Whose Right to Die?

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

What, then, should be U.S. policy regarding physician-assisted suicide and euthanasia? Magazine and television stories about patients who want to end their suffering by means of physician-assisted suicide or euthanasia help to reinforce the seemingly inherent link between pain and such interventions. As an oncologist I have often personally cared for patients who suffer despite all available treatment. Only the callous and insensitive would deny that in such cases physician-assisted suicide or euthanasia can offer obvious benefits -- can end a life that is worse than death.

But these cases distort the picture. The question is not about whether intervention is right for this or that particular patient. In any given case it may be the ethical thing to do, whatever the law says—and should be done. The question confronting the United States is one of policy: Should we broadly legalize physician-assisted suicide and euthanasia? We must not be swayed by a few—or even a few thousand—wrenching cases in which such intervention seems unequivocally right.

Most of the patients interested in physician-assisted suicide or euthanasia will not be suffering horrific pain. As noted, depression, hopelessness, and psychological distress are the primary factors motivating the great majority. Should their wishes be granted? Our usual approach to people who try to end their lives for reasons of depression and psychological distress is psychiatric intervention—not giving them a syringe and life-ending drugs.

Legalizing physician-assisted suicide and euthanasia, some argue, would not benefit only those who eventually made use of these procedures; it would also provide "psychological comfort" or "reassurance" to millions of other Americans, who would know that if they were dying and things got really bad, they could end their lives. However, the one study we have—the Boston study mentioned previously—shows that for every cancer patient who is likely to be reassured by a discussion of physician-assisted suicide or euthanasia, another patient finds that such a discussion would decrease his or her trust in the care being provided.

Whatever the benefits of legalized physician-assisted suicide and euthanasia, they must be measured against the dangers of legalization. In considering dangers we must consider more than potential violations of safeguards, although the Dutch experience indicates that the danger is real. (It is hardly surprising that, according to surveys, those who are most opposed to physician-assisted suicide and euthanasia include those most likely to experience abuse and coercion: the old, the less well off, and minorities.) For instance, how would legalization affect our society's already tenuous commitment to providing quality health care for the millions of people who die every year?

Providing the terminally ill with compassionate care and dignity is very hard work. It frequently requires monitoring and adjusting pain medications, the onerous and thankless task of cleaning people who cannot control their bladders and bowels, and feeding and dressing people when their every movement is painful or difficult. It may require agonizing talks with dying family members about their fears, their reflections on life and what comes after, their family loves and family antagonisms. Ending a patient's life by injection, with the added solace that it will be quick and painless, is much easier than this constant physical and emotional care. If there is a way to avoid all this hard work, it becomes difficult not to use it.

Broad legalization of physician-assisted suicide and euthanasia would have the paradoxical effect of making patients seem to be responsible for their own suffering. Rather than being seen primarily as the victims of pain and suffering caused by disease, patients would be seen as having the power to end their suffering by agreeing to an injection or taking some pills; refusing would mean that living through the pain was the patient's decision, the patient's responsibility. Placing the blame on the patient would reduce the motivation of caregivers to provide the extra care that might be required, and would ease guilt if the care fell short. Such an easy, thoughtless shift of responsibility is probably what makes most hospice workers so deeply opposed to physician-assisted suicide and euthanasia.

There is one final matter to consider: the possibility that euthanasia not only would be performed on incompetent patients in violation of the rules—as an abuse of the safeguards—but would become the rule in the context of demographic and budgetary pressures on Social Security and Medicare as the Baby Boom generation begins to retire, around 2010.

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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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