Assisted Suicide: The Liberal, Humanist Case Against Legalization

K. Yuill

• Publisher: Palgrave Macmillan
• Year: 2013
• ISBN:
  9781137286307
• Topic: Medicine
• Subtopic: Nursing

This book presents an atheistic case against the legalization of assisted suicide. Critical of both sides of the argument, it questions the assumptions behind the discussion. Yuill shows that our attitudes towards suicide – not euthanasia – are most important to our attitudes towards assisted suicide.

1

Defining the Terms

Such is the cultural divide on the issue that neither side will even agree on the terms used. In fact, the words themselves have become a key battleground for the two sides of the debate. The way the language evolves over time indicates a shift in meaning behind the words rather than just increasing use of marketing ploys or politically correct terms. It also gives an important indication of where the debate is headed. Therefore, it is worth analysing in depth the words used by both sides.

However, pinning down such moveable targets is difficult. There has been a shift in the language of assisted suicide over the years, particularly from the campaign for voluntary euthanasia, associated with eugenics, medical efficiency and Malthusian perspectives in the inter-war years, to an emphasis on autonomy and the ‘right to die’ in the 1970s and 1980s, to a new concentration on embedding suicide as a treatment choice. Much as there are some false distinctions made within the literature, there are also many real distinctions cloaked by terminology.

Whereas some of the terms cannot easily be pinned down, others are unknowable. On some levels, the term ‘death’ seems obvious; the animate becomes inanimate, human beings cease being human, subjects come to be objects. We recognize death when we see it. But what does death mean for the individual, for the self? Is it the end of the individual or can an individual’s interests exist after death? Do we ‘experience’ death or is it the end of all experience? Is death a negative to life or simply nothingness? How should we understand our own individual non-existence? It is impossible to avoid these philosophical questions when asking what appears to be a simple question. Within the contested meaning of terms exists what is ultimately behind the entire discussion of assisted suicide – a crisis of human meaning, a confusion of past, present and future, and a misunderstanding of human life.

Before launching into such deep waters, it is worth attempting to clarify as much as possible the basic terms that provide common grounds for the debate. Even this task is complicated; the terminology used often reflects the attitude expressed towards the issue of legalization.

Definitions

There are several definitions of the terms involved. Nearly twenty years ago, Ezekiel Emanuel usefully provided a basic, working definition of some of the terms current in the early 1990s:

Voluntary active euthanasia: Intentionally administering medications or other interventions to cause the patient’s death at the patient’s explicit request and with full informed consent.

Involuntary active euthanasia: Intentionally administering medications or other interventions to cause a patient’s death when the patient was competent but without the patient’s explicit request and/or full informed consent (e.g. patient was not asked).

Nonvoluntary active euthanasia: Intentionally administering medications or other interventions to cause a patient’s death when the patient was incompetent and mentally incapable of explicitly requesting it (e.g. patient is in a coma).

Terminating life-sustaining treatments (passive euthanasia): Withholding or withdrawing life-sustaining medical treatments from the patient to let him or her die.

Indirect euthanasia: Administering narcotics or other medications to relieve pain with incidental consequence of causing sufficient respiratory depression to result in a patient’s death.

Physician-assisted suicide: A physician providing medications or other interventions to a patient with understanding that the patient intends to use them to commit suicide.¹

Publishing late last year in the UK, the Commission on Assisted Dying used these terms:

assisted suicide: providing someone with the means to end his or her own life

voluntary euthanasia: ending another person’s life at his or her own request non-voluntary euthanasia: ending another person’s life when the individual is incompetent to consent to or refuse euthanasia and has made no prior decision

assisted dying: a compendium that can refer to voluntary euthanasia and/or assisted suicide.²

We might also add another accepted definition:

mercy killing: a compassionate act taken to end the life of a patient by someone who is not a doctor.

There are also recent neologisms like ‘directed death’, ‘hastened death’, or ‘self-directed death’ or ‘self-deliverance’. Some are simply euphemisms. Those who oppose the legalization of assisted suicide, however, often prefer the catch-all term ‘euthanasia’. Like the discussion in general, the language used by both opponents and proponents has changed over the years, giving an indication of shifting meanings as well as indicating which side of the debate the person using the term occupies.

Euthanasia, the term favoured by all sides up until the 1940s, simply means, from the Greek eu, meaning good, and thanatos, meaning death, a good death. So far, there is little controversy (few would wish for bad death). However, it has come to mean that doctors under certain circumstances be allowed to ensure an easy death not just by acting to quell pain but to actively kill the patient in order to prevent needless suffering. Peter Singer defined euthanasia as ‘the killing of those who are incurably ill and in great pain or distress, for the sake of those killed, and in order to spare them further suffering or distress’.³

Voluntary euthanasia implies that those who are killed are in agreement with their killing and have made a request for it. Involuntary euthanasia is when someone is killed who either did not request or actively opposed being killed. It may be that others think a death is good though the subject does not agree. Non-voluntary euthanasia refers to those situations where the person killed is not able to assent to the death and has made no prior consent. Confusingly, in the Netherlands and Belgium, where euthanasia is legal, the term implies voluntary euthanasia.

Just as bewilderingly, the terms distinguish between ‘active’ and ‘passive’ euthanasia. Passive euthanasia is sometimes used by both sides of the discussion to refer to the removal of life-saving or life-sustaining equipment and thus causing a death. Active euthanasia means to take deliberate action to end a patient’s life, such as administering poison or smothering the patient. But surely passive euthanasia – letting someone die, usually of a disease – must be in a different category, given the essential moral difference, although sometimes small, between letting something happen and making it happen. The latter is action (we will discuss a theory of action through which we can characterize suicide in Chapter 4).

Euthanasia generally implies an agreement amongst at least several people that the patient would be better off dead. Prior to the Second World War, euthanasia implied that the patient no longer wished to live – usually meaning forgoing the final weeks or months of a painful and debilitating disease – but also was used to signify the ‘help’ given to those whose existence, it was deemed, did not benefit wider society. In the United States especially, euthanasia and eugenics were closely associated and supporters of euthanasia, like Nobel Prize-winner Alexis Carrel, declared that sentimental prejudice should not obstruct the quiet and painless disposition of ‘incurables, criminals, and hopeless lunatics’. Peter Singer goes further than most recent advocates in admitting that approval of voluntary euthanasia includes some involuntary euthanasia in a few very extreme cases.⁴

Whereas the proposed legislation in the UK is the ‘Assisted Dying’ Bill and ‘death with dignity’ is the preferred term in the US states of Oregon and Washington, where assisted suicide is legal, and by the organization Compassion and Choices, these terms hardly specify what is being sought. What exactly is ‘dignity’ and who defines it? The concept of death with dignity begs the question: are other deaths necessarily without dignity? Historically, the term ‘death with dignity’ was used by Representative Dr Walter W. Sackett, Jr., who introduced proposals using the term during the 1960s and 1970s in the Florida Legislature. Dr Sackett acclaimed his legislation as being a means of allowing the severely retarded in Florida’s institutions to ‘die with dignity’ simply by refusing to treat infections and pneumonia.⁵ Such slippery terms mirror the slipperiness of the debate.

It is only relatively recently that campaigners have called for voluntary euthanasia or assisted suicide only and not euthanasia in general. After all, it makes sense, if the aim is to alleviate suffering, to extend the power to end suffering not just to the individual involved but to doctors and, perhaps, to those nearest and dearest to the patient. The patient may not, in some instances, be able to act in his best interests. Perhaps the patient made clear her wishes but lacks the function to give final assent to the act. Up until 1970 (and, to a lesser extent, today) campaigners for a change in the law sought the legalization of both euthanasia and assisted suicide. Since then the emphasis has shifted to autonomy.

The evolution of terminology

By the 1950s euthanasia advocates advised changing the terminology in order to distance themselves from Nazi eugenics programs and well-documented and horrific medical experimentation during the Third Reich. In the New Republic, a euthanasia proponent called for new expressions: ‘If we call these situations “assisted suicide” rather than “mercy killing”, the moral content would be considerably changed . . . The term “murder” implies anger: it is not the word to use for a courageous act of compassion.’⁶

We can see in outline a fundamental problem besetting those in favour of legalization: how does one legitimate acts of mercy at the same time as what was called even in the 1930s ‘the right to die’? A mercy killing is clearly not a suicide unless one argues that the ‘killer’ acts on behalf of the patient and follows either wishes expressed by the patient or concludes from a range of evidence that death would be what the patient wanted in that specific situation if she was able to express her wishes.

The term euthanasia, while it remains in the title of many groups, has decidedly fallen out of favour amongst activists if not opponents. In the United States the Euthanasia Society changed its name in 1974 to the Society for the Right to Die (SRD), reflecting the new emphasis on autonomy and civil rights. As prominent member of the SRD, newspaper columnist Abigail ‘Dear Abby’ Van Buren, noted in 1974, ‘a bill with the word “euthanasia” in it will never get passed’.⁷ In 1977 the Euthanasia Educational Council changed its name to Concern for Dying (CFD).

Euthanasia remains the favoured term for opponents because it emphasizes a key point they wish to make; if assisted dying or assisted suicide is allowed, it will soon extend to voluntary euthanasia and to involuntary euthanasia (this is the ‘slippery slope’ theory that will be discussed in the next chapter).

Assisted suicide vs assisted dying

More recently, and particularly after 9/11, the word ‘suicide’ has fallen out of favour. One of the major themes in this book is that the apparent coherence behind the case for legalization quickly dissolves when looked at closely. The term ‘assisted dying’ is now the term of choice but is not simply the product of the search for more politic terms since the term ‘suicide bombers’ entered the news. Instead, it appears to denote a shift away from the emphasis on autonomy and self-determination towards a demand that death become a medical choice. We need to ask whether there are any real differences and, if so, what are they?

Some proponents now consider suicide to be pejorative; many activists would like to deny the association of suicide with, to use yet another favoured phrase, ‘aid in dying’. Language evolves, proponents of a change in the law note, and to label aid in dying at the end of life as suicide is ‘inaccurate, biased, and pejorative’. ‘Just as terms like “retarded” and “handicapped” have gone by the way, so should the term suicide.’ Advocates argue that it is in fact the disease that kills; they simply call for the individual’s freedom to exercise choice in how they die.⁸

Using the term suicide is ‘hurtful’ to those in the invidious situation where they must make such a choice. Charlene Andrews, the patientplaintiff in Gonzales v. Oregon, pleaded with reporters: ‘Please do not call it suicide; that is an insult to my fight against cancer.’ Compassion and Choices states ‘[I]t’s inaccurate to call it suicide when a dying patient chooses to ingest medication to bring about a peaceful death. Labeling that “suicide” is politicized language that implies a value judgment and carries with it a social stigma.’ The California campaign manager for Compassion and Choices, Steve Hopcraft, adds: ‘The word “suicide” is completely pejorative. It’s really insulting to people . . . who are facing a very grim and painful death — to call their desire to end their own suffering suicide. These people are dying from their disease, they’re not committing suicide.’⁹ Whereas language undoubtedly does evolve and no one would wish to insult people in terrible circumstances, the language of the campaigners is evasive rather than clarifying. In the United Kingdom, Dignity in Dying gives an indication of the differences between assisted dying and assisted suicide: ‘Assisted dying is different to euthanasia and assisted suicide. Euthanasia is a term often used to describe life-ending medication being administered by a third party. Assisted suicide refers to providing assistance to die to someone who is not dying.’¹⁰

Shall we accept the term ‘assisted dying’ over ‘assisted suicide’? After all, there may be the need for a term covering the different elements of voluntary euthanasia, where the patient agrees to be killed but someone else does the killing, and assisted suicide, where the patient takes the action aided by someone else, usually a doctor. Given that, if we view the needs of the patient as paramount, the effects of both actions are the same, shall we not use the broader term? There are reasons to reject ‘assisted dying’ as a useful term.

First, the vagueness of ‘assisted dying’ creates more questions than it answers. Presumably, capital punishment is a form of assisted dying. Or is it assisted dying only in cases where the prisoner agrees with his punishment? Or perhaps we should accept the idea that the difference pointed out by Dignity in Dying between ‘the dying’ and everyone else; assisted dying is helping the dying to die whereas assisted suicide is assisting someone who is not dying to die. But this in turn begs questions. Who is not progressing steadily towards death? How are we to define ‘the dying’ and by which criteria? And who defines it? And why should ‘the dying’ be a separate moral category?

‘Assisted dying’ means different things to different people. In the way it is defined by Compassion and Choices and Dignity in Dying, the use of ‘assisted dying’ also implicitly condemns suicide. To Dignity in Dyin...

Table of contents

• Cover
• Title Page
• Copyright
• Contents
• Foreword
• Acknowledgements
• Introduction
• 1. Defining the Terms
• 2. An Analysis of the Key Arguments on Both Sides
• 3. The Origins of the Right-to-Die Movement
• 4. Considering Suicide
• 5. For Abortion, Against Assisted Suicide
• 6. The Coercive Implications of Legalization
• Conclusions
• Notes
• Bibliographic Essay
• Index