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
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