I recently received a mailing from “compassion & choices”, an organization lobbying for “compassion in dying” and “dying with dignity”. They’re touting this as a “civil rights struggle” but I fear that it will result in the further erosion of civil rights.

Insufficient pain medication

The main argument in favor of “death with dignity” appears to be the excessive pain that terminally ill patients are in. To quote Compassion and Choices,

The patient’s condition must cause severe, unrelenting suffering which the patient finds unacceptable and intolerable.

They are in so much pain that they cannot interact with their family and friends. They would be better off dead, and allowing them an assisted suicide is the only compassionate choice.

The problem with that logic, however, is that the true compassionate choice would be to remove their pain and allow them extra precious months with friends and family.

Many patients do not receive appropriate medication because doctors today are afraid to prescribe appropriate levels of pain medication to patients in intense pain, even terminally ill patients. The DEA has been fighting a war to keep doctors from prescribing appropriate pain medication, and to keep pharmacists from filling such prescriptions. Even for terminally ill patients in intense pain.

If we allow patients to end their pain through assisted suicide, this takes pressure off of our lawmakers to rein in the DEA and the crazy drug laws that force patients to endure unnecessary pain in the last months--or even years--of their lives. I know that it sounds selfish and completely lacking in compassion to forbid people from ending their painful lives, but it seems even more selfish and compassionless to enable bad laws by killing the people who are the most hurt by those bad laws.

In today’s environment, assisted suicide laws are misguided. I am reminded of one of the scenes in Walter M. Miller’s wonderful “A Canticle for Leibowitz”. In the world’s first nuclear war, the people most affected by nuclear radiation rose up against the political and military leaders who caused their pain and suffering. The second time around, the political and military leaders have set up a system whereby people in excessive pain from nuclear radiation can turn themselves in for “Green Star Relief”: assisted suicide.

An abbot is arguing with a Green Star doctor who wants to set up on the monastery grounds. The doctor argues that, “Well, it’s certainly better than letting them die horribly, by degrees.”

“Is it? Better for whom? The street cleaners? Better to have your living corpses walk to a central disposal station while they can still walk? Less public spectacle? Less horror lying around? Less disorder? A few million corpses lying around might start a rebellion against those responsible. That’s what you and the government mean by better, isn’t it? The very existence of the Radiation Disaster Act is the plainest possible evidence that governments were fully aware of the consequences of another war, but instead of trying to make the crime impossible, they tried to provide in advance for the consequences of the crime. Are the implications of that fact meaningless to you, Doctor?”

Like Miller’s compassionate law that made nuclear war more likely, assisted suicide laws make pain more likely. They make reasonable pain medication less likely. Instead of prescribing enough pain medication to keep the patient alive and coherent for a longer period with their friends and family, we tell them that they can live in pain or we can help them die earlier.

After a long discussion, Miller’s doctor says, “Pain is the only evil I know.”

“Don’t be an accomplice,” replies the abbot.

And that’s what we are. When we provide suicide for those who want to die only because we forbid effective medication, we are an accomplice in their death; we are an accomplice in the evil of expediency over fixing bad laws. More than an accomplice, we have made death their only reasonable option and then we pretend that they still have options.

Loss of effective voices

In 1993 Peter McWilliams wrote an incredible book called “Ain’t Nobody’s Business If You Do” about, among other things, the hypocrisy of our current drug laws. McWilliams, as it turns out, had an ulterior motive for ridiculing the drug war: he had AIDS, and his disease was kept in check only by using an illegal drug, marijuana. Marijuana itself didn’t cure him, but it allowed him to take his medication regularly without vomiting it back up.

He was able to live a relatively normal life with this medication, but he had to break the law to get it.

McWilliams was later arrested for his crime, and during his trial he died: unable to use marijuana while under the scrutiny of the criminal justice system, he choked on his own vomit while taking his AIDS medication. He died in his bathtub. A painful death, and for the period in which he was unable to use marijuana, a painful life. But during that time he was a powerful voice against the hypocrisy of the anti-medical marijuana movement.

If McWilliams had had the option of a quick and easy assisted suicide, would he have resorted to the dangers of the black market to maintain a reasonable quality of life? Would he have written his powerful book? Would he have fought his court case for as long as he did?

It may be selfish to have wanted McWilliams to stay alive during his pain, but if America ever comes to its senses regarding medical marijuana, McWilliams’ case will be part of the reason. His pain will have saved lives. Whether it enables cures or simply more effective pain medication, his pain will have extended other people’s lives so that they will be able to spend precious extra months or even years with their families, loved ones, and friends.

The solution when someone is in pain is to alleviate their pain, not offer to kill them. The evil is all the worse when the medication is already available but simply forbidden.

An industry of death

Another danger is the slippery slope that will result when we make death an option. The call today is for death with dignity for the terminally ill. The emphasis is on interminable pain. But life itself is terminal. When there is money to be saved and money to be made providing for assisted suicide, there will be an expansion of what is pain and of what is terminally ill. It is only logical that if pain is the evil we know, that eventually pain will be the only consideration.

And then we will start to redefine pain. We will expand terminal pain to include lesser diseases, to include emotional pain and terminal depression, and then severe clinical depression.

I can even see justification for providing a legal outlet for assisted suicide after a failed love affair: how we’ll have fewer murder-suicides if we allow the choice of assisted suicide.

And we will begin to recommend death as an option more and more, to save money and to remove any pain and incapacity that makes us uneasy.

The industry will grow and compete with nursing homes.

The biggest problems will be problems we can’t even see yet. When we create an industry that makes money or saves money from assisted suicide, the slope will be slippery in many directions that we can’t even predict.

There will be suicide parlors, suicide doctors specializing in a “gentle, peaceful death”, and final choice caterers for that last visit with friends and family. Money flowing everywhere, as long as we convince more people that they need this service for themselves or for those in their care.

We see that slippage in Florida, where they have crafted their “living wills” law so that courts can try to guess what a patient probably wanted based on things said in passing long ago while watching television.

Personal vs. public choice

There will be a shift from personal choice to public choice. Especially in an era of increasing public health assistance and an increasingly older population in which public assistance and social security is already strained, assisted suicide will become a fiscal necessity.

In the same way that assisted suicide will take the pressure off of politicians to end oppressive drug laws, it will take the sting out of the denial of medical care.

Does this have anything to do with Terri Schiavo?

Well, yes and no. Obviously, it does, the mailing from Compassion & Choices came because of her; they are appearing on television to discuss her case and displaying her case prominently on their web site.

On the other hand, it doesn’t, because Terri Schiavo was almost certainly already dead. I can only speak to what I saw in the media, which had to bolster one side in order to maintain “balance”, but most likely the Schiavo case was not what an assisted suicide is usually for: a conscious person making a clear decision to end their life once it has become too painful to continue living. To quote Compassion & Choices, “terminally ill, mentally competent adults”.

The Schiavo case shows the path that “compassionate deaths” will follow, and it brings up some related issues.

In Florida, responsibility for determining when someone is dead is up to the state, once the guardian brings it to their attention. Terry Schiavo’s guardian claimed that after that determination, responsibility was completely out of his hands. Even if he was wrong (as I suspect he was), that is the direction we’ll go. First we’ll provide the guardian plausible deniability, but eventually there will simply be no guardian. Once the state has determined that an individual is dead, what is the point of keeping them alive? The expense doesn’t justify keeping a corpse hooked up to a machine.

This will eventually be the rationale even if the corpse is conscious. In the end, it’s all about money and expediency.

Further, the one court case I could find that dealt with the Schiavo issues (as opposed to the appeals cases that dealt with procedural issues) scares me more than a little. The court case wasn’t just about whether she was dead, but about discerning her preferences in the absence of a direct statement regarding her preferences.

Florida has a law that allows the courts to determine the coma patient’s intent in the absence of a clear statement of intent. For Terri Schiavo, as near as I can tell from the court documents, they determined with “clear and convincing evidence” what her wishes were based on (a) throw-away comments during news broadcasts and television shows, and (b) that most people of her age group would probably feel the same way.

On one of the newsgroups I take part in it was seriously speculated, and agreed to by others in the discussion, that she was very concerned with her appearance and obviously she wouldn't want to be alive while looking like this. From the court documents, that does in fact appear to be the point of Schiavo’s throw-away comments: she wouldn’t want to live if she looked that bad.

My personal preference is that living wills stating what to do in cases like this are useful insofar as they allow the state not to have to make the determination about when someone is dead or alive. That’s a dangerous thing for the state to do. But even disregarding that personal preference, the determination of intent as seen in the Schiavo case is a very dangerous slope. I hope that she was already dead: we can’t be killing people just because they aren’t as pretty as they once would have liked to be.

Kinder, gentler death?

According to their mailing, “A gentle, peaceful death is what Compassion & Choices is all about.” I would quote Dylan Thomas:

Do not go gentle into that good night.
Rage, rage against the dying of the light.

Rage against the poor policies that take effective medication away from the terminally ill. Rage against policies that seem tailor-made to become cost-saving measures for government and hospitals by killing those who cost too much money to keep alive.

Rage against expediently removing the victims of bad laws so that they won’t ever complain again, nor rebel against those responsible.