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Jacob M. Appel

Jacob M. Appel

Posted: July 16, 2009 06:21 PM

Next: Assisted Suicide for Healthy People

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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.