Posted on November 3, 2014 at 1:38 PM
by Craig Klugman, Ph.D.
Over this past weekend, Brittany Maynard took her own life. At 29-years-old, Mrs. Maynard took her prescription for assisted suicide to end her life before her terminal brain cancer pushed her into a quality of life that she found unacceptable. She was young, articulate, and facing a very short lifespan where she would lose control of her body and mind, becoming increasingly dependent on others to complete activities of daily living.
Mrs. Maynard had stated her intention to take her life in an internet message that she sent out into the world. She had moved to Oregon from her home state of California in order to be able to take advantage of the Death with Dignity law there. Mrs. Maynard became the center of a Compassion and Choices campaign—an organization whose origins are in the right to die movement.
Oregon legalized assisted suicide in 1997 and since that time, close to 1,200 people have secured prescriptions but only 752 have taken the drug. Many do not take the drug because they die before they get the chance or they change their mind. Some studies suggest that what people seek is a sense of control when dealing with diseases that remove that. In 2014 alone, 7 states introduced death with dignity bills. In all but two the bills were defeated or expired. In New Jersey and Pennsylvania the bills are still under consideration. Assisted suicide in the United States is currently only legal in 5 states: Oregon, Washington, Montana, New Mexico, and Vermont.
In a highly divided nation, assisted suicide is a contentious issue along with same-sex marriage and abortion. In general, most palliative care and hospice organizations are against it. Some people see assisted suicide as cowardly, immoral, violating God’s will, removing the possibility of salvation, and as reprehensible. Some believe that physicians and other health care providers who write such prescriptions are violating the Hippocratic Oath as well as the healing and treating role of a physician. Others hold that the consideration of suicide is a sign of mental illness and that such people should be treated for depression and not be considered capacitated to make such a permanent decision.
Let us also remember that suicide holds a very strong stigma in mainstream U.S. society and in the Catholic, Jewish and Islamic traditions. A suicide in the family has historically been considered shameful and for the person who took his or her own life, meant committing an egregious sin. Americans are divided on their approval/disapproval of assisted suicide. Those with strong evangelical or Catholic religious identities and minorities are more likely to oppose assisted suicide than others. People with more education or who affiliate as Democrats and independents are more likely to approve of it. Individuals who have done advance care planning are also more likely to approve. These numbers are fairly close to beliefs about suicide in general which are more lenient toward those who have pain from disease than those who are physically healthy.
Despite cultural and religious taboos, for some people suicide may be the right choice. For Mrs. Maynard and her family that seems to have been the case. It was also the right choice for Gillian Bennett who took her life earlier this year to avoid her indignities from her dementia. A common question we ask healthy people when they are doing their advance care planning is to think about what makes your life worth living when deciding what treatment you do or do not want. We emphasis freedom of autonomy then. But when it comes to suicide, there is a knee jerk reaction that anyone who considers it must be depressed or irrational and therefore her or his autonomy should be curtailed. Or there is a feeling that these people have a disability and being in a tyranny-of-the-abled culture, these people are pressured to kill themselves in order to avoid being a burden on their families. From that perspective, society fails at offering support and creating a caring environment.
Clearly assisted suicide is not the answer for every patient who is terminally ill. A patient and family has many factors to weigh in their end-of-life decision-making which includes the prognosis for their disease and dying; their personal values; their relationships; their personal notion of what makes life worth living, have meaning; and their tolerance for pain. As the Oregon experience has shown, for many patients, assisted suicide is about having a feeling of control. The decision is a very personal one that needs to take into account not just the patient but also their family. That this was, controversially, the right decision for Mrs. Maynard does not mean it is the right decision for anyone else.
Many proponents of palliative care and hospice feel that their work means that assisted suicide is not necessary. Such statements make an assumption that suicide is a bad thing. Sudden, unplanned suicide by healthy people is tragic and leaves survivors with questions and often guilt that they could have done more. But that is not the case here. For Mrs. Maynard, even though palliative care could help with her acute symptoms, it could not assist with her existential ones—watching her lose control over her body and mind, the loss of what she felt was her dignity as others had to take on more and more of her daily activities of living, and living with the knowledge that for her, this diminishment was not a life she wanted to experience. The patient needs to know what other options are out there. The patient and family need social and spiritual support. And pain needs to be handled. A person in severe pain has trouble making decisions because the pain clouds everything. I would suggest that a person’s pain must at least be tempered if not under control, for him or her to make a rational choice about suicide.
The other consideration is that Mrs. Maynard and her family moved to Oregon in order to participate in assisted suicide. I think the fact that the family had to pick up and move away from their friends and support network in order to fulfill their own autonomous desires is shameful. Assisted suicide should be a last choice option taken only after rigorous screening and consideration of all options. But at the end of the day, if a patient is rational, not clinically depressed, and has the support of family, then he or she should have the right to leave this life according to her or his conscience when facing a debilitating, painful, and terminal disease. That this family had to move to accomplish this is sad. Rather than surrounded by the people and places she has known, Mrs. Maynard had to go elsewhere.
Let us recall that suicide by itself is legal. She could have simply stopped eating and drinking. But many people are unsuccessful in suicide attempts, often causing themselves more pain and suffering as a result of the attempt. Mrs. Maynard and some others want to be sure that their suicide is done successfully with a minimum of pain, with dignity, and with surety of success.
No patient should be forced into suicide. No physician should be required to or be reprimanded for not writing a prescription. But for a small subset of those with terminal illnesses, who are able to fulfill a rigorous review of their situation (as is the case in Oregon and Washington), then assisted suicide should be a compassionate and human option that allows a person to maximize living and minimize time spent dying. There may be pills to help with physical pain, but there is no pill that alleviates existential suffering.
Rest in peace Mrs. Maynard. Rest in peace.