As the movie “Me Before You” shows, assisted suicide is marketed most often through the story of one person in tragic circumstances, who decides to end their life, supported by compassionate friends tearfully cheering them on.
One death may not appear to significantly impact public policy, society or healthcare, but when a state decides to legalize assisted suicide as official public policy, it introduces new and powerful incentives and disincentives for all others. As Colorado and Washington D.C. contemplate assisted suicide measures, this is a good time to count the costs of such drastic societal change.
Three stokes this life-and-death issue fears that all of us will likely face: fear of uncontrolled pain, fear of catastrophic health care costs, and the fear of abandonment, isolation, or loneliness during illness. These fears are stoked by the myth that there are two and only two alternatives: uncontrolled suffering or merciful death.
The public debate typically imagines the case of a terminally ill patient who is imminently dying. But that is not reality. Dramatic incentives for doctors, patients, family members, healthcare institutions, insurers, and society will be inevitably created, and perhaps impossible to limit, when suicide is merely another “healthcare” option. And the cost of care will be weighed against the inconvenience of living.
Case in point: Stephanie Packer, a 31-year-old mom who could get suicide drugs for a co-pay of $1.20, but was denied coverage for chemotherapy to treat her auto-immune disease. Her story should be a cautionary tale for those claiming easy access to death will cause no social catastrophe.
First, there will be incentives to broaden the available class of patients. It is impossible to legalize assisted suicide for just one individual, although that is the way assisted suicide is typically marketed. Law doesn’t work that way. Assisted suicide would have to be legalized for a class of patients, and it is impossible to coherently limit that class.
Most of the criteria used to define the class are heavily subjective. The notion of terminal illness is really a social definition, not a medical definition. Doctors have data about the probability of death but not the certainty. Yet, doctors will be the ones doing the monitoring based on subjective criteria.
Although limiting the class to the terminally ill seems a simple guideline, in fact, discussions of pain and suffering as criteria for assisted suicide opens the door to many who are not dying, which is precisely the thrust of the movie “Me Before You.”
And if a “right” to assisted suicide is created, government officials are not going to be able to limit the reasons for the right, or have the motivation to do so. Look no further than more than 40 years of abortion policy for proof, for while it was sold to the American people for reasons of rape, incest and the life of the mother, in fact, abortions can legally occur through all 9 months of pregnancy for any reason or no reason at all.
Secondly, legalizing assisted suicide will create disincentives to properly diagnose and effectively treat depression in the chronically ill and the terminally ill. Many patients who make a request for death are suffering from a clinically diagnosable mental illness, which if effectively diagnosed and treated, will often result in the patient revoking their request for death.
Obviously, one solution should be access to good counseling.
Cases in the Netherlands demonstrate that depression is no longer seen as a mental illness needing diagnosis and treatment for those requesting death. Instead, it is considered a legitimate reason for requesting death.
Third, legalizing assisted suicide will create disincentives against developing and providing palliative care. The worst part of the proposal to legalize assisted suicide is involving the medical profession to “sanctify” the process, and that’s why doctors are always involved in marketing assisted suicide.
Medical ethics have traditionally focused physicians on healing and alleviating suffering.
As one hospice physician emphasized, “only because I knew that I could not and would not kill my patients was I able to enter most fully and intimately into caring for them as they lay dying.” We should not strip away that ethic by legalizing assisted suicide.
Fourth, legalizing assisted suicide will create enormous incentives against regulation. The Dutch experience demonstrates the futility of reliance on legal regulations to maintain limits. The practice of euthanasia has moved from the terminally ill to the chronically ill, from untreatable physical illness to cases of treatable psychological distress, and from voluntary euthanasia to involuntary euthanasia. The incentives will be toward making sure that every patient has the fullest access to this new right and option, inevitably creating pressure on all patients. And without proper regulation, these deaths will be cloaked in secrecy.
Fifth, legalizing assisted suicide will create incentives against alternatives for the chronically and the terminally ill as the least costly treatment for any illness is lethal medication. Great Britain, where assisted suicide is prohibited, has many palliative care centers, while the Netherlands, where assisted suicide is legalized, has few. If assisted suicide is always available, and always the cheapest option, why invest in new treatments and medical procedures?
Legalizing assisted suicide for any will undermine healthcare for all. In order to maintain the highest quality healthcare that will serve the most people and relieve the most suffering, society must focus on improving the care of the suffering individual while refusing to legalize assisted suicide.
Attorney Clarke Forsythe is Acting President & Senior Counsel at Americans United for Life (AUL) Action, and author of Abuse of Discretion: The Inside Story of Roe v. Wade (Encounter Books 2013).