Suicide, assisted suicide, and physician-assisted suicide

Something like one million people each year in the United States try to kill themselves (with various levels of determination) and about four percent of them succeed. That makes suicide the 10th-leading cause of death: way ahead of homicide, and about on a par with auto accidents. About half of those attempts involve people with alcohol, tranquilizers, or opiates on board, raising the question of whether the person involved would make the same choice sober. (The answer might be “yes”: someone could decide in cold blood to kill himself and have a drink or three to steel himself to do it, or someone in chronic pain and taking opiates for it could decide that the pain is more than she wants to handle for years to come.)

In many cases, the impulse is transient; of those who survive suicide attempts, fewer than 10% eventually finish the job. Even people who, seemingly by chance, survive suicide attempts using methods that kill 95% or more of the people who try them (e.g. jumping from tall buildings or bridges, gunshots to the head) mostly don’t try it again. That suggests that most of those who succeed in taking themselves off were not acting on a steady, settled decision that life wasn’t worth living.

That being the case, preventing someone from committing suicide seems as straightforward a public-health objective and medical responsibility as preventing any other sort of sudden death.

Suicidal thoughts are even more widespread than suicide attempts. Physicians and other service providers know something – not as much as they would like, but something – about how to keep those thoughts from turning into attempts, and how to reduce the lethality of the attempts that are made. (Keeping guns out of the hands of those who might use them on themselves ranks high, since guns are especially effective means of ending one’s own life.)

Much of the burden of this work falls on psychiatrists. Those I know are proud of their many successes and intensely distressed by their occasional failures. So it doesn’t surprise me to find my friend Keith Humphreys, who teaches psychiatry, strongly opposed to having physicians – and psychiatrists above all – involved in helping people kill themselves. And published descriptions of Belgium’s legal Kevorkians are not encouraging in terms of how much care they use to avoid helping to end the lives of people who would, if they survived, be happy about it.

With all that said, I still think that people who have formed and held the view that their lives would be better shorter ought to be allowed to act on that view. The fact that much suicide is impulsive doesn’t mean that all suicide is impulsive. The fact that some people might change their minds later, either spontaneously or as the result of a medical breakthrough, doesn’t – in my view – justify the state in requiring someone who doesn’t want to go on living to do so anyway.

And the right to die ought logically to include the right to seek help in dying from a willing helper. There’s not much that can be done to prevent suicide by someone sufficiently determined and capable (physically and psychologically) of acting without help; but when someone asks for help that creates the opportunity, by surrounding the act of helping with appropriate rules, to try to screen out the cases where the intention is impulsive.

Where I agree with Keith is in thinking that the helper should not be a physician (with some exceptions I’ll get to). Physicians have the social role of protecting life and health; getting them involved in killing those who aren’t dying creates too much role tension, given that in the vast majority of cases the goal ought to be prevention.

But the real reason not to get docs involved in assisted suicide is that their professional knowledge and skill are almost completely irrelevant to the task. A physician can provide (probabilistic) information about the subject’s current and likely future health status, including mental health. “Is my depression going to get any better?” is a question a psychiatrist can try to answer. But “Would I be better off dead?” isn’t a medical question, and therefore a medical professional has no qualification for offering an opinion.

Nor is a physician needed to provide technical help, except where the laws get in the way. A breathing mask or plastic bag plus a tank of nitrogen will kill someone reliably and painlessly, and a plumber is more likely than a physician to be able to provide the requisite equipment and aid in its use. “Physician-assisted suicide” is an artifact of a world in which suicide is illegal, and some of its more reliable means (opiates and barbiturates, for example) available only with medical approval. In the special case of death by intravenous injection, skilled help is necessary simply because most of us don’t know how to mainline, even if we had the equipment and the nerve. That makes the physician the natural helper for someone who is already dying and in intense physical pain; a lethal dose of morphine or its equivalent can be given without anyone explicitly asking for a lethal dose when nothing less than a lethal dose will stop the pain.

But in the cases Keith addresses – physically healthy people who want to die because they can’t see any end to the suffering from their life situations or their somatic or mental illnesses – I’d want to keep the doctors far away. Someone in that situation ought to be allowed to register his or her decision to stop living, and – after some waiting period and approval by an actual “death panel” based on the panel’s conclusion (perhaps having taken psychiatric or other medical advice) that the subject’s intention is serious and not merely impulsive, is not made under pressure from others, and that the reasons the subject offers for the decision are not likely to materially change in the near future – be allowed access to carry out his or her intention without interference, and with help from willing helpers.

Of course this is personal. I’m now at an age where I’m going through the deaths of older relatives and friends, and every year my age gets closer to theirs. Some live well to the very end, but by no means all. I can think, without pausing, of five people close to me whose lives would have been improved by a fatal stoke months or years before the Man with the Sickle eventually showed up. I’ve spent enough endless hours in nursing homes to be absolutely certain I want to die before I land in one.

Yes, I’m worried that permission to die could evolve into social pressure to die. (See Tom Schelling’s “Strategic Relationships in Dying.”) And of course your mileage may vary. If your moral or religious principles forbid suicide, no one should try to change your mind, and you shouldn’t have to be involved in helping anyone else. But none of that seems to me an adequate reason to force continued life on those who are tired of it.

Footnote I note that Arthur Caplan, whose exquisite ethical sensibility requires that people who want to live die instead unless they can get replacement kidneys in ways that Caplan finds acceptable, also holds that people who want to die should be required to live until Caplan is satisfied there’s no “slippery slope” nearby. Seventeen people will die today in the United States waiting for kidneys, but Caplan and friends have made sure that potential living donors (you can get along just fine on one kidney) can’t be compensated for donating, so the waiting lists just keep getting longer.

In the good old days, the people who told you that innovations to alleviate human suffering (vaccination, anaesthetic-assisted childbirth, contraception, IVF) were e-e-e-e-villll and must be forbidden by law were called “bishops.” Now they’re called “bioethicists.” This represents dis-improvement in two important ways: (1) Bishops had more impressive costumes; (2) The separation of church and state doesn’t work to keep the bioethicists from imposing their professionally hyperactive consciences on the rest of us, whether we agree with them or not.

Author: Mark Kleiman

Professor of Public Policy at the NYU Marron Institute for Urban Management and editor of the Journal of Drug Policy Analysis. Teaches about the methods of policy analysis about drug abuse control and crime control policy, working out the implications of two principles: that swift and certain sanctions don't have to be severe to be effective, and that well-designed threats usually don't have to be carried out. Books: Drugs and Drug Policy: What Everyone Needs to Know (with Jonathan Caulkins and Angela Hawken) When Brute Force Fails: How to Have Less Crime and Less Punishment (Princeton, 2009; named one of the "books of the year" by The Economist Against Excess: Drug Policy for Results (Basic, 1993) Marijuana: Costs of Abuse, Costs of Control (Greenwood, 1989) UCLA Homepage Curriculum Vitae Contact: Markarkleiman-at-gmail.com

10 thoughts on “Suicide, assisted suicide, and physician-assisted suicide”

  1. Consider paying for kidneys after you have raised the unpaid organ donation rate to that of Spain: 36 per million against 26 in the USA, or 38% higher. (Most of Europe is well below the USA, so this is not about socialized medicine). Spain has opt-out, but according to Dr. Rafael Matesanz, the great guy who runs the system, it never enforces it: doctors always obtain consent. The number of donations rose in 2014, in spite of a welcome fall in traffic deaths. It's done by superior organisation – for example, the organ donation coordinator in a hospital is not a lowly administrator or nurse, but a full-fledged doctor working in the ICU – buttressed by a strong social consensus. There's a lot you can say against the Spanish Catholic hierarchy, but not on this. Would the consensus survive the introduction of payment?

    1. Spain does worse than California actually.

      Within the constraints of the law, it should be possible to compensate people for the time off work, lost wages and other costs. We had a nice discussion of that here http://med.stanford.edu/healthpolicyforum/past-ev

      Last note that the 18 a die dying figure excludes people who are removed from the list before they die because they are too sick to receive a transplant, the actually number of deaths per day IIRC is about 30.

      1. Don't the Swedes compensate? I don't have any problem with this.

        I used to give blood at my old employers' in Strasbourg. Again contrary to stereotype, the French are solid blood donors – at the Council of Europe, a higher ratio in the Alsatian support staff than among the well-paid and professionally high-minded international administrators like me. In the 70s, the blood collection team brought a terrific workman's breakfast: sausage, baguette, cheese, and coarse red wine, nominally to replace the iron. Medical correctness put paid to the wine, to my regret. I can see hobos giving blood on exchange for free booze, but not civil servants in steady jobs.

        1. I used to donate in college. There were these lovely senior citizens, mostly ladies, who were so nice and gave you snacks after. (Not anything as exciting as your breakfast. Cheezits and such.) It was great if you were feeling a little homesick.

      2. Not sure I have an opinion about these extra costs… but just out of curiosity, who would be paying them?

    2. Spain apparently offers compensation to families of deceased donors: "Spanish compensation is ordinarily presented as 'funeral assistance' or 'family assistance' at the time of death." From Beard and Osterkamp, p. 2, "The organ crisis: a disaster of our own making," by T. Randolph Beard and Rigmar Osterkamp, Eur J Health Econ (2014) 15:1–5.

  2. That Vice TV segment about the South Asian black market for kidneys was pretty chilling and gave me a lot of pause about kidney sales.

  3. I hope I am allowed to agree on a well-implemented suicide regime and to disagree about organ sales.

    I wouldn't go for the death panel though. Who'd want to serve on it? You'd have to dragoon people. I need more information on this actually. How many people are there who are incurably/untreatably depressed? (I guess most of us could easily bang out something for terminally ill, in-pain people whose treatment is failing them?) I know this happens bc I've heard of people checking out after years of fighting deep depression. Still… I wonder what the stats are for eventual recovery. That's actually a pretty tough issue. I wonder if we put enough research $$ into this.

    Anyhow, soon we will grow new organs in petri dishes, I assume?

    1. Wikipedia on tissue engineering here. In 2011, an Italian surgeon implanted a tissue-grown windpipe in a Swedish hospital. A glass replica (sic BBC – surely it must be a soluble glass analogue?) of the patient's trachea was created in London, then seeded with his stem cells in Sweden. He was an African PhD student in Iceland, so it's a nice advert for European cooperation and multiculturalism. Other approaches use scaffolds from animals or cadavers – these are just inert collagen, there is in principle no risk of rejection. Of course, it's a fair distance from windpipes, which are passive tubes, to constantly pumping hearts, let alone complex biochemical factories like kidneys and livers, but the hearts at least would be a good bet for the near future.

      Update 4/09: Trust Auntie to get the science wrong. The UCL team started with detailed 3D scans from Stockholm, then fabricated a glass mould. The actual trachea scaffold was cast out of a “nanocomposite polymer“. I was wrong in guessing this is soluble, it’s clearly permanent.

  4. Re the Keith piece on depression and suicide: good for you for asking questions. And while it may be unfair to blame doctors for not previously having had miraculous new treatments… the creation of those new treatments does throw a monkey wrench into the whole works.

    Just a quibble though. You said this: "Mental illnesses can make life extremely stressful, sad and challenging. " Well, I think they can actually *hurt.* (I said it was a quibble…) Depression is a kind of pain. It is suffering. Otherwise I don't think we'd see people heading for the exits. The way you had stated it sounded a little minimizing. (But that's not to say I am ready to help them get to the exit.)

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