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Physician-Assisted Suicide

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Parent Issue
Month
September
Year
1998
Copyright
Creative Commons (Attribution, Non-Commercial, Share-alike)
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Agenda Publications
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Physician-Assisted Suicide

Why You Should Vote "NO" on PROPOSAL B

By ELIZABETH CLARE

Come the general election on November 3, Michigan voters will be deciding on a proposal to legalize physician-assisted suicide. Proposal B, spearheaded by the southeast Michigan-based Merian' s Friends Committee, is entitled the "Initiated legislation to legalize the prescription of a lethal dose of medication to terminally ill, competent, informed adults in order to commit suicide."

I believe that folks should vote NO on Proposal B and that legalized physician-assisted suicide in any form, no matter how restricted, is dangerous.

The proposal would, according to the official ballot language:

1 ) Allow a Michigan resident or certain out-of-state relatives of Michigan residents confirmed by one psychiatrist to be mentally competent and two physicians to be terminally ill with six months or less to live to obtain a lethal dose of medication to end his her life. (emphasis mine)

Both Merian's Friends Committee, and the law if Proposal B passes, sum this up as "the terminally ill patient's right to end unbearable pain or suffering" (emphasis mine). The official ballot language continues:

2) Allow physicians, after following required procedures, to prescribe a lethal dose of medication to enable a terminally ill adult to end his/her life.

3) Establish a gubernatorially appointed, publicly-funded oversight committee, exempt from Open Meetings Act and whose records, including confidential medical records, and minutes are exempt from Freedom of Information Act.

4) Create penalties for violating law.

This is such a hot topic. We live in the state where Jack Kevorkian has helped over 100 people commit suicide in the last eight years and has harvested organs from one of those people. The lawyer who has successfully defended Kevorkian in court over the years is now the Democratic candidate for governor. If the Merian's Friends proposal passes, Michigan will be the second place in the world where physician-assisted suicide is legal. (Oregon is the first and currently the only place.)

I can already hear politically progressive readers protesting. How can this proposal with its clear language about terminal illness and unbearable pain be dangerous? Isn't physician-assisted suicide a simple matter of choice? Wouldn't this stop crazies like Jack Kevorkian by creating penalties for any one who assists suicide outside the proposal's guidelines?

Let me address each of these questions, using the framework of secular, progressive politics. I will not be arguing about the choices individual people make at the end of their lives in the privacy of their own homes and families. Rather I want to focus on the institutions and societal forces that come into play around the issue of physician-assisted suicide. What will happen in this country if assisted suicide becomes legal and accepted? This country where oppression of poor people, old people, people of color, disabled people runs rampant; where access to health care is much less than universal; where 42 million Americans have no health insurance, where health care is increasingly profit driven. It is this larger context that makes physician-assisted suicide dangerous.

So, how can Proposal B be dangerous? The answer centers upon the ethical concept of a slippery slope--that the acceptance of one seemingly innocuous act can lead to the acceptance of another slightly less innocuous act and then to another until a culture is accepting or condoning an act that previously would have been unthinkable. Physician-assisted suicide is entirely slippery in this manner. The step from advocating physician-assisted suicide for terminally ill people to advocating it for people who are incurably but not terminally ill is small and almost imperceptible. The step to enlarging the definition of unbearable pain to include the emotional and psychological is equally small. Then the steps from physician-assisted suicide to voluntary euthanasia to involuntary euthanasia are easier to make. And down we slide.

The reality of an incremental slide from the seemingly innocuous to the unthinkable is not a figment of my overactive imagination. Rather we have already witnessed this slide both internationally and in the U.S. In the Netherlands, where physician-assisted suicide is an accepted but not a legal practice, statistics taken in 1990 suggest that over half the deaths per year caused by physician-assisted suicide and euthanasia are involuntary--that is physician-assisted deaths neither initiated nor chosen by the patient. This in a country that fifty years ago successfully resisted participating in the Nazi's campaign of involuntary euthanasia. This in a socially progressive country that 25 years ago had strict regulations controlling physician-assisted suicide, guidelines based upon terminal illness and patients' requests.

In the U.S. Jack Kevorkian provides another inescapable example of the slippery slope. When Dr. Death started helping peopie commit suicide, he talked about terminal illness, unbearable pain, the need to treat pain, about strict guidelines. Eight years later we have watched as he has allegedly helped kill over 100 people. Among them have been people who were severely depressed, at least one person who was in great physical pain but who said she wouldn't be interested in suicide if she could find effective pain control, and a number of people who had multiple sclerosis and quadriplegia - conditions in no way terminal. (For more details and documentation, see Wesley Smith's book, Forced Exit.)

Since when is it acceptable to help a severely depressed person kill herself rather than to help her find good mental health care? What about a healthy person with quadriplegia, depressed because he rarely leaves his bedroom and doesn't have a power wheelchair? Is it acceptable to help him commit suicide rather than help him get the resources necessary for basic mobility and independent living? I believe the answer is a resounding no, but it is exactly what Kevorkian has allegedly done. We have watched from the sidelines as he slides all the way down to the bottom of the slippery slope, unable or unwilling to prosecute the man many anti-physician-assisted suicide activists call a serial killer.

I hear you say, "Yes, ethical slippage around assisted suicide may occur, but we've learned from the Netherlands' mistakes. And Jack, well he's off the deep end." You may think that the way legalized physician-assisted suicide is being used in Oregon proves that we have learned from others' mistakes. A report released last month states that in the ten months since the Oregon law has been in use, eight people have committed suicide with the assistance of their doctors and another two received prescriptions for lethal medication but died of natural causes. Physician-assisted suicide advocates claim these numbers prove that the law is not being abused. I think it's too early to tell. The law has only been in place for ten months after two voter referendums and a lengthy court battle questioning its constitutionality . Will there be ethical slippage over two years, five years, a decade? I hope not, but I don't think we can definitively know after ten months. Additionally, nothing in the law penalizes doctors for not reporting physician-assisted suicides. Consequently, there will undoubtedly be some under-reporting.

But regardless of whether or not we are learning from the mistakes made in the Netherlands and by Kevorkian, I believe the all-too-real potential for ethical slippage is contained in the very language of Proposal B, in the phrases "terminal illness" and "unbearable pain." Terminal illness means by definition that a person has six months or less to live. It is a prediction of the future, a prediction that many doctors admit is hard to make accurately. Only hindsight proves the accuracy. I know people diagnosed as terminal years ago who are still alive today.

The reliance on terminal illness to safeguard physician-assisted suicide strikes me as shaky. If the diagnosis of terminal is in at least some cases uncertain, shouldn't we ask some hard questions about depression, doctors and power, the treatment of marginalized people by the medical establishment? Depression often follows the diagnosis of terminal illness, and thoughts of suicide often follow depression. What happens if that depression goes untreated? What happens if the person is poor and/or uninsured? Will the physician go into detail about all the possible options for care, including hospice and adequate pain control? Will the doctor be willing to consider costly treatments? What happens to disabled people, whose lives are often not valued by the medical establishment? Would the diagnosis of terminal illness provide an excuse, an easy way out, a door to encouraging certain people to end their lives?

And what about unbearable pain? Who gets to decide what is unbearable? What if a person just diagnosed as terminally ill is terrified by the thought of unbearable pain but is not yet in actual pain? If unbearable pain is one of the criteria for physician-assisted suicide, will doctors, who in the U.S.are notoriously reluctant to effectively and aggressively treat pain, take even a more hands-off approach? What happens if the patient is a woman, a person of color, or an old person, all of whom, studies show, are less likely to receive effective pain control? Maybe in an ideal world terminal illness and unbearable pain would not invite ethical slippage. But in the world as it is, where the quality of disabled people's lives is always in question, where racism, sexism, and the profit motive riddle the medical establishment, Merian's Friends' proposal rests at the top of a very real slippery slope that places many people at risk.

You, my reader, may ask, "Why speak of institutions and oppression? Isn't physician-assisted suicide really about personal choice?" Let me ask in return, "What good is choice if there are not a multitude of options?" The "choice" of physician-assisted suicide doesn't look so much like a choice if you don't have health insurance or are under-insured, if your health care comes in harried visits to the emergency room or the free medical clinic. Choices disappear if your doctor doesn't listen to your reports of pain, isn't trained in the effective control of severe pain, or is reluctant to prescribe morphine for fear of causing addiction. It's hard to make an honest choice when there is in many places a long waiting list for underfunded hospice care. Suicide starts looking not like a choice but the only way out. I believe it's impossible to talk about personal choice without examining this larger context.

Of course the word choice invokes all the pro-choice arguments for access to safe, legal abortion. And there's an implicit assumption that if you're pro-choice around abortion, you need to be pro-physician-assisted suicide. In truth choice is a complex matter that plays itself out in many different ways depending upon the arena. For example, the court decisions made in support of legalized abortion have always tempered the notion of personal and private choice with the notion of viable life. Roe v. Wade uses the viability of a fetus as a significant dividing line. Before viability--the first two trimesters of a pregnancy--a woman's privacy and right to control her own body are held as primary; after viability--the third trimester--the life of the fetus, unless the mother's life or health is in danger, becomes more important. We must examine the same tension when dealing with end-of-life issues: how to protect all viable human life while giving people as many choices about their own lives and deaths as possible. Current options, such as the right to refuse medical treatment and the use of durable power of attorney, fall on the side of giving people choices while not threatening other human life. But legalized physician-assisted suicide, poised as it is on a slippery slope, has great potential to threaten viable human life and therefore, I believe we must forego it.

"OK," you may say, "maybe this proposal isn't the best idea, but if it will stop Kevorkian--make his dealings, which are clearly outside the bounds of this proposal, illegal--isn't it worth a small risk?" I say, let's make physician-assisted suicide illegal outright and lock Dr. Death behind bars, where any former physician belongs who no longer has a medical license and goes around plugging people into a homemade death machine.

The answer to the issues surrounding physician-assisted suicide isn't to pass a measure that is likely to start a process of ethical slippage toward involuntary euthanasia. Rather let's make some sweeping changes in the world. Start by making sure everyone has health insurance and access to good health care. Fund hospice and home care programs. Support independent, community-based living for disabled people. Make sure doctors can and will treat pain aggressively and effectively. Work for a world where the lives of old people, ill people, disabled people, poor people are fully valued. The answer here isn't legalizing physician-assisted suicide but creating social change.

Elizabeth Clare is an essayist, poet, and activist. Her first book, a collection of essays, will be published next year. She belongs to Not Dead Yet, a disability rights group that opposes euthanasia and physician-assisted suicide. You can reach Not Dead Yet at (734) 662-1258.

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...in the world as it is, where the quality of disabled people 's lives is always in question, where racism, sexism, and the profit motive riddle the medical establishment, Merian's Friends' proposal rests at the top of a very real slippery slope that places many people at risk.

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