabled people than those who are actually dying. They also note that, like other difficulties in life, dependency is a circumstance to which people adjust with time. To accept that worries about the potential need for living assistance are a reason for doctors to write lethal prescriptions is to put disabled people at material risk and to send the message that such lives are not worth living. That is why nine national disability-rights organizations have come out strongly against legalizing assisted suicide, and not one such national group supports it.

The NEJM study also reports that the people who committed assisted suicide had shorter relationships with the doctors who prescribed lethally than did a group of control patients who died naturally under their physicians' care. The exact time difference is not given but we do know from earlier media reports that a patient's relationship with a death-doctor is likely to be quite short. The first woman to commit assisted suicide in Oregon had a two-and-a-half-week relationship with the doctor who wrote her lethal prescription. Her own doctor had refused to assist her suicide, as had a second doctor who diagnosed her with depression. So she went to an advocacy group and was referred to a death-doctor willing to do the deed. Hers was not a unique case, as the report shows. This isn't careful medical practice, it is rampant Kevorkianism.

Assisted suicide would really be about money

In the end, assisted suicide would be less about choice than about profits in the health-care system and cutting the costs of health care to government. This is the conclusion of none other than Derek Humphry and pro-euthanasia attorney Mary Clement, who in their new book Freedom to Die admit that cost-containment may become the bottom-line justification for physician-assisted suicide (PAS):

A rational argument can be made for allowing PAS in order to offset the amount society and family spend on the ill.... Since the largest medical expenses are incurred in the final days and weeks of life, the hastened demise of people with only a short time left would free resources for others. Hundreds of billions of dollars could benefit those patients who not only can be cured but who want to live.

Imagine a health-care system in which the profit incentives favor killing as the best treatment for cancer, Lou Gehrig's disease, multiple sclerosis, spinal injury, Alzheimer's disease, and the many other medical conditions that in some way touch us all. Imagine the money to be made by for-profit HMOs if they are spared the expense of caring for such patients until the end of their natural lives. (The drugs for an assisted suicide cost only about $40, whereas it might cost tens of thousands of dollars to treat the patient properly.) And imagine the potential for abuse and coercion in a healthcare system in which killing can lead to greater profits, not to mention increased stock values and performance bonuses. Since our moral values often follow our pocketbooks, the result would be a profound devolution of our culture and of the ethics of medical practice.

To legalize physician-assisted suicide would be to take up again the practices of ancient societies that exposed disabled infants on the hillside and left the elderly and infirm by the side of the road. Protecting the lives of vulnerable people against medicalized killing is essential not only to this country but also to the world. After all, if we can export rock music and consumerism, we can certainly export the twisted values of Jack Kevorkian. That would be a tragic fate for a country that Abraham Lincoln once called the last best hope of earth