Assisted Suicide, Human Rights and Wrongs

May 30th, 2010

By Dan Miller

The controversy over assisted suicide has been much in the news of late, in the United States, Canada, Britain and probably elsewhere. Here is an interesting case, but not relevant to this article.

As with most controversies many on all sides of the issue present persuasive arguments. I suspect that most people would nevertheless prefer not talk about it. Death is not a pleasant thing to consider despite its universality and despite the great rewards said to be available in Heaven for those who credit that concept.

In my view, the question is an intensely personal and serious one to be answered by individuals according to their own lights rather than dictated by what the government, family, friends, other people’s religious organizations or even majority opinion may consider proper. Those who have religious convictions against suicide or enabling it should be free to conform to their religious views but not to require others to conform to them. Those who think suicide is a bad idea for whatever reason should be free to neither commit suicide nor assist others to do so. By the same token, those who make a very difficult and troubling but well informed decision to end their lives should not be legally restrained; nor should they be denied assistance from those willing and competent to provide it.

Oregon has a Death with Dignity law. It “was enacted in late 1997, allows terminally-ill adult Oregonians to obtain and use prescriptions from their physicians for self-administered, lethal doses of medications.”

During 2009, 95 prescriptions for lethal medications were written under the provisions of the DWDA compared to 88 during 2008. Of these, 53 patients took the medications, 30 died of their underlying illness, and 12 were alive at the end of 2009. In addition, six patients with earlier prescriptions died from taking the medications, resulting in a total of 59 DWDA deaths during 2009. This corresponds to an estimated 19.3 DWDA deaths per 10,000 total deaths.

The law requires an informed decision by the patient:

“Informed decision” means a decision by a qualified terminal patient, to request and obtain a prescription to end his or her life in an humane and dignified manner, that is based on an appreciation of the relevant facts and after being fully informed by the attending physician of:

(a) His or her medical diagnosis;

(b) His or her prognosis;

(c) The potential risks associated with taking the medication to be prescribed;

(d) The probable result of taking the medication to be prescribed; and

(e) The feasible alternatives, including, but not limited to, comfort care, hospice care and pain control.

The Oregon statute also provides,

If in the opinion of the attending physician or the consulting physician a patient may be suffering from a psychiatric or psychological disorder or depression causing impaired judgment, either physician shall refer the patient for counseling. No medication to end a patient’s life in a humane and dignified manner shall be prescribed until the person performing the counseling determines that the patient is not suffering from a psychiatric or psychological disorder or depression causing impaired judgment.

For a patient to receive medication to end his life, the patient has to have given the matter substantial thought, and the thought cannot be implemented immediately.

The State of Washington passed an initiative to allow assisted suicide in 2008 and legislation is pending but “in suspense” in California. Initiatives and legislative action to permit assisted suicide have most often failed.

The argument against assisted suicide which I find most compelling is that people in great and probably terminal pain are generally too out of their heads to make “rational” decisions and may be pressured by others to end it all. The new Nebraska law imposing strict requirements for informed consent before any abortion can lawfully be performed might serve as a useful guide in this context. As noted here,

Among other things, the required procedures include informing the pregnant woman of the nature and severity of any medical problems associated with the specific type of abortion contemplated, of the name of the physician to perform the abortion, of available alternatives to abortion, that she cannot be compelled by anyone to have an abortion, that medical assistance benefits may be available for prenatal care, childbirth, and neonatal care and that the father is liable to assist in the support of her child, even if he has offered to pay for the abortion. Certification by a medical professional that the woman does not appear to have a perception of compulsion or to be under duress, based on an examination at least one hour prior to the contemplated abortion, is required. The woman must also certify that she has been advised of the matters contemplated by the statute and appropriate records must be kept. (emphasis added)

Unfortunately, it seems likely that many who are in dire enough condition to desire euthanasia are no longer in a position to give truly informed consent and are probably stuck. For others, it should be possible to make their desires known before the situation arises.

Living wills generally express desires for end of life care, including that in specified conditions no heroic actions be taken. I assume that they rarely request assisted suicide because it is generally unlawful.

Generally, a living will describes certain life prolonging treatments. You, the declarant, indicate which treatments you do or do not want applied to you in the event you either suffer from a terminal illness or are in a permanent vegetative state. A living will does not become effective unless you are incapacitated; until then you’ll be able to say what treatments you do or don’t want. They usually require a certification by your doctor and another doctor that you are either suffering from a terminal illness or permanently unconscious before they become effective as well. This means that if you suffer a heart attack, for example, but otherwise do not have any terminal illness and are not permanently unconscious, a living will does not have any effect. You would still be resuscitated, even if you had a living will indicating that you don’t want life prolonging procedures. A living will is only used when your ultimate recovery is hopeless.

Under a state statute modeled after the Nebraska abortion informed consent law but dealing with assisted suicide, there should be requirements for (a) a psychiatric evaluation at the time the living will requesting euthanasia is to be signed to determine whether the person involved is competent and whether he is motivated by feelings of external compulsion, (b) a similar evaluation if possible while the patient is still sentient but likely soon to be in the condition specified in the living will and (c) a medical certification before euthanasia is to be performed that the conditions specified in the living will exist. If the patient has not been improperly motivated by others and the conditions expressed in his living will are present, his wishes as expressed should be honored.

I wrote here that society in the United States is based on traditions generally observed in Judeo-Christian religion:

We should act on the assumption that the United States’ Judeo-Christian heritage is good rather than bad, that it merits our determined defense and that there are objective standards of right and wrong. . . . [S]ome of us may not know exactly where the standards came from or why, and there is less than unanimous agreement at the periphery as to what they are. Still, I think we can agree that the basics do exist, that they work and that we ignore them at our national peril. It strikes me as plausible that the basic moral teachings of traditional religions which succeeded over the centuries did so because their basic principles worked and were grounded in the nature of man. …

There must be tolerance toward those who disagree, within limits: those who wish to celebrate Saturnalia, or nothing at all, rather than Christmas, for example. That seems very unlikely to harm others and they should be free to do as they wish; that tolerance must be reciprocated if it is to persist. For example, those who wish their non-belief to be tolerated must learn to tolerate such things as Christmas trees, Easter bunnies and the public display of the Ten Commandments.

By the same reasoning, those who disapprove of suicide, no matter how vehemently, should not on that account prohibit those who have made a well founded, well informed but different decision from implementing it or those who are prepared and competent to assist them by honoring those decisions from doing so.

Permit me to add a personal note: I think Hospice is wonderful. It has provided great comfort and care to several of my friends — one here in “third world” Panama — in recent months. Both remained alert until very close to the end and, I understand, they suffered little pain. They died where they wanted to, at home. When the time comes, that will probably be my choice. I don’t know whether I would have the courage or the cowardice to commit suicide, assisted or otherwise. However, whatever may ultimately be my choice is not one I would wish to impose on others. As noted in the second paragraph, the choice is and should be an intensely personal one.


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9 Responses to “Assisted Suicide, Human Rights and Wrongs”



  1. TempleCat |

    Excellent article. It’s pretty hard to look someone in the eye who is in the final stages of a devastating disease, and past a point where pain medication does any good, and tell them they must suffer. Instead, send them home to be with family and friends and provide them the dignity to face death on their own terms.

    When our pets become sick or injured and we are faced with a decision at the vet’s that will end their suffering, our hearts break, but we do the right thing. When it’s your mother, sister, father, brother, partner, friend… a human being capable of telling you “please make it stop”, we sometimes lose the proper level of compassion.

    Nebraska’s anti-abortion law fails in many ways (besides being unconstitutional). One being that it doesn’t address fetuses who have developed severe abnormalities, or cases of rape and incest. With this new law a woman would have to carry a child with no brain, for example, to term. Or in cases of rape and incest, a 10 year old girl who does not make it to an abortion clinic before the end of the 4th month would be forced to keep it. Any law modeled after this travesty would likely have the same faults in judgment if it is not better written.


  2. d |

    I think we just don’t want to believe there is no hope for our loved ones,holding on too long. With pets,you know when to give up. How can you possibly tell someone is in their right mind,if they want to end their life? It’s a hard call,one I would not want to be responsible for.


  3. Dan Miller |

    d,

    I too would hate to have to make such a decision for someone else. That’s why I suggested the concept of living wills to permit people to make the decision for themselves when still capable of doing so, with what I consider appropriate safeguards.

    There are no easy answers, but I think difficult ones nevertheless must be sought.


  4. Tom Carter |

    I agree that assisted suicide is a humane alternative that individuals should have the legal right to pursue. I’m certain that if I were suffering from an incurable disease and in severe pain, I would want that option to be available. I also agree with the value of living wills, so that at the moment of greatest stress no relative has to try to guess what his/her loved one really wanted.

    TempleCat, I’m not sure why you think the Nebraska law is unconstitutional. As quoted here (I haven’t read the full text of the law), it certainly includes some detailed requirements for informing the woman and evaluating her psychological condition, but it seems to me that it’s within the bounds of existing law. Sometimes people who are pro-choice (as I am) take things too far, such as demanding that minors be allowed to have abortions without parents consenting or even being informed (or, if appropriate, judicial consent). Sometimes we miss the point that many young women (and girls) go into an abortion without full information and in a state of desperation. Making sure they know what they’re doing and are in a stable state of mind doesn’t seem excessive.


  5. TempleCat |

    Tom – Nebraska’s law is unconstitutional under both Roe v. Wade and Planned Parenthood v. Casey (which upheld R vs W).

    “The states are not free, under the guise of protecting maternal health or potential life, to intimidate women into continuing pregnancies. ~Justice Harry A. Blackmun, Roe v. Wade, 22 January 1973”

    I have no problem with informed consent in some circumstances. In most cases, once a woman voluntarily sees the ultrasound (they are not required to look, but they do have to hear a description)they tend to feel better about having the abortion because the fetus doesn’t look human. This was an unintended side effect of the pro-life insistence on it. However, this also means that a woman who is distraught in finding out that she cannot carry a child to term due to complications is also subjected to being told how advanced she is, in detail. This is the cruel side of this law. And even this can be interpreted as intimidation.

    I also agree on the living will. Family members can’t be trusted to all agree on what should be done at the end of life, or even afterwards. Doing so will save you from procedures you don’t want and will provide peace of mind to family.


  6. Dan Miller |

    TempleCat,

    We disagree on the constitutionality of the new Nebraska abortion laws. I think they comport with Roe v. Wade and its recent progeny as I tried to explain in my recent abortion law article, a restatement of which I think is unnecessary here.

    Informed consent is good, but to the extent that the new Nebraska law on that goes too far, constitutes compulsion and violates the United States Constitution it should ultimately be struck down to the extent — but only to the extent — that it does so. To the extent that the different states wish to deal with things differently, they are empowered to do so provided only that they remain within the parameters of their own constitutions and those of the United States Constitution.

    Anticipating this, the various parts of the Nebraska laws are expressly severable; one or more can stand if others fall. Should the law as applied, as distinguished from as written, go too far it should also be rejected in individual cases. Any law can be applied wrongly, but that is no reason prima facie to reject all laws.

    Obviously, the situation of a mature adult approaching what he expects to be inevitable death in great pain is different from that of a pregnant woman trying to decide whether to give birth to or to abort her fetus. Both should have the opportunity, and the right, to know their conditions and the consequences of the actions they contemplate. I offered the Nebraska informed consent abortion statute as a model on which an assisted suicide statute might be based. A simple cut and paste job would not be good. Often, when the time comes, someone suffering agonizing pain due to a terminal condition is no longer in a position to give informed consent. That’s why I suggested living wills as a partial solution, and suggested what I consider appropriate safeguards.

    As neither a woman of child bearing age, a male young enough to put one into that condition, nor one suffering or likely soon to suffer from a terminal illness or sufficient pain to make suicide appealing, I have no personal dog in this fight. I would, however, very much like to see ideologies separated from the discussion and for it to go forward based on contextual realities.

    Having said that, as is the case with everyone I know, my ideology affects my perceptions; I think the government should interfere in my life (and death) only to the limited extent that what I do affects others adversely, and take appropriate but minimal steps to ensure that I am sufficiently sentient to understand the consequences when I make my decisions.

    Since the Supreme Court in Roe v. Wade and in subsequent cases decided that the states have legitimate interests in fetal well-being which increase as the fetus matures and becomes “more nearly human,” and since there is wide disagreement on the proper extent of state involvement in protecting those interests, I think it best for the individual states to experiment a bit; some may get it wrong, some may get it right and some may strike a generally acceptable balance. We have no all-wise philosopher king to make decisions for us, and for the Federal Government to try to fill that void would, I think, be a big mistake.


  7. TempleCat |

    Mr. Miller. Much of my concerns over the unconstitutionality of Nebraska’s law comes from the article “Caitlin E. Borgmann: New Nebraska abortion laws defy Constitution” at: http://www.omaha.com/article/20100425/NEWS0802/704259989

    In the sense that forcing a woman to carry a child to term regardless of its health conditions is related to forcing someone to die painfully because of a health condition, the matter is somewhat similar. It boils down to what the government says you can and cannot do in regards to your own health and well-being, and you being able to decide what is best for you.

    Coincidentally, I live in Oregon.


  8. d |

    The difference in those two senarios is,that the woman is deciding for the fetus,to end his life,the suicide victim, makes his own life and death decision,with assistance. That being said I am pro-choice. These two things are completely different,because most abortions take place when there is nothing wrong with the fetus,and at the beginning of his life. He has no choice,and no voice. I know,but still pro-choice,because of the safety of clean clinics with real doctors,instead of alleys and quacks. If a woman does not want to carry the child,he is toast,legal or not. We do,however, hold old powerless, folk hostage to suffer their last days in pain if they are unable to end their own lives. I could not do it because I believe in the unforgivable sin,suicide.


  9. Anonymous |

    Everyone should be responsible and have advance directives in place just in case something happens and you cannot walk, talk, hear, and you are literally and completely incapacitated, then no one is forced to make a decisions for you regarding your life . I think part of being a responsible adult is that you have made those decisions prior to some unforeseen event.


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