How Should We then Die? (eBook)

II

WHY ASSISTED DEATH?

The memory of her agony is etched indelibly in my mind. When I met her, she was doubled over in pain, kneeling at the side of the bed as if pleading with God for mercy. Her cancer had invaded the bottom of her spine, rendering the bone fragile and unstable. The bottom of the spine had collapsed inward, crushing the delicate nerves at the base of the spinal cord. And so she was in agony, finding only minimal relief by kneeling and doubling over. She had been in that position for days, unable to sleep and without relief, and had now come to the hospital for help. With tears of exhaustion and desperation, she pleaded for relief.

That night I struggled to manage her pain, trying different drugs and doses. Finally, with a continuous infusion of hydromorphone (a morphine-like drug), I was able to achieve some control of the pain. I remember going to check on her in the middle of the night. She was finally lying on her side, comfortably asleep. I slowly exhaled a sigh of relief. I was only a young resident at the time, and her pain had made a powerful impression on me. Indeed, I have rarely seen such a severe pain crisis any time since. Pain robbed that woman of her dignity; it left her desperate and broken in spirit. So long as she was in agony, she could think of nothing but freedom from the pain. The relief of her pain restored her dignity, allowed her to breathe, to rest, to be human.

The Indignity of Suffering

It is sometimes said that we fear dying as much, or even more, than we fear death itself. The possibility of enduring raw physical agony on the journey toward death fills us with real apprehension. In truth, medicine has powerful tools at its disposal to relieve or control physical suffering, and modern palliative medicine is entirely devoted to maximizing comfort and dignity for patients as they journey toward death, holistically addressing physical, emotional, and spiritual needs. But many people are still largely unaware of the possibilities of effective pain and symptom control for the dying, and it is a sad travesty that training and resources are still not sufficient to ensure universal access to high-quality palliative care even in some developed countries. Hence, in our imagination, the journey toward death retains the specter of uncontrolled suffering, and the possibility of a “death with dignity” by having your doctor cause your death in the manner and timing of your choosing seems like an appropriate means of avoiding needless suffering. We don’t want pain, suffering, and dying to rob us of our dignity.

Dignity is a big concept; it concerns our sense of our own value, the value that others perceive in us, and how we should be treated in accordance with that value. Of course, you do not need to have your life ended by your doctor or to commit suicide in order to die with dignity. But the essential argument for physician-assisted death is that the option of physician-assisted death gives patients the confidence that they can avoid suffering and thereby maintain their dignity up until their very last moments. By offering to cause the patient’s death upon their request, we allow patients to take control over the manner and timing of their death, so that they need not live in fear of suffering during the dying process.

Defining Physician-Assisted Death

Clear definitions are essential. By physician-assisted death, I am referring to intentional and deliberate actions on the part of the physician aimed at causing the death of the patient. These are actions where death is the stated purpose and goal of the intervention. Two different kinds of actions by physicians to cause death may be distinguished. Physicians may provide a prescription for a lethal dose of a drug that the patient then administers to herself. The physician makes the lethal drug available, but the patient must take it by her own hand. This is traditionally referred to as physician-assisted suicide. Alternately, the physician may directly administer the lethal dose to the patient, usually intravenously. This is traditionally referred to as euthanasia. From an ethical standpoint, there is no real distinction between physician-assisted suicide and euthanasia, since in both cases the doctor is deliberately and knowingly acting to cause the patient’s death and is responsible for the patient’s death. There is, however, an important practical distinction between these two kinds of physician-assisted death; patients seem reluctant to self-administer a lethal drug and to actually cause their own death. In jurisdictions where both physician-assisted suicide and euthanasia are legal, patients overwhelmingly opt for the latter; they seem to greatly prefer having the doctor administer the lethal drug. In this way, prohibiting euthanasia while legalizing physician-assisted suicide creates a practical limitation to widespread adoption of physician-assisted death—many patients find it difficult to bring themselves to cause their own death.

Physician-assisted suicide and euthanasia can be clearly distinguished from other issues in end-of-life care or decision-making such as palliative care, terminal sedation, or withholding or withdrawing life-sustaining therapies. None of these practices necessarily require the doctor to deliberately aim at causing the patient’s death. Death may follow the decision to withdraw life support (which is not really an action but rather the cessation of action), but the actual cause of death is the underlying illness. Life-sustaining treatments are not discontinued in order to bring about the patient’s death; rather, they are discontinued because it is recognized that they are no longer effective or appropriate. As an intensive care specialist, I have been involved in this decision many times. In these cases, patients are persistently critically ill despite aggressive life-sustaining therapies, and it becomes clear that the patient will not recover. I can assure you that I have never withdrawn life support specifically in order to cause a patient’s death. Of course, were I to withdraw life support in order to cause the patient’s death, then my action would be the ethical equivalent of euthanasia. The intention, or goal, of the action is the key distinguishing feature.

The act of deliberately causing the death of another person has traditionally been referred to as homicide, and the act of deliberately causing one’s own death is traditionally called suicide. Advocates for physician-assisted death dislike and avoid these terms because they are heavily freighted with negative value judgments or stigma—“medical homicide” doesn’t sound good, even if it is the most accurate term to describe what happens with euthanasia. Advocates argue that because a health-care professional is administering death according to the patient’s voluntary request, the act is something much closer to suicide than homicide. But the word “suicide” is also avoided because, again, it makes us uncomfortable. Advocates for physician-assisted death argue that it is different from suicide because it feels different from committing suicide. The American Association of Suicidology contends that suicide and physician-assisted death are categorically different because they generally involve very different experiences of dying.2 Suicide is committed alone, through violent means, in isolation from others, and feels like “self-destruction” (their term). On the other hand, they suggest that physician-assisted death feels like an act of “self-preservation” (their term) that aims at preserving the person’s sense of dignity, is performed in comfort by a trained professional, and is often enacted in the company of supportive family and friends.

There is no doubt that the experience of physician-assisted death is probably quite different from the tragic loneliness of acting alone to cause one’s own death by other (possibly more violent) means. And, for an organization such as the American Association of Suicidology, it is important to distinguish between physician-assisted death and suicide because they do not want the legalization of physician-assisted death to undermine their efforts at suicide prevention.

Yet mere differences in the typical experience of death between physician-assisted death and suicide do not resolve the basic moral question of whether it is appropriate to deliberately cause someone’s death. Is it right and good to end an innocent person’s life upon their request so long as one is doing so in the most humane manner possible? Put simply, is physician-assisted death a morally appropriate and praiseworthy type of suicide or homicide? Is homicide appropriate (praiseworthy, even) when it is performed by a doctor at the patient’s invitation and with the good intention of relieving suffering? Why not? This is the question we must answer.

Why Some People Want Physician-Assisted Death

Before we examine the “why not” of physician-assisted death we should seek to understand the “why.” We naturally find life precious. To seek death seems difficult and foreign to us. Why, then, do patients want to have their life ended by their doctor? Because physician-assisted death has been legal in several locations around the world for some time, we can look back and understand why patients in those places are seeking euthanasia. A number of key studies have been published, looking at this question. Patients who were seeking and preparing to obtain euthanasia were asked why they wanted to have their life...