Sunday, November 22, 2015

Why I Need to Leave the United States to Die

In the United States, legislation to allow death with dignity or aid in dying is passing one state at a time. These laws generally allow doctors to help someone die if that person has a terminal illness and six months or less to live. While I applaud that effort and know that it represents great advancement, I can’t accept that the only situation in which I can choose assisted dying is if I have a terminal disease. What if I have dementia or some chronic pain related to my neck injury? In some other countries, I would be allowed to choose assisted suicide or aid in dying if I have a terminal illness, unendurable pain, or a disability.

Even if I concede that the only time I should get to choose assisted dying is when I have a terminal disease, there would still be obstacles. Certainly medical doctors have information about diseases and what happens when conditions worsen and perhaps have an indication of how long a person might live, but the truth is they could be wrong. No one knows for sure what will happen in the future. Forcing me to wait, say, six months, when a doctor predicts I would be near death, could mean I would be unable to act on my decision when the time came. There is no guarantee after that six-month period that I would be able to take medicine or swallow or be cognizant enough to state my wishes clearly. So why should I have to wait for a doctor-defined deadline even if I have a terminal illness? Why not allow me to make that choice when I know it is the right time for me to die?

In all cases possible, I should be the person making a decision about my living and my dying where I am not hurting someone else. If I am unconscious or become unable to communicate, I will have made sure beforehand that I’ve provided enough information about what I want so that everyone involved is able to act in accordance with my wishes.

Asking someone to help someone else die by suicide is a very big thing to ask. I would even suggest that it is too much to ask, except for the fact that there are so many dangerous ways people can attempt suicide that could cause injury, and the safest method I am aware of is administering certain medication available only to physicians. To my knowledge, no one else has legal access to this medication. So given that the safest and most comfortable way to obtain aid in dying is to do it with the guidance of a physician, I don’t see any other option than to ask for a doctor’s assistance.

I have read of a physician suggesting that anyone can cause their own death by not eating or drinking liquids. I admit that if we could easily and effortlessly make this choice on our own, we would, and that would be preferable. But I don’t think many people have the stamina to go this route.

At the same time, suicide is not something that should be taken lightly, whether we are acting on our own or asking for assistance. So it is perfectly reasonable to try to create some criteria to ensure certainty and that no vulnerable person is coerced into taking their own life.

The thing that makes aid in dying work is if it is my decision and not someone else’s decision. So to the extent the stipulations are so stringent that you are taking away my choice, denying me the choice of aid in dying is just as bad as forcing me to choose it. Further, what reinforces that it is freely chosen is having the person actually take the medicine on their own. You can’t guarantee that I will have the capacity to do that or be able to state my wishes in the future, so why deny me the choice to do it when I am able to state my decision with 100 percent certainty, use my hands, and swallow?

This is what we should be afraid of: insurance companies denying treatment to someone for a disease and offering coverage for assisted dying instead. We should be afraid if someone else makes the decision and not the actual person being aided in dying. But if the decision is coming from an internal soul searching and certainty, I believe it should be respected in all cases.

I’m sensitive to the argument that people deemed not worthy in our society would be pressured to choose aid in dying or that someone might be forced to choose assisted suicide not because they want to die but because of the financial hardship caused by choosing to treat a disease. I also acknowledge the potential for people to choose assisted suicide only out of a fear of being a burden to others or because of a temporary circumstance such as untreated depression.

So I think it is important to address these concerns, but the solution is not to prevent someone who is absolutely certain of their decision from exercising their right to die. Instead, I would advocate several social and economic reforms.

Since insurance involvement with our health care system can deny payment and interfere with the doctor-patient relationship in many instances—not just in end-of-life decisions—I call for an end to this system and the creation of a single-payer health care system in its place.

And let’s do all the hard work of creating a world where painful social interactions such as bullying, child abuse, sexual assaults, domestic violence and all other unnecessary cruelty and suffering do not happen. Let’s offer supports to minimize the impact of financial considerations on choosing assisted suicide: affordable education options, housing and employment opportunities. Let’s provide treatment for chemical dependency, depression and other emotional traumas and losses that can make it difficult to want to go on with living.

But the truth is we will all die someday, and we should all have the nonnegotiable personal autonomy to decide when and how. Just because someone’s situation does not fit an established criterion like a life-threatening disease or six months left to live is not reason enough to take away their ability to choose aid in dying. I would prefer to die after a painful six months with a terminal illness than live ten years with dementia. It is not anyone else’s right to decide that it should be the reverse.

My choice may be different from someone else’s, but I would never advocate for us all to be the same in any area of our lives, including when it comes to choosing how to die. It is important that each of us makes our own decisions about health care at the end of life and about any prolonging of our lives. For us all to have true autonomy to make those choices, we as a society must address poverty and economic inequality, and we must solve the problem of for-profit health insurance and health care systems.

We don’t know someone else’s pain, suffering or circumstances. Making a decision about the end of life for someone else, or setting the bar so high that one cannot choose assisted dying in the case of dementia, depression or some other health condition, is not acceptable. We should only ascertain certainty. That is all.

One of the obstacles to creating true autonomy around end-of-life decisions is the burden of stigma attached to suicide. It makes it that much harder for people to talk about it—both people who want to consider it and the loved ones they would leave behind. But not all suicides or suicide attempts are the same. This is very similar to how we can’t treat all assisted dying cases as exactly the same. There are variations in diseases and in circumstances and pain. The quality of life for one person is measured differently from that of another. Ultimately what we should be measuring for is certainty in making this choice and nothing else.

We should do what we can to prevent suicide when that is not the ultimate intent of the person taking those actions, but we need to allow for assisted dying and suicide in all circumstances where we can ascertain certainty.

If we believe someone wants to live even as they are stating their certainty about wanting to die, we should do what we can to offer help as we continue to assess the situation. We get to have autonomy in our choices, but we shouldn’t take away a helping professional’s discernment in that process. That is what being a helper in any situation is about. It is not just a one-way street. If it was, we might as well be seeking this medical help (or any help) from a machine. No doctor should ever be required to assist if they’re not comfortable with that responsibility, and no doctor should be required to help in any one particular situation if not comfortable with the circumstances surrounding that particular person and situation. If we believe someone is asking for help to stay alive even if indirectly by way of a suicide attempt, we should offer it whether as a professional, friend or acquaintance.

Conversely, we need to respect someone else’s decision even if it does not line up with a choice that we would make ourselves or fit our idea of when it would be acceptable to choose or ask for assisted dying. While no one should be required to assist someone with dying, I challenge people to ask why I can choose assisted dying in the case of a terminal illness and not dementia, for example. To go even further, I may have limits to what I want to experience emotionally, physically or in age-related conditions that are very different from someone else’s preferences. Just because it falls out of the norm of what is typical in our society does not mean it is not the right decision for me or another person to make.

So let’s continue to work toward a more compassionate society, where everyone has a good quality of life, but let’s be very clear that the choice to obtain assisted dying or decline medical attention and all other choices about our living or dying need to come from within. While we want some safeguards and standards, let’s not be paternalistic and controlling of what someone else can do if they are not hurting someone else. One of the best ways to squelch the conversation and continue to stigmatize suicide is to say it is unacceptable to consider suicide in certain cases but acceptable in other cases, or that it is not acceptable under any circumstance. We really don’t know what is the right decision for another person to make about anything in their lives, including death.

People continue to worry about the “slippery slope” in relation to many controversial topics such as sexuality and certainly in death and dying. I can’t count the number of times I’ve seen “slippery slope” used in reference to assisted suicide. There is no slippery slope if you agree that we each should be making the decision for ourselves. There only is a slippery slope if you believe that outside control is being lost in the process. The truth is we can’t control people in any instance. Ultimately we cannot control someone else’s thoughts and values or even what actions they take.

And why would we want to, if they are not hurting someone else? We should all have personal autonomy when it comes to decisions that directly affect us.

Each of us are unique in every area of our lives. If that were not true, this would be a very boring world to live in. We should all be free to make decisions in all areas of our health. We should not automatically just do what someone else does or what someone else wants us to do or what a doctor suggests. We ought to do what is right for us given all the options and assessing our unique circumstance. Assisted dying is just one of those many options we have when assessing our health, when we acknowledge that death will happen to all of us—the question is when and how.

Life is a mystery. Trusting people to make their own decisions when it comes to death and dying, or anything else for that matter, is not always easy.

While coming to an understanding of what is certainty and measuring this certainty is important, it is not and will never be an exact science. I believe we lose the true value of living when we start acting like machines, when we think we can know and understand everything at the cost of our sense of embodiment, embracing our emotions and dwelling in the mystery of living and dying. This very real tangible loss of our humanness in how we do health care and many other things in our society is the reason I am questioning how we face death and dying in the United States. Living life will never be without its mysteries, and why would we ever want it to be? Who really knows what will happen in the future? Taking the risk to make decisions not knowing the future is what living life is about almost on a daily basis.

So even if it looks like a suicide is a loss, we cannot really know that that is true for that particular person who chose to end their life. In fact, I believe it can be a courageous decision to affirm our uniqueness and what we truly want in every area of our life. The feeling of disempowerment when we have no choice but to continue to live life no matter what is much worse than feeling empowered to have a choice and then taking the responsibility to make that choice.

The question is not, Will suicide happen even if we try to make it difficult? The question is, Will we continue to stigmatize it and therefore not have the opportunity to talk about these things in advance? Instead, we should start to engage in the conversation so that we can ultimately discern the differences between the times people are having difficulty and truly wanting help to stay alive and the times it is an empowered choice to choose to die.

We can decide on some criteria for determining an individual’s certainty, such as requiring two doctors to give permission for assistance in dying. But ultimately we have to accept that living life is a mystery and trust people to make their own decisions when it comes to death and dying as well as any other area of their lives.

Choosing assisted dying or choosing to do anything that cannot be undone in our living or dying is a personal decision that no one else ought to be making for us. Only we know the answer that is right for us about anything important in our lives.

Those who seek certainty in everything in life are likely to experience a lifelessness while still alive that is much worse than any assisted dying or suicide could ever be.

In addition to preventing unnecessary suffering in the world and suicide attempts by people who do not really wish to die, it is also important to build a world where we all take personal responsibility for our choices and have the confidence and awareness to be able to make the difficult choices in our lives, whether it is choices in our living or choices in our dying.

I believe we should take the stigma away from suicide so that it can be consciously chosen and so that it does not have to be a secret, which is probably one of the more painful aspects about it for everyone involved.

There is some possibility that the people who are successful in suicide are very certain, in comparison to individuals who make an attempt but are not really wishing to die and somehow survive. However, those individuals who have succeeded in suicide are not here to confirm that theory. Moreover, the fact that it can be so difficult to talk about suicide makes it hard to know after the fact whether that really was their sincerest, conscious choice made without any reservations. No wonder, then, that we are often surprised when someone dies by suicide. It just makes the pain all that much worse for people left behind when we can’t be more open that choosing to die may be the right choice for some of us at some point in time.

Whether we call it assisted dying or assisted suicide, and no matter at what age or what conditions or illnesses are surrounding the decision, as long as it remains stigmatized, the pain for those left behind will be even more heightened than it needs to be.

Loss is painful and relationships are complex whether we are living or dying, whether a death is by suicide or has some other cause. Someone choosing something we would not want them to choose can be painful, whether it is something that happens in life or in death. And I don’t think that will ever change. This concept is not limited to suicide or assisted dying. Learning how to respond to pain in our lives and the world is just as important as letting in the joy and love that exist. If we don’t acknowledge pain and joy as equal aspects of life, I believe we experience a kind of death in our life that is far worse than any meaningful and conscious choice to die.

In another essay I have questioned what exactly is a suicide. There are many actions that may contribute to our living and dying. Just because it is an action that may takes years to kill us does not mean it is not suicidal. Eating poor nutrition and working a stressful job are just two examples of routine actions that can lead to our death, as is declining medical intervention. So choosing assisted dying or suicide is just one more way to use our personal autonomy to consciously decide when the time is right for us to die. To stigmatize it or not allow it in some instances means people will only search for more creative ways to act on their wishes and not talk to others about it in advance.

Life is short. Death may come sooner than we expect. Making conscious choices in every moment of our living and dying is the key to leading a meaningful life.

Copyright 2015 by Susan Miranda.  All rights reserved.  No part of this writing may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the copyright holder. For reprint permission, email

Saturday, February 7, 2015

Why I Support Death with Dignity and Physician-Assisted Suicide

It is better to kill oneself intentionally than to live unintentionally.

Life and death exist on a continuum. In each moment we are living but also dying. There can be a consciousness in every moment of our lives. There can also be a lack of consciousness. Being alive only because I have not yet died is not the most intentional way to be alive. Extending life through medical life-saving measures chosen as if there were no other choice or from an internal motivation of being afraid to die is not being intentional either.

We are all going to die. Let me repeat that: We are all going to die.

Yet we live in a culture in the United States that is very afraid of death. There is a huge stigma associated with the act of suicide or even someone considering suicide.

By advocating for individuals to have the right to choose their own death, I am not saying it is okay for our society to remain the way it is. Society alienates people and operates on scarcity, and often people have barely enough to survive.

Sometimes a person expresses the wish to die because they lack hope for their life and their future, given their circumstances. Just a few examples are being bullied in school, dealing with the numerous prejudices that exist in a callous society, being burdened with debt or difficulty in managing the complex capitalistic money systems and coping with severe depression. I believe there should be universal access to counseling, medication, and treatment for chemical dependency and other problems people face. Even more importantly, I support any movement to make this world more hospitable, more caring and more compassionate for individuals who are seeking help and not wanting to end their lives.

People worry that someone may have regrets or would change their mind about dying or suicide if they only were to live longer. But some people would choose consciously and intentionally to end their life and would not regret it or change their minds if they lived longer. They know within themselves that their time for being alive on this earth is over. This may be because they have a terminal illness, but it may be for other reasons. With all the stigma around suicide, it can be very challenging to claim this truth.

If we want to make it easier for people to not have regrets, we must empower people from youth on to know themselves fully and to question everything outside themselves, including the patronizing attempts to control whether they can end their lives. We should all be doing the very hard work of creating real social, racial, environmental and economic justice in the world, so that individuals can make choices in their lives from an abundance of options. But even if we had that abundance, we will all still die at some point, and having the autonomy to make decisions about our lives and bodies is part of that justice we should all be working toward.

People sometimes have regrets when choosing life-extending medical interventions. The complications and difficulties of the treatments can far outweigh the chance for a better quality of life. Life-saving measures can lead to life-damaging results, like serious infections, bed sores, chronic diarrhea or worse.

When I consider these possible outcomes and how they would affect someone’s quality of life, I know that choosing to die is not the worst option. I don’t believe that living at all costs is a better choice than suicide.

We have this one precious life, and really the only person who knows what we need to be doing in any moment is us.

If we can’t choose to die, we can’t fully choose to live.

To think that we should not have this choice to die is to suggest that we don’t get to have an internal truth about what we should really do in other moments as well. Our internal knowledge about so many things gets minimized and often erased in a culture that stamps out our intuition and our feelings and our autonomy. People question whether or not a woman can choose abortion without regrets. People question whether a transgender youth can choose hormones without regret. People question whether a sex worker can intentionally and consciously choose sex work and feel empowered. The fact that some do and some don’t, and we could not possibly know what is right for someone else to do, is a complexity we don’t seem to be able to live with.

Many actions, thoughts and words make up our lives, and some of them may contribute to our dying. What we eat, risks we take and even what seem like normal behaviors in a contemporary society like driving a car or consuming alcohol or going to a stressful office job may all contribute to our dying. Everything we do matters, and whether I die from a single act to end my life or daily acts that end my life, what matters to me the most is the level of consciousness and intentionality that goes into those acts.

We can enhance our lives, live fully, breathe deeply, take in nourishments, experience joy and play in many ways. I would argue that when we are not living fully, we are killing ourselves, killing our spirits, killing our emotions and the joy that we could have had. That is the tragic death in my mind. To be alive and not be living fully is far more tragic than any suicide.

Is it unrealistic to want to live in a world where people are fully alive? Why is it so hard to allow personal autonomy and personal empowerment? There is complexity in every single issue I have ever written or talked about, whether sex, money or death and dying. Why do we need to control so much of what people do with their bodies and with their lives when they are not harming anyone else?

Society tries to control what people do by creating laws and stigma around certain activities, but ultimately we cannot control people, nor should we want to, unless someone is really doing harm to someone else. There will always be the few brave individuals who blaze their own path even if they are stepping outside of the law or into public criticism. For those who choose to follow the status quo only because they are afraid to question it, there is a price to be paid that is even greater than being judged for being different or for stepping outside the norms. Choosing to do something that not everyone would choose is not harmful. It is simply different from the norm. It is time we embrace the diversity in all aspects of our living and, dare I say, our dying.

The assumption that someone is harming us by being selfish if they were to die by suicide presupposes that we are not harming each other in our living. Relationships hurt sometimes, and ultimately we can’t and shouldn’t try to control others in life or death. Being selfless is a wonderful thing when it can be done authentically. But no amount of giving to another individual at our own expense will feel good if we are not first and foremost being true to ourselves.

Whether giving to a child or an elderly person dependent on us, giving to a friend in need or a stranger on the street, whether sacrificing our life for another’s such as saving someone from a burning building, from drowning or from being run over by a car, none of this is inherently good unless it is coming out of our own internal strength and self-esteem, what we are truly able to give. So too with the decision to live or die, whether it is by declining medical attention or requesting medication from a physician or dying from our personal choices about how to live on this earth. Whichever way we choose, my hope is that it comes out of a truly authentic desire to make the choice to be alive or not be alive.

I am not enhancing anyone’s life, including my own, if I choose to stay alive because of society’s taboos or other people’s desires for me, when I would rather not continue living. That choice does not enhance my relationship with others or my quality of life. This is true whether it is an active suicide, physician-assisted suicide or declining medical intervention that is routinely accepted in a technologically advanced society.

Over thirty years ago I almost killed myself from active alcoholism and depression. I do not regret that I have been alive for the past thirty years. I also would not regret it had I died thirty years ago.

Yes, there would be some things I have experienced these past thirty years that I would have missed out on: the children I got to love and the friends I have met over the years and the wonderful experiences I have had traveling and the writing I have published.

The truth is I will die at some point anyway, and there will always be something else I could have experienced had I had one more day. Often, what is or what was is good enough. In a culture obsessed with wanting more, that is a difficult concept to embrace—the idea that we don’t always have to do more or be more or even live one more day if we believe that is not the right thing to do. I will always pay close attention to my internal wisdom on what choice I should make today about living and dying, just as I have every day for the past thirty plus years.

We are all going to die. Let me repeat that: We are all going to die.

Many self-destructive acts seem as if they are not suicidal, but in truth they may be, like drug and alcohol use, fast driving or risky activities of all kinds. I emphasize they may be self-destructive or suicidal. We really don’t know what goes through the mind of anyone, including that of a person who has died by suicide. We should not judge if we have not walked the exact same path that person has walked.

I could choose to die from just not treating a simple infection. Is that suicide? I could die from having an asthma attack and not calling 911. Is that suicide? I could die from losing my recovery from alcoholism and getting into a car accident while drunk. Is that suicide? I could die from eating poor nutrition or smoking cigarettes every day. Is that suicide?

I would rather make an intentional decision to die than to live half alive and only be alive because I didn’t have the courage to choose to die. Doing nothing is also a decision and not necessarily a better decision than doing something, even if the decision does not make sense to anyone else. And just because society would be more comfortable with an accidental suicide as opposed to an intentional suicide does not mean that I have to respect that distinction.

It is such a high priority to me to not be in pain and to have a good quality of life in every moment in which I live. As I age, should I encounter illness or pain that leads me to decide it’s not worth extending my life, I want to have the option to end my life with medicine that could ease that transition.

What I know from all of my sexuality education work over the past two decades is that if I wait for the world to get where I want to be, I will never be where I want to be. So I choose to proclaim my vision of how I want the world to be, even when that vision is yet to come to fruition in the world.

To honor how I want the world to be, I have embraced and advocated for self-pleasuring and the importance of the relationship with self. I have said that obligation is not love and friendship is just as important as any other relationship we could ever have. I have said that it does not matter what we do or say, as much as how we do or say it, and that includes how we die.

I don’t wait for society to catch up before I say we should legalize drugs and provide treatment for addictions. I don’t wait for society to agree before I say we should decriminalize prostitution and provide livable, decent jobs for all people in every country and address poverty so no one is taking any job (whether sex work or anything else) because they don’t have another option.

I recognize that my choices may seem unusual, but I question what appears to be an automatic reflex of choosing extreme medical intervention, and I wonder about a society where we allow it to happen just because we are afraid to let go and die. How I live in each moment and the experiences I have in each moment are such a high priority to me that I cannot even contemplate the need to live a really long life over having a good quality of life. I cannot contemplate making decisions out of a fear of dying rather than living fully and intentionally right now.

If my life were to end tomorrow, I can honestly say that the moments I have had so far have been meaningful. Yes, there are things I would miss if my life were to end soon. But as painful as life can be, it is much more painful when I do not let go. I live my life as best I can, so that when the day comes, I will be ready to let my life end. I do not wait to say or do what is most important to say and do in all of my meaningful relationships.

If it happens that I live a long life without illness, pain or hardship, I am open to it. But I say no to extravagant intervention along the way or life-saving measures and surgeries and expensive technology. I have to ask, Is that suicide? I also have to ask, How different is a denial of medical intervention from actively taking one’s life when there’s no terminal illness at all?

Copyright 2015 by Susan Miranda.  All rights reserved.  No part of this writing may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the copyright holder. For reprint permission, email