Text for Walzer: Feed the Face

Feed the face

Michael Walzer. The New Republic. Washington: Jun 9, 1997.Vol.216, Iss. 23;  pg. 29, 1 pgs

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.