Is assisted suicide ethically permissible if it is rare?

A recent JAMA article (subscription needed) shares the findings of a study which considers the “Attitudes and Practices of Euthanasia and Physician-Assisted Suicide in the United States, Canada, and Europe.”  As California has become the most recent state to add an “assisted death” law to the books, it is important to consider how the practices of euthanasia and physician-assisted suicide are viewed in places that have had them in place for a while.  Might they give us a hint of where we are headed?

The article highlights many important issues related to PAS and euthanasia.  It concludes,  “Euthanasia and physician-assisted suicide are increasingly being legalized, remain relatively rare, and primarily involve patients with cancer.  Existing data do not indicate widespread abuse of these practices.”  Implied in that sentence, then developed later in the article, is that the authors do not believe that there is a “slippery slope:”  “In the United States, the concern that minorities, the disabled, the poor, or other socioeconomically marginalized groups might be pressured to accept PAS does not seem to be borne out.  The demographic profile of patients in the United States who have received these interventions is white, well-educated, and well-insured.”  While that might be heartening at some level to those who fear for the marginalized of society, it does not remove all concerns, because the practice is not yet widespread in the United States.  The slope may be longer and less steep than first imagined, but it still appears to be a slope.

The JAMA study is helpful, but it does not address the ethical issues associated with this controversial issue.  One wonders if PAS is ethically permissible because it is rarely used?  Or, if it would somehow be less permissible if it were used more?  As more states move to enact PAS, I can easily envision proponents citing this article saying, “See, it’s not as bad as people say!”  True as that might be, it is not a substantial ethical argument.  It sounds like a modified version of an argument that many of us used with our parents when we were teenagers:  “It’s ok, Mom & Dad, everyone is doing it!”

Interestingly, JAMA notes that studies from Washington state and Oregon show that “[P]ain is not the main motivation for PAS.  Typically, less than 33% of patients experience inadequate pain control. The dominant motives are loss of autonomy and dignity and being less able to enjoy life’s activities.”  With that being the case, one might suspect that the patient requesting physician-assistance would be asked to undergo a psychiatric evaluation.  But, “[I]n Oregon, less that 5% of patients received a psychiatric evaluation and in Washington state only 4% were referred for psychiatric evaluations.”  Further research is needed here.

At a recent chaplain’s conference, I spoke with a chaplain from a large healthcare organization in California.  He told me that his organization was working on policies related to California’s newly implemented “End of Life Option Act.”  When I remarked that it sounded like a challenging endeavor, the chaplain repeated what many PAS advocates have said, “Dying patients seem to like having control over the end of their lives, even if they only have the lethal dose of drugs available to them, but do not use them.”

As the pressure mounts across the nation to pass PAS laws, we would do well to reassess these arguments and to develop a more thorough approach to define what we as a society want to affirm at the end of life.

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Madelaine Wong
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Good article. You hit on a number of important points, including the denial by many that the slippery slope exists. The danger this blasé attitude poses is to vulnerable populations. I have written a dystopian novel on this topic. Soon to be releases.

Jon Holmlund
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Jon Holmlund

Sounds like the JAMA article didn’t say anything new. As I pointed out on July 28, at least some in Oregon are not willing to concede that there are “no abuses,” given the lack of documentation around the practice of PAS there. And the experience in the Netherlands and Belgium is rather darker, more reflective of the slippery slope, as others, such as Dr. Arthur Caplan, have observed. Again, 5 key arguments against PAS are 1) it destroys the physician’s role as healer; 2) it cannot be limited to those who freely request death; 3) it diverts attention from proper… Read more »