Editor's note.
The following excerpt, "The Risks of Legalization" [of assisted
suicide], is taken from a supplement produced last April 1997, by the New
York State Task Force on Life and the Law. It updated the task force's highly
influential 1994 report which was titled "When Death Is Sought: Assisted
Suicide and Euthanasia in the Medical Context." Both thoughtfully argued
the case against assisted suicide. The original report has been quoted far
and wide and was referenced last year by the Supreme Court when the High
Court refused to find a constitutional right to assisted suicide. The supplement,
which came out after the Court's decision, offered a synopsis of the dangers
that would accompany the legalization of assisted suicide.
The Ninth and Second Circuits [whose decisions were heard by the
U.S. Supreme Court last year] both dismissed the risks associated with legalizing
physician-assisted suicide as insubstantial, and claimed that, to the extent
risks exist, they can effectively be eliminated through state law or regulation.
Our concerns about the risks of legalizing assisted suicide are set forth
in detail in "When Death is Sought", and will not be restated
in depth here. We take this opportunity, however, to outline briefly the
primary risks associated with
legalization:
* Undiagnosed or untreated mental illness. Many individuals
who contemplate suicide - - including those who are terminally ill - - suffer
from treatable mental disorders, most commonly depression. Yet, physicians
routinely fail to diagnose and treat these disorders, particularly among
patients at the end of life. As such, if assisted suicide is legalized,
many requests based on mental illness are likely to be granted, even though
they do not reflect a competent, settled decision to die.
* Improperly managed physical symptoms. Requests for assisted
suicide are also highly correlated with unrelieved pain and other discomfort
associated with physical illness. Despite significant advances in palliative
care, the pain and discomfort that accompanies many physical illnesses are
often grossly undertreated in current clinical practice. If assisted suicide
is legalized, physicians are likely to grant requests for assisted suicide
from patients in pain before all available options to relieve the patient's
pain have thoroughly been explored.
* Insufficient attention to the suffering and fears of dying patients.
For some individuals with terminal or incurable diseases, suicide may appear
to be the only solution to profound existential suffering, feelings of abandonment,
or fears about the process of dying. While the provision of psychological,
spiritual, and social supports - - particularly, comprehensive hospice services
- - can often address these concerns, many individuals do not receive these
interventions. If physician-assisted suicide is legalized, many individuals
are likely to seek the option because their suffering and fears have not
adequately been addressed.
* Vulnerability of socially marginalized groups. No matter
how carefully any guidelines for physician-assisted suicide are framed,
the practice will be implemented through the prism of social inequality
and bias that characterizes the delivery of services in all segments of
our society, including health care. The practices will pose the greatest
risks to those who are poor, elderly, isolated, members of a minority group,
or who lack access to good medical care.
* Devaluation of the lives of the disabled. A physician's
reaction to a patient's request for suicide assistance is likely to depend
heavily on the physician's perception of the patient's quality of life.
Physicians, like the rest of society, may often devalue the quality of life
of individuals with disabilities, and may therefore be particularly inclined
to grant requests for suicide assistance from disabled patients.
* Sense of obligation. The legalization of assisted suicide
would itself send a message that suicide is a socially acceptable response
to terminal or incurable disease. Some patients are likely to feel pressured
to take this option, particularly those who feel obligated to relieve their
loved ones of the burden of care. Those patients who do not want to commit
suicide may feel obligated to justify their decision to continue living.
* Patient deference to physician recommendations. Physicians
typically make recommendations about treatment options, and patients generally
do what physicians recommend. Once a physician states or implies that assisted
suicide would be "medically appropriate," some patients will feel
that they have few, if any, alternatives but to accept the recommendation.
* Increasing financial incentives to limit care. Physician-assisted
suicide is far less expensive than palliative and supportive care at the
end of life. As medical care shifts to a system of capitation, financial
incentives to limit treatment may influence the way that the option of physician-assisted
suicide is presented to patients, as well as the range of alternatives patients
are able to obtain.
* Arbitrariness of proposed limits. Once society authorizes
physician-assisted suicide for competent, terminally ill patients experiencing
unrelievable suffering, it will be difficult, if not impossible, to contain
the option to such a limited group. Individuals who are not competent, who
are not terminally ill, or who cannot self-administer lethal drugs will
also seek the option of physician-assisted death, and no principled basis
will exist to deny them this right.
* Impossibility of developing effective regulation. The clinical
safe-guards that have been proposed to prevent abuse and errors are unlikely
to be realized in everyday medical practice. Moreover, the private nature
of these decisions would undermine efforts to monitor physicians' behavior
to prevent mistake and abuse.