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Assisted Dying Debate - Jimmy Akin’s Opinion - Dilbert Blog

Assisted Dying Debate – Jimmy Akin’s Opinion

Background: A few weeks ago I made a public call for a qualified person to explain to my readers why assisted dying should NOT be legal. I asked because I had never met anyone who held that opinion and I wondered if such a person even existed. (Seriously.)

Jimmy Akin (see his website) volunteered, as did some readers of this blog. Jimmy has experience explaining this very topic, he’s a skilled communicator, and several readers suggested him. He also has a deep personal connection to the topic as you will read in his answers.

What follows is Jimmy’s unedited (long!) responses to my questions on assisted dying. Based on your comments and my own reactions, I will send a few follow-up questions to Jimmy before putting this debate through what I have been calling the Rationality Engine, described in my earlier post.

At this point in my exchanges with Jimmy you will see our biases on full display. The point of the Rationality Engine is to use public scrutiny (you folks) to scrub our bias out of the topic over time. Once I publish the Rationality Engine it becomes a living document that gets updated when anyone has a better argument or new data. 

You should be skeptical of the Rationality Engine, for lots of reasons. This will be the third test of it. I believe it worked on the first two topics I ran through it. See here and here. But we are still in the test phase. Let’s see what happens.

I would love to see your comments. And I apologize if this is not entertaining for you. Sometimes the point is just to make the world a little better. 


Jimmy Akin’s Responses on Assisted Dying

1. What standard would you use to deny me the right to a painless death at the time of my choosing?

Denying people rights to painless deaths is not something I’m interested in.

Hopefully, as medical science progresses, deaths will be fewer and farther between, but, when people do die, I would love for their deaths to be painless, and I support greater efforts toward pain relief.

As phrased, the question is not relevant to the discussion at hand and needs to be framed in a more relevant way.

I hate trying to do that on my own, because a partner in dialogue could say that I have reformulated it in a way that does not reflect his view, but rather than throwing the question back without interacting with it, I’ll make a good faith effort in this direction.

The first problem is that this question confuses the issue of physician-assisted suicide with the issue of painless death. They are not the same thing. Many people have painless deaths without physician-assisted suicide, and other people may commit physician-assisted suicide without it being painless.

The second problem is the idea that one has or should have a right to a painless death “at the time of my choosing.” This description leaves out the relevant medical circumstances described in the proposed California legislation. As phrased, the question would appear to assert a right to pain-free suicide under any and all circumstances.

If that’s the intent then this should not be a debate about physician-assisted suicide but about assistance for suicide in general.

At present, California law does not prohibit suicide but it does prohibit helping someone commit it:

Every person who deliberately aids, or advises, or encourages another to commit suicide, is guilty of a felony [California Penal Code, section 401].

Since the purpose of civil legislation is to promote the common good, the legislature of the state of California appears to believe that this provision promotes the common good—and I agree.

Since the topic for this discussion is physician-assisted suicide in cases of terminal disease (as described in the text of the proposed law, online here), I’ll assume that you support the requirement that people not aid, advise, or encourage others to commit suicide in general. Otherwise, we’d be having a much broader discussion.

The present question thus is not whether you should have a legal right to kill yourself at any time but whether you should have the right to medical assistance in killing yourself upon contracting a terminal disease.

The third problem with the question is the language of “denying” someone “the right” to this assistance. This language is emotionally and conceptually charged in a way that distorts the discussion. In particular, this language attempts to slip in the assumption that a person has a right to a particular thing.

Since the law of the state of California does not provide a legal right to the thing in question, the right would presumably be a moral right.

I would then turn the question around and ask: What makes you think you have a moral right to medical assistance to kill yourself upon contracting a terminal disease?

What theory of morality and rights do you propose that supports this?

Why that right in particular and not some other?

For my part, I don’t think such a moral right exists, and, for the reasons which will be explained below, I don’t think that such a legal right should be created.

2. Explain what you mean by the “common good” in the case of assisted dying. And can you give an example from real life (as opposed to a thought experiment) where you see the common good standard applied to the satisfaction of society’s majority?

Let’s deal with the second question first, because the answer is shorter.

It seems to me that there are any number of examples where the majority of society believes that a particular policy promotes the common good better than the alternative.

To take a few examples from the U.S. Constitution, it seems to me that most Americans think that the fact that slavery is illegal promotes the common good better than having it be legal (13th Amendment). Similarly, most think that allowing women the right to vote is better for the common good than a male-only vote (19th Amendment). And most American seem to think that allowing the sale of alcohol is better for the common good than Prohibition was (21st Amendment).

As to the first question, as I am using the term, the common good includes both the good of individuals, considered as individuals, and the good of individuals considered as a group.

If only the first element is considered, the result would be individualism (giving the good of the individual primacy over the good of the group). If only the second element is considered, the result would be collectivism (giving the good of the collective primacy over the good of the individual).

Neither individualism nor collectivism promotes the common good of society. Both the good of the individual and the good of the group must be taken into account.

This is one reason why U.S. law recognizes that individuals possess rights that are not to be infringed, even when doing so would be popular with the majority.

The common good is violated in multiple ways by physician-assisted suicide:

1) In the first place, it involves a violation of the innate human dignity of the individuals who commit suicide.

This may not be obvious to everyone today. Our culture has been affected by a view that downplays or rejects the dignity of human beings. Sometimes we are considered merely collections of chemicals (“ugly bags of mostly water”) that have no intrinsic dignity.

The historic view, of course, is that we do possess innate dignity. Our present purposes do not require us to determine whether this dignity is the product of a soul or an emergent property of a complex physical system. The important thing is that the dignity is real, and so it has consequences for how people must be treated.

Ultimately, one must make a choice between the two views. We’re either ugly bags of mostly water or we’re human beings with intrinsic dignity.

If the former view is chosen then it abolishes all moral values. Objectively speaking, we would have no dignity, no rights, and it would be no more immoral to kill a human being than it would be to pop a water balloon. On this view, our lives are meaningless, and so is the debate over physician-assisted suicide. There is no right or wrong on this issue, because there is no right or wrong to begin with, and life and death mean nothing.

If the former view is chosen then human beings require respect that water balloons do not. By virtue of their intrinsic dignity, their lives mean something, and they must be respected. It becomes wrong to kill an innocent human being.

That applies to all innocent human beings, regardless of how close or far they are from their natural deaths. Just because you are older or in poorer health doesn’t mean that you have any less a right to life. You still have your innate human dignity, and so your life must still be respected.

The fact that we have intrinsic dignity has implications for our behavior toward ourselves. Just as we must respect the dignity that others have, we must respect our own dignity. This is the just love of self. It is the basis of the universal ethic of reciprocity: Love your neighbor as yourself.

Yet we can fail to show ourselves this love. It is possible to disrespect ourselves, to debase ourselves, to degrade ourselves. All of these are ways of failing to show ourselves the love and respect that we deserve on account of our innate dignity. When we do these things, people may say, “Show yourself some respect. That’s unworthy of you. Don’t settle for this. You deserve better than that.”

This principle, combined with the former one, leads to the conclusion that we need to respect our own lives, and thus in every human society, both historically and today, there is a stigma against suicide—a recognition that when suicide occurs, something is wrong, something bad has happened.

This applies when a person in good health is tempted to commit suicide, and it applies when a person in poor health is tempted to do so.

A person killing himself is not a desirable outcome. The innate human dignity that we possess demands that we seek another solution, such as treating the cause of the situation.

If a person has a disease that is causing the person physical or psychological pain that makes them want to commit suicide then the thing to do is not to get a doctor to help them commit suicide. The thing to do is to treat the causes of their situation.

Either the pain that is causing their desire to die should be treated or—better yet—the underlying condition causing this anguish should be treated.

Given the limitations of medical science at any particular time, the latter may or may not be possible, but we have arrived at a point where we have effective pain management (see below). There may be various barriers preventing it from being used in particular cases, but there again the solution is to remove the barriers, not kill the patient.

Helping patients find the relief they need better corresponds to the requirements of human dignity than helping them kill themselves. The common good is thus promoted on the individual level by helping the patient find relief.

2) Because physician-assisted suicide involves others in suicide—doctors, pharmacists, nurses, etc.—it also involves a violation of their dignity.

This is true regardless of whether they favor physician-assisted suicide. A person who becomes complicit in the killing of an innocent person—either by directly performing the killing or by assisting in it—debases himself. He violates his own dignity by violating the dignity of another.

It does not matter if the person wants him to do this. Just as torturing another person is wrong even if the other person wants to be tortured, so killing (or helping kill) another person is wrong even if the person wants to be killed.

Violating the dignity of another entails a violation of one’s own dignity.

This violation is particularly acute when the person in question is professionally charged with being a healer.

Thus the American Medical Association opposes physician-assisted suicide. Its policy on the subject states:

It is understandable, though tragic, that some patients in extreme duress—such as those suffering from a terminal, painful, debilitating illness—may come to decide that death is preferable to life. However, allowing physicians to participate in physician-assisted suicide would cause more harm than good. Physician-assisted suicide is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks.

Instead of participating in physician-assisted suicide, physicians must aggressively respond to the needs of patients at the end of life. Patients should not be abandoned once it is determined that cure is impossible. Multidisciplinary interventions should be sought including specialty consultation, hospice care, pastoral support, family counseling, and other modalities. Patients near the end of life must continue to receive emotional support, comfort care, adequate pain control, respect for patient autonomy, and good communication [SOURCE, emphasis added].

Physician-assisted suicide thus directly harms the common good on the individual level regarding physicians as well as patients.

3) In addition to the direct violations of human dignity involved in the acts of suicide and the assisting of suicide, legalizing physician-assisted suicide would produce various other problems which would further damage the common good. These would include:

  • Pressure being put on patients to kill themselves.
  • Abandonment of patients once it is determined that cure is impossible.
  • Denial of insurance payments for medical treatments when physician-assisted suicide is an option.
  • Slowing of medical progress.
  • Further damage to the ethic of life in our society.
  • Pressure being put on patients to kill themselves.
  • Abandonment of patients once it is determined that cure is impossible.
  • Denial of insurance payments for medical treatments when physician-assisted suicide is an option.
  • Slowing of medical progress.

We will explore some of these in greater depth as the discussion proceeds, but it is important to note that the argument does not depend on these factors.

Physician-assisted suicide is principally wrong because of the direct violation it involves of the dignity of patients and medical professionals, as discussed above.

3. Explain how the common good is achieved by making my grandmother suffer, against her will, for an extra month before death. How did that make things better for others?

I’m not in favor of making your grandmother suffer, against her will or otherwise.

I’m in favor of getting your grandmother the pain relief she needs in her last month of life. That will make things better for her.

Which would you prefer: A grandmother who is suffering so much that she wants to kill herself? Or a grandmother who is getting enough pain relief that she doesn’t want to kill herself?

Which situation better promotes the dignity of your grandmother?

I know what I’d want for my grandmother.

As far as how having a culture that promotes pain relief over physician-assisted suicide benefits society, we’ve already covered that in brief and will explore it further below.

4. Oregon already has an assisted dying law. What problems have you seen with Oregon’s experience?

[Note: I assume a California law would be essentially similar to Oregon, maybe with some upgrades.]

This question is better left to those who specialize in this area. The following link from the Patients Rights Council may be helpful:

http://www.patientsrightscouncil.org/site/oregon-ten-years/

Regardless of particular problems with the Oregon law, the fundamental problem with it is that it leads to people killing themselves and it makes others complicit in this act.

For the proposed text of the California law, see here:

http://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201520160SB128

For a critique of the California law, see here:

http://www.patientsrightscouncil.org/site/wp-content/uploads/2015/02/Analysis-SB-128-End-of-Life-Option-Act-02-15.pdf

5. Do you think the folks in Oregon would agree with you that their law allowing assisted dying has not worked for their common good? If not, what can you point to as an example of why they don’t understand their situation?

In regard to the first question, I’m sure that many of them would agree with me that their law has not promoted the common good. I am sure others would disagree. How many would fall into which group, I do not know. I have not conducted a poll. I suppose that you have not as well.

Even if either of us had conducted a poll, its results would be of questionable value since (a) the results of polls can be dramatically affected by the way the questions are asked and (b) I imagine that most Oregonians have not closely monitored their law or the effects that it has had. Ordinary folks in every state rarely make a close, longitudinal study of the effects of particular laws. They are too busy living their lives and trying to make ends meet.

Further, as the Patients Rights Council points out, there are significant problems with data collection regarding the Oregon law, making it difficult to determine precisely how it is functioning. Thus even people trying to follow the situation closely have difficulty obtaining the needed data.

6. Do you believe psychological anguish is “pain” in the context of end-of-life decisions about reducing pain? For example, if you are trapped in a broken body that will never improve, slowly going mad, strapped to a hospital bed, with no end in sight, do you consider this pain?

Of course. Only a monster would think otherwise.

But if I may ask, what’s with the lurid, tendentious phrasing of these questions?

I could paint the plight of the victims of such laws in similar terms (e.g., “Why do you favor a policy that would lead heartless doctors and greedy insurance companies to deny my grandmother the pain relief that she desperately needs and instead pressure her to kill herself against her will?”).

I would prefer to have a calm and deliberative discussion that sheds light rather than simply generating heat.

You mentioned in your preface having bias on both sides stripped out of the discussion as it progresses. It seems to me that such phrasing is a prime candidate for that.

7. There is legitimate concern that some elderly and disabled folks will be pushed into making an assisted death decision by caretakers seeking their own convenience, or an inheritance. Given that concern, if the law said you could include in your Health Directive an absolute ban on assisted dying options, would that reduce your concerns?

For example, I would gladly accept the risk of my family encouraging me to die early because once my family wants me dead it is time to go anyway. You, on the other hand, could put in your Health Directive that no assisted dying option can be contemplated should you become mentally feeble. You would have nearly zero risk of an unwanted assisted death at that point.

[Note: My assumption is that even if the new law in California is silent about your Health Directive, the current law would let you ban assisted dying in that document.]

I very much appreciate you saying that it is a legitimate concern that elderly and disabled folks would be pushed toward physician-assisted suicide. I think a variety of factors, including economic ones, would conspire to do just that.

The possibility of advanced medical directives prohibiting this course of action would reduce some of my concerns, but it would by no means eliminate them.

In the first place, a huge number of people would fail to even consider the question because a huge number of people do not like making end-of-life decisions. They procrastinate making them, and they either don’t make them at all or simply give someone power of attorney to make decisions for them at the last minute.

In the second place, as long as a person is not in a mentally incapacitated condition then they could change what’s in their healthcare directive, and thus pressure could be brought on them to do so when they are weak and vulnerable but still able to change the document.

In the third place, the question of whether they are incapacitated—and to what degree—would become a bone of contention. Unscrupulous individuals might thus claim that they were not sufficiently incapacitated when they were pressured to change their healthcare directive, when in fact they were.

In the fourth place, the law would continue the devaluation of the life of the individual. The degree to which the life of the individual has been devalued already is illustrated by the statement, “once my family wants me dead it is time to go anyway.” This statement is very alarming. The value of the individual is not the subject of a collectivist determination, even of one’s own family.

It is also not clear why such a determination should be limited to the proximity of natural death. Why not let them take a vote at any time and urge the person to commit physician-assisted suicide regardless of their medical condition?

If we are agreed that aiding, advising, or encouraging people to commit suicide should not be legal in general (per the California Penal Code, section 401) then there needs to be a specific reason—related to one’s medical condition, not the patience or goodwill of one’s family—why it should be legal in the proximity of natural death.

Finally, and most fundamentally, I am not concerned simply about the people who don’t want to die. I am concerned about the people who do want to die and how the act of physician-assisted suicide deprives them of their dignity and represents a failure of human compassion. These people deserve better, and we need to get them the pain relief they need.

8. Do you believe physical pain can be nearly eliminated by drugs at the end of life, and that doing so is already the common practice?

Today, pain can be eliminated by drugs, for it is possible to place someone in a medically induced coma. The fact that it is possible to anesthetize a person and then cut them open and perform major surgery on them also demonstrates this fact.

It does not appear that it is common, at this point, to place patients in medically induced comas.

This may be due to a number of factors. One of these is that many people feel that their pain is adequately relieved without this step.

It is important to bear in mind that there is a tradeoff of benefits here, and a completely pain-free existence is not necessarily what is most desirable. We all experience pain as we age, and it is easy for younger people who are still in the prime of life to imagine any future degree of pain as intolerable. And yet, as the pains associated with age and/or disease occur, we find that we can deal with them better than we thought.

Thus many individuals who could end all pain by a medically induced coma may rationally decide that they would prefer to remain conscious and experience the benefits of consciousness, even if it means living with a certain level of pain.

The fact that the vast majority of people do not commit suicide as the pains of old age come on illustrates this fact.

Another consideration that likely reduces the use of medically induced comas is hesitation on the part of physicians to prescribe them and insurance companies to fund them for purposes of pain relief.

This raises questions about whether our medical system has focused enough attention on and willingness to perform this procedure when it is the only way to bring a person’s pain level down to what that person considers tolerable.

Indeed, many have faulted our medical system for being too focused on curing the patient, irrespective of pain, and not providing adequate pain management (whether by medically induced coma or otherwise).

I saw this firsthand when my wife was dying of cancer. The nurses who were in charge of her morphine initially undermedicated her. It was only after they were informed that her condition was terminal and that she was within a few months of death (actually, it turned out to be days) that they began to give her the level of morphine that she needed to keep her pain level down. They thus, out of a false hope of a cure, failed to provide the kind of pain relief that was needed.

Rather than the two of us simply trading personal observations about the possibilities and challenges of pain management, however, let’s listen to what the American Medical Association has to say on this matter. According to the report “Physician-Assisted Suicide” (CEJA Report 8—I-93; online here; free registration req.):

Inadequate pain relief is only rarely due to the unavailability of effective pain control medications; more often, it may be caused by reluctance on the part of physicians to use these medications aggressively enough to sufficiently alleviate the patient’s pain. Further efforts to educate physicians about advanced pain management techniques, both at the undergraduate and graduate levels, are necessary to overcome any shortcomings in this area.

Pain control medications should be employed in whatever dose necessary, and by whatever route necessary, to fully relieve the patient’s pain. The patient’s treatment plan should be tailored to meet the particular patient’s needs. Some patients will request less pain control in order to remain mentally lucid; others may need to be sedated to the point of unconsciousness. Ongoing discussions with the patient, if possible, or with the patient’s family or surrogate decision maker will be helpful in identifying the level of pain control necessary to relieve the patient’s suffering in accordance with the patient’s treatment goals. Techniques of patient controlled analgesia (PCA) enhance the sense of control of terminally ill patients, and, for this reason, are particularly effective. Often, it is the loss of control, rather than physical pain, that causes the most suffering for dying patients.

The first priority for the care of patients facing severe pain as a result of a terminal illness or chronic condition should be the relief of their pain. Fear of addiction to pain medications should not be a barrier to the adequate relief of pain. Nor should physicians be concerned about legal repercussions or sanctions by licensing boards. The courts and regulatory bodies readily distinguish between use of narcotic drugs to relieve pain in dying patients and use in other situations. Indeed, it is well accepted both ethically and legally that pain medications may be administered in whatever dose necessary to relieve the patient’s suffering, even if the medication has the side effect of causing addiction or of causing death through respiratory depression.

Relieving the patient’s psychosocial and other suffering is as important as relieving the patient’s pain. When the treatment goals for a patient in the end stages of a terminal illness shift from curative efforts to comfort care, the level of physician involvement in the patient’s care should in no way decrease. Patients in these circumstances must be managed “in a setting of [the patient’s] own choosing, as free as possible from pain and other burdensome symptoms, and with the optimal psychological and spiritual support of family and friends.” Because the loss of control may be the greatest fear of dying patients, all efforts should be made to maximize the patient’s sense of control.

Accomplishing these goals requires renewed efforts from physicians, nurses, family members and other sources of psychological and spiritual support. Often, the patient’s despair with his or her quality of life can be relieved by psychiatric intervention. Seriously ill patients contemplating suicide may develop a renewed desire to live as a result of counseling and/or anti-depressant medications. When requests for assisted suicide occur, it is important to provide the patient with an evaluation by a health professional with expertise in psychiatric aspects of terminal illness.

The hospice movement has made great strides in providing comfort care to patients at the end of life. In hospice care, the patient’s symptoms, including pain, are aggressively treated to make the patient as comfortable as possible, but efforts to extend the patient’s life are usually not pursued. Hospice patients are often cared for at home, or, if their condition requires care to be delivered in an institutional setting, intrusive medical technology is kept to a minimum. The provision of a humane, low technology environment in which to spend their final days can go far in alleviating patients’ fears of an undignified, lonely, technologically dependent death [pp. 3-4, emphasis added].

9. In the United States alone, and in your lifetime, how many people do you think will be in terrible pain and wishing they had an assisted dying option?

[Note: My estimate is 100 million people over my remaining lifetime.]

We’re straying from the question of California, but that’s okay. I don’t see how it’s possible to answer this question without doing a survey that neither one of us has done.

There would need to be several preliminaries to be considered in doing such a study. Among them would be defining our terms.

Many people experience terrible pain—physical or otherwise—at points in their lives and momentarily consider suicide or at least wish they were dead.

Indeed, this is particularly common during the stresses that often accompany being a teenager, a young adult, or at a major traumatic event in life, such as the loss of a loved one, divorce, long-term unemployment, serious illness, or the midlife crisis.

Fortunately, such moments usually pass, and the person afterwards decides that it was a good thing that they did not kill themselves and that they prefer living, even if it means living through such moments.

I could see 100 million being too low a number if we’re counting people who have a brief flirtation with the idea of suicide.

I could see 100 million being far too high if we are talking about the number of people who are in a terminal condition and who would seriously pursue physician-assisted suicide.

10. In the United States alone, and in your lifetime, how many people do you think would choose an assisted death only to learn their disease has a cure just around the corner?

[Note: My estimate is 100 people.]

At least in the next few years, extraordinarily few people would fall into this category, and I wouldn’t base an argument against physician-assisted suicide on this.

For the time being, the rate at which new, dramatic cures will continue to be discovered and deployed will remain slow and thus will not impact a large number of people.

If, under an ideal scenario, medical science experiences a dramatic rise in the rate of such cures—say twenty to thirty years from now—then more people might be impacted, but it is not certain that such a rise will take place, particularly if the socialization of medicine proceeds apace in the United States and if physician-assisted suicide becomes commonplace—both of these having the effect of disincentivizing the discovery of new cures.

11. In the United States alone, and in your lifetime, how many disabled people do you think would be successfully persuaded to end their lives early for the sake of someone else’s convenience should assisted dying be the law everywhere?

[Note: My estimate is nearly zero. Too many eyes watching. I would be interested in Oregon’s experience, if known.]

We don’t know Oregon’s experience because data is not collected on this question.

I’m not sure if this question is meant to refer to people who are physically disabled on an ongoing basis and who are not terminally ill, whether it includes those who are mentally disabled in some degree but not terminally ill, or whether it includes those who are physically or mentally disabled due to terminal illness.

My answer would be the same in any case: Lots of people.

The idea that there are too many eyes watching is not accurate. I’ve seen the pressure to bring about early patient death even in situations when physician-assisted suicide was not legal.

My own wife had pressure put on her not to avail herself of the potentially lifesaving treatment options that were available to her.

I saw the way the medical professionals around her shook their heads and rolled their eyes—behind her back—when they heard that she did want to pursue them.

When confronted with the question of whether she wanted to pursue these techniques or forego them and simply die, she replied firmly: “I. Want. To. Live.”

She had the strength to say that, but how many people in a weak and vulnerable position would have the strength to stand up for themselves in that way, and how many—discouraged by those around them, with some even thinking “once my family wants me dead it is time to go anyway”—would simply give in to the death wish others have for them?

The fact is that, for all the good they do, medical professionals providing end-of-life care are not strongly emotionally invested in the survival of the patient. They can’t be, or it would tear them apart emotionally. They maintain professional detachment, and at some point they conclude that the patient isn’t going to be getting better and may start feeling that it would be better for the patient to just die.

And it isn’t just medical professionals who think this way. The patient’s own family members feel the pressure of seeing their loved one suffering and wishing that the person was no longer in pain.

I know what that’s like. I’ve been there.

In my case, I was absolutely determined to make sure that my wife got all the medical care she wanted to have, and I made sure she did.

But I know the pressure that people are under as they watch their loved one suffer, and I know how human frailty can cause people to falter and even put pressure on a loved one to go ahead and die, even if that’s not what the loved one wants.

Incidentally, my wife’s experience occurred in the early 1990s, when the culture of death was far less advanced and when physician-assisted suicide was not legal anywhere in the United States.

It also occurred in Arkansas, a state not known for being pro-euthanasia.

If my wife could have pressure put on her in early 1990s Arkansas to allow her life to end earlier than it otherwise would have then you can bet that the same psychological dynamics among medical professionals and family members would cause pressure to be put on lots of people were physician-assisted suicide legal.

And many, at their most weak and vulnerable, would give in.

Personally, I prefer living in a world where the AMA, the Catholic Church, and disabled rights groups fight for the value of life. That creates a powerful counter-force against slipping toward a culture that is casual about life and death matters.

Agreed! And heartily so!

That said, would you be comfortable with the law allowing assisted dying as an option while the major opposition groups hold to their legitimate concerns about the process?

No, I wouldn’t be comfortable with that, for the reasons given above.

And let’s say the groups I mentioned encourage people to opt out of the assisted dying option in their Health Directives. One could further imagine the law in California requiring Health Directive instructions to include opposition opinions from the mentioned groups.

Would that scenario meet the common good standard, given that everyone gets heard, everyone gets the option they want, and the value of human life is always put center stage in the process?

The proposed scenario—which amounts to a kind of informed consent for physician-assisted suicide—would be better than a situation that did not require informed consent, but it would not be sufficient to ensure the common good.

It is not a sufficient condition for the common good to offer everyone the option they want in a particular situation, whether it’s physician-assisted suicide or anything else. Many people want options that would harm themselves, other specific individuals, or society as a whole. In fact, most of us probably want such options at different times.

The whole point of having legal prohibitions on things is to prevent such options from being exercised.

Consider the regulations that exist on the purchase of weapons. Regardless of what one might think about gun control, given the amazing destructive power of some weapons (nuclear, chemical, biological, kinetic kill, etc.), I think virtually everyone would agree that certain, highly destructive weapons simply should not be available for purchase by the general public, even with informed consent, training requirements, etc. Having those weapons commercially available to the general public would not promote the common good. Yet some people (e.g., terrorists, or people who just think it would be cool to own a nuke) might want to purchase these weapons. Thus, giving everyone the option they want, plus informed consent, is not a sufficient condition for promoting the common good.

I pick this example because it’s a clear one that I expect we can both agree on, and it illustrates the principle that informed consent is not sufficient for the common good.

The proposed scenario for informed consent before physician-assisted suicide thus would be slightly less bad than a scenario without informed consent, but neither would promote the common good.

12. Some have argued the slippery slope case. If you share that view, can you give examples in which the slippery slope actually happened for the worse?

[Note: I will be arguing that the slippery slope argument is not credible in any debate.]

If you’re claiming that slippery slope arguments are never credible in debates then I will be very curious to see how you argue this.

There are slippery slope situations in life. Sometimes they are engineered deliberately. Several decades ago, anti-smoking advocates wanted to exclude smoking from public life (and private life, too, though we aren’t there yet). They knew that society would never tolerate the kind of smoking bans that we live with today, and so they began by advocating only what they proposed to be sensible smoking bans in certain areas (e.g., hospitals). They did this with an eye to gradually increasing the scope of these zones and the strength of the bans, and they’ve been very successful.

Similarly, gun control advocates know that there is no chance of enacting a nationwide gun control ban any time in the near future. As a result, they have sought to pass what they propose to be sensible gun regulations (e.g., “assault weapon” bans) with an eye toward gradually expanding these and hopefully one day passing a more general, nationwide ban.

Also, pro-life advocates do not presently have the ability to pass a nationwide ban on abortion. They therefore attempt to protect what children they can with an eye to gradually protecting more and more.

One can see the kind of efforts described above as good or bad things, but they are attempts to engineer slippery slope situations.

And these are not secret attempts. Various advocates of these positions have indicated what their long term, desired goal is and that their current efforts are meant to be interim, incremental measures that will hopefully bring about a gradual change in public opinion, allowing their longer-term goals to be achieved.

This is not to say that all advocates of the present restrictions on these topics have such long-term goals. Some may want to stop with present restrictions or not go much further, but the point is that there are people attempting to engineer slippery slope situations, and sometimes they achieve significant success (as in the case of anti-smoking advocates).

Since this is a known phenomenon that is admitted by different types of activists, it would seem difficult to claim that slippery slope argumentation is always irrelevant in any debate.

It is thus worth asking whether such a situation might apply in the present debate: Is physician-assisted suicide meant to be an incremental measure leading to something else?

An obvious thing that it might be meant to lead to is full-blown euthanasia, whereby doctors wouldn’t just provide the means of suicide to others but would actually perform mercy killings.

It also might be meant to lead to a broader social and legal acceptance of suicide, to the development of a right to a painless suicide—perhaps one taxpayers would be expected to pay for.

Or there could be a desire on the part of some advocates to lead to a situation in which euthanasia would be used for eugenic purposes.

In fact, some advocates of physician-assisted suicide probably do have such broader goals in mind. Whether a substantial number do, or whether they would be successful in achieving such goals, longer term, is another matter.

In its report on physician-assisted suicide, the American Medical Association has this to say about slippery slope concerns:

Permitting physician-assisted suicide opens the door to policies that carry far greater risks. For example, if physician-assisted suicide is permitted, then there is a strong argument for allowing euthanasia. It would be arbitrary to permit patients who have the physical ability to take a pill to end their lives, but not let similarly suffering patients die if they require the lethal drug to be administered by another person. Once euthanasia is permitted, however, there is a serious risk of involuntary deaths. Given the acceptance of withdrawal of life-sustaining treatment by proxies for incompetent patients, it would be easy for society to permit euthanasia for incompetent patients by proxy.

The Dutch experience with euthanasia demonstrates the risks of sanctioning physician-assisted suicide. In the Netherlands, there are strict criteria for the use of euthanasia that are similar to the criteria proposed for physician-assisted suicide in the United States. In the leading study of euthanasia in the Netherlands, however, researchers found that, in about 28% of cases of euthanasia or physician-assisted suicide, the strict criteria were not fulfilled, suggesting that some patients’ lives were ended prematurely or involuntarily. In a number of cases, the decision to end the patient’s life was made by a surrogate decision maker since the patient had lost decision-making capacity by the time the decision to employ euthanasia was made [p. 4].

I think these concerns are reasonable. However, my argument against physician-assisted suicide does not depend on there being slippery slope considerations.

My point is that physician-assisted suicide is wrong in and of itself and should not be legal because of the harm it would do directly and immediately to patients and medical professionals, not merely because it might lead to worse situations in the future.

[Update: The following questions added from comments.]

13. How do you weigh the elements of “common good”? When something is good for one and bad for another, how do you compare?

This question is of a general nature, so I’ll keep the answer on the level of general principles. Additional details would need to be specified to relate it directly to physician-assisted suicide.

As we’ve noted, the common good requires more than just providing good things for the multitude. It also requires respecting the dignity and rights of individuals.

As a matter of principle, every person is equal and has equal dignity and equal innate rights. Nobody is intrinsically more important than anyone else.

How what’s good for one is to be weighted and compared with what’s bad for another will depend on what good and what harm we’re talking about.

If performing a specific act would, let’s say, provide a modest economic gain to Person A but violate the right to life of Person B then the action would be immoral. One person’s modest economic gain does not trump another person’s right to life.

Even if a modest economic gain were to be given to many people, it would not trump a fundamental right like the right to life. Thus, you could not deliberately murder an innocent person in order to economically advantage a large number of people.

It is only after the intrinsic rights of individuals have been respected that extrinsic goods (like money) come into play.

The situation described above is not a direct parallel to the situation of physician-assisted suicide, but it illustrates some of the principles involved in relating the good of one to the harm of another.

14. What does “Do no harm” mean in an era when medical science can keep you alive and imprisoned in your own body indefinitely? Is that not harm?

We’re not yet in an era when medical science can keep you alive indefinitely. There are still firm limits on the human lifespan, though there are situations in which people can be kept alive for a long time while experiencing a serious medical condition.

I assume that it’s this kind of situation that the inquirer refers to, since normally we don’t feel imprisoned in our bodies. Having a body is simply what it means to be alive. It isn’t a matter of being imprisoned.

But there are situations when we are suffering to the point that we might feel imprisoned. In this case, it is the suffering that causes this experience.

Living while suffering is not a new and separate form of harm, independent of the suffering itself. If the suffering were removed then the sensation of imprisonment would be removed as well. Living while suffering minus the suffering is simply living.

The question thus reduces to the issue of suffering and pain management. If someone is suffering such that they feel imprisoned—whether this suffering is physical or psychological—then the thing that needs to be fixed is the suffering. The patient doesn’t need to be killed.

As the American Medical Association points out:

Requests for physician-assisted suicide should be a signal to the physician that the patient’s needs are unmet and further evaluation to identify the elements contributing to the patient’s suffering is necessary. Multidisciplinary intervention, including specialty consultation, pastoral care, family counseling and other modalities, should be sought as clinically indicated [op. cit., p. 5].

15. If someone is brain-dead, would you keep them alive for the common good?

The subject of brain death is problematic. If a person really had a dead brain—one in which there is no metabolic activity and thus one decaying in their skull—then no, I wouldn’t use artificial means to keep the rest of their body functioning metabolically.

However, the term “brain death” is not used to refer to this literal state of affairs. Instead, it has been used metaphorically to refer to states of affairs that fall short of this. As such, it is a prejudicial term that has a tendency to skew the discussion by making it sound as though a form of death has occurred when this is not clear.

At present, the subject of “brain death” is too subjective and ill-defined to be philosophically or legally useful. What the term means and how we can know when its conditions are fulfilled needs to be further explored.

As a result, the question would be answered differently, depending on the way brain death is defined. If it is defined in some ways then the dignity of the person, and thus the common good, might require supplying them the things needed for life (at a minimum, nutrition and hydration—i.e., food and water).

On the other hand, if brain death is defined in such a way that the brain is not maintaining the life functions of the rest of the body then it would not be necessary to preserve those functions. Allowing them to cease would be morally permissible.

16. My personal observation, and that of others, is that pain management at the end of life is a myth unless you want the patient unconscious. Old people are not good at advocating for their own pain relief. Do you believe pain relief is achievable for all people in the real world?

Please see the discussion of pain management above for a general treatment of the subject.

In terms of the present question, I can’t speak to the personal experience of the inquirer, but the idea that pain relief is a myth at the end of life unless unconsciousness is induced seems clearly false. Many people die with little or no pain (e.g., the classical case of “dying peacefully in one’s sleep”).

Others experience greater degrees of pain, but still degrees that can be successfully treated by modern pain management techniques.

It is true that some individuals experience pain that can only be satisfactorily treated by inducing unconsciousness, but this is far from the universal experience, and dismissing other forms of end-of-life pain management as “a myth” seems patently false.

As to whether pain relief is achievable for all people in the real world, this question could be taken in a way that falls into an absolutist, “if even one person” position.

Politicians may like to demagogue issues by saying “If X happens to even one person, that’s too many,” and such claims may even be true. For example, it’s true that if even one person is murdered, that’s too many. However, “if even one person” arguments famously lead to bad policies that do more harm than good.

For example, suppose someone argued, “If even one person is murdered by a knife, that’s one too many, therefore, we must ban all knives.” This argument ignores all the good that knives do.

The same would be true if someone argued, “If even one person dies in a car crash, that’s too many, so we must ban all cars.” This argument ignores all the good that cars do.

In both cases, the proposed policies would do great harm to society. They would, in fact, cost more lives than they saved, because knives and cars are often essential to saving lives (think: surgery and ambulances).

“If even one person” arguments allow the perfect to become the enemy of the good, and thus they tend to cause more harm than good.

This would be the case if one were to argue that if pain relief isn’t achievable for all people in the real world—i.e., if even one person doesn’t get the pain relief that is desired—then we should have a society-wide policy of allowing physician-assisted suicide.

Such an argument would miss the various ways that such a policy would harm society, both directly and indirectly. As always, it would harm society most directly by violating the dignity of the individuals so killed.

Finally, if—as the inquirer says—“old people are not good at advocating for their own pain relief,” then the solution is to provide better pain-management advocates for them. Not point them toward suicide.

Further, if they aren’t good at advocating for the pain management they need then how do you expect them to stand up to pressure from medical professionals and loved ones who want them to quietly kill themselves?

If this argument proves anything, it proves too much. If old people are already in danger of those around them not providing them the pain relief that they need because they aren’t good at standing up for themselves then we should not create a situation where those around them may pressure them to commit suicide.

17. Does the Catholic Church teach the sanctity of life or reverence for life? The latter would suggest that you could end your life in a dignified fashion. The former does not.

I haven’t argued anything in this discussion on religious grounds, since not everybody is religious—much less Catholic. People of multiple faith perspectives, or no faith perspective, can be opposed to physician-assisted suicide, as illustrated by the opposition of the American Medical Association to the practice (the AMA not being a group with any faith position, and one composed of members who have all kinds of faiths—or none).

That being said, the Catholic Church teaches both the sanctity of human life and reverence for human life. The two are not in opposition. If human life is sacred then it must be revered. Reverence is the natural response to the sacred.

I gather that the inquirer is using the terms somewhat differently. It seems clear, though, that the inquirer wishes to draw a distinction between two ways of treating life, one of which would allow one to “end your life in a dignified fashion” and the other of which would not.

This raises the question of what ending one’s life in a dignified fashion means. In the present context, the language could be seen as euphemistic and misleading.

Nobody is interested in depriving people of dignity as they die. We all want to do whatever we can to protect and enhance the dignity of the dying.

The phrase “ending your life in a dignified manner” appears to mean killing oneself as an alternative to dying naturally, with suffering depriving the natural death of dignity.

From a Catholic perspective, this has matters backwards. Suffering does not deprive one of dignity. However, killing oneself violates the innate dignity that a person has. It is contrary to the just love of self. People who are driven to kill themselves by intense suffering deserve better.

Compassion and respect for human dignity demand that we address their suffering and, to the extent possible, its causes.

Killing oneself is always a tragedy, and especially so when there is an alternative, such as the one provided by modern methods of pain management.

As a society, we shouldn’t settle for suicide as a solution to this problem. We can do better, and that is true from any faith perspective—or none.

18. If people choose assisted death often enough, could it reduce the amount of efforts that go into curing those problems?

Absolutely! It not only could reduce them, it would reduce them.

The advancement of medicine is driven by the need to treat and cure people of their health problems. If you eliminate the people who have the health problems, you thereby eliminate the incentive to improve medicine.

Why bother going to the difficult work of finding and developing a cure if there is the simple alternative of getting rid of the patient?

Just imagine all of the medical treatments we have today that would not exist if we had simply used euthanasia on all the people who suffered from them in the past.

If we were, today, to simply euthanize everyone in certain medical situations then there would be no further research on treating or curing those conditions.

Thus, to the extent that physician-assisted suicide becomes popular, it will have a corresponding and diminishing effect on the progress of medicine. We may still get medical progress, but it will be less than it otherwise would be.

This highlights one of the ways in which physician-assisted suicide and other forms of euthanasia are harmful: They put the emphasis on killing the patient rather than curing the disease.

However, while physician-assisted suicide would harm the progress of medical science, this is not the principal reason that it is wrong. It is principally wrong because it directly violates the dignity of the individual and thus the common good.

—- End of Jimmy Akin’s comments —

What do you think? And be nice. Jimmy is gutsy to be part of this and his intentions seem exactly right to me. I hope you respect that.

Scott

@Scottadamssays