Physician-Assisted Suicide in the Western World

I was truly shocked when Daniel Kahneman, the Israeli behavioral economist and Nobel price recipient in economics for 2002, committed physician-assisted suicide (PAS) in Switzerland, the Mekka of PAS on March 27, 2024. He was 90 yrs old and as far as I know from reading about him he was in good health, both physical and mentally, especially for a 90 year old man. He knew what he was doing and arrived stealthily to Switzerland to die. I write stealthily because he was aware of the fact that this is not only illegal but also not popular way to exit one’s life in Israel. Actually, as most readers know, assisted or not Jewish law strictly forbids suicide. Why do people choose PAS in the first place? Many claim they want to die with dignity, on their own terms, not in suffering and pain. Some do not want to be a burden, especially not financial on their families.

Others, including Professor Kahneman, who knows? Are they tired of living? Are they suffering from perhaps unrecognized depression? Are they afraid of pain in their final days? Perhaps all of the above and some more. And does not modern medicine have many answers how to alleviate pain, fear, depression? Yes, it does. But in the case of PAS this type of suicide is justified by claiming that such patients are fully cognizant of their action and have the right to end their life on their own terms. Fine, but why not treat pain more rigorously, why not treat depression properly and why not involve loved ones? And by the way, there are two groups of patients where PAS or outright suicide is or at least was until recently unacceptable. People with disabilities, including people with dementia have unalienable rights just like other citizens, including “Life, Liberty, and the pursuit of Happiness” as expressed in the United States Declaration of Independence.

People with disabilities are rightly concerned that they might be forced into PAS or even worse that euthanasia, that might be considered and extension of PAS, might be imposed on them, in particular on patients with dementia. Many disabled persons value and enjoy life, perhaps even more than healthy people who never experience any health issues. The second group are psychiatric patients who suffer from depression and are suicidal: if patients who lost their will to live or are afraid of pain appearing with the progression of underlying disease are eligible for PAS, then why treat psychiatric patients? If they do not want to live just let them die, it is their choice and their life. This is what I heard from undergraduate students who took my bioethics class ten years ago. Oh wait, I forgot one group – children, yes children are allowed to commit PAS in Belgium and the Netherlands. They have to understand the outcome of their disease and the meaning of death and suicide.

Hippocrates oath taken by medical doctors as a part of graduation ceremony has been modified by many medical schools so it softens its pro-life parts, i.e., prohibition of PAS or euthanasia, and of abortions. I wondered how physicians feel after causing death of people who were not criminals on death row. Dr. Jack Kevorkian, the infamous doctor from Michigan was convinced PAS was a good deed, perhaps he just enjoyed killing people. He even developed a killing machine that he used to assist around 130 people to die. I wonder what kind of doctor or person can do these things. I also wonder about family members and friends who were present during PAS and witnessed the death, often unnecessary, of their loved one. Many describe it as a beautiful event, both before the death when the family gathers to celebrate life of a person about to be put to death, and how they felt after witnessing the death.- remorse, guilt, relief? I have never witnessed such an event, but I do find it abhorrent – it is witnessing an execution.

As acceptance of PAS has grown so has acceptance of euthanasia, at least under somewhat extreme circumstances. Hurricane Katrine brought total devastation to New Orleans in Louisiana in 2005. Part of this disaster was due to failure to evacuate people in time. Catastrophic flooding followed and many people perished. One hospital was unable to evacuate all patients in time. A doctor who stayed took the reins into her hands and euthanized patients the staff had difficulties moving to the roof for evacuation by helicopters. Patients who were immobile because of obesity or dependence on oxygen were sacrificed and perished as the doctor used opiates to kill them. Help arrived the next day. Though there was initially a big scandal and she was arrested, in the end she was set free not suffering any consequences.

PAS is not widespread in the USA, but it is gaining traction. This is a state issue so it has to be legalized in each state where it is supposed to be performed. A minority of states allow it; New York State was the most recent one to legalize it. Though it is not widespread as in the Netherlands, Belgium, Canada or Switzerland it is gaining steam in the US, especially in more liberal states. I have the impression just watching interactions between faculty and medical students that that the only barrier between them and using PAS is the law which prohibits it, at least in Georgia. It is frightening how quickly PAS is accepted as a legitimate medical procedure once it is legalized. This is happening in Canada where 1 in 20 deaths is occurring by PAS or euthanasia. PAS was legalized in 2016, and it actually includes euthanasia as well. It is called Medical Assistance in Dying (MAiD) by the Canadian government. There is also considerable support for euthanasia of certain psychiatric cases currently under debate. MAiD has been offered to patients with disabilities {instead of help with living conditions). Some impoverished elderly have opted for MAiD as well. It is a shame that Canada with its universal health care subsidized by provincial funding has stooped down. That this is happening in countries with highly developed medical research and medical care is shameful’

Suicide is forbidden in Halacha because it represents killing of body, or rather somebody belonging to God, not the person residing in the body. Jewish law prohibits not only suicide but also hastening death. According to Maimonides suicide is murder and the person committing suicide us then murderer as stated in Mishneh Torah. The burial and mourning ceremonies are modified for person who has taken his/her own life. These rules did not apply to Jews who took their own lives rather than converting to Christianity in Middle Ages during crusader wars. PAS does bring premature death, it may also bring unnecessary death. And so does euthanasia. Jewish law also recognizes that there are circumstances where prolonging life is an exercise in futility and that it is clear that nothing can be done for the patient except to let the person die in peace. I hope that Israel will keep its head up and do whatever it can do to adhere to our sacred Jewish values where saving one life equals to saving the whole world.