The topics of euthanasia, suicide, and physician assisted suicide (PAS) are poorly understood; however, this clarification is increasingly important in our society. Five U.S. states, as well as the country of Canada, have passed laws legalizing PAS and, although a number of state legislatures have previously rejected legalization, the momentum seems to be building for expansion of the number of those that accept it.
Explore this issue:May 2018
PAS has been legal for some time in various European countries, while Great Britain, always the leader in hospice and other palliative concepts, has yet to embrace either PAS or even the concept of euthanasia.
First, let’s classify the topics. Euthanasia is a generic event and suicide a specific one; and importantly, the two are not mutually exclusive. Euthanasia results from actions meant to directly cause death. Passive euthanasia represents the allowance of death by withholding or withdrawing treatment, while active euthanasia results from a deliberate act meant to end life, such as the administration of a lethal potion. It is my belief that suicide, whether assisted or unassisted, can be considered a form of self-imposed euthanasia.
The outline below is a suggested categorization of these topics:
- Self-conceived or self-inflicted (unassisted)
- Active (physician or lay person involvement)
- Passive (physician or lay person involvement)
Self-conceived and self-inflicted suicide is self explanatory. Getting a handle on data is another matter, however, because in certain parts of the world the act is illegal. The World Health Organization estimates that one million self-inflicted deaths occur globally per year. This figure represents approximately 1.5% of all deaths—a number that makes suicide the 10th leading cause of death worldwide. Almost certainly, these figures are gross underestimates. There are more than 31,000 suicides recorded in the U.S. annually.
Whether suicide is self-inflicted or assisted, the differences are critical to understanding the interdigitation of this nomenclature. In assisted suicide, there is an active and a passive version. In the latter, the physician is only allowed to supply the information and/or the tools for the patient to induce his or her own death, outside the physician’s presence. In this setting, the person destined to die actually administers the potion.
This is the permitted method in Canada and in the U.S. states that allow PAS. The antithesis of this would be active assisted suicide, in which the physician or even a lay person administers the lethal cocktail. This is the model in the Netherlands and other countries. American physician Jack Kevorkian, MD, tested this limit in 1998, and spent eight years in prison for second-degree murder after he personally euthanized a patient and aired the act on network television.
In parts of Europe, such as in Germany, Luxembourg, Belgium, and Switzerland, the active assistance of a person other than a physician is acceptable. Notably, in Germany, while lay people are permitted to assist, physicians are forbidden from participation of any kind. The public has apparently neither forgiven nor regained trust in the profession for its shameless complicity in mass killings in the 1930s in which death panels decided whether or not a life was deemed unworthy of living—i.e., those with severe birth defects, mental illness, and others were assigned to be euthanatized. (The book Death and Deliverance by Michael Burleigh [Cambridge University Press, 1995] is an important work that offers eye-opening revelations on this subject. The author asks why so many ordinary Germans abandoned concern for the weak in favor of a vulgar ideology of social Darwinism that dragged the whole society down to the laws of the jungle; and, importantly, the medical profession was at the heart of the program and did most of the killing.)
Since a rendezvous with death is common to all of humankind, shouldn’t medical caregivers—the overseers of dying—be an important part of those discussions that standardize, regulate, and establish the ethics and the legal language applied to the process? —Roy B. Sessions, MD
Given this classification, let’s look at applicability. The U.S. has a shifting social landscape that is undergoing gradual secularization, and without very specific legal, moral, and ethical standards relative to the subjects of this essay, the boundaries of correctness will certainly be tested. As a means of demonstrating this eventuality, consider the rules governing this issue in Switzerland, in which there is now a “not-for-profit” business that will provide active euthanasia for money. Many Europeans and citizens of the U.K. who don’t have easy access to death travel there for life’s closure. This company is Dignitas (which means “dignity” in Latin), and if you write them a check, they will end your life.
Until I began research for a book that included this subject, I naïvely failed to appreciate the complexity of the subject. The tendency is to focus on the morality of the issues, and that’s not necessarily unwise, but that’s personal, and no doubt, personal standards can be complex. The complexity to which I am referring, however, is the law. In my opinion, the gold standard for study of the law was developed by Supreme Court Justice Neil M. Gorsuch, who has written extensively on the subject. (For a review of the case law as well as a discussion of concepts, read Gorsuch’s thorough and well-written book, The Future of Assisted Suicide and Euthanasia [Princeton University Press, 2006].) The U.S. Supreme Court’s 1997 decisions in Washington v. Gluksberg and Vacco v. Quill held that there is no constitutional right to physician-assisted suicide, whether by passive participation or by direct infliction of death. In not ruling either for or against in these cases, the Court sidestepped the moral issues and left the path of resolution to the individual states.
Additionally, by this “non-ruling,” the court has encouraged the contentious and age-old question to surface—should there be only one law of the land, or is an array of state laws the preferable model? The current trend of leaving it to the states will continue until the Supreme Court rules otherwise, and in so doing will have to supersede its previous action.
The Physician Voice
Lest we repeat the error of our previous ways, physicians should work to insure control of many non-administrative issues such as dying and death, which should be within the dominion of the profession. Since a rendezvous with death is common to all of humankind, shouldn’t medical caregivers—the overseers of dying—be an important part of those discussions that standardize, regulate, and establish the ethics and the legal language applied to the process? I believe they should!
If, however, our leadership avoids the hard work and intellectual tenacity that philosophers, ethicists, sociologists, and legal scholars bring to the discussion table, we will be excluded from crucial social and legal debates. Poets, legal scholars, theologians, and philosophers have written extensively about death and dying, while the people who frequently witness death—physicians, nurses, hospice personnel, and others—rarely write about it. In a similar paradox, the medical profession has changed dramatically in recent times, and much that has transpired has been outside of our control. In my opinion, the failure of cohesive and effective physician leadership has in no small measure been responsible for this state of affairs.
Whatever the extent of the medical profession’s participation in the forthcoming discussion regarding PAS and euthanasia, it must be based on a practical brand of scholarship that possesses the underpinnings of humaneness and morality, while perpetuating an intense value for life. In deciding the future of this matter, the individual physician or lay person must not lose touch with what “feels” right and what “feels” wrong. These instincts are profound in insightful and substantive people, and they provide a moral compass that should generally be followed. From my own personal perspective, if an act or action feels wrong, then it usually turns out to be just that.
It has been said that wrong is always wrong, even though everyone is doing it, and right is always right, even if no one is doing it. While these statements are simplistic given the complexity of contemporary social and human behavior, the spirit of the statements can be borrowed and employed. After all, a physician’s behavior should be founded on a simple and unselfish premise—service to humankind. In keeping with that, is it “mission correct” to provide help in dying, whether by suicide or natural causes? In one form or another, physicians have been helping people die since times of antiquity; the notion of terminal sedation is hardly new. This latter action involves making someone comfortable with repeated small doses of a sedative that increases somnolence, decreases respiration, and invites such things as pneumonia that in turn accelerate the terminal approach to death. If one must classify this action, it probably lies somewhere between passive euthanasia and physician-assisted suicide. In previous writings, I have emphasized the importance of the trust between physician and patient, and this deed, as much as any other, exemplifies the sine qua non of trust!
By writing this essay, I challenge physicians in general and our leadership in particular to get involved in this debate. Whatever your personal feelings, make them known!
Dr. Sessions is semi-retired but teaches at The Medical University of South Carolina in Charleston and consults at the Ralph Johnson VA Medical Center.