In the New York Times this morning Ezekiel Emmanuel has a short op-ed piece entitled “Four Myths about Doctor-Assisted Suicide“. Ezekiel Emmanuel, in case you didn’t know, is the brother of Rahm Emmanuel, former White House Chief of Staff and now Mayor of Chicago. His brother Ezekiel has been writing negative things about assisted suicide for years, and takes this opportunity — so close to the election — to keep playing his game of denial (based, I believe, largely on a misreading of the historical evidence regarding the reasons for the contemporary interest in assisted dying), because the question is being debated in New Jersey and is on the ballot in Massachusetts in the upcoming election.
So, what are the four myths about assisted suicide that Emmanuel seeks to disclose, and how valid are the points he is seeking to make? The first one has to do with pain. This is predictable, for the truth is that pain is not the only or the main reason why people seek assisted dying. Indeed, most people who opt for assisted dying have other things on their mind. This is now well-known. Emmanuel says that they are depressed, but that is not the point. Of course, when you are dying or are suffering from seriously chronic degenerative conditions, or severe disability (such as Tony Nicklinson), there is every chance that you won’t be in the best frame of mind, but to speak of depression at this point is scarcely relevant. Some opponents of assisted dying think that depression is a good reason not to provide help to die for those so afflicted, but this is a ridiculous requirement if, in fact, the decision is made in circumstances where one might reasonably be depressed, and, indeed, people who suffer from pathological forms of depression over many years, and who have had enough of life lived under a dark cloud, are reasonable candidates for assistance to die, if that is what they choose. Depression itself is not necessarily an impediment to reasonable or autonomous choice.
In general, though, assisted dying has more to do with being in control of one’s life, and most of those who choose assistance in dying tend to be well-educated and accustomed to having this kind of personal control. This will come under the next “myth”, but it is worthwhile considering at this point. Emmanuel, like Margaret Somerville, thinks that
[i]f interest in legalizing euthanasia is tied to any trend in history, it is the rise of individualistic strains of thought that glorify personal choice, not the advances of high-tech medicine.
And why not? What is it about people like Emmanuel and Somerville that dismisses the concerns of those who wish to be in control of their dying? Why should it be thought appropriate to force people to die in ways that they themselves would not choose, if given the choice? The supposition is ridiculous. A few generations ago people were more or less locked into a niche in the social hierarchy of society, and few there were who found their way out of it. But it is different now (although with the decline of the middle class this trend may reverse itself), and people are much more in charge of their lives than they have ever been. Women are no longer forced to follow the marriage track, or to be content to spend their lives raising kids, washing clothes and cooking meals for their menfolk. They can have careers and life projects of their own. So, it is true, individualism is at the centre of the renewed concern over individual control of dying. There is no reason, aside from religious ones, and a few factitious scare-mongering considerations, why people need be forced to die in the way prescribed by their diseases – or, it is fair to add, forced to live in ways prescribed by their disabilities.
This is why Emmanuel is completely wrong about his second myth, that interest in and support for assisted dying
is the inevitable result of a high-tech medical culture that can sustain life even when people have become debilitated, incontinent, incoherent and bound to a machine.
His answer to this is that the ancient Greeks and Romans commended euthanasia as a way out of an intolerable life, so it can’t have anything to do with advanced medical technology. This is a non sequitur. Yes, the ancient Greeks and Romans, in particular, the Stoics and Epicureans, and even Plato, advocated (or justified) euthanasia or assisted suicide in cases where life had become intolerable, as Plato says in The Laws, either as a result of shame or intolerable suffering. But that does not mean that advanced medical technology has nothing to do with the increasing prominence of the issue today. For advanced medical technology has made it possible for people to live far longer than the biblical “three score years and ten,” often surviving long enough so that the value of life becomes severely diminished by chronic or degenerative conditions. It is simply implausible to claim that this trend, made possible by advanced medical technology, combined with an increased recognition of human rights — and not just an intense individualism (as Somerville calls it) – is not a large part of the reason for the increasing support being given to assisted dying by the public at large.
The third “myth”, according to Emmanuel, “is that it will improve the end of life for everyone.” It won’t, he says, because statistics show that only a few people take advantage of assisted dying legislation.
[E]ven in places where physician-assisted suicide is legal, very few people take advantage of it.
And that is true. Even people who have the opportunity to receive legal physician-assisted suicide, as in the state of Oregon, and even those who apply for and receive prescriptions for lethal medications, do not take advantage of the opportunity. But that does not mean that the availability of assisted dying does not make the end of life easier for everyone, because, after all, knowing that, if things get to the stage when life has become an intolerable burden, they have the choice, is a great comfort. This is the crucial thing. It is reassuring to know that, should life become intolerable, one will not be trapped in circumstances that have become unbearable.
Emmanuel’s fourth and last “myth” about assisted dying
is that it is a quick, painless and guaranteed way to die.
But, as he says, nothing is guaranteed here, and he explains that things can go wrong with an assisted suicide.
Patients vomit up the pills they take. They don’t take enough pills. They wake up instead of dying. Patients in the Dutch study vomited up their medications in 7 percent of cases; in 15 percent of cases, patients either did not die or took a very long time to die — hours, even days; in 18 percent, doctors had to administer a lethal medication themselves, converting physician-assisted suicide into euthanasia.
And then he points out that, in places where euthanasia is illegal, this extra assistance could not be given. But one has to wonder about Emmanuel’s reference to “the Dutch study,” (my italics) as though there had been only one. Assisted dying in the Netherlands has been studied endlessly, so which one Emmanuel is referring to here is anyone’s guess, and so is its reliability. However, if there have been problems like the ones described, there are remedies for them, and any jurisdiction which failed to address these shortcomings of the process by which assisted dying is administered would be derelict in its duty of care.
But this is not the end, for worse is yet to come. Let me quote the whole of the last paragraph of Emmanuel’s column:
Instead of attempting to legalize physician-assisted suicide, we should focus our energies on what really matters: improving care for the dying — ensuring that all patients can openly talk with their physicians and families about their wishes and have access to high-quality palliative or hospice care before they suffer needless medical procedures. The appeal of physician-assisted suicide is based on a fantasy. The real goal should be a good death for all dying patients.
First of all, the appeal of physician-assisted dying is not a fantasy. Part of Emmanuel’s problem here is that he keeps up the charade of pretending that this is suicide in the ordinary sense. Plenty of dying people already kill themselves in ways and in circumstances that are less than dignified and successful, with or without the benefit of assistance. More and more people are demanding the right to die in ways of their own choosing, with assistance from those who have the expertise to make sure — if not to guarantee — that taking their dying into their own hands will be successful. And while certainly the goal of caring for dying patients should still be pursued by all means available, there is no inconsistency between good palliative care and assisted dying. Reading Julia Lawton’s The Dying Process should convince any reasonable person that the only way to ensure that palliative care is not the supervision of a nightmare is to allow those who wish to, to speed up the process of their dying when things have reached a point where continuing to live is in direct contradiction with the individual’s sense of what is important in their lives. It is pathetic that someone like Emmanuel should present such a weak-kneed argument against assisted dying, and should hide behind overcooked tall-tales, rather than accept the fact that many people want to have the choice, and that having the choice is often more important than the deed.
There is one other aspect of Emmanuel’s argument that needs to be considered. After telling us that only the educated, well-off, independently minded people make use of assisted dying, Emmanuel manages to suggest, nonetheless, that the poor will be most at risk if assisted dying is legalized:
Whom does legalizing assisted suicide really benefit? Well-off, well-educated people, typically suffering from cancer, who are used to controlling everything in their lives — the top 0.2 percent. And who are the people most likely to be abused if assisted suicide is legalized? The poor, poorly educated, dying patients who pose a burden to their relatives.
There is something obviously perverse about this. Legalise assisted dying, we are told, and the only people to take advantage of it are the well-off and the well-educated. And yet the people at risk will be the poor! Yet there is not one smidgeon of evidence that this is true — not one! All the studies show the same thing. The people who opt for assisted dying are those accustomed to having control over their lives. So, why should the poor be at risk? There is no reason to think that they will be. Indeed, since the poor and the disadvantaged are often the most religious, not only will they less often take advantage of assisted dying, it seems reasonable to suppose that many of their reasons for not doing so will be religious, and that religious leaders may reasonably be thought to be taking advantage of their positions of power and influence to convince the faithful that pain and suffering at the end of life is purposed by God, and that only God may set them free.
What Emmanuel does is to build up to a “catch-22″ conclusion, but it is one not dictated by the facts. Indeed, it is hard, reading Emmanuel, to understand the sources of his opposition to assisted dying. So far as his religious convictions go, he seems to be committed to Judaism as a way of life, though he himself is, I believe, an atheist. Judaism, generally, is strongly opposed to suicide, and this may be a part source of his opposition. I think that the main reason for his opposition lies in a deep historical misunderstanding. He writes an essay on the history of euthanasia and physician-assisted suicide entitled “Why Now?” which is published in a collection edited by his ex-wife Linda, Regulating How We Die: The Ethical, Medical, and Legal Issues Surrounding Physician-Assisted Suicide. In general, he seems to think that social Darwinist perspectives are the most salient sources of the contemporary interest in physician-assisted dying. I think this is quite wrong. Perhaps I will get a chance sometime in the future to address Emmanuel’s position more thoroughly. For the moment, it suffices to point out that the position taken in the New York Times article and the reasons for taking it amount simply to a rehashing of worn out arguments. It adds nothing new, and continues to confuse the issue with irrelevant concerns. Emmanuel really needs to think this through again more carefully.