Leon Kass, the chairman of the President's Council on Bioethics, opens Thursday morning's council meeting with an apology. The council has been trying to broaden the discussion of moral issues related to aging, he says. It prefers thoughtful, humanistic exchanges to hot-button issues like the one it's about to discuss. He sounds like a parent announcing at dinner that due to exceptional circumstances, dessert will have to be served before vegetables tonight—but don't expect this to happen again. How embarrassing. I was planning to skip the thoughtful, humanistic sessions that follow this one. They're titled "Long-Term Care and New Patterns of Decline," "Assessing Outcomes in Medical Care," and "Ends and Priorities in Medical Care." If I were a better humanist, I'd endure them. But I'm getting old just thinking about it.
The whole reason I came to this session is that it's a hot-button issue. If they serve dessert first, eat it. The speaker is Herbert Hendin, medical director of the American Foundation for Suicide Prevention. The topic is legalized assisted suicide and euthanasia in Oregon and the Netherlands. The patients in question are old folks, and Hendin looks the part. He credits the colleague who prodded him to begin investigating these issues. The colleague is now dead.
But looks can be deceiving. The administrators of assisted suicide in the Netherlands opened their doors and files to Hendin, expecting him to like what he saw. Oops! He didn't. He describes the Dutch system as a slippery-slope nightmare. Most Dutch doctors have suggested or feel free to suggest euthanasia to their patients. Some patients are pressured into it by the presentation of ugly alternatives. Most terminations aren't reported. Nobody can second-guess what the doctor did, because the other party to the alleged agreement is dead. Several thousand people are terminated by physicians each year without giving consent, says Hendin. He quotes a doctor who said he euthanized a patient because "it would have taken another week before she died, and I just needed this bed." You know doctors—they feel competent to decide anything. In the Netherlands, this now includes deciding when you should die.
Worse, says Hendin, the Dutch experiment didn't improve the care given to people at life's end. Palliative and hospice care got worse, because euthanasia and assisted suicide became easier options. The Dutch like to point out that their suicide rate fell, but Hendin projects numbers on a screen to show that the suicides were more than replaced by a rise in assisted suicides and euthanasia. The increase stopped recently, he notes, when the Netherlands began to improve hospice and palliative care.
The Oregon story is a bit different. Oregon doesn't limit assisted suicide to patients who are suffering. All you need is a prognosis of six months or less to live. The reporting form has one line to attest that the patient is terminally ill and one more line to summarize the diagnosis. Nothing else has to be reported. Few patients who request assisted suicide are referred for psychiatric evaluations to screen out remediable depression. Few are referred for palliative care consultations to explain how their suffering might be relieved short of suicide. If your family doctor won't approve your request, supporters of assisted suicide know where to find a doctor who will. Oregon has done a good job of training nurses in palliative care, but few hospitals provide such care, and one study shows the percentage of inadequately treated pain cases has increased since legalization. Some experts think cuts in state reimbursement to doctors for palliative care have encouraged a bias toward assisted suicide.
Hendin thinks the option to end life weeds out the morally firm doctors and corrupts the weak. In Oregon, he found family doctors who had assisted in one or two cases and were so upset that they stopped participating. The doctors who had done five or 10 cases were less troubled. They'd become "hardened," he says.
That's the bad news. The good news is that physicians' support for euthanasia or assisted suicide drops by two-thirds as they learn more about psychiatric screening and palliative care. Too many don't know about the latest techniques to relieve suffering. Too many don't know that depression is separable from terminal illness and can be cured. They don't know that under these conditions, most people who initially want assisted suicide decide against it. Hendin says a bunch of doctors who've recently been trained in palliative care now publicly regret some of the suicides they assisted. Once you show that suffering can be relieved without killing, almost nobody chooses killing.
This is music to the ears of several conservatives on the council. They expected assisted suicide to sweep the country. But if Hendin is right, council member Peter Lawler concludes excitedly, the opponents will win, because "in the long term, the truth is on our side." Hendin agrees. "If you don't have legalization for 10 or 15 years, there's a good chance the issue will become irrelevant," he says. "No suicide prevention measure for the elderly would be more effective than good end-of-life care." The conversation turns political. Hendin analyzes the states in play and notes proudly that nine states have recently banned assisted suicide. He describes his advocacy in Hawaii and gives the council pointers in how to spin the issue. You're not trying to take away a right, he explains. "You're giving them a right that they don't have"—the right to palliative care. "How you frame it seems to have a great effect on what happens," he says.
The more philosophical conservatives are wary of this approach. Kass and council member Gil Meilaender worry that it buys into a therapeutic mindset. They question the diagnosis of sadness in terminally ill people as treatable depression. Meilaender's view is simple: Dying sucks. "That's a good reason to be depressed," he argues; there's no reason to "feel chipper about it." He prefers a moral approach, telling patients that while it's natural to wish for death, they ought not act on that wish. Hendin, the doctor, turns the tables. Depressed people are deadened to such moral considerations, he says. So, while it's natural to wish to tell them they ought not kill themselves, you ought not act on that wish.
The more Hendin explains about assisted suicide, the more it sounds like the early history of legalized abortion—the networks of sympathetic doctors, the allegations that they've become hardened to killing, the simultaneous public feeling that the practice shouldn't be prosecuted but shouldn't be encouraged, either. The resemblance disconcerts me. The practice of regulating abortion has proved much uglier than the concept. Hendin wants cases more thoroughly reported to the state. He wants them reviewed by more doctors and hospital committees. Women seeking abortions used to go through that. It was phony and degrading. How many doctors and bureaucrats do you want signing off on your plea for a fatal dose?
Hendin says a study in Oregon showed that people who asked for assisted suicide when it was illegal had "an inordinate need for control." He's seen the same pattern in other suicidal patients. Alfonso Gomez-Lobo, one of the council's conservatives, suggests that depression robs these people of autonomy, and maybe this argument could sway libertarians. Hendin agrees: "One of the key features of depression is an inability to see alternatives." But he thinks the chief distortion is ignorance of palliative care, which makes people think they have to choose between suffering and suicide. "That's not much of a choice," he says.
I've heard this line of argument from abortion opponents, too. The woman doesn't really want the abortion; she's been pressured by her boyfriend or her family or the abortion industry. She doesn't know her baby's heart is beating. She doesn't know that a crisis-pregnancy center can take care of her and the baby. Sometimes it's crucially true. But more often, the moral certainty that no woman would freely choose abortion leads pro-lifers to deny autonomy in the name of protecting it. If you tell the doctors and bureaucrats that you aren't depressed and you really want the pills now so you can choose when to end your life, will they second- and third-guess you? Will they say it isn't the real you talking?
It turns out they already do. According to Hendin, the common first reaction of people who become quadriplegic is to wish for their own death. If you ask to be taken off the respirator, the law says hospitals have to comply, but they don't. They've learned from experience that if they can stall you long enough to free you from dependence on the respirator, you'll have changed your mind. "So they tend to ignore the law, and nobody complains afterwards," he says. Same goes for terminal illness: If they can stall you long enough to relieve your symptoms, you'll be willing to go on living.
Maybe. I like the idea of making relief possible without killing. If technology made possible the termination of pregnancy without killing—by transferring the fetus to an artificial womb, for example—I think I'd go for a ban on fetal killing. If similar technology exists for terminal illness, shouldn't assisted suicide remain illegal? Still, something troubles me about the distrust that permeates Hendin's analysis, right down to ballot measures, which he opposes because "people aren't informed." In suicide, the only life at stake is your own. And while the real you may not be the you who speaks through a fog of depression or medical ignorance, it sure as hell isn't somebody else.