Beware Assisted Suicide’s Fog of Ambiguity

S hall a person diagnosed with a terminal illness be able to legally obtain a lethal cocktail for self-administration prescribed by a health care professional in the United States? Medical aid in dying (MAiD), a.k.a. physician-assisted suicide, is currently legal in ten states, the District of Columbia, and several countries. Proposals are under consideration in at least 19 other states. This week, the New York State Assembly passed the bill Medical Aid in Dying; in Delaware, a bill “Relating to End of Life Options” has passed both chambers and is awaiting the governor’s signature. While motivated by compassion, proponents of MAiD seem to place personal autonomy above all other considerations. A death, any death, must be considered with utmost deliberation and compassion. Rather, proponents of assisted suicide argue their cause using ambiguity and fear.

First, we are told that individuals diagnosed with a terminal illness or condition have a right to end their lives. Does that right of the individual trump its impact on others? Do not friends and family, caregivers, and the writer of the prescription (especially if he or she has not developed a relationship with the patient) experience regret? Could something more have been done? Do I want to be cared for by doctors who endorse MAiD? Might they be giving up on me? Are the disabled and the socially disadvantaged more at risk? Is this how we want society to function? While many may say they support MAiD, they are not being apprised of the harm posed to others, including the most vulnerable among us, this “right” being camouflaged in a fog of ambiguity.

Second, we are told that, while Canada, the Netherlands, and other countries have seen death by assisted suicide grow at rates exceeding 30 percent per annum in most cases, the United States would not experience the same slippery slope. The slope is enabled by wording that includes ambiguous eligibility criteria and then by gradual liberalization of interpretation. Outside the U.S., deaths for loneliness, eating disorders, autism, dementia with an advance directive, and mental illness are legal, and direct injection, a form of euthanasia, has replaced self-administration in almost every case. According to annual reports, 60,301 persons in Canada have died by MAiD since its legalization. Euthanasia now accounts for 4.7 percent of deaths in Canada, the fifth-largest cause of death there. The Netherlands reports that 5.8 percent of Dutch deaths are by euthanasia, with rates up to 15 percent in some urban areas.

Reporting from the U.S. contradicts the supposition that we can avoid the slippery slope, as rates appear to increase similarly (30 percent per annum). In every U.S. state where MAiD is legal or proposed, the law opens the door by allowing the practice in cases of a terminal illness or “condition.” Reporting from the states is incomplete, in part because the underlying condition rather than the cause of death must be cited in death certificates. Nonetheless, data are available for deaths whose reported causes include anorexia, arthritis, and diabetes. In none of those conditions is death an immediately foreseeable outcome. Further, in each state where MAiD has been legalized, amendments to widen eligibility either have been granted or are under discussion. The amendments include provisions for tourism, the possibility of self-injection, a shortening of the reflection period, reduction of informed-consent safeguards, and the ability of certain nonphysicians to prescribe.

Third, might initiation of MAiD erode support for palliative care and disability services? Several hundred persons euthanized annually in Canada have not had access to palliative care. Several hundred disabled persons euthanized annually in Canada could not access sufficient support services. The disabled among us are particularly vulnerable to devaluation. The United Nations Committee on the Rights of Persons with Disabilities recently recommended that Canada stop performing MAiD when natural death was not reasonably foreseeable, citing “negative ableist perceptions of the quality and value of the life of persons with disabilities, including that ‘suffering’ is intrinsic to disability.” With rising costs, inadequate insurance coverage, and the increasing corporatization of medicine in the U.S., might MAiD be increasingly resourced? Is this how we view our societal obligations? Could this become the killing of the (economically unprofitable) oldies?

Fourth, proponents attempt to persuade by showing examples of individuals undergoing extreme suffering, thereby stoking fear of death. Certainly, death is scary. Fortunately, however, medical practice now enables adequate pain control for almost every condition. Interestingly, inadequate pain control was not among the five most common reasons for MAiD requests in Oregon. In my clinical experience, death with dignity can be managed with attentive medical care and palliative services.

Fifth, we are told MAiD is not suicide. According to proposed legislation in New York State: “Action . . . shall not be construed for any purpose to constitute suicide, assisted suicide, attempted suicide, promoting a suicide attempt, euthanasia, mercy killing, or homicide.” Laws in other states read similarly. Notwithstanding the euphemistic language, and contrary to the expectation that the conventional suicide rate might decrease in jurisdictions where MAiD is legal, economic researchers Sourafel Girma and David Paton (2022) have found a statistically significant uptick in non-assisted suicide of about 6 percent overall in the U.S., with a 13 percent increase for women where MAiD is permitted.

To paraphrase Monsignor Romano Guardini in The Lord, the psyche can sicken its relation to the truth, by subordinating it to “necessity” and screening it in a fog of ambiguity. “We fell morally ill because we got used to saying something different from what we thought,” Václav Havel wrote. Supporters must reflect on the downstream societal damage enabled by legitimizing suicide under any other name.