The ongoing public debate over the legalization of assisted suicide draws participants whose primary concern is not the issue itself but who find it the ideal occasion to advance collateral social initiatives. Thus, as he revealed in the haunting polemic with which he began his notorious public career (Prescription: Medicide [1991]), Jack Kevorkian was not particularly concerned about the issue of legalized assisted suicide. Rather, he saw assisted suicide as the ideal way to advance his real agenda, the legalization of human vivisection.
The editors of The Case Against Assisted Suicide: For the Right to End-of-Life Care, Drs. Kathleen Foley and Herbert Hendin, are renowned clinicians, researchers, and teachers. And they too—while not otherwise to be compared to the serial mercy killer of Michigan—seem to approach the debate over assisted suicide as an opportunity to promote their agenda. In the case of Foley and Hendin, that agenda is improvement in the palliative care of terminally ill patients. As the comedian says, not that there’s anything wrong with that. Still, there is a significant difference between opposing assisted suicide on deontological grounds and using such opposition to advocate a change in health care policy.
But surprisingly, it is this very weakness (from the purist’s point of view) that gives this splendid collection of essays its strength. None of the essays argues against assisted suicide and euthanasia simply because killing is wrong. Rather, each one points out how legalization of such practices would achieve a goal that is the opposite of the one its supporters claim it would. Speaking concretely, it would yield less relief of suffering, less patient autonomy, corruption of the practice of medicine, and a decline in the quality of palliative care. And then there really is the pesky problem of the slippery slope.
The list of contributors—only a few of them can be mentioned here—reads like a Who’s Who of palliative medicine and medical philosophy. For example, Professor Harvey Chochinov, M.D., Ph.D., of the University of Manitoba and his colleague Dr. Leonard Schwartz discuss the prevalence of treatable depression among the terminally ill. More importantly, they describe the existential factors that lead some to seek hastening of death. They point out that fear of abandonment is a terrible concern of the dying. In this regard, it is worth recalling that assisted suicide has been called “abandonment institutionalized.”
Dame Cicely Saunders is recognized as the founder of the modern hospice movement. Any patient who now enjoys good pain control by taking a sustained-release opioid owes her a debt of gratitude for her discovery of the importance of dosing opioids around-the-clock rather than “as needed” for pain. (The fundamental importance of that discovery is underscored by the fact that it now seems obvious.) She describes how hospice care has obviated the desire for assisted suicide in many patients and how legalizing suicide would “undermine the right for respect and care for a great many vulnerable, already disadvantaged, people.”
Attorney Diane Coleman, president of the disabilities rights group Not Dead Yet, demonstrates how the same society that cannot be bothered to provide the necessary assistance to enhance the lives of disabled people seems to jump to support any disabled person’s request for assisted suicide. Ordinarily a request for assisted suicide from a young woman experiencing a recent miscarriage, impending divorce, death of a brother, and the cancer diagnosis of her mother would be recognized for what it is—the deperate cry of a clinically depressed person. But when that person was Elizabeth Bouvia, “confined” to a wheelchair, a legion of lawyers leaped to secure her right to suicide. “All they see is the wheelchair,” as a disabled friend of mine once remarked. Coleman notes the contempt for the disabled that is inherent in laws that would allow assisted suicide on demand.
Assisted suicide is currently legal in Oregon, and its moral equivalent, euthanasia, is now permitted in Holland. Does the real world experience match the dire predictions of its opponents? Sadly, it does that and more. In an earlier book, Seduced by Death: Doctors, Patients, and the Dutch Cure (1996), Hendin described how the actual witnessing of the effects of legalized euthanasia, far more than any theoretical consideration, persuaded him of its pernicious impact. In this collection, he updates his observations. It is more than coincidence that palliative care facilities in Holland are among the worst in Europe. Hendin credits Derek Phillips, a sociologist who has lived and worked in the Netherlands for thirty years, with the insight that the Netherlands is a country in which “indifference masquerades as tolerance.”
N. Gregory Hamilton, Clinical Professor of Psychiatry at the Oregon Health Sciences University, describes the impact of legalized assisted suicide in Oregon. It has led to a “culture of silence,” in which even the censure of doctors assisting in the death of their patients has been forbidden by state law. The annual reports of the Oregon Health Department are designed to obscure the realities, pressures, and ambivalences of the people who die by assisted suicide. The only source of information for the report is the very doctors who feel the procedure is justified, and who are unrestrained by the long-forgotten oath “to give no deadly medicine to any one, even if asked, nor to suggest any such counsel.”
Foley and Hendin conclude their collection of essays with a call to “change the culture.” They want doctors to do a better job of recognizing and treating depression in the terminally ill, and of understanding the ambivalence that so often stands behind a call for hastened death. They call for increased resources to better integrate the disabled into the community. They would have the palliation of the Medicare hospice benefit extended beyond its currently defined beneficiaries (terminally ill people expected to live six months or less). Indeed, care of terminally ill people is currently in need of such improvement that there are few aspects of it that would not benefit from a major overhaul.
If severe pain were uncontrollable, that would be a tragedy. That it is controllable, but is so seldom properly treated, is not a tragedy but a scandal. The same is true of other distressing symptoms that may plague us in the final months of life. The proper response to this scandal, as amply demonstrated by this book, is not to kill the one in distress. Rather than abandoning him in his anguish and terror, we should be present with him in his suffering—is that not, after all, what the word “compassion” means? The dying deserve the latest scientific palliative interventions, and also the venerable recognition of the intrinsic value of every human life.
Unfortunately, given its frank title, this volume is unlikely to be read by many supporters of assisted suicide. That’s a shame, because the book might very well change their opinions. This book is highly recommended to anyone interested in the question of assisted suicide—and to anyone who expects ever to suffer from a fatal illness.
Eric Chevlen, M.D., is a pain and palliative care specialist and coauthor, with Wesley J. Smith, of Power Over Pain: How to Get the Pain Control You Need (2002)
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