Suicide Issue Now in Court of Public Opinion

By rejecting the idea that mentally competent, terminally ill people have a constitutional right to a doctor’s help committing suicide, the U.S. Supreme Court has offered no quick fix for the prolonged and agonizing debate on the issue.

The unanimous decision means that Americans will probably have to resolve the question themselves, vote by vote, in the “laboratory of the states,” as Justice Sandra Day O’Connor wrote in her assent to the strongly worded opinion crafted by Chief Justice William H. Rehnquist.

Naturally, reactions to the long-awaited decision were divided. Doctors attending a meeting in Chicago of the American Medical Assn., which opposes doctor-assisted suicide, shouted and cheered when the ruling was announced. The National Right-to-Life Committee vowed to “mobilize in all 50 states to fight efforts to legalize direct killing of the vulnerable through state courts, state legislatures and referenda,” said director David O’Steen.

Advocates voiced defiance and dismay. For his part, Dr. Jack Kevorkian of Michigan, who has admitted to participating in 45 suicides since 1990 and was not a party to the cases reviewed by the court, remains undaunted. “Dr. Kevorkian is going to continue to do what’s right,” said his lawyer, Geoffrey Fieger.

Some of the most vocal mainstream supporters of assisted suicide are in the AIDS community, where there has been a documented rise in assisted suicides in recent years. The Court “has ruled against empowering people . . . to freely choose in a dignified and humane way the manner and time of their death,” said Daniel Zingale, executive director of AIDS Action, a national advocacy group.

Between the extremes of staunchly for and against, however, is a large and complex range of concerns that are likely to undergo severe tests in the “laboratory” of politicking and public discourse. Indeed, one of the distinguishing features of this life-and-death controversy is the apparently large number of thoughtful, reasonable people who believe the practice is morally justified in some cases as a last resort--but who are still against legalizing it because the risks are so great.

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The New York State Task Force on Life and the Law, an advisory group of medical and legal experts, began studying doctor-assisted suicide in 1992. Although numerous members believed the practice was ethical in some circumstances, the group unanimously came out against legalization in its 1994 report because “the strong likelihood of mistakes and abuse outweighed any benefits legalization might achieve in isolated cases.”

The task force, like many ethicists struggling with the issue, found the safeguards often proposed to cover the practice only create more dilemmas. As usually envisioned, doctor-assisted suicide applies to a patient with no more than six months to live, who initiates the request, is capable of giving informed consent and swallows a fatal dose of barbiturate and other drugs on his or her own.

But attorney Carl Coleman, the task force’s executive director, pointed out that such safeguards are inherently unfair, because they deprive people who cannot swallow of such aid in dying. It is similarly arbitrary, he and others note, to rule out someone in pain who has seven months to live--even if doctors could determine the final days with precision.

At the same time that the Supreme Court ruled against a right to physician-assisted suicide, it resoundingly supported the now-established right to refuse medical treatment, including respirators or feeding tubes.

Barbara Koenig, an anthropologist who heads the Stanford University Center for Biomedical Ethics, says she is in the same bind. “There are situations in which it can be a morally justified act in the context of an established doctor-patient relationship” she said. “But this is not the time for legalization.”

With the stark inequities in health care for the rich and poor, as well as the current cost-cutting pressures in managed care, she fears that some people would be coerced, if only unconsciously, into seeking assistance in dying.

In his opinion, Rehnquist also raised the specter of abuse. “Legal physician-assisted suicide could make it more difficult for the state to protect depressed or mentally ill persons or those who are suffering from untreated pain and from suicidal impulses,” he said.

But others dispute that fair safeguards are impossible to draw up. In addition, they say that because a small number of doctor-assisted suicides are already known to be occurring, legalization will make the practice safer.

“It isn’t a question of should we do it or not, but how can we do it to protect the rights of patients and the integrity of the profession,” said Dr. Lawrence Schneiderman, a UC San Diego internist and ethicist.

The burgeoning debate “will be a mess for a long time,” Schneiderman said. “The so-called back-room abortion will have its equivalent in the so-called back-room assisted suicide.”

The ability of opponents or just mild skeptics of assisted suicide to raise questions about any proposed safeguards is likely to figure prominently in the coming political debate. In a sense, some say, the political process itself gives an advantage to opponents of legalizing the practice because raising doubts or fears is easier than convincing the public that it is a safe and beneficial procedure.

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While public opinion generally runs in favor of legalizing doctor-assisted suicide, much of that support appears to be soft. An AMA poll last December found that 50% of the 1,000 surveyed were in favor of legalizing doctor-assisted suicide, but half of the respondents changed their minds after being told about alternatives like hospice care and about potential abuses.

Both sides of the argument agree that the debate reflects rampant public discontent with medicine as usual. Medical researchers have recently shown that hundreds of thousands of Americans annually die lonely and in unnecessary pain, undergoing futile treatments, often attended by physicians who know virtually nothing about their lives, never mind their feelings about death. These are the victims of modern medicine’s “frustrated mastery,” as the ethicist Daniel Callahan views it.

“The issues here are really not constitutional issues,” said Dr. Joanne Lynn, director of George Washington University’s Center for Care of the Dying, who opposes legalization of the practice. “They’re really about what kind of support we want to give each other at the end of life. There has to be a commitment to a better course of living with even a bad disease, a course that is meaningful and supportive and comfortable.”