Despite the outlaw of PAS by the greater part of states, by a 61% to 34% majority, adults across the U.S. are in favor of an individuals right to physician-assisted suicide for anyone with less than six months to live, and said that they would support a law such as Oregon’s in their own state (Taylor, 2002).
The first argument in favor of PAS has to do with personal autonomy. Every individual has the right to control their life and to decide how they live. In the same way, individuals also have the right to control their death. They have an inherent right to choose death over pain and indignity. The terminally ill and their families should not be forced to suffer through a long and painful death, even if the only way to alleviate the suffering is through suicide. Advocates of PAS have been increasingly vocal during recent years, sparked by the highly publicized cases of Drs. Jack Kevorkian and Timothy Quill. These cases have centered on the plight of dying patients with terminal illnesses. But it is more than just the well-known cases that deserve a voice. Across the country, thousands of virtually unknown cases speak just as loudly. Sue Hess (2001), in a letter to the Vancouver Sun movingly writes:
"I have multiple myeloma...a rare bone marrow cancer...[that] destroys the blood, bones, immune system, kidneys and sometimes liver and spleen. The worst of it is the disintegration of the skeleton...Unless one is lucky enough to die of sepsis first, the death is long and agonizing. The act of sitting up can fracture the vertebrae and lifting the dinner tray can fracture both forearms. Who deserves that? For what principle?" (p. A16)
Ms. Hess has the questions right, and for all she must endure on a daily basis, I for one believe that she has deservingly earned the right to end her suffering, if she so chooses. But for some non-believers, that may not be enough to help them see the morality in PAS, so I will persist and explore the legal facets of PAS.
PAS is a natural extension of personal autonomy, and one aspect of that autonomy is the right to determine what treatments are accepted or refused. Refusal of life-sustaining medical interventions such as respirators, ventilators, artificial nutrition and hydration, is legal, widely accepted and commonly practiced. So one is effectively permitted to commit suicide by refusing treatment. And it is not only the refusal of treatment that is accepted and practiced; it is the withdrawal of treatment. One has to stretch the mind to perceive an ethical difference in unplugging a machine and prescribing a lethal dose of medication for the terminally ill patient. And though the U.S. Supreme Court has refuted this observation, it is clear that in both cases, the primary goal can be seen as the prevention of suffering at the end of life. Moreover, proposals for legalization frequently have more specific safeguards incorporated than do existing regulations on the withdrawal of treatment (Sobel & Lavon, 1997).
Another argument is that simply knowing that one can control the timing and manner of death serves as a form of psychological “insurance" for the dying. Recognizing there can be an escape from the suffering of their illness may alleviate some of the stress associated with the dying process. This argument is clearly illustrated in a letter by Gayle Stelter (2001):
"For almost seven years I have been living with cancer, mostly joyously and gratefully, but gradually seeing the disease encroaching relentlessly on my once healthy body. Throughout these years, I have thought long and hard about death and I've discovered that it's not the prospect of death itself that is so frightening, but the process of dying. So to give myself courage, I have held an option in reserve. When I can see no quality ahead, when I am capable of bidding my loved ones a coherent farewell, when I am still in control of my resources, I will enlist someone's help to speed me on my journey... For those of us who may choose to leave while there is still an element of control, of coherence, may we be fortunate to have a friend, a loved one, a health professional who will use their gifts in order that we may be excused. To deny such expert guidance in this last rite would be both heartless and inhuman.” (Vancouver Sun, p. A16)
Moreover, withholding physician assistance in dying increases the risk that individuals determined to end their lives will attempt to do so by nonmedical means, perhaps violently, possibly endangering others or further magnifying their own suffering as well as becoming more burdensome to their family and friends (Hull, 2003).
One of the most common arguments against PAS is the fear that its legalization would create an outbreak of unnecessary suicides and leave the door open to exploitation of PAS by doctors, insurance companies and even families of the terminally ill. Contrary to this dispute, however, is marked evidence from the state of Oregon. In its five years of experience with assisted suicide, there has not been a single documented case of abuse, nor did opponents' claims that Oregon would become a suicide haven ever materialize. What did occur was a tremendous improvement in end-of-life care for the terminally ill. Moreover, lifting the stigma of assisted suicide made people more comfortable in approaching their physicians and voicing their concerns about their end days. Even more compelling is that the majority of physicians reported that following the required counseling phase of patients requesting PAS, which includes presenting options such as hospice care, palliative care and enhanced pain management, roughly 46 percent of patients changed their minds about wanting a hastened death. Of those patients who received the medication, fewer than half used it (Halpern, 2003).
Critics of PAS charge that legalization would escalate a slippery slope to involuntary euthanasia. This slippery slope is the course from assisted suicide for competent, terminally ill adults to euthanasia for patients who cannot give consent: the unconscious, the mentally ill, and children. Additionally, opponents speculate that individuals of lower socio-economic classes or other disenfranchised groups will be "coerced," either directly or indirectly, into requesting PAS as a means of resolving the difficulties posed by their illness. Family members may subtly suggest that death, since inevitable, would be preferable if it occurred sooner rather than later because of the social and financial burdens involved in caring for terminally ill family members (Emanuel, 1997).
Often, opponents will turn to the Netherlands in their arguments, citing that the Dutch allow euthanasia as well as PAS. And if legalized in the U.S., it will only be a matter of time before we will also begin to accept and practice euthanasia. In reality, if PAS is legalized using the model from Oregon, the arguments of the opposition do not have much basis. As Oregon’s Death With Dignity Act shows, the law is quite specific and narrow in application. The law allows state residents with less than six months to live, the right to request medication to end their lives in a humane and dignified manner. However, the patient must ask three times over a period of no less than 15 days, twice orally and once in writing; a second physician must corroborate the diagnosis and prognosis and affirm the patient's mental competency as well as the voluntary nature of the request; both physicians must approve the request, and they must refer the patient to counseling if there are signs of depression or other mental disorders; and finally, the patient has to be able to swallow the drugs without assistance, as the physician is not allowed to intervene at the bedside (Robinson, 2003).
What is more, additional amendments were added to the Oregon law in 1999 discouraging patients from committing assisted suicide alone or in a public place, allowing pharmacists to refuse to fill lethal prescriptions if their beliefs are disrespected, and allowing health care facilities to prohibit participation in assisted suicide on its premises (Hemlock.org). These amendments to the original law further protect against coercion, abuse and the financial risks posited by opponents.
Moreover, rules regarding PAS in the Netherlands differ from what U.S. laws would require in the following respects: they do not stipulate that a patient must be terminally ill, and they do not require that a patient be experiencing physical pain or suffering - a patient can be experiencing psychological suffering only. It should also be noted that in the Netherlands the law actually prohibits assisted suicide and euthanasia. But those who practice it are exempt from prosecution if they follow specific procedures. This fact alone negates any similarity opponents apply to compare PAS in the Netherlands and PAS in the U.S. Oregon’s law, on the other hand, undoubtedly protects those that cannot defend themselves or those who are not of the mind to make such vital decisions. The nature of the law explicitly shows that PAS will not put us on the “slippery slope,” where euthanasia is ultimately legalized as acceptable practice for a wider patient population, including non-terminal and non-voluntary patients.
In conclusion, PAS is ethical, humane, compassionate, and deserving of legalization. There are those who challenge PAS insisting that life is too precious to take away in such a manner. To those, I leave the summation of the argument to The Eighth Bishop of Newark of the Episcopal Church John Shelby Spong (2003), “Death is what gives conscious life its uniqueness. Remove death from life and life becomes enduring boredom, an endless game of shuffleboard. We make life precious by embracing the reality of death not by repressing it or denying it”.
References
Americans United for Life. (2001). Assisted suicide laws in the United States. Physician assisted suicide: Legislation and policy guide. Chicago: Author.
Emanuel, E. (1997, March) Whose Right To Die? The Atlantic Monthly,279/3, 73-79.
Halpern, R.L. (2003). Death with dignity bill in Hawaii being ignored. Retrieved July 24, 2003 from http://www.hemlock.org/News/EditNews.asp?NewsID=118.
The Hemlock Society USA. (2002). Guidelines for Physician Aid in Dying Legislation. Retrieved July 27, 2003 from http://www.hemlock.org/changing_laws.asp#Amendments
Hess, S. (2001, February 24). Living with dying. [Editorial]. Vancouver Sun, p. A16.
Hull, R.T. (2003). The case for physician-assisted suicide. Free Inquiry, 23, 35-36.
Pickett, J. (Ed.). (2000). American Heritage Dictionary (4th ed.). Boston: Houghton Mifflin Company.
Robinson, B.A. (2003). Physician assisted suicide: Activity in Oregon. Retrieved July 24, 2003 from http://www.religioustolerance.org/euth_us1.htm.
Sobel, R.M. & Lavon, J. (1997). Physician-assisted suicide: compassionate care or brave new world? [Editorial]. Archives of Internal Medicine, 157.
Spong, J.S. (2003). Death: A friend to be welcomed not an enemy to be defeated. Address to the national convention of the Hemlock Society, San Diego, 10 January 2003. Retrieved July 28, 2003 from http://www.hemlock.org/news/EditNews.asp?NewsCategory=Special+Report+3.
Stelter, G. (2001, February 24). Living with dying [Editorial]. Vancouver Sun, p. A16.
Taylor, H. (2002). 2-to-1 majorities continue to support rights to both euthanasia and doctor-assisted suicide. The Harris Poll, 2. Retrieved July 26, 2003 from http://www.harrisinteractive.com/harris_poll/index.asp?PID=278