I heard about a year ago that one of my favorite authors, Terry Pratchet of the Disc World series, was diagnosed with Alzheimer’s disease. I recently saw a documentary he made about his desire to ‘die with dignity’ and the process he would have to go through to end his life on his terms. This got me to thinking about the idea of suicide, assisted end-of-life care and the right to die. This could be a huge topic so first I want to define what we are talking about. There are three metrics dealing with euthanasia.
Active vs. Passive
Firs, the difference between Active and Passive euthanasia. The active form is the stereotypical (but not exclusive) act of popping pills, being given an injection, using an object for asphyxiation, etc…all of these require the individual or another to DO something to bring about death. Passive euthanasia, as implied, is to bring about death by inaction; such as not feeding or hydrating, NOT resuscitating, not providing medication or simply turning off a life-support machine.
Voluntary vs. involuntary
Another metric is voluntary and involuntary, obviously voluntary is someone who agrees to have the procedure done while the involuntary is where an individual expressly refuses to give consent – like in capital punishment – or is incapable of giving consent – like in brain injury or similar incapacity.
Desired vs. coerced
The last metric is actually a subset of voluntary…does agreement represent what was truly desired or was it coerced. Genuine desire is the ‘selfish’ wish of the individual to end their life. Coerced can be more complicated; obviously it means being forced into a decision they may not actually wish to do but it can also mean being forced to do something they desire but NOT at this time. This was one of the big issues that arose in the Terry Pratchet documentary “Choosing to Die”.
Now, we are NOT going to cover the religious objections to right-to-die for the obvious reason that as a skeptical show, we think religious thinking as ‘bad thinking’. However, that does not mean that we can simply say “assisted suicide” is always and at all times okay…well at least not until we take a skeptical look at the issue.
Right of self-determination
The documentary was focused on a non-profit group Dignitas, which provides people with the means to ‘choose death’ for about $4000. One interesting thing that was mentioned in the documentary was the idea of the right of self-determination. This term is usually used to refer to a PEOPLES right to political sovereignty. The operator of Dignitas makes the assertion that from the EU charter of rights that the right of self-determination also applies to the literal SELF and from this one has the right to choose death. We accept this when it involves a woman’s right to her body when we discuss abortion, or to Jehovah Witnesses right to refuse lifesaving medical procedures, the impossibility of one individual to own another (i.e. slavery)…we seem to accept as a culture that the one thing a person has unequivocal and absolute right to is their bodies. The operators of Dignitas, as well as through supporting assisted suicide, believe this right extends to the ultimate choice…continued existence.
First, we should acknowledge that there are cases of people who are suicidal by impulse and not for ‘logical’ reasons. That the desire to end-life is ‘ill informed’ and as such the individual is unable to exercise their right due to ‘diminished capacity’…the tried and true story of the young lover rejected and sees no point in continuing…or perhaps less romantic those individuals who suffer from bouts of depression, or are suffering from temporary distress. In the same way that we say that a person cannot give valid consent to medical procedures if they lack the appropriate level of understanding with regards to the possible outcomes. We have put a value on life and most people accept that one limitation on the absolute right-to-die is that the conditions of distress should be permanent or terminal.
The Assistant aspect
One big issue we will talk more about later, but I see as a red-herring, is the ‘assisted’ part of suicide. I think there are a large number of people who due to the incapacitation caused by their illness are incapable of ‘self-ending’ their lives. We have no problem with people helping the infirm vote in an election, have medical procedures done on them, etc. In fact in our society we feel that if an infirmity prevents on individual from exercising a ‘normal’ right, society should make extraordinary efforts to ensure the individual is provided equality in expressing their rights, for example access to schooling or opportunity to vote. I think the root of our concern with the ‘assistant’ is to insure that the act was voluntary and desired. In the same ways that we provided safeguards to ensure that un-coerced voting or medical treatment could be used in this case.
What I think is the big question is “How can we ensure that an individual is ending their life for ‘selfish’ reasons and not because others desire it.” This coercion can come in three main forms.
The burden factor
An individual may feel (or be made to feel by society or their family) that they are a burden (financially, emotionally and physically) on their family…they may feel a form of peer pressure to ‘end their life’ not because they no longer wish to live but they wish to cease being a burden on their family/loved-ones. In societies that lack substantial safety nets this can be a major motivator. Although I hope to always live in a country where medical illness will not pose a risk factor to my family’s financial existence; in those countries where this is a valid concern perhaps it may be acceptable to consider these factors.
The economic factor
The burden factor was from the perspective of the individual and their family, the economic factor is more focused on the medical establishment. In countries where medical expenses are paid by the state, there may be the honest desire to allocate limited resource in areas that may ‘do more good’. Conversely, in for-profit medical systems, often terminal patients have exhausted their financial resources and are relying on charity (public or private) which does not prove the monetary return the ‘non-terminal’ could provide…they may wish to open up beds for a ‘paying’ customer. Doctors, administrators etc. may (in their less ethical times) attempt to put pressure on a terminally ill patient to hasten their own demise.
The legal factor
Lastly, one of the main points of the Pratchet documentary was the risk to those who would assist others to end their lives. One of the main characters in the documentary was an individual who was suffering from a neural degenerative disease. At the time of the documentary he was financially well off – he could afford both medical treatment and living assistance; he had all his faculties but was losing his ability to operate his limbs…most importantly his ability to feed or drink for himself. This was an issue because once he lost his ability to ‘self-end’ he was putting at legal risk his wife; who he had no doubt would help him ‘expire’ when living was unbearable. If his wife (or any other person) helped they could be charged with a criminal offence and be sentenced to jail time. The legal pressure thus forced this man to end his life before he truly desired because he knew due to the current legal regulation he would be unable to do so later (or not without sacrificing his love-ones freedom)
<WARNING – these video is very distressing >
For legal reasons, the above video is more stop action although the audio is okay and necessary to provide context for this next video
There is strong movement to legalize assisted suicide. In the US, a number of grassroots driven laws have been enacted to provide a legal frame work for assisted suicide. One of the reasons for the success in passing these laws is the understanding that passive euthanasia is a relatively common practice now (largely by compassionate medical practitioners but also more rarely by the unscrupulous ones as well). A common term in cancer wards is ‘death by morphine’, where doctors will allow patients to be administered large doses of morphine for pain under the pretext of ‘pain management’ but with the ultimate ending of an overdose.
The law in Canada is typically, suicide itself is not an offence however to assist one in suicide is a federal crime. The Criminal Code explicitly makes it illegal to assist in the voluntary death of an individual. “Everyone who (a) counsels a person to commit suicide, or (b) aids or abets a person to commit suicide, whether suicide ensues or not, is guilty of an indictable offence and is liable to imprisonment for a term not exceeding fourteen years”. There has been a number of cases that have attempted to expand an individual’s right to ‘die with dignity’ with the most famous being Sue Rodriguez and Robert Latimer.
The American laws stress two important factors…a drawn out process of consent, so as to ensure the desire is genuine and persistent and not a whim…as well the assessment of willingness must be a group process involving the patient, doctor and several witnesses so as to ensure the desire was genuine and not coerced. I think that any law in Canada that made provisions for assisted suicide as well as self-suicide (it is important to remember that a large number of people have experienced extreme misery, pain and suffering due to ‘botched’ suicide attempts…this law could help provide people with ‘safe suicides’).
Of course on big issue is ‘how long the process’, ‘how many witnesses’ and ‘how genuine is the need’. These are complicated questions but not impossible ones. This provides us with an opportunity to use the poliskeptic method. By seeing how the current laws are working (or failing) in other jurisdictions (Oregon and Washington state or The Netherlands, Luxembourg and Colombia) and develop our own regulations. If we do nothing, we stand back and condemn people (both the individual and those forced to witness) to the anguish, pain and suffering of continued existence.