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“Suicide Kits” for Sale

photograph of Amazon search bar

This article discusses suicide. Following common journalistic ethics practice, precise details about means or resources for committing suicide may have been deliberately left out or altered.

Method matters. Depending on the study, between 80% and 90% of people who attempt suicide and fail do not go on to attempt suicide again. The public health implication is that by regulating the availability of popular and effective means of suicide – mainly firearms and select chemicals and pharmaceuticals – deaths from suicide can be prevented.

Given this, what should we make of the fact that highly purified sodium nitrite, an increasingly popular option for suicide, has been readily available for purchase on Amazon in the United States? A lawsuit filed on September, 29th accuses Amazon and Loudwolf – a sodium nitrite manufacturer featured on Amazon – of “promoting and aiding” the suicide of two teenagers. A Twitter thread by Carrie Goldberg, a lawyer working on the case, characterized Amazon as a “serial killer.”

The case will likely turn on a number of details alleged by the plaintiffs: that Amazon recommendations packaged together sodium nitrite with other supplies and informational materials in so-called “suicide kits”; that Amazon failed to enforce its own policies; that Loudwolf failed to include FDA-required warning labels on sodium nitrite; that Amazon was previously warned and did nothing about sodium nitrite sold on its platform being used in suicides; that no information was included about methylene blue (the recommended treatment for sodium nitrite poisoning); that there is no compelling reason to allow household purchases of pure sodium nitrite; and, of course, that both deaths were minors.

Abstracting away from the details, however, the case is part of a decades-long pattern of the internet facilitating suicide – from providing community, to disseminating information, to assisting the purchase of supplies.

It began in 1990 with alt.suicide.holiday, a Usenet news group (similar to an internet discussion forum). Users would frankly discuss suicide and share tips and resources. While that group is now defunct, there have been multiple variants. The popularity of sodium nitrite as a means of suicide is attributed to a recent iteration. In many U.S. jurisdictions, advising or encouraging suicide is illegal, so these sites’ relationship with the law is complex – so too is their relationship with the media. Such forums begin as niche communities of the suicidal for the suicidal, and end up as New York Times exposés (most recently in December of 2021). Once aware, grieving families and the broader public often push (successfully) for these sites to be shut down or hidden from internet search results.

In contrast to the prevailing public health or prevention narrative of suicide, the leitmotif of these communities is, in their words, “pro-choice.” The idea is that the right to suicide is simply an extension of our personal autonomy and right to self-determination.

Especially in liberal individual rights-oriented contexts, autonomy is an enormously important ethical principle and people are given broad latitude to make their own decisions as long as they do not negatively impact the rights of others.

In American medicine, for example, patients have an almost unlimited license to refuse treatment. However, humans are not always autonomous actors. Children for instance are not allowed to make their own medical decisions. Being intoxicated is another common exception. In rare cases, people have been known to commit sexual assault or other crimes under the influence of the sleep aid zolpidem (Ambien). The defense is that these were not autonomous actions; that they did not flow from the authentic reasons and desires of the offender.

Can suicide be an autonomous act? Under the prevailing medical account of suicide, in which suicide results from serious mental illness, it almost definitionally cannot. In American law, risk of harm to self or others is grounds for violating patient autonomy and forcibly administering treatment.

That a person is suicidal is treated as evidence that they are not in sound mind and not an autonomous decision maker. Suicidality discounts autonomy.

Those in the online suicide “pro-choice” community challenge this logic and hold that suicide can be a reasonable reaction to a person’s life and circumstances, and people should have access to the knowledge and means to kill themselves relatively painlessly. In this they have at least some philosophical company. Thomas Szasz, a controversial Hungarian-American philosopher and psychotherapist, long asserted that suicide was simply a choice as opposed to an expression of sin or illness.

Szasz is an extreme case and was broadly skeptical of the very designation of mental illness. However, in contrast to a previous Christian sanctity-of-life framing, there is growing acceptance in the Western world that suicide may not always be unreasonable. Instead, it can be an understandable response to circumstances in which someone’s quality of life is below some personal threshold. A good case in point is the right-to-die movement, which advocates for medical-aid-in-dying and physician-assisted suicide. Ten states currently have medical-aid-in-dying in which a terminally ill person with six months or less to live is able to request a lethal medicine they can ingest. Supporters of medical-aid-in-dying stress that the practice is distinct from suicide, partly to escape the stigma associated with suicide, but the conceptual distinctions are slippery.

America is comparatively conservative, but several nations have far more permissive laws when it comes to assisted suicide. Belgium, the Netherlands, and Canada, among other countries, allow for voluntary euthanasia on the basis of extensive and untreatable mental suffering even absent terminal illness or, indeed, any physical illness whatsoever. (The ethics of this have been previously discussed here at the Prindle Post.) The 2018 case of Aurelia Brouwers, who was voluntarily euthanized in the Netherlands after years of failed mental health treatment, brought broader attention to the practice. She was the subject of a short film documentary.

Once it is accepted that unbearable suffering alone is an adequate basis for suicide, then distinctions about how long someone has left to live, or whether that suffering is mental or physical become secondary.

The process of seeking assisted suicide on the basis of mental suffering is supposed to have extensive safeguards, yet critics worry that slip-ups happen. Note, though, that the locus of discussion shifts from the act of suicide to the process of doing it responsibly and ethically.

Surprising to some, among the staunchest critics of the right-to-die movement are segments of the disability rights movement. The concern is that people may be pressured into choosing assisted suicide due to discrimination against people with disabilities or inadequate medical care, i.e. that these decisions are not fully autonomous. Of course, there will always be reasons for suicide, and these reasons may often be due to larger social and economic failings. Poverty is a known contributing factor to suicide. How reasonable this is may depend on where one is standing. In individual cases it is partly the environmental factors – poverty, debt, personal tragedy, discrimination – that can make suicide seem an appropriate response to circumstance. And yet, it may appear ghoulish to have a state-sanctioned process that facilitates suicides partly driven by these factors that the state itself perpetuates (or at least is often in the best position to address.)

Negotiating the appropriate policy prescription remains an impossible task. Mental health professionals, suicide prevention advocates, the American right-to-die movement, disability rights activists, and the online suicide pro-choice community can all share a broader commitment to self-determination and yet disagree vehemently about specific issues: when suicide is an autonomous act, what kind of safeguards need to be in place, what counts as unbearable suffering (or a lack of possibility of improvement), and what action is justified to prevent suicides.

Still, vanishingly few people would consider 16-year-olds killing themselves with online instructions and chemicals purchased on the internet as anything other than a tragedy.

It is statistically likely that had the teens in the lawsuit against Amazon attempted suicide with a less lethal method, they could have been successfully treated and their suicide attempt would have been a thing of the past.

Without speculating on the details of the specific case, it is nonetheless worth acknowledging that Amazon, whatever its failing as a corporation, cannot be the sole cause of this or any suicide. People are seeking information and supplies. And at least some suicides will default to known, highly lethal methods like firearms. It is also true that while the majority of those who attempt suicide and fail do not attempt again, previous suicide attempts are the single biggest risk factor for a later successful suicide. Put cynically, there is a demand. Regulating supply, while important given the relevance of the method, can only do so much. Suicide often exists at the intersection of means, mental health, and personal and environmental circumstance.

One relatively radical way to think about suicide would be as a regulated right – something permitted but tightly controlled. The provision of medical care and mental health care would presumably be part of seeking state-sanctioned suicide. People would need to have good reasons (whatever society decides those reasons are) for seeking materials-for or aid-in suicide, and undergo an appropriate approval process.

As countries like the Netherlands and Canada illustrate, negotiating what this approval process should be like is fraught. The balancing point of different communities with an interest in suicide including the suicidal, their families, mental health professionals, disability rights activists, religious communities, and the state will undoubtedly be a precarious one. Nonetheless, taking seriously the demand for suicide could plausibly help to bring suicidality out of the dark as something that people can talk seriously about and potentially get treated for. Surely a society ought to inquire as to why its citizens wish to take their own lives.

If you or someone you know is struggling with thoughts of suicide, (prevention-focused) resources can be found at SpeakingOfSuicide.com/resources.

The Right to Die and Government Intervention

stained glass depicting two figured displaying mercy to dying man

On June 14th 2022, 44-year-old Federico Carboni became the first person to die as a result of physician-assisted suicide in Italy. Carboni was paralyzed in a car accident in 2010 and fought for many years for access to death with dignity. In 2019, Italy’s Constitutional Court ruled that assisted suicide is constitutional under the conditions that the patient seeking it is capable of making autonomous decisions and is in overwhelming and persistent pain. Health authorities granted permission in November 2021 for the death to take place. Carboni died in his own home as a result of taking a prescribed lethal drug.

Euthanasia is very controversial in Italy; it is opposed by the Catholic Church. Indeed, in a dominantly Catholic place like Italy, some are concerned that religious values are unduly influencing the extent to which people can behave autonomously. A debate about this general issue is raging across Europe:

Should people be able to choose the conditions of their own death? Should doctors ever assist patients in bringing about death? If so, how and under what conditions?

There are two general types of euthanasia: passive euthanasia – the withholding of life preserving treatments – and active euthanasia – administering a lethal drug to directly cause the death of the patient. Active euthanasia is legal in Belgium, Luxembourg, and the Netherlands. Passive euthanasia is legal in those three countries and also in Finland, Sweden, Norway, and Austria. Euthanasia of any form is illegal in France, but they allow patients who are terminally ill and in terrible pain to be kept under “deep sedation” until they die.

In 2014, Belgium became the first country to provide access to active euthanasia to children with parental consent. To qualify, the child must demonstrate that they understand what will happen when they are euthanized and they must be in serious pain. In Belgium and in the Netherlands, patients can request euthanasia if they feel that they can no longer live with mental illness. In 2016, Mark Langedijk, a patient in the Netherlands, became the first person to be euthanized because he no longer wanted to suffer from alcoholism, a problem for which he unsuccessfully sought treatment in rehab twenty one times (for discussion, see Marko Mavrovic’s “What It Means to Legalize Euthanasia”).

Euthanasia is controversial in the United States as well. Physician-assisted suicide is legal in ten states: California, Colorado, Hawaii, Maine, New Jersey, New Mexico, Oregon, Vermont, Washington. The practice is illegal in 33 states.

Those who support euthanasia often argue that respecting the conditions under which a person wishes to remain in existence and those under which they don’t is fundamental to treating that person with dignity. What’s more, governments shouldn’t be in the business of preventing these kinds of decisions. Human beings are not the property of any government; it should not be in a position to answer for a person what is, at its core, perhaps the most deeply personal question there is: the question of whether to continue to have subjective experiences at all.

If this is the case, whether someone is permitted to die humanely and on their own terms shouldn’t vary from one country or region to the next. Instead, it should be understood as a universal human right.

Many who agree with these points about respect and dignity argue that there continues to be a role for the state in all of this.

Even if governments ought not to get involved in answering the general question of whether patients have a right to die, it might be important for them to have a set of laws and policies in place that lay out the conditions under which it can happen.

If governments have an obligation to protect their citizens, some patients might need protection against manipulation, coercion, and impaired thinking. For instance, a person who is suffering from a lengthy disease might be concerned that they are too much of an emotional and financial burden on their family. Though they might not actually want to die, they may choose euthanasia to save their loved ones’ time and money. Another person might, in a moment of frustration and pain, make a decision to end their own life that they might not have made at a later time. A person may be too young or incapacitated to make a truly autonomous decision. These might all be legitimate reasons for state intervention.

We might also consider the issue from perspectives other than suffering individuals who might have their preferences thwarted. A country’s health care system is one of its central human services. The government has an interest in making sure that people are well cared for, and that doctors and other medical professionals have the kinds of values to do their jobs well. They want medical professionals who have respect for life and don’t have inclinations to do their patients harm.

In response, advocates of death with dignity argue that respect for life entails more than extending any given life as long as possible. When we say that life is valuable in the case of a human person, it is because there is a subject present who is capable of valuing their own existence and of having positive experiences in the world. Real respect for life entails empathy for living things when what is valuable about life for a given person is forever beyond their reach. Sometimes, death is a health care decision.

In the United States, twenty-seven states still use the death penalty as punishment. In most of these states, euthanasia is illegal. This sends the message that the state is in a position to judge when a person should die before the natural termination of their life, and is even justified in executing the person itself, but a suffering patient, in consultation with their doctor, is not in a position to make the same decision about their own life in accordance with their own values. This set of policies suggests that such governments value retribution more than mercy and control more than autonomy.

Cryonics: The Trap Objection

photograph of hand pressed on thawing glass

Cryonics is the technique of preserving the bodies (or brains) of recently deceased people with the hope that future scientific advances will enable these people to be revived and live on. The technology to revive cryons (i.e., cryonically preserved people) doesn’t exist, and there’s no guarantee that it will ever be developed. Nevertheless, there’s a chance that it will be. This chance motivates people to spend money to undergo cryonic preservation.

The basic argument for cryonics is that it might not work, but what do you have to lose? As my colleague Richard Gibson has noted, we can think of the cryonics choice as a wager.

If you choose not to be preserved, then you certainly won’t enjoy any more life after death (I’m assuming there’s no spiritual afterlife). But if you choose to be preserved, then although there’s a chance you won’t be revived, there’s also a chance that you will be revived, enabling you to enjoy more life after you die.

Therefore, choosing preservation is a better bet, assuming the costs aren’t too high. By analogy, if you have to choose between placing a bet that has no chance of winning, and placing a bet that has some unspecified but non-zero chance of winning, the latter is definitely the better bet (ignoring the costs of placing the bets).

I want to explore an objection to this argument. Call it the Trap Objection. The Trap Objection questions the presupposition that revival would be a good outcome. Basically, the Trap Objection points out that while revival might be a good outcome for a cryon, it’s also possible for a cryon to be revived into a situation that is both undesirable and inescapable. Thus, the wager is less straightforward than it appears.

To appreciate the Trap Objection, first note that life is not always worth living. Life is filled with lots of bad things, such as pain, grief, and disappointment, to which we would not be exposed if we were not alive.

Most of us believe that most of the time the good in our lives outweighs the bad, and thus life is on balance worth living despite the drawbacks. Such assessments are probably usually correct (although some question this). It sometimes happens, though, that the bad things in life outweigh the good.

For example, the life of someone with an agonizing incurable illness may contain lots of pain and virtually no compensatory goods. For this person, life is no longer better than nothing at all.

Second, note that sometimes suicide is on balance good and consequently justified when life is no longer worth living. For example, the incurably ill person may reasonably view suicide as preferable to living on since living on will bring him more bad than good but death will permanently close the account, so to speak. And because suicide is sometimes justified and preferable to living on, it is sometimes a great misfortune when someone loses the capacity to choose death. If the incurably ill person were unable to choose to escape the agony of his life, this would likely be a great misfortune for him.

Let a Trap Situation be any situation wherein (i) a person’s life has permanently ceased to be worth living yet (ii) the person has lost the capacity to choose to end their life. For example, individuals with late-stage Alzheimer’s disease are often in Trap Situations, unable to enjoy life but also unable to end it. Trap Situations are very bad, and people have very good reason to want to avoid them.

Now we are in a position to formulate the Trap Objection. The Trap Objection is that there is a chance that choosing cryonic preservation will lead to a Trap Situation, and until we have some understanding of how high this chance is and how bad the most likely Trap Situations would be, we are not in a position to determine whether cryonic preservation is a good or bad bet. But a death without cryonic preservation will certainly not lead to a Trap Situation. Thus, choosing against preservation is arguably the safer and better option.

By analogy, if you have to choose between placing a bet that has no chance of winning or losing any money, and placing a bet that has some unspecified chance of winning you some unspecified amount of money and some unspecified chance of losing you some unspecified amount of money, the former is arguably the safer and better bet (ignoring the costs of placing the bets).

Cryonics could conceivably produce many types of Trap Situations. Here are some examples.

Brain Damage: The cryonics process irreversibly damages a cryon’s brain. The cryon is revived and kept alive by advanced technology for centuries. But the cryon’s brain damage causes her to suffer from irreversible severe dementia, rendering the cryon unable to enjoy her life and also unable to end it.

Environmental Mismatch: A cryon is revived into a radically unfamiliar social, political, and technological environment. The cryon is unable to adjust to this new environment and reasonably wants to end her life. The cryon is unable to end her life, however, because suicide is culturally and legally prohibited, and the means exist to enforce this prohibition.

Valuable Specimen: The technology to revive cryons is developed in the distant future. Future humans are interested in learning about 21st century humans, but only a few have been successfully preserved. A cryon from the 21st century is revived and studied. The study techniques are barbaric and make the cryon miserable to such an extent that the cryon reasonably wants to kill herself. But because the cryon is a valuable specimen this is not permitted.

Mind Upload: A cryon’s brain is scanned, and the cryon’s consciousness is uploaded to a virtual world that is owned and operated by a technology company. The cryon finds life in the virtual world to be unbearably depressing and wants to opt out, but because the activities of the virtual world’s digital inhabitants generate economic value for the technology company, inhabitants are not permitted to terminate themselves. Mental processes in the virtual world are simulated at 1,000 times their normal speed, such that one day in the real world feels like one thousand days to the digital inhabitants. The virtual world is maintained for 50 real-world years, which the cryon experiences as 50,000 years of unbearable depression.

This sampling is meant to illustrate that revival needn’t be a good thing and might actually be a very bad thing – even an astronomically bad thing, as in Mind Upload – for a cryon. It does not represent an exhaustive mapping of the relevant possibility space.

I don’t know how likely it is, either in absolute or relative terms, that a cryon will be revived into a Trap Situation, although the likelihood is definitely non-zero. Moreover, it’s unclear how to go about determining this likelihood from our current perspective. Contemporary cryonic practitioners will claim that they would never revive a cryon into a Trap Situation. But it is very unlikely that the technology to revive cryons will be developed within the (natural) lifespan of any living cryonic practitioners. Moreover, the world could change a lot by the time the technology is developed. So, the significance of these claims is dubious.

It seems that even if we ignore pre-preservation costs, choosing cryonic preservation is not clearly a safe or good option.

If you are so terrified of nonexistence that you would prefer the chance at any sort of future life to certain annihilation, then cryonic preservation does seem reasonable. But this preference seems unreasonable. In some situations, the certainty of death should be preferred to the uncertainty of life.

On the Morality of Allowing Euthanasia for Those with Mental Illness: Part 2

photograph of empty hospital bed with curtains closed

In a previous post on Canada’s decision to allow those with a mental illness to seek medical aid in dying, I discussed some of the factors that need to be considered when evaluating the moral permissibility of euthanasia. These considerations, however, are generally raised in response to cases of intolerable and incurable physical suffering. Things become a lot more complicated when this suffering is instead mental.

Why might this be the case? One of the most common arguments in favor of the moral permissibility of euthanasia is based around the idea of autonomy. This concept holds that we should get the final say on decisions that affect the course of our lives. And this includes choices about how and when we die. This is why we might see a case of suicide as tragic or regrettable, but are usually reluctant to say that someone who takes own life does something morally wrong. But what happens when the process used to make such choices becomes unreliable?

One way of understanding autonomy is through the satisfaction of desires. We all have many desires: A desire to see the climate crisis resolved, a desire to study orbital mechanics in college, or the desire to eat an entire cheese pizza for dinner. The extent to which we have autonomy over these things is determined by our ability to satisfy these desires. So, while I can do something to reduce my carbon footprint, the complete resolution of the climate crisis is entirely out of my control. This, then, is something over which I do not have autonomy. When it comes to what I eat for dinner or what I study at college, however, I have far more autonomy. To say that I should have autonomy over the time and manner of my death, then, is to say that I should be able to satisfy whatever desire I have regarding my death. If that desire is to end my life prematurely, then I should be allowed to do so. And if for some reason I need assistance in ending my own life, then there can be nothing wrong with another person providing this.

The problem with desire-based theories like this is that there are many cases in which we don’t desire what’s good for us. This can happen in one of two ways. Firstly, we can desire things that are bad for us. That cheese pizza might be delicious – and give me thirty solid minutes of bliss – but the long-term effects will be bad for me. I’ll gain weight, raise my cholesterol, and suffer through an entire evening of gastric distress. Secondly, we can fail to desire things that are good for us. While I might thoroughly enjoy studying orbital mechanics, it may very well have been the case that a degree in ornithology would have been far more enjoyable and rewarding.

These concerns are compounded in cases of mental illness, as sufferers may be more prone to form desires that are bad for them. But to discount all of the desires of the mentally ill is to show enormous disrespect for their dignity as persons. So how can we discern the good desires from the bad?

One solution might be to refer to distinguish between “first-order” and “second-order” desires. First-order desires are precisely the kind of desires we’ve been considering so far – desires about what to eat, what to study, and when to die. Second-order desires, on the other hand, are desires about desires. To illustrate the difference between these two, consider the case of Mary. Mary is a smoker. Every morning, she wakes up with a powerful desire for a cigarette. A desire that she promptly satisfies. Then, throughout the day, she desires many more cigarettes – a full pack’s worth in fact. Mary, however, deeply regrets being a smoker. She hates the harmful effects it has on her health and her wallet. She wishes that she didn’t desire cigarettes. So, while Mary’s first order desire is to smoke cigarettes, her second order desire is precisely the opposite.

How does this help us? Well, we might argue that when considering how best to respect a person’s autonomy, we should focus purely on an individual’s second-order desires. This, then, would permit us to do something like forcefully prevent Mary from smoking (say, by confiscating her cigarettes and preventing her from buying more). Similar reasoning can be applied to the many cases where someone’s desires have been corrupted by addiction, deception, or general human flaws like laziness and procrastination.

In the case of mental illness, then, we now have a tool that allows us to look past someone’s immediate desires, and instead ask whether an individual desires to have such desires. If we can show that someone’s desire for death has come about as a result of their mental illness (and not, say, by a reliable process of informed reasoning) we could argue that – since the individual does not desire that desire – helping them end their life would not be respectful of their autonomy. If, however, their second-order desire is in favor of the desire to die, respect for autonomy will once again lean in favor of us helping them to end their own life.

All of this is to say that allowing euthanasia in cases of severe and incurable mental illness is enormously complicated. Not only does it involve all of the usual considerations that are relevant to euthanasia, it also contains an additional set of concerns around whether helping a patient end their own life will truly see us acting in a way that respects their autonomy. In order to ensure such respect, we should focus not just on what an individual desires, but on their attitudes towards those desires.

On the Morality of Allowing Euthanasia for Those with Mental Illness: Part 1

photograph of empty hospital beds and drawn curtains

Starting in March 2023, Canada will allow those with a mental illness to seek medical aid in dying. Canada first legalized euthanasia in June 2016, but – like most jurisdictions that have passed such laws – restricted access only to those with a terminal illness. This law was expanded in 2021 to also include patients with a “grievous and irremediable medical condition” (that is, those who are going through incurable suffering, but who are not dying). Canada’s most recent amendment will now see them join the Netherlands as one of the first countries in the world to make euthanasia available for those with a severe and incurable mental illness.

What should our ethical position be on this law? Fortunately for us, euthanasia is an incredibly fertile area in moral philosophy. Generally, philosophers separate cases of euthanasia into one of two kinds. The first of these describes scenarios in which a doctor withdraws lifesaving or life-sustaining treatment from a patient. Suppose, for example, that a terminal cancer patient has only months to live, but is currently undergoing an aggressive course of chemotherapy to try and extend her life by several weeks. This treatment comes at an enormous physical and mental toll, however. Given this, she elects to cease treatment in order to maximize her quality of life in what little time she has left. This is what is referred to as “passive” euthanasia. Passive euthanasia can be contrasted with cases in which a doctor intentionally intervenes in order to end a patient’s life. Suppose, for example, that the patient above wanted to avoid the unnecessary pain and suffering that her illness will bring in the months preceding her inevitable death. Given this, she asks her doctor to administer a morphine overdose to end her life quickly and painlessly. This is what is referred to as “active” euthanasia.

This distinction is important, as many jurisdictions that criminalize active euthanasia have no such prohibitions against passive euthanasia. And this sentiment is often echoed by doctors. The American Medical Association (AMA), for example, has previously stated that active euthanasia is “contrary to that for which the medical profession stands and is contrary to the policy of the AMA.” Despite this, they hold that the passive euthanasia should be “the decision of the patient and or his immediate family.”

This distinction is an interesting one – especially since, in many cases, passive euthanasia can bring about far more suffering. Consider a terminal patient whose life is being prolonged using a respirator. Suppose, then, that this patient – knowing that her final weeks will be filled with unbearable suffering – elects to end her life prematurely. There are two ways in which this could be done: The first option would be to remove her respirator. The second option would instead involve administering a morphine overdose, quickly and painlessly ending her life. According to the approach outlined above, the former option (a case of passive euthanasia) would be acceptable, even though it sentences the patient to the harrowing experience of slowly suffocating to death. The latter option (a case of active euthanasia) would instead be seen as morally impermissible, despite the fact that it involves far less suffering for the patient.

Given the fact that passive euthanasia can often be far worse than active euthanasia, it might be tempting to think that there’s no important moral difference between the two. But some philosophers still believe there is. Philippa Foot, for example, argues that it all comes down to whether or not we are the agent of harm. Foot emphasizes that any harm that befalls a person (including death) comes as the result of a sequence of events – sort of like a long line of dominoes. The morally important question then becomes: who started this sequence of events? If it’s us – that is, if we are the one who tipped the first domino – then we are, according to Foot, the “agent of harm,” and therefore find ourselves morally responsible for the harm in question. If, however, the sequence of events is already in motion, then we’re off the hook. To use Foot’s own examples, this is the kind of reasoning that would allow us to drive past a dying person on the side of the road in order to save five other people, but would not allow us to drive directly over another individual for the same reason.

Returning to the discussion of euthanasia, Foot’s approach allows us to make a moral distinction between active and passive euthanasia on the basis of who sets the harmful sequence of events in motion. When we remove the respirator from a patient, the sequence of events that leads to her death comes about as the result of her disease. When we administer a morphine overdose, however, we initiate a new sequence of events – a sequence that we are responsible for. We become the agent of harm.

So, does all of this mean that providing active euthanasia (including in cases where a patient is suffering from a severe and incurable mental illness) is morally wrong? Not necessarily. While we’ve shown that there is an important moral distinction to be made between cases of passive and active euthanasia, we have not yet shown that this distinction is significant enough to make one kind (passive) always morally right, and the other kind (active) always morally wrong.

And there’s something even stranger going on here. Consider a case where someone suffering from a mental illness takes her own life. While we might see this as tragic or regrettable, few – if any – of us would say that the individual did something morally wrong. And this is interesting. Because if we insist on holding that active euthanasia is morally wrong, we are essentially saying that it’s morally impermissible for us to help an individual do something that is otherwise morally permissible. This is a strange conclusion indeed. In fact, we’d be hard-pressed to think of many other cases where it’s wrong for us to help someone do something that’s right. This strange anomaly just goes to show how complex this discussion is, and how much more there is to be said on the matter.

Defining Death: One Size Fits All?

photograph of rose on tombstone

In 1844, Edgar Allen Poe published a short story titled The Premature Burial. The main trope at play in the story was the common Victorian fear of being buried alive. The main character suffers from a condition which causes him to fall into catatonic states in which it is difficult to detect breath. The body exhibits little to no motion. In response to his all-consuming fear, he designs a coffin that will allow him to alert the outside world through the ringing of a bell if he is confused for dead and accidentally buried alive.

Determining when death has occurred is not an easy matter, either historically or in the modern age. In some cultures, family members would wait until putrefaction began in order to bury or otherwise perform death ceremonies with the bodies of their loved ones, just to make sure that no one was being disposed of who was, in fact, still alive. As time progressed, we used the presence of circulatory and respiratory functioning to determine that someone was alive. The modern world presents a new set of puzzles: we are able to keep the circulatory and respiratory function going indefinitely with the help of medical technology. When, then, is a person dead?

The way that we answer this question has significant practical consequences. Hospitals are frequently low on beds, personnel, and other resources, especially during outbreaks of disease. Patients can only permanently vacate those beds when they are well enough to leave or when they are dead. We also need to be able to harvest certain organs from donors, which can occur only after the patient is dead.

What’s more, it would be unusual if there was variation among definitions of death across the country. The result could be that a person is dead in one state and not in another. In response to this concern, in 1981, the Presidential Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research arrived at the following definition which they expressed in the Uniform Definition of Death Act: An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead. A determination must be made in accordance with accepted medical standards.

Since the time that the Commission took up the issue, this definition has faced a range of objections from all sides. No one is particularly bothered by the first criterion, but the second is the source of much debate. Some object that the Presidential Commission requires too much for a person to be considered alive; they argue that it is not the case that the entire brain must cease to function, only that the higher brain has irreversibly stopped working. They reason that it is the higher brain that is responsible for the characteristics that make an entity a person: consciousness, personality, memory, a sense of psychological continuity, and so on.

Others argue that the Commission has not gone far enough, in other words, they argue that a person who is kept alive on a ventilator is still alive, even when they have no brain function of any kind. It is possible for the body to do things while kept alive on a ventilator that only living bodies can do; among other things, bodies can go through puberty, carry a fetus to term, grow taller, grow hair, and so on. Some argue that to call such bodies “dead” is just demonstrably inaccurate.

It seems that our social conception of death has a crucial metaphysical component. Most cultures with advanced medical technology don’t tend to wait to declare a person dead until they start to decay. It’s worth asking — what, exactly, is it that we are trying to preserve when we categorize a being as “alive”? Are we being consistent in our standards? Under ordinary conditions, we wouldn’t hesitate to say that grass, clams, or coral reefs are alive (when they are). Would we use the same standards to determine when these organisms are no longer alive that we would use to determine whether a human person is no longer alive? Some argue that testing for the biological functions that give rise to personhood is the right approach when it comes to determining the status of a human being. Are humans the only organisms to whom we should apply that test?

Questions about death are philosophically compelling to reflect on in the abstract, but they are also practically important for everyone. The decision that someone is dead has significant consequences that will inevitably be devastating to some people. Consider the case of Jahi McMath and her family. In 2013, Jahi underwent a standard procedure to get her tonsils removed; she experienced severe blood loss which led to significant brain damage. She was declared brain dead on December 12th, 2013, three days after the procedure. Jahi’s family fought to overturn the diagnosis, but a judge agreed with the hospital that Jahi was brain dead. The family did not give up, but transferred Jahi to a private facility for care where she was connected to life-sustaining technology for almost four years. Jahi was declared dead in June, 2018; the cause of death listed on her death certificate was “complications due to liver failure.” Jahi never regained consciousness.

Jahi’s mother sold her house and spent all the money she had to pay for Jahi’s care, and she does not regret doing so. She appreciated the opportunity to watch Jahi change and grow, commenting to reporters, ““She grew taller and her features started to change and she went through puberty and everything. And I know for sure, dead people don’t do that.”

According to the Uniform Definition of Death Act, Jahi died in 2013, not in 2018. Not everyone agrees with the standard established by the act. People have different religious, cultural, and philosophical understanding of when death occurs. That said, a person isn’t alive simply because there is someone willing to insist that they are — Julius Caesar and Elizabeth I are dead regardless of anyone’s protestations to the contrary. The time and resources of medical professionals are limited. When someone believes that the life of someone they love is at stake, they may be willing to pay any amount of money in order to keep hope alive. Liberal democracies allow for pluralism about many things. Should the definition of death be one of them?

Autonomy, Euthanasia, and Non-Terminal Patients

photograph of hospital room with empty beds

In March of this year, changes to the law regarding assisted suicide and euthanasia in Canada loosened some of the restrictions about who is eligible to apply. Assisted suicide and voluntary active euthanasia has been legal in Canada since 2016, however, the law governing such procedures was recently challenged for being too restrictive and not in keeping with the original ruling of the Supreme Court. Initially, to be eligible for assisted suicide or euthanasia the patient’s terminal condition must have been considered “reasonably foreseeable,” but now that criterion has been dropped so that even people suffering from grievous and irremediable mental illnesses will be eligible. But this new-found freedom only raises more questions about the concept of consent, especially in those cases where patients with impaired mental faculties express a desire to end their life.

There are relatively few nations in the world which permit either physician-assisted suicide or physician-assisted euthanasia, and even fewer that permit them for people who are not terminally ill. For example, in the United States passive euthanasia is legal, and in a few states voluntary active euthanasia is permitted but only in situations where there is a terminal illness. On the other hand, Canada will now join nations like Belgium and the Netherlands in permitting voluntary active euthanasia and assisted suicide to patients who are not terminally ill. In Belgium, patients with psychiatric conditions, even children, can request euthanasia. But in non-terminal situations where a patient may request that their life end because of a psychiatric condition like depression or dementia, the issue is complicated. In all of the above nations, the notion of informed consent is paramount, but it isn’t always easy to determine if a patient is competent enough to provide consent.

As Scott Kim, a psychiatrist and philosopher, notes,

“It is not easy to distinguish between a patient who is suicidal and a patient who qualifies for psychiatric euthanasia, because they share many key traits…one does not need to be a psychiatrist to appreciate how psychiatric disorders, especially when severe enough to lead to euthanasia requires, could interfere with a patient’s ability to make ‘voluntary and well considered’ decisions.”

Unlike in the case of terminal illness which may be determined by a chemical or imaging test, it can be difficult to say for sure whether a patient with a psychiatric illness has “unbearable suffering without the prospect of improvement.” For example, a Dutch woman elected to be euthanized 12 months after her husband’s death for “prolonged grief disorder,” despite being otherwise physically healthy. To make this determination even more complicated, just last year, the Dutch Supreme Court expanded the law to extend this choice to those suffering from dementia as well.

Those who defend the idea of psychiatric-assisted dying in non-terminal patients argue that the suffering caused by mental illness justifies physician-assisted dying, but only if the patient is able to request such a procedure autonomously and rationally. However, some philosophers and ethicists take issue with this criterion. In a paper on the subject, Jukka Varelius points out that, “Given that the distress of a psychiatric patient undergoes can be very severe and that there may not always be adequate means of alleviating it (short of ending the patient’s life), the idea that psychiatric-assisted dying could sometimes be morally acceptable does merit attention.” Indeed, many argue that excluding the mentally ill from enjoying this freedom on the basis of disability is objectionably discriminatory.

For a patient to make an autonomous decision, it is commonly thought that it must be voluntary, intentional, and based on sufficient understanding of the nature and consequences of the decision. But certain mental illnesses undermine a patient’s ability to understand the world. A similar problem occurs in cases of dementia. As noted in a paper on the subject from the Journal of Neurology, “those suffering from dementia suffer from a disease that itself infiltrates the very center of autonomy and voluntariness.” But Varelius makes the case that even if their conception of reality is distorted, non-autonomous psychiatric patients can also suffer unbearably if they are unable to express a reasoned decision to end their life. It is already common practice, for example, to engage in non-voluntary euthanasia by withdrawing life support from non-autonomous patients if it is deemed to be in the patient’s best interests, such as those who are in an irreversible comatose state or those with severe brain damage. It is, however, difficult to argue that we have any certainty regarding the patient’s personal preferences. Because of this, our standards involving autonomous choice may be less important than we often make them, and it would be cruel to claim that the suffering we force people to endure due to our skepticism of their “true” interests is not morally significant.

On the other hand, many may argue that there is a significant difference between active and passive euthanasia, or even that passive euthanasia should be endorsed at all. Also, when it comes to issues like dementia and mental illness, it won’t always be clear if suffering can be abated. Longitudinal studies show that patients with chronic psychiatric disorders sometimes get better or worse for reasons beyond the control of healthcare providers. So, it might not ever be clear whether there are other reasonable alternatives to euthanasia. And, without the ability to predict the future or have a meaningful conversation with a patient, there is no more reason to think that a person would want to be euthanized than to think that they wouldn’t.

There is also strong rejection of euthanasia from psychiatrists stemming from the nature of the profession. A fundamental core of psychiatry, to many, is to prevent suicide and to address hopeless, helplessness, the desire to die, and the inability to see the future. The shift in policy towards psychiatric euthanasia is considered a fundamental change to the practice of psychiatry. Many worry about slippery slope precedents of the ever-expanding criteria for euthanasia which are beginning to include reasons those who feel “like they have a completed life” and are tired of living. And some studies of the system in Holland reveal that the no-reasonable-alternative criterion is not always met.

For these reasons, it is difficult to assess whether a decision is autonomous or how important that determination is in many of these cases. We need to explore the various frameworks in place to determine appropriate eligibility criteria and approval processes. Finding the right balance (if there even is such a thing) may be something that can only be learned the hard way.

Art, Death, and Experience

photograph of rollercoaster at dusk

In 2010, Lithuanian artist Julijonas Urbonas created a work of conceptual art that posed, and continues to pose, a fascinating challenge to contemporary notions of death. The piece is called the “Euthanasia coaster,” represented materially by a small model of a roller coaster made of thin wire. Described on Urbonas’ website as “a hypothetic death machine in the form of a roller coaster,” the machine is “engineered to humanely–with elegance and euphoria–take the life of a human being,” or more accurately, twenty-four human beings at once.

Urbonas is right, the model does have an austere elegance. The tracks rise in a narrow but staggeringly tall parabola, then plummet back to the ground, finishing in a series of loops that grow smaller and smaller until the ride is over. The loops generate enough centrifugal force that the passengers are deprived of oxygen quickly enough to die before the car reaches the end of the line.

When we talk about medically-assisted suicide, we usually ask whether or not the terminally ill have the right to humane euthanasia. A far less common but no less interesting question, which takes for granted the notion that those who wish to die have a legal right to do so, is whether or not euthanasia in a clinical hospital setting is the best way to aid the suffering. Has the ritualistic and cultural significance of death been eroded by our efforts to be humane, and are there ways to restore that lost meaning to our final moments?

It’s easy to be put off by the idea of death by roller coaster. Urbonas was partly inspired by his stint working at a theme park, but to many, hopping on a coaster may seem a flippant or macabre way to spend one’s last moments. However, the roller coaster is a very polyvalent symbol, especially in relation to death. It isn’t a space for quiet reflection, like a hospice, but a visceral experience of power and speed. It’s also a communal experience, which reminds us of how often death is a solitary experience in the modern world. There also may be meaning in the form of the coaster; tall, sloping coasters often resemble mountains, which have long been associated with divinity (Mount Olympus is just one example), and the idea of ascending to one’s death has parallels in many world religions.

Perhaps most importantly, the ride creates an increased sense of bodily awareness in the participant, just as the body is about to die. You give up bodily control to the track, but you get something in return: terror and ecstasy. These words, terror and ecstasy, are often linked in the ancient Greek tradition of death. Through this piece, Urbanos seems to suggest that we have lost touch with that older tradition, and exchanged the vitality of full acceptance for sterility.

The idea of death as a machine is bound to make us flinch. The guillotine, which has inspired terror and revulsion for centuries, is a machine of death inspired by Enlightenment values. It kills with cold, rational efficiency, and in many ways, Urbanos’ coaster is the anti-guillotine. His work is about joy rather than rationality, and though it may involve a kind of spectacle, like the guillotine, it’s less about efficiency and more about the bodily experience of the deceased. His work also reminds us that we live in a culture where death and mourning are relegated to private spaces. Roller coasters are hulking monuments that dominate the landscape, and their silhouette of sprawling rib-like tracks are unmistakable from a distance. Death is not hidden in Urbanos’ work, but forced out into the open.

It is, of course, just a conceptual experiment. Urbanos has no plans to actually build his roller coaster of death, as the legality (and ethics) of the machine would be highly questionable. But his art still raises many questions about how we experience death, and whether or not we should expand the options available to those suffering from terminal illnesses. The solution to their plight isn’t to build a macabre theme park, but to question our understanding of death as unspeakable and unthinkable.

Marieke Vervoort and Deciding How to Die

On Tuesday, October 22nd, Belgian Paralympian Marieke Vervoort ended her life. She had signed papers eleven years prior gaining authorization to decide when to end her life, as medical aid in dying is legal in Belgium. Vervoot had a degenerative spinal disease that caused intense pain and interfered with her ability to sleep, sometimes limiting her rest to minutes a night. She won multiple Olympic medals for wheelchair racing: gold and silver medals at the 2012 London Olympics, and more in Rio de Janeiro. In interviews she explained how participating in sports kept her alive, and how the intensity of her pain could at times make those around her pass out.

Vervoot expressed that without the authorization papers she obtained over a decade ago, she would have chosen to die sooner. “I’m really scared, but those papers give me a lot of peace of mind because I know when it’s enough for me, I have those papers,” she said. “If I didn’t have those papers, I think I’d have done suicide already. I think there will be fewer suicides when every country has the law of euthanasia. … I hope everybody sees that this is not murder, but it makes people live longer.” Vervoot’s statement suggests that allowing people to make their own determinations regarding ending their lives is actually a way of valuing life – not only out of respecting their autonomy (their ability to make choices regarding their own life paths), but also offering encouragement and protection.

This attitude towards aid in dying is consistent with cases in the US, though there are important distinctions in the law between Belgium and the states where physician aid in dying is legal. The US requires a person to have a terminal illness, assessed by two diagnosing physicians, in order to be considered a candidate for aid in dying. However, the trend of patients going through the process of seeking aid in dying, but ultimately looking for something more complex than to die immediately bears true: a full one-third of the patients in Oregon and California do not end up taking the prescribed medication after going through the procedures of procuring aid in dying. This tendency is attributed to the importance of having control over the manner in which you die, for which having the option (rather than following through) is sufficient.

In California and Oregon, “pain” does not make the top three reasons that a patient reports seeking aid in dying; “autonomy” typically tops the list. As for people in all stages and conditions of life, having control over the narrative and shape of one’s life is critically important. One of the principal harms of illness is that it can take so much of this control away from a person.

It has been twenty years since Oregon adopted its Death with Dignity Act, and now most Americans support physician aid in dying. The characterization of these policies, now passed in nine states (plus DC), as “deciding how to die” plays a significant role in the public discussion. But this support is only currently available for patients who are terminal, not patients like Vervoot.

The difference between cases like Vervoot’s and cases that are legal in the US is the presence of a terminal diagnosis. This constraint restricts aid in dying from being available to those patients with dementia or with other degenerative conditions, like Vervoot or actor/comedian Robin Williams.

There are a cluster of cases that raise worries about broadening aid in dying policies to include patients beyond those with terminal diagnoses. Cases where individuals are not getting sufficient treatment, and therefore they may have a reasonable chance at a good or worthwhile life (by their own standards). And yet, the healthcare system’s not providing such options cause justifiable concern among disadvantaged groups. In such cases, a patient may opt to end their life due to injustices present in the healthcare system rather than an objective terminal diagnosis.

It is telling that the policies in the US are promoted by groups with names like “Death with Dignity”; the effects of illness on terminal patients’ lives are the focus of the discussion, empowering patients to make decisions about the end of their lives in the face of degenerating conditions and abilities. However, the very conditions said to be threatening patients’ “dignity” can be the very same conditions that differently abled individuals live with every day. For this reason, some disability rights advocates find some aid in dying discourse demeaning for people that judge their lives to be meaningful and fulfilling while also living with conditions that require significant interdependence and care: “Some right-to-die activists have written about assisted dying as an antidote for indignity that occurs at the end of life, such as needing help to dress or use the bathroom. If you’re a person with functional limitations, that’s a real slap in the face,” says Carol Gill, PhD, APA working group member and professor of disability and human development at the University of Illinois at Chicago. The stigma of living a dependent life alters doctors’ and patients’ assessments of the quality of life, and so rather than providing resources to reduce the burden of the “debilitating” conditions, physicians sometimes offer aid in ending life: “There are no assisted-dying laws that guarantee those resources, and that feels discriminatory to a lot of people with disabilities,” she says.

Practical considerations must inform the moral ones in cases like these, and the reality of healthcare disparities in the US make the question of physician aid in dying worrying for many. If patients are more likely to seek aid in dying because their health needs are not being met, this presents a real justice concern because health care resources are not being distributed equitably or anywhere near sufficiently. These factors for choosing aid in dying will weigh more heavily for disadvantaged groups, and facing the decision to hasten death could be less of an empowering narrative than the one Vervoot tells (she said it gave her control and put “my own life in my hands”). These concerns regarding vulnerable populations and the value-laden judgments regarding which lives are worth living even count against the policies allowing aid in dying that the US has passed.

There are a variety of conditions that could interfere with someone’s ability to live what they deem to be a worthwhile life. Both psychological and physical conditions can bring about such states, and terminal and non-terminal conditions may meet this standard. The relevant distinction may turn on whether reasonable hope of treatment exists or not. As we have seen, there are a number of practical difficulties to determining which cases fit into which category, especially given the inadequate care currently on offer and the unjust distribution across vulnerable populations.

Aid in Dying in New Jersey

photograph of private hospital room with comfort items

On August 1st, New Jersey’s Aid in Dying for the Terminally Ill Act came into effect, and, after the included waiting period, August 16th marked the beginning of its effectiveness. This brings New Jersey into the group of states, including Washington, D.C., that allow terminally ill patients to determine the manner in which their lives will end. Maine has a bill that will go into effect in September, which will bring the group of states/DC that have aid-in-dying legislation to ten out of fifty-one

Legal principles in aid-in-dying cases rest on core values that the US Constitution is designed to protect. The major legal principles that have been relevant physician assistance cases include the Due Process Clause and the Equal Protection Clause. 

The Due Process Clause protects our liberty to make our own decisions about the most important parts of life – like marriage, children, etc. These kinds of life events are recognized by the government as particularly important for individuals and are thus left to individual discretion. The Supreme Court case of Washington v Glucksburg raised the question of whether this reasoning could be extended in order to protect individual choice in end-of-life care. The plaintiff argued that end-of-life is one of those important times in our lives. As such, terminally ill patients should be able to be allowed control and physician aid in dying should therefore be legal. But the Court unanimously held that physician aid in dying was not covered by the due process clause, blocking one avenue to federal protection. 

In the Supreme Court case of Vacco v Quill in 1997, the plaintiff argued that the 24th amendment and the Equal Protection Clause made it the case that physician aid in dying should be legal. The legal principle in the case was that like cases should be treated alike, and the plaintiff argued that “voluntary passive euthanasia” was sufficiently like physician aid in dying. “Voluntary passive euthanasia,” where a patient’s death is hastened by the removal of treatment, was legal. Terminal patients could opt to cease medical intervention and/or life supporting aid such as feeding tubes, respiratory aid, and hydration. Because ceasing intervention amounted to hastening death just as physician aid in dying amounts to hastening death for the terminally ill, we should not allow some patients but not others the opportunity to have control over their deaths. Thus, the plaintiff argued, because we should treat like cases alike, and physician aid in dying is basically the same as voluntary passive euthanasia, physician aid in dying should also be legal. The ruling, however, was that the state did not have an interest in protecting the process of hastening death, and the case is often cited as establishing that there is no state interest in protecting a citizen’s “right to die.” 

Because of these Supreme Court cases, there is no protection at the federal level for physicians to intervene and allow terminally ill patients to control their own deaths. This, however, has not stopped the nine states and D.C. from either legally outlining such a protection through legislation or through judicial precedent. Opposition, on the other hand, is often motivated by the moral evaluation of the intervention more than the legal standing. 

The main values that conflict in the moral debate over aid-in-dying are the inherent value of life on the one hand, and the rights of liberty or autonomy to determine how your life is shaped and will unfold on the other. For many, it is a grave moral wrong to end a person’s life, regardless of the circumstances (for discussion see Marko Mavrovic’s “What It Means to Legalize Euthanasia”). This may be the most central ethical prescription for creatures with the moral standing that comes with being a person. However, for most there are exceptions to this tenant. Perhaps ending someone’s life in self-defense isn’t completely morally forbidden, or perhaps there exists some moral calculus that points to a good (like the avoidance of harm) that could justify the sacrifice of one person’s life.

If we admit cases like these into our moral perspectives, we move away from absolute evaluations and allow for the weighing of morally relevant features; we could think it’s likely that there are other goods which compete with the value in not ending life. Non-interference with how a person wishes to live their life is a core moral value that can be at odds with the duty to preserve life. When a competent person makes up their mind to end their suffering, it is unclear to many that it is right to prevent this. And when there are experts that can ensure a safe and humane procedure, this leads to many advocates defending physician aid-in-dying legislation. Growing support appears to favor allowing terminal patients more autonomy in how they spend and end their final months.

What It Means to Legalize Euthanasia

photograph of empty hospital room with flowers

Euthanasia and physician assisted suicide are gradually gaining acceptance: both legally and socially. As of 2016, Canadians have a right to assisted suicide. New Jersey may become the next American state to allow some form of medically assisted suicide, joining a list that includes California, Colorado, Hawai’i, Montana, Oregon, Vermont, and Washington. The national debate surrounding Dr. Jack “Death” Kevorkian, who oversaw the deaths of over one hundred people and was subsequently sentenced to 10-25 years in prison, seems like the distant past. But now it is time to shine that spotlight of public attention on euthanasia once more.

Dr. Kevorkian once explained his rationale for administering lethal injections: “My aim in helping the patient was not to cause death. My aim was to end suffering.” The arguments in favor of euthanasia (lethal injection administered by a physician) and physician assisted suicide (lethal prescription taken by the patient) are in ways difficult to combat. Who are we to deny a suffering soul an accelerated but peaceful passage to the Afterlife? Who are we to judge someone for exercising their right to a dignified death? Some argue that to deny euthanasia is to deny a permanent reprieve from suffering.

Proponents of euthanasia typically use terminally-ill patients who are enduring pain and have no prospects for improvement as the kind of patient who exemplify a situation in which euthanasia is the most merciful option. Few would not have sympathy for this request and might therefore approve of euthanasia in this limited circumstance. But it would be useful to explore how even this narrowly defined support can actually permit scenarios beyond terminal illness.

When introduced into legislation and enforced by governments, euthanasia fails to be constrained to that limited circumstance. Some may argue that this a misapplication of the ideal extent of permissible euthanasia. The legalization of euthanasia is a prime example of how the ideal application and the actual reality of a concept often fail to mirror each other perfectly. Indeed, even the most stringent restrictions on euthanasia allow for certain individuals to be euthanized when they ostensibly should not have been.

For example, the Netherlands – one of the first countries to decriminalize euthanasia – have very strict criteria for legal euthanasia. After the patient has been euthanized, the Regional Review Committee reviews the following “due care” criterion (if the case fails to meet the any of the criterion, the physician is to be prosecuted):

    • the conviction that there was a voluntary and well-considered request from the patient
    • the conviction that there was hopeless and unbearable suffering of the patient
    • has informed the patient about the situation in which it was present and about its prospects
    • the patient has come to the conclusion that the situation in which they found no reasonable alternative
    • has consulted at least one other independent physician , who has seen the patient and gave his judgment in writing about the aforementioned due care criteria.
    • has carefully completed the termination of life or assisted suicide.
  • In 2016, these seemingly restrictive criteria nevertheless approved Mark Langedijk for euthanasia not because of a terminal illness but because of alcoholism. The despondent 41-year old alcoholic, who entered rehab 21 times, conceded that “enough is enough” after his marriage ended and he moved back in with his parents. It appears that Langedijk displayed hopeless and unbearable suffering, yet it is doubtful whether he could have made a voluntary or well-considered decision because of emotional strain of his alcoholism and the related desperation. This particular case is relevant because it intersects with the suicide crisis facing middle-aged men.

But Langedijk should not be considered an exception to the rule in the Netherlands. The percentage of those euthanized because of terminal illness is dropping. People enduring psychological turmoil such as social isolation or loneliness, criteria that have not traditionally been  considered justification for euthanasias, are becoming a growing subgroup. And there is reason to believe that this gradual widening of the acceptable criteria is an inevitable phenomenon not unique to the Netherlands.

In Oregon, the latest report shows that over half of people given the lethal prescription in 2016 listed “burden on family” and “financial implications of treatment” as their end of life concerns. Neither of these reasons relate directly to the physical suffering of the patient or their state of health, yet it is becoming an increasingly accepted justification for physician assisted suicide.

When patient autonomy is held above all other concerns governing medicine, the physician must oblige the request of the patient, whether the patient is about to die in 3 weeks and is in tremendous physical pain or is simply depressed. When the vague notion of mercy for suffering individuals is held above all other concerns, one must accept the necessary conclusion that non-physical, non-chronic forms of suffering–such as psychological turmoil–fall under the expansive list of reasons that would permit euthanasia. In fact, it seems with either justification, there would be few instances in which euthanasia would be not be permissible. This trend should not come as a surprise. Therefore, those claiming that the legalization of euthanasia is for only terminally-ill patients in physical pain are being disingenuous. The Mark Langedijks of the Medical World are not anomalies of legalized euthanasia; they are, or will soon become, normalized.

This trend in and of itself may not be morally troubling for some, namely those who value patient autonomy or dignified deaths. But the implication of the legalization on the government-civilian relationship is morally significant. What does it mean when your government allows euthanasia? How does that shift the nature of the relationship between the state and the civilians?

Perhaps the legalization of euthanasia indicates that your government values your personal liberty. Perhaps it indicates that your government is progressive, on the cutting-edge of medical ethics. But it might also indicate that your government no longer values the unconditional protection of innocent human life. Maybe it shows that your government values certain lives over others.

When a state, such as the Netherlands, examines cases of euthanized people, it is indirectly making a judgment on whose life is worth living. If an individual fails to meet one of the six criteria, they cannot be euthanized and they are to be kept alive. It is the life of the individual who fails to meet the criteria that the state deems worth saving. Some argue that the converse is true: the lives that meet the criteria are the lives the state deems not worth saving.

Indeed, activists for the disabled fear that the legalization of euthanasia relegates the status of those with physical impairments. In his piece for The Guardian, Craig Wallace writes that offering euthanasia to the disabled is not “an act of generous equality” but a “fake cruel-one way exit for vulnerable people locked out of basic healthcare and other social and community infrastructure.”

Echoing the sentiment of Wallace’s op-ed, Jamie Hale argues that people with disabilities are the strongest opponents to assisted suicide. Hale addresses the “financial burden” concern expressed by those in Oregon and says that it would be felt by the disabled, too. “People who are disabled, ill or elderly are constantly taught that funding our health and social care is a burden – that we are inherently a burden,” she writes. “I am given so little of the social care that I need that I am forced to rely on unpaid care from friends to survive.” With physician assisted suicide as an option, insurance companies and socialized healthcare may be incentivized to pursue the far cheaper lethal prescription over actual treatment.

In California, this reordering of priorities has already occured. “Stephanie Parker was informed by her insurance company that the chemotherapy she requested to treat terminal Scleroderma was not an option they were willing to provide,” writes Helena Berger. “Packer’s insurer then offered $1.20 co-pay for a handful of life-ending prescription drugs.”

There is a specter haunting the world. But is the specter laws prohibiting euthanasia or laws permitting euthanasia?

Reflection on Responsibility: National Suicide Prevention Month

Photo of a sign at the Golden Gate Bridge that says "Crisis counseling - There is hope - Make the call - The consequences of jumping from this bridge are fatal and tragic".

Content warning: discussion of suicide

September is National Suicide Prevention month, and September 10th marked World Suicide Prevention Day.  Organizations such as the Suicide Prevention Lifeline, American Foundation for Suicide Prevention and the International Association for Suicide Prevention all hosted social media hashtags and encouraged everyone to spread awareness of suicide and how to prevent it. Suicide has long been considered an epidemic in the United States, but a recent study published by the CDC in July showed that the rate of suicide in the U.S. has increased dramatically in the past 20 years. By and large, suicide is considered negative in our society, often framed as tragic due to its preventability. Several pop culture idols have committed suicide since the beginning of 2018, including chef and TV personality Anthony Bourdain and fashion designer Kate Spade. During this month, it is pertinent to examine exactly what our culture’s stance on suicide truly is. Does framing suicide as negative require us to make judgements about those who commit it? Does an anti-suicide stance require us to also oppose assisted suicide? And finally, who should we hold accountable for fixing and preventing the suicide epidemic; our culture, ourselves, or our public institutions?

As quite literally a life or death matter, the way that we talk about suicide is a delicate matter. In an article titled “Is Suicide Selfish?” Senior Director of Suicide Prevention and Postvention Initiatives, Shauna Springer, examines from a psychological perspective if we can truly hold those who attempt or commit suicide can considered selfish. While Springer doesn’t deny that suicide has consequences on those other than the victim, she holds that it ultimately is not a selfish act, due to the fact that “suicidal mode is an altered state of consciousness.” Because those suffering from suicidal thoughts “often have distorted perceptions of reality,” we cannot make judgements about their character and actions in a similar way that we would a healthy person. Others however, feel differently. In an article titled I Still Think Suicide Is Selfish And No, I’m Not Ignorant For Believing So” Lesly Salazer defends her position by using her personal experience with depression and suicidal thoughts. Salazer explains that growing up, she was told “‘There’s more to life than yourself and your sadness. You can’t let your emotions overpower your common sense. God has a plan for you, and killing yourself is just plain stupid.’” She believes that this attitude toward suicide saved her life, because she felt she was doing a moral wrong by killing herself. The traditional methods of hotlines and therapy did not work for Salazer, though she acknowledges they may help some. In conclusion, Salazer defends her belief that suicide is selfish on the basis that such a belief might prevent people from killing themselves. However, one could argue that such an attitude towards suicide might actually hinder people from finding help, because they do not feel like they can talk about their suicidal thoughts. While it might help some like Salazer, it has the potential to hurt many others.

If we decide as a culture and society to take a negative stance toward suicide, can we also consistently advocate for methods that make ending one’s life easier or less painless? The legalization of physician assisted suicide has been a debate in recent years, with states like Oregon and California passing legislation to legalize physician-assisted suicide. But how do suicide prevention organizations view physician assisted suicide? In October of 2017, the American Association of Suicidology released an article clarifying that they, as an organization, do not considered assisted suicide as suicide, but instead as “death with dignity’ or “physician aid in dying.” The article explains that the organization “ does not assume that there cannot be ‘overlap’ cases, but only that the two practices can in principle be conceptually distinguished and that the professional obligations of those involved in suicide prevention may differ.” The organization goes on to list 15 key differences between physician-assisted suicide and the type of suicide that the AAS aims to prevent. The key distinctions AAS claims exist between suicide and physician-assisted death are medical and conceptual. One observation is that those seeking assisted suicide are often facing physical chronic illness, whereas those seeking to commit suicide are often plagued by mental illness, impairing their judgement and ability to make reasonable decisions. However, those against physician-assisted suicide argue that taking such a stance worsens the stigma associated with mental illness as not as serious or legitimate as physical diseases and conditions. Should the decision to end one’s life be treated differently or more dignified on the basis of physical or mental conditions? A previous Prindle Post article by Amy Elyse Gordon examines this issue. One could surely argue that in the case of terminal illness, physician-assisted suicide provides relief and control to those facing death. Additionally, this type of ending one’s life may not have the same adverse effects on family and friends as other forms suicide do.

If we accept that suicide is detrimental to society, whose responsibility is it to prevent it? This question is a difficult one, because it, in a way, assumes that suicide can be influenced by others, and that they in some way hold a moral responsibility to prevent it. At what level we hold people accountable can be difficult to determine. Giving the government the complete burden of preventing suicide may lead to its criminalization. Indeed, suicide was considered a crime in the U.K. until 1961, when suicide became framed less as a sin or moral wrong and more of a medical and psychological problem. However, the government can help prevent suicide in more ways than criminalization. A 2016 study found that rising poverty rates were highly correlative of rising suicide rates during the 2008-2009 economic recession. This study suggests that poverty and economic burden can influence the rate of suicide and if our goal is to prevent suicide, perhaps we should hold our politicians and government accountable for supporting those that are impoverished or enforcing stricter regulations on financial institutions to ensure economic stability. On the other hand, some might argue this alone is not enough.

Suicide is undoubtedly influenced by mental illness in many cases, regardless of external factors. Perhaps it is the responsibility of organizations such as the American Foundation for Suicide Prevention to help support those who feel suicidal and raise awareness about the topic. Some might argue this still is not effective enough alone because those who are considering suicide may not have access to these resources or may not have the motivation to seek out help.

So, we might then believe that it is every individual’s responsibility to prevent suicide. One example of the application of this type of thinking is the involuntary manslaughter sentencing of Michele Carter in 2017. Carter was a teenager suffering from mental illness, whose boyfriend, Conrad Roy III, committed suicide in 2014 (discussed in detail in this Prindle Post article). Text messages minutes before his Roy’s death show that Carter encouraged him to kill himself, texting him to get back in the carbon monoxide car after he had second thoughts about killing himself. Carter’s verdict implies that people can be held legally and morally responsible for their loved one’s decision to commit suicide. In the case of Carter, it was not just her failure to stop Roy, but also her encouraging attitude toward suicide that made her guilty,  according to the judge. If we decide to hold individuals accountable for preventing suicide, we may have to accept verdicts such as the one in the Michele Carter case. This becomes difficult, because it implies that those surrounding suicidal people, including loved ones, could be held legally and morally responsible for their death. Additionally, is assigning blame in the case of suicide really necessary or morally correct?

Suicide is not an easy topic, and probably never will be. The decision to take one’s own life cannot be boiled down to one or even a few causes. During September, we should all collectively think critically about suicide and how we are failing as a society to prevent it.

“Unbearable Suffering” and Mental Illness

Photograph of a single bed with a curtain and chair

Trigger warning: suicide attempts, multiple mental illness mentions

List of international suicide hotlines: http://ibpf.org/resource/list-international-suicide-hotlines

Aurelia Brouwers’ Instagram bio is terse and pointed: “BPD, depression, PTSD, anxiety etc. Creative. Writer. Gets euthanasia Januari [sic] 26. Fights till then for this subject.”

Brouwers was a twenty-nine year old Dutch woman who suffered from multiple mental disorders. She received her first diagnoses of depression and Borderline Personality Disorder at the age of twelve. As she recounts: “Other diagnoses followed – attachment disorder, chronic depression, I’m chronically suicidal, I have anxiety, psychoses, and I hear voices.” After an estimated twenty failed suicide attempts, Brouwers thought she found the solution to her suffering via euthanasia or physician-assisted suicide (EAS). EAS has been legal in the Netherlands since 2002, but Brouwers faced obstruction as her request was refused by multiple doctors. She finally turned to The Hague’s End of Life clinic, which approved her request and set a date for January 26 of this year. Scenes from Brouwers’ last fortnight of life were recorded by RTL Nieuws journalist Sander Paulus, who noted the young woman’s ongoing mental distress as well as the conviction with which Brouwers anticipated her euthanasia date. Footage featured by the BBC shows Brouwers collectedly making plans for her cremation ceremony with a funeral consultant. On January 26, surrounded by loved ones and two doctors, Brouwers consumed a liquid poison and “went to sleep.”

Brouwers’ case stoked vigorous debate in the Netherlands and elsewhere regarding the intent of euthanasia legislation. Her youth is one point of contention. Another factor is the nature of her affliction. In the discourses following Brouwers’ life, we see evidence of an assumed distinction between physical and psychiatric disorders. Journalist Harriet Sherwood went so far as to note in the tagline for her Guardian article that ”there was nothing wrong with her [Brouwers] physically.”

While psychiatric disorders are still primarily diagnosed via mental and behavioral markers, it is not strictly correct to assume that mental health disorders lack physical foundations. Often, the ways in which we speak of mental disorders reveal our imperfect knowledge of the biological elements (as differentiated from the more traditionally observed psychosocial components) of mental disease. This relative ignorance exists in part because researching biomarkers for psychiatric disease is a complex undertaking. What is known is that mental illnesses can often be life-long conditions that require ongoing treatment, treatment that appears to have been provided in Aurelia Brouwers’ situation.

The 2002 Dutch act exempting physicians from prosecution in specific EAS cases requires ”due care” by the attending doctor. This includes ascertaining unbearable suffering on the part of the patient without hope of improvement. The Netherlands is joined in this relatively open model by other European nations, including Belgium, Luxembourg, and Switzerland. Several American states, the Australian state of Victoria, and Canada also allow EAS, but in much more restricted circumstances mirroring the “Oregon model,” which stipulates a terminal illness with established life expectancy.

Arguments in favor of euthanasia often rest on the basis of respect for individual autonomy and on compassionate grounds. Here, for the sake of simplicity, I assume ethical assent to these grounds in support of voluntary euthanasia or physician-assisted suicide which is at the informed, long-standing behest of the patient. This is the only form of active euthanasia currently legal anywhere (whereas what some call ”passive” euthanasia or the withdrawal of futile treatment is considered to be normal medical practice). These moral justifications – autonomy and compassion – are taken as reasonable in states in which EAS is legalized. In the Netherlands, however, where EAS has been legal for sixteen years, Brouwers was initially refused by several doctors, and garnered national attention. Why?

Brouwers’ example seems to challenge notions of what constitutes “unbearable suffering,” impossibility of improvement, and “terminal” conditions. Popular conceptions of mental illness present it as something that one can “overcome” through patience or willpower, although the same perceptions do not apply to a broken bone or a cancer diagnosis. Dutch psychiatrist Dr. Frank Koerselman, speaking to the BBC, notes that Borderline Personality Disorder, from which Brouwers suffered, is known to decline in severity after the age of 40. But BPD was only one of Brouwers’ multiple diagnoses, which taken together, caused her immense suffering. Along these lines, some argue that her mental disease was itself terminal, as does Kit Vanmechelen in the BBC article. Brouwers had already engaged in numerous, though incomplete, suicide attempts.

What happens, though, when we allow EAS for psychiatric suffering as well as physical suffering (the more traditionally accepted justification)? As a society, our understanding of mental suffering does not seem to be as advanced as that of physical suffering (only recently was it discovered that emotional pain activates neural correlates similar to physical pain).

Many believe that it is a mistake to open this door. Dr. Koerselman opposes EAS for psychiatric disorders, in part because he posits it is not possible to distinguish a rationalized decision to die from a symptom of mental disease itself. On the other hand, a recent study of Belgian mental health nurses’ attitudes toward euthanasia for unbearable mental suffering found a widely positive response. Nurses were the subjects for this study because of their closeness to patients’ lives and frequent role as intermediate and advocate between patients and doctors.

Ethics is about individual cases, as well as the general principles that they reveal or elicit along the way. The case of Aurelia Brouwers is undeniably a tragic one, although Brouwers herself appeared to find some peace in her capacity to make an informed choice, supported by medical care. But what her life surely reveals is that we need to invest more in exploring the genesis and maintenance of mental disorders within our societies. One in four people world-wide will suffer from some form of mental illness. We need to invest more in understanding the biological bases of mental illness, as well as the social structures that are implicated in psychiatric disorders’ psycho-social components.  In the words of Brouwers, “I think it’s really important to do this documentary [of Brouwers’ life] to show people that mental suffering can be so awful that death, in the end, is the lesser of two evils.” As a society, we need to do better by those who experience mental pain.


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Me Before You: Portraying Euthanasia in Film

In early June, Me Before You, a film set in a small town just outside modern-day London, was released in theaters. The movie depicts a budding relationship between a young woman and a man from vastly different backgrounds. Lou has been trapped in the same town her whole life doing the same mundane tasks, while Will lived a lavish life of adventure and exhilaration until it was altered drastically after a motorcycle accident. The accident caused him to become a quadriplegic, ending his life as he knew it.

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A Right to Die

The California legislature recently passed a controversial bill, which they are calling the “End of Life Option Act”. If signed by the Governor, it will go into effect this January. The bill states that it would allow adults suffering from terminal illness that meet “certain conditions” to request and be administered a dosage of life-ending drugs. There would need to be documentation of both oral and written requests. As an accompaniment, it adds that doctors, workers, etc. will not be treated as criminals or subjected to disciplinary action as a result of the lawful practice of this procedure. Euthanasia Pro Con does a very good job of bringing together some of the various arguments for and against the so-called “right-to-die” laws.

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