Suicide Prevention Must Be for Everyone

New York’s governor Kathy Hochul has placed a much-needed focus on suicide prevention. If she wishes to maintain this strong record, she must veto A-136. The reason is simple: A-136 would legalize suicide in New York. Additionally, it is deeply disrespectful to the disabled, and would create the laxest MAiD regime of any state in the U.S.

A-136 was passed by the New York State Assembly and Senate this spring, and would legalize “Medical Aid in Dying” (MAiD) for the terminally ill, specifically for patients whose doctors believe they have less than six months left to live. These patients would be able to request a prescription for a lethal dose of medicine from a doctor, and to kill themselves by swallowing that dose. This process is identical to a standard suicide-by-poisoning—except that it would be condoned by the state and abetted by a physician.

The American Medical Association has consistently opposed MAiD, because a doctor’s role is to heal or to provide comfort and pain relief, not to facilitate suicide. In fact, the same day that the New York State Senate passed the bill, the AMA reaffirmed its opposition to MAiD and other forms of physician-assisted suicide.

It’s tempting to imagine that in an end-of-life context, MAiD isn’t “really” suicide because the person who requests it was already going to die—but common sense shows that this is false. When someone suffering from a terminal illness kills herself in any other way, we call this suicide. We mourn these suicides, and we rightly try to prevent them.

Of course, some people seem to think that in an end-of-life context, suicide can somehow be a legitimate choice. They imagine that this is a special situation, that suicide is justified when death is proximate and when the final months of your life may involve great suffering. On this view, suicide can be a reasonable way for a person to exercise agency over a death that is already inevitable. But the reasoning here faces a terrible problem: It implies that most suicides are legitimate.

Watching the state senate debate the bill, I was struck that none of its supporters seemed to have a good account of why suicide prevention is normally a good idea. For example, the bill’s sponsor in the senate, Brad Hoylman-Sigal, claimed that MAiD access is an important right—that if we don’t offer MAiD to the terminally ill, we are failing to respect their autonomy. But if this is true for the terminally ill, why wouldn’t it be true for everyone else? Many people who struggle with suicidality and depression express a desire to end their own lives. Are we failing to respect the autonomy of those who suffer from severe depression when instead of helping them to end their lives we engage in suicide prevention efforts?

Similarly, one of the bill’s supporters explained that she voted to legalize MAiD because “some pain can’t be controlled.” But this is true for many types of pain. And in particular, it can be true of the pain that causes suicidality. Doctors do not always have the ability to instantly and permanently control the terrible mental anguish that can make life feel intolerable to a person suffering from severe depression. Usually things eventually improve, but this can be a process, one that may feel unacceptably slow to the person suffering from depression. If the terminally ill have the right to end their lives in order to avoid uncontrolled pain, should we offer the same right to people who find their depression intolerable?

The reality is that if we want to take suicide prevention seriously, we can’t act as though autonomy and pain management are legitimate reasons for suicide—not in an end-of-life context or any other context. We must either insist that suicide is not the answer, even when you’re suffering and even when it looks attractive, or we must give up on suicide prevention altogether. Because suicidality almost always involves the kind of suffering that makes it seem attractive to end your life.

Because of this, we shouldn’t be surprised about the suicide rates in Oregon, which was the first U.S. state to legalize MAiD. Over the past twenty years, the Oregon suicide rate has increased more quickly than the national average. Now Oregon’s suicide rates are more than a third higher than those of the nation as a whole. And that is only the official suicide rate; if we include MAiD deaths, we see that Oregonians are more than twice as likely as the average American to take their own lives.

Of course, I imagine that most of the bill’s proponents believe that suicide prevention is normally a good idea. But the grim reality is that the proponents of MAiD want the right to kill themselves in the event that their lives come to resemble that of someone who is disabled, or who suffers from serious chronic illness.

This is one reason that disability rights organizations like Not Dead Yet consistently and vehemently oppose MAiD legalization. And strikingly, most people who request MAiD in Oregon do so out of a desire to avoid life as a disabled person. They think it is better to end their lives than to experience the loss of autonomy, the loss of ability to do their favorite activities, or the feeling that they are “a burden to others.” (Fewer than half of Oregon’s MAiD recipients cite concerns about pain as a reason for requesting MAiD.) In other words, MAiD proponents don’t think a disabled life is worth living, or at least, they don’t think it’s unconditionally worth living.

If we are to really value disabled lives, we must categorically reject this way of thinking. Disability is never a legitimate reason to end your life. It doesn’t matter whether you’re in the middle of your life or near the end of it, and it doesn’t matter if the disability is permanent or temporary. 

Fundamentally, offering MAiD to the terminally ill implies at least one of two unacceptable conclusions. It implies that we should offer suicide to anyone who wants it, or that we should offer people suicide on the basis of disability.

There are also many problems with the specific language of the bill, which would be laxer than any MAiD law on the books in any U.S. state. To give just a few examples: A-136 doesn’t require screening for depression, or even a review of the patients’ medical and psychiatric history. It is quite dangerous from a lethal means safety perspective, as it allows terminally ill patients to take suicide pills home. The bill also has lax reporting requirements and virtually no oversight. It creates many opportunities for coercion and abuse—especially for the marginalized.

Moreover, Columbia physician Lydia Dugdale recently pointed out in the New York Times that this bill would make many people eligible for MAiD who are not terminally ill in any normal understanding of the term. Amy Paulin, the bill’s sponsor in the Assembly, has confirmed this. When asked if a diabetic who refuses treatment would be eligible for MAiD, she acknowledged that he would be. And under a similar law in Colorado, patients who suffer from the highly controversial diagnosis of “terminal anorexia” have died by MAiD on that basis. Anorexic patients and diabetic patients are both at heightened risk of depression. They are often vulnerable, and can be expensive and inconvenient for hospitals to care for. It would be unconscionable for Gov. Hochul to sign a bill allowing doctors to prescribe suicide to patients who are suffering from depression, and who are also expensive for their care providers.

Instead, we need an unwavering commitment to suicide prevention. We owe this to everyone, regardless of whether they are depressed, sick, or disabled; regardless of whether it’s expensive to care for them; and regardless of whether they have six months left to live or six hundred.