The Case for “Death with Dignity”
by Benjamin Studebaker
Brittany Maynard, a 29-year old newlywed, recently learned that she has terminal brain cancer. Brain cancer is an awful way to die–sufferers often experience morphine-resistant pain, personality changes, and loss cognitive and motor skills. So she decided to relocate to Oregon, one of 5 US states that has a “death with dignity” law, allowing people with terminal disease to commit assisted suicide. On November 1, she intends to kill herself. Should euthanasia be permitted? Under what circumstances might it be ethical? These are the questions I pursue today.
There are many views with respect to assisted suicide. Here are a few of the most popular:
- The “Right to Die” View: this view holds that all people are entitled to kill themselves if they so choose, and that it is not society’s business to force them to live against their own wills by state coercion regardless of whether or not they have a terminal illness (e.g. Jacob Appel’s view & Swiss law).
- The Oregon View: the Oregon law holds that a person can commit suicide if two doctors certify that the patient has less than 6 months to live and the patient successfully passes a series of tests to establish that she isn’t depressed, acting impulsively, or being coerced. This permits assisted suicide, but only in limited cases.
- The Perverse Incentives View: many opponents of euthanasia argue that if assisted suicide is legalized it will put implicit and/or explicit pressure on elderly, disabled, or poor people to kill themselves (e.g. Marilyn Golden’s view).
- Religious Views: many religious people hold that suicide necessarily violates god’s plan and is therefore disrectful sinful no matter the circumstances (see Evangelium Vitae #66).
As we discussed last week, the religious views are problematic–if an omnibenevolent god has created a universe in which it is possible for human beings to commit suicide, it may well be part of his plan that people sometimes do so. An omnipotent god’s plans cannot be meaningfully challenged or undermined by the acts of mortals.
What about the “right to die” view? Should people possess an inviolable right to bodily autonomy that includes the right to end one’s life? In On Liberty, John Stuart Mill argues that people should not be coerced by society unless their actions would harm others. He calls this the harm principle:
…the only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others. His own good, either physical or moral, is not sufficient warrant.
The harm principle would not permit society to ban assisted suicide to save the soul of the person committing suicide or to prevent the person from committing a self-harm of any other kind. If however we were to cogently argue that assisted suicide causes harm to other people aside from those who willingly wish to partake in assisted suicide, that would provide grounds for regulating it. There are several groups that can potentially be harmed by assisted suicide aside from those who would voluntarily commit it:
- Dependents, family, and friends, who would lose a person whose life benefits them directly.
- Society as a whole, which would lose the productive capacity of the person.
- People who, in line with the perverse incentives view, commit assisted suicide under external compulsion.
There are cases in which the harms caused to others aside from the voluntarily suicidal might outweigh the benefit of giving individuals the freedom to choose whether they live or die. For this reason, we should not support a strict right to die, but rather a delimited one. Only in certain circumstances should a person be permitted to commit assisted suicide. What are those circumstances?
Oregon law limits assisted suicide strictly to the terminally ill, and its very thorough regulatory process circumvents the objections raised by the perverse incentives view. Because prospective suicides must have a terminal illness certified by two doctors and pass a series of tests to prove they are not clinically depressed, acting impulsively, or being coerced, it is impossible for the Oregon law to cause serious additional harm to any of the three aforementioned groups. Society, friends, and family members are going to lose the person to the terminal illness within 6 months anyway, so the early departure is of little significance next to the pain and suffering that would be endured if the prospective suicide was forced to wait for death. The perverse incentives view fails to make much of a dent in Oregon’s position because it does not make assisted suicide readily available to the elderly, disabled, or poor, unless those individuals are also suffering from a terminal disease.
At the very minimum, Oregon’s “death with dignity” law is on sound footing. But is it possible that there are additional cases in which assisted suicide might be justified that are not yet covered under Oregon law? Quite possibly–we can imagine cases in which a person does not have a terminal illness per say, but has a disease that will likely drastically reduce their quality of life (e.g. Alzheimer’s). While someone with Alzheimer’s may go on living for years, the person will experience frightening cognitive decline, becoming a serious burden on friends, family, and/or the state. If someone with Alzheimer’s wished to opt for assisted suicide, this might well be beneficial to themselves, their families, and wider society. The difficulty is the extent to which this might open the door to the perverse incentives objection. If someone were legally allowed to commit assisted suicide in response to Alzheimer’s, Parkinson’s, or other chronic ailments, it becomes possible that they might be pressured to do so by a society or family that wishes to divest itself of the costs of caring for the individual.
To justify this kind of expansion, it would be necessary to highly regulate this process. Those wishing to commit assisted suicide for non-terminal reasons would need to undergo psychiatric evaluation to ensure that the decision is being made rationally. Prospective suicides would need to be screened for depression and other forms of mental illness. The state would also need to confirm that they were not acting impulsively or under the influence of coercion by an interested third party. There is no obvious reason why the state could not feasibly and adequately legalize and regulate this process–it would only require slight modifications to the regulatory scheme already in place in Oregon. This scheme has been quite effective so far–only 750 Oregonians have committed assisted suicide since their law went into effect in 1997, a rate of just over 40 per year. Even in Switzerland, where regulations are comparatively lax, only around 1000 people have committed assisted suicide over the past 12 years, many of which are “suicide tourists” from other European countries that do not as of yet permit the practice.
In sum, there is no compelling reason to ban assisted suicide whenever a prospective suicide can establish that he has rationally come to the conclusion that his life is no longer worth continuing for quality of life reasons. A terminal illness is the most obvious quality of life reason, but chronic illnesses should also be considered potentially valid. Extant assisted suicide laws establish that it is possible to permit assisted suicide with regulations and restrictions without it leading to a slippery slope in which happy and health old, disabled, or poor people are pressured into the practice. As I write this, only 5 US states permit assisted suicide (they are: Washington, Oregon, Montana, New Mexico, and Vermont). More should legalize the practice. It should also be adopted in additional European countries, so that very sick people are not forced to make arduous journeys to the few European countries that presently allow it.
The case for dementia could prove difficult. My mother has it, and by the time she was diagnosed, there were obvious signs of it. But before then, the signs were there, just not so noticeable to doctors and those who hadn’t been around her much. At what point does someone with dementia become unreasonable? It’s such a slow disease, it’s hard to say. This could get very hairy.
I would like to allow people with dementia to have a right to end their own lives, but how could this be done?
I see two different ways to resolve this:
1. If someone can prove to a psychiatric professional that he rationally believes that he has dementia, we permit him to commit assisted suicide even if doctors are not able to confirm it.
2. If someone is diagnosed with dementia, we permit him to commit assisted suicide even though his dementia may be interfering with his rational decision-making.
The former prioritizes the rationality of the sufferer, the latter prioritizes establishing that the condition is real.
I think 1. is problematic on legal terms. Doctors usually have to confirm a diagnosis, certainly for something as controversial as euthanasia.
2. is problematic as well. If being of sound mind is a prerequisite for allowing someone to self-terminate, then having dementia (which is pretty much equal to being of unsound mind, at least legally speaking) would obviate any possibility of legal self-termination.
So it seems there’s a small window of opportunity (theoretically speaking, of course) for someone with dementia to make a rational decision to die. Unfortunately, at the still-rational stage, doctors are not likely to confirm the diagnosis. I know the way doctors are about this. My mom has it, and when I had to sell her house, I couldn’t get the neurosurgeon who gave her prescriptions for dementia to confirm that she actually had it. Previously he had even explained to me that he was very close to certain that she has Lewy bodies dementia. I couldn’t believe he would prescribe medications for it and not formally diagnose it. But docs are very careful to avoid lawsuits.
I failed to say this before, but in general I agree with everything you said in this post. It was especially interesting to hear the argument that ending your own life could cause harm to others, which is why the Oregon law stipulates that the patient must be terminally ill. For some reason I hadn’t quite put those two things together before, but it makes a lot of sense.
Yeah, neither option is going to fully satisfy the criteria for a terminal illness under the extant Oregon law, so the question is where (if anywhere) the law should be amended so as to make additional space. We’d probably have to protect doctors from lawsuits by potentially upset family members (or other third parties), too. I’m glad you liked the piece! Thanks for reading.
Very much enjoyed it. I like your clear writing style. A pleasure to read!
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