Death on Demand

Should laws against assisted suicide be rescinded as "paternalistic?" Should assisted suicide be transformed from what is now a crime (in most places) into a sacred "right to die"? Should assisted suicide be redefined from a form of homicide into a legitimate "medical treatment" readily available to all persistently suffering people, including to the mentally ill?

According to Brown University professor Jacob M. Appel, the answer to all three of these questions is an unequivocal yes. Writing in the May-June 2007 Hastings Center Report ("A Suicide Right for the Mentally Ill?"), Appel argues in that assisted suicide should not only be available to the terminally ill, but also to people with "purely psychological disease" such as victims "of repeated bouts of severe depression," if the suicidal person "rationally might prefer dignified death over future suffering."

Given the emphasis assisted suicide advocates and the media normally give to the role of terminal illness in the assisted suicide debate, it might be tempting to dismiss Appel as a fringe rider. But he most definitely is not. Over the last several years, advocacy for what is sometimes called "rational suicide" has been growing increasingly mainstream, discussed among the bioethical and academic elite in mental health publications, academic symposia, and books. Indeed, it is worth noting that Appel's essay appeared in the world's most prestigious bioethics journal.

As disturbing as Appel's proposal is—it is essentially a call for death-on-demand—it is refreshing that Appel has written so candidly. After years of focus group-tested blather from the political wing of the euthanasia movement claiming that legalizing assisted suicide would be strictly limited to the terminally ill, we finally have a clearer picture of where the right-to-die crowd wishes to take America.

Moreover, unlike a restricted right to assisted suicide, Appel's call for near death-on-demand is logically consistent. There are two weight-bearing intellectual pillars that support euthanasia and assisted suicide advocacy: (1) a commitment to a radical individualism that includes the right to choose "the time, manner, and method of death" (often called "the ultimate civil right" by assisted suicide aficionados); and (2) the fundamental assumption that killing is an acceptable answer to the problems of human suffering. Appel describes these conjoined beliefs succinctly as the "twin goals of maximizing individual autonomy and minimizing human suffering" by avoiding "unwanted distress, both physical and psychological" through creation of a legal right "to control . . . when to end their own lives."

Hoping to whistle past the graveyard, some might dismiss all of this as mere theoretical posturing. Were it so. Assisted suicides for the mentally ill are already taking place in euthanasia-friendly locales. Indeed, nearly every jurisdiction that has legalized assisted suicide for the seriously ill—as well as those that have refused to meaningfully enforce anti-assisted suicide laws—has either formally expanded the legal right to die to those suffering existentially, or shrugged in the face of illegal assisted suicides of the depressed. To wit:

Switzerland: In February, the Swiss Supreme Court ruled that the mentally ill have a constitutional right to assisted suicide, because, as reported in the International Herald Tribune, "It must be recognized that an incurable, permanent, serious mental disorder can cause similar suffering as a physical (disorder), making life appear unbearable to the patient in the long term."

The Netherlands: The Dutch Supreme Court issued a similar ruling back in 1993 when it approved a psychiatrist assisting the suicide of his chronically depressed patient who wanted to die due to unremitting grief caused by the deaths of her adult children—even though the doctor never attempted to treat the woman. The basis for the ruling followed the above described logic of euthanasia: Suffering is suffering and it doesn't matter whether the cause is physical or emotional, meaning that Dutch mercy killing need not be limited to the sick and disabled.

The United States: We saw a similar phenomenon in America's reaction to the decade-long assisted suicide campaign of Jack Kevorkian. Not only were the majority of Kevorkian's "patients" not terminally ill (most were disabled)—but several were not even sick. For example, Marjorie Wantz, Kevorkian's second assisted suicide who died on October 23, 1991, complained about severe pelvic pain. Her autopsy revealed that nothing was wrong physically. It turned out that she had been hospitalized previously for mental problems. In 1996 Rebecca Badger went to Kevorkian complaining of having multiple sclerosis. Her autopsy proved that she was disease free. It was later reported that she had been depressed and addicted to pain pills. Despite these and other such cases of his assisting the depressed to kill themselves, Kevorkian remained publicly popular until he was finally jailed in 1999 after he videotaped himself murdering Lou Gehrig's patient Thomas Youk by lethal injection.

Oregon : Advocates for legalizing assisted suicide frequently tout Oregon's law as proving that assisted suicide can be restricted to the terminally ill. In actuality, little is known about what is happening in the state because it gets information about these practices almost exclusively through self-reporting by participating doctors.

Even so, the curtain was pulled back briefly when a peer-reviewed article in the June 2005 American Journal of Psychiatry appeared describing a potential assisted suicide of a psychotic man that was disturbingly similar to what is happening in the Netherlands and Switzerland. After cancer patient Michael J. Freeland received a lethal prescription, he had to be hospitalized for mental illness. Despite being delusional, his psychiatrist permitted him to keep the fatal overdose, in the doctor's words, "safely at home"—even though this same doctor advised a court that Freeland would "remain vulnerable to periods of delirium" and would "be susceptible to periods of confusion and impaired judgment." (Freeland died naturally nearly two years after receiving his lethal prescription—meaning he was also not terminally ill as defined by Oregon's law when he was prescribed the lethal overdose in the first place.) Needless to say, nothing was done to remedy this apparent breach of law.

The natural trajectory of assisted suicide advocacy leads to such ever-widening expansions of killable categories: from the terminally ill, to the disabled and chronically ill, to the "tired of life" elderly, and eventually to the mentally ill. Appel understands this and approves. He writes:

Contemporary psychiatry aims to prevent suicide, yet the principles favoring legal assisted suicide lead logically to the extension of these rights to some mentally ill patients. But now that several Western nations and one U.S. state have liberalized their laws, it seems reasonable to question the policies that universally deny such basic opportunities to the mentally ill.

With the truth now clearly in view, the time has come to have real debate about the so-called right to die. This debate should not pretend that the practice will be limited and rare and it should fully address the societal implications of transforming assisted suicide into a mere medical treatment.

So, let's argue openly and frankly about the wisdom of permitting near death-on-demand as a method of ending serious and persistent suffering. Let's discuss whether "choice" and "individual autonomy" requires that we permit licensed and regulated euthanasia clinics to serve anyone who has made an irrevocable decision to die.

Indeed, let's argue whether or not society owes a duty of prevention to the self-destructive who are not acting on mere impulse. But finally, let's stop pretending that assisted suicide legalization would be just a tiny alteration in public policy restricted only to the terminally ill. That clearly isn't true.