In 2008, the state legislature of Washington passed what was called the Death with Dignity Act, a law that legalized physician assisted suicide. Under the law, terminally ill patients (predicted to have less than six months to live) can request prescriptions for lethal medications from their physicians, under a series of safeguards: multiple requests for example, determination of competency, and the like. Then, if the patients so choose, they can ingest the pills at the time of their choosing, thus controlling the manner and location of their demise, a last act of control in the face of an otherwise debilitating illness.
I have no beef with the letter or spirit of Washington’s law. I have long contended that in rare circumstances, physician assisted suicide is a compassionate and morally appropriate policy. Nor am I worried about the way the Washington law has worked in practice. Indeed, a New England Journal of Medicine study from April demonstrates that patients have chosen assisted suicide sparingly, and without undue coercion from clinicians urging them to “off themselves”.
My beef is not with the letter of the Washington law, it’s with the name. I think it is wrong-headed to equate assisted suicide with the concept of a dignified death. Such a link unduly narrows the concept of dignity, and potentially undermines our ability as clinicians to help patients find other ways of achieving a dignified death.
According to dictionary.com, dignity is defined as “bearing, conduct, or speech indicative of self-respect or appreciation of the formality or gravity of an occasion or situation.” By this definition, someone with dignity carries themselves in an impressive manner. Think Helen Mirren as opposed to Jenny McCarthy.
In medical circles, the concept of dignity is a bit removed from this lay usage. Dignity refers to people’s right to be valued and treated ethically. Going back to Kant, dignity refers to the importance of treating people like ends, not means. At times, dignity is lumped together with the right of self-determination. Mainly, the word is used in medical contexts with very little clarity, often undefined by those wielding the word except to say: “X would deny patient dignity, therefore we should be against X.”
I agree with supporters of Washington’s law that physician assisted suicide can be part of a dignified death. But there are plenty of other ways for terminally ill patients to control the circumstances of their death, making it wrong to equate dignity with suicide. For example: How about more aggressive use of palliative care? Too often, patients with advanced illness are treated aggressively with “salvage chemotherapy” or with “IV pressers”, when their quality or even quantity of life would be better served by aggressive palliative care.
I worry that patients suffering from terminal illnesses will perceive an unnecessary dichotomy, between continued aggressive care and death with dignity, a.k.a. physician assisted suicide. Those who are morally opposed to suicide may then fail to pursue other dignified ways of controlling their destiny.
The Washington researchers point out in their New England Journal article that only 114 patients at the Seattle Cancer Care Alliance inquired about the Death with Dignity program, a tiny number compared to the number of patients who died of their cancers in the Seattle area over the time period the investigators studied. In other words, people are not rushing to kill themselves. But what the researchers could not comment on was the number of patients who unnecessarily suffered at the end of life because the death with dignity law misdirected their attention from palliative care to assisted suicide.
There are many ways to die with dignity. Let’s not propagate the mistake of equating dignity with suicide.