Imagine Emma Sue Schroeder, an 84-year-old American cancer patient whose life expectancy is under six months. She signs an advance directive against what is conventionally called artificial life support. But this does not satisfy her. Feeling that her life holds only suffering and degradation, she wants to die right away, although she can still eat and breathe on her own. She wants her doctor to prescribe lethal medication so she can commit suicide. Should it be legal for her doctor to do this?
It is legal in California, Montana, Oregon, Vermont, Washington state, and, following a referendum last month, Colorado as well. (DC also passed an assisted suicide referendum, but Congress must approve it.) Many mainstream American doctors and bioethicists support such legalization. Their arguments often invoke personal autonomy. For example, in a 1994 book that is still widely discussed and admired, the legal theorist Ronald Dworkin maintains that prohibiting physician-assisted suicide in cases like the above “is a devastating, odious form of tyranny.” Similarly, the Berkeley doctor Lonny Shavelson defends his state’s recent legalization on the grounds that it accords with a fundamental principle of medical practice: “We never tell a patient: ‘This is what you have to do. You have no choice.’”
Thus, Shavelson apparently also holds that it would be odious to deny terminal patients the right to physician-assisted suicide.
At this point, I imagine many readers nodding along in agreement. But let’s now imagine Emma Sue’s equally hypothetical daughter, Rachel. Fifty-two and healthy, Rachel has lost her executive job, her life savings, her house, her looks, and her husband. Having suffered seven years of living alone in a cold, noisy one-room apartment and getting subsistence wages for toiling long hours at grueling drudgework that she herself believes is degrading, Rachel wants her doctor to prescribe lethal medication so she can commit suicide. Should it be legal for her doctor to do this?
The moral inconsistency of the expanding assisted-suicide regime
It is not legal in any state, nor are mainstream American doctors and bioethicists prone to advocating legalizing physician-assisted suicide in cases like Rachel’s. And many people’s moral intuitions do a 180-degree turn in that case: They see her decision as a permanent solution to a temporary problem — a “solution” that ought to be forbidden by law.
But why isn’t prohibiting physician-assisted suicide in a case like Rachel’s also a devastating, odious form of tyranny? If Emma Sue can get physician-assisted suicide, why should Rachel have no choice?
Consider these three positions about physician-assisted suicide.
- Physician-assisted suicide should be illegal for everyone.
- Physician-assisted suicide should be legal for only the terminally ill.
- Physician-assisted suicide should be legal for all competent adults.
So far, the debate in America has been mainly between positions 1 and 2. Either physician-assisted suicide should be universally forbidden, or it ought to be made available only to the terminally ill. In contrast, I think the debate should be between positions 1 and 3: Physician-assisted suicide ought to be universally forbidden, or universally permitted for competent adults. Both those positions, I contend, embody reasonable — although opposing — viewpoints, and I will not try to decide between them here. But I will argue that position 2, the one adopted by several states, is morally untenable.
Why do so many people think otherwise? What reasons could justify legalizing physician-assisted suicide for only the terminally ill?
A common answer involves the prospects for an eventual changed outlook in people denied suicide assistance. For example, consider the Philosophers’ Brief — a Supreme Court brief by six philosophers in favor of legalizing physician-assisted suicide for the terminally ill. In the introduction that he wrote to this brief, Dworkin says, “States may be allowed to prevent assisted suicide by people who — it is plausible to think — would later be grateful if they were prevented from dying,” such as “a sixteen-year-old suffering from a severe case of unrequited love.”
But why suppose this condition would allow suicide assistance for the terminally ill and no one else? The terminally ill are not the only people who may have strong and stable suicidal desires grounded in conditions that are unlikely to change. Consider, for example, quadriplegics. Moreover, even the suicidal desires of some people in Rachel’s position may be unlikely to change. How many impoverished, unattractive, unloved 50-something women with menial jobs later come into money, love, or better jobs? If Rachel’s attitude toward her reduced circumstances has been stable for a long time, it may be reasonable to suggest it is unlikely to change.
No state has legalized physician-assisted suicide for people who are not terminally ill. However, since they are apt to live longer, their suffering, if not alleviated, is apt to last longer. Of course, they may still have more chance for a brighter future. But doesn’t respect for autonomy mean that all competent adults — including healthy and able-bodied ones like Rachel — should be free to decide for themselves whether their prospects for long-lasting suffering outweigh their prospects for a brighter future?
My intent here is not, necessarily, to advocate that healthy and able-bodied people ought to be granted the right to physician-assisted suicide. It is, rather, to expose the facile thinking that is often brought to bear on this subject when the people committing suicide are old, or sick, or infirm.
Some people seem to think that the life of a young, healthy person must be preserved by force of law, against the wishes of that person — perhaps because life itself is intrinsically valuable, or because we don’t want to open the door to “slippery slope” regimes that normalize suicide. But then why aren’t the lives of the terminally ill also intrinsically valuable, and where is the concern about nudging old people toward legalized suicide?
Do we selectively define and treat depression?
When I present versions of this argument, people often raise the issue of “depression.” What if Rachel is clinically depressed? Rather than suicide assistance, shouldn’t she be given treatment for her depression?
The conventional answer is yes. But shouldn’t that judgment apply with just as much force to Rachel’s terminally ill mother? Studies of clinical depression in the terminally ill have reported incidences as high as 77 percent. If you are horrified by the waste that could result from giving people like Rachel suicide assistance, why aren’t you horrified by the waste that could result from giving suicide assistance to the terminally ill? After all, to quote an article from the Journal of the American Medical Association, “There is a general consensus that individuals with a major depression can be effectively treated, even in the context of terminal illness.”
All the states allowing physician-assisted suicide stipulate that terminal patients have to be competent to make this decision. Additional restrictions, such as waiting periods, come into play as well. Such restrictions could clearly be applied to all adults. In a legal regime that did not limit physician-assisted suicide to the terminally ill, any adult requesting physician-assisted suicide could be screened for competence, with a single standard used to determine competence in the healthy and able-bodied, the disabled, and the terminally ill.
Granting suicide assistance to more people might well result in more suicides, since illegality is an obvious barrier. But withholding suicide assistance might well increase the amount of misery in the world. What should get priority: preserving autonomy and avoiding misery or preserving life with its prospects for a changed outlook? The answer is unclear. What is clear is that the double standard embodied in the position enshrined in the laws of a growing number of states gives the lives of terminally ill people less protection from suicidal desires than the lives of the rest of us. To quote Diane Coleman, founder, president, and CEO of the disability rights group Not Dead Yet, which categorically opposes physician-assisted suicide, “Equal rights means equal suicide prevention.”
I would add that it might also mean equal access to suicide. What is morally and philosophically untenable is the double standard found in the laws of a growing number of states.
The Orwellian overtones of “death with dignity”
The bias in the policies gaining traction in the United States becomes especially stark when we consider the much-discussed issue of dignity. The Philosophers’ Brief stresses the importance of making physician-assisted suicide available to a terminal patient who seeks to avoid “an existence the patient believes to be one of intolerable indignity” and “who believes that further life means only degradation.”
The word “dignity” is a staple of discussions of end-of-life issues, where it often follows the words “death with.” (In fact, “Death With Dignity Act” is the official name of the laws in some of the states permitting physician-assisted suicide for the terminally ill.) People unfamiliar with these discussions might expect the phrase “death with dignity” to refer to a manner of dying — for example, a stately exit accompanied by ceremonial farewells.
Instead, death with dignity is generally regarded as ending (or preventing) a life that lacks dignity, by which is meant life degraded not by circumstances like Rachel’s — our hypothetical 52-year-old whose life has taken a negative turn — but by illness and disability. This reflects our society’s widespread readiness to suppose that illness and disability undermine human dignity. And even many terminally ill people buy into this line of thinking. For example, the Oregon Public Health Division’s report for 2015 on physician-assisted suicide uncritically cites “loss of dignity” as one of “the three most frequently mentioned end-of-life concerns,” figuring in over 75 percent of requests for suicide assistance.
In contrast, imagine a healthy woman who wants suicide assistance because she feels that having been raped makes her existence one of intolerable indignity and degradation. I find that almost no one — certainly none of the American college students I teach — is prepared to accept that woman’s assessment of her situation. It will be argued that her judgment has been warped by archaic sexist attitudes. It will be suggested that she needs therapy to overcome this misguided feeling.
Here is my challenge: Why aren’t you equally appalled by the ableist idea that terminal illness, with its accompanying frailties and disabilities, renders a person deficient in human dignity?
Once again, I see two reasonable policies. One is to let all competent adults decide for themselves what conditions, if any, render their lives too degraded to be worth living. This would mean legalizing suicide assistance for all competent adults and not letting the determination of competence hinge on whether outsiders approve of the suicidal person’s values about dignity. The other policy would to make physician-assisted suicide illegal for everyone. As I have indicated, I will not try to decide between these alternatives here. But a society that “pathologizes” suicidal feelings of indignity and degradation in rape victims while endorsing them in the terminally ill is, I contend, engaging in a horrifying, odious form of bigotry.
In his still-influential book, Life’s Dominion: An Argument About Abortion, Euthanasia, and Individual Freedom, Dworkin proclaims his support for “a régime of law and attitude that encourages each of us to make mortal decisions for himself.” But he does not carry this proclamation to its logical conclusion. That would entail legalizing physician-assisted suicide for healthy young adults — the very adults our society values most — as well as for the terminally ill.
Do you recoil at this? Are you healthy? Do you think that your health makes your life more valuable than a terminally ill person’s? Do you think that his life should get less protection from suicidal desires?
If so, the disability-rights movement has a bumper sticker for you: “I support the right to die. You go first.”
Felicia Nimue Ackerman is professor of philosophy at Brown University as well as a writer whose poems and short stories have been widely published. She also writes a monthly column for the Providence Journal.