Prescribing Suicide

In 1983, a young woman drove home on a country road in southwest Missouri.  Suddenly, she lost control, overturned the car, and was ejected from her vehicle.  She landed face down in a ditch over thirty-five feet away from the scene of the accident.  Paramedics arrived fifteen minutes later and revived her, but the young woman had suffered severe anoxic brain injury leaving her in a persistent vegetative state.  With no improvement in sight, her parents decided to withdraw her artificial nutrition and hydration which were sustaining her vital organs.  Healthcare workers at the hospital hesitated.  The family sued.  The case made it to the Supreme Court, where the Court ruled 5-4 that patients and their surrogates had a right to refuse life-sustaining interventions.  As a result, the parents of Nancy Cruzan withdrew her nutrition and hydration to allow their daughter to die.  Seven years after her car accident, Nancy Cruzan expired making her the first “right to die” case to make it all the way to the Supreme Court.

Spring Boarding Physician-Assisted Suicide

Following in the footsteps of Nancy Cruzan’s “right to die” case, a group of physicians argued that if patients have a right to refuse life-sustaining treatments, then they should have a right to request life-ending treatments.  In Vacco v. Quill, Dr. Timothy Quill et al. claimed that prohibiting patients the right to assistance in dying was unconstitutional and violated the Equal Protection Clause.  In 1997, the Supreme Court disagreed.  According to the ruling, patients do not have a “right to die.”  Moreover, refusing treatments and requesting assistance in dying (arguably a type of treatment) is not the same thing.  Much like the criminal code where manslaughter differs from murder, refusing life-sustaining treatments and requesting assistance in dying may have the same outcomes, but there is a difference in causation.  The intention behind the act matters.

Today, nine jurisdictions have approved Physician-Assisted Suicide (PAS):  eight states and Washington, D.C.  Some states have laws against PAS and several other states have pending PAS legislation.  State laws vary because the federal government has passed legislative authority to the states.  Each year there are numerous PAS state bills proposed in state legislation, but passing bills takes years to accomplish.  Moreover, many bills never make it through the vetting process.

Many opponents argue that relief from pain is not a legitimate reason for permitting assisted suicide.  Fair enough, but relief from pain is far from the main reason why people choose the PAS option.  In Oregon, the number one reason why people opt for PAS is to maintain autonomy (96%).  Only 30% of people included pain as a factor in their decision-making.

Unsupported Reports

Opponents of PAS describe the consequences of enacting such a law.  Describing the recent legislation passed in New Jersey, the Heritage Foundation stated:

“In this scenario, it is the poor, the uneducated, and the socially marginalized who are most likely to be pressured into taking their own lives. These are the same populations who are the least likely to have someone else advocate on their behalf for proper care.”

However, the data doesn’t support this accusation.  In Oregon, over 95% of participants are white, half have an Associates Degree or higher, and the majority (59%) are over 65.  A far cry from the poor, uneducated, and socially marginalized individual demographic.

The Heritage Foundation further states:

“As the demand for end-of-life care continues to increase, physician-assisted suicide emerges as a cheap alternative to appropriate palliative or hospice care.”

But the data indicates that 91% of patients who opted for PAS in Oregon over the last twenty years were enrolled in hospice at the time of their death.

Semantic Gymnastics

According to the Death With Dignity National Center – an organization devoted to promoting death with dignity laws, using the term ‘suicide’ is “inaccurate, biased and pejorative…hurtful and offensive.”  Thus, terms like Physician Aid in Dying or Medical Aid in Dying are “value-neutral” and should be used as replacements.

How is it inaccurate?  People who opt for PAS in the United States must be able to self-administer the medication, otherwise, it is considered a criminal act.  The definition of suicide is the act or an instance of taking one’s own life voluntarily and intentionally.  The fact that they are in the dying process (technically from the moment we are born, we all fit in this category) does not change this.  We can’t arbitrarily change the definition of words to justify our agendas.

And whose values do we want to be neutral?

Necessary Considerations

Since Canada’s End of Life Option inception in 2018, 2500 patients have chosen the option.  However, the line between PAS and Euthanasia in Canada is blurred.  There is no distinction between the two, legally.  Interestingly, out of the 2500 patients, only one has chosen to self-administer the medication.  The rest have chosen to have a clinician administer the drug.  Thus, 99% of Canadian patients chose euthanasia over suicide.  Why?  Is this just to ensure the administration of the drugs is done properly, or are there other reasons?

I think one of the motivating factors with this issue is validation.  If a physician prescribes a drug for me to end my life, then it validates my rationale to commit suicide.  But why do we feel the need to validate our feelings?  What role, if any, does guilt play?

Compassionate Caregivers

Health care providers often assume the burden of making difficult decisions for their patients.  That’s compassionate care.  Telling a family there is no hope of recovery for their loved one (i.e. the patient is dead by neurological criteria) and recommending that all interventions be withdrawn or withheld eases the burden of family decision-making.  Easing suffering is one of the most compassionate acts caregivers can perform.  I can’t help but wonder if seeking the PAS option is another way of patients asking physicians for this burden to be lifted.  A prescription for medication to end a life not only provides the patient validation but also communicates that their life may be better off ended.  The question is, Are there instances where death is a better alternative?

I’ve treated many patients at the end of life, and I sympathize and empathize with their suffering.  It is almost unbearable to watch your loved one suffer and families don’t want to live with the idea that they were a part of causing the death of their loved one.  Though the feeling is not accurate (as it’s the underlying disease that causes the death of the individual), the feeling remains.  There are many options to assist families at the end of life.  The push for PAS tells us that we are not meeting the needs of many of our patients.  The fact that many PAS patients enroll in palliative and hospice care tells us that, at minimum, we need to do better job in these areas.

References

  1.  Oregon Health Authority, DWDA, Year 21, 2018
  2.  Burke, Monica, Physician Assisted Suicide Comes To New Jersey.  Here’s Why It’s Badly Misguided, 4/19/2019.  https://www.heritage.org/life/commentary/physician-assisted-suicide-comes-new-jersey-heres-why-its-badly-misguided
  3.  Oregon Health Division 1998-2015
  4.  https://www.merriam-webster.com/dictionary/suicide
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