The following articles include discussions of the ethical and philosophical ideas behind this issue.  Is there a right or wrong answer?  What is the motive behind the desire to legalize such actions?  Two notable writers address these aspects of the debate.

Death with Aesthetics

By Wesley J. Smith (Source)

We don’t speak plainly in public discourse anymore. Rather, we equivocate and deploy euphemisms to sanitize our debates. Take the passing of Brittany Maynard by her own hand, which the media has repeatedly characterized as an act of “dignity.” To be sure, Maynard died with human dignity—but not because she committed suicide. Human dignity is intrinsic. Indeed, to accept the premise of suicide as death with dignity says—or at least strongly implies—that patients who expire naturally die with indignity.

When we look more deeply at arguments in favor of legalizing assisted suicide, we see that the assisted suicide discussion is really more about what I will call the aesthetics of dying than it is about potential pain. This is no small matter. Nor is it in the least a frivolous concern. Worries about lost looks or, perhaps, how the sick room might smell can be devastating to those approaching the end of life.

Indeed, our self-esteem—and perhaps more important, how we perceive that others view us—can materially impact our mental and emotional states as we approach the end of life. (For example, I used to be a hospice volunteer. One of my patients became so distraught by his changed appearance that he covered all the mirrors in his home.)

Maynard’s evocative explanation for eschewing hospice in favor of suicide illustrates how potent aesthetic fears (if you will) can be:

I considered passing away in hospice care at my San Francisco Bay-area home. But even with palliative medication, I could develop potentially morphine-resistant pain and suffer personality changes and verbal, cognitive and motor loss of virtually any kind.

Because the rest of my body is young and healthy, I am likely to physically hang on for a long time even though cancer is eating my mind. I probably would have suffered in hospice care for weeks or even months. And my family would have had to watch that.

It is worth noting that Maynard fixated on a worst-case scenario. Indeed, many with brain cancer die peacefully, their symptoms well managed and their pain controlled.

Along this same line, she told Elite Daily:

Not only do I want to save myself from that fate [of suffering and decline], but I love my family too much to make them carry the memories of my deterioration for the rest of their lives.

Yes, Maynard was worried about suffering. Who wouldn’t be? But she seemed even more intent on not forcing her family to suffer by witnessing her loss of beauty, vitality, and capacity.

This is how the assisted-suicide movement hurts the very people it claims to champion. During my years working with hospice, I was struck by how my patients would focus intently my [sic] face when we first met. I soon realized they were seeking assurance of acceptance. For sick, disabled, disfigured, and dying people, our faces can be like mirrors: If they sense that we think they are less than “we” are, it can crush the spirit. Yet, isn’t this the very message conveyed when we validate suicide as the “dignified” way to die?

I saw the impact of such advocacy with my last hospice patient, Robert Salamanca, who died of Lou Gehrig’s disease. This was in the late 1990s, when a case was before the Supreme Court (unsuccessfully) seeking the legalization of assisted suicide.

As with Maynard, the media went into a feeding frenzy, presenting emotional and highly publicized profiles of ALS patients who wanted “to die with dignity.” These programs made Bob’s burden much harder to carry. “They are trying to drive me from the well-lit boulevards into the dark alley!” he told me angrily after watching such a feature on Nightline.

Bob was so incensed by these attitudes that he wrote a column—typing it one letter at a time, using the only finger he could still control—for the San Francisco Chronicle. From “I Don’t Want a Choice to Die,” which ran on February 19, 1997:

Euthanasia advocates believe they are doing people like me a favor. They are not. The negative emotions toward the terminally ill and disabled generated by their advocacy is actually at the expense of the “dying” and their families and friends. We often feel disheartened and without self-assurance because of a false picture of what it is like to die created by these enthusiasts who prey on the misinformed.

Supporting assisted suicide, Bob insisted, disrespected his dignity by denying the value of his life:

Many pro-euthanasia groups “showcase” people with ALS. They portray us as feeble, unintelligible and dying by slow suffocation. This is absolutely false, and I protest their efforts vehemently. . . . We are not people just waiting for someone to help us end our misery, but to the contrary, we are people reaching out to love—to be loved—wanting to feel life at its best.

He concluded:

In my view, the pro-euthanasia followers’ posture is a great threat to the foundation upon which all life is based, and that is hope. I exhort everyone: Life is worth living, and life is worth receiving. I know. I live it every day.

Bob died peacefully—with dignity—in his sleep. I was honored to give his eulogy.

There is no question that Maynard’s perspective is integral to the assisted-suicide debate. But Salamanca’s should be, too. Ultimately, his view accords more with the true meaning of human dignity and the intrinsic value of all our lives.

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Bioethicist: Why not allow non-doctors to offer assisted suicide for profit?

By Michael Cook (Source)

Assisted suicide is an idea which keeps evolving in unpredictable ways. Who could have foreseen the development of groups of non-doctors which help hundreds of people to die in Switzerland? They are non-profits and charge only for membership and handling fees. But what if companies saw a commercial opportunity in the market for ending one’s life?

Almost everyone finds the notion utterly repugnant, including ardent supporters of assisted suicide. If funeral homes offer creative services for the already dead like drive-through viewing and car-shaped coffins, imagine what tacky deals they would dream up for the about-to-be dead. If you have any doubts about this, check out the options at Golden Gate Funeral Home, an innovative service in Dallas catering for African-Americans.

Now a bioethicist from the University of Tübingen in Germany has pointed out that “commercially assisted suicide” (CAS) – paying a non-doctor to kill patients – is a logical development of physician-assisted suicide.

Roland Kipke argues in the leading journal Bioethics that there are no ethical arguments against CAS which cannot also be deployed against physician-assisted suicide (as in Oregon). It is not a popular cause, as the thought of CAS horrifies both supporters and opponents of assisted suicide.

Kipke rolls out several arguments which support CAS. It is not a breach of medical ethics because no doctor is involved. A for-profit provider will be more readily available than a doctor, who may have qualms of conscience.

He takes a very sceptical view of the competence of doctors. A commercial provider may not be skilled at detecting depression, but neither are doctors:

“The most common psychiatric disorder, and, at the same time, the disease that is most commonly associated with suicidal intentions, is depression. Several studies clearly show that a large number of physicians fail to recognize the depressive disorders of their patients. This is particularly remarkable because people with depression account for about 10% of a GP’s patients…. Therefore, it is not justified to say that doctors are in general particularly able to assess the conditions for an autonomous decision for suicide.”

Nor are doctors particularly competent at prescribing adequate doses of drugs to commit suicide.

“a doctor does not normally learn (in education and medical practice) how many grams of sodium pentobarbital cause a quick death. Above all, the necessary knowledge about the correct dosage is limited and can easily be acquired by non-physicians.”

Kipke feels that patients would have more autonomy in making their final decision if they use a commercial provider.

“Studies have shown that doctors’ assessment of the quality of life and of the suicidal wishes of seriously ill patients depends significantly on the psychological situation of the doctors themselves, and that they systematically underestimate the quality of life of their patients. Quite a few doctors also advocate directive counselling, even on morally controversial issues. It is probable that this is not fundamentally different with regard to their decisions for or against suicide.”

Finally, would CAS be another step forward in the demeaning commercialisation of human life? Not really, says Kipke. “Doctors always earn their living from the needs of their patients: no one takes offence.” Why not a commercial provider of death services?

I detect an element of savage satire in Kipke’s dry academic prose. His modest proposal is not so much a trial balloon for CAS as an attempt to prove that legalised physician-assisted suicide must inevitably lead to commercial assisted suicide. Denying this, he argues, is quite illogical.

“… there is not a single ethical reason that speaks persuasively only against CAS. Either the arguments do not apply to CAS, or they do apply but equally or even more so to PAS … To reject CAS while endorsing PAS is, therefore, not ethically justifiable: it is not a coherent ethical position. Therefore, the position of the liberal advocates of PAS has to be revised. Either they have to expand their advocacy to include CAS and therefore radicalize their position considerably or they have to revise their rejection of some arguments that are generally raised against assisted suicide.

Perhaps it is a good argument to deploy in a debate. If commercial suicide services are too dangerous, what evidence do you have that physician-assisted suicide is any less so?