[Update 5/18/15: I have begun evaluating the top-rated comments for consideration as upgrades to the living debate. When I think I have a good set of objections/upgrades I will issue a new (or confirmed) verdict.]
In prior posts, Jimmy Akin provided the seed argument against physician-assisted death that I will pass through what I call the Rationality Engine.
If you have been following the Rationality Engine (performed on two other topics so far) you know this is the verdict phase. I will give you my judgment on the “claims” made in this debate followed by a summary verdict at the end.
(This is crazy long. There was no way to shorten it.)
This is a living debate, by design. All verdicts are preliminary and subject to change with new data or better thinking.
I start by reiterating the known bias in the participants (a repeat) followed by my verdicts.
Rationality Engine Host (me): I have personal experience with six relatives who suffered in the final months of their lives. I do not want to go that way. And I do not want you to go that way either, unless it is your preference.
I am a non-believer in souls and deities. But in recent years I have become pro-religion because I see it as a benefit to people’s lives. We are all different, and religion fills a need in some folks. I’m a fan of anything that works.
Debate Participant (Jimmy Akin): Jimmy is affiliated with the Catholic Church but does not work for it. His personal experience with the topic includes his wife passing from cancer while pressure was being put on her by others to not use treatments that could extend her life.
The point of the Rationality Engine is to use public scrutiny to scrub out the bias in the debate over time. Some bias has already been identified (by readers and by Jimmy) and I attempted to remove it in this draft. When you see more bias, call it out in the comments.
The truth filter used for the Rationality Engine attempts to find at least two pieces of support for every claim. Reliable data and replicated science will always be the top filters for truth, along with logic and reason. But if any of that conflicts with our personal observation, or the observations of others, that too has to be factored into a verdict.
Claims – Verdict Phase
Claim 1: Well-meaning doctors, family, and friends will have a natural desire to end the suffering of a patient because we feel empathy and we imagine we would want death in that situation. This primes all people involved to be coercive even if only in a subtle and unconscious way.
Verdict: True. People are influenced by incentives of all kinds. There is no claim about the degree of this influence.
Claim 2: The AMA, the Catholic Church, and disabled rights groups oppose physician-assisted death. Even if you disagree with their position, collectively they form a useful counter-force against society slipping into a death culture.
Verdict: This is my own claim. I take it as a given that creative tension on important (life and death) topics is more good than bad. Humans do not want to be casual decision-makers on such topics.
Claim 3 and 4: The common good is not served by allowing people a legal option to harm themselves, for two reasons among others:
- Claim 3: We have lots of laws that limit personal choice for the common good. For example, you can’t drive at night on the freeway with your headlights off because your choice could kill someone, including yourself, and we are all components of the common good.
Verdict: True that such laws exist on other topics and form a useful analogy to this topic.
- Claim 4: Our sense of the value of human life (and dignity) is influenced by the actions of individuals and by laws. Legalizing physician-assisted death, along with widespread use, would decrease the value we assign to life by treating it the way we treat food that is past its expiration date.
Verdict: True. If something is moved from a class of things that is treated as special to a class of things that are routinely discarded, it would necessarily change how observers value the thing. No claim is made to the degree of this change.
Claim 5: The so-called Slippery Slope argument is real, and intentionally engineered in some issues. Proponents for gun control, medical marijuana, pro-life, and bans on smoking all took small steps (because that’s all they could get) with a strategy of getting people used to the new situation before going for more.
Verdict: True by the definition offered. But it should be noted that people who favor the change in question will label it “progress” while those opposed might call the same history a “slippery slope.”
Observation confirms that some folks who favor physician-assisted death would be happy to see the laws extended to make it easier for patients with treatable conditions (such as unhappiness) to end life. But no claim has been made that the organized folks seeking physician-assisted suicide rights in California have ambitions beyond what they state.
It is likely that the proponents of doctor-assisted dying who base their argument on compassion for the patient have no motive to extend the laws to include people with treatable issues. I am in that class.
But it is fair to assume that some subset of the “less government” crowd favor individual rights over the common good. For that subset, any laws that removes government from decisions is a step in the right direction and presumably they would favor the right of an individual to end life for any reason at any time.
No judgement is being made here on which approach is better. I limit this verdict to noting that some subset of citizens would be delighted with greater change than the current laws on physician-assisted death contemplate. While I would not label this as a “slippery slope,” it does have the quality recognized in this claim: One step in a particular direction is likely embolden more change in the same direction.
No verdict is yet offered on whether creating more options for a self-directed death is good or bad for society.
Claim 6: Proponents of physician-assisted death in California are limiting their focus to terminal patients in pain who have a sane preference for death.
But if that right is established by law, it will make it easier for proponents of even greater euthanasia rights to push for more. This would be a threat to the disabled and the elderly.
Verdict: True. Observation confirms that when it comes to human issues, movement in a particular direction will increase the odds of more movement in the same direction. No claim is yet made about how much the odds change for this particular topic or whether such change should be seen as progress or moral decline.
Note: Jimmy Akin does not rely on the slippery slope argument but in response to my question he does call it out as a legitimate concern. Jimmy’s objections are to the proposed law on its own merits, not simply a concern that things could worsen.
Claim 7: A Dutch study of their physician-assisted suicide laws showed that in 28% of cases the strict criteria were not fulfilled. This suggests a high potential for abuse of the law beyond its intended boundaries.
Verdict: True. Sloppy compliance is common to most laws than involve lots of participants. Humans are sloppy creatures.
There is no claim that the “shortcuts” taken by Dutch doctors led to a negative outcome. So an equally valid interpretation (lacking any data) is that Dutch doctors were just skipping some steps they saw as less important, with the full knowledge of the patient and family.
So it is true that the potential for problems exists. No data has yet been offered to suggest such problems are common.
Claim 8: The Common Good can include a situation that is bad for one member of the group and good for another. The relative weight of the individual concerns matters. For example, an inconvenience to one person would be ranked lower than physical harm to another.
Verdict: True. This describes the common understanding of the Common Good.
Claim 9: There is no objective standard for the Common Good, so once we leave the realm of the obvious (death versus inconvenience), humans can be expected to disagree, especially when self-interest is involved.
Verdict: True. We see that in this debate.
Claim 10: When reasonable people disagree about what constitutes the Common Good, there is no objective standard to break the tie.
Verdict: True. No one has suggested an objective standard for this topic. But subjective standards of many types are clearly in play.
Claim 11: A mind that is “trapped” in a non-functional body is just one of many forms of pain and need not be treated differently for the discussion of physician-assisted death. Pain is pain.
Verdict: True by general agreement.
Claim 12: A brain without consciousness, that is still functioning to keep the body alive, has human dignity.
Verdict: True. Humans assign dignity to lifeless bodies. This is why we have laws and taboos against defiling corpses. And if you believe the body with no consciousness is still alive, you assign a different type of value to it, but dignity is universally assigned to human bodies, by general agreement, regardless of their state of life.
Claim 13: A brain that has no consciousness and is not capable of keeping the body alive without medical intervention no longer possess the dignity of a living person. (But it would maintain the dignity we accord to corpses.)
Verdict: Dignity is subjective (discussed later). Some folks would apply the same level of dignity to a body on life support with no consciousness as they would to the living. Others would see a body with no consciousness as a piece of meat.
Claim: It is rare for a person to experience pain in the final months of death. Most deaths are either sudden, involve pain for a short period, or involve manageable levels of pain using medications. And as stated, improvements in pain management, including induced coma options, could reduce the issue of pain management to a trivial number of cases.
Revised per Jimmy Akin on 5/5/15 to:
Claim 14: It is rare for a person to experience extreme, untreatable pain in the final months before death.
True: As far as we know, any type of pain can be eliminated by a drug-induced coma. All participants on this topic agree that for a variety of practical and human reasons, drug-induced comas are rarely used.
So it is true that all pain can be removed. My personal observation, confirmed by many third-parties, is that full pain relief is a rarity for a variety of practical reasons.
Jimmy Akin does not offer any data on how often pain is treated by induced coma but he agrees it is not widespread practice at the moment. He recommends improvements in this area.
Claim 15: It would not make sense to pass a law that benefits only the rare exceptions of people who cannot be relieved of pain (as horrible as they are) when you consider the wider impact on human dignity and other practical matters (discussed further down).
Verdict: False (because the assumption is false). Personal and third-party observations are consistent in pointing out that substantial discomfort in the final months of life is a common situation.
Claim 16: Old people are not good advocates for their own pain relief.
Verdict: True by observation and third-party accounts. I am aware of no argument against this claim.
Claim 17: When mentally weak patients are not good advocates for their own pain relief, the most reasonable solution is to give them better advocates, not make it legal for them to take their own lives.
Verdict: False. Most humans would agree that better advocacy for patient pain-relief would be a positive step. But it is not logically a replacement for the doctor-assisted death option. A hammer is not simply a better screwdriver. It is a different tool for a different situation.
Claim 18: From a Catholic perspective, pain and suffering before death do not decrease human dignity.
Verdict: True. Some might even say suffering is noble and it increases dignity. No one has yet suggested that suffering, viewed in isolation, decreases human dignity.
Claim 19: From a Catholic perspective, ending your own life decreases human dignity.
(Note: Jimmy’s views on life are obviously informed by his faith, but in this case he is putting forth an argument based on reason as he sees it. (He also agrees with the AMA and they are not a religion.) That said, no differences of opinion between Jimmy and the Church have been noted.)
Verdict: True. That is the position of the Catholic Church as I understand it.
Claim 20: The only arguments against physician-assisted death are based on religion. (The implication is that atheists would call it magical thinking.)
Verdict: False. Advocates for the disabled make a solid argument against physician-assisted death without a call to faith. They make a case that legalizing physician-assisted death would increase pressure on some of their members to take the option.
Claim 21: As a society, we should not settle for doctor-assisted death because we can do better.
Verdict: Unclear. Humans do not agree on what “doing better” means in this context. Many would not see an induced coma, for example, as doing better than a dignified passing with a doctor’s assistance.
Claim 22: Legal options for assisted death would decrease the efforts put into finding cures. Why find cures when you can just get rid of patients?
No pharmaceutical company ever rejected an opportunity that could net $10 billion just because it could have been $11 billion if not for all the doctor-assisted dying. And I can imagine no greater drug opportunity than one in which folks are literally killing themselves because there is no better option.
Update: The first sentence of the verdict was unnecessary (and potentially misleading). The point is better captured in the last sentence.
Claim 23: Pain can be completely removed by drug-induced coma. Therefore, no one needs to suffer before death.
Verdict: True in concept. In practice, for a variety of practical reasons, doctors do not routinely eliminate pain for patients in their final months. Sometimes doctors don’t want to hasten death. Sometimes the patient is a bad advocate and admits to family that there is pain while “not wanting to bother” doctors with such things. And sometimes patients need to be awake for procedures that could extend a conscious life (with pain) which is generally considered a better medical outcome than death.
Claim 24: In California it is illegal to aid or encourage another to commit suicide, therefore the legislature of California appears to believe it promotes the common good.
Verdict: False. We do not know what is in the minds of lawmakers. But we do know that lawmakers respond to money interests and the need to get reelected. And in any case, we live in a Republic, so lawmakers are explicitly allowed to ignore the public majority. Nothing useful to this topic can be inferred from the actions or opinions of lawmakers.
Claim 25: It is not accurate to say a citizen of California is being “denied the right” to physician-assisted death because rights are created by laws and that right has not been created.
Verdict: Abstain. This claim is based on wording and not substance. All parties agree that the right does not exist in law in California (and most other states), and that some folks would like to keep it that way. There is no argument here on substance.
A popular argument one sees on the Internet is that “rights” are not granted by governments, but rather by nature or a deity. By this view we are born with certain “inalienable” rights. But this describes a preference more than a reality. The practical reality is that laws create our rights.
Claim 26: There is no “moral right” that supports the idea of allowing physician-assisted death.
Verdict: Abstain. There is no agreed definition of a moral right. It can only be said that some folks would place a higher moral value on a physician-assisted death with dignity than would others. That preference does not imply a moral right.
Claim 27: The “common good” standard is the most reasonable standard for deciding on the legality of physician assisted death.
Verdict: Agree. That is the standard humans use for all important questions because laws based on that standard have a good chance of working. If that standard is ignored you rarely succeed in the long run.
Claim 28: The “common good” includes both the good of individuals and the good of individuals in a group. Both are important.
Verdict: True. The common good often requires individuals to sacrifice for the good of the whole, but the common view recognizes such contributions and values the individual as part of the common good for that very reason.
Claim 29: Physician-assisted death violates “innate, intrinsic, human dignity.”
Verdict: Split verdict. Human dignity is a phenomena of the mind (at the very least). For some folks, physician-assisted death violates that sense of dignity. For others, a painless, loving death assisted by doctors and family members is the most dignified way to go. (Bias alert: I hold the latter view of dignity.)
Claim 30: For the purpose of discussing physician-assisted death, it does not matter if human dignity is the product of a “soul” or an emergent property of a complex system.
Verdict: True. In this context, I interpret “emergent property” to mean that people have thoughts and feelings about human dignity, and that situation is part of our real world and experience.
Claim 31: Human dignity (whether soul-based or an emergent property of a complex system) is real, and has consequences for how people must be treated.
Verdict: True. This entire topic involves our different ideas of what constitutes human dignity. Clearly our thoughts and feelings about dignity are real.
Claim 32: Because humans have innate “dignity,” their lives “mean something” and they “must be respected” to a higher degree than we respect inanimate objects, for example.
Verdict: True. Most people feel that human life has special value compared to inanimate objects. All sides seem to agree on that point. And since value is subjective, the agreement on what constitutes value is enough to create value. And clearly all animals have a bias for life.
Claim 33: No one has less right to life based on how near or far they are to death.
Verdict: True. The law does not decrease your rights based on proximity to death.
Claim 34: Dignity applies to ourselves as well as others, and it is possible to disrespect yourself.
Verdict: True. Using the “emergent properties” definition of dignity one sees people reducing their own dignity (as folks experience that phenomenon in their minds) on a regular basis.
Claim 35: We “deserve” love and respect because each of us has human dignity worthy of that love and respect.
Verdict: False. The word “deserve” attempts to replace reason with emotion. No one in this world “deserves” anything. This topic is better served with clear language.
Claim 36: Because of the near-universal belief in human dignity (or a similar concept) throughout history, and across societies, there has always been a stigma connected with suicide (i.e., when suicide occurs, something bad or wrong has taken place).
Verdict: True. The taboo against suicide crosses all cultures as far as I know. And it is fair to assert that some version of “human dignity” plus a healthy dollop of religion is behind those feelings. Update: Some cultures have viewed suicide as an honorable death in cases that involve, for example, shame, failure, or military suicide missions. My verdict is that these are special cases, so Jimmy’s main point stands. There are no cultures in which the public is pro-suicide as a philosophy that applies to the average citizen.
Claim 37: Physician-assisted death is never a desirable outcome in a world in which human dignity matters and pain can be totally eliminated by medications (which might include an induced coma.)
Verdict: False. Personally, I would prefer (and desire) death to a permanently induced coma because it is easier on family and friends and it wastes less money. In my experience, my view is the common one. I have never heard anyone but Jimmy Akin express a desire for permanent coma over death. But one assumes others share that view.
Claim 38: Putting a terminal patient into a pain-free coma until death preserves human dignity.
Verdict: Split verdict. For Jimmy Akin, a pain-free coma does preserve human dignity, and many folks would agree. For me, a pain-free coma would be among the worst ways to maintain human dignity. Lots of folks would agree with that position as well. Since Jimmy has offered only a non-religious argument on this topic, it becomes a matter of “emergent property” disagreements about what constitutes dignity.
Claim 39: There are practical barriers to full pain-elimination in the real world, for a variety of reasons, but our efforts are better served by fixing that situation as opposed to promoting physician-assisted death with its human dignity issues.
Verdict: True, in terms of weighing priorities. But a toolbox has more than one tool in it for a reason. Pursuing a perfect hammer design does not help you saw a board. Total pain management is just one tool, and an important one. But for the future we can predict, many folks will not have a pain-relief option short of coma. And reasonable people can prefer a managed death to a permanent coma.
[Note: I do not know the AMA’s position on increasing the use of permanent comas for pain management. That would be important to know.]
Claim 40: Helping a patient find pain relief better corresponds to the requirements of human dignity than letting them die, even if they prefer death.
Verdict: False. Using the “emergent properties” definition of human dignity we observe a majority of Californians (according private polls) favoring physician-assisted death. The most common view for this group is that human dignity is best preserved by giving a dying patient and his family control over how things end. Since we are viewing human dignity as an “emergent property” for this discussion, the majority view is what defines human dignity and how it is best addressed.
Claim 41: A medical professional would debase herself by being part of a system that assists in the killing of innocent people. This too is a violation of human dignity for the professionals involved.
Verdict: True for professionals who hold a specific view of human dignity similar to what Jimmy Akin describes. False for professionals who see greater dignity in helping people avoid pain before passing.
I have heard no one suggest that medical professionals be coerced into the business of assisted dying. One assumes that most of the professionals volunteering for this sort of work are the ones who believe assisted dying is a positive thing for human dignity.
One further assumes that adult professionals can (usually) assert their preferences to avoid being in situations they feel would debase them.
That said, in the real world a “family doctor” will have a strong emotional incentive to stick with a patient to the end, even at the risk of debasing her own sense of self. I judge that risk to be real and unavoidable. I have no data to size the problem, but common sense says it would be large.
And one can imagine professional nurses following a doctor’s orders over their own moral objections. People need jobs, and angering the boss is not a good strategy.
Claim 42: Violating the dignity of another is a violation of one’s own dignity. In other words, if I kill you, my dignity suffers as well.
Verdict: True. Humans generally do not consider it dignified to violate the dignity of another.
Claim 43: Asking a professional to violate your dignity (in any way) does not make the violation acceptable because human dignity is bigger than personal preferences.
Verdict: True. Inserting a professional into the process would not alter the way we interpret dignity in this context.
Claim 44: The American Medical Association opposes physician-assisted death, explaining that it would cause “more harm than good” for three given reasons:
- It is fundamentally incompatible with the physician’s role as a healer.
- Difficult or impossible to control
- Would pose serious societal risks
Verdict True, that is their position.
Claim 45: Legalizing physician-assisted death would put pressure on patients to kill themselves.
Verdict: True. Once physician-assisted suicide is legal and acceptable, we could expect that in some situations family members would, out of kindness or greed, recommend death to suffering. This could reasonably be seen as “pressure” on a patient that is not in a good place to make decisions.
No claim is made about the degree of this problem. And as noted, we would not know if such pressure is happening in Oregon because these things happen in private.
Claim 46: Patients are more likely to be abandoned once it is thought a cure is impossible.
Verdict: False, primarily because “abandoned” is a loaded word. We see no evidence that professional medical folks “abandon” anyone who can benefit from medical treatment. Professional ethics and economics are strong forces.
It would be more accurate to say that if we introduce a new option (assisted death) it is likely to have an impact on how doctors set priorities. And that might indeed move resources and attention away from the so-called lost causes toward those that can still be helped. It is not obvious that society would be worse for this shift, so long as the dying are not literally “abandoned” and their pain is treated as much as possible.
Claim 47: People might someday be denied insurance payments for medical treatments when physician-assisted death is an option.
Verdict: False. Insurance companies could not get away with denying treatment plans that have a chance of working. If they tried, they would not be in business long.
Claim 48: Medical progress will slow because there is no point trying to solve a problem already “solved” by assisted death.
Verdict: False. If the best available solution to a particular type of health problem is death, that’s a market every pharmaceutical company wants to enter. People pay a lot to avoid death.
Claim 49: Human dignity is better served by giving grandma enough pain medication to eliminate suffering, not allowing her to suffer and giving her only the option of death.
Verdict: False. Human dignity is a psychological phenomenon, meaning dignity exists as a common, shared idea. A solid majority of Californians already prefer an assisted-death option. The majority opinion forms our understanding of how “human dignity” is “better served” and they have spoken.
Claim 50: There are reported problems with Oregon’s laws on physician-assisted death.
Verdict: True. Every system from governments to hospitals experiences problems. As noted earlier, we have no way to know if the reports out of Oregon are an indication of the full problem or if they are of the tip-of-the-iceberg.
Claim 51: It is impossible to know how many problems Oregon has had with their physician-assisted death laws because it is unlikely all problems are reported.
Verdict: True. The types of problems folks expected, such as influencing a relative to choose death, happen behind closed doors. We would not know how bad it is.
Claim 52: If a family member coerced grandma to seek assisted death for personal gain, no one would know of this crime. Grandma would soon be dead and the perpetrator would not talk.
Verdict: True. We do not always know what happens in private conversations.
Claim 53: It is irrelevant to the discussion whether Oregonians are happy with their law because they are not likely to be well-informed about how it is working for individuals. That sort of data is not tracked, and it would be impossible to obtain data on whether family members were being coercive.
Verdict: False. While it is true that citizens are under-informed on this topic, we live in a political system in which the satisfaction of the majority is a major factor in all decision. It would be reasonable for California voters to think that if Oregonians like their law, we would like one that is similar.
In the real world, most decisions are made with incomplete data. And in the real world, problems tend to surface over time no matter how private they are at the beginning. A reasonable person can conclude that we would know by now if the Oregon experience was a disaster. And no reasonable person would expect perfection in a system of this scope.
Claim 54: A poll of Oregonians regarding their experience with physician-assisted death would be unreliable because the way you ask the question will influence the result.
Verdict: True that the wording of polls influences the results. So one poll on the topic would be unreliable. But if every poll produced a majority in favor, no matter the wording, that would be meaningful.
Claim 55: In the context of this discussion, psychological anguish is considered pain, not just physical pain.
Verdict: True by agreement of the participants.
Claim 56: An advanced medical directive (in which you state your end-of-life preferences while still healthy) would eliminate some but not all concerns about a patient being coerced into choosing death.
Verdict: True. An advanced medical directive could, for example, state that you never want an assisted death option under any circumstance. But an elderly person could also be influenced by an unscrupulous relative to change an advanced medical directive.
One can imagine steps that would improve the advanced medical directive system. For example, a patient might be required to undergo a more rigorous process to change a directive that had banned assisted death to one that allows it. That would flag most problems unless the conspiracy involved doctors and the entire family.
Claim 57: Some folks will not set up an advanced medical directive, so that is a problem.
Verdict: True. Patients who do not have an advanced medical directive are disadvantaged in lots of ways.
One can imagine assisted death being totally banned for those who have no advanced medical directive in place. But again, unscrupulous family members can influence a patient to sign anything.
Claim 58: A person can be coerced to change their advanced medical directive while still mentally capable but susceptible to manipulation.
Verdict: True. Humans can be influenced lots of ways and for lots of reasons. We have no data to suggest how much of a problem it would be in this situation.
Claim 59: There is no objective standard for deciding if someone is mentally incompetent, so some people will be making advanced medical directives under coercion.
Verdict: True. People influence other people all the time, for a variety of selfish and unselfish reasons. One need not be mentally degraded to be influenced by others.
Claim 60: Including a physician-assisted death instruction in an advanced healthcare directive would devalue human life by reducing it to a check box on a form.
Verdict: True by agreement. Opponents would view this as a violation of human dignity. Proponents of physician-assisted dying would prefer society to assign less value to the painful final days of life while giving greater weight to personal choice and pain avoidance.
Claim 61: Complete pain relief is medically possible, as demonstrated by anesthesia during surgery.
Verdict: True, especially if the patient is asleep. There are real-world reasons that this level of pain relief is not common, but it is medically possible.
Claim 62: The assisted death pills used in Oregon have not worked every time, especially when they cause vomiting. No data is available on how often complications arise.
Verdict: There are reports from Oregon of patients vomiting up the pills before death. And common sense tells us that if the pills worked every time they would be the drug of choice for executions. (In states where lethal injections are legal, the process does not work every time.)
Claim 63: Complete pain relief in the form of induced comas is not common practice today, probably for a variety of reasons.
Verdict: True. Observation confirms it is not common practice.
Claim 64: A rational person can decide to live in pain until the end of life for a variety of reasons.
Claim 65: Physicians are reluctant to induce comas in today’s world.
Verdict: True. We rarely see it.
Claim 66: Insurance might not cover induced comas for pain relief. (Speculation.)
Verdict: Unknown. In the short run, insurance companies will be wise to do cover whatever a doctor recommends. In the long run, millions of bodies in comas would bankrupt the system.
Claim 67: According to the American Medical Association, physicians are reluctant to be aggressive in pain medication and they believe education can help.
Verdict: True. One assumes education helps in most areas. No claim is made about how much help the education would bring.
Claim 68: Patients suffer less when they have a sense of control over their own suffering. So one path for improvement is allowing more patients to regulate their own pain meds as is sometimes the case now.
Verdict: True that a sense of control provides a degree of psychological comfort. And there is no debate that patients should sometimes control their own pain meds.
Claim 69: We have no data to tell us how many people might want a physician-assisted death. The number could be in the hundreds-of-millions someday as science continues to improve at keeping people alive long after their bodies have become useless.
Verdict: True. This is my claim. There is no way to know how many might someday want the option, but the trend in medicine is toward keeping people alive longer no matter the quality of life. Billions of people will die in your lifetime. It is not unreasonable to think hundreds-of-millions of people will prefer a painless end to years of misery.
Claim 70: It is possible that someday our skills at pain relief (without coma) and mood regulation will be so good that dying will rarely be preferred. In that case, a law allowing physician-assisted dying would create far more risk than benefit.
Verdict: True in the sense it is possible. But legal, economic, emotional, and professional factors limit the odds of this possibility being realized anytime soon.
Claim 71: In some cases a person might choose death right before an incurable condition finds a cure. That situation is rare now, but could change as the rate of cures advances.
Verdict: True as a possibility.
Claim 72: We have no data on how many folks would be encouraged to take their lives if physician-assisted death were legal in more places, but it would probably be “lots of people” because even in today’s world we see dying people pressured to forego potentially life-extending procedures toward the end of life.
Verdict: True. If physician-assisted dying becomes available in California, and relatives think it is a good option for a particular case, we could expect subtle and not-so-subtle pressure on patients. Here I am not judging that pressure to be either good or bad. It is likely to be a mix.
— Added Claims since first posted —
Claim 73: Doctors might encourage people toward assisted dying to free up organs to help the living.
Verdict: True. One imagines that some doctors in some places will believe the common good is best served by ending the suffering of the dying while preserving the life of someone who could live for years. Doctors are human, but they are also highly-trained professionals who would be on the alert for their own behavior crossing ethical boundaries. A doctor’s self-interest would probably steer her away from organ harvesting as a top priority.
Claim 74: Doctors are human, and their opinions of what constitutes a “life worth living” could influence what they recommend to patients.
Verdict: True. Doctors are likely to recommend (or create subtle influence) toward an outcome they see as the best for all.
The argument in favor of physician-assisted dying is fairly simple. In tragic situations that involve long-term, hard-to-treat pain, some citizens prefer a gentle passing under a doctor’s direction, and they would like that right put into law. Supporters of physician-assisted dying base their preferences on compassion for current and future patients.
There is an enormous practical and financial advantage to physician-assisted death when the alternative is long-term hospital care. But no one has publicly argued that money is more important than compassion for a suffering patient. For our purposes here I will note the economic component but will not include it in the verdict because neither side considers money more important than human life.
Proponents of physician-assisted dying often point to Oregon’s law as a success. And they point to personal freedom as the philosophical basis for creating laws allowing physician-assisted dying.
Opponents of physician-assisted suicide make the following objections that have been addressed in the claims/verdicts section above:
1. Taking a life for any reason violates Human Dignity and devalues life
2. Total pain relief is a better goal
3. Risk of painful death in some cases
4. Risk of coercion from family/doctors/friends
5. Oregon’s experience is largely unknown
6. The AMA objects because assisting death is incompatible with the ethics of healing.
7. Disabled rights groups object on the grounds that assisted dying devalues imperfect human bodies and could put pressure on some members to take the option.
8. Better pain relief and total cures might become available to patients who stay alive.
Religion has been left out of this discussion because believers can be found on both sides of the issue. Compassion does not have a favorite book.
Value of Life
Opponents of physician-assisted dying say that allowing it into law would devalue life.
Proponents of physician-assisted dying would agree, in a sense. The whole point is to demote “life” in the final months as an absolute good and assign greater value to freedom of choice, compassion, and escaping agony. Under this view, value is something we can manage by agreement. It does not exist as an absolute quality of the universe.
Verdict: Both sides agree on this point. It is a factual statement of what the law intends.
Opponents say physician-assisted violates human dignity. My verdict is that human dignity exists as an emergent system (per Jimmy Akin), meaning we all have a common view of what human dignity means. For example, across cultures and across history, spitting on another person is seen as a violation of dignity. Humans share a sense of human dignity and it is an important factor in physician-assisted dying.
The complication arises when reasonable people disagree about what violates human dignity. Proponents of physician-assisted dying would say that allowing grandma to suffer in a hospital bed for months while begging for a painless death is a violation of human dignity.
Likewise, proponents of assisted dying would say that keeping a body alive when it has no hope of regaining consciousness violates human dignity.
And lovers of personal freedom would argue that denying an adult citizen any important rights is a violation of human dignity.
I pause here for a bias alert…
Bias alert: I have often advised people to trade human dignity for success. When I want something, and I am formulating a plan, the first question I often ask myself is “How can I trade some human dignity to get what I want?”
In my personal worldview, human dignity is a top priority until something more important comes along, which it often does.
For example, war is a violation of human dignity, but we wage it whenever there is a risk to our freedom. And putting people in prison is a violation of human dignity too, but we haven’t come up with a better idea.
I would argue (seriously) that making humans work in cubicles is a violation of human dignity. But here too we put practical considerations above dignity.
— end of bias alert —
So we have two views of how best to preserve human dignity. One group says physician-assisted dying violates human dignity. Others say eliminating suffering while valuing personal freedom is one of the best ways to preserve human dignity. As a judge in this debate, what standard would I use for a verdict?
Since human dignity is a psychological phenomenon (an emergent property), one way to arrive at a verdict is by looking to the majority opinion. If 99-out-of-100 people agree that a thing is a violation of human dignity, then it is so by definition.
According to polls, a clear majority of Californians favor physician-assisted dying when you ask the question right. [I have that on good authority but need a citation.] This implies that the majority of Californians do not feel human dignity is at risk in a meaningful way. When religion is removed from the equation, the psychology of the majority defines our sense of human dignity. And the majority has spoken.
Verdict: The majority of citizens in California favor physician-assisted dying. The majority view has the most influence on what constitutes human dignity and the majority does not think it is a major problem in this case.
On the question of risk, every human endeavor has some. People die from sporting accidents, hospital mistakes, accidental police shootings, and a million other causes. We routinely accept personal risks in pursuit of higher objectives, including recreation. In the case of assisted dying, the higher objective is compassion and relief from agony. It comes with risks that the assisted-death pills will not kill as painlessly as hoped, and perhaps a cure for the patient is right around the corner. These risks are well within the tolerance we routinely accept for other human activities of value.
Physician-assisted death is unique among risks because the whole point is to die. So the biggest risk (death) is off the table.
Verdict: Physician-assisted dying has risks for the individual. But these are informed risks and, as far as we know, well-within the tolerance we accept for other activities.
A worrisome risk with physician-assisted dying is that some patients might be coerced into it. An advanced medical directive can mitigate some but not all of that risk because that too can be the product of coercion.
The problem with the coercion argument is that other people’s interests and opinions are worthy of consideration. Decisions are not made in vacuums. A patient generally considers the feelings and opinions of loved ones, and most of us would agree that doing so makes sense.
I have seen no data to suggest coercion is a problem in Oregon, but that data would not be available even if coercion was widespread. It is the sort of problem that is not reported.
A credible supporter of physician-assisted dying would acknowledge the risk of coercion. As is often the case in society, a benefit to one group can come at a a cost to another. But that alone is not a reason to deny the benefits to the larger group. The balance must be weighed. But how do we weigh alternatives when no data is available about the risk of coercion?
Hospitals are a good analogy. Hospital mistakes kill thousands every year, and some portion of those accidents surely come after a patient is coerced into a medical procedure. But that must be compared to the hundreds-of-millions of people who are profoundly helped by hospitals. You and I do not need to know exactly how many people die from hospital mistakes in order to judge hospitals a good thing overall. The benefits are clearly larger than the risks.
In the case of physician-assisted dying, and in California in particular, it is reasonable to estimate tens-of-thousands patients would seek physician-assisted dying over the next few decades. Compare that group of people to the few who would be coerced into a premature death by evil relatives without being detected by doctors, nurses, and other relatives.
By any objective estimation we are comparing a huge group of people avoiding agony to a small group of people who were coerced into avoiding agony by dying a few months (on average) earlier than nature planned. When coercion is involved, we see the perpetrators as despicable. But keep in mind that the patient’s experience is a reduction in suffering. And for the religious among us, they would say the patient meets God a bit sooner. This is the only crime in which the victim comes out ahead.
Pain Relief Instead
Opponents of physician-assisted dying favor greater efforts to achieve complete pain relief (which could include induced comas) as a better option for maintaining human dignity to the end. In today’s world, total pain relief is not always an option, for a variety of reasons. The AMA agrees that complete pain relief is not common practice and further education in that area would be useful.
My verdict on complete pain relief is that it is a worthy goal for the future but it is not part of the real world today. Nor does it seem to be coming soon because the problems are not on the technology side of things. For starters, dying patients are not good advocates for their own pain relief. (I have witnessed that first-hand.) Sometimes doctors need to keep a patient awake to keep them alive. And I can imagine doctors not wanting to induce a permanent coma if it feels like hastening death, or even murder.
The bottom line on pain relief is that there is much room for improvement but little reason to believe it will provide adequate pain relief in the near term. That leaves plenty of situations in which physician-assisted dying can be considered a medical option.
Bias alert: People can hold different views of what violates human dignity. In my view, inducing a permanent coma is a far larger violation of human dignity than physician-assisted death. I do not know how common that view is.
— End of bias alert —
Verdict: The total pain-relief objective is a worthy goal and it would be a reasonable alternative for some patients. But until it becomes a practical option it is not part of this discussion. There is no reason to believe total pain relief will be an option in the next several years.
There is legitimate concern among disabled rights groups that legalizing physician-assisted dying would put pressure on some of the disabled to end their lives. An honest proponent of physician-assisted dying would acknowledge this risk to be real, but size unknown.
Here we must keep in mind that a dying patient is also a disabled person for all practical purposes. Physician-assisted dying is about giving extra rights to a subset of the differently-abled (my preferred term). For some folks, the option of a painless ending would be a huge benefit. For others, it poses a risk of coercion and it devalues their lives.
It is tempting to say disabled folks should decide among themselves. But the folks entering that class as dying patients are not good advocates. And the law of the land says we all get to vote on topics of this nature. So how does one balance competing interests among the differently-abled?
On one side we have perhaps tens-of-thousands of Californians who will seek to end their suffering over the next few decades. Given the attention this issue gets from disabled rights groups, and the disabled themselves, plus family members, it is hard to imagine coercion reaching a level that it becomes a bigger problem than the suffering of tens-of-thousands of people.
The bigger issue is that physician-assisted dying devalues “imperfect” lives.
Bias alert: In all likelihood I will join the ranks of the disabled at some point in my life, preferably toward the end. You probably will too. I understand the argument that physician-assisted dying could devalue the lives of the disabled, but I only understand it on an intellectual level. I have no internal experience that would say people will value my life less if I injure my leg. I certainly don’t think of other people that way. Nor am I aware of anyone else who thinks that way. I acknowledge that such biases can be subconscious.
For over three years I lived with a disability. I lost my ability to speak thanks to a disorder called spasmodic dysphonia. During that time I did feel that my value to society was less because I could produce less. And my value to my family was less because I could not participate in conversations, make phone calls, or do many of the typical parent functions. But I never felt my value as a human being was diminished.
— end of bias alert —
Society has demonstrated time and again that it will fight to protect the dignity of all citizens. That reflex is baked into our national experience as well as our DNA. Problems pop up all the time, in lots of areas, but society is quick to pounce on them. This debate is a clear example of that.
Within families it is especially hard to imagine anyone but a sociopath devaluing a family member because of a disability. And family members will be influencing most decisions.
Doctors have dedicated their lives to working with sick people, so it is hard to imagine them mentally sorting their patients by value. That would conflict with their professionalism and personal values in nearly every case.
Disabled folks and the groups that support them have been highly effective in promoting their interests. We would expect them to be extra watchful if physician-assisted dying became legal in California.
I judge the risk of coercion for physician-assisted dying for the differently-abled to be real, but limited in scope. The size is probably in the range of patient abuse in elder care facilities, meaning it happens way too often, but the benefits of elder care still outweigh the risks.
The American Medical Association opposes physician-assisted dying because it violates the ethics of the profession. But individual doctors are free to decide what types of practices are offensive to them. We observe the same situation with abortion. It is fair to assume that most doctors will seek to avoid this area of medicine while some may see it as extraordinarily helpful for patients in need.
Verdict: The AMA’s position is exactly what we would hope to see from a professional organization of healers. It serves as a good counter-force to keep most doctors primarily focused on healing and out of the death business.
Most Americans take the position that individuals should have any type of freedom that does not hurt others. But in this case, opponents make a reasonable case that a physician-assisted dying law would literally kill some folks prematurely, violate human dignity as some would define it, devalue life as some people see it, and be an ethical burden on doctors. And there is a real risk that the pills sometimes do not get the job done. There is also a risk that a cure is around a corner and patient might miss out. And coercion is always a big concern.
I judge those risks to be real and substantial. (Any premature death or risk to the disabled is a substantial problem.)
Those real risks and problems must be weighed against the tens-of-thousands of patients who are in agony and want control over their own final chapter.
Ultimately the discussion boils down to how we rank a number of subjective factors. Based on observations over a lifetime, the following ranking seems most common for Americans:
2. Pain relief
3. Value of the painful last months of life
4. Human Dignity
5. Unpredictable but small risk to self
6. Unpredictable but small risk to others
I base the ranking on what people would be willing to trade. We often risk pain and discomfort to obtain freedom, but we rarely do the reverse. And most people would give up some human dignity to reduce the risk of injury.
Based on the rankings, it makes sense that a majority of well-informed Californians favor doctor-assisted dying. But a reasonable person could rank dignity higher than freedom, for example, because all of this is subjective.
This verdict is preliminary. I will be reviewing comment and upgrading it accordingly.
Many thanks to Jimmy Akin for a well-reasoned opinion to seed the Rationality Engine. But going forward we can depersonalize it and look to the facts and arguments alone.
For the proposed text of the California law, see here.
For a critique of the California law, see here:
One new development in pain r