Next: Assisted Suicide for Healthy People

Advocates for physician-assisted suicide have in recent years focused upon the rights of the terminally ill and severely disabled to control their own destinies. Oregon's Death With Dignity Act of 1994 and Washington's Initiative 1000 of 2008 both limit medical providers to prescribing life-ending drugs to situations in which patients have only six months remaining to live. Many advocates for a "right to die" would also like to see such opportunities expanded to include fully-competent patients with locked-in syndromes, quadriplegias, and other forms of extreme disability, specifically in cases where these victims express an ongoing and rational desire to die, but are physically incapable of ending their own lives. To deny such patients assistance is, to my own thinking, a form of torture by inaction. However, the physician-assisted suicide movement -- and western society generally -- must now confront a far more challenging ethical dilemma: How should we handle healthy individuals who request medical assistance to end their own lives?

This week, the simultaneous suicides of British conductor Edward Downes and his wife, Joan, in Switzerland, have generated considerable controversy. While seventy-four year-old Joan apparently suffered from an imminently fatal cancer, her eighty-five year-old husband was "merely" increasingly deaf and blind. To critics interested in drawing bright and arbitrary lines, she might have qualified as a terminal case, while he might not have. However, most compassionate individuals, once they embrace the legitimacy of assisted suicide under some circumstances, would have little difficulty permitting these brave souls to die together. But what if one partner had been dying while the other had been in the full bloom of health? This is no longer an abstract philosophical inquiry. For George and Betty Coumbias of Vancouver, it has become a pressing matter of life and love and death.

As reported in the media, George Coumbias suffers from debilitating and potentially-deadly cardiac disease. His wife, Betty, also in her early seventies, is in good health. However, according to human rights attorney Ludwig Minelli, the director of the Swiss suicide-assistance organization, Dignitas, Mrs. Coumbias wishes to die alongside her husband during simultaneous suicides. She explained her motives in a 2007 documentary film, The Suicide Tourist: "From the day we got married, [my husband] was all my life....I love my two daughters, but I love him more, and I don't think I can face life without him, and since we read about Dignitas, we felt, What would be better than to die together, you know, to die in each other's arms?" The Coumbias are not the first couple to express a desire to depart side-by-side. In one highly-publicized case, on New Year's Day 2002, the octogenarian son and daughter-in-law of Admiral Chester Nimitz carried out a carefully-orchestrated death pact -- even writing checks to their children dated January 2 in order to avoid taxes. Other couples have done the same, although outside the media spotlight. But the Coumbias may be the first pair to seek legal sanction for such an arrangement. Minelli intends to petition the Canton of Zurich, where assisted-suicide is already permitted for the unwell, to grant local physicians the authority to prescribe lethal medication to healthy people. If his request is rejected, he plans to appeal to the Administrative Court of Zurich and even to the Federal Court of Switzerland. How unfortunate that so much cross-border legal wrangling is necessary for the Coumbias to do as they wish with their own bodies.

I do not know whether Betty Coumbias' decision to end her own life reflects deep wisdom or poor judgment -- much as I do not know whether she will enjoy an afterlife of eternal harmony or experience a sudden and irreversible cessation of being. Personally, I happen to find her devotion to her ill husband admirably romantic and all-too-rare. Yet this is beside the point. What matters is that the person best suited to determine Betty Coumbias' destiny is Betty Coumbias. Personal autonomy has long served as the core principal of both American medical ethics and liberal democracy. Individual choice should not yield to societal preference simply because the question is no longer how to live, but how to die.

I do not mean to suggest that autonomy does not have its appropriate limits or that suicide-on-demand should not be subject to meaningful regulation. Mental capacity -- the legal standard for making medical decisions -- should be required to honor such a request. Psychotic patients, for example, ought not be allowed to kill themselves during psychosis. Similarly, a seventeen-year-old girl, distraught after an argument with her boyfriend, should not be able to walk into a hospital emergency room and demand an immediate overdose of Tylenol. Society is within its bounds to require rational, informed choices, expressed over a reasonable period of time. Efforts should be made to ascertain that no undue pressure or duress lies behind the longing to die. Indian widows, coerced into throwing themselves onto funeral pyres, do not further the cause of individual liberty. Needless to say, despite the cries of alarmists, no sane people intend to force assisted suicide upon the unwilling to fullfill some dystopic vision.

If the healthy are granted the right to die, gray areas will inevitably arise. That does not mean that all areas are gray. A standard that one might use in determining whether to approve a suicide request could be: Under these circumstances, would any reasonable person make such a request? In the case of Betty and George Coumbias, the answer is an easy yes. A consistent plea to die in the arms of a beloved spouse, expressed over a period of two years, is not a wish that a set of officious Platonic guardians should second-guess. If Betty Coumbias had only six months left to live and expressed such a desire, most assisted-suicide advocates would support her cause. Why should she have any less control over her own life because she is fortunate enough to be in good health?

Some supporters of physician-assisted suicide may worry that assisted suicide for the healthy is too much, too soon, and risks turning the general public against a noble cause. That is not a concern to be dismissed lightly. But Betty Coumbias does not owe her body to the assisted-suicide movement any more than she owes it to those who oppose assisted suicide. Her life is hers and hers alone. A free society, to be truly worthy of that name, owes her, and other healthy, competent individuals with similar wishes, the right to live and to end their lives on their own terms.

Comments

[onenation]

So...
A trip to the school board committee meeting to work for better schools is to tough.
If you can't just get it from Limbaugh, it is to dificult, and he said we are all gona die.
If you are 25 and die in a war, that is ok. But if -.99 (conception), that is so bad you can just give up.

[onenation]

And how about the people, especially kids, of Jones Town?

Not so simple??

[sharonms]

If someone chooses to end his or her life, it should be no one's business. It's a horrible choice - and hurts loved ones - but the LAWS should have no say in this.

[tbone99]

In lieu of little affordable health care and almost no mental health care which offer the option of being zapped wit electricity or beng served toxic chemical cocktails to keep a happy face on prove that the choice of euthanasai is the only sane one.

Our governement has made clear that they only value people who who make six figures and up.
Anyone considered not a producer is a burden to society, so for those of you who who want to philosophize - you need to face the facts on the ground.

[WorkingClass]

All your life other people tell you how to live. Its not surprising they want to tell you how and when to die. Bob Dylan said - "When you die they let you off the hook".

[Stanley Terman]

Trex86 is correct: A well-crafted advance directive can determine WHEN to Permit Natural Dying, with adequate comfort care so the process is peaceful. Remember "No man is an island," and take literally, what Mrs. Coumbias said, "I don't think I can face life without him." Okay, she does NOT think so now, in anticipation of her husband's death--but she might change her mind, as many people do. The State is required to protect people from making very harmful irreversible decisions, and the decision to commit suicide--for healthy people--qualifies. That said, I am in favor of strategic planning to stop intake of even oral food and fluid in a health body that can still swallow--if the mind has been devastated by Advanced Dementia. (See the 2009 book, "Peaceful Transitions: An Ironclad Strategy to Die When and How YOU Want.")

[TeeLolly]

As long as the state permits people to die when they have no health insurance and lack the funds to pay for needed life-sustaining medical care, the state has no business telling anyone whether he or she should be permitted to die ...

[milesz]

Let's first get the nomenclature right: a terminally ill competent person who wishes to die with dignity is NOT a suicide! Those suffering from disease that is NOT life-threatening do not fall into this same category.

[Lionel De Mun]

I don't get the point of this suicide (assisted or not) epidemia.
In days of yore, for better or worse, most people tried to stick to life, and I've been told life was pretty much harder a few decades ago , people in wars or in camps tried everything to survive in front of overwhelming odds.Nowad­ays it seems that lots of people don't want to put up a fight anymore in font of outrageous fortune and want to be put to sleep like cats and dogs. There is something deeply troubling, even weird, in such a behaviour.

[tbone99]

Fewer people live in fear of helll and billions of people live in a world in which humans are nothing more than a commodity ,in some ways it is actually trying to wrest some kind of control from corporate feudalism

[jcwtts1]

Slipper Slope. I believe deeply in a persons right to determine their own fate... if terminal. If they are healthy, as tough as it may seem today, they have to push on. You can't start providing suicide pills for healthy people. Her husband is going to die. She is going to live. It gets better. There is no way to tell if she is depressed, no way to tell if he is having an undue influence on her. No. If she were terminal I would say let her go. She is healthy she should stay. Further, by euthanizing healthy patients you confirm every negative awful fear of the people against assisted suicide. You weaken the chance of people who need it getting the service. In a healthy person assisted suicide is murder.

J

if you have lost someone close to you you realize you aren't rational for a period of time surrounding their death. You may think you are. You may believe deeply, too your core, that you are, but you are not.

[tbone99]

Why must we push on ?

if we don't want to live in a world in which life requires more than we have to give , why not opt out?
Obviously people are going to find a way if their pain outperforms their coping skills , so why force them to do it in some painful and often incompetent way where the taxpayer ends up supporting their life support for the next thirty years.

Its not like we are lacking for humans

[dotsthefunist]

Having had so many friends commit suicide I've seen the mess and loose ends that weren't cleaned up
have to be dealt with by the people who usually had no idea that their friend,loved one was going to actually pull it off and end it . We wonder if it was our fault,could we have helped if we had known ,our hurt in missing them compared to the pain they were in is the mystery of life and death .

If a physically healthy person ( and who is healthy compared to what ) wants to end their life because they feel they couldn't start living or that life was just too hard for them to deal with it should be a legal option . I am surprised there haven't been law suits filed against the people who actually go past the suicide attempt stage and join the ranks of those that do succeed so it isn't just another attempt.

" Life sucks then you die " is kinda funny ,if you are constantly in love or feel you are relied on by those that need you for what ever reasons you live to wake up again .
Is life legal in a world where you may just be a race,creed or color that annoys the power mad survivors in what is becoming a reality t.v. show ?

This is a subject that shouldn't be pushed under the rug ,like it or not all humans ARE humans .

[been2there]

Actually, she may well be just as terminal as her husband. People do die of a broken heart; she sounds like a prime candidate for this. Denying her the chance to die with her husband is likely to get her nothing but a few months of severe depression--and that is just plain cruel. Trying to balance letting those whose misery--whatever the cause of that misery--bring it to a dignified end against the need to prevent impulsive actions from prematurely ending lives is going to be difficult. Although I have suffered severe depression most of my life, I have never truly wanted to die; what I wanted was to live, not just exist. I can, however, understand those who do want to die and end the misery. I have been mighty close.

[Chrisallalone]

If Mrs. Coumbias wishes to end her life, I don't believe her society can forbid or prevent her. However, I don't think that means she has the right to ask that a physician perform that task, and were I a physician, I certainly would not wish to do so.

Moreover, I'm not sure that just because a desire is stated consistently and calmly over time, that automatically makes it rational -- and certainly not "romantic.­" I adore my husband, and if I were dying I would take great comfort in the notion of his continuing his life and finding future happiness. Such unwillingness as this to live without someone sounds like an unhappy dependency or depression, not a state of good mental health and clear judgment.

[cgr]

This invites the sort of discourse that society needs to have, but frankly I'm surprised to see anyone put it out there. All the ideologues will no doubt rush forth with harsh condemnation: life-is-sacred, etc., and will turn deaf ears to any further discussion. Even just those heavily influenced by conformity will dismiss it, having accepted without question the reifications of society.

But open minds will consider. The Chinese have a saying: "How calmly the poppy petal falls". Like the poppy petal, in the grand scheme of things we are a part of the ongoing, seamless process that is reality, a tiny part of the constant exchange of energy, of life, death and regeneration. I believe in the individual's right to making choices about for his/her own life and death.

Society has become so complex, nearly everything is legislated, and so too this sort of thing involves legislation now. But it's a freedom, and a right, I think, that can't really be taken from us. if a certain quality of life was gone, I know I would choose to die by my own choice rather than suffer and, let my love ones to suffer helplessly by, deplete finances clinging to "Life". Death comes to us all, only the ego resists. There's a lovely peace in accepting one's own mortality.

I hope your blog is a catalyst to a lot of musing, listening and discussion. Open minds, open hearts, life at its most dynamic.

[Ohioan730]

I want people to have all the control over their lives that they want. If they want to die, let them.

This is the troubling part--is this going to open the door for chronic sufferers of depression and mood disorders to be considered? Where is the line going to be drawn? Just trying to think like a lawyer in this case because ultimately something like that would be resolved in court and there is a compelling argument to be made on both sides:

Is a mentally ill person even capable of making that decision for themselves? How will it be determined?

Is the suffering of a person afflicted with mood disorders in any less "pain" than someone else because its a different kind of chronic pain and not necessarily physical?

Will they be required to exhaust all treatment possibilities first the way chronically physical pain sufferers do? Mood disorders have more varying treatment plans.

Was Vonnegut a prophet?

I know it sounds silly but that could be where this argument is heading in the near future. Its going to stir up the Fundamentalists something awful. Would they condemn it? These are not helpless fetuses were talking about. They seem to support the death penalty so I wonder what would be their argument.

Interesting hypothetical situation, I think.

[TRex86]

Assisted suicide AKA "aid in dying" physicians to abet a suicide. Hence, this is very much about changing the role of physicians, in this case, prescribing lethal drugs to the healthy partner of a sick person. This doesn't work in the medical model. Controlled substances must be prescribed to the person that has the disease.
Moreover, overwhelming evidence indicates that a request for hastened death is a symptom of treatable depression. No doubt the partner of a dying person would also be depressed. In neither case is the treatment of choice for depression a lethal overdose. Setting aside the dreadful sentimentality of this essay it radically restructures the role of physicians.
Keep in mind its naivete. Most physicians know nothing about palliative medicine. Nor do they have skills at managing depression. How then does their lack of skills logically translate into granting them a 007 license to give lethal medicines to non-sick people? Under the laws of Oregon and Washington any two doctors can certify a patient for a lethal OD. Appel proposes extending this bizarre role to prescribing for the partners of the sick.
In radically changing medicine from its Hippocratic roots ("I will give no poison") the problem of counter-tr­ansference arises. For me to give a patient a lethal prescription I must suspend my objectivity and believe that his/her life isn't worth living. Such a decision gets deep inside the psychology of physicians and isn't about the patients. It's a very bad idea.

[TimmyTurnersDad]

Thank you sir for this wonderful post. I'm guessing you are a doctor. Either way, you are right on the money. If that lady wants to do herself in because her husband is dying, there are many ways to do it. On her own. Any ethical doctor would have nothing to do with this. As far as I'm concerned, nothing else needs to be said on this matter.

[Unitynow8]

Why does it have to be a doctor doing the assist?

[tbone99]

I guess fundamentalists believe you need to kill another person before you get the right to die.

[afram1]

Troubling.

I believe this is the start of a slippery slope that takes humanity in the wrong direction.

I believe that human beings should be allowed to have the individual choice on how to end their lives, but personally, I find it troubling and morally repugnant.

To each his own.