By Eric Pavlat
The topic of physician-assisted suicide, or PAS, is a confusing and heart-wrenching issue for many. In some ways, it can touch us more personally than abortion, as we are all likely to face difficult end-of-life choices at some point, whether for ourselves or for a loved one. We have to navigate Church teaching on bioethics; where science advances quickly, the Church ruminates deliberately, and almost no one is an expert. For this reason, we are often hesitant to speak to others about PAS.
But culture isn't standing still around us. The courts are setting precedents—as with the Terri Schiavo case in Florida—and the mass media are doing their best to promote assisted suicide as a heroic act of self-determination, as in the recent Oscar-winning film Million-Dollar Baby. We need to talk openly about this phenomenon before the media, the courts, and the legislatures go any further. And we must be able to engage those who disagree with the Church's position on PAS—more often than not, Democrats.
As I mentioned in "How to Talk to Democrats about Abortion: Five Strategies for Making the Pro-Life Case" (October 2005), the most important step you can take in any conversation is to pray for your interlocutor. After prayer, locating common ground outside the PAS issue is crucial. Whether on the topic of national security or the local sports team, any kind of agreement can greatly diffuse an otherwise difficult "us vs. them" situation. As a result, you are much more likely to be considered reasonable—and to be listened to as a result.
But before charging into battle, it's important to be familiar with the facts necessary to make your case. Following are a few points that will help you on your way.
A Crash Course in the Debate
It's important to understand the distinction between the terms "assisted suicide" and "euthanasia." The former describes a situation where the doctor (or some other agent) provides the means for a patient to commit suicide, but the patient follows through on the final act himself. Euthanasia, on the other hand, is carried out from beginning to end by a doctor on the patient's behalf.
In the wake of the Schiavo case, there was much debate over the question of care for the severely handicapped or terminally ill, and what exactly those appropriate levels of "care" were. At the base level is ordinary care—generally speaking, that which any prudent person would administer in similar circumstances. It could include keeping the room at a comfortable temperature, providing attentive human contact, and ensuring that the patient has enough to eat and drink. Ordinary care is considered mandatory by the Catholic Church.
Proportionate treatment (or proportionate means), which is also mandatory, is any medical action that meets all of the following three criteria: (1) It has a reasonable chance of curing the patient or assisting with the cure; (2) it does not carry a significant risk of death; and (3) it does not, in and of itself, present an excessive burden. For example, a sterile blood transfusion during surgery would be considered proportionate treatment, as the risk and burden involved are relatively low compared with its curative potential.
Disproportionate means, on the other hand, are not mandatory. If any treatment would present an excessive burden—in terms of finances, emotions, religious beliefs, or the pain of the procedure—or fail to offer a reasonable chance of curing the patient, it is optional. Withdrawing disproportionate treatment is an act that, according to Dr. Kathleen Foley, former chief of pain service at Memorial Sloan-Kettering Cancer Center, "respects [the] patient's autonomous decision not to be battered by medical technology" ("Competent Care for the Dying Instead of Physician-Assisted Suicide," New England Journal of Medicine). There comes a time when continued attempts to cure are neither compassionate, wise, nor medically sound.
Palliative care refers to the alleviation of pain or other symptoms, though some expand the definition to include the provision of mental, emotional, and spiritual support. A caregiver is required to offer palliative care—or at least pain management—as far as he is able, but it is not mandatory for a patient to accept. In fact, as Pope John Paul II said in The Gospel of Life, it is even "licit to relieve pain by narcotics, even when the result is...a shortening of life, 'if no other means exist.'
The issue of artificial nutrition and hydration is not fully defined; the question is currently being examined by the Magisterium, but the most recent pronouncement came from John Paul II himself in March 2004, when he stated that it is immoral to remove a feeding tube from anyone in a persistent vegetative state, calling it "euthanasia by omission." Outside of a vegetative state, however, there are situations where a feeding tube would become burdensome and thus constitute disproportionate care—as in the case of a person dying from advanced stomach cancer—so these decisions must be made prudently on a case-by-case basis.
For more information on this issue, visit www.euthanasia.com. For frequent updates on current court cases and legislation, check www.internationaltaskforce.org, and www.lifenews.com/bioethics.html. Once you've been armed with the latest facts and information, you're ready to begin the discussion.
Strategy No. 1: Oppose the Status Quo of End-of-Life Pain Management
First, we must recognize a basic truth: Patients in our medical system often have insufficient access to pain relief. Therefore, it's vital to support increased patients' rights, including access to health insurance, a choice in doctors, the latitude to see an independent specialist, open access to all of one's personal medical records, and the right to use palliative treatments. It's equally important to support the right of doctors to manage their patients' pain properly without fear of government interference and prosecution.
The issue of pain is an emotionally striking one, so it's comforting to know that pain can be controlled. According to a report by the New York State Task Force on Life and the Law titled When Death Is Sought: Assisted Suicide and Euthanasia in the Medical Context, "Modern pain relief techniques can alleviate pain in all but extremely rare cases." In fact, according to Dr. Eric M. Chevlen, the director of palliative care at St. Elizabeth Health Center in Youngstown, Ohio, "90 [percent] of cancer patients in pain can have dramatic relief with relatively simple oral therapies." Dr. Chevlen is also the author of the book Power Over Pain: How to Get the Pain Control You Need (International Task Force, 2002), a useful resource for those suffering due to a lack of proper palliative care. The American Pain Foundation estimates that with today's technology, "close to 98 [percent] of all pain problems can be relieved or reduced."
But most doctors have never actually studied pain in any detail. According to Pain Net Inc., "Of all pain practitioners, fewer than 10 [percent] are proficient in more than eight out of 130+ diagnostic or therapeutic procedures relative to pain." For this reason, it's important to advocate a greater focus on pain in medical schools and continuing-education courses in pain management for all medical doctors, especially those frequently involved in end-of-life situations. We can also urge recognition for patients' rights to see pain-therapy specialists (which some health-care plans are trying to restrict).
What cannot be accepted is the notion that assisted suicide is a form of comfort care. Dr. Gregory Hamilton, the chair of Physicians for Compassionate Care, put it bluntly in an article in the Oregonian: "Comfort care results in a comfortable patient; assisted suicide results in a corpse."
Strategy No. 2: Emphasize the Need to Diagnose and Treat Depression
One of the chief arguments for PAS appeals to the American ideal of autonomy. The desire for self-determination resonates strongly with many Democrats, and they believe that the denial of these rights is un-American.
Of course, a love of personal freedom is not unique to Democrats, and it's easy for anyone to agree that we should have the freedom to live our lives as we see fit. But that freedom must come with restrictions. For example, child pornography is illegal in America—even in the privacy of one's home—and no judicious person would consider it a permissible use of our freedom. Clearly, Americans acknowledge the need to limit certain behaviors. The question is, what actions should be permitted or restricted?
The issue of autonomy assumes that the person attempting to exercise his personal freedom can make decisions in a rational manner. But in fact, when it comes to requests for PAS, rational decision-making is rarely in play. Suicidal feelings in a person who has been diagnosed with a terminal illness are no different from those experienced by someone who isn't terminally ill. Depression, family conflict, hopelessness, feelings of abandonment—these are the conditions that lead to suicidal thoughts, regardless of one's physical state.
According to the British Journal of Psychiatry and the New York State Task Force, between 93 and 95 percent of those contemplating suicide have a diagnosable mental disorder, most commonly severe depression. Is mental disorder also in play for the terminally ill who request suicide? One study in the American Journal of Psychiatry reported, "All of the patients who had either desired premature death or contemplated suicide were judged to be suffering from clinical depressive illness; that is, none of those patients who did not have clinical depression had thoughts of suicide or wished that death would come early." The New York State Task Force report states that "depression accompanied by feelings of hopelessness is the strongest predictor of suicide for both individuals who are terminally ill and for those who are not." It is depression or other mental illness, not one's physical condition, that makes a person suicidal.
Pain plays an obvious part in this—diagnosable anxiety and depression, for example, are higher in cancer patients with pain. Not only is uncontrolled pain an important risk factor for suicide, in that it contributes to hopelessness and depression, but depression and anxiety can often augment the patient's experience of pain. This brings us back to the need for pain therapy.
The New York State Task Force report notes that "the notion of competence to make treatment decisions, or the capacity to make a particular decision...presumes that the patient is not clinically depressed." In the presence of clinical depression, there can be no true autonomy, no ability to make a rational decision or a clear, objective request for death.
The good news is that mental illness, once diagnosed, is treatable. In a 1992 article for American Medical News,suicidologist Dr. David C. Clark observed that depressive episodes in the seriously ill "are not less responsive to medication" than episodes in those who are not.
The same opinion is held by Dr. Joseph Richman, former president of the American Association of Suicidology, who wrote in a letter to the editor of the Journal of Suicide and Life-Threatening Behaviour, "Effective psychotherapeutic treatment is possible with the terminally ill."
And in testimony to the New York State Task Force in 1992, Dr. William Breitbart of the Memorial Sloan-Kettering Cancer Center agreed, reporting that more than 80 percent of their patients diagnosed with major depression can be treated effectively. The New York State Task Force report puts the number even higher, saying "treatment for depression resulted in the cessation of suicidal ideation for 90 percent" of patients.
Finally, it's important to remember that the desire for suicide is often transient. In a study published in the Journal of the American Medical Association, the cases of 886 people who were rescued from attempted suicides were followed over a five-year period. At the end of those five years, only 34 had since taken their own lives.
Where there is depression, there is no true autonomy. Treating patients for pain and depression, as well as other mental illnesses, can eliminate suicidal desires by giving the patient more control. In that way, we can help them achieve self-determination instead of self-destruction.
Strategy No. 3: Oppose Discrimination Against the Disabled and the Poor
If any one element has stopped PAS bills and ballot measures from becoming the law of the land, it has been the public efforts of activist groups for the disabled such as Not Dead Yet. While groups like the former Hemlock Society (now named Compassion and Choices) were founded on the belief that some lives were "not worth living" and that they were doing a service to the disabled by expanding their autonomy to include a "right to die," this kind of attitude actually betrays a prejudice against the disabled—one that would inevitably make the "right to die" a "duty to die."
This sort of prejudice is already seen on the opposite end of the spectrum in the abortion debate. Dr. Anthony Vintzileos, a board member of the American Institute of Ultrasound Medicine, estimated in a May 2005 article for the New Jersey Record that 90 percent of women who receive a prenatal diagnosis of Down syndrome for their children choose to abort. People with disabilities are considered to have no real quality of life, nothing to contribute, and nothing to live for.
The poor are also potential targets. Already receiving substandard medical care, the impoverished will be the last to ask for a second opinion, the first to see themselves as worthless, and the most likely to be dismissed as having nothing to contribute to society. If an authority figure were to counsel a poor person to ease the financial burden of medical care on his family through PAS, it would be difficult to say no.
Democrats largely identify themselves as friends of the underdog and protectors of the weak. What better way to open their eyes to the injustice of PAS than by pointing out the potential for victimization of the disabled and poor at the hands of an often profit-driven health-care industry?
Strategy No. 4: Examine Data from Europe
At this point, your interlocutor will likely argue that "Doctors would never do that," or that there should be guidelines to make sure that this victimization could never take place. The best response is simply to have a look at euthanasia in Europe (including its legal form in the Netherlands).
Many familiar with the history of euthanasia recognize that the idea was a natural outgrowth of social Darwinism, where the strong survive and the weak are left behind. According to the New York State Task Force report, "The practice of mass murder in Nazi Germany...began with the active killing of the severely ill, and built upon earlier proposals advanced by leading German physicians and academics of the 1920s.... Like policies currently advocated in the United States, these proposals were limited to the incurably ill, and mandated safeguards such as review panels." R. J. Lifton, author of The Nazi Doctors: Medical Killing and the Psychology of Genocide, is quoted in the report as saying that the phrases "life unworthy of life" and "killing as a therapeutic imperative" were vital in soothing the public's conscience when it came to the Nazi program of genocide: "The medicalization of killing—the imagery of killing in the name of healing—was crucial to that terrible step."
It's ironic that the Netherlands—whose doctors once refused the Nazis' genocidal agenda—is now the site of the most extensive assisted suicide and euthanasia program in the world. Though euthanasia was not legalized in the Netherlands until 2002, it was commonly practiced well before then, with almost no danger of prosecution for the doctors performing it. The International Task Force on Euthanasia and Assisted Suicide reports that, according to the Dutch government–sponsored "Remmelink Report" examining death rates in Holland from 1990:
• 2,300 people died through voluntary euthanasia
• 400 died through assisted suicide
• 1,040 died through involuntary euthanasia—euthanasia was performed without the patient's knowledge or consent, even though 72 percent of those patients had never indicated any desire for it
• 8,100 died from a deliberate overdose of pain medication to hasten the patient's death, though in 61 percent of these cases the patient gave no consent.
Of the estimated 130,000 deaths in Holland in 1990, 9.1 percent were the direct result of assisted suicide or euthanasia. And given that these numbers were voluntarily provided by doctors at a time when euthanasia was still technically illegal, it's likely that the actual number of deaths through euthanasia was even higher. According to a February 1999 article in the Journal of Medical Ethics, almost 59 percent of euthanasia cases in Holland in 1995 went unreported, in clear violation of the guidelines in place. However, not a single Dutch doctor was prosecuted under the criminal charges of euthanasia, assisted suicide, or anything related.
Euthanasia was technically illegal but not prosecuted in the Netherlands for more than a decade. Today, those over 16 can be euthanized for any reason; in certain circumstances, those as young as twelve can opt for euthanasia. Currently, the Netherlands is considering allowing euthanasia for infants, though some Dutch doctors have openly admitted to euthanizing infants already. Those who believe there is no "slippery slope" need to take another look.
And while some may argue that the situation in the Netherlands at least offers patients more options when faced with end-of-life decisions, the reality is just the opposite. Hospice care—palliative centers that make up an important component of end-of-life treatment—is practically nonexistent in Holland. England, for example, had 183 hospices in 1999. The Netherlands, with a quarter of England's population, had only three. Clearly, with such easy access to euthanasia, little effort is expended to offer alternatives to end-of-life pain management when it's not as cost-effective as a quick death.
What does this have to do with the United States? Dr. Herbert Hendin, executive director of the American Suicide Foundation, made the connection clear in his 1996 testimony before Congress, wherein he declared that Dutch "patients and doctors...see assisted suicide and euthanasia, intended as an unfortunate necessity in exceptional cases, as almost a routine way of dealing with serious or terminal illness. The [American] public has the illusion that legalizing assisted suicide and euthanasia will give them greater autonomy. If the Dutch experience teaches us anything, it is that euthanasia enhances the power and control of doctors who can suggest it, not give patients obvious alternatives, ignore patients' ambivalence, and even put to death patients who have not requested it."
This is the "safety" that guidelines provide, as both history and current events have borne out. If we were to open the doors to PAS in the United States, a brave new world of involuntary euthanasia would be inevitable.
Strategy No. 5: Oppose Profiteering by Managed-Care Providers
If assisted suicide were legalized, managed-care providers would inevitably embrace it as a money-saving technique. The New York State Task Force report states that "under any...system of health care delivery...it will be far less costly to give a lethal injection than to care for a patient throughout the dying process." A 1998 study conducted by Dr. Daniel P. Sulmasy in the Archives of Internal Medicine found that doctors who are cost-conscious and practice resource-conserving medicine were six times more likely to write illegal, lethal prescriptions for their terminally ill patients. Dr. Diane Meier, a former advocate of assisted suicide, said in a 1998 New York Times article, "Legalizing assisted suicide would become a cheap and easy way to avoid the costly and time-intensive care needed by the terminally ill."
Substantiating this claim is the fact that Oregon's Medical Assistance Program (OMAP) for the poor moved to provide physician-assisted suicide to its recipients as soon as the Death with Dignity Act was passed in 1997. Only 18 months later, the OMAP announced plans to cut back on pain medication coverage for the same population. Hospice care has also suffered—the International Task Force reports that one Oregon insurance company has a paltry $1,000 cap on in-home hospice care. With the cost of a lethal overdose running about $35, there would be little motivation to pay any more for palliative treatment.
If this is how a liberal, Democratically controlled state government behaves, is there any doubt how profit-minded managed-care providers would react if assisted suicide were legalized throughout the United States? We would begin to see a new stratification of society, where the under-insured would be advised to settle for assisted suicide, while those with better insurance could get the medical assistance they needed. According to the International Task Force, "If policies or laws permitting assisted suicide are approved, assisted suicide could become the only type of 'medical treatment' to which certain people—those who are members of minority groups, those who are poor, or those who have disabilities—would have access. The last to receive health care would be the first to receive assisted suicide."
The Dead End of Assisted Suicide
Legalizing assisted suicide could send us down a road from which there is no return. We can do far more to aid suffering patients by improving pain management and mental health care through legislative reform than we can by legalizing their self-destruction. Euthanasia, in practice, almost inevitably becomes eugenic in nature, which is an affront to the disabled and a serious threat to the lives of the poor and unwanted. Further, the decriminalization of assisted suicide and euthanasia in Europe has produced horrific results that no sane nation would want to imitate.
It's a noble impulse that drives Americans to help those struggling through illness and decline, but we can't let the desire to ease another's suffering lead us to believe that there are quick fixes or easy answers in euthanasia. Instead, we must respond with love, prayer, and compassion—not with murder. As John Paul II wrote in Evangelium Vitae, "True 'compassion' leads to sharing another person's pain; it does not kill the person whose suffering we cannot bear."
Surely, the truly compassionate Democrat must agree.
Eric Pavlat is a convert from pro-choice agnosticism whose conversion story was printed in Surprised by Truth 2 (Sophia Institute Press, 2000). He is a board member of Democrats for Life of Maryland, Inc.
Printed with permission from Inside Catholic.