Assisted Suicide is not Progressive

The following article was was written by Ira Byock and published in The Atlantic under the title: Physician-Assisted Suicide Is Not Progressive.

By Ira Byock - The Atlantic, October 25, 2012

"Right to die" is just a slogan. No civil right to commit suicide exists in any social compact. 

Ira Byock

The issue of legalizing physician-assisted suicide doesn't fall cleanly along liberal-conservative lines. However, it's fair to say that most social conservatives ardently oppose assisted suicide, while a clear majority on the political left support legalization. That's the case in Massachusetts where Question 2 is on November's ballot, and according to recent polling is very likely to pass.

I am an outlier, in that I am a registered Democrat and progressive, as well as a physician who has cared for people with life-threatening conditions for more than three decades. I support universal health care, voting rights, disability rights, women's rights, Planned Parenthood, gay marriage, alternative energy, and gun control. I yearn to see an end to the war on drugs and the war in Afghanistan. And, I am convinced that legalization of physician-assisted suicide is something my fellow progressives should fear and loathe.

When cast as a rights issue, it's hard for progressives to resist. But "the right to die" is just a slogan. No civil right to commit suicide exists in any social compact. Human beings have a biologically imposed obligation to die; and, as Jean Paul Sartre reminded us, suicide is always an option. However, even if a civic right to suicide did exist, suicide and assisted suicide are very different things. Suicide might be a purely private act; but physician-assisted suicide involves two people, one of whom is trained, certified, licensed, and compensated by society.

Supporters of initiatives to legalize physician-assisted suicide worry about people who die badly. On that we agree. If the moral worth of a society can be measured by how well it cares for the most vulnerable of its members, the America in which I live and practice medicine scores poorly. Much of the suffering I see among people with advanced illness is preventable. Many of the indignities I witness are imposed.

Sick people commonly endure undertreated physical suffering and a dizzying array of system-based personal assaults. There is a maze of appointments, irrational insurance hoops, and requirements, and indecipherable bills. I hear patients express embarrassment at becoming a burden to those they love, dread at the prospect of draining their family's savings and shame of being forced into medical bankruptcy. Public policies could go a long way to dissolving this quagmire, but legalizing physician-assisted suicide isn't one of them. Giving doctors lethal authority would address none of the deficiencies in medical practice, health care financing or social services that bring ill people to contemplate ending their lives.


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Whose Right to Die?

Oregon is often held up as an example of a place where legalized physician-assisted suicide has worked well. Its Death with Dignity Act is a template for legislation in other states, including Massachusetts. It is widely assumed that if a terminally ill individual qualifies for a lethal prescription, he or she automatically qualifies for hospice care. Not true. In actuality, criteria for physician-assisted suicide in Oregon are more liberal (sic) than eligibility for hospice care.

Under scrutiny from the federal government in it's zeal to curtail Medicare fraud and abuse, hospice programs are under pressure to discharge patients who are not actively declining. In 2010, 16% of hospice patients in America were eventually discharged from hospice care. These are people with cancer, emphysema, heart failure, or dementia whose conditions improve slightly, often as a result of the meticulous care hospice has been providing. They are still dying, just not quickly enough for the bureaucracy.

No provision in Oregon's Death with Dignity Act, nor in the proposed Massachusetts law protects patients who obtain lethal prescriptions from losing hospice services if they live a bit too long.

Proponents of physician-assisted suicide portray the American Medical Association's and Massachusetts's Medical Association's steadfast opposition as self-serving. But this turns the situation on its head. In this instance the medical associations are advancing progressive values. Since antiquity, doctors have had more power than patients. From the earliest times the profession has honored self-imposed boundaries put in place to protect vulnerable people. Clinical Ethics 101 includes three inviolable prohibitions: Doctors must not intentionally kill a patient, must not have sex with a patient, and must not financially benefit beyond reasonable compensation for their professional services.

Barbara Wagner

In 2008 Barbara Wagner sought chemotherapy for late stage lung cancer. The Oregon Health Plan office refused to authorize the $4,000 per month treatment because it was not approved for her condition, but listed among the services it would pay for were prescription drugs to end her life. "To say to someone, we'll pay for you to die, but not for you to live; it's cruel," Wagner told the Eugene Register-Guard.

The term Orwellian is overused, but seems apt here. Orwell understood the power of language to reshape moral thought. In today's "Newspeak" the Hemlock Society morphed into Compassion and Choices, which promotes "death with dignity" and objects to the word "suicide," preferring "aid-in-dying" and "self-deliverance." These terms sound more wholesome, but the undisguised act is a morally primitive, socially regressive, response to basic human needs. Progressives in Massachusetts who vote for Question 2 should remember that by the end of Orwell's 1984 the protagonist, Winston Smith, loved Big Brother.

An authentic progressive agenda for improving the way we die would begin by tying physician and hospital payments to quality of care, not quantity of tests and treatments, and doubling the ratio of nurses and aides to residents in nursing homes. (Honoring the inherent dignity of a person starts with ensuring there's someone to answer the bell when the person needs help getting to the bathroom.) Also high on a liberal agenda should be repealing regulations that require sick people to give up life-prolonging treatments to receive hospice care. Finally, it's past time to insist that every medical student receives adequate training and passes competency tests in symptom management, communication and counseling related to serious illness and dying -- skills that most physicians lack today.

America is failing people who are facing the end of life and those who love and care for them. Giving licensed physicians the authority to write lethal prescriptions is not a progressive thing to do.

Ira Byock is director of palliative care at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., and author of The Best Care Possible: A Physician’s Quest to Transform Care Through the End of Life.