Whose Right to Die?

America should think again before pressing ahead with the legalization of physician-assisted suicide and voluntary euthanasia
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Life in the Balance

The debate over physician-assisted suicide and voluntary euthanasia will soon reach its most important stage in this country. Last spring the Second and Ninth Circuit Courts of Appeals handed down momentous decisions striking down state laws in New York and Washington that forbid physician-assisted suicide. Although the Second and Ninth Circuit Court cases focus on physician-assisted suicide, and although there are important differences between physician-assisted suicide and voluntary euthanasia, the legal reasoning that would justify physician-assisted suicide would almost certainly extend to voluntary euthanasia. The intensity of the debate on both issues will grow during the wait for rulings this year by the Supreme Court, which has accepted the two circuit-court cases for review.

From Atlantic Unbound:

"Kevorkian Behind Bars" (April 1999)
A cartoon by Sage Stossel.

In physician-assisted suicide a doctor supplies a death-causing means, such as barbiturates, but the patient performs the act that brings about death. In voluntary euthanasia the physician performs the death-causing act after determining that the patient indeed wishes to end his or her life. Neither term applies to a patient's refusal of life-support technology, such as a respirator or artificial nutrition, or a patient's request that it be withdrawn; these have had ethical and constitutional sanction nationwide for years. And neither term applies to what is sometimes called indirect euthanasia, when the administration of drugs primarily for pain relief may have the secondary effect of causing death, as the physician is well aware. This practice, too, is ethically and legally sanctioned.

In formulating their decisions the circuit-court judges made a number of assumptions about the actual or likely circumstances surrounding cases of death by active intervention. Their judgments are based on misreadings of history, misinterpretations of survey data, mistaken reasoning, and simple misinformation.

Myth No. 1: It is primarily advances in biomedical technology—especially life-sustaining technology—that have created unprecedented public interest in physician-assisted suicide and voluntary euthanasia. "The emergent right to receive medical assistance in hastening one's death [is an] inevitable consequence of changes in the causes of death, advances in medical science, and the development of new technologies. Both the need and the capability to assist individuals [to] end their lives in peace and dignity have increased exponentially" (Ninth Circuit Court of Appeals).

Physician-assisted suicide and euthanasia have been profound ethical issues confronting doctors since the birth of Western medicine, more than 2,000 y ears ago. All the arguments made today to justify—or condemn—the two practices were articulated before any modern biomedical technology existed. The ancient Hippocratic Oath enjoins physicians to "neither give a deadly drug to anybody if asked for it, nor make a suggestion to this effect." The oath was written at a time when physicians commonly provided euthanasia and assisted suicide for ailments ranging from foot infections and gallstones to cancer and senility. Indeed, the Hippocratic Oath represented the minority view in a debate within the ancient Greek medical community over the ethics of euthanasia.

Even in America legalized euthanasia, rather than being a new issue, has been publicly debated and rejected—a fact the courts failed to mention. Modern interest in euthanasia in the United States began in 1870, when a commentator, Samuel Williams, proposed to the Birmingham Speculative Club that euthanasia be permitted "in all cases of hopeless and painful illness" to bring about "a quick and painless death." The word "painless" is important: the idea of euthanasia began gaining ground in modern times not because of new technologies for agonizingly prolonging life but because of the discovery of new drugs, such as morphine and various anesthetics for the relief of pain, that could also painlessly induce death. Over the next three decades Williams's proposal was reprinted in popular magazines and books, discussed in the pages of prominent literary and political journals, and debated at the meetings of American medical societies and nonmedical professional associations. The debate culminated in 1906, after the Ohio legislature took up "An Act Concerning Administration of Drugs etc. to Mortally Injured and Diseased Persons"—a bill to legalize euthanasia. The merits of the act were debated for months and were covered extensively in the pages of The New York Times, which vigorously opposed legalization, and in medical journals. The Ohio legislature overwhelmingly rejected the bill, effectively ending that chapter of the euthanasia debate.

Thus, decades before the discovery of penicillin (1928) and the development of mechanical respirators (1929), dialysis (1945), and other life-sustaining technologies, serious public discussions of physician-assisted suicide and euthanasia took place in the United States (and also in European countries). These discussions were couched in the same language we use today—"patients' rights," "the relief of pain and suffering," "the loss of dignity."

Indeed, rather than creating a perceived need for physician-assisted suicide and euthanasia, advances in life-sustaining technology should help to obviate them. Patients who are being kept alive by technology and want to end their lives already have a recognized constitutional right to stop any and all medical interventions, from respirators to antibiotics. They do not need physician-assisted suicide or euthanasia.

Myth No. 2: Legalizing physician-assisted suicide and euthanasia is widely endorsed. "There is unquestionably growing popular support for permitting doctors to provide assistance to terminally ill patients who wish to hasten their deaths" (Ninth Circuit Court of Appeals).

Yes, polls show that a majority of Americans support physician-assisted suicide and euthanasia—indeed, have supported legalizing them for almost twenty-five years. But the support is neither strong nor deep. Careful analysis of the polling data suggests that there is a "rule of thirds": a third of Americans support legalization under a wide variety of circumstances; a third oppose it under any circumstances; and a third support it in a few cases but oppose it in most circumstances.

Americans tend to endorse the use of physician-assisted suicide and euthanasia when the question is abstract and hypothetical. One formulation that has been used for almost fifty years and elicits widespread agreement is "When a person has a disease that cannot be cured, do you think doctors should be allowed by law to end the patient's life if the patient and his or her family request it?" The question has several flaws, the most important one being that "to end the patient's life" is vague and specific neither to physician-assisted suicide nor to euthanasia. The phrase could mean simply stopping life-sustaining technologies that are keeping the patient alive, which is already legal.

Other, more carefully designed questions can elicit majority support for physician-assisted suicide and euthanasia, but only when patients are described as terminally ill and experiencing unremitting physical pain. Support dwindles when the public is asked about physician-assisted suicide and euthanasia in virtually any other situation. Two thirds of Americans oppose physician-assisted suicide or euthanasia when a terminally ill patient has no pain but wants to die because of concern about being a burden to his or her family, or because he or she finds a drawn-out dying process meaningless. The most accurate characterization of the survey data is that a significant majority of Americans oppose physician-assisted suicide and euthanasia except in the limited case of a terminally ill patient with uncontrollable pain.

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Presented by

Ezekiel J. Emanuel

Ezekiel Emanuel is director of the Clinical Bioethics Department at the U.S. National Institutes of Health and heads the Department of Medical Ethics & Health Policy at the University of Pennsylvania.

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