By this time next year, physician-assisted suicide will have become legally permissible in California. Just last October, bill ABX2-15, the California End of Life Option Act, was signed into law by Governor Jerry Brown, allowing for a patient with a terminal illness to “request for a drug prescribed pursuant […] for the purpose of ending his or her life” . Although already legally permissible in four other states, the adoption of physician-assisted suicide (PAS) in California once again provokes questions of both its morality and ethicality in the U.S., where PAS is not yet widely implemented as medical policy. The incorporation of this bill into law suggests that there is increasing momentum towards patients’ rights to autonomy and a changing public opinion on the amount of value that life holds. These changes in thought could affect other medical programs and decisions in the future.
The term “intrinsic value of life” references the value that life holds in itself, through the happiness or well-being that it brings, and the other experiences to which it leads. Some examples of other concepts that hold intrinsic value are friendships and knowledge. Most central arguments against a policy like physician-assisted suicide assert that although PAS puts a patient’s personal wants over that of a doctor or the state, those patients may not know what is best for their ultimate well-being, as suicide destroys the talent and capacity left in a person, diminishes the intrinsic value that life possesses, and causes worry over potential abuse of the system. However, while suicide possesses a stigma, it may nevertheless provide benefits for certain groups of people, especially those at end-of-life stages. Vanderbilt University professor of philosophy John Lachs believes that the uniqueness of human life lies in the ability to consciously enjoy it, and when the ability to experience life disappears or the joyfulness of life is overshadowed by pain and suffering in those who are terminally ill, PAS becomes justified (2). Consequently, the California bill mandates that only patients with terminal illnesses, who arguably do not have any intrinsic value left in life, are qualified to request an aid-in-dying drug, which differs from the much more open laws in other countries that allow other people, such as psychologically ill patients, to request PAS, as will be discussed later.
Another popular argument against PAS is that a government has an obligation to protect its people, and it cannot do so if terminally ill people are allowed to request suicide. In response, Lachs acknowledges that “the state can impose a variety of demands and limitations on its citizens, though only ones that promote the common good”, but also comments that “the existence of people in excruciating pain […] contributes nothing to the common good” (2). Likewise, the government also has an obligation to allow the autonomy of its people. Patient autonomy involves patients’ rights to refuse or request certain procedures; thus, patient autonomy holds intrinsic value and elicits respect from both government and hospitals. The recent incorporation of the right to request PAS into California law illustrates the political inclination more towards the idea of patient autonomy, demonstrating the slight concession of control that the state government has allowed.
On the other end of the spectrum, some countries in Europe seem to fully embrace the idea of PAS as a viable solution to end-of-life issues. Many Western European countries such as Belgium, Germany, and the Netherlands have legalized physician-assisted suicide and have been practicing it for years. For instance, in the Netherlands, in 2005, just three years after its euthanasia-legalizing act was passed in 2002, 1.7 percent of all deaths in the country were attributed to physician assisted suicide and euthanasia, according to a study published in The New England Journal of Medicine in 2007 (3). However, the study notes that “in effect [the act] simply legalized an existing practice, since physicians had not been prosecuted for actions to end the lives of patients”, and that in 2001, before the Euthanasia Act, ironically a larger percentage (2.6 percent) of deaths had been credited with physician help. These percentages amount to thousands of patients every year, most of whom are affected with terminal cancer or cardiovascular disease, and around half of which are given a week to live. Additionally, in the Netherlands, the relationships between the patient and a doctor need not be close in order for the patient to request PAS. A significant number of patients go to mobile euthanasia clinics to request such procedures, a highly controversial system where a strong relationship between patient and physician is not required for the administration of aid-in-dying drugs. Ethically, doctors should familiarize themselves with a patient and his or her personal issues before deciding to perform PAS, to avoid any unjustified attempts at suicide. Thus, such an extremely liberal PAS program would be hard-pressed to find public support in the U.S., so nationwide incorporation of PAS into law similar to the extent of that of the Netherlands is still distant from reality.
On a similar note, the Netherland’s idea of physician-related suicide is much looser than that of the United States in a sense that it is not limited just to patients with terminal illnesses. Interestingly, a recently published article early February this year, led by bioethicist Scott Kim of the National Institutes of Health, found that patients with psychiatric disorders account for a significant portion of the requests for help to end their lives, but the definition and degree of psychiatric illness to which PAS is granted varies greatly across doctors (4). Illnesses ranging from depression and PTSD all the way to eating disorders and autism elicit different responses from different physicians, and there is no countrywide standard for the extent of ailment that justifies PAS. Issues of standardization and the justification of physician-assisted suicide cause problems for those who worry about the ethicality of such loose regulations, and the Netherlands, the country at the forefront of such legislation, is left to deal with them. The future of physician-assisted suicide in the United States, however, still remains unclear.
Since the passing of the Oregon Death with Dignity Act in 1997, physician-assisted suicide seems to have generally gained some public support, at least in the liberal Pacific Northwest, where both Oregon and Washington state have legalized PAS. The annual 2015 Death with Dignity Act Report states that 991 patients in Oregon have so far taken advantage of this legislation since its inception, with increasing percentages of the population requesting this type of end-of-life treatment every year (5). However, even then, the number of Oregon residents requesting PAS amounts to only a small number in the large scheme of possible PAS candidates, and the legalization of PAS has not caused a huge change in end-of-life care. But the legalization of physician-assisted suicide in a state like California sets a new precedent for the United States. Washington University in St. Louis biomedical ethics professor Charlie Kurth points out that California is a trendsetter for many controversial political and social issues in America, and he notes that “how California goes, so goes much of the country, at least shortly thereafter”. However, Kurth speculates that the social acceptance of PAS in the general United States will be slower, saying, “I suspect that it won’t be something that happens quickly, but people are becoming more comfortable with physician-assisted suicide in the United States. Whether the right to do so, I think, is a different question.” He elaborates that these issues will be fraught with disagreements between various groups of people as the implementation of PAS gets closer: “Maybe part of what’s driving [conflict] is that the baby-boom generation is starting to get into their seventies, and so you’ve got a significant chunk of the population who is now thinking much more seriously about it. […] I also suspect that you’ll see physicians separating on the issue; some will clearly be uncomfortable, but perhaps a significant chunk of them will think that this is an important part of what they can do for individuals that are suffering.” In regards as to what will ultimately happen to the concept of physician-assisted suicide in the U.S., the approaching situation in California next year will be a strong indicator for predicting developments in the future.