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Will Physician Assisted Suicide Lead To Rational Suicide

Is physician assisted dying/suicide (PAD/PAS) just the first step onto the slippery slope of normalizing suicide? Should we democratize suicide for all autonomous citizens, stripping away the physician’s involvement and clearing the decks of the ruse of easily manipulated subjective criteria that PAD/PAS legislation has established in this country?

In the US, eight states and the District of Columbia have passed laws supporting PAD/PAS. New Jersey will become the ninth in August. However, at the American Medical Association (AMA) 2019 Annual Meeting, delegates voted overwhelmingly to affirm the current policy opposing physician-assisted suicide.

The current Code of Ethics states that “permitting physicians to engage in assisted suicide would ultimately cause more harm than good” and that “physician-assisted suicide is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks.”

Nonetheless, a 2018 survey conducted by Medscape showed that 58% of physicians support PAD/PAS, up from 46% in 2010. Couple that with a 2018 Gallup poll that showed 72% of the general public supported physicians being able to help terminally ill patients die. Hence, there is an obvious disconnect.

Advocates for assisted suicide tug at the heartstrings of those who need persuasion proclaiming this act is justified as a caring nation, utilizing the “intractable pain of the individual” argument. Research does not support this argument.  In fact, according to the Oregon Death With Dignity Act 2018 Data Summary,only 25.6% of respondents who opted into the PAS process cite pain or concern about inadequate control of pain as a reason. The top reasons from the Oregon report, a state with the most history, are:

  • Loss of autonomy (91.7%)
  • Less able to engage in activities (90.5%)
  • Loss of dignity (66.7%)
  • Feelings of being a burden (54.2%)
  • Losing control of bodily functions (36.9%)

Therefore, it is disingenuous and misleading to focus on pain.  The vast majority of people jump to say “I want that pill” when hearing this as a justification for legislation, but they have only read the headlines. It’s an emotional reaction, rather than one based upon evidence.

First, it is not a pill and the law is not designed to help those who fear a debilitating illness, a decline in the quality of their life, or are in the throes of chronic and painful illness. Legislation does not provide a remedy for someone suffering from decades-long deteriorating neuro-degenerative disorders such as Parkinson’s, ALS, or Huntington’s, nor a severe cognitive disability, nor any of the dementias that last for more than a dozen years.

As it stands now, the law only addresses those who present with a terminal illness and have less than six months to live, certainly a moveable target. However, mission creep, which would extend the six months to “some point in the future” and change the definition of terminal disease has already been proposed in Oregon’s legislature.

Undoubtedly, the preliminary step for legalizing physician assisted suicide appears to be just that…step one. We are a society of individuals who covet autonomy, so the idea that a terminal illness and a short period of life expectancy would hold fast as prerequisites for legally ending one’s life with a physician’s assistance seems to be destined for expansion as it has in the Netherlands, Belgium, and Switzerland.

In 2002, these countries started where we are today. The slippery slope is being proven out and is a heads-up to the US that assisted suicide will not stay within the boundaries of a six-month lifespan. According to Paige Cunningham JD PhD, Executive Director of The Center for Bioethics & Human Dignity (CBHD)

Patients who have requested PAD/PAS include those who are depressed, have a mental illness such as psychosis, have experienced sexual abuse, are disabled, are unhappy with their looks, are distraught over a sex change operation, or are bored with life. Couples who do not want to live apart have chosen to die together. Children are no longer protected and have been euthanized even though they are not legally able to consent.

Professor of Ethics at Protestant Theological Seminary in Groningen Theo Boer, who sat on the Dutch Euthanasia Review Committee for over a decade, publicly admitted “We were wrong, we were terribly wrong…I used to be a supporter of the Dutch law…[but] once the genie is out of the bottle, it is not likely to ever go back again.”

His concerns are being borne out by activities to expand legally sanctioned suicides. In 2017, the Netherlands proposed a “Completed Life” bill which would offer a lethal poison pill to anyone over 70 years of age who chooses to end their life, leaving the physician out of the equation. This is the “rational suicide” or “self-chosen death” argument.

Essentially, this is about rational older adults who have decided they have achieved their purpose for living and who are not interested in experiencing the physical or mental decline they anticipate accompanies aging. They see a self-chosen death as the answer. This discussion is also taking place in small pockets of society across the US.

In the May 2018 issue of the Journal of the American Geriatrics Society, Dr. Meera Balasubramaniam discusses rational suicide in older adults, a desire for suicide in the absence of diagnosed psychiatric illness. In a public access summary , “What are the Social Causes of Rational Suicide in Older Adults?” Elizabeth Dzeng, MD, PhD, MPH and Steven Z. Pantilat, MD, conclude:

We believe that the legalization and more widespread acceptance of [physician assisted death/suicide] was a necessary societal precursor to the rationalization of suicide in older adults. Just as PAD/PAS is increasingly accepted as a rational response to relieving suffering in the setting of terminal illness, PAD/PAS establishes a foundation for acceptance of suicide as an ethically and personally permissible response to the natural degradation of the human condition from age.

Add to that, the 10,000 people each day who are turning 65. If a majority of those fear a loss of autonomy and the AMA asserts an incompatibility of PAD/PAS with its core principle of healing the sick, is a discussion about Completed Life too hard to imagine? A Completed Life bill would place decisions back in the hands of the aging individual, not physicians.

Then there are those who are caught in-between. They are neither dying nor over the age of 70. However, as cited above, Section 1, 13(b) of the Oregon House Bill 2903 proposes a fix to that by re-defining terminal disease to include “a degenerative condition that will, at some point in the future, be the cause of the patient’s death.” This definition opens the floodgates to interpretation since we are all degenerating and at some point, will be dead.

Are these the serious societal risks that the AMA references in its Code of Ethics? Between PAD/PAS, its potential expansion, and A Completed Life, is the US on a path toward broad government sanctioned suicide?

Or should we be our brother’s keeper and direct our efforts toward ameliorating the myriad conditions that are bringing society to this point?

 

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