Lakewood the Thinking City
Our discussions on assisted suicide took place at Fairview Park Regional Library on seven Monday evenings from September 29 through November 10. Participants ranged in age from about 30 to over 60. Their number at the beginning was about 10, but dwindled to five or six. At least one person, and probably more, declined to participate because of antipathy to the subject.
The basic question was: “what (if anything) should the law say about assisted suicide a) by doctors, b) by non-doctors? Should the law prohibit it, ignore it, or allow it with regulation (and what regulation)?”
At the beginning of the first meeting, each participant was asked to make a list of all possible conclusions, and of all possible arguments for each conclusion – including both those the participants agreed with and those they did not agree with. A compilation of these lists is given at the end of this summary.
The general course of discussion was as follows: The question of the right to assisted suicide quickly gave way to the question of the right to suicide itself. Although counter-arguments were given, the group as a whole agreed that there should be a right to suicide, as well as a right to assistance. However, there was a significant amount of controversy over possible restrictions on this right, centering on issues concerning medical condition (e.g. terminal illness), irrationality, and abuse. There were also other issues briefly discussed, such as method (active or passive). Specific legal restrictions were suggested occasionally but were not discussed explicitly due to lack of time.
The basic issues, then, are these:
Should (or does) a person have a right to suicide?
If so, does a person have a right to assistance in suicide? By doctors only, or by anyone?
Should the right to assisted suicide be restricted on the basis of medical condition?
Should it be restricted so as to guarantee the patient is rational?
Should it be restricted (or prohibited) so as to protect against abuse?
Should it be restricted as to the method employed?
These issues will be considered in turn:
Should a person have a right to suicide? The predominant opinion was that a person should have such a right, based on this argument:
Each individual has exclusive ownership of his or her own life.
Ownership of something includes the right to destroy or eliminate it.
Thus, everyone has the right to choose to end his her or her life.
Arguments to the contrary conclusion – that a person does not have the right to
suicide – were considered. These versions were presented:
An individual does not have exclusive ownership of his or her life
because of connections to others (e.g. family).
Without exclusive ownership one cannot destroy something unilaterally
(without the consent of others).
Thus, no one has the right to unilaterally end his or her own life.
Everyone has the duty to contribute to society.
One cannot contribute to society if one is dead.
Therefore, one should stay alive as long as possible.
Choosing to die means not staying alive as long as possible.
Therefore, no one should choose to die.
The second of these arguments was criticized in several ways. For one, there is an ambiguity in the term “contribute to society.” Does it mean one ought to perform altruistic activities, or does it mean that one ought to produce a net gain for society, even from selfish motives – as an honest businessperson does, for example. Second, the value premise – especially if we take “contribution” in the altruistic sense – seems too demanding. Do we have to contribute to society all the time? Third, the factual premise is open to question: those who are contemplating suicide don’t seem to be making a contribution to society; on the contrary, they are usually a burden. Indeed, consideration of burden to society led to a counterargument: In an overcrowded world, the individual is a burden on society, and therefore ought to be allowed – indeed helped – to end his or her life.
The first of the two arguments was not discussed at length, perhaps because it slipped through the cracks or perhaps because criticisms of it were thought to be analogous to criticisms of the other.
The argument against suicide on the grounds of its basic immorality was considered. It can be put as follows:
The law should prohibit immorality.
Suicide is immoral.
Therefore, the law should prohibit suicide.
This argument was not explicitly proposed by anyone in the group, but was examined as a challenge that had to be countered. In the discussion, those who endorse this argument and those who oppose it were seen to have fundamental differences concerning their conceptions of morality and of the function of the law. Those who favored this argument see morality as applying to all kinds of actions, not merely those that affect others. And they see the law as having the function of enforcing morality, not merely regulating the interactions of people. These two conceptions were defined but they were not debated.
If a person has the right to suicide, should that person have the right to assistance in suicide? The predominant opinion was yes, the person does have a right to assistance. The argument was based on the principle that if a person is entitled to do something at all, he or she is also entitled to get assistance in doing so. This was brought out by analogy with activities such as moving a box. (If you’re entitled to move a box, you’re entitled to get help in doing so.) The argument assumes no significant difference between suicide and other activities.
Another argument in favor of the right to assistance is that to allow suicide without assistance but to prohibit it with assistance would be to discriminate against those who are prevented by disability from committing suicide themselves.
It was also argued that assisted suicide is more justified than suicide without assistance. The argument is that a potential suicide would not be a good judge of his or her own rationality, but a potential assistant might be. The assistant, then, would be able to prevent irrational decisions.
Should the assistant be a doctor, or non-doctor, or both? The predominant opinion is that anyone should be allowed to give assistance, whether a doctor or not. The argument for this was an extension of the argument for the right to assistance: The right to assistance is a right of the person choosing suicide, not of the person giving assistance, and just as the right to receive assistance is not restricted by type of person in the ordinary case, so it is not restricted by type of person here. The assistant should be whomever the patient chooses, or whoever can help in the most effective, least pain-giving way.
Insofar as it is desirable to have a doctor for some purposes – e.g. to give injections – it was brought out that nurses and perhaps other medical personnel are gradually extending their sphere of competence.
An objection was raised to having doctors as assistants, namely that their doing so would conflict with their function of preserving life and health. Therefore it was suggested that suicide assistance be made a medical specialty, with only certain doctors allowed to provide such a service and all others prohibited. Perhaps clinics could be established to provide suicide assistance.
Should the right to assisted suicide be restricted? The chief restrictions were those having to do with:
medical condition (assisted suicide to be allowed only when the patient is
terminally ill or in intense pain)
rationality (assisted suicide to be allowed only when the patient is known to be
rational)
These two restrictions are paired because they were related in the discussion.
At first glance, such restrictions are paradoxical. As mentioned above, the consensus view was that everyone should have a right to suicide, and to assisted suicide. When we conceived of that right, we conceived of it as absolute. Yet when we imagined that absolute right exercised absolutely – in any conceivable situation, and therefore arbitrarily – we felt uncomfortable. So it seems that we do, yet do not, believe in the absolute right to suicide.
An example illustrates the point: Suppose a person said: “I have just experienced the happiest time of my life. I will surely be less happy from now on, and I can’t stand the thought of that, so I will commit suicide.” Would this decision to commit suicide be legitimate? The group hesitated to say yes, but why should we hesitate, if we believe that everyone has the right to take their own life?
The paradox can be resolved, and the two chief restrictions explained, on the assumption that no one wants to die except under certain terrible circumstances, namely intense pain and/or terminal illness. It follows that a person would not choose suicide under any other circumstances. And if a person seems to choose suicide under other circumstances, the choice is irrational – the expression of a passing impulse rather than the person’s whole personality.
In short, the right to choose suicide is accepted, and accepted absolutely, but the choice to suicide is recognized as a real choice – a rational choice – only under certain circumstances, namely intense pain and/or terminal illness. Thus the absolute right to suicide coexists with the restriction of that right in practice.
While this viewpoint seemed to fit the feelings of some of the group, it was criticized by others. The criticisms were based on the difficulty of enforcing the restrictions in a justifiable way. For one thing, it was held that we can’t determine what is rational and what isn’t. Is smoking rational, for example? Or eating too much chocolate? Second, it is difficult or impossible to determine what a person’s true motives are, especially if that person lies about them. Third, doctors may err in diagnosing an illness as terminal – a patient diagnosed as terminal may live for many years, and on the other side there is the possibility of a doctor falsely diagnosing an illness as terminal in order to profit from expensive end-of-life care. Finally, it may be difficult to determine how badly a person is really suffering.
The relation of irrationality and depression was also discussed, although not enough to bring out any clear conclusions or viewpoints. The starting point was the contention that a desire to commit suicide must be the result of depression. One argument, then, is that depression is irrational and irrational choices of suicide should not be allowed; therefore suicide should never be allowed. Another argument is that depression is treatable and therefore not the kind of irremediable disease that justifies suicide. On the other side, it was pointed out that “depression” is ambiguous, referring either to clinical depression or to everyday depression. The latter doesn’t make a person irrational, and the former can be medicated so as to make the patient rational. In any case, the critical view holds, the decision to commit suicide may well spring from causes other than depression.
The only other restriction suggested concerned the method of assisting suicide, active vs. passive. On this there was no definite consensus, but the preponderant opinion seemed to be that the active-passive distinction is unfounded and that there should be no restrictions based on such a distinction. Whatever method brings about the least pain should be used. Various examples were given to confound the attempt at making the distinction: withdrawing life support; giving medication; lethal injection or inhalation. Which of these measures are passive, and which are active? Does it make sense at all to talk about assisting in a passive way? Similarly, the notion of passive suicide was challenged. Consider the examples of stopping treatment, or of refusing treatment when first proposed: These are presumably passive measures, but can they be considered suicide?
Finally, it was suggested that assisted suicide be subject to certification and that certification be denied if anyone objected. A criticism was that almost anyone could object, and so assisted suicide would in effect be prohibited by this provision.
The problem of abuse: Should the right to assisted suicide be restricted (or prohibited) so as to avoid abuse? The problem of abuse arose because the typical patient contemplating suicide was seen as old, infirm, mentally diminished and/or emotionally dependent, thus vulnerable to persuasion by relations or friends. Such friends or relations, if unscrupulous enough, might lead the patient to commit suicide when doing so is not in the patient’s best interests and thus really not the patient’s choice. (Again, the right of the individual to choose suicide is recognized; but when suicide stems from the patient’s vulnerability it is seen, on this view, as not really being chosen.) The problem is especially significant when assisted suicide is in question, since the role of assistant offers greater opportunity for persuading the vulnerable. Thus it might be concluded that special restrictions should be put on the right to assisted suicide, or if restrictions are not sufficient, that assisted suicide be prohibited altogether.
The counterargument is that even when the patient is vulnerable, he or she is still making a choice, and – at least in the absence of the restricting conditions discussed
above – everyone should be allowed such a choice. If one makes a choice out of vulnerability, it still is a choice, and in the general case we allow such choices, as for example in the case of TV evangelists. The government should not serve to protect people from themselves.
It was agreed that certain conditions would make the choice of suicide illegitimate, namely:
Deceit
Irrationality (however defined)
Physical force
Furthermore, killing under the guise of assisting suicide – pseudo-suicide – is obviously illegitimate.
With regard to all of these factors, safeguards must be set up. Of course, the safeguards might be evaded, but the same holds true of all safeguards against all dangers. The consensus view was that it’s worth taking the risk.
But even in the absence of all these factors, persuasion to suicide seems suspicious. In making a final decision on whether such suicide is legitimate, several aspects or factors were considered: economic gains as the basis of the persuasion, the doctor as the persuader, coercion, and “taking advantage:”
PERSUASION FOR ECONOMIC GAIN: It’s bothersome to think of someone being persuaded to commit suicide for economic reasons. But it was argued that we see nothing wrong with making decisions for economic reasons, even when – or especially when – the decision involves sacrifice by the decision-maker.
The argument was made that such a decision involves economic discrimination, in that patients with fewer resources are more likely to be pressured to commit suicide. But, it was argued, the same economic discrimination exists in health care already. (And is it true that the poor would be more subject to pressure? The pressure might be greater on those with greater resources to be received by their beneficiaries in case of suicide. See the hypothetical example below.)
To undercut the misgivings over economic persuasion, it was explained that they result from our unwillingness to admit a scarcity of resources, which leads to our refusal to admit a real economic benefit from ending life.
To test our views on economic persuasion and motivation, the group considered a hypothetical example, as follows: “A man in his mid-50s is bedridden and helpless due to a wasting neurological disease. He is not in great pain. He will never be rid of his disease, but his doctors predict he will live another 10 to 15 years. His care and treatment cost a great amount of money and are using up his estate, which he had planned to leave to his children and grandchildren, especially for his grandchildren’s education. He asks his doctor to assist in his suicide. Should his doctor be allowed to do so?” Everyone agreed in giving a “yes” answer, approving the suicide.
Still, persuasion on economic grounds remained bothersome. It was suggested that review boards should insure that economic considerations are not decisive.
PERSUASION BY DOCTORS: In considering this question, the group first imagined a doctor persuading a patient to commit suicide for the doctor’s financial gain, and that seemed sinister. But it is merely an instance of the situation just discussed – persuasion on economic grounds – and it was felt that the economic arguments offered by doctors can be just as good as those offered by anyone else. So persuasion by doctors is not to be ruled out because of the doctors’ motives or the type of incentive they might offer the patient. Rather, persuasion by doctors is suspect because doctors are in a privileged position that gives them increased opportunity to deceive the patient. (But in that case, the situation would be one of deceit, which was recognized above as a factor making persuasion illegitimate.)
COERCION: Coercion does not eliminate choice. Rather, it is an intrusion which eliminates an alternative the coerced person would have preferred. (For example, the gunman who says “Your money or your life.” The victim would have preferred to stay alive and keep his money. The gunman’s intrusion took that alternative away.) And since coercion is an intrusion, if the patient can remove the intrusion there is no coercion.
The predominant viewpoint was this: Persuasion is legitimate if it is not coercive and a persuasive conversation is surely not coercive if the patient can end the conversation. What if the persuasion is browbeating, designed to be unpleasant for the patient? This makes no difference. As long as the patient can end the browbeating, there is no coercion and the persuasion is legitimate.
Thus coercion was added to the list of elements that make persuasion illegitimate. But whether coercion occurs must be decided on a case-by-case basis, and the frequency of occurrence is questionable.
“TAKING ADVANTAGE:” An example of “taking advantage” in the morally reprehensible sense: Mr. A goes into a grocery store which has set up a sample-stand to introduce their customers to a new cheese snack. Mr. A eats 50 of these cheese snacks. He has taken advantage of the grocery store.
This provides a definition: When A takes advantage of B, there are limited alternatives open to B. (The grocery store may put up the sample-stand or not, but it does not have the alternative of preventing individuals from taking as much as they wish.) One of the alternatives has consequences that B did not wish for (A eating 50 cheese snacks), and A uses that opportunity (eats the 50 cheese snacks) for his own benefit and presumably to the detriment of B.
If a vulnerable patient is persuaded to suicide by a friend or relative, does that constitute taking advantage, and if so, is such persuasion illegitimate? This was not discussed explicitly, but the issue seems parallel to that of coercion. On the one hand, suppose a patient dependent on the affection of her son, and suppose that her receiving that affection has the unwished-for consequences that the patient must commit suicide; the son is clearly taking advantage of his mother, and one might argue that is wrong. On the other hand, the patient still has a choice; she can still choose to reject the son, affection and all (just as the grocery store had the choice of taking down the sample-stand). The proponent of this view might say, “Remember, we’re not concerned here with the virtue or villainy of the person who seeks to persuade the patient, but only with the question of whether the patient had a choice.”
Regulation of the right to assisted suicide: As mentioned above, suggestions as to how assisted suicide should be regulated appeared from time during the discussions, though they were never codified nor discussed explicitly. These regulations were suggested:
1) Assisting doctors should belong to a separate, segregated branch of
medicine.
2) Each decision for suicide should be reviewed by a board to insure that
the decision is authentic – i.e. not the result of a passing mood, not coerced,
etc. Special care should be given to the economic considerations involved.
(How much importance economic considerations should be allowed to have,
however, was not settled. See the discussion above.) The composition of
the review board was not discussed, nor was the question as to whether the
board’s deliberations should be open to the public (like court proceedings) or
kept secret.
3) The patient’s consent should be strongly documented.
4) Certification should be required for any assisted suicide.
CATALOGUE OF
POSSIBLE ARGUMENTS
I.
In favor of allowing
assisted suicide:
Assisted suicide should be
legal (with no regulation at all).
… because it would end suffering for terminal patients
with no hope.
… because an individual should have the right to end
prolonged or unnecessary suffering.
…
because we should have the right to determine to end life.
…
because as part of the right of privacy, a person has the right to choose how
and when they die and to do so in a humane way (analogy with abortion).
…
because it would save on unnecessary medical costs that cannot improve a
patient’s condition but only prolong life.
Assisted suicide by doctors
should be illegal.
… because it
would give physicians too much power – as killers.
… because it conflicts with the “do no harm” principle.
… because of the difficulty in defining who is a
“doctor.”
… because religion is opposed to it.
Assisted suicide by others
than doctors should be illegal.
… because non-doctors are not medical experts, or are not
competent.
…
because professionals are more easily regulated
… because
an individual should be able to choose to use modern medicine to decrease their
life span as well as increase it..
…
because assisted suicide is a contract between two consenting people, and
therefore should be allowed, by analogy with other things people are allowed to
submit to even though we might think them regrettable (e.g. phen-fen).
… because life is cheap and the world is overpopulated.
Assisted suicide should be
explicitly allowed by law. [I construe
this to be different from the above conclusion in holding that the law should
explicitly address the question of assisted suicide, as opposed to being silent
about it.]
… because individuals would then be allowed to reach
agreements among themselves.
… because it allows individuals to get help without fear.
… because it allows for regulation. [What regulation is desirable?]
… with regard to doctors in particular, it
allows them to help without being in fear of the
law.
And because doctors, not others, are the
experts
And because it allows
doctors to act knowing the rules.
…
with regard to non-doctors in particular, it avoids the doctor’s conflict with
“do no harm.”
Assisted suicide should be
“ignored.”
… because it goes on now as doctors use their own
judgment, whereas any laws will push
present
practices to one extreme or the other (prohibition or euthanasia).
… because the government has no standing to rule on
suicide.
… because it leaves an intensely personal matter in the
hands of family, where it belongs.
II.
Against allowing assisted suicide:
Assisted suicide should be
illegal.
,,, because it would lead to abuse or evil purposes.
.. because it would lead to disrespect for
life.
… because of the sanctity of life.
… because suicide is wrong and assisted suicide is
murder.
… because there is a thin line between murder and
assisted suicide.
… because suicide
is a crime and a sin.
… because assisted suicide would “slide into
euthanasia.”
,,, because it could instill fear in the elderly or infirm
that they could be put away before
they are ready.
… because of the slippery-slope argument. [same argument?]
… because people who don’t know about the state of
medicine should be protected.
… because murder could be disguised as assisted suicide.
… because economic factors would lead to suicide with
others’ encouragement.
… because of the difficulty of defining acceptable
conditions.
… because the decision is reached by two people whereas
suicide should involve only the
suicide.
… because the decision for assisted suicide affects more
than the individuals directly
involved.
… because no one should play god and decide who should
die and when.
… because medical breakthroughs could bring a cure for
the patients’ illnesses.
For allowing assisted suicide
in a qualified way:
Assisted suicide by doctors
should be illegal.
… because it would give physicians too much power – as
killers.
… because it conflicts with the “do no harm” principle.
… because of the difficulty in defining who is a
“doctor.”
… because religion is opposed to it.
Assisted suicide by others
than doctors should be illegal.
… because non-doctors are not medical experts, or are not
competent.
… because professionals are more easily regulated.
Assisted suicide should be
allowed only by non-doctors (but must define who this would be, and also
possibly define age and waiting period).
(No reason given for this conclusion.)
Assisted suicide should be
decided by a board or committee consisting of a variety of clergy, medical and
human service professionals who could listen to each case to determine the
reason for and appropriateness of such action.
They would rule to legally authorize suicide if all criteria had been met. Elected positions. (No reason given for this conclusion.)
Assisted suicide – assisted
by a doctor – should be allowed when requested by the patient, when there is no
hope for recovery, when the patient is
suffering and when a second doctor has signed on. (No reason given for this conclusion.)
Assisted suicide should be
allowed by law, but with the medical profession deciding how it is to be
regulated. The law would provide the
means to police it and to apply sanctions.
(No reason given for this conclusion.)
Assisted suicide should be
allowed by limited classes of non-doctors such as ministers or psychiatrists,
working with the patient’s doctor. (No
reason given for this conclusion.)
Assisted suicide should be
allowed if a doctor attends and: the
doctor can expertly evaluate the patient’s status, is trusted by the patient to
execute the procedure, is aware of effective means, is familiar with the death
process, and is trusted by the public.
(No reason given for this conclusion.)
It is impossible to reach a
conclusion.
… because there are too many variables. [What are these variables?]
It should be allowed when
there is no one to help care for the patient who is terminal but not requiring
hospitalization or hospice care.
--
G.B.