The notion that dying is a right seems nonsensical to argue: death is given to all of us equally without the need of anyone’s sanction. The right to die well, on the other hand—well, that’s another matter entirely. A good death is, in many cases, something our fellow human beings have great power to grant or deny, and is therefore, sadly, a right for which we must indeed fight.
The notion that we’d even need to fight for the right to die well has only come to make sense relatively recently, within the last forty years or so. Prior to that, our ability to prolong dying—meaning, keep extremely ill people going in hopes that they might overcome whatever health problem threatens even when the likelihood is vanishingly small—was actually fairly limited. But with the advent of modern intensive care units and all the amazing technology that’s emerged in the last four decades, we can now stretch the quantity of out our last days often to weeks or even months. Unfortunately, a similar stretching of quality hasn’t yet occurred; if anything, we see the opposite (to be fair, the same technology also stretches some lives to years and even decades, meaning it’s enabled some people to recover from insults that in the past would have undoubtedly killed them).
Health providers don’t wield this technology to prolong suffering intentionally. As I argued in a previous post, Knowing When To Stop, it’s quite difficult to predict the timing of death, even in the terminally ill. In one sense, then, the horrific deaths many patients experience at the hands of modern medicine reflects our species’ profound optimism bias. Even when in our hearts we know it’s time to stop, we often don’t.
Yet as we learn more about our own biases, we begin to have more responsibility for mastering them and for making decisions from a place of realistic compassion, not naive hope. If we set aside for purposes of this discussion those patients I discussed in that previous post who we genuinely think might have a chance to recover and focus instead on those who clearly don’t, the need to establish an approach about how to effect death humanely becomes readily apparent. As a result of technological advances, we’re now at a point in our history where we must make active decisions to hasten death, in many instances, in order to prevent suffering that often results from our ability to prolong it. Which makes it all the more tragic when we choose not to.
Only three states in the U.S. allow assisted suicide: Oregon, Montana, and Washington. The requirements are that a patient must be of sound mind as confirmed by a physician and other witnesses and must be diagnosed with a terminal illness. But what’s fascinating to me about the way people think about this is the following: though most of the people I’ve asked the question “Are you afraid to die?” have responded “I’m afraid to die in pain,” most of them also, while still in a state of good health, have a difficult time envisioning themselves choosing to swallow poison (admittedly, I’m referring to anecdotal responses of a small number of people). And though intellectually we may feel we could certainly be brought to the point where we could swallow poison, I suspect few of us can really project how we’d feel about it at the moment we would do it. But when you listen to people with terminal illnesses who actually do go on to end their lives, you find what is to me a surprising thing: almost to a person (of those assisted suicides actually documented) they say they feel ready, willing, and able. Apparently it is possible to reach a point in one’s dying where fear evaporates under the onslaught of discomfort.
It may be strange to say it, but I find this comforting. Death may be inevitable, but fear of death need not. I’d like my death to be as painless as the next person, but if I see it coming (a possibility that increases each year with each technological advance), I’d also like to face it without fear. I don’t know which, in general, causes more suffering in the end, extreme physical pain or the terror of imminent non-being. But if extreme pain also has the power to extinguish extreme fear, all the more reason to think the ability to commit suicide at the time of our own choosing might represent the crucial difference between a good death and a bad one.
So my wife and I have discussed it. “You’ll help me take myself out if it gets to that point, won’t you?” she asks me occasionally. I tell her I will—and I really will, if it comes to that—but I wonder how. Not just how I’ll be able to get myself to participate in the death of someone I love (even seeing her in agony, death is just so final), but even I, as a doctor, will make it happen in a state in which it’s illegal.
Though it could be argued the laws against assisted suicide in human beings are largely the product of misguided religious thinking, I suspect there’s also involved a secular reluctance to allow our fellow human beings to kill themselves. Even though in many cases it’s hard to argue the prohibition against assisted suicide is actually humane, it’s also quite a difficult thing, emotionally, to allow a suicide to happen, much less to view it. And yet, compassionate action is often hard in general. Tough love typically doesn’t feel good to anyone involved, the giver or the receiver, for example, but it is usually, when done appropriately, compassionate and wise.
From the Nichiren Buddhist—and I think secular humanist—perspective the alleviation of pointless suffering must be considered the primary aim in terminal cases. The key concept here, it cannot be overemphasized, however, is “pointless.” Nichiren Buddhism, at least, is founded on the principle that suffering has a critical function in many instances as the catalyst for valuable inner change. Pointless suffering, however, of which the preventable suffering of the terminally ill is but one example, remains, from the Buddhist perspective, the great enemy of us all.
Though I’m pledged to prolong life where I can, I’m also pledged to alleviate pointless suffering. Thus, I very much believe in the right of people to freely choose the method and time of their own demise when they find themselves in circumstances where such a choice has become the only option to relieve their pointless suffering. We remain profoundly uncomfortable as a society with this position, but our own technological advances will eventually force us to embrace it. As more and more people die in needless pain and more and more people sit watching, eventually, I believe, we will accumulate enough collective experience to make peace with the notion that what we currently do with our pets is far more humane than what we mostly do with each other.
Alex Lickerman is an internal medicine physician at the University of Chicago who blogs at Happiness in this World. He is the author of The Undefeated Mind: On the Science of Constructing an Indestructible Self.