The New York Times recently released an article stating that the state of Washington had a total of 36 legal assisted suicides since the passing of its legislation last year. I personally applaud Washington State for having the courage to allow people dignity and ease of pain. When I debate people on this subject they commonly refer to suicide as being murder of one’s self. The dogma of Dante’s Divine Comedy and its circle reserved in hell for those who leave life on their own terms has entered the collective consciousness of the religious right and made its way into politics. The best argument I have heard against religious claims came from a PBS documentary on the subject. Watch and share your thoughts and feelings on the sensitive issue.
First permit me a bit of a rant – though let me be clear that this is not directed at Neal per se (whose use of the term might well have been just an off hand remark). I am always skeptical of political commentary that includes the term “the religious right”. By “religious right” I guess one means the vast majority of Americans who are religious and lean toward social conservatism? No matter how many Americans are included, the more important question is: How does this slur (and let’s admit that the term operates as a slur) actually inform the debate? By using the slur, one pretends that social conservatives don’t have any actual arguments for their positions (on abortion, gay marriage, euthanasia) but are instead simply “imposing” their religious views on others. That presumption is so atrociously ignorant that I am just tired of combatting it. In the view of many SHAFTers I am probably a member of the “religious right”, but I have NEVER used religion as an argument on those topics on this blog (or really anywhere else).
To the point of the post: Is the American Medical Association a part of the so-called “religious right”? That would be news to social conservatives, who have butted heads with the AMA for years on abortion. But the AMA – the largest organization of physicians in the country – has been consistently and vigorously against assisted suicide and euthanasia. They see it, not surprisingly, as a rather obvious violation of the hippocratic oath. And keep in mind that if you have a right to die, that means someone has a duty to kill. What the AMA has been saying for decades now, loud and clear, is that doctors do not want that obligation.
The experience of the Netherlands should give us pause because it shows that slippery slope arguments are not just scare tactics. They started decriminalizing assisted suicide in the mid 1980s. Later they permitted euthanasia. Though their system is meant to have regulations to prevent abuse, the overwhelming evidence is that these regulations are ineffective. Studies show that anywhere between 500 and 1000 patients are euthanized without consent annually. The rules are so widely disregarded that some hospitals in the Netherlands encourage sick patients to tell their doctor if they do NOT wish to be euthanized should they become incompetent. A recent report there concluded that euthanasia was “beyond effective control”.
I have not seen this Frontline episode, but there was a similar PBS documentary a year or so ago on the topic. It was heart-wrenching, and one must have nothing but compassion for those people who are clearly facing a terrible trial. Our medical technology certainly makes for very complicated problems, it can be both a blessing and a curse. My above comments should in no way be taken to mean that I am naive or uncaring about the human face of this problem. The AMA’s view is that there is evidence that access to quality palliative care is not always ensured, and that if it were the requests for PA-suicide would be all but eliminated.
“In the view of many SHAFTers I am probably a member of the “religious right” . . . ”
Not in my view. The “religious right” in my mind are people like Glenn Beck, Bill O’Reilly, Mike Huckabee, and Sarah Palin.
I would just caution that the AMA is a professional organization primarily looking out for the interests of physicians, and will naturally favor the position most favorable to them in terms of litigation. Terrible to be so cynical, but that’s the world we live in…
To me the term “religious right” mean those who are informed politically primarily through their religious affiliation. Religion almost always dictates a position that most would consider right-wing. There are, of course, left-wingers whose opinions are also informed religously. I know quite a few liberals who are also anti-abortion. For some reason, however, their numbers aren’t enough to constitute the category “religious left.” If you are a Christian, you typically: favor small government, disfavor welfare or collective charity (outisde church activity), think homosexuality is a sin, think abortion is murder, think suicide is sinful, disfavor miscegenation, and so on. It’s a broad brush, but it does capture a pretty well-defined class of people.
The presumption, though,is that the “religious right” is somehow arriving at their beliefs in some irrational manner, while those that do not have religiously informed moral views somehow arrive at their beliefs through pure reason. But this strikes me as false. I think most people, on the left and the right, have beliefs without having many good non-emotional reasons for having them.
Kleiner,
Instead of citing horror stories from other countries, why don’t you tell us what YOU think. If you’re not simply reciting dogma, what are your reasons for not allowing a person to say when enough is enough.
I thought I did make clear what I think.
My “horror story” was meant as a public policy argument. The lesson to be learned is that the logic of assisted death naturally expands into even uglier things – that killings motivated by a distorted sense of mercy lead to killings that have nothing to do with the best interest of those killed.
And I think assisted suicide and euthanasia are unnecessary. Following the APA, I believe that if adequate palliative and hospice care were provided, no one need suffer the horror stories of excruciating pain in terminal illness. We should put more resources to this end, and many doctors probably need better training.
I don’t think people need help dying, but in some cases they do need help seeing that their lives have meaning even in their suffering. It is a strange (and, Kant would say, irrational) thing to eliminate suffering by killing those who suffer.
I would also point out that, even if someone disagrees about the meaning of life and suffering, to demand assisted suicide (to say you have the “right to die”) implies that someone has the duty to kill you (or to help kill you). I think it is morally wrong to participate in this dehumanization, and I am against any public policy that would require it. This is the APA’s view, which is not driven, it seems to me, out of self-protection from litigation but from the Hippocratic Oath and the very meaning of their vocation.
Look, people don’t have a right to everything that they might want. It is as simple as that.
Many think that PA suicide is unnecessary for yet another reason: with the sorts of safeguards that most would want, including waiting periods, (and, again, the Netherlands shows that these are insufficient) most candidates for PA suicide could die as quickly through terminal dehydration (and with palliative care this is painless). I don’t think thirsting oneself to death is morally upright, but people already have the freedom to do this and terminal dehydration does not open up the moral hornet’s nest that PA suicide (much less active euthanasia) does. (See Miller and Meier article in ‘Annals of Internal Medicine, vol 128 no7, 4.1.98).
Dr. Kleiner,
I think your point about hospice care makes a lot of sense, but aren’t there cases where all the morphine and counseling in the world still leave the patient trapped in a bed, either in agonizing pain or only a very hazy consciousness? Are there never cases where one’s quality of life is so low that it’s too much to ask a person to go on? And what about cases (say on an isolated battlefield in a war) where access to good end-of-life care simply isn’t possible?
Mike L – I don’t know if there are any cases where palliative care is ineffective in the ways you suggest. I am not a doctor, but it is worth pointing out that the AMA thinks that proper palliative care need not these ill effects. Also worth noting that some studies of people in Oregon have shown that pain is not the primary reason people have opted for PAS. “Control” and “choice” (and a fear of dependency) are more often cited as main motivators, not “pain”.
Battlefield assisted suicide seems very problematic. Almost no one – not even assisted suicide advocates – think that this should be allowed as an “on the spot” kind of choice. Psychological evaluations would be required to make sure the person is mentally and emotionally stable, for instance. Hard to see how you would satisfy all of the regulatory precautions on a battlefield.
One point of clarification here: people are free to kill themselves. Suicide is not illegal (and it would be pretty hard to punish!). The question here is whether or not people have a right to insist that other people (physicians) assist them in killing themselves. Again, people can already choose to die through terminal dehydration. This right is well-established based on the principle of autonomy that is pretty basic to medical ethics.
Professor Kliener the system that is set up in Washington follows along similar lines as dehydration suicide. In Washington the physician merely gives the patient (after long series legal and medical checks) a prescription for a pill that ends their life. The choice and the final administration of the prescription is up to that patient. We don’t charge people that sell the various other tools of suicide as people who assisted that suicide, and we most certainly do not charge drug companies of murder if a customer purposely overdoses. In much the same way doctors are just allowing the choice and are not committing the actual administration.
This brings me to my question, how is “pulling the plug” different from assisted suicide, if in either case the doctor has the ability to extend the miserable remnants of life the patient has left?
First, I don’t think that choosing terminal dehydration is morally good, I was just pointing out that it is already legal within the established practices of medical ethics so the push for PA suicide seems unnecessary.
In any case, I don’t think terminal dehydration and PA suicide are similar. It might be useful to define some terms:
- Euthanasia can either be voluntary (proceeds from competent patient request), involuntary (proceeds against the will of the patient) or non-voluntary (involves an individual who is not competent to give consent). For our purposes, let’s just presume we are speaking of voluntary (though the slippery slope argument suggests that one quickly moves to other types upon permitting voluntary).
- VAE voluntary active euthanasia: physician kills the patient (administers a lethal dose)
- VPE voluntary passive euthanasia: physician allows the patient to die (“pulls the plug”)
- PAS physician assisted suicide: physician provides the means (information, prescription, needles, etc) for a patient to kill themselves
As you say, in the case of PAS the physician “merely gives the patient a prescription” and it is up to the patient to actually do the deed. But you act as if this is no small thing. But the APA disagrees, they see using medical knowledge to bring about death as a basic violation of the hippocratic oath and the meaning of their vocation. And while the physician does not do the actual killing, by providing the means they are clearly complicit in the act. The doctor is made to participate in the hastening of death where the cause of death will not be natural.
This leads to your next point. You ask how “pulling the plug” (VPE) is different than assisted suicide. A good question. But I think the view that there is no difference between the two involves a metaphysical confusion about causes.
Case A (VPE): Patient with terminal cancer. Doctor removes them from life-extending treatment (chemo, whatever). The patient dies. Cause of death: cancer.
Case B (PAS): Patient with terminal cancer. Doctor gives them a prescription for a lethal dose of morphine and instructs them on how to administer it. The patient dies. Cause of death: morphine overdose.
“Killing” and “letting die” are not the same. One is an act of commission and the other an act of omission. Now it might be the case that some acts of omission are also deserving of moral blame (if I pull the plug on someone against their will, for instance). But looking at the two hypothetical cases above, in the first case the cause of death is man and in the latter case the cause of death is the illness. No one, in Case A, would say “cause of death was the doctor pulling the plug”. What they would rightly say is, “cause of death was cancer.”
That we are tempted to think that these two things are identical suggests a deeper problem – the underlying conceit that man has conquered nature in such a way that all events are ultimately under his control and direction.
Excuse me, I meant to say “In any case, I don’t think “pulling the plug” and PA suicide are similar.”
I think terminal dehydration actually falls under the same conceit that I identify at the end of my last post. But at least it does not require the active complicity of others, as does PAS.
That we are tempted to think that these two things are identical suggests a deeper problem – the underlying conceit that man has conquered nature in such a way that all events are ultimately under his control and direction.
I think you’re kind of showing your hand here. I don’t think you can get away from the gravitational field of your religious convictions, that all things death-related are up to God and not us. This is the pink elephant in all your remarks. I don’t mean to be disrespectful, but this disqualifies much of your argument. “Slippery slope” is not so much an argument here as it is a rhetorical fallacy. You’re also appealing to consequence when you say that “right to die” implies “duty to kill.” If that was a true proposition then it would be correct to invert it (modus tollens), but I don’t think it is a valid proposition. There will probably always be physicians who won’t want to end life, as there will be those who think it is the correct thing to do — just as today there are doctors unwilling to perform abortions and those who think it is correct. (I believe) it is more important to leave consequence out of it and ask whether the act itself is acceptable. This may be hard to do, since modern rhetoric concentrates heavily on arguing to consequences — to its detriment, IMO.
That we are tempted to think that these two things are identical suggests a deeper problem – the underlying conceit that man has conquered nature in such a way that all events are ultimately under his control and direction.
Sorry, I’m not finished mining this statement — because if there’s one thing humanity has shown beyond a shadow of a doubt is our capacity to both kill and “let die” and our command over the distinction, and our ability to carefully choose one from the other. In war we even have names for it, like “collateral damage.” I don’t think you can claim that there’s some kind of lapse in our general understanding.
I don’t think he was making that claim, just responding to Neal.
On your first point, I don’t see that one must needs understand the point that not all events are ultimately under the control of man as a religious point. Martin Heidegger (usually presumed to be an atheist) makes this same point in Question Concerning Technology. The point just seems obviously true whether God exists or not. Man is not the cause of all things, some events are caused by external non-human causes. I have a hard time seeing how anyone could deny that claim. We don’t cause tsunamis or sunshine. And we don’t cause cancer or the flu. When people die it is not always traceable to a human cause. Sometimes it is (murder). But sometimes people die from lion attacks. And sometimes people just die of cancer. Does saying this manifests some hidden religious agenda?
Worth noting that there are plenty of non-religious, indeed purposely non-theological, arguments against suicide. See Kant, who tries to couch his moral philosophy in pure reason (something some SHAFTers, insofar as new atheism is just recycled enlightenment thought, might well be attracted to).
Regarding the right to die and the duty to kill. The right to die is a “positive right” rather than a negative one. A positive right is a right which obliges an action while a negative right is a right that obliges inaction. The right to die clearly is a positive right since it requires the action of another person.
I am not the one who makes this connection. People like Jacob Appel (an outspoken proponent of physician assisted suicide) make this point. If the right to die is not an empty right, the state will have to require that some physicians (who have a monopoly on prescribing medications) help to kill. The state could mandate this (and might need to, in light of the incredible resistance to the practice from doctors) as a prerequisite for having a medical license. I don’t know – and neither do you – if there will be willing doctors. But if there aren’t, and you have a positive right to die, then the state could mandate that a doctor help you kill yourself.
I’m not sure I follow your second point. Collateral damage – if it is justified at all (and I have serious suspicions that it is) – is a different matter altogether. Collateral damage is a killing, not a ‘letting die’. But I feel that I am missing your point here.
Collateral damage was just a tangential way to illustrate that we as a species understand the distinction between “letting die” and actively killing very well. Whether collateral killing is actually active killing or “letting die” is debatable. I think the US Mil would argue that it isn’t actually killing but rather letting the chips fall where they way.
Your point about positive rights and compelling doctors to kill people is interesting in light of the abortion debate. As far as I know doctors are not compelled to perform abortions, yet women seem to have no trouble finding doctors willing to do it. Abortion as a procedure is probably in the job description for some Ob/Gyn positions, but it is not mandated by law that a doctor perform them.
I don’t think we clearly apprehend the difference between killing and letting die. Neal’s question (how are ‘pulling the plug’ and assisted suicide different?) demonstrates as much. The point is that, with positive rights, it would have to be mandated by law if the need arose. This is not scare tactic argumentation, this is what assisted suicide proponents like Jacob Appel say. I think this should trouble you.
Aside on abortion, though I am not intending to derail the debate: there is currently debate about whether a doctor or a hospital could decline to perform certain procedures. FOCA (which Obama promised to sign but thankfully has not) would basically abolish conscience clauses and hospitals would not receive any federal funding (ie, medicare patients) if they refused to perform abortions. The US Conference of Catholic Bishops has threatened to shut down Catholic hospitals (a huge part of our health care infrastructure) if FOCA is passed.
Collateral damage is not really a case of ‘letting die’. Those that try to justify such things typically appeal to the doctrine of double effect (that one is morally responsible only for the things they intend, but are not responsible for unintended though anticipated effects). So the US military wouldn’t deny that their actions killed innocents (since some of their actions plainly do), instead they would just argue that they are not morally culpable fort those killings.
Enough of defending my view. Can someone make an argument for why suicide is morally good, and why assisted suicide is good public policy? I am hoping someone comes up with something better than ‘I should have a right to the things I want’. I am interested in hearing Hunt’s argument in particular. Most pro euthanasia and assisted suicide arguments are utilitarian, but she does not think we should make consequentialist arguments.
As he says in the clip:
“If I go through with it, I die, as I must at some point. If I don’t go through with it, my choice is essentially to suffer, and to inflict suffering on my family, and then die.”
I argue that if you are to die anyway, it is morally good to do so without causing those close to you more pain, and without stacking up huge medical bills to be paid by those you leave behind. The result is the same, but staying alive hurts others more than suicide does.
I’d have to say again that the issue about coercing doctors to kill people is in all likelihood a moot point since I suspect there is already a de facto procedure and perhaps even protocol physicians undertake in end-of-life situations. There’s much that happens in hospitals that the general public and legislators are unaware of. If you know any doctors I suggest you ask them about this, but don’t be surprised if they’re less than loquacious. To me, end-of-life seems far less fraught with moral peril than the issue of abortion; however, far more wrenching. Making PAS explicit and lawful would allow doctors to act above-board and be subject to review, oversight, and so on. In this way, the matter is very much like abortion pre RvW, when doctors acted individually and illicitly to their detriment and the detriment of their patients.
The US Conference of Catholic Bishops has threatened to shut down Catholic hospitals (a huge part of our health care infrastructure) if FOCA is passed.
Doesn’t surprise me in the slightest; Catholics already demonstrated their willingness to withhold treatment that doesn’t fit with Church dogma. Condoms in Africa, anyone? You might describe this as the Church taking its ball and going home, except that “the ball” is pretty huge chunk of the world’s wealth.
I am hoping someone comes up with something better than ‘I should have a right to the things I want’
You can’t simply boil that sentiment down to simple indulgence; this amounts to poisoning the well on a perfectly valid argument. In the end-of-life situation, if respecting individual choice isn’t honored then, then when?
In general, I would only defend suicide for healthy individuals in rare scenarios like astronauts in space facing calamitous circumstance and horrific death — that kind of thing. We all know from the movies about the infamous “suicide pill” to be issued to spies at risk of torture and death, etc. Some parallels can be drawn to the medical cases as well. If a person’s prospect is merely torture and then death, suicide seems a rational option (contra Kant) — as Joe said and as testified in the video.
I’ll relent on the collateral damage debate. Since I have the very notion, I’m more than happy to call it killing.
And, I’m a “he” not a “she”.
I agree that the issue is a wrenching one, and I can only have pity for those who are facing such a difficult trial.
On the practical side I know many doctors. My dad and sister are both physicians, and the former serves on the ethics board of his hospital. We talk about these issues often. They both echo, and tell me that most docs do, the APA sentiments on the hippocratic oath. But I don’t think I have been clear on the right-duty point. My point was not meant to be a practical one, it is a principled one. I am not asking the practical question as to whether there will be willing participants. The question is, do I have the right to oblige someone to help me kill myself? Hunt puts it this way, “In the end-of-life situation, if respecting individual choice isn’t honored then, then when?”
So Hunt wants to make it an issue of autonomy. That is a good starting point – patient autonomy is a well-established principle in medical ethics. But I would argue (and most in the profession agree) that patient autonomy generally only includes negative rights – their autonomy can oblige inaction. For instance, they are free (autonomous) to refuse medical treatment and free to refuse food and water. That negative right requires inaction; it is not lawful to force medical treatment or force feed an unwilling competent person.
But physician assisted suicide is quite different. Does my autonomy (“respecting individual choice”) extend to requiring that others help me achieve my ends? I say no. I don’t think you have a right to oblige others to help you kill yourself. Arguing that you do not have that positive right is not, in my view, an unjustifiable restriction on your autonomy. In other words, I do think your argument is a matter of “indulgence” (that I have a right to the things I want), and I don’t think your argument is valid because it relies on an ambiguity on the meaning of freedom/autonomy.
Here is an analogy: I have the right to free speech. That is a negative right, a right that requires the inaction of the state (the state cannot censor my expression). But my right to free speech is not a positive right, it does not oblige the state and others to give me a platform from which to speak. So I think you have a right to autonomous decision making with your life, and that right includes potentially obliging others to inaction. But that right does not include obliging others to actions which help you achieve your particular ends (in this case, death).
From the public policy point of view, on balance I think the state has more compelling reasons to not legalize PAS than to legalize it (potential for abuse, vulnerability of marginalized groups, devaluation of the lives of the disabled, increase financial incentives to limit care, near impossibility of effectively regulation and limiting the practice, pressure on patients, disincentives to medical innovation, etc).
Perhaps Hunt will want to argue that the so-called “right to die” is a positive right, not a negative one. If so, I would have these questions for him:
If you do have the positive right to die, is there any principled reason that the corresponding obligation that requires others to act should be restricted to assisting you in killing yourself? Why would that not extend to obligating others to kill you (active euthanasia)? And if you have the positive right to die, is there any principled reason why should this obligation that others help kill or kill you be restricted to cases of terminal illnesses?
have the very notion = hate the very notion.
But I just want to say that I’m as much against making our world into “Soylent Green” as kleiner or anyone else is. If “being a burden” is the precipitating reason for the desire to end life, then I’m all against it.
For those interested in the Dutch situation, here is a pretty comprehensive overview of the legal developments in the Netherlands regarding euthanasia and assisted suicide.
http://www.firstthings.com/onthesquare/2010/03/sympathectomy-of-the-soul