By Rachel Jacobi, Science and Technology Editor
I was introduced to the concept of assisted suicide with the fiction novel “Me Before You” by Jojo Moyes. Published in 2012 and later turned into a movie, the controversial novel follows a romance in which the male protagonist, paralyzed by an accident, makes a conscious decision to undergo an assisted suicide procedure in an elite Swiss facility.
The clinic that assists the protagonist with his death does actually exist in Switzerland. This clinic, Dignitas (named for “death with dignity”), offers ‘accompanied suicide’ as one of its services. Their website advertises that “Dignitas can arrange, on reasoned request and medical proof, for its members the possibility of an accompanied suicide.” At Dignitas, prerequisites for undergoing this process include possession of sound judgment, enough physical mobility to self administer a drug, and the cooperation of a physician — which is only obtained if the individual is suffering from a terminal illness, an incapacitating disability, or unbearable pain.
Physician-Assisted Suicide (PAS), or medical aid in dying, is not simply the withdrawal of medical care, like when ‘pulling the plug.’ PAS involves lethal intervention by a physician, deliberately designed to cause death.
As of 2019 in the United States, a legal prescription for such medication is available to adult residents of a few states that have embraced ‘death with dignity laws.’ These states include California, Colorado, District of Columbia, Hawaii, Maine, Montana, New Jersey, Oregon, Vermont, and Washington. Not unlike Switzerland, individuals pursuing a PAS must be mentally sound, diagnosed with a terminal illness (defined as six months left to live, and confirmed by two physicians), and a capability to self administer the medication — either orally or via injection. In the U.S., any licensed physician in any of the above-mentioned states can agree to prescribe the medication necessary for PAS, although they legally retain the right to not participate.
To induce death, the method that Dignitas offers is a fast-acting and lethal barbiturate — a sedative that acts as a central nervous system depressant — that the patient consumes by dissolving a capsule in drinking water. Following consumption, the patient falls into sleep within minutes, and painlessly dies. In the U.S., physicians can determine the medication for this as there is no specific drug that physicians are required to prescribe. Patients can receive an oral dosage of pentobarbital, a fast-acting barbiturate that slows the activity of the brain and nervous systems. In large doses, it will shut down the activity of the brain and heart in as quickly as one minute. Secobarbital is another prescribed barbiturate for PAS. More common than pentobarbital, it is given at 9000 mg. in capsule form to induce a quick, painless death. Due to the high cost of these medications, beginning in 2015, other medications have also been used, and alternatives continue to be explored.
PAS is not a common procedure. In Colorado, the number of reported deaths by PAS for 2019 is 129, and in California, the number of reported deaths by PAS in 2018 was 337. Further, although PAS has been legal in Oregon since 1997, and has one of the highest numbers of reported deaths, that number is still relatively low, at 1,657 patients.
Despite the legality of PAS and the strict guidelines for eligibility, PAS remains an uncomfortable issue. Those that support PAS argue that overtreating patients takes a toll on frail patients and burned-out doctors, and continuing treatment when it will do little but prolong pain is cruelty. They differentiate PAS from suicide by pointing out that patients are terminally ill and mentally sound, and are thus making a logical, rather than irrational, decision to end physical pain on their own terms.
However, in addition to it being a morally questionable practice, many problems exist with PAS. First, there are instances that the prescribed drugs sometimes result in adverse outcomes, including unconsciousness, nausea, vomiting, and an extended death that can take up to 24 hours. Further, despite the laws that allow physicians to opt-out, there is evidence of physicians being intimidated or pressured into participating involuntarily in PAS. Finally, many experts argue that, similar to otherwise healthy individuals who commit suicide because of severe emotional pain, people who opt for PAS do so because of severe physical pain that possibly leads to emotional complications, and should be treated for clinical depression. However, many PAS patients fail to be referred for psychiatric evaluation before being prescribed lethal medication.
Today, PAS remains prohibited by most states and countries. The ethics of PAS are medically and legally complex, and the morality of physicians medically assisting patients in dying is the cause for great debate. While many that are pro-PAS argue the importance of individual autonomy, in most cases the ethical and practical cons of PAS overwhelm that consideration. Moving forward, politicians and physicians need to seriously examine the ethical and practical questions surrounding PAS, and consider whether this practice truly is the best option for suffering patients.