While the blogosphere has erupted into justified joy and admiration of NASA’s success in landing the Mars rover, Curiosity, on the red planet, which has occasioned so much exultation at human achievement, I have chosen to highlight an achievement of another sort: namely, the publication in a Charleston newspaper of a remarkable article on assistance in dying. Few newspapers have achieved this level of understanding or support for something that more and more people, despite the almost universal religious condemnation of assisted dying, are coming to recognise as an important human right. Nevertheless, in recognition of NASA’s achievement, here is a picture of the “sky crane” landing operation that was undertaken late on a Martian afternoon, which happened without a hitch, so we are told. Just imagine! Sending tons of equipment millions of miles and setting down a one ton nuclear powered vehicle without damage, after slowing it down from 20,000 kilometres an hour so that it could land gently on the surface of the planet (as in the artist’s rendition below).
Bill Thompson, who has been a feature writer for the Charleston Post and Courier since 1980, publishes a remarkably thoughtful, insightful, and positive article on what he calls “elective” or self-chosen death. Taking his inspiration from South Carolina author Richard Côté, and his new book, In Search of a Gentle Death: The Fight for Your Right, Thompson’s article — entitled “Are our lives our own? The ethics of ‘elective death’” – goes into some detail defining the different types of elective death, from assisted suicide to euthanasia, and is one of the very few writings on this topic that appears to understand the simple truth that pain and suffering at the end of life is sometimes not able to be controlled, even with all the wonders of modern medicine. Indeed, as Thompson points out, it is the fact that we are surrounded by such wonders that has brought us to the point at which we have arrived, where not only do people die more and more often in institutional situations, but where the ability to keep people alive has brought about vastly increased and increasing demand for the right to a self-chosen death.
As the bioethicist Dr. Robert Sade, of the Medical University of South Carolina puts it:
I think that 5- to 10-percent of end-of-life pain that can’t be controlled is an overstatement. Nevertheless, it does happen. And when life becomes unbearable … it should be permissible for people to end their lives.
Unfortunately, though, as Richard Cote points out, only a small minority of people have access to, or can afford, palliative care. In Canada, so far, this fact cashes in in terms of politicians’ demand that no assistance in dying be provided until everyone in the country has access to adequate palliative care, meaning that those who are suffering now will be forced to pay the price in suffering for the failure to provide palliative care services for all Canadians, even when it is well-known that even with palliative care services some people will find suffering at the end of life intolerable.
Another thing that Bill Thompson acknowledges in his article is something that is often simply hidden behind soothing words about the capabilities of modern palliative medicine to deal with all the pain and suffering of the dying. José Pereira, whose article, published in Current Oncology last year, on the illusion of safeguards in the application of laws governing assisted dying in the Netherlands and Belgium (available here), has been thoroughly debunked by Jocelyn Downie, K. Chambaere, and J.L. Bernheim (available here), suggested that there are no symptoms that cannot be controlled by palliative medicine. Refractory symptoms, Pereira suggested, can always be controlled by means of palliative sedation, if all else fails (Pereira, 4). But this ignores something that Thompson chooses to highlight in his article; namely, that pain is not the only refractory symptom in need of palliation. According to Dr. Bert Keller, a bioethicist who retired from the Medical University of South Carolina in 2005.
[t]here is pain that we call physical and pain that is mental or emotional, but the line between them is often blurred. Pain is subjective. When a person really is experiencing such pain that appears to be of a more existential kind, I’d want to determine first if that patient is not suffering from situational depression or not under the influence of some psychoactive substance that could be altering their reasoning process.
But if such a person has gone through counseling and been checked to see what’s going on, my answer would be, yes, it is their decision.
This is an aspect of suffering that is often simply overlooked in discussions of assisted dying. People may suffer severe existential breakdown towards the end of life, which not only intensifies physical pain, but can make life itself an intolerable burden, especially with the indignities that accompany the worst symptoms of the physical disintegration of the body. Dying can be a horribly complex reality which may include the stench of unhealable wounds, the vomiting of fecal matter, uncontrollable incontinence, and other signs of bodily decay and deterioration — states of the body which the anthropologist Julia Lawton calls “unboundedness”, and which many people experience as intolerable indignity. As I was writing this I received an email from a physician in the United States who very kindly expressed his support for my “cause of compassion and support for those who are literally tortured by their own body or disease or degenerative disorders.” This is precisely the point. People are, more often than we would like to think, tortured by their diseases and by their experiences while dying, and they are forced by law to undergo this torture in the name of beliefs which most of us no longer share, and even when we do, may not wish to honour in our final days.
Which leads us inevitably, to the religious perspective on assisted dying, which Bill Thompson does not neglect. However, just in the language used by the Roman Catholic theologian whom Thompson consulted on the ethics of assisted dying, what religion has to say is shown to be largely irrelevant to the larger question of the right of persons whose end-of-life suffering has become intolerable, to receive assistance to die in ways consistent with their own beliefs and priorities. Before coming to the Rev. Jeffrey Kerby’s views, however, it is worthwhile considering the following claim about assisted dying made in a brochure produced by the National Catholic Bioethics Center (available here):
Euthanasia has been defined by Pope John Paul II,* in The Gospel of Life [the encyclical Evangelium Vitae, available at the Vatican site here], as “an action or omission which of itself and by intention causes death, with the purpose of eliminating all suffering.” Supporters of euthanasia often justify it or physician-assisted suicide on the grounds that the pain of terminal illness is too great for the average person to bear. They hold that it is more merciful to kill the suffering patient. The Pope, as representative of Christ on earth, holds that “euthanasia is a grave violation of the law of God, since it is the deliberate and morally unacceptable killing of a human person.” It is a fundamentally unreasonable act. [my italics]
*Pope Wojtyła. Wikipedia has now added, to the article about Wojtyła, that he is sometimes now called “John Paul the Great”! The presumption of the religious never ceases to amaze me!
That, of course, is a bald lie. Supporters of euthanasia do not justify it “on the ground that the pain of terminal illness is too great for the average person to bear.” What supporters of assisted dying claim is simply that suffering is sometimes too great to bear — not for average, weak, or people described in some other specific way, but simply that for some people suffering can become intolerable, and when it is, the option for assistance in dying should be open to them. Catholics always deliberately get this wrong. Their arguments are almost always deliberately misleading as to the basis of support for assisted dying, because from the Catholic point of view it is always wrong. Indeed, unaccountably, the National Catholic Bioethics Center, as we have just seen, considers it to be an irrational act.
Nonetheless, let’s get on with Jeffrey Kerby’s views:
I would argue [he says] that dignity is endowed by our creator, and we must follow the natural cycle that our creator has established. One must let the natural process of life take its course. But to actively assert ourselves in that process is not to respect the design of nature. [my italics]
One only needs to read this in order to see that it is absurd. Quite aside from the fact that the word ‘dignity’ is clearly here just marking time; if it is wrong to “assert ourselves” in the natural process, and “must let the natural process of life take its course,” as Kerby says, unthinkingly, then it must be wrong to cure disease, reduce pain, or do anything else to divert the natural course of things. This is something that Hume pointed out to happy effect in his article “On Suicide,” though natural law ethicists take exception to his claim. But if Kerby is right, then we must, like the animals of the field, simply suffer and die without intervention of any kind. And then, to add absurdity to absurdity, Kerby runs off with the hounds by bringing in the perspective of faith:
St. Paul would tell us that whether we live or die, we are the Lord’s. Often, without that perspective, a person can come to any number of conclusions, particularly when suffering is involved.
When we understand our lives are not our own, we understand that there is a dignity that has to be respected even in the dying process. The active taking of one’s life is never permissible morally, but to allow the body to follow through in the natural process of dying is permissible, and sometimes even expected.
Having said this — which we are supposed, I think, to see as enlightened and progressive — Kerby immediately goes on to say that some people would be surprised at how flexible the church can be in these matters. But if it is all as stupid as this, what difference would this supposed flexibility make? Not only can reflections such as these have no bearing on what people may be allowed to do in a secular democratic society, it is not clear that they make any sense at all. Using an arbitrary marker such as what is or is not “natural” (whatever that is taken to mean) to distinguish between permissible and impermissible actions is to say exactly nothing. Using an aspirin is to assert oneself in respect of a natural process — a headache, perhaps — so speaking of “natural” death is as meaningful as speaking of “natural” headaches. There is more theology going on behind the scenes, but no one ever tells us what it is. How is natural death unlike natural headaches, in such a way that it makes sense to say that interventions to assist people to die with the least amount of pain are unlike interventions to help people to control the pain of their headaches, so unlike as to be forbidden? No answer is forthcoming.
Not one thing that is said by Catholics can make assisted dying seem like an unreasonable choice, when life has become an intolerable burden. Richard Côté points out that there is not one negative word about suicide in the Bible, although there are seven instances of suicide recorded in it. Most Christian denominations condemn it, and not only, as Côté says, conservative ones. Buddhists do not. For Islam and conservative Jews suicide is forbidden outright, but, according to Côté, when
death is imminent and pain is inescapable, many devout religious believers put aside religious dogma and opt for the most practical ways they can to deal with their imminent fate.
What is reasonable in end-of-life situations depends a lot on whose point of view you take. Saying, as the National Catholic Bioethics Center, located in Philadelphia, does, that suicide is always an unreasonable act, is a bit of nonsense masquerading as religious truth. The people who jumped from the Twin Towers on 9/11 did so to escape a worse end than they would otherwise have suffered, and probably did so to escape being consumed by fire. We may regret the situation that enforced this choice upon them, but no reasonable person can say that what they did was unreasonable. So, too, the act of someone in the face of intolerable suffering at the end of life, whether that suffering be that of physical pain or existential disintegration and the multiple indignities that may consume one at the end of life, cannot simply be labelled unreasonable or irrational. To use the word ‘dignity’ so that it refers to all human life without exception, even to that life which is experienced by the individual as a cruel contradiction to one’s dignity as a person, is merely to misuse the word as though it were in itself, whatever the context, a token of real meaning. As Hobbes so poignantly said:
… words are wise men’s counters, they do but reckon by them; but they are the money of fools, that value them by the authority of an Aristotle, a Cicero, or a Thomas, or any other doctor whatsoever, if but a man. [Leviathan, Part I, Chap. 4]
Theologians are most guilty of that kind of use of langauge, counting on the authority of the context to give their words weight and meaning. Did Bill Thompson count on us seeing through the hollowness of Kerby’s ”reasoning”? I think so; at least, I hope he did. The rest of the article is too perceptive for him simply to have missed the emptiness of Kerby’s theological wordplay.
Other good things about Thompson’s article include the deflation of the old canard about slippery slopes. Bert Keller, whom we met above, says that he doesn’t
see that [slippery slopes] as a worrisome thing. I don’t think slippery slope arguments are compelling arguments. I don’t have that fear.
And almost nothing is said about the risk to vulnerable people. This is good, because that argument (if it can be called that) ignores the fact that the dying are themselves, by any reasonable standard, vulnerable, and using vulnerability itself as an argument against assisted dying, is to exploit the vulnerability of the dying in a brutally cynical way. But as to whether assisted dying should be put into the hands of physicians, as is common in Europe: on this Thompson appears to share the hesitation of Richard Côté, who thinks “that physician-assisted suicide is improper and should not be done.”
That is, however, a peculiar restriction. It was argued in the House of Lords in 1936, for example, that laws regarding euthanasia were not required because physicians know when it is time to assist patients on their way, and laws are not necessary to regulate a medical practice that was already accepted as a part of normal medical care. There are, in my view, strong reasons why doctors alone should not govern the practice of assisted dying. There may be conflict of interest involved. Religious scruples may make assisted dying inaccessible to some. And, while physicians are well-placed to assess the suffering of individual patients, it is the patient’s experience of suffering that should govern whether or not suffering is intolerable, not the external judgement of someone else, however knowledgeable.
Of course, as in Switzerland or Oregon, physicians need not necessarily be the ones to administer the drugs. In the case of assisted suicide, the patients themselves administer the drugs, as Elizabeth did in Zürich. Euthanasia, when the person is unable to administer the necessary drugs by their own action, may add complications, but since many doctors already help their patients to die, even in situations where it is illegal, there seems little reason to exclude physicians from those entrusted with providing assistance for patients to die. Indeed, the attitude of physicians to assisted dying will become, for many, if not most, patients, an important criterion for choosing a doctor as one’s own general practitioner or specialist. Not only will physician participation in assisted dying not be a basis for mistrust between doctor and patient — something frequently argued by those who are opposed to assisted dying – a physician’s refusal to participate in or support assisted dying will become, in time, I suspect, a strong reason to distrust that person’s willingness to provide comprehensive and compassionate care.