Marilyn Golden
Executive Committee,
California Disability Alliance (CDA)
LOOK DEEPER
Assisted suicide seems, at first, blush, like a good thing to have
available. But on closer inspection, there are many reasons that legalizing
assisted suicide is a terrible idea.
HOW MANY WOULD BE HELPED AND HOW MANY WOULD BE HARMED
While an extremely small number of people may benefit, they will tend to
be at the upper end of the income scale, white, and have good health
insurance coverage. At the same time, large numbers of people, particularly
among those less privileged in society, would be at significant risk of
substantial harm. We must separate our private wishes for what we each may
hope to have available for ourselves some day and, rather, focus on the
significant dangers of legalizing assisted suicide as public policy in this
society as it is today. Assisted suicide would have many unintended
consequences.
MANAGED CARE AND ASSISTED SUICIDE ARE A DEADLY MIX
Perhaps the most significant problem is the deadly mix between assisted
suicide and profit-driven managed health care. Health maintenance
organizations (HMO's) and managed care bureaucrats are already overruling
doctors' treatment decisions, sometimes hastening patients' deaths. The
cost of the lethal medication generally used for assisted suicide is about
$35 - $50, far cheaper than the cost of treatment for most long-term medical
conditions. The incentive to save money by denying treatment is already a
significant danger; it would be far greater if assisted suicide is legal.
It's not coincidental that the author of Oregon's assisted suicide law,
Barbara Coombs Lee, was an HMO executive when she drafted it. Assisted
suicide will accelerate the decline in quality of our health care system.
A 1998 study from Georgetown University's Center for Clinical Bioethics underscored the link between profit-driven managed health care and assisted suicide. [*1] The research found a strong link between cost-cutting pressure on doctors and their willingness to prescribe lethal drugs to patients, were it legal to do so. The study warns there must be "a sobering degree of caution in legalizing [physician-assisted suicide] in a medical care environment that is characterized by increasing pressure on physicians to control the cost of care."
The deadly impact would come down the hardest on socially and economically disadvantaged groups who have less access to medical resources and who already find themselves discriminated against by the health care system: poor people, people of color, elderly people, people with chronic or progressive conditions or disabilities, and anyone who is, in fact, terminally ill will be put at serious risk.
Dr.Rex Greene, a cancer specialist in Los Angeles for 23 years and a leader in his field, underscored the heightened danger to the poor. He said, "The most powerful predictor of ill health is [people's] income. [Legalization of assisted suicide] plays right into the hands of managed care."
Supporters of assisted suicide frequently say that HMO's will not use assisted suicide as a way to deal with costly patients. They cite a 1998 study in the New England Journal of Medicine that found the savings of allowing people to die before their last month of life would be $627 billion, which is only .07% of the nation's total health care costs per year. But this study has several significant problems that make it an unsuitable basis for claims about assisted suicide's potential impact. The researchers based their findings on the average cost to Medicare of patients with only four weeks or less to live. But assisted suicide proposals (as well as the law in Oregon, the only state where assisted suicide is legal) define terminal illness as having six months to live. The researchers also assumed that about 2.7% of the total number of people who die in the U.S. would opt for physician assisted suicide, based on reported physician-assisted suicide and euthanasia deaths in the Netherlands. But Dutch doctors are not required to report such deaths, which casts considerable doubt on this figure. And how can you compare the U.S. to a country that has universal health care? All these considerations would skew the costs much higher.
FEAR, BIAS, AND PREJUDICE AGAINST DISABILITY
Another major problem with assisted suicide is who ends up using it,
both in Oregon and in the only other place on earth where it is legally
tolerated, the Netherlands. The point of assisted suicide is purported to
be relief from untreatable pain at the end of life. However, all but one of
the people in Oregon who were reported to have used that state's assisted
suicide law during its first year wanted suicide not because of pain, but
for fear of losing functional ability, autonomy, or control of bodily
functions. [*2] Oregon's second year report has similar results. Further,
in the Netherlands, more than half the doctors surveyed say the main reason
given by patients for seeking death is "loss of dignity." [*3]
This fear of disability typically underlies assisted suicide. Said one assisted suicide advocate, "Pain is not the main reason we want to die. It's the indignity. It's the inability to get out of bed or get onto the toilet...[People]...say, 'I can't stand my mother - my husband - wiping my behind.' It's about dignity." [*4] But needing help is not undignified, and death is not better than dependency. Have we gotten to the point that we will abet suicides because people need help using the toilet?
SUPPOSED SAFEGUARDS
Assisted suicide proposals are based on the faulty assumption that you
can make a clear distinction between who is terminally ill with 6 months to
live, and everyone else. Everyone else is supposedly protected and not
eligible for assisted suicide. But it is extremely common for medical
predictions of a short life expectancy to be wrong. Studies show that only
cancer patients show a predictable decline, and even then, it's only in the
last few weeks of life. And with every disease other than cancer, there is
no predictability. [*5] Prognoses are based on statistical averages, which
are nearly useless in predicting what will happen to an individual patient.
Moreover, doctors and the courts frequently classify people with long-term
disabilities as "terminally ill." Thus, the potential effect of assisted
suicide is extremely broad, far beyond the supposedly narrow group the
proponents claim.
This poses considerable danger to people with new or increasing disabilities or diseases. Research overwhelmingly shows that people with new disabilities frequently go through initial despondency and suicidal feelings, but later adapt well and find great satisfaction in their lives. [*6] However, the adaptation usually takes considerably longer than the mere two week waiting period required by assisted suicide proposals and Oregon's law. People with new diagnoses of terminal illness appear to go through similar stages. [*7] In that early period before one learns the truth about how good one's quality of life can be, it would be all too easy to make the final choice one that is irrevocable, if assisted suicide is legal.
OTHER SUPPOSED SAFEGUARDS
In Oregon's law and similar proposals, doctors are not supposed to write
a lethal prescription under inappropriate conditions that are defined in the
law. This is seen as a supposed safeguard. But what's happened in several
cases in Oregon is "doctor shopping" - if one physician refuses assisted
suicide because the patient doesn't meet the conditions in the law, another
physician s sought who will approve it, often one who's an assisted suicide
advocate. Such was the case of Kate Cheney, age 85, whose case was
described in The Oregonian in October 1999. Her doctor refused to prescribe
the lethal medication, because he thought the request was actually the
result of pressure by an assertive daughter who was stuck with caregiving,
rather than the free choice of the mother. So the family found another
doctor, and Ms. Cheney is now dead.
There is one safeguard in most assisted suicide proposals - for HMO's and doctors: the "good faith" standard. This "safeguard" provides that no person will be subject to any form of legal liability if they claim that they acted in "good faith." A claimed "good faith" belief that the requirements of the law are satisfied is virtually impossible to disprove, rendering all other proposed "safeguards" effectively unenforceable.
SO-CALLED "NARROW" PROPOSALS WILL INEVITABLY EXPAND
As the New York State Task Force on Life and the Law wrote, "Once
society authorizes assisted suicide for...terminally ill patients
experiencing unrelievable suffering, it will be difficult if not impossible
to contain the option to such a limited group. Individuals who are not
(able to make the choice for themselves), who are not terminally ill, or who
cannot self-administer lethal drugs will also seek the option of assisted
suicide, and no principled basis will exist to deny (it)." [*8]
The longest experience we have with assisted suicide is in the Netherlands, where not only assisted suicide but also active euthanasia is practiced. The Netherlands is a very frightening laboratory experiment where, because of assisted suicide and euthanasia, "pressure for improved palliative care appears to have evaporated," [*9] according to Dr. Herbert Hendin in Congressional testimony in 1996. Assisted suicide and euthanasia have become not just the exception, but the rule for people with terminal illness.
"Over the past two decades," Hendin continued, "the Netherlands has moved from assisted suicide to euthanasia, from euthanasia for the terminally ill to euthanasia for the chronically ill, from euthanasia for physical illness to euthanasia for psychological distress and from voluntary euthanasia to nonvoluntary and involuntary euthanasia. Once the Dutch accepted assisted suicide it was not possible legally or morally to deny more active medical (assistance to die), i.e. euthanasia, to those who could not effect their own deaths. Nor could they deny assisted suicide or euthanasia to the chronically ill who have longer to suffer than the terminally ill or to those who have psychological pain not associated with physical disease. To do so would be a form of discrimination. Involuntary euthanasia has been justified as necessitated by the need to make decisions for patients not competent to choose for themselves." [*10] In other words, for a substantial number of people in the Netherlands, doctors have decided patients should die without consultation with the patients.
Furthermore, assisted suicide proponents and medical personnel alike have documented how taking lethal drugs by mouth is often ineffective in fulfilling its intended purpose. The body expels the drugs through vomiting, or the person falls into a lengthy state of unconsciousness rather than dying promptly, as so-called "death with dignity" advocates wish. Such ineffective suicide attempts happen in a substantial percentage of cases -- estimates range from 15% to 25%. [*11] The way to prevent these "problems," in the view of euthanasia advocates, is by legalizing lethal injections by doctors, which is active euthanasia. This is an inevitable next step if society first accepts assisted suicide as a legitimate legal option.
We are told by assisted suicide proponents that these things will not happen. But why not? How can the proponents, or anyone, stop it? The courts have already completely blurred these categories. If the next step is wrong, then taking this step is tantamount to taking the next step.
NOT TRULY FREE CHOICE
Assisted suicide purports to be about free choice. But there are
significant dangers that many people would take this "out" due to pressure,
such as elderly individuals who don't want to be a financial or caretaking
burden on their families. There's a significant amount of well-documented
elder abuse in this country, and it's very often by family members, [*12]
which could easily lead to such pressures. Also, leaders and researchers in
the black and Latino communities have stated their fears that pressures to
choose death would be applied disproportionately to their communities.
[*13] Other people would undergo assisted suicide because they lack good
health care, or in-home support, and are terrified about going to a nursing
home. Assisted suicide would actually result in deaths due to a lack of
choices for many people. Given the absence of any real choice, death by
assisted suicide becomes not an act of personal autonomy, but an act of
desperation. It is fictional freedom; it is phony autonomy.
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FOOTNOTES:
1. Sulmasy, Daniel P., M.D.; Benjamin P. Linas, B.A.; Karen F. Gold, Ph.D., and Kevin A Schulman, M.D. "Physicians Resource Use and Willingness to Participate in Assisted Suicide." Archiv. of Internal Med., Vol. 158 (May 11, 1998)
2. Report from the Oregon Health Division, published in the New England Journal of Medicine, February 18, 1999, Vol. 340, Issue 7, "Legalized Physician Assisted Suicide in Oregon: The First Year's Experience."
3. Karen Birchard, "Dutch MD's Quietly Overstepping Euthanasia Guidelines: Studies," Medical Post, VOLUME 35, NO. 11, March 16, 1999
4. Richard Leiby, "Whose Death Is It Anyway? The Kevorkian Debate. It's a Matter of Faith, In the End," Washington Post, August 11, 1996
5. Lamont, EB, et al. Oncology (Huntington) 1999 Aug;
13 (8):1165-70
Maltoni, M. et al. Eur Joul of Cancer. 1994; 30A (6):764-6
Christakis and Iwashyna. Arch of Int Med 1998 Nov 23;158(21):2389-95
Lynn, J, et al. New Horiz 1997 Feb;5(1):56-61
6. Louis Harris & Associates, The ICD Survey of
Disabled Americans: Bringing Disabled Americans in the Mainstream 55 (1986)
KA Gerhart et al., Annals of Emergency Medicine, 1994, vol. 23, 807-812
P Cameron et al., Journal of Consulting and Clinical Psychology, 1973, vol.
41, 207-214
C Ray & J West, Paraplegia, 1984, vol. 22, 75-86
R Stensman, Scandinavian Journal of Rehabilitation Medicine, 1985, vol. 17,
87-99
JR Bach & MC Tilton, Archives of Physical Medicine and Rehabilitation, 1994,
vol. 75, 626-632
GG Whiteneck et al., Rocky Mountain Spinal Cord Injury System Report to the
National Institute of Handicapped Research, 1985, 29-33
MG Eisenberg & CC Saltz, Paraplegia, 1991, vol. 29
7. New York State Task Force on Life and the Law (1994): "When Death is Sought: Assisted Suicide and Euthanasia in the Medical Context," p. xiv
8. New York State Task Force on Life and the Law, "When Death is Sought," 1997 supplement
9. Herbert Hendin, M.D., "Suicide, Assisted Suicide and Euthanasia: Lessons From the Dutch Experience," U.S. House of Representatives, Committee on the Judiciary, Oversight Hearing, April 29, 1996.
10. Herbert Hendin, M.D., "Suicide, Assisted Suicide and Euthanasia: Lessons From the Dutch Experience," U.S. House of Representatives, Committee on the Judiciary, Oversight Hearing, April 29, 1996.
11. Journal of the American Medical Association, August
12, 1998, Volume 280, No. 6, page 512.
New York Times, December 3, 1994: Letter to the Editor from Derek Humphrey,
founder of the Hemlock Society and author of Final Exit
12. The National Elder Abuse Incidence Study (NEAIS) was conducted by the National Center on Elder Abuse at the American Public Human Services Association. It showed that, in 1996, 450,000 elders age 60 and over were abused, according to a study of observed cases. In almost 90 percent of the elder abuse and neglect incidents with a known perpetrator, the perpetrator was a family member, and two-thirds of the perpetrators were adult children or spouses.
13. Clarence Page, Chicago Tribune, February 24, 1999
Penny Montemayor, Coalition of Concerned Medical Professionals, as quoted in
"The Death Debate: Making Sense of California's Proposed Death with Dignity
Bill," San Francisco Bay Guardian, July 14, 1999
"Blacks Wary of Right-to-Die," Ann Arbor News, February 26, 1997
"Blacks Fearful of White Doctors Pulling the plug," Detroit Free Press,
February 26, 1997