An argument against physician-assisted suicide

New Jersey is considering following four other states in legalizing physician-assisted suicide. The Death with Dignity Act would allow people with less than six months to live to receive a prescription for a fatal cocktail and then to commit suicide at the time of their choosing in the privacy of home. Recently, I had the opportunity to participate in a debate on the merits of the proposed law.  While I oppose this act, the wisest comments were not from the panel, but from the “audience” who carried on a vocal and revealing discussion and taught me a great deal.

While many people spoke, and all were interesting and articulate, there were two stories that, at least for me, paraphrased the core ideas. These comments placed physician-assisted suicide in the context of modern society.

The first was a woman who described her life over the past few years and the future that she seeks.  She is a nurse with a long experience working in hospitals, nursing homes and even in hospice care. She is now dealing with her second cancer, which has metastasized and from which she will eventually die.  She is receiving excellent care, including chemotherapy, and for now the disease is in control, and she is living a “great” life.

She reflected that she loves each day, and fights for every quality moment.  She plans to continue to do whatever it takes to live well for as long as she can, however, she knows that the cancer will eventually end her life.  She does not plan to commit suicide, but absolutely refuses to live a life without quality.  Therefore, just in case her condition deteriorates to the point that it is leached of all beauty and meaning, she wants to have the option of suicide.  As she has a long attachment to the medical profession, she trusts doctors to provide that gentle end.

The second illuminating comments came from the family of a man who recently died of lung cancer. The daughters of this patient detailed a long chain of atrocious medical care. They described physician neglect, poor communication, and refusal to answer questions or return phone calls.  At the end of his life, as he lay dying, hospice workers did not follow-up, did not show-up and did not replace faulty vital medical equipment. It was a horrible story of suffering through a painful end and the failure of multiple caregivers to address pressing need.  Desperate, on his dying bed, their father begged his daughter to write a book about “why people must suffer.”

In both cases, the nurse and the surviving family, support suicide.  The first, because she wishes to maintain control.  The second, because they believe patients cannot depend on doctors and even hospice may fail to give comfort and hope.

I understand their points of view and cannot help but empathize with their pain. Nonetheless, after listening carefully and further thought, I conclude that the contrast between these two experiences is the strongest testimony against the Death in Dignity Act and physician-assisted suicide.

If end-of-life for most patients were like that of the nurse, the “freedom” of suicide might make sense.  That is, if everyone planned for dying, everyone had the best support and everyone received optimal medical care to achieve quality at the end of life, then perhaps elective death should be an option.  If even with perfect, compassionate and complete treatment, there was uncontrollable suffering, perhaps taking one’s life might be a way to find peace.  Presumably, this would be a very rare event (in Oregon where suicide is legal, only 1 out of 750 use it), but dying would comfort some and many would welcome having the choice of suicide as giving them control.

However, tragically, the experience of the medically sophisticated nurse is the exception, not the rule. Most patients and families do not plan for end of life events. Often, doctors do not communicate regarding these vital issues and rarely do patients hear the precious words, “we do not have to treat the disease; we can just keep you comfortable.”  Very often, even with a terminal illness, patients do not understand what is going on and therefore descend into pain, fear, and isolation. Many die in institutions, on machines, with chemotherapy infusing even as the code team performs CPR.  Although many people try and as a society we have the best of intentions, quality of life at the end of life is not guaranteed and perhaps not even likely.

If we ratify suicide we may be helping a very few, but we neglect many.  We fail to emphasize quality life, at the end of life, by good communication, good planning and good care.  We fail to demand of doctors and the medical system what is possible.  We discard the potential to live, learn and love in the last days, weeks, or months, and instead say, “Your life is worthless, make it easier on all of us, take this pill and die.”

While I appreciate the freedom to choose suicide in a perfect world, for the average patient and family, we have a long way to go.  We are allowing ourselves to be distracted and neglect life’s potential by focusing on an inadequate, controversial, and ethically questionable alternative, instead of demanding of ourselves and our society improved life at its end.  That is the vital conversation and we all have much to learn.  Quality at the end of life must be our destination, and we must not stray from that path.

James C. Salwitz is an oncologist who blogs at Sunrise Rounds.

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  • Allie

    I’ve never understood the either/or argument over this issue. This argument states without proof that if we agree to physician assisted suicide we will “fail to emphasize quality life” etc, etc. By believing in physician assisted suicide I am telling people, “Your life is worthless, make it easier on all of us, take this pill.” Really? I doubt the author would agree with a pro-assisted suicide person saying that just by being against it he is saying, “I really don’t ultimately care how much pain and suffering you are in, keep breathing no matter how difficult because it makes my conscience feel better.” Neither argument is fair. Both sides can have “both/and.” I can believe in comprehensive medical care that values patient’s lives until their last moments and is creative and inventive in palliative care no matter what stance I take on physician assisted suicide.

    • Ron Smith

      Hi, Allie (and everyone else).

      One of the early arguments that I remember in the abortion debacle of Roe v. Wade was that there wouldn’t really be that many pregnancies terminated. Proven to its fault, human nature sank to its deepest. We have consumed the lives of almost any many children here in the US as were lost in all of World War II.

      Careful attention to the past is a strong caution to think the worst in the future. We will sink to the bottom of the bucket again without a doubt.

      At the core the issue of assisted suicide is the fallacy that any man can be master of their own fate. We want to do what is right in our own eyes as we live out our time on earth. As we want to live without discomfort, we also want to die without pain.

      For those who believe they have no hope in a future beyond death, the argument would philosophically make sense. But the sheer fact that we can apprehend our death with such fear says we know otherwise.

      Those who try to say that they don’t fear death betray themselves by the long, and sometimes extreme lengths they go to retain life. If indeed there is nothing after death then why do we fear it, fight it, and then at the end try to exercise control over it?

      That we can think about and pour over death is something no other creature does. It is beyond instinct or other biologic source. It proves that mankind was made for life and that separation of ourselves from our bodies is not ‘right.’

      It is the same thing as knowing right from wrong. Anyone who has ever made the comment ‘that isn’t fair’ are actually saying ‘I know what is right, and what you did was wrong and unfair.’ How could we ever make that statement otherwise?

      Besides being assured that, like abortion, assisted suicide will be brought to its extreme expectations, the same core problem remains; humans are corrupted. We don’t need new laws to change us from the outside. We need a new self on the inside.

      Until that happens, you can rest assured that if assisted suicide fulminates, we will consume our elderly, sick, disabled of mind and body, and finally those that ‘someone’ deems unworthy with no less fervor than we have the killing of our unborn since 1973.

      The answer to our life is not the control of our death.


      Ron Smith, MD
      www (adot ronsmithmd (adot) com

      • Allie

        I respect your decision to express and live out your views on life and death however you want to. But, I don’t believe you have a right to force your views on these cosmic ideas on me or anyone else. It seems like you are alluding to an afterlife as part of your argument, and that’s a fine belief for anyone but a terrible reason to make a law for everyone.

        We don’t force a doctor to do an abortion or a patient to have an abortion against their will, and no one will ever force you to do a physician assisted suicide against your will. So your dog in this fight is only that you want to restrict the actions of other people to conform to your personal cosmic views. Yet, we all should have the right live out and die out our own beliefs, particularly when they affect only ourselves (which is even more true in physician assisted suicide than abortion). I am grateful that I live in a country where abortion is option for me (and I hope it stays that way), and I would like to live in a country where physician assisted suicide is an option for me. It being an option for me has no effect on what happens to you or anyone else who wants to live into a different understanding of reality from me. But I don’t want to live beyond my willingness to live subservient to your understanding of reality.

        • Ron Smith

          Hi, Allie.

          Your respectful response is certainly appreciated. If you will bear with me for this further response I would most grateful.

          I understand fully the issues of abortion and euthanasia from the standpoint of Laura, my youngest daughter. You see Laura was born with unintended fetal isotretinoin embryopathy, which is intrauterine exposure to Accutane. She was born severely affected, and passed away in 2012 at age 24. I never heard her say ‘Daddy’ or even roll over.

          I even considered, albeit briefly, abortion. And I longed for her to be free of pain, to the very moment we had to remove her from life support after she suffered a spontaneous brain stem bleed.

          Now if it were purely physician assisted suicide, that is the termination of a painful existence, that is at issue, then how appealing that would be.

          Remember that it is with our intellect that we apprehend truth which we nurture in our heart. It is from that incubator that our will acts.

          Now if truth is relative, and your version and mine version and the next person’s version are all a little different, then there is a problem. The problem is that there is not one definition of what is pure physician assisted suicide.

          Your concept of a physician acting nobly in response to your reasonable desires to prevent yourself pain, could then be extrapolated to me. As the father of a severely disabled child choosing to act for her because I think that her life has reached a point where it is not worth living or is too costly to live, should I have the option to choose to end her life?

          You can see why I think we must apprehend an absolute truth. If we freely interpret our own truth, then the result will be that the purest version of physician assisted suicide will become active euthanasia where someone else decides your fate against your will.

          It all comes back to what truth you have installed in yourself. If there is no absolute right and wrong, then you are bound to become a victim of the liberal thinking with which you claim to be free.

          If you say that truth is just however you believe, but have ever complained about something being fair or unfair, then you have betrayed your deep-seated belief that there is an absolute truth. You are expressing in those words ‘fair’ and ‘unfair’ that you do fall back to an absolute truth when it is suits you.

          Consider this last point. When Roe v. Wade was decided, late-term abortion as we know it was still essentially unthinkable. Relative truth has carried us to the point forty years later that the difference between lawful killing and infanticide is a mere matter of the child’s pelvic station…a few lousy centimeters. Now there is even further talk of being able to end a child’s life say within the first twenty-four hours after birth.

          How then can we think that anything less than active third-party euthanasia will be the certain result of any form of physician assisted suicide?

          Warmest regards,

          Ron Smith, MD
          www (adot) ronsmithmd (adot) com

    • James_94

      Once we put on the table the option of killing a patient rather than treating them, that is going to affect how some patients are treated. If a doctor (or insurer, who’s paying the doctor) has the option to kill you rather than try everything in their arsenal to help ease your struggle, it *will* affect the quality of care for at least some dying patients.

      • Allie

        The problem is that isn’t what we are putting on the table. We aren’t putting on the table “killing a patient RATHER than treating them.” The doctor doesn’t have an option to kill you against your wishes in PA- suicide. And I’ve never seen any proof that it *will* affect the quality of care of any dying patients.

  • Ron Smith

    Hi, Allie.

    You are very kind in your comments. And it important I think for me to say that I wouldn’t try to foist my personal beliefs on anyone. We are all created with the same free will to choose by fiat or by example.

    It saddens me to think of unborn children with severe anomalies. I’ve had a handful over the last thirty years in my practice that were difficult, very difficult. The longest trisomy 18 child lasted only about 6 weeks. I remember one child that was anencephalic. Another child with Potters syndrome lived less than 24 hours as the ventilator struggled to fill the almost non-existent air sacs. I’ve waked with other children to death’s door in varied, but similar situations. Those all break my heart. But they also challenge me.

    I don’t think the movement in our throw-away society toward throwing away people who merely by situation, sickness, or inconvenience bears witness to our long history of unusual courage in the face of extreme hardship. Maybe I’m a dying breed. I still open the car door for my wife after 36 years. I still respect and love my Mother and Father. He is 83 and was recently diagnosed with stage 4 lung cancer. I told my brother that he would teach us as much about anything else he taught us by his courage as he dies.

    Courage is the point at which all other virtues are tested. Has my generation neglected and failed to express how important that is? I’m 55 and I only suspect that you are younger than me. You would be qualified to give my generation a pass or fail there.

    Anyway, let me say that whatever differences remain between us, let us still be friends.

    Warmest regards,

    Ron Smith, MD
    www (adot) ronsmithmd (adot) com

  • 1SB

    I do not know how the Oregon law is worded but I fail to understand why we constantly battle this issue. We spend millions of dollars figuring out how to maintain life and very little in helping people have a quality death. It is truly sad.

    No one is saying that doctor assisted suicide would be decided at a single moment of time. It would make sense that for patients who are living horrible, excruciatingly painful lives, so that every day for year if asked, “would you like to end it?”, would say yes, are the people we are talking about.

    The process would be just like. Like the Ethics committee in hospitals, where a patient would be evaluated at 3 mo, 6mo, 9mo and at the year point. If they were still alive and desperate to die,…could.

    Having such a process in place allows those who fear, “how bad will it be at the end”, a little piece of mind to know they do have some control over their lives after all.

    • James_94

      “We spend millions of dollars figuring out how to maintain life and very little in helping people have a quality death.”

      I’m all for palliative and hospice care, in order to help someone have a quality death. We’ve made great strides towards those ends, although of course we still need to work on making it even better.

      That’s a different animal to killing our patients because they’re “living horrible, excruciatingly painful lives”.

      I’d rather we focus our resources on helping to make sure the end of peoples’ lives are as peaceful, dignified and pain-free as possible. But that does cost money. My fear is that if we accept that rather than go out of our way and spend the time and money to ease them towards a good, natural death, we can just leave them in such “horrible, excruciating pain” that they’ll beg us to kill them to put them out of their misery, the latter will end up being the default, especially for patients without a lot of financial means.

      It’s always going to be cheaper to kill someone than to treat them. Do you trust your insurance company, or the government, enough that you think they will happily spend money on you when they don’t have to? I don’t. I’d be afraid that the rich would have the resources to buy themselves a comfortable and dignified natural death, and those with less means won’t get any decent comfort care so they’ll beg to be put down like a dog instead.

      I will never, ever put myself under the care of a physician who thinks it’s okay to kill me rather than treat me. That’s scary.

      • fatherhash

        it’s also cheaper to put someone on a DNR status….does that mean it’s spreading like wildfire and should’ve never been allowed? this slipper slope argument that once we allow it, insurance and govt will force it on us seems scary, but not necessarily inevitable.

  • James_94

    Laura’s body was Laura’s. Once she was created by her mother and her father, she was herself.

    And she’s very lucky she had two such loving parents. That’s a gift not every child gets.

  • katerinahurd

    Do you think that medicalization of death was initiated by physicians who consider death their ultimate enemy? What assigns quantity in the qualitative experience of pain? Why don’t you address issues such as futility of medical interventions that are inherently unethical since they reduce the patient into an experimental guinea pig? Do you think that the dissociation of the disease from the patient works against any compassionate care by the physician toward the patient? Who would assign a monetary value to dying?

  • Ron Smith

    You know, my wife Stacy, was the one the character. My years of work with extremely premature neonates caused me such fear. I knew what she and we faced in a way that Stacy didn’t. Stacy would have left me to deliver Laura. That wouldn’t have happened though and the thought of aborting her was a passing consideration born out of fear, something I’m not proud of.

    What matters though is what we do in the end. We made the decision to love her no matter what long before she was born. There was never any turning back.

    I wrote a short book about her called “Forever and A Day for Laura Michelle’ that is free on iTunes if you want to know more about her.

    Thanks so much for your kind comments as well.

    Warmest regards,

    Ron Smith, MD
    www (adot) ronsmithmd (adot) com

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