Jonah Rubin
MD, soon Pulmonary/Critical Care fellow, views my own.

Societal Suicide: The Fatal Flaw of the Medical Aid in Dying Act

After last week’s vote in its Assembly and Senate, New Jersey is now a governor’s signature away from becoming the eighth state to allow physician-assisted suicide (PAS). This continues an unsurprising but disappointing decline along the slippery slope of devaluing human life that can have, and has had, dire consequences.

Every human heart must ache with compassion for the suffering, terminally ill patient who pleads for their own death. In addition to physical pain, which modern medicine can fortunately generally control quite well, the associated emotional, psychological, and existential pain is incomprehensible. But lack of a good solution does not justify accepting a terrible answer that leads to worse problems, and state legislated suicide is one such terrible answer, for medicine and for society.

The concept of “life not worth living”, which is precisely under discussion, gained prominence in the United States in the early 1900s. Some of this country’s most distinguished scientists, politicians, and philanthropists (including Carnegie and Rockefeller) viewed the lives of “imbeciles”, or the lesser educated lower classes, as not worth living and not worth reproducing. Tens of thousands of Americans were forcibly sterilized, sometimes unsuspectingly, so that with time the United States population would evolve into a purely elite society (a concept called “eugenics”). On a much smaller scale, some Americans were even passively euthanized. The Nazis learned from the Americans in their own pursuit of a “master race”, and legalized forced sterilizations and euthanasia on a much broader scale. As one American participant noted, “the Germans are beating us at our own game.” Ironically, the Nazis so fervently believed they were acting mercifully that they initially would not euthanize Jews – it was a kindness the Jews did not deserve. History is clear on where this philosophy led.

This is not to say that legalizing PAS will lead to a holocaust. But history has demonstrated clearly the extreme danger of devaluing human life and how the process begins. We could not have perceived in advance the atrocities caused by this philosophy in the 1930s, and we cannot definitively perceive now where the same philosophy will lead in 2020. But devaluation of human life has never led to anything good for humanity – which is intuitive.

Still, it is easy to speculate about where this very short and slippery slope could land. Currently in the United States, PAS is legal in some states but euthanasia is not. The difference is who performs the final act; PAS is when the physician provides the lethal medication but the patient must ingest it himself, whereas euthanasia is when the physician himself administers the lethal medication. But once the line is crossed into directly enabling someone to be killed, this distinction is arbitrary. Soon, advocates of PAS will point to the suffering terminally ill patients who are physically unable to ingest their own medications but similarly begging for death. Where is our compassion for this patient? Surely this patient deserves the same opportunity for “death with dignity” as one who could perform the act himself! Proponents will thus shift from advocating for PAS to advocating for voluntary euthanasia. But voluntary euthanasia is also discriminatory, because it only offers death with dignity to those who can request it. Where is our compassion for the terminal, suffering patient who lacks capacity to request euthanasia, but certainly would request it if he could? Advocates of voluntary euthanasia will thus begin to argue for involuntary euthanasia. And why offer euthanasia only to those suffering from a terminal illness? What of those who suffer from severe psychiatric illness or physical disability and can live decades with a horrifying quality of life? Isn’t that an even worse fate than that of the patient with only a few months to live? When we begin presuming for others that their life is not worth living, we will have regressed right back to the early 1900s. But once we accept PAS, there is no logical reason not to follow down this path.
Unfortunately, under the banner of compassion, this devaluation of human life has already begun and extends even beyond what compassion can justify. The State of Oregon became the first in the United States to legalize PAS. In 2016, lethal prescriptions were written for 204 patients. Only 5 of them were first referred for a psychiatric evaluation to ensure that depression or other treatable psychiatric conditions were not underlying their request for death. Compassion cannot justify allowing a patient to end their life before exhausting every other possible means of alleviating their suffering. A psychiatric evaluation should be the absolute minimal requirement – many people assume it is – and yet in Oregon it’s not.
And this leads to why PAS is a problem for the medical community itself as well. The original Hippocratic oath explicitly included “neither will I administer a poison to anybody when asked to do so, nor will I suggest such a course.” At a time when medicine offered nothing for pain control, Hippocrates still appreciated the danger of physicians playing God. The goal and efforts of the medical community must be entirely to heal. As it debases itself by assisting suicide, it shifts its priorities from saving life to managing life. It will, as it had, lead to offering death when it could instead prolong meaningful life.
About the Author
Jonah Rubin received his BA from Yeshiva University and MD from Columbia University, is completing Internal Medicine residency at Columbia University Medical Center/NewYork-Presbyterian Hospital, and will be a Pulmonary Critical Care fellow at Harvard University/Massachusetts General Hospital. He has a strong interest in the intersection of medical ethics, end of life care, and secular and Jewish law. Views are his own.
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