The debate over assisted
suicide reached this page eight weeks ago, when Michael J. Sandel criticized
the philosophers' brief, in which six leading liberal philosophers urged the
Supreme Court to overturn state laws prohibiting doctors (or anyone else) from
helping terminally ill patients kill themselves. Suicide, the philosophers
said, is a "liberty right," and assistance is morally legitimate and
should be legally permitted whenever it is requested by competent persons
exercising that right. Our lives are our own, and we can choose and arrange our
own deaths. Sandel, however, pointed out that there is another understanding of
human life, which denies the individual's absolute ownership and asserts
instead a larger, divine or communal, interest: we are not the sole authors of
our life drama. He urged the Court not to be too quick to choose between these
radically different understandings.
I am not going to choose
between them either: they are each partly right. But, even if the philosophers
have the better case, there are still very strong arguments against the
legalization of assisted suicide in this country, here and now. These have to
do with another right that men and women hold: not to be killed, or pressed to
kill themselves, or quietly hustled off in any way before their time. The
relevance of this right, given the radical inequities of health care in the United States, is
forcefully argued in a book-length report published by the New York State Task
Force on Life and the Law, When Death Is Sought. Consider some of its
arguments.
Advocates of assisted suicide
recognize that legalization would require a regime of restraint and precaution.
No assistance without second opinions, psychiatric consultations, strenuous
efforts to relieve the pain and provision of hospice services: that is the
maximal program, and all of it is morally necessary.
Only after everything else
has been tried, and the patient's intentions repeatedly queried, could the
lethal pill or injection be allowed. But who would pay for all these services?
And how is it possible, without a national health care system, to guarantee
that they will in fact be provided for all patients, rich or poor, young or
old, majority or minority, with familial support or isolated and alone?
The philosophers' brief
argues that if suicide is a right, then the state is obligated to protect its
exercise-and thus ensure the necessary safeguards. And the philosophers seem to
assume that, once the Court recognizes this right, the legislative and
executive branches of government will see to it that what is necessary in
principle is provided in practice. They write as if philosophical argument and
judicial decision can generate an equality of treatment that doesn't exist and
has never existed in American medicine.
Of course, it's not out of
the question that state governments or the federal government would require
expensive consultations and therapies for patients who threaten to kill
themselves. As in the case of hospitalization after childbirth, governments
might step in to mandate the extra care, and also to force insurance companies
to pay for it-especially if there were highly publicized stories about people
dispatched in a hurry, without the consultations and therapies. But this seems
a terribly uncertain way of forcing health care provision, and the victory, if
it were won, would benefit only an oddly restricted group. Terminally ill
patients who don't threaten to kill themselves, because they have moral or
religious objections to suicide, would not benefit at all. Still, why not allow
assisted suicide, and try to guarantee the necessary safeguards, for those
without objections? The point of the safeguards, after all, is not to provide
suicidal patients with free care but only to make sure that they really want to
die.
But the question of how many
people really want to die doesn't depend only on the treatment provided to
those who announce that they want to die. As the Task Force report argues, the
number of people who consider suicide, and the number who choose suicide, is
largely determined by the quality of care provided to the whole cohort of very
sick people, before the thoughts occur and the choices are made. And the
quality of care actually provided right now to poor people (many of them
members of minority groups) ought to worry the defenders of assisted suicide.
There probably are a lot more suffering and suicidal people in this country
than they imagine, and it isn't likely that all or even most of them would
suddenly receive, after a Court decision, the care they require.
According to the Task Force
report, "advances in pain control have rendered cases of intolerable and
untreatable pain extremely rare." But cases of untreated pain are not rare
at all, and statistical studies of the available data on who gets palliative
care are depressingly familiar. Patients at clinics and hospitals that serve
minority populations, for example, are three times more likely to receive
inadequate pain relief than those treated elsewhere. I suspect that a study of
hospice care would show even greater disparities. There are problems for the
middle class also: many insurance policies don't cover expensive forms of pain
relief (while some cover only the most expensive technological interventions
but not more ordinary medication). And, then again, there are millions of
Americans with no insurance at all, and this number seems to be growing.
Ironically, the chief problem
with assisted suicide may not be moral or legal so much as financial: it is
just too cheap relative to the available medical alternatives. And, in a world
of market medicine and tightening government budgets, cheap is all too likely
to mean attractive. Once again, the money needed to care for those who threaten
suicide, and even for all terminally ill men and women, including the very old
and very poor, might be forthcoming. The equal protection clause would seem to
require it, and our collective uneasiness with suicide might help to loosen the
national purse strings. But I doubt it.
The vulnerable population is
just too large for this particular social experiment. I don't mean that people
would be assisted against their will (though there would probably be cases like
that), but rather that the suffering that leads them to seek assistance in
dying will often be avoidable suffering, and that it will be distributed, as it
is now, in morally unacceptable ways.
Reading the arguments about
assisted suicide reminded me of a line from Bertolt Brecht's The Three-Penny
Opera: "First feed the face, and then talk right and wrong." As a
general rule, that statement is itself wrong, of course, but it can sometimes
serve as a salutary warning. First, provide decent health care for the living;
then, we can have a proper debate about the moral problems of death and dying.
