John is an 18-year-old young man who has struggled with depression for most of his life. He has tried to commit suicide in the past. Now that he is an adult, he has decided to take his own life and end his struggle. He purchased a gasoline-powered water pump to poison himself with carbon monoxide.
Mark is a 40-year-old man who just received a diagnosis of terminal cancer. He has a wife and young children. He would like the option to take a lethal drug that would allow him to die peacefully before his health declines to the point that he is in unbearable pain and a burden on his family.
Amos is an 81-year-old man who is in generally good health, but is unable to do some of the things he used to enjoy doing. He feels that he has led a good life and is ready to move on before he physically declines any more than he already has. He would like to go to a clinic in Europe to die.
Somewhere in the last twenty years, the idea of compassion changed. There was a time when compassion meant caring for the suicidal person, not enabling him to go through with it. Compassion used to mean stepping into a messy situation and convincing the person that he didn’t have to end it all, that his life still had meaning and value. Now compassion means providing a way for certain groups of suicidal people to end their lives because they want relief from physical, emotional, or financial pain more than they want to continue living.
In the above examples, John’s story is based on an incident out of Massachusetts in which a young man’s girlfriend, who lived 50-miles away, encouraged him to follow through with his plan to commit suicide over text messages and phone calls. Currently, there is a lawsuit to determine whether she is guilty of manslaughter.
Amos is a fictional character inspired by a nurse who decided that she did not want to grow old and physically decline. She was a healthy 75-year-old woman with a partner of 25 years and adult children who stay in contact with her. She didn’t want to age, and she didn’t want to be a burden on people. She went to Switzerland to die.
Mark is a fictional character loosely based on a man who chose to go to Switzerland to die after he found out he had cancer. In the real-life case, the man was not terminal, and his wife and daughters did not want him to go through with it.
These stories can help us understand the new legislation out of California. California is the fifth state to legalize physician-assisted suicide. Advocates tout the bill (ABX2 15, “End of Life Option Act”) as providing an option for terminally ill people who wish to end their lives peacefully and at a time that they desire. Detractors say that the bill opens the door for abuse and exploitation, and if other countries are any indicator, physician-assisted suicide will expand beyond the terminally ill.
The California bill is for people like Mark. Or, real-life people like Brittaney Maynard, the 29-year-old woman who was diagnosed with terminal brain cancer. She died by assisted suicide last year after moving from California to Oregon where physician-assisted suicide is legal. Her case sparked a national debate over legalizing physician-assisted suicide in various states, including California.
In our three examples, the arguments for why it is okay to provide pills to let someone like Mark commit suicide could easily apply to John or to Amos. The argument for physician-assisted suicide is based on the newer version of compassion, one that elevates choice and autonomy over care and dignity. An argument from compassion could apply to John and Amos’s cases as much as it does to Mark’s case. Indeed, all three would qualify for assisted suicide in places like Belgium or the Netherlands where laws have expanded to include physician-assisted suicide for people with depression or for children over the age of twelve.
Advocates of physician-assisted suicide tell stories of their loved ones being placed on machines at the end of their life or undergoing painful chemo, suffering and in pain until the end. Often people will say that they never want to go through what one of their parents or a loved one went through before they died. To them, the option of a peaceful death via suicide keeps them from this bitter fate. However, there are other options that do not involve suicide and maintains the dignity of the individual. There is comfort care.
A quote attributed to Hippocrates reads that physicians should “cure sometimes, treat often, and comfort always.” In medicine there is an in-between state where the goals are no longer curing, but switch to comfort so that the person can still have meaningful interactions with her loved ones and not suffer unbearable pain. For example, a person can decide not to undergo chemo therapy and, instead, have a better quality of life for her last few months. A palliative care physician who taught one of my clinical ethics classes said that there have been great advances in palliative care therapy. People do not have to die in pain.
As to the fear of being hooked up to machines, there are times when a machine would be burdensome and yet due to its minor efficacy, should not be part of a patient’s treatment plan. This isn’t giving up on a patient. It is not negligence, and it is not physician-assisted suicide. It is recognizing that this machine will cause more harm than good by burdening the patient rather than helping him.
There are even cases when it would be ethical to withdraw machine support because the machine is doing nothing to help the patient’s condition and is not staving off the progression of the disease. This can be an ethically gray area where the clinical details make a difference, but in the cases when treatment is not working, then the patient is often weaned off of the machine and the goals are switched to comfort care as the untreatable disease finally takes the person’s life.
Often, the person who wishes to have physician-assisted suicide says that she does not want to be a burden on anybody. While this is a noble sentiment, it is wrong. Every one of us, from the moment we came out of the womb as a vulnerable, helpless baby, has been a burden on our loved ones and on society. That is part of being human. Even in the prime of our lives, we affect the people around us. We can burden them and we can help others carry their burdens. Indeed, love is often about helping someone carry their burden. As noble as the sentiment sounds, it dismisses what it means to be human and live in community.
However, there is one burden that a person does not have a right to require of someone. It is the burden of taking another life. The physicians who prescribe these medicines are asked to carry the burden of administering death, a burden that physicians were never meant to carry. Originally, the Hippocratic Oath said that a physician should not give poison to anyone even if asked to do so. Physician-assisted suicide changes the role of the physician from doing no harm to doing what the patient asks whether it brings him harm or not.
Governor Jerry Brown ultimately decided to sign the bill because he would want the option of physician-assisted suicide in the face of “prolonged and excruciating pain.” Not only does this fly in the face of medicine, but it ignores hospice and palliative care.
Rather than adopting legislation that would provide adequate comfort care to those populations that do not have access to it, something that is badly needed in our skewed healthcare system, the California bill and Governor Brown’s reasoning helps promote the notion that suicide is at best, as compassionate an option as palliative care, and at worst, the only option in the face of suffering at the end of life. In the midst of a terminal diagnosis in which a person’s life is already cut short, a truly compassionate perspective would seek to manage the pain and provide opportunities for more meaningful moments with loved ones, not eliminate suffering by eliminating the person.