Politics & Policy

The Lethal Logic of Assisted Suicide

(Dreamstime)
Ryan T. Anderson's plea for caring, not killing.

Do no harm. It used to be at the heart of medicine. Now our public policy is increasingly making just the opposite the protocol. When physician-assisted suicide becomes legal, the rule of law, no longer erring on the side of life at the beginning and at the end of our lives, when we are most vulnerable, is no longer a protector but a grave menace.

Ryan T. Anderson is the author of a new report, “Always Care, Never Kill: How Physician-Assisted Suicide Endangers the Weak, Corrupts Medicine, Compromises the Family, and Violates Human Dignity and Equality.” Anderson is the William E. Simon Fellow at the Heritage Foundation and the founder and editor of the wonderful resource Public Discourse. We talk about the paper, the grave harm that is assisted suicide, and better alternatives that protect life and human dignity — and all of us from a dangerous health-care and legal environment.

Note: Next Monday, Ryan and I will be co-hosting a joint National Review Institute–Heritage Foundation event on this topic next Monday. Please join us in person or online. It will be livestreamed, information here.

 

Kathryn Jean Lopez: What’s the big deal about physician-assisted suicide right now?

Ryan T. Anderson: Because this year alone, 18 states plus D.C. are considering whether to allow doctors to assist in the killing of patients. Physician-assisted suicide directly conflicts with the Hippocratic oath, which proclaims: “I will keep [the sick] from harm and injustice. I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect.” This is an essential precept for a flourishing civil society. No one, especially a doctor, should be permitted to kill intentionally, or to assist in killing intentionally, an innocent neighbor.

Human life need not be extended by every medical means possible, but a person should never be intentionally killed. Doctors may help their patients to die a dignified death from natural causes, but they should not kill their patients or help them to kill themselves. This is the reality that such euphemisms as “death with dignity” and “aid in dying” seek to conceal.

Allowing physician-assisted suicide would be a grave mistake for four reasons. First, it would endanger the weak and vulnerable. Second, it would corrupt the practice of medicine and the doctor–patient relationship. Third, it would compromise the family and intergenerational commitments. And fourth, it would betray human dignity and equality before the law. Instead of helping people to kill themselves, we should offer them appropriate medical care and human presence. We should respond to suffering with true compassion and solidarity. Doctors should help their patients to die a dignified death of natural causes, not assist in killing. Physicians are always to care, never to kill.

 

Lopez: This is such a difficult, personal topic. Who are you to say — from the top — that choosing death isn’t “caring.” If you’re miserable and are only going to get worse?

Anderson: Death is a very personal issue that will affect all of us. And we need to craft public policy that will best protect human dignity even amid suffering. To think this through I looked to some of our wisest physicians. People like Dr. Paul McHugh and Dr. Leon Kass. For readers who aren’t familiar, Dr. McHugh is the University Distinguished Service Professor of Psychiatry at Johns Hopkins University School of Medicine and was psychiatrist-in-chief at Johns Hopkins Hospital from 1975 to 2001. Dr. Kass is a medical doctor, distinguished philosopher at the University of Chicago, and former chairman of the President’s Council on Bioethics.

McHugh points out that “with physician-assisted suicide, many people — some not terminally ill, but instead demoralized, depressed and bewildered — die before their time.” Dr. Kass explains that physician-assisted suicide “is, in fact, the state’s abdication of its duty to protect innocent life and its abandonment especially of the old, the weak, and the poor.”

Dr. Kass adds: “Healing is thus the central core of medicine: to heal, to make whole, is the doctor’s primary business.” Killing is thus incompatible with caring. Dr. Kass explains: “Can wholeness and healing ever be compatible with intentionally killing the patient? Can one benefit the patient as a whole by making him dead? . . . ‘Better off dead’ is logical nonsense.” Indeed, “to bring nothingness is incompatible with serving wholeness: one cannot heal — or comfort — by making nil. The healer cannot annihilate if he is truly to heal. The boundary condition, ‘No deadly drugs,’ flows directly from the center, ‘Make whole.’”

 

Lopez: How does assisted suicide corrupt the practice of medicine and the doctor–patient relationship? Isn’t there plenty else that does that already?

Anderson: The heart of medicine is healing. Doctors cannot heal by assisting patients to kill themselves or by killing them. They rightly seek to eliminate disease and alleviate pain and suffering. They may not, however, seek to eliminate the patient. Allowing doctors to assist in killing threatens to fundamentally corrupt the defining goal of the profession of medicine. Again, I cite Drs. Kass and McHugh.

In testimony before the U.S. House of Representatives, Dr. Kass elaborated on this point:

The legalization of physician-assisted suicide will pervert the medical profession by transforming the healer of human beings into a technical dispenser of death. For over two millennia the medical ethic, mindful that power to cure is also power to kill, has held as an inviolable rule, “Doctors must not kill.”

Dr. McHugh agrees that this inviolable rule is essential to the practice of medicine:

Since ancient Greece physicians have been tempted to help desperate patients kill themselves, and many of those Greek doctors must have done so. But even then the best rejected such actions as unworthy and, as the Hippocratic Oath insists, contrary to the physician’s purpose of “benefiting the sick.”

For this reason, the American Medical Association (AMA) code of ethics rejects physician-assisted suicide. The AMA states: “Physician-assisted suicide is fundamentally incompatible with the physician’s role as healer.” And dozens of professional associations and groups representing vulnerable persons oppose physician-assisted suicide, including the

American Medical Association,

World Health Organization,

American Nurses Association,

American Association of Critical-Care Nurses,

Hospice Nurses Association,

Oncology Nurses Society,

American Osteopathic Association,

American Psychiatric Association,

American Academy of Hospice and Palliative Medicine,

American Academy of Pain Management,

American Academy of Pain Medicine,

American Academy of Orthopaedic Surgeons,

American Academy of Physical Medicine,

Society of Critical Care Medicine,

American Academy of Neurology,

American Neurological Association,

American Society of Anesthesiologists,

American Society of Clinical Pathologists,

College of American Pathologists,

American Society of Abdominal Surgeons,

American Association of Clinical Endocrinologists,

Society of Medical Consultants to the Armed Forces,

American Institute of Life-Threatening Illness and Loss,

Massachusetts Medical Society,

Disability Rights Education and Defense Fund,

ADAPT (American Disabled for Attendant Programs Today),

American Association of People with Disabilities,

Association of Programs for Rural Independent Living,

Justice for All,

National Council on Disability,

National Council on Independent Living,

National Spinal Cord Injury Association,

Not Dead Yet,

TASH,

World Association of Persons with Disabilities, and

World Institute on Disability.

Physician-assisted suicide will create perverse incentives for insurance providers and the financing of health care. Assisting in suicide will often be a more “cost-effective” measure from the perspective of the bottom line than is actually caring for patients. In fact, some advocates of physician-assisted suicide and euthanasia make the case on the basis of saving money.

Baroness Mary Warnock, a leading ethicist in the United Kingdom, has argued that “if you’re demented, you’re wasting people’s lives — your family’s lives — and you’re wasting the resources of the National Health Service.” Warnock went on to suggest that such people have a “duty to die.”

 

Lopez: You write: “The right not to be killed cannot be effectively protected in a nation that allows physician-assisted suicide.” Explain.

Anderson: We have not seen a single jurisdiction that has allowed physician-assisted suicide adequately protect against coercion. The evidence from these jurisdictions, particularly the Netherlands, which has over 30 years of experience, suggests that safeguards to ensure effective control have proved inadequate. In the Netherlands, several official, government-sponsored surveys have disclosed both that, in thousands of cases, doctors have intentionally administered lethal injections to patients without a request, and that in thousands of cases they have failed to report cases to the authorities.

The “safeguards” in most of these state laws are woefully inadequate. As I explain in the report, a family member or friend who might benefit financially from the death of a patient may act as a witness that the patient is voluntarily requesting the lethal prescription, and doctors who support the ideology of death and have never before met the patient (or the patient’s family) can judge the patient to be “qualified” under the law. Finally, at the time of administering the deadly drug, there are no safeguards to ensure voluntariness or competence or to guard against coercion. Such a measure woefully fails to protect autonomy.

Physician-assisted suicide would transform our nation’s legal system. A society that creates a right to assisted suicide will seriously compromise the natural right not to be killed. As the legal scholar John Finnis has argued, “A whole new breed of lawyers and law teachers and judges will rapidly come into existence to give effect to the new régime.” With this new set of legal officials interpreting and enforcing new laws, society can expect to see more people have their right not to be killed violated.

 

Lopez: “The people most likely to be assisted by a physician in their suicide are not simply suffering from terminal illness, but also from depression, mental illness, loneliness, and despair.” Why do you say this? Aren’t you just scaring people unnecessarily?

Anderson: Not at all. This sad reality is one reason why so many medical professional associations and disability-rights groups oppose physician-assisted suicide, as I document in the report. To give you an idea, here’s how the liberal New York State Task Force on Life and the Law, established by Governor Mario Cuomo, explained its own report:

The Task Force members unanimously concluded that legalizing assisted suicide and euthanasia would pose profound risks to many patients. . . . 

The practices will pose the greatest risks to those who are poor, elderly, members of a minority group, or without access to good medical care. . . . 

The clinical safeguards that have been proposed to prevent abuse and errors would not be realized in many cases.

“Researchers have found hopelessness, which is strongly correlated with depression, to be the factor that most significantly predicts the wish for death,” write Dr. Herbert Hendin and Dr. Kathleen Foley. Dr. Hendin reports:

Mental illness raises the suicide risk even more than physical illness. Nearly 95 percent of those who kill themselves have been shown to have a diagnosable psychiatric illness in the months preceding suicide. The majority suffer from depression that can be treated. This is particularly true of those over fifty, who are more prone than younger victims to take their lives during the type of acute depressive episode that responds most effectively to treatment.

From their decades of professional medical practice, Drs. Hendin and Foley report that when patients who ask for a physician’s assistance in suicide “are treated by a physician who can hear their desperation, understand the ambivalence that most feel about their request, treat their depression, and relieve their suffering, their wish to die usually disappears.” They conclude: “Patients requesting suicide need psychiatric evaluation to determine whether they are seriously depressed, mentally incompetent, or for whatever reason do not meet the criteria for assisted suicide.”

Yet only five of the 178 Oregon patients who died under the Oregon assisted-suicide laws in 2013 and 2014 were referred for any psychiatric or psychological evaluation. Remarkably, patients were referred for psychiatric evaluation in less than 5.5 percent of the 859 cases of assisted suicide reported in Oregon since its law went into effect in 1997. “This constitutes medical negligence,” writes Dr. Aaron Kheriaty. Dr. Kheriaty concludes, “To abandon suicidal individuals in the midst of a crisis — under the guise of respecting their autonomy — is socially irresponsible: It undermines sound medical ethics and erodes social solidarity.”

 

Lopez: What is the lethal logic of physician-assisted suicide you refer to?

Anderson: The “lethal logic” I mention in the report is the slide from physician-assisted suicide (PAS) to voluntary euthanasia, to involuntary euthanasia. It’s happened in Europe. And there’s little reason to doubt it would happen here.

With PAS, a doctor prescribes the deadly drug, but the patient self-administers it. While most activists in the United States publicly call only for PAS, they have historically advocated not only PAS but also euthanasia: the intentional killing of the patient by a doctor.

This is not surprising: The arguments for PAS are equally arguments for euthanasia. Neil Gorsuch, currently a federal judge, points out that some contemporary activists fault the movement for not being honest about where its arguments lead. He notes that legal theorist and New York University School of Law Professor Richard Epstein “has charged his fellow assisted suicide advocates who fail to endorse the legalization of euthanasia openly and explicitly with a ‘certain lack of courage.’”

The logic of assisted suicide leads to euthanasia because, if “compassion” demands that some patients be helped to kill themselves, it makes little sense to claim that only those who are capable of self-administering the deadly drugs be given this option. Should not those who are too disabled to kill themselves have their suffering ended by a lethal injection?

And what of those who are too disabled to request that their suffering be ended, such as infants or the demented? Why should they be denied the “benefit” of a hastened death? Does not “compassion” provide an even more compelling reason for a doctor to provide this release from suffering and indignity?

Judge Gorsuch notes that for the Dutch, “it is the physician’s assessment of the patient’s quality of life as ‘degrading’ or ‘deteriorating’ or ‘hopeless’ that stands as the ultimate justification for killing.” Professor Keown confirms that “the undisputed empirical evidence from the Netherlands and Belgium shows widespread breach of the safeguards, not least the sizeable incidence of non-voluntary euthanasia and of non-reporting.” In October 2013, three judges of the High Court of Ireland voiced the same concern: “The incidence of legally assisted death without explicit request in the Netherlands, Belgium and Switzerland is strikingly high.”

And as I point out in the report, children are now being euthanized in Belgium and the Netherlands. The U.N. Human Rights Committee has even formally condemned this Dutch infanticide.

 

Lopez: Your paper is relatively long. Why?

Anderson: Simple — this is a complicated issue, and appealing just to sound bites or Hallmark style “compassion” isn’t enough. There’s also a lot of spin and misdirection coming from activists lobbying for assisted suicide. Since this is the first Heritage report on the issue, we wanted it to be comprehensive. In order to responsibly educate, we had to look at all angles of this issue and detail exactly how it can harm society, families, the dignity of people in the eyes of the law, and the practice of medicine.

 

Lopez: Why is it so important to get law and policy right?

Anderson: Our law and our public policy shape our culture, and our culture will either view the elderly and the disabled as burdens to be disposed of, or as people to be loved and cared for.

Many people don’t see this connection between law and culture. My Ph.D. is in political philosophy, and much of my work at Heritage has focused on the importance of marriage as an institution and religious liberty — and how the law will either support or undermine these institutions. Many people think about law and policy only in terms of individuals — individual rights and individual harms. But that’s a woefully insufficient way to think about politics. My work has really focused on the importance of institutions, and how the law shapes institutions. As I point out in the report, physician-assisted suicide will change the practice of medicine and the nature of intergenerational family obligations. You need a philosophy of institutions as well as of individuals to understand this.

 

Lopez: “For those in physical pain, pain management and other palliative medicine can effectively manage their symptoms. For those for whom death is imminent, hospice care and fellowship can accompany them in their last days. Anything less falls short of what human dignity requires. The real challenge facing society is to make good-quality end-of-life care available to all.” That seems easy to say from a computer in a think tank. Another thing if you’re living it, or your parent is, or your spouse. 

Anderson: No doubt, death is an absolutely heart-wrenching issue to see unfold, especially with a close family member. What we owe our loved ones is true compassion. For this, I looked to Ted Kennedy’s widow. Victoria Reggie Kennedy campaigned against a bill that would have legalized assisted suicide in Massachusetts on precisely these grounds. Kennedy noted that “the proposed law is not about bringing family together to make end of life decisions; it’s intended to exclude family members from the actual decision-making.”  She went on to explain how her husband was able to die a true death with dignity by avoiding the pressures of assisted suicide:

When my husband was first diagnosed with cancer, he was told that he had only two to four months to live, that he’d never go back to the U.S. Senate, that he should get his affairs in order, kiss his wife, love his family and get ready to die.

But that prognosis was wrong. Teddy lived 15 more productive months. . . .  Because that first dire prediction of life expectancy was wrong, I have 15 months of cherished memories — memories of family dinners and songfests with our children and grandchildren; memories of laughter and, yes, tears; memories of life that neither I nor my husband would have traded for anything in the world.

When the end finally did come — natural death with dignity — my husband was home, attended by his doctor, surrounded by family and our priest.

Mrs. Kennedy concluded that most people wish for a good death “surrounded by loved ones, perhaps with a doctor and/or clergyman at our bedside.” But with PAS, “what you get instead is a prescription for up to 100 capsules, dispensed by a pharmacist, taken without medical supervision, followed by death, perhaps alone. That seems harsh and extreme to me.” Indeed it is.

Though I became aware of her story only after my report went to editing, Kara Tippetts provides another example of what a natural death with dignity looks like.

 

Lopez: You point out that in the U.S. there is “one palliative care physician for every 1,200 persons living with a serious or life-threatening illness.” What is palliative care, and if all you say is true should, we be having a great-awakening-like movement for its expansion?

Anderson: Let me quote Mrs. Kennedy again:

My late husband Sen. Edward Kennedy called quality, affordable health care for all the cause of his life. [PAS] turns his vision of health care for all on its head by asking us to endorse patient suicide — not patient care — as our public policy for dealing with pain and the financial burdens of care at the end of life. We’re better than that. We should expand palliative care, pain management, nursing care and hospice, not trade the dignity and life of a human being for the bottom line.

Palliative care focuses on improving a patient’s quality of life by alleviating pain and other distressing symptoms of a serious illness. Palliative care is an option for people of any age at any stage in illness, whether that illness is curable, chronic, or life-threatening.

When a patient receives a terminal or life-altering diagnosis, the subsequent life changes are not limited to the medical challenges. Patients encounter the physical trauma of the medical diagnosis while also experiencing psychological difficulties, social changes, and even existential concerns. In Oregon Health Authority research, 91 percent of those who were assisted with suicide cited loss of autonomy as their motivation to end their lives, and 71 percent cited loss of dignity as their motivation. Only 31 percent cited inadequate pain control. These needs require different forms of care. Palliative care seeks to take into consideration every facet of the patient’s situation — with professionals who can attend to all aspects of the patient’s needs.

 

Lopez: How does assisted suicide compromise the family?

Anderson: There is a natural cycle to human life. Human beings enter the world as entirely needy, totally dependent newborns. Many people exit life dependent on others as well. Along the way, there will undoubtedly be periods of trial and tribulation when people need the assistance of others. Traditionally, the family has been a central social institution for weathering life’s storms. Mothers and fathers take care of children at the dawn of life, and then children take care of their aging parents at the twilight.

Family life is meant to include shouldering one another’s burdens and assisting those in need. In my report I cite the provocatively titled essay “I Want to Burden My Loved Ones,” by ethicist Gilbert Meilaender. He explains why he refuses to accept the logic of atomistic individualism:

Is this not in large measure what it means to belong to a family: to burden each other — and to find, almost miraculously, that others are willing, even happy, to carry such burdens? Families would not have the significance they do for us if they did not, in fact, give us a claim upon each other. At least in this sphere of life we do not come together as autonomous individuals freely contracting with each other. We simply find ourselves thrown together and asked to share the burdens of life while learning to care for each other.

In a society with PAS, the clear moral message transmitted by the law is that some lives are “not worth living” and that some people have a duty to end their lives.

These cultural pressures are not merely the suppositions of cultural philosophy. They play out in real life. Dr. Hendin has documented many such stories, such as this one:

A wife who no longer wished to care for her sick, elderly husband gave him a choice between euthanasia and admission to a home for the chronically ill. The man, afraid of being left to the mercy of strangers in an unfamiliar place, chose to have his life ended; the doctor, although aware of the coercion, ended the man’s life.

These stories are not isolated incidents. Dr. Hendin reports that a study of Dutch hospitals found that “doctors and nurses reported that more requests for euthanasia came from families than from patients themselves. The investigator concluded that the families, the doctors, and the nurses were involved in pressuring patients to request euthanasia.” The same pressure is evident in the limited places where physician-assisted suicide is legal in the United States. Oregon Health Authority research found that 40 percent of those who were assisted with suicide cited being a burden on family or friends and caregivers as their motivation to end their lives.

 

Lopez: How does it violate human dignity and equality?

Anderson: Perhaps the most profound injustice of PAS is that it violates human dignity and denies equality before the law. Every human being has intrinsic dignity and worth. For our legal system to be coherent and just, the law must respect this dignity by taking all reasonable steps to prevent the taking of innocent lives. Classifying a subgroup of people as legally eligible to be killed violates our nation’s commitment to equality before the law and shows profound disrespect for the elderly and disabled.

The D.C. assisted-suicide bill, like most, attempts to define which lives are unworthy of legal protection and therefore eligible for physician assistance in killing. That definition is unavoidably a statement of who is unworthy of legal protection. There is no way around it. The attempt to define which lives are eligible for suicide is a grave injustice: It violates human dignity and equality before the law. It declares that some lives matter less than others.

Disability-rights groups are particularly concerned about the ways in which assisted suicide deprives disabled people of the law’s equal protection. Diane Coleman, president of Not Dead Yet, summarized these arguments in an article for the Disability and Health Journal. Coleman explains that the push for assisted suicide undermines the value of the lives of people with disabilities:

The primary underlying practical basis for the physician’s determination that the individual is eligible for assisted suicide is the individual’s disabilities and physical dependence on others for everyday needs, which is viewed as depriving them of what nondisabled people often associate with “autonomy” and “dignity,” and may also lead them to feel like a “burden.” This establishes grounds for physicians to treat these individuals completely differently than they would treat a physically able-bodied suicidal person.

The law and government officials would treat suicidal disabled citizens differently from able-bodied citizens:

Not Dead Yet’s central argument is that legalized assisted suicide sets up a double standard for how health care providers, government authorities, and others respond to an individual’s stated wish to die. Some people get suicide prevention while others get suicide assistance, and the difference between the two groups is the health status of the individual.

As Coleman notes, “Assisted suicide singles out some people with disabilities, those labeled ‘terminal’ or very severely impaired, for different treatment than other suicidal people receive.” Government policy should seek to respect the innate dignity of the disabled by eliminating every form of unjust discrimination against them, not by expressly approving the worst form of discrimination.

 

Lopez: Is this an argument that is over already? When it’s available in some states, isn’t it eventually just going to go national? That certainly appears to be the trajectory at the moment.

Anderson: Not at all! Only three states allow physician-assisted suicide, and many states have explicitly rejected it. As more people learn the truth about it, more and more people will refuse to allow the vulnerable to be put at risk and our health-care system to be corrupted.  

Doctors should help their patients die a dignified natural death, but doctors should not assist in killing or self-killing. Physicians are always to care, never to kill.

Physician-assisted suicide endangers the weak and marginalized in society. Where PAS has been allowed, safeguards that were put in place to minimize this risk have proved inadequate and over time have been weakened or eliminated altogether.

Introducing PAS changes the culture in which medicine is practiced. It corrupts the profession of medicine by permitting the tools of healing to be used as techniques for killing. It also distorts the doctor–patient relationship by reducing patients’ trust of doctors and doctors’ undivided commitment to the healing of their patients. Physician-assisted suicide also creates perverse incentives for insurance providers and the financing of health care.

Worse yet, PAS negatively affects our entire culture. The temptation to view elderly or disabled family members as burdens will increase, as will the temptation for elderly and disabled family members to view themselves as burdens. Instead of solidarity through civil society and true compassion, PAS creates quick-fix, discriminatory, and lethal solutions.

The most profound injustice of PAS is that it violates human dignity and denies equality before the law. Every human being has intrinsic dignity and is the subject of immeasurable worth. No natural right to PAS exists, and arguments for such a right are incoherent. A legal system that sought to vindicate a right to assisted suicide would jeopardize the real natural right to life for all of its citizens.

For all of these reasons, citizens and policymakers need to resist the push for physician-assisted suicide.

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