On Tuesday, Sept. 26, Dennis Hollinger, Ph.D. , President & Colman M. Mockler Distinguished Professor of Christian Ethics and Dr. Karen Mason, Associate Professor of Counseling and Psychology testified before the Joint Committee on Public Health at the Massachusetts Statehouse regarding Physician Assisted Suicide and House Bill 119A, An Act Relative to End of Life Options. The following are their transcribed testimonies.

Dennis Hollinger, Ph.D.,
Testimony on Physician Assisted Suicide

There have been at least three major ethical arguments given to support physician-assisted suicide.  While these arguments at first glance seem laudable, each carries with them logical and ethical flaws.

 

Compassion

The most frequently heard appeal for medical assistance in dying is that it’s only compassionate to end the agony of a person in severe pain by taking their life.  As human beings we of course have moral obligations to show compassion to all humans, and especially those enduring extreme hardship, suffering and injustices.

But compassion is not a moral principle isolated from other principles and virtues.  In other words, compassion is not the moral trump card.  And as the late Dr. Edmund Pellegrino (Georgetown U.) once put it, “Compassion should accompany moral acts, but it does not justify them.”

The word compassion comes from the Latin term, meaning to suffer with.  We do not suffer with a dying patient in pain by ending their life, but by providing compassionate care that aims to mitigate the pain and suffering.  Palliative care (the art of pain control), hospice care and terminal sedation (an induced continuous sleep mode) are all means of providing compassionate care at the end of life.  These are clear alternatives to assisted suicide.

Autonomy/Freedom

A second major argument for physician-assisted suicide is that since we are autonomous beings we should have, in the face of pain and suffering, the freedom to end life as we see fit; and that entails medical assistance.  This is an old argument for euthanasia as Seneca, the Roman Stoic Philosopher once contended, “As I choose the ship in which I sail and the house in which I shall inhabit, so I will choose the death by which I will leave life.  In no matter more than in death should we act according to our desire.”

But there are fundamental flaws in this argument.  First, physician assisted suicide is never an autonomous act.  It involves doctors who must acquiesce to the request, nurses who accompany the act, families who are impacted by the act and the whole of society to which the person belongs.  An isolated autonomy denies the bonds of solidarity and community in which all humans reside and through which they find meaning, solace and identity.  Moreover, the principle of autonomy or freedom as a grounds for assisted suicide “accords rights only to those who are fully autonomous, putting the demented, the … [mentally impaired], or the permanently comatose at serious risk.”   Autonomy, applied to medically assisted dying, discriminates against suffering patients who are unable to make autonomous judgments.

Assisted Suicide is No Different than Treatment Termination

A third argument for assisted suicide is that it is no different than treatment termination, in which medical support is withdrawn and the patient dies.  Treatment termination is widely accepted and practiced everyday in hospitals around the world.  In both treatment termination and assisted suicide death is the outcome, thus goes the argument, there is no moral distinction between the two.

But there is a major flaw in this argument.  Namely, in treatment termination the disease takes the life, while in assisted suicide a human action involving death inducing drugs takes the life.  As Oxford ethicist Nigel Biggar points out, this argument for assisted suicide “suffers from a major flaw… by its implicit denial of any moral difference between involuntary homicide and murder, the outcome—death—being the same in both cases.”   In one action the intention is death.  In the other action the intention is to let nature or divine providence take its course.

Conclusion

Assisted suicide suffers from major flaws logically and morally.  But beyond that human life is a gift to be protected, nurtured and honored.  We do not protect, nurture and honor life when we grant a legal right to actively terminate it.

Karen Mason, Ph.D.,
Testimony on Physician Assisted Suicide

Legalizing Aid in Dying may open the door to suicide because of the interrelationships between suicide and Aid in Dying procedurally, morally and psychologically.

1. Procedurally

2. Morally

• I came to realize this moral interrelationship while interviewing 15 Catholic, Jewish and Protestant clergy about their moral deliberations on suicide, ending futile medical treatment, Aid in Dying and euthanasia using vignettes (Mason, Kim, Martin & Gober, 2017). What struck us is that the respondents used the same moral principles to deliberate morally on vignettes depicting each of these types of death. The primary principles used were sanctity of life and the preservation of the natural course of life and others.

3. Psychologically

Another interrelationship is psychological. What has struck me is the similarity of the underlying psychology in those who request Aid in Dying and those at risk of suicide.

Herbert Hendin (1997), former Medical Director for the American Foundation for Suicide Prevention and professor in the Department of Psychiatry and Behavioral Sciences, New York Medical College has written that seriously or terminally ill people who wish to end their lives are not significantly different from other suicidal people.
Burdensomeness:

• One psychological similarity is feeling one is a burden to others. A person who is depressed may be unable to go to work or contribute positively to the family. If this depressed person perceives him/herself to be a burden, she or he may make the mental calculation “my family would be better off without me,” “they would be better off if I were dead.” This thinking is a robust predictor of suicide risk (Chu et al., 2017; Kanzler, Bryan, McGeary, & Morrow, 2012).

• Some who request Aid in Dying similarly dread dependence on others. Legalizing Aid in Dying will result in an erosion in the belief that people, even those who cannot contribute productively, are not burdensome because life in all its forms is valued.

• Ganzini, Silveira, and Johnson (2002) found that patients with amyotrophic lateral sclerosis (ALS) who were interested in assisted suicide had greater distress at being a burden than ALS patients not interested in assisted suicide.

• Ganzini and Back (2003) found that people who requested Aid in Dying had a life-long value of control, dreaded dependence on others, were ready to die and assessed their quality of life as poor.

• Kaplan and Schwartz (2008) conducted psychological autopsies on Kevorkian’s 93 Aid in Dying cases. More than one-third (37%) of the decedents for whom depression data was available (the first 47 cases) were described as depressed. This percentage was higher for women (40%) than for men (30%). 90% of the first 47 cases were reported as having declared that they had a high fear of dependence on others in their disabled condition.

Depression:

• Since Ganzini & Back (2003), a number of studies have found a relationship between depression and considering Aid in Dying (Marrie et al., 2017). Depression is also related to suicidal thinking (Franklin et al., 2017). Depression can distort judgment and affect the capacity to make an Aid in Dying decision (Quill, Back, & Block, 2016).

• Hendin offers this example: “A 64-year-old woman with advanced lung cancer requested death. She was treated with a combination of analgesics (morphine and acetaminophen) on a regular basis…She was also started on antidepressants … and agreed to talk with a psychiatrist. Her mood improved rapidly, there was dramatic reduction in her pain, and she began to view her life more positively. She spoke openly about dying but wanted to be alive as long as her pain could be controlled. When asked whether the doctors should have “killed” her when she requested it, she responded with a definite no, recognizing that pain had so depressed her that she could only wish for death” (p.  211).

• Smith et al. (2015) compared 55 Oregonians who requested Aid in Dying with 39 Oregonians with advanced disease who did not pursue Aid in Dying. The predictors of requesting Aid in Dying included: increased education, higher levels of depression, hopelessness, and higher levels of dread of dependence and lower levels of spirituality. No differences were found on pain or perceived level of social support

Conclusion:

I am concerned that legalizing Aid in Dying may be related to an increase in suicide.

• Jones and Paton (2015) found that in Oregon and Washington, legalizing Aid in Dying was associated with a 6.3% increase in total suicides (including assisted suicides). The increase was 14.5% in individuals over 65 years old. More research like this is needed to clarify the relationship between Aid in Dying and suicide. Some have argued that Aid in Dying prevents suicide because Aid in Dying provides people with terminal illnesses the opportunity to wait longer before death, knowing that Aid in Dying is available. This study found no evidence that Aid in Dying was associated with significant reductions in suicide for either older or younger people, and, there was NO significant decrease in suicides, even among those older than age 65.

 Additional Resources

• Life’s Worth: The Case Against Assisted Suicide (Critical Issues in Bioethics Series) by Mr. Arthur J. Dyck (Author), Mr. Dennis P. Hollinger (Foreword), Mr. Francis J. Beckwith (Foreword)
• Preventing Suicide: A Handbook for Pastors, Chaplains and Pastoral Counselors by Dr. Karen Mason
• Seduced by Death: Doctors, Patients, and Assisted Suicide by Herbert Hendin M.D. 
• Aiming to Kill by Niger Biggar
• Dignity and Dying: A Christian Appraisal by Mr. John F. Kilner (Editor), Mr. Edmund D. Pellegrino (Editor), Mrs. Arlene B. Miller (Editor)
  

References

Edmund Pellegrino, “Euthanasia and Assisted Suicide,” in John Kilner, Arlene Miller and Edmund Pellegrino eds., Dignity and Dying:  A Christian Appraisal (Grand Rapids:  Eerdmans, 1996), 110.
Seneca, Laws IX: 843.
Pellegrino, 109.
Nigel Biggar, Aiming to Kill:  the Ethics of Suicide and Euthanasia (London:  Darton, Longman and Todd, 2004), 67.

Chu, C., Walker, K.L., Stanley, I.H., Hirsch, J.K., Greenberg, J.H., Rudd, M.D., & Joiner, T.E. (2017). Perceived problem-solving deficits and suicidal ideation: evidence for the explanatory roles of thwarted belongingness and perceived burdensomeness in five samples. Journal of Personality and Social Psychology.
Doernberg, S.N., Peteet, J.R., & Kim, S.Y.H. (2016). Capacity evaluations of psychiatric patients requesting assisted death in the Netherlands. Psychosomatics: Journal of Consultation and Liaison Psychiatry, 57(6), 556-565.
Franklin, J. C., Ribeiro, J. D., Fox, K. R., Bentley, K. H., Kleiman, E. M., Huang, X., & … Nock, M. K. (2017). Risk factors for suicidal thoughts and behaviors: A meta-analysis of 50 years of research. Psychological Bulletin, 143(2), 187-232.
Ganzini, L., & Back, A. (2003). From the USA: Understanding requests for physician-assisted death. Palliative Medicine, 17(2), 113-114.
Ganzini, L., Goy, E.R., & Dobscha, S.K. (2008). Why Oregon patients request assisted death: family members’ views. Journal of General Internal Medicine, 23(2), 154-157.
Ganzini, L., Silveira, M. J., & Johnston, W. S. (2002). Predictors and correlates of interest in assisted suicide in the final month of life among ALS patients in Oregon and Washington. Journal of Pain and Symptom Management, 24(3), 312-317.
Goy, B.R., Carlson, B., Simopoulos, N., Jackson, A., Ganzini, L. (2006). Determinants of Oregon hospice chaplains’ views on physician-assisted suicide. Journal of Palliative Care, 22(2), 83-90.
Hendin, H. (1997). Seduced by Death: Doctors, Patients, and the Dutch Cure. New York, NY: W.W. Norton & Co.
Jones, D.A., & Paton, D. (2015). How does legalization of physician-assisted suicide affect rates of suicide? Southern Medical Journal, 198(10), 600-604
Kaplan, K.J., & Schwartz, M.B. (2008). A psychology of hope: A biblical response to tragedy and suicide. Grand Rapids, MI: Eerdmans.
Kanzler, K.E., Bryan, C.J., McGeary, D.D., & MOrrow, C.E. (2012). Suicidal ideation and perceived burdensomeness in patients with chronic pain. Pain Practice, 12(8), 602-609.
Marrie, R.A., Salter, A., Tyry, T., Cutter, G.R., Cofield, S., & Fox, R.J. (2017). High hypothetical interest in physician-assisted death in multiple sclerosis. Neurology, 88(16), 1528-1534.
Mason, K., Kim, E., Martin, W.B., & Gober, R.J. (2017). The moral deliberations of 15 clergy on suicide and assisted death: a qualitative study. Pastoral Psychology, 66(3), 335-351.
Pereira, J. (2011). Legalizing euthanasia or assisted suicide: the illusion of safeguards and controls. Current Oncology, 18(2), e38-e45.
Quill, T.E., Back, A.L., & Block, S.D. (2016). Responding to patients requesting physician-assisted death: physician involvement at the very end of life. JAMA: Journal of the American Medical Association, 315(3), 245-246.
Smith, K.A., Harvath, T.A., Goy, E.R., & Ganzini, L. (2015). Predictors of pursuit of physician-assisted death. Journal of Pain and Symptom Management, 49(3), 555-561.