One of the issues that comes up repeatedly in debates over death-accelerating medication for the terminally ill, as that description probably makes clear, is terminology. Advocates of legislation like California’s SB 128 do not like to see the word “suicide” associated with their proposal. It’s “physician assisted death,” “death with dignity,” or, in the words of SB 128 co-author Senator Bill Monning, a “peaceful and compassionate transition.”
Those who oppose such legislation, on the other hand, almost always describe the act as a form of suicide. The coalition of groups fighting SB 128 in fact call themselves “Californians Against Assisted Suicide” (CAAS). Their web address is “http://noassistedsuicideca.org.”
If you ask advocates why they resist the term suicide, they say it’s a question of definition. Suicide, by their argument, is a choice to kill yourself that involves some sort of mental impairment such as depression or mania. Says Senator Monning, “We’ve talked against ‘physician assisted suicide’ because that’s a clear medical diagnosis of an irrational act.”
Advocates are not proposing that depressed people should be able to act on their depression, but rather that sick people in their right mind shouldn’t have to keep suffering. “I don’t have a suicidal bone in my body,” insisted Brittany Maynard, the 29-year-old terminally ill Californian who advocated for such legislation before her death. “I don’t want to die. If anyone wants to hand me a magical cure and save my life so that I can have children with my husband, I will take them up on it.” It’s hard to argue with that.
And legislation like SB 128 also requires that those who would consider such a step must be mentally competent. In California, candidates would have to be examined by two separate doctors who would each have to confirm the patient has less than six months to live and is of sound mind. If either doctor were to have any concerns about the mental condition of the patient, the person would have to be evaluated by a psychologist.
Of course, none of this is as simple as it sounds. As Executive Director of the California Catholic Conference Ned Dolejsi points out, psychological evaluation occurs only if insisted upon by one of the physicians, who do not themselves have expertise in psychology. “Doctors are telling us, we don’t want that responsibility,” says Dolejsi. “Their job is not to make sure you’re in the right state of mind, their job is to deal with your health care.”
There are also stories where this system has failed. (When it comes to assisted suicide, you quickly discover that everyone has their horror stories.) CAAS points among others to the story of terminally ill 85-year-old Kate Cheney, who wanted to die in Oregon, where the procedure is legal (and requires only one physician). Her physician refused. A second physician provided by her managed care provider ordered a psychiatric evaluation. The evaluation found that Ms. Cheney, who had early dementia, lacked “the very high level of capacity required to weigh options about assisted suicide.” She was denied.
Her daughter insisted her mother be evaluated by a second psychologist. Though that psychologist worried that Ms. Cheney’s “choices may be influenced by her family’s wishes,” he gave Cheney the go ahead.
Requiring two separate physicians to sign off on someone’s mental state could alleviate some of that problem, but it doesn’t address Dolejsi’s broader point about the competence of those physicians to make such an assessment in the first place. (And to be clear, these physicians need not work in relevant fields, like oncology or gerontology. Does it really make sense that the state would allow an anaesthesiologist, gynecologist or urologist to evaluate someone’s psychological condition?)
It’s also true that there is political upside in avoiding the term "suicide." Compassion and Choices, the national advocacy group for death with dignity legislation, trumpets a 2014 Gallup poll that found that as of 2013, 70 percent of Americans were in favor of some form of physician assisted death. But check the actual poll and you discover that percentage drops to just 51 percent when the word suicide is used. A year later, it was 69 percent versus 58 percent; a year prior, it was 64 percent versus 53 percent.
Perhaps 2014 represents the start of a greater comfort; but in general, whether instinctively or based upon reflection, people seem to resist legislation that mentions suicide.
There’s a larger social concern here, as well. Yes, for those terminally ill patients who undertake it, physician assisted, medically-accelerated death may not have the motivation of other suicides. Rather than a function of being depressed, it may be a choice borne out of an honest assessment of reality.
But such choices don’t take place in a vacuum. And allowing some people to end their lives may have unintentional, dangerous effects on others who are are suicidal.
That sounds like fear mongering—another frequent tactic on both sides of this debate. But suicide contagion, the phenomenon in which one person taking their life can trigger others to try to do so, is a documented fact. Indeed, in my discussions with Compassion and Choices, board member Reverend Ignacio Castuera actually noted the terrible string of suicides that have been plaguing the Stanford University area since October.
And in 2013, a study of the Centers for Disease Control and Prevention documented that suicides among people 35-64 increased a staggering 49 percent in Oregon in the years from 1999-2010, as compared to 28 percent nationally. Oregon’s Death with Dignity Act began in 1997.
Are we to assume that’s just coincidence? Castuera argues that “correlation is not causality.” He hypothesizes that it could be Oregon’s weather, or the number of poor people in the state, or the number of veterans. Or it’s just the state of our country: “It’s not an unintended consequence of the law. It’s a preexisting characteristic of America.”
Toni Broaddus, Compassion and Choice’s California Campaign Director, notes again that the terminally ill enabled by the bill have vastly different motivations than those who commit suicide, and thus they are not likely triggers for those who are suicidal. “To me it’s like apples and oranges.” But one’s motive has nothing to do with whether you’re a trigger for others.
Maybe it doesn’t matter what we call this procedure. There does seem to be something a bit cruel about opponents insisting on the term at this very difficult moment in these people’s lives. It’s inflammatory—rarely a recipe for a thoughtful conversation. And Broaddus is right, in many cases this is apples and oranges.
But what should concern us is how such legislation might affect other fragile members of our community—the depressed and often the young—for whom suicide is a very real threat. We might not intend a law like SB 128 to send the message that ending your life is okay, that sometimes human life really is less meaningful and worthy of support. But if people receive the law in that way—and the evidence from Oregon seems hard to simply write off—such legislation poses a whole other very serious health problem that must be taken into account.