Bioethics Discussion Blog: Assisted Suicide: Who Should Assist? Should It Be Done?

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Saturday, July 16, 2005

Assisted Suicide: Who Should Assist? Should It Be Done?

Should there be laws in the United States that permit assisted suicide? Well, in a recent posting elsewhere, I expressed my views against physician participation and wrote: "I think that assisted suicide, if it is to be accepted by all states be accomplished by trained and certified technicians with legal access to specific death drugs. No physician participation should be involved except for diagnosis and prognosis."

Bob Koepp read that comment and wrote me the following:

I think all we know about human nature suggests that "certified technicians" who specialize in killing will demonstrate considerably less reticence about exercising their "craft" than would ordinary citizens in intimate relationships with those seeking death. Most friends and family members who are asked for such assistance try very hard to dissuade the "seekers."

IF the "seeker" was motivated by concerns related to medical questions, consulting a physician would be appropriate. But I think that people might have sound reasons for seeking death that are not medical in nature, which would not be reflected in a physician's diagnosis and prognosis.


I responded with:

What if there were regulatory laws as currently in Oregon by which the two physicians would have to screen the patient for depression and also to provide the technician (and patient of course) with a dx and prognosis and suggest any approaches to the symptoms without need for suicide. Finally, if all the I's are dotted and T's crossed, it would be up to the technician to make the final decision as to whether to grant the patient's request for assisted suicide. The main point here is that the final decision for prescribing the patient the deadly pills would not be up to the physician but up to the tech who will know and obey the law. ..Maurice.


And Bob responded with:


Someone should conduct the following experiment (please excuse the deception -- it's necessary). Take two groups of randomly selected physicians. Those in Group A are approached by patients who say they want to kill themselves, but don't ask for any assistance. Those in Group B are approached by patients who also say they want to kill themselves, but do ask for assistance. How do the physicians respond to these different patients?

Quite apart from such an experiment, I don't think physicians are all that good at diagnosis and prognosis, and setting them up as gatekeepers to "legitimate" assisted suicide invites problems. Physicians no less than the rest of us are prone to letting their prejudices influence their judgments. A physician who believes strongly in the "rightness" or the "wrongness" of assisted suicide will be inclined to interpret signs and symptoms in a way that comports with his/her prior convictions. Word gets out about which physicians are more likely than others to support requests for assisted suicide, and it is to these physicians that people seeking such assistance will turn. Where's the objectivity in such a system?

I understand and share your concern with preventing suicides, the vast majority of which seem to me to reflect serious depression or desperation born of ignorance about viable alternative courses of action. Only a very few suicides seem to me to be likely candidates for classification as "rational suicide," and only a few of these few involve any sort of request for assistance. And then, as I mentioned in my previous message, even among these "few of the few," those approached for assistance are often unwilling to provide such assistance, even though the person making the request might have good reasons for wanting to die.

I would actually go further, and suggest that the mere fact that a would be suicide seeks material assistance should often be interpreted as a call for help of a different sort, since it is very rare indeed that such assistance is actually necessary to the performace of the deed. For how many of the suicides so far "assisted" in Oregon, the Netherlands, Belgium, Switzerland... was the person actually incapable of killing him/herself? How many people, whether or not they actually _needed_ assistance, when once supplied with effective means to end their lives have then not put them to their "intended" use? With respect to those who don't use the means provided, I think the natural conclusion is that they didn't want to kill themselves so much as they wanted to feel some sense of control. Did the physicians who screened them misdiagnose?

In short, I think there are very, very few cases where assisting in a suicide could withstand critical scrutiny. But in recognition of those very, very few cases, I think assisted suicide should be decriminalized.

Creating a new body of law to "legalize" and "regulate" the "practice" of assisted suicide, provides a patina of respectability to "following the rules" in an area that probably is beyond the reach of general rules. And I persist in my belief that when we explicitly recognize a separate class of "workers" with a special "expertise," those workers become _more_ inclined than the rest of us to engage in the activity in question, and _less_ reflective and _less_ critical of their own actions. Rather than regulating assisted suicide, I think every purported assisted suicide should be critically scrutinized for any evidence that those providing assistance have negligently endangered another's welfare, or worse, have intentionally acted contrary to the interests of another. We already have laws against such behavior, whether it involves suicide or other activities.

Bob Koepp


I would like to read what other visitors think about assisting a suicide attempt either in the context of a suffering patient or in any other situation. Specifically, should any assistance be necessary? As Bob noted: “I would actually go further, and suggest that the mere fact that a would be suicide seeks material assistance should often be interpreted as a call for help of a different sort, since it is very rare indeed that such assistance is actually necessary to the performance of the deed.” Well, except for a quadriplegic who wanted to die, I suppose that is true. Anyway, what do you think? ..Maurice.

6 Comments:

At Saturday, August 05, 2006 7:16:00 PM, Anonymous Anonymous said...

Why r you so against it? Do you like that some people kill cops so they can get their "suicide by cop"? or murder some one so they can get the death sentence, or what about being on welfare and taking ure hard earned $ because the only thing they can do in life is sit around waiting for the reeper?Maybe your beleifs say one who commits suicide will go to hell, well they are not every ones beleifs!!!!! M.F.!! Im a prisoner of life, i dont have acces to a gun, or a large amount of lethal drugs, i tried hanging myself, but reflexes got me out of it... stupid reflexes. im to scared to jump off something high, or cut myself. My life is filled with me bring no pleasure to anyone, my father killed himself because he fucked up so bad in life. i got no friends, cantr make no friends, have no niche, im better off dead. I would die if i could get ahold of some heroin and a bid hypodermic needle, and directions to make it ready for me. i dont want to kill or harm anyone else but me.... ( there is assisted suicide but you have to KILL SOME ONE TO GET IT) maybe it could be you, your wife, husband, child, mother father, grand child, or you could do america a favor a d let me die you stupid stuborn soab.

 
At Saturday, August 05, 2006 9:24:00 PM, Blogger Maurice Bernstein, M.D. said...

Anonymous, I can understand your frustrations to accomplish something that for you is not easily accomplished. Maybe the reason that you can't accomplish the act of suicide, by whatever methods you described, is that somewhere in your mind you have doubts that this is the right action. No matter how terrible your life has been for you, there may be a better life ahead than simply to die. If you haven't had a chance to get professional help for how you feel and to get medication to reverse your unhappiness perhaps that is what you should do now. ..Maurice.

 
At Monday, December 04, 2006 9:07:00 PM, Anonymous Anonymous said...

I think that our culture's attitude to suicide causes a lot more grief than if we adopted a more understanding attitude. I currently suffer from major depression and have been struggling with it for 4 years. I have not committed suicide because I am aware of the trauma it would cause the people I love, putting all my strength into recovering.
I feel we need to reconsider our own motives in preventing people from suiciding - are we doing what is best for them? Just as someone dying from a terminal illness wants to escape the pain and horror of their final months, sufferers of a permanent mental illness wish to escape from the humiliation, suffering and torture that they face.
Our society does not understand mental illness. I found out, to my horror, that asking for help was only the beginning of my suffering, as I then had to deal with the ignorance, mistrust and prejudice of those around me (my life has been utterly destroyed), and the patronising optimism of doctors and counsellors.
I don't know yet whether my condition is permanent, but the idea of living like this for the rest of my life, or even for several more years, fills me with absolute horror. I am not advocating suicide as an option for a temporary ailment, but if a schizophrenic is sick of their rollercoaster of medication I would never presume to tell them that they have to live with it because of misplaced morality. If my condition continues, I will feel no scruples in constructing some sort of acceptable death for family and friends before waving them goodbye.

 
At Thursday, February 15, 2007 8:45:00 PM, Anonymous Coranth Gryphon said...

First, it's important to distinguish assisted suicide from euthanasia. I'm sure that any medical professional knows the difference (or at least I'd hope so), but most people don't.

In euthanasia, the 'assistant' does the killing. In assisted suicide, the 'assistant' only provides the means.

That distinction, often blurred, is crucial because it is the providing of the means that is the core of the issue. Sure, anyone can commit suicide if they really want to. But the means they must rely on are often messy. Anyone can buy a metal spike at a hardware store and fall on it to punture their skull. Anyone can crush their windpipe with a hammer. And fireams are fairly easy to get for most.

The issue isn't killing youself. It's dying with dignity. It's making a choice, and carrying through that choice in an efficient and rational manner. Many people assume that suicide can never be rational. But to address the issue of assisted suicide, we have to disregard that assumption and move to the question of means and situation.

If someone does chose to kill themself, how are they going to do it? Who will find the body? How much clean-up will there be? Anyone who claims to rationally have considered suicide has thought of all these things. And the whole issue of assisted suicide is really about whether we (as a society) will allow someone to make that choice and take that action in an efficient and safe manner, or whether we're going to force them to hide what they're doing by making it as difficult as possible.

Which brings up the other point raised about most such requests merely being cries for help. I'll grant that many are. But those who are secretly (or not so secretly) crying for help are not really making a rational decision in the first place. So, the issue of means doesn't apply.

Finally, a minor comment. You suggested a system where "the final decision for prescribing the patient the deadly pills would not be up to the physician but up to the tech". While I respect you desire to shield physicians from making those choices, this seems to defeat most of the point.

If we (again, as a society) truly wish to limit suicides only to those who have rationally considered it, and perhaps even have some objective standards as a threshold (such as Oregon's terminal illness requirement), then the people who need to be involved in that decision making process need to be highly qualified. They need to help make sure the rational decision is fully thought out. Yet even most doctors are not qualified for this type of counseling, and anyone with lesser training certainly wouldn't be. So, creating a new certification/licensure for those who would dispense these drugs doesn't really help. It just shifts the decision away from those who are more qualified to be part of it.

But most important, we need to remember that we're not talking about euthanasia. We're talking about providing someone with safe and efficient means to do something that they can already do in other messy ways.

In the end, the choice to live or die is always going to be up to the individual. All we can ever regulate is how safe and clean we're willing to allow that choice to be.

 
At Thursday, October 25, 2007 4:01:00 PM, Anonymous Anonymous said...

I just recently wrote a paper dealing with the issue of Physician Assisted Suicide and why I believe that it should remain illegal in this country. My main argument was that if we as a nation were to legalize physician assisted suicide and it were to become a common practice in the other forty-nine states beside Oregon, I think that we would find that the face of our healthcare system and our healthcare professionals would begin to change. When doctors begin their profession, they have to take what is known as the Hippocratic Oath. By taking this oath, doctors have agreed to “do no harm". The trust and respect of Physicians from their patients would be harmed if they were seen as being ready to help aid their patients in the act of suicide at any time. Another good point that this argument leads to is the idea that perhaps if suicide were an option for patients and their physicians, health care professionals as well as hospice workers might not give as much attention to pain control and things such as palliative care if they view suicide as a practical alternative.
If we allow physicians to assist their patients in committing suicide what is to keep us from allowing a physician to euthanize a patient for other reasons than the patient’s own best interest. I think that there is a definite balance between a person’s own rights and decisions and the governments hand in helping them make decisions, however I think that if someone chooses to take their own life that they should just do it and not involve anyone else in the process, especially a medical professional. If we allow such things to go on that we, as a nation, will find we are headed down a steep slope and that the face of our healthcare system will change, and probably not for the better. The line needs to be drawn somewhere and I think that not allowing physician assisted suicide is a good place to draw it.
I feel that physician assisted suicide should not be legalized in America and should be made illegal in Oregon. The legalization of PAS would change the face of healthcare, change the way that healthcare professionals are viewed and trusted by their patients, open doors to more unethical practices within the healthcare system. Instead of legalizing PAS, doctors should be encouraged to continue placing emphasis on offering terminally patients and their families the opportunity to receive counseling, palliative care, and enhanced pain management.

 
At Tuesday, May 13, 2008 7:59:00 PM, Anonymous Sukes said...

When you have someone close to you that is in pain, and you wish you could do whatever you can to relieve them of that pain, you will. Even if it means letting them leave you. My Grandfather and that of a friend have both been taken. Both were in tremendous pain and we turned to hospice care. While alive in his final days, he was lucid, but he seemed drugged. It was like he was alive but not really. His pain was no fully relieved and instead it was nagging. My Grandad never told me this but I thought that maybe he wished he could have taken his leave. Not because of his pain or the idea of what was to come, but I got the impression that he felt like he was just done with life. He had lived and was ready. He had no more to do or pass on. And he was ready to end everyones anxiousness. We never spoke of suicide and still do not. But if we were more open to the idea and realized that this "slope" can be leveled off, maybe some people could go off happily and peacefully in there last moments.

 

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