Debate Over Legalizing Physician-Assisted Death for the Terminally Ill

Four experts in ethics and palliative care argue the pros and cons of Death With Dignity laws.


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Andrew Solomon, PhD

Daniel P. Sulmasy, MD, PhD

Peter Singer, MA, BPhil

Baroness Ilora Finlay, FMedSci

When hope of recovery is gone, when one achieves relief from physical symptoms only at the cost of mental clarity, and once dignity is lost to physical deterioration, the wish to end one’s life may be rational.

—Andrew Solomon, PhD
For more than 25 years, I’ve looked after dying patients. I’ve had countless conversations about death and dying, and … it is through compassion that I see how dangerous it is to license doctors to provide lethal drugs.

—Baroness Ilora Finlay, FMedSci

On November 1, 2014, 29-year-old Brittany Maynard ended her life through physician-assisted death, reigniting the controversy surrounding Death With Dignity laws, which allow physicians to prescribe life-ending drugs to terminally ill patients. Diagnosed with glioblastoma multiforme in January, Ms. Maynard was given 6 months to live. Afraid that she would suffer unremitting pain and cognitive and motor loss, she moved from California to Oregon, one of five states with laws legalizing physician-assisted death—often referred to as physician-assisted suicide—so she could choose “death with dignity.”

“Having this choice at the end of my life has become incredibly important,” wrote Ms. Maynard in an essay posted on CNN.com.1 “It has given me a sense of peace during a tumultuous time that otherwise would be dominated by fear, uncertainty, and pain.”

Description and Perception

Since Oregon’s Death With Dignity Act became law in 1997, 752 patients have participated in physician-assisted death; 400 more people received prescriptions to end their lives but never took the medication.

Despite outcries from opponents of assisted death that facilitating suicide in any context devalues human life, there is growing support of the Death With Dignity movement across the country, with 70% of Americans in favor of allowing doctors to hasten a terminally ill patient’s death when the process is described as “ending the patient’s life by some painless means,” according to a 2013 Gallup Poll.2 However, support for the process drops to 51% when it is described as doctors helping patients “commit suicide.”

According to the latest information, seven states, including Connecticut, Hawaii, Kansas, Massachusetts, New Hampshire, New Jersey, and Pennsylvania, have pending bills in favor of physician-assisted death.

Arguing the Pros and Cons

Although ASCO has taken no official position on physician-assisted suicide, in a 1998 position statement on high-quality end-of-life care,3 which neither supported nor condemned the practice, the Society recommended that physicians engage their patients in discussions about their concerns regarding how they might die; explain what comfort care will be provided; and assure patients that they will not be abandoned.

“The most important response to the physician-assisted suicide debate is to take every responsible measure to assure that all physicians are well trained in optimal end-of-life care and to remove all barriers to the delivery of such care,” said the statement.

In November 2014, Intelligence Squared U.S. Debates, a nonpartisan, nonprofit organization in New York, argued the ethics of the issue and whether death with dignity laws devalue human life and lead to a slippery slope, where vulnerable patients are pressured to choose death, or are a recognition of everyone’s basic human rights to autonomy and freedom from pain and suffering.

The motion “Legalize Assisted Suicide” was argued by four authorities in ethics and palliative care and then voted on by audience members. Arguing for the motion were Peter Singer, MA, BPhil, the Ira W. DeCamp Professor of Bioethics at the University Center for Human Values at Princeton University; and Andrew Solomon, PhD, Professor of Clinical Psychology at Columbia University. Arguing against the motion were Baroness Ilora Finlay, ­FMedSci, Professor of Palliative Medicine at the Institute of Cancer & Genetics at Cardiff University School of Medicine in Wales and President of the British Medical Association; and Daniel P. Sulmasy, MD, PhD, the Kilbride-Clinton Professor of Medicine and Ethics in the Department of Medicine and the Divinity School and Associate Director at the MacLean Center for Clinical Medical Ethics at the University of Chicago Medicine.

The ASCO Post has excerpted portions of the debate here. (To watch the full debate, go to http://fora.tv/2014/11/13/Legalize_Assisted_Suicide.)

PRO

Andrew Solomon, PhD

Because much of modern medicine prolongs not living but dying, we need to rethink death itself. Making someone die in a way that others approve, that he feels is anathema, is an odious form of tyranny. Aiding dying needs to be tightly regulated, as any life or death matter does, from driving to surgery. However, although no one should be pressed into assisted dying, no one should be categorically denied that right. It’s about dignity.

Brittany Maynard, who captured headlines for choosing to end her life at the age of 29 at the end of a battle with brain cancer, said, “It has given me peace. I do not want to die, but I am dying, and I want to die on my own terms.”

It’s not about depression. When hope of recovery is gone, when one achieves relief from physical symptoms only at the cost of mental clarity, and once dignity is lost to physical deterioration, the wish to end one’s life may be rational.

Some people may find great meaning in those very final stages, whereas others may not be interested in finding that meaning. And from a nontheological point of view, it can be argued that the meaning people attach to that stage of life is an artifact of the human imagination.

It’s not about suicide. Suicide responds to personal disintegration, whereas this precludes it. And it is about the limitations of medicine. It’s nothing short of medical arrogance to say that palliative care and hospice care can adequately deal with the end of every life. Hospice, in fact, can impose an authoritarian, hard, paternalistic view that the hospice way of dying is the only way.


CON

Daniel P. Sulmasy, MD, PhD

I am a physician, and part of my job is to help people die with dignity and in comfort. However, I don’t want to help you or your daughter or your uncle commit suicide. And you shouldn’t want me to. I urge you to oppose physician-assisted suicide, because it’s bad ethical reasoning, bad medicine, and bad policy.

We strongly support the right of patients to refuse treatments and believe that physicians have a duty to treat pain and other symptoms, even to the point of hastening death. However, empowering physicians to assist patients with suicide is quite another matter, striking at the heart not just of medical ethics, but also of ethics itself. That’s because the very idea of interpersonal ethics depends upon our mutual recognition of each other’s equal independent worth, the value that we have simply because we are fellow human beings.

Now, is assisted suicide death with dignity? The word “dignity” has at least two senses. Proponents use the word in an attributed sense to denote the value others confer on them or the value they might even confer upon themselves. But there’s a deeper, intrinsic sense of dignity. Human dignity ultimately rests not on a person’s interests, but on the value of the person whose interests they are. I don’t have to ask you what your preferences are to know that you have dignity.  

Assisted suicide and euthanasia require us to accept that it is morally permissible to act with the specific intention of making a somebody into a nobody, to make the person dead. Intentions, not just outcomes, matter in ethics. Intending that somebody be turned into a nobody violates the fundamental basis of our interpersonal ethics, our intrinsic dignity.

Paradoxically, in physician-assisted suicide and euthanasia, patients turn control over to physicians, who assess their eligibility and must provide the means. And, further, since death obliterates all liberty, saying that respect for liberty justifies the obliteration of liberty undermines the value that we place on human freedom.

 

PRO

Peter Singer, MA, BPhil

First, we believe that people should be the ones to decide for themselves whether they think that continued life is worthwhile for them or not. We don’t think that it should be up to anybody else to say, “We think your life is worthwhile.” And, second, we think that there is a lot of unnecessary suffering, whether it’s excruciating pain or not; suffering and distress of various sorts will continue in this system, and for the foreseeable future, it could be relieved by a relatively simple legislative reform that has been shown to work.  

Now, in fact, [the Northeast] region took a little step closer to that. The New Jersey State Assembly voted to pass the Aid in Dying for the Terminally Ill Act, which is similar to the other legislation that we’ve been discussing. It voted 41 to 31—a fairly clear majority. Of course, it still has to go to the Senate, where it would need the assent of the governor, so it still has some way to go.  

I want to quote one of the supporters of the bill whose name is Janet Colbert. She’s a retired oncology nurse, so she knows a lot about cancer and about people dying of cancer. She now herself has terminal liver cancer, but she supports this [bill] because she said, “As I battle my illness, I would like the choice and comfort that come with the option of aid in dying.”


CON

Baroness Ilora Finlay, FMedSci

I’m a palliative care physician. For more than 25 years, I’ve looked after dying patients. I’ve had countless conversations about death and dying and supported each one individually, not with some type of formula death. It is through compassion that I see how dangerous it is to license doctors to provide lethal drugs.

When you normalize physician-assisted suicide, the underlying social dynamic changes. Laws aren’t just regulatory instruments; they send a message. And the message they send is that if you’re terminally ill, ending your life is something that you ought to think about.  

Changing the law isn’t simple and straightforward. So, what are some of the problems? Let’s look at prognosis. Prognoses are notoriously inaccurate. Even the most expert [at predicting when death will occur] has a 50/50 chance of being wrong about a life expectancy of 6 months. Oregon’s law requires a prognosis of 6 months or less [to be eligible for assisted death], yet 2 years, 9 months from request to death has been recorded. Pathologists tell us that at postmortem, about 1 in 20 [patients] is found to have died of something different from the condition for which he or she was treated.

Forty percent of seriously ill people have some mental disturbance often attributed to the illness, anxiety, or treatment. And in 13% to 14% [of the cases], this is a major, treatable depression. Yet Oregon’s own research shows that about 25% of those seeking assisted suicide have depression, which is sometimes missed or overlooked. 

[Outside] pressures [on the patient] may be more difficult to pick up than depression. Coercion can be subtle—the costs of care, life insurance about to expire, or just caregiver fatigue (the person who picks up that their family is stressed and doesn’t want to be thought of badly).

And what of doctors? For the doctor under pressure, it is all too easy to give into the pressure to prescribe. Doctors must recognize dying, not impose futile treatments, and relieve distress.  

It’s all too easy to be swayed by emotion and fear, but human beings are uniquely interconnected. If I accede to the request to provide lethal drugs, I actually give the message, “Yeah, I think you’re right. You’d be better off dead.” I don’t give the message that you are of worth. I’ve been there myself. My own mum was in a hospice dying, angry, terribly angry that I was opposing the assisted suicide that she wanted. She thought it was the answer. This fiercely independent lady dreaded dependence. It broke my heart, and I was torn apart by it.

So, she battled with us and then went home. To everyone’s surprise, she didn’t die; she lived 4 more years. And in those 4 years, she saw her two great grandsons born. And she said they were the richest years of her life. They were important to her and to us all.

[Assisted suicide] is not like in the movies. Assisted suicide isn’t straightforward and clean and quick. Some people take a long time to die, up to 104 hours. That’s not dignified. Don’t vote for this dangerous law that actually deprives people of the possibility of having their dignity and having doctors who have to work to improve their quality of life. This law allows them to throw in the towel.

Results of the Debate

An audience vote before the debate showed that 65% were in favor of the motion to “Legalize Assisted Suicide”; 10% were against the motion; and 25% were undecided. After the debate, 67% voted for the motion. According to the rules of the debate, the opposing side had to pick up 2 or more percentage points to win the debate. In the final tally, 22% of the audience participants voted against the motion, an increase of 12 percentage points over the original vote, and the side arguing against physician-assisted suicide was declared the winner. ■

References

1. Maynard B: My right to death with dignity at 29. November 2, 2014. Available at http://www.cnn.com/2014/10/07/opinion/maynard-assisted-suicide-cancer-dignity. Accessed December 1, 2014.

2. U.S. support for euthanasia hinges on how it’s described. Gallup, May 29, 2013. Available at http://www.gallup.com/poll/162815/support-euthanasia-hinges-described.aspx. Accessed December 1, 2014.

3. Cancer care during the last phase of life. J Clin Oncol 16:1986-1996, 1998.



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