In my bioethics class we have been discussing death, terminating medical treatment, and physician assisted suicide. Most of my classmates have been soundly in support of a so-called "right to die", though they usually recognize some of the tensions present in the existence of such a right.
I'm still working through the issues - part of the reason for this post - I don't completely have my mind made up, but I'm leaning strongly against the idea that there could ever be a "right to die". For the purposes of this post, I am thinking mostly of physician assisted suicide, though perhaps the same questions and responses apply to termination of treatment.
First, I see an overriding importance of life. Life, quite simply, has value. Even if the human is in a persistent vegetative state their life must have value. We believe that nature - animals, plants, the Earth itself - has value, how much more so then the value of the human! There is value in the life, and that is important.
But more than the reasons against a "right to die", I have been considering the reasons in favor. Most people can see the appeal of these arguments, and they can be difficult to refute. I have been considering the roots beneath the arguments. I am becoming convinced that the "right to die" is premised on faulty assumptions, and that when pressed, these assumptions unravel quickly.
In my experience there are three basic reasons given to support a "right to die". The first is the idea that it allows a person to die with dignity. But this is incongruous. When we think of those who have died with dignity the first people who come to mind are usually those who have suffered boldly. I thought of John Paul II. Laura mentioned martyrs. I can see no connection between opting out of life via suicide (physician assisted or otherwise) and dignity. In fact, even if a person has the most noble reasons for opting out of life (i.e. to mitigate the suffering of others), it seems that they are de facto choosing a route that denies the dignity in persisting through suffering and overcoming hardship. If dignity is truly a concern then suicide is far from the obvious choice; and I would contend that most frequently suicide is fraught with tones of cowardice, an element diametrically opposed to dignity.
The second reason in support of a "right to die" is that allowing physician assisted suicide gives people a chance to alleviate pain and suffering. But are pain and suffering actually bad things in themselves? Aren't there times when it is good to feel pain? When it is good to suffer? Aren't these things actually neutral? Even if unpleasant, isn't it better for us to live through pain than to seek an artificial - and permanent - escape from it? What troubles us more - the pain we feel when a loved one dies, or not feeling sad when a loved one dies? I would certainly find the later more troubling. Can we say with any certainty then that dissolution of pain is good? No. But we can say that anyone seeking a life without pain has taken a troubling course.
Finally, the "right to die" is supported by an argument from autonomy. This says that we cannot know what it is like to be in the shoes of the person making the decision, and we must respect their choice because they are a rational being. Despite studies showing that 95% of suicidal persons suffer from depression, we'll assume that the individual making this choice is completely healthy. The argument is really a quality of life argument. It says that the individual making the choice knows best what their quality of life is, and if they deem it low enough, then they can terminate their life. Ultimately, the claim is that we cannot assess quality of life from the outside.
But if this is the case, couldn't a healthy, happy person simply decide that their quality of life was personally too low? Even if they were eminently comfortable, typically happy, with terrific friends and family, meaningful employment, etc. - they are in the best position to decide whether their life is worth living. How can we allow physician assisted suicide for the terminally ill and at the same time condemn suicide generally? The two are facially inconsistent. One says we cannot assess another's quality of life, while the other assess another's quality of life.
Moreover, the autonomy of the suicidee should not be the paramount value. Especially given that two people with exactly the same symptoms/quality of life may come to different determinations about the appropriateness of suicide. If we respect the autonomy of one, we respect the statement they make by their suicide - that life is not worth living at a particular level of quality. For all those who chose to live at that same quality, this statement is a condemnation of their autonomous decision. We cannot respect the autonomy of some while disrespecting it for others.
Finally, we must consider the fact that if physician assisted suicide is allowed and accepted, there will be greater external pressure for the terminally ill to choose this option. In fact, their autonomy will likely be coerced in this direction.
I certainly still have questions, and any comments on any of these issues is more than welcome (actually invited). As I see it now, the importance of life easily trumps the "right to die", especially when we consider the problems underlying the "right's" corresponding justifications. A "right to die" is a figment constructed on unfit assumptions.
If you think you've had too much of this life
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Oof, you're making me think way too early in the morning. But I did have a couple of thoughts while reading this. Does this also apply to someone requesting not to be put on life support in the first place ? Is preventing treatment the same as terminating it once it's been started?
Also, what about a terminal cancer patient who chooses to forego treatment so they may enjoy their time with loved ones instead of being sick from the treatment? They are stopping the treatment that could extend their life because they believe they'll have a higher quality of life without the side effects of treatment.
That's all I have this early on a Monday, maybe I can come up with something more coherent later.
I'm really concerned more w/ physician assisted suicide than I am with termination of treatment.
I do see a difference between the two, though it may be smaller than most people think on first glance. After all, what would we call a diabetic who decided to end their life by stopping their insulin injections? Would we call it suicide? Or termination of treatment? I'm not sure yet, but I'd press people to think long and hard about that.
Finally though, I think there's a big difference between never begining treatment (i.e. the cancer patient refusing chemo or the do-not-recessitate patient) and removing yourself from it once it has begun. It seems to me once you begin treatment, it simply becomes another part of you and what your life involves. Like a pacemaker. That's treatment, but it is literally a part of you. How would we feel about someone who volunatarily has their pacemaker removed, knowing full well the consequences of their action? I think we'd be troubled. And we probably should be equally troubled if someone terminates any other treatment knowing that it will lead to death.
okay, i'm going to play devil's advocate here, especially with your christian beliefs...
couldn't you argue that jesus, in a way, committed suicide? as the son of god, it was well within his power to stop his death. but, in the end, he chose to end his human life earlier.
i'm not exactly clear on your arugument about sacrificial death... ie: the need of the many outweigh the need of the few. like spock in star trek II, or even bruce willis in armagedon.
for the record, i am all for living wills. if someone does not wish to remain in a vegetative state and has stated so before hand, then i say their wishes should be granted. the important part, i think, is that the person states their wishes plainly so as to not have various sides arguing this or that.
as for physician assisted suicide, i often think it is the job of the physician to help people feel better, which for me, means helping cure the disease or ease the symptoms. however, as someone who lived with a terminally ill person for the better part of his life, i can see how someone would look to a doctor for assistance. however, i thnk if one chooses suicide, they are better off going it alone, rather than seek help. to seek assistance in suicide gives the family someone to blame, and in the end, ends up hurting the assistant and shows a level of (bad) selfishness.
if you take your life in your own hands, make sure it's just your own hands.
I don't think you can use the Jesus example. He didn't cause his death - at best it's parallel to refusing treatment, and I think most people acknowledge that that's ok.
Secondly, I'd agree that there are more issues when talking physician assisted suicide than when talking about suicide itself. It does seem to create trouble for the doctor, and we have to wonder about the healing/harming dichotomy in assisted suicide cases. There does seem to be some contradiction of the hypocratic oath.
Third, in cases of persistent vegitative state, I think there's a legitimate argument that we need to follow living wills. But I'd ask you whether or not we'd follow that will if the person said they wanted all medically available treatment and to be kept alive as long as possible? Interesting to think of it in reverse...
I'm not quite clear what you're getting at on the "needs of the many" idea. I had been saying that we need to consider the interrelation between the individual seeking death and other members of society, and that these other interests weigh against allowing the person to committ suicide - because even if there is a financial/emotional burden on others in the community, the value of life and society's ability to protect life, are more important than relieving that burden.
Have you ever seen a terminal cancer patient in the last stages? Or an individual in the final few months of Alzheimer’s disease? I don’t think you have. I don’t think you actually have any real life experience with the terminally ill—because if you had, you wouldn’t write so flippantly about John Paul II or the “dignity” of suffering.
A patient diagnosed with stage IV non-Hodgkin’s lymphoma generally presents with fever, exaggerated sweating, dramatic weight loss, and “bone pain”—a technical term associated with a cancer so aggressive that it progressively eats away at the skeleton from the bone marrow out. The liver, the lungs, and the digestive system have all begun to very slowly, very painfully shut down. Control over the bowels and bladder weakens, then goes altogether. These symptoms don’t go away. They get worse. Not long into stage IV the pain is so severe that patients cannot eat, or sleep without heavy sedation. By all outward appearances, a cancer patient at this stage looks to be wasting away. Physiologically, that is exactly what is happening.
The “right to die,” as you deride it, is not about martyrs or popes. When you walk into a hospice—and I suggest you do before you start to criticize anybody for “unfit assumptions”—there are very few people talking about the appropriateness of pain or the autonomy of the suicidee from a purely theoretical perspective.
I reject your first “rejection.” You see no dignity in suicide. That is a fair enough opinion. Why do you assume that simply being alive lends any dignity to the alternative? A human being in agony, unable to perform the most routine tasks—eating through a needle, defecating in bed, sleeping only when induced to do so by a morphine drip—this individual probably cares very little about “persisting through suffering and overcoming hardship.” The cancer is terminal. It isn't going to be overcome. That's the point.
Your second position is less a statement on pain and suffering than it is a series of rhetorical questions leading to a total non sequitur, but let’s give it a whirl.
You write: “But are pain and suffering actually bad things in themselves? Aren't there times when it is good to feel pain?” The “right to die” debate isn’t a discussion about heartache, or the challenges we face in life as part of the human experience, or even the pain and suffering of horrible diseases generally. It is a very narrow discussion about a very specific part of life, and only that at the very end of things.
You continue: “Even if unpleasant, isn't it better for us to live through pain than to seek an artificial - and permanent - escape from it?” Probably yes, for most of us, although I’m not entirely certain what you mean by an “artificial escape.” But living through a painful experience is preceisely what we are not talking about. The subjects of this discussion aren’t going to live through the experience.
You then ask: “What troubles us more - the pain we feel when a loved one dies, or not feeling sad when a loved one dies?” More than any other statement in this entire post, this one proves to me that you have zero practical experience in this arena. Are you suggesting that family members don’t mourn when an individual chooses to end his life? Or that family members who are party to that decision actually wanted their loved one to be sick and to die?
Then, finally, you tell us: “we can say that anyone seeking a life without pain has taken a troubling course.” It’s worth repeating myself—we aren’t talking about seeking a lifetime without pain, we are talking about ending the remainder of a life that will be little but pain. If there is any substance to the argument that pain and suffering is good for cancer victims, it isn't posted here.
As your third objection to physician assisted suicide, you write: “the autonomy of the suicidee should not be the paramount value. Especially given that two people with exactly the same symptoms/quality of life may come to different determinations about the appropriateness of suicide. If we respect the autonomy of one, we respect the statement they make by their suicide - that life is not worth living at a particular level of quality.”
You seem to suggest that a law legalizing physician assisted suicide is equivalent to a law mandating physician assisted suicide. It’s not so and you know it. If this country creates a legal opportunity to exercise the right to die, then it gives that final and difficult decision to everyone. Respect for autonomy is letting people make that decision for themselves with as little intrusion as possible. It isn’t a statement that life for everyone who is eligible for the choice is completely worthless. In the health care system you wrote about so recently, we could do better for patients who choose not to die today. As it is, why should you--and not the patient--get to decide?
We don’t even have to get into the slippery slope problem—legaliztion is not a statement that suicide is okay for everyone, or that the terminally ill will begin to be pressured to kill themselves. Very smart lawyers, such as yourself, can legislate for precisely the effect they have in mind. In Oregon, the only state to have legalized physician assisted suicide, the law can only take effect when an individual is terminally ill, has less than six months to live, has made two oral requests and one written request for assistance, has convinced two doctors she is sincere and acting freely, and has been informed of the “feasible alternatives, including, but not limited to, comfort care, hospice care and pain control.” When all of those conditions are met, who are you to call a person who opts out of six months of debilitating pain a "coward?"
Nobody disagrees with the proposition that “life, quite simply, has value.” But when you say that “autonomy is subordinate” to “life” in general, what you really mean is that somebody else’s decision about life and death is subordinate to your particular opinion on the matter.
Well, I think you've missed my point on a couple of issues here.
First, I do have limited experience with terminal illness. I have been incredibly fortunate in this regard. But I am entirely aware of the possibility that I may not be so fortunate in the future. I have had some experience with terminal illness, and the little suffering that I have seen has not been easy. I can only imagine the difficultly that would come with a more intense and immediate experience of terminal illness. But I can - and do - imagine. I fear. I understand. Your comments are relevant, but off the mark. Terminal illness is not something to be taken lightly, these are grave issues. This is why I write about them, this is why I am passionate.
Moreover, despite the practical realities of terminal patients, physician-assisted suicide is a question that raises deep philosophical issues. Different people come out differently. Not everyone with a terminal illness comes out in the same corner on this issue - simply a further indication that the relevant criteria seem to be philosphical underpinnings. It is these I am attempting to address, and I believe they can be dealt with irregardless of personal experience. There are those with terminal illnesses who will agree with me. There are those who will disagree. Experience can change a person's perspective - but it can change it in either direction.
That being said, I get the impression that you don't understand the dignity in suffering boldly. Let's just look at the concept of dignity. What is it? Dictionary.com gives us "the quality or state of being worthy of esteem or respect." Whom do we respect? We respect those who can face hardship. Who do not shrink from a task because it is difficult. Whether someone has a terminal illness or not does not affect their dignity. Their reaction to that illness does. I maintain that those who face boldly - who, despite the pain, persist on living, who do their best to appreciate and take joy in life - those are the noble. That is dignity.
I wrote before that "frequently suicide is fraught with tones of cowardice" (if any, I would expect this is the phrase you took as "flippant"). It is a painful and unfortunate truth. We don't like to look down on others when they have choose to take a smaller burden. Especially when, through no fault of their own, they have been dealt a hand which demands tremendous suffering, the depth of which can only be truly appreciated when encountered in graphic terms. But the person who affirms their "inherent nobility and worth" (definition #2 of dignity) is the person who persists through suffering. The person chosing suicide effectually says "my life can have no worth if lived like this." That, painfull as it is to recognize, is not a statement consistent with dignity.
Moreover, dignity does not require success. Even if the cancer cannot be overcome, the relevant criteria for dignity is the approach to that cancer. Does the person approach it in such a way that they affirm their value? The third definition of dignity is "poise and self respect". Does the person respect the inviolability of their self? Or do they see their self as merely this suffering body? The image of self is a significant factor of dignity. Those who take a wider view of self - one that transcends immediacy and physical condition - are those who carry themselves with dignity.
I also want to address the comment regarding the nature of pain. I was in no way saying that family members don't feel pain when a loved one dies. This discussion was completely divorced from the specific context of the terminally ill. So let me put it a better way:
Imagine a fellow who is married. He loves his wife, and they have tremendous plans for the future - family, careers, travel, etc.. He comes home from work one day to find that she has been killed. What do we imagine his response would be? One of immense pain. Now, suppose that instead he lives in a state of being where pain does not exist, and simply replied "oh, well," and went about his life without ever suffering from the event. This would trouble us very much. We would say, with great ease, that there was something amiss with a person who lived in a state of being where pain was entirely absent.
The point is, suicide is a pursuit of precisely this state. The person seeking to be pain-free is seeking to be like the man who says "oh well." This is troubling. When we evaluate the man who says "oh well" we acknowledge that there is something wrong. The essence of suicide, on the other hand, instead affirms that it is better to be like the man who says "oh well" than the man who feels great pain.
Also, I am aware of the distinction between mandating and permitting PAS (from here on out, physician assisted suicide is abbreviated PAS). The problem is, in permitting it you allow those who choose the option to make a value judgment about the quality of life of others in exactly the same situation. "Life at this quality is not worth living" is the statement of the suicidee. For someone else at that same level of quality, such a statement can be entirely disheartening, offensive, and at the same time, coercive. That troubles me.
And finally, we cannot say that PAS is a right justified by autonomy if we don't also say that suicide generally is acceptable. If autonomy is the relevant criteria, why should only the terminally ill patient have a right to decide at what quality of life they will live and die? If autonomy is the relevant criteria, we can all decide the appropriate quality of life at which to take our lives. There is no meaningful distinction between the terminally ill and the healthy with regard to autonomy.
Hopefully this cleared up some of the things I was unclear about. I'm sorry that my original post seemed more unfeeling than I actually am. These are difficult discussions, and difficult decisions. No one takes these lightly, and though I am taking a stance in this post, I want everyone to know that all sides of this debate have value. Even if we come out one way, it is important to recognize that both sides are doing their best to explore the human condition and find a path which fits with what we have uncovered.
what does "facially" mean?
It means on it's face, without regard to specific facts. What context was it used in? (I don't feel like going to look for it).
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