Abstract
Entering an arena where so many distinguished commentators have already slugged it out is a daunting task. So rather than attempting to weigh arguments for and against, this discussion will confine itself to analysing and elucidating some of the linguistic underpinnings of the debate – the ways in which the notion of physician-assisted suicide is framed.
Framing, says Goffman, is the process by which we provide background understanding, and structure meaning of events – particularly social ones (Goffman, 1974). The most fundamental way we do this is linguistically. The categorisation of words creates instant bias toward one interpretation or another. Thus the words we choose not only reflect what we are trying to say, but also control meaning in and of themselves (Somerville, 2003; Tucker and Steele, 2007).
If we begin by looking at the ways we typically frame death and dying, we find that there have been quite profound changes over time. Obituaries, the news reports of death, make sense of death by creating a narrative about the person who has died. They present what is important and noteworthy in a manner intended to provide structure and comfort to those left behind. But while their function and significance has not changed, their content has. In a comparative analysis of obituaries appearing in The New York Times over three periods, Phillips (2007) notes significant differences. While in 1899 and 1959 obituaries typically described the process of dying, including the place and time of death and the details of comfort, pain, symptoms and other biological facts, notices from more recent years emphasise a warrior metaphor – the ability to control the circumstances of death, to fight a battle against it, claiming autonomy and agency for the dead person. When we thus discuss the dead as if they were still living, we avoid the distress of death, and move from the reality of our mourning – as Haussamen puts it, ‘language squirms to avoid the finality of death’ (Haussamen, 1998). While death cannot be conquered, it can be pushed aside and marginalised in its cultural expression.
However, one can only speculate whether this death denial may have consequences. Might it, for example, lead to an under-estimation of the true need for palliative care resourcing (Emanuel and Emanuel, 1998; Somerville, 2003)?
Furthermore, the pretence of control has led to some very strange linguistic frames. For example, it is now commonplace to use the expression ‘the right to die’ – as if one had any choice about the matter! In a recent example of this, Babylon and Monk-Turner (2006) posed the question ‘Should incurable patients be allowed to die?’ The image is almost reminiscent of King Canute – a stern-faced, single-minded committee opposing the incoming tide of death.
This brings us to the biggest linguistic trick of all. The word ‘euthanasia’ (a good death) appears to promise what we all hope for. Indeed, one might think it the mantra for palliative care – a death that is ‘free from avoidable distress and suffering for patients, families, and caregivers; in general accord with patients’ and families’ wishes; and reasonably consistent with clinical, cultural and ethical standards’ (Field and Cassel, 1997).
But to imply that this is what euthanasia means is to leave out the most essential part. Euthanasia is in fact a new word for the act of killing. We are not talking about care for the dying, but the killing of a consenting adult (Callahan, 1997). Sulmasy (1998) claims the word euthanasia is a deceptive euphemism and argues that an unambiguous definition for what is being proposed should be an essential first step towards critical analysis of the practice. He proposes ‘euthanasia’ should be clearly described as: ‘An act in which an agent creates a new, lethal pathophysiological state with the specific intention in acting thereby causing a person’s death’.
Euphemisms can be dangerous. While to say somebody ‘passed away’ rather than died may be no more than an avoidant figure of speech, at worst cultivating the denial of death and dying, using the term ‘euthanasia’ may cause actual harm. It may ‘disguise a practice which one might abhor if it were given another name’ (Mitchell, 1999–2000).
It is difficult at this point not to recall that it was this precise euphemism which under the Nazi regime was used to cover up the killing of thousands of people deemed to be too disabled to live. To reincarnate such a term and put it to use as if it were a natural part of the provision of humane palliative care is simply inappropriate and has even been described as abhorrent (Michalsen and Reinhart, 2006).
And so to physician-assisted suicide. Again, we need to pay attention to the linguistic frame of the phrase. The emphasis on ‘assistance’ seems to imply that physicians would be simply being helpful – surely a proper role to take on. But if we examine this more carefully, a physician has a responsibility to assist only in a very specific context. Doctors have a duty to relieve suffering and promote well-being within the domain of ill health. If, for example, a patient requests her physician to be her friend, her lover, her teacher or her stockbroker, a physician will quite rightly refuse. Indeed, to acquiesce would be to transgress professional boundaries. Similarly, if a patient requests her doctor to treat her in a manner that will make her illness worse, her physician is not only permitted to refuse to provide such assistance, but indeed is obliged to do so.
Can we reasonably assume that the act of suicide should be included as an area where a physician should give assistance?
The epidemiological data suggest otherwise. It is estimated that close to 90% of people who suicide have a psychiatric diagnosis at the time of their death (Conner et al., 2001); in young people, mental disorders remain the strongest risk factor for suicide (Beautrais, 2000).
But, argue those in favour of physician-assisted suicide, this does not apply to those with terminal illness. These are not people with despairing emotional states but rather rational human beings wanting a sensible degree of control over the circumstances of their death (Tucker and Steele, 2007).
Again, the data simply do not support this. Patients with terminal illness wanting to hasten their own death have been found to have higher rates of depressive symptom scores, lower family cohesion and a greater sense of being a burden on their families (Kelly et al., 2004). The strongest predictive factor for a wish to hasten death in those with terminal illness is not pain, or health status, but hopelessness (Akechi et al., 2001; Breitbart et al., 2000; Chochinov et al., 1998).
So in what way should a physician assist a patient who is suicidal? Managing suicidality is an onerous task requiring considerable attention to mental state, social context, and uniquely individual intrapsychic factors (Long et al., 1998). However, in the phrase ‘physician-assisted suicide’ we are suddenly confronted with the idea that not only should physicians not attempt to treat the despair underlying suicidality, but they should in fact hand over a prescription for lethal drugs. Again the language cloaks the reality. Physician- assisted suicide in the Oregon model merely obliges the physician to assess the patient and then hand over the prescription. He has no further obligation to ‘assist’ in any way at all.
So rather than being an assistant, the physician is being asked to be a gatekeeper – to decide who should receive suicide prevention, and who should be given suicide assistance (Coleman, 2010).
And how will this be determined? Firstly, the patient must be ‘terminal’ – the Oregon statute defines this as being a 6-month life expectancy. This despite the well-known inaccuracy in temporal prognosticating – indeed, statistics from Oregon give the latency between receiving the prescription for lethal drugs to death as a maximum of 1009 days – over 2 years (Oregon Health Authority, 2011).
Secondly, she must be competent – again, a notoriously problematic assessment involving a weighing of the risks and benefits of the decision, the patient’s own rationale for her decision, and the fact that patient decisions often fluctuate from one time to another (Ganzini et al., 2003).
And finally, the patient should be suffering pain or indignity – or should be fearful of such suffering in the future. But again, we have linguistic challenges. What constitutes dignity? Is it really undignified to require help for daily tasks such as dressing or bathing? Or as some authors have put it: ‘Have we gotten to the point that we will abet suicides because people need help using the toilet?’ (Golden and Zoanni, 2010). Should dignity not go beyond notions of self-control, independence and physical strength, to reclaim its original meaning of honour and esteem – and should we not endeavour to reassert that caring lovingly for someone is itself an act of dignity (Byock, 1997)?
These are all complicated decisions. Are doctors in a position to manage them? What about physician factors? Kelly et al. (2003) draw attention to the complexity of physician responses to the care of the terminally ill, reflecting at times their own sense of helplessness and demoralisation. Or as Pellegrino puts it: ‘Physicians, like all other human beings, cannot entirely escape their own prejudices and biases about what constitutes quality of life, a good death, and whether suffering has meaning’ (Pellegrino, 1998).
So it seems the deconstruction of the term physician-assisted suicide reveals it to be not so much a way of looking after patients in their terminal illness, as a way of handing over enormous extra power to physicians. It is to expect them to act as gatekeepers in a terrain full of complexity, ambiguity and uncertainty. It is to confirm the already too prevalent belief that death represents some kind of failure and must be tamed. It is to attribute to physicians ‘the power of gods’ (Callahan, 1997).
Is this really what we meant to mean?