The Freedom Not to be Free

Physician aid-in-dying (PAD) is a controversial medical procedure that has emerged in North America and Western Europe as a way to help terminally ill patients cope with their pain as they near the ends of their lives. America is trending toward acceptance of PAD because it allegedly provides additional freedom to patients, but this is a simplification of the ethics of the procedure. In examining the common arguments for PAD, it becomes clear that PAD represents a serious ethical danger to our society and should be rejected in all instances.

First, the safeguards in place fail to protect patients. Despite assertions by PAD supporters that safeguards—such as requirements that patients must be competent, request the medication, self-administer it and be within six months of death—guards against PAD abuse, this is not accurate. A case-by-case, systematic analysis in the Michigan Law Review of Oregonian patients who chose suicide shows that doctors often disagreed about the patients’ capacity to decide to end their lives. Multiple cases showed that patients who met with three doctors, all reporting that the patients were not in an appropriate mental state to make the decision, were nonetheless quickly approved over the phone by the pro-PAD organization Compassion and Choices. This may seem surprising, but PAD laws allow any physician, including those hired by Compassion and Choices, to approve patients regardless of past rejections. Clearly, these “safeguards” do not really guard against much.

Terminal patients also often experience psychological effects that distort their ability make the decision to kill themselves, but those effects are dismissed by supporters of PAD legalization. As patients experience pain and approach the end of life, they may begin to develop a retrospective, tunnel vision of the past, obscuring both their perception of the value of life and their understanding of possible alternative procedures. According to studies involving doctors in Oregon, near-death patients overwhelmingly expressed a dismal view of their lives and “dreaded the thought of being dependent on others.” Patients faced with our culture’s emphasis on self-sufficiency, combined with a new, distorted black-and-white frame through which to view life, see the prospect of dependent life as worse than death. These cultural analyses are not just conjecture. According to research at Harvard Medical School, most patients with a terminal illness develop self-induced depression at the idea of their new loss of control.

The same evidence indicates that patients in situations of terminal illness are simply not in a sound enough mental state to make the decision to commit suicide. Their condition restricts their capacity to choose freely by psychologically compelling them to commit suicide. Alternatively, palliative care aimed to alleviate pain allows the patient to think clearly again, according to surveys by Brunel University of Medical Professionals. If PAD were legal, patients would be either discouraged from receiving or unable to get palliative care. According to a 2008 ABC News report, Oregonians Barbara Wagner and Randy Stroup were denied life-saving care because it was too expensive, but were offered suicide drugs by their healthcare providers. Patients, instead of gaining the “right to die,” have simply given healthcare companies trying to cut costs the “right to kill.” This instance of monetized suicide, per se, does not stand alone; rather, it has spread through many of the states that have legalized PAD. Just this year after California legalized PAD, Stephanie Packer was denied the coverage of critical chemotherapy treatment that her doctors recommended for her condition, while her insurance was perfectly happy to cover her cheap end-of-life drugs.

Second, PAD violates medical ethics and millennia of precedent set by the Hippocratic oath, which states, “I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan.” Even more modern oaths in the United States, such as the Osteopathic Oath, which states, “I will give no drugs for deadly purposes to any person, though it be asked of me,” reaffirm this concept of the physician as a caretaker and healer, not a killer.

PAD undermines these sacred medical oaths and threatens the feeling of safety and comfort doctors should provide when giving medical assistance. National groups like National Hospice and Palliative Care Organization and the American Medical Association recognize that physician assisted suicide is “fundamentally inconsistent with the physician’s role as healer.” The legalization of assisted suicide thus significantly injures the credibility of the medical community.

Third, the ethical domino effects of PAD are horrendous. The fact that the alleged safeguards fail means that we should be concerned with the ethical consequences of PAD. We need to ask the question: What distinguishes PAD from other practices that are ethically unacceptable? If there is evidence that the same ethics behind PAD have justified other ethically abhorrent practices post-legalization, then PAD must be rejected; and this is precisely the case. In the words of the News Sentinel’s editorial board, “after years of decline, suicide rates have risen sharply in the last few years. It can’t be a coincidence that this epidemic is happening at the same time efforts to legalize physician-assisted suicides in states across the country are getting so much attention.”

Since the legalization of PAD in Western European countries, ethical violations of much worse magnitude have entered into the realm of possibility for decision-makers: child euthanasia with no age limit in Belgium and involuntary euthanasia and assisted-suicide for those who have depression in the Netherlands. It seems as though lawmakers now are willing to use any reason to justify PAD. One frightening example in Belgium shows an elderly woman who went on a hunger strike after being denied euthanasia because she had no justification for it. After the woman refused to eat for days, the government approved being “tired of life” as sufficient justification for euthanasia. A similar justification exists in the Netherlands as well.

These unethical practices around the world are completely logical in the ethical terms of PAD. Laws against suicide are a legal protection for those in danger of self-harm, so if PAD says those legal protections no longer apply for certain people, what does that say about how our society values those people? Nothing could indicate more strikingly the extent of social Darwinism than a society that says that certain individuals stop being worthy of protections when they near the end of life and cease to be sufficiently productive to deserve the equal protection of the law.

Even if an individual should have the freedom to commit suicide, dozens of family members and friends will suffer, and even the most strident proponents of individual freedom do not believe that individuals have the right to hurt others. There is a qualitative difference in the effect of a loved one’s passing when the patient chooses to die, rather than lives life to its natural end. Feelings of betrayal, rejection, abandonment, and failure spread throughout the web of personal relationships which the patient had, according to the Survivors of Bereavement by Suicide organization in the United Kingdom. “I didn’t provide enough,” “I couldn’t comfort enough,” “I wasn’t there,” are some of the thoughts that describe the psychological state of those left behind by suicide. The worst of these feelings is not a result of the patient passing away, although no doubt there is pain which stems from that; rather, the pain comes from the perception of agency which the patient had before dying. Why should the law provide a quick route to alleviating immediate pain at the expense of relatives and friends who will carry deep pain for decades to come?

Life should not be valued by the number of years one has left, but by the life itself. To be clear: society must recognize and protect the value of every human life, no matter how dull or difficult to support those lives may be. Freedom is the last refuge of embattled proponents of PAD. Given the first issue about patient decision-making, the concern for retrospective tunnel-vision, and the monetization of suicide by healthcare providers, PAD is evidently not a “freedom.”

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