Suicide and its Assistance

Medical science has made and is continuing to make rapid advances in extending longevity. But frequently the extensions involve prolonging miserable lives without improving them—the lives of people gravely damaged in accidents (as by being rendered quadriplegic), or suffering from painful, even grotesque, illnesses (like amyotrophic lateral sclerosis), or horribly deteriorated mentally or physically by old age, or in terminal decline and clearly doomed though medical science may keep them alive for a few more months. Especially in the United States, with its culture of optimism (perhaps a consequence of its being a nation of immigrants) and its religiosity, most people want to postpone dying at whatever cost in discomfort. Why religious people tend to feel this way is unclear. For some Christians, dying in pain is welcomed or at least endured because it makes them feeler closer to Christ, who died in pain on the cross; others believe that the decision as to when a person dies is reserved to God—that is the stated basis of the official Catholic position that suicide is a mortal sin.

But not all people feel that way, even in the United States. Many people who are suffering acutely, or anticipating suffering acutely, incur net disutility from continuing to live, especially but not only very old people. Some people who want to die commit suicide, but others do not—out of fear that their attempt will fail and leave them even worse off than before, or because they lack confidence that they can kill themselves discreetly and painlessly, or because of the stigma that attaches to suicide, or because of the public character of a suicide—one cannot dispose of one's own corpse. These people who want to die but shy away from committing suicide show by their inaction that actually they derive greater utility from continued to live, because of the cost of suicide to them. But they would be better off if they could eliminate that cost, or at least reduce it to the point at which they would consider themselves better off dead than alive.

Which is where physician-assisted suicide enters the picture. The costs of suicide that I listed in the preceding paragraph all disappear if a physician is the agent of death—even the stigma cost, because if killing a person who wants to die is a lawful form of medical "treatment," this signals that suicide is proper, at least when a physician by assisting in the act validates its propriety.

The religious people whom I mentioned will not be assuaged; but religious people shouldn't be permitted to impose their sectarian values (as distinct from the values they share with the population in general) on others, including both religious and non-religious people, who do not share the abhorrence that some religious people feel toward suicide.

Paradoxically, allowing physician-assisted suicide could (though it seems unlikely that it actually would) reduce the suicide rate. A just-published biography of the very distinguished federal court of appeals judge Henry Friendly reports that he committed suicide in his 80s because, suffering from a variety of ills that were not disabling and did not prevent him from doing his judicial work, he was afraid that he would become disabled and when that happened be unable to end his life though desperately eager to do so. Had he been able to pre-arrange a painless physician-effected death to occur when he reached a specified stage of disability, he would not have killed himself when he did. Physician-assisted death is thus an option, and a less costly one than killing oneself unaided.

Physician-assisted suicide is now legal in Belgium, Colombia, Luxembourg, the Netherlands, Switzerland, and three U.S. states (Montana, Oregon, and Washington). It is quasi-legal in France, and is tolerated in a number of countries in which it continues to be illegal. In the United States it is opposed by a majority of physicians, although mainly older ones. I think their opposition is based largely on public-relations considerations similar to those that make physicians unwilling to serve as executioners, though they would be the logical persons to give lethal injections to the condemned. The image of the physician as a lifesaver is blurred if he is also a lifetaker.

There is also concern that families of a demented or otherwise badly disabled person, or even health insurers and Medicare administrators, will pressure physicians to end the person's life, even if it is known that the person would have wanted his life extended as much as possible regardless of the quality of that extended life. Nazi Germany undertook large-scale euthanasia in the 1930s, though mainly on eugenic rather than cost grounds; the program was abandoned under Catholic pressure but there is fear that physician-assisted suicide might be the precursor for renewed support of involuntary euthanasia—though that seems extraordinarily unlikely. Countries and states that authorize physician-assisted suicide impose strict requirements that minimize the danger of involuntary euthanasia—too strict, some believe (such as the requirement in Dutch law that the patient's suffering be "unbearable" before he can invoke physician assistance to end his life). These requirements (which further reduce the stigma of physician-assisted suicide by confining the practice to cases of genuine desperation) are not airtight, or uniformly observed. Any system will be abused. The question is whether the incidence of abuses, combined with the other costs of the system, outweigh the benefits.