When ‘Give Me Liberty’ Means ‘Give Me Death’: in Support of Death with Dignity

On October 5 of this year, Governor Brown made California the fourth state in the union to pass legislation protecting “death with dignity,” or the right of terminally ill patients with six months or fewer to live to seek a prescription of lethal barbiturates to end their lives.  The End of Life Option Act allows adults deemed mentally competent, and assessed as suffering from an incurable disease by two physicians, to issue a series of requests—both written and verbal—to obtain drugs that will allow them to take their deaths into their own hands if and when they choose to do so.  The process involves several waiting periods and evaluations between the multiple required requests, and the patient must physically self-administer the medication if they choose to follow through.  In addition to the four states—Oregon (1998), Washington (2009), Vermont (2013), and California (2015)—protecting the option of death with dignity, twenty-three states are considering similar laws regarding aid in dying to limit the suffering of the terminally ill.  Opposition to the movement centers on certain religious principles, the value of a life, and risk of abuse of the freedom provided by the legislation.  However the limited interpretation of death with dignity options as dangerous encouragement of assisted suicide loses sight of key provisions fundamentally tied to the character of the movement, and strictly outlined in the text of the statutes.  Death with dignity laws only provide the option of—and do not encourage—aid in dying, and the primary motivation behind taking advantage of these laws stems from values rooted in autonomy and freedom.  Additionally, several principles supposedly violated by the death with dignity option are in fact upheld by it.   Thus similar legislation should pass in states that show interest in following in California’s footsteps.

The End of Life Option Act and analogous laws preserve precisely that: the option for patients with mortal illness to choose when and how to die.  Maintaining the availability of the option does not imply that terminally ill patients must make use of such legislation.  In all cases, the laws even specify that those who have initiated the process of taking advantage of aid in dying can change their minds at any point along the way.  The

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Fig. 1: Signing letter from California’s End of Life Option Act (Gov. Edmund G. Brown)

stories shared on the webpage of the Death with Dignity movement—particularly those posted by patients considering use of aid in dying—echo the same themes highlighting the importance of the option: “When I say physician-assisted dying should be an option for everyone I really do mean ‘option.’ No one is forced to use it, and if you who disagree with it you don’t have to.…Not everyone is going to agree with the choice and they don’t have to….you choose how to live your life, you should be able to choose how to die” (Shelfer).  Additionally, death with dignity laws do not require or incentivize physicians to comply with patient requests to write the lethal prescription.  Physicians may opt not to participate in the process for any reason of their choosing.

As professed by Immanuel Kant in his description of enlightenment, “One age cannot bind itself, and thus conspire to place the succeeding age in a situation in which it becomes impossible for it to broaden its knowledge…[the true legal question is] could a people have imposed such a law upon itself?” (Kant 61).  In the case of aid in dying laws, the conflict lies not in one age constraining posterity, but in those who do not know the suffering of terminal illness trying to restrain the terminally ill from exercising a freedom over their own mode of passing.  Peter Richardson’s 2011 film How to Die in Oregon details the stories of individuals and families impacted by death with dignity options or lack thereof.  Living in Washington before the state passed its aid in dying law, Randy Niedzielski suffered terribly through a prolonged death from a brain tumor, often imploring his wife “Nancy, you have to change that law.  You can’t let anyone else go through this” (Richardson, How to Die in Oregon).  The opposition correctly declares that the state should not encourage a patient to use aid in dying; however these fears cause them to undervalue the importance of honoring the freedom of the terminally ill by offering an option for them to alleviate their own suffering.  Simply because terminally ill, mentally competent adults can decide when the pain becomes too much to bear and determine when their lives are no longer to be lived does not mean that they must make use of the laws.  However, for patients like Randy, the option to choose would prove vital to the preservation of what little freedoms remain to a person whose disease has already stolen so much.  Kant’s fundamental consideration of whether a people could impose a given law upon themselves extends to the discussion of death with dignity.  Legislators and voters must contemplate whether those suffering from mortal illness would or could limit themselves further by refusing to pass a law offering a choice in the mode of their own deaths.  If “enlightenment is mankind’s exit from its self-incurred immaturity” (Kant 58) then to serve a true manifestation of freedom, that exit—from immaturity or from life—must also be chosen by and imposed by the self.

Another large concern voiced by critics lies in the potential for people to act on death with dignity laws out of guilt or due to pressures from people looking to take advantage of the terminally ill for reasons of inheritance or other financial concerns.  However, most patients considering aid in dying do so with resistance from loved ones and with very specific, personal reasoning backing their choices.  Cody Curtis, a wife and mother dying of aggressive liver cancer, explained, “I am not going to be humiliated with losing control of my bodily function again.  This will be tidy, and while not easy for my family, it’s a lot better than the alternatives” (Richardson, How to Die in Oregon).

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Fig. 2: Motivation behind patients’ choices to seek lethal medication (Emily Barone)

Moreover, statistical analysis of the hundreds of people who have procured the medications to end their lives show that loss of autonomy (91%), lowered dignity (81%), and lack of freedom to participate in life as they desire to live it (89%) are the overwhelming reasons for pursuing death with dignity provisions.  Financial implications (3%) fall far behind these factors in terms of patient consideration.  The burden on caretakers (40%) also lies lower in the realm of concerns (Barone).  People taking advantage of death with dignity legislation demonstrate less concern with financial implications of end-of-life care—and even with burdening loved ones—than they do for the limitations their ailments place on their freedom and autonomy.  Freedom serves as the major impetus behind terminally ill patients’ decisions to end—or consider ending—their lives in a way they choose.

Furthermore, Oregon’s pioneering statute protecting aid in dying procedures dictates that prescription of the life-ending medication requires “valid requests…signed and dated by the patient and witnessed by at least two individuals who, in the presence of the patient, attest that to the best of their knowledge and belief the patient is capable, acting voluntarily, and is not being coerced to sign the request,” and at least one such witness must not be any of the following: a relative of the patient; entitled to part of the patient’s estate via a will or legal proceedings; a worker involved with a health care facility in which the patient receives treatment or resides; or the patient’s attending physician (127 Oregon Rev. Code. Sec. 810.2.02.).  Two physicians must independently affirm the diagnosis of terminal illness, and patients may rescind the request at any point; such conditions, in addition to the aforementioned reasoning of the vast majority of death with dignity users, indicate that the laws defending aid in dying in Oregon, Washington, and Vermont (with California’s End of Life Option Act not yet in effect) adequately protect against abuse.  In a demonstration of the commitment to appropriate use of the law, volunteers trained by Compassion and Choices, a nonprofit partner of the Death with Dignity movement, offer consultations and counseling to patients considering using their states’ aid in dying resources.  These workers not only offer assistance in discussing end of life choices, but also ensure to the very end that patients know their options remain open.  As revealed in the powerful opening scene of How to Die in Oregon, Compassion and Choices personnel make clear the choices available to the patient: “I’m going to ask you those two questions again.  And I’m serious. You know that at any point you have the right to change your mind?  And what will this medication do?” (Richardson, How to Die in Oregon).  “Those two questions” are at this point already incredibly familiar, having been reviewed throughout the consultation process with the patient and any family members the patient chooses to include.  They come up once more before the patient decides to ingest the lethal dose.  These consistent reminders that the death with dignity laws constitute a choice, never a requirement, indicates the commitment of voters in Oregon, Washington, and Vermont to passing only laws with strict enough conditions to prevent the abuse that opponents cite as an overwhelming risk.  This commitment no doubt contributes to the fact that “the State of Oregon reports of no evidence of coercion since the law’s implementation in 1998, and the state of Washington also hasn’t found any incidence of coercion” (DeathwithDignity.org).

Primary opposition to death with dignity laws comes from the Catholic Church.  In the narrow defeat of the Massachusetts proposal in 2012, the Church funded 80% of the opposition campaign, and representatives from the U.S. Conference of Catholic Bishops profess a belief that death with dignity laws “institutionalize an injustice in which society decides some people’s lives are not [as] worth protecting as others” (Sanburn).  However, legislation protecting death with dignity passes no judgement on whether any lives are or are not “worth protecting”; it offers a choice to each terminally ill patient regarding the way in which he or she prefers to end life. The choice, and the judgement about the value of the remaining life, lies with the patient.  Such staunch commitment to individual choice reflects the existentialist principle of man as “responsible for what he is…solely responsible for his own existence…responsible for his own individuality…[and possessing] the freedom of the individual subject to choose what he will be” (Sarte 23).  People seeking a way to exit life through death with dignity see this range of choices narrowing under the constraints of illness.  They witness their own vitality receding, and face the fear of merely existing rather than living the life they have loved.  As Simone de Beauvoir asserts in her Ethics of Ambiguity, “To exist is to make oneself a lack of being; it is to cast oneself into the world” (42).  Terminally ill patients making use of death with dignity desire to keep themselves from ending life merely existing, lacking true being.  They know their illnesses divest them of the choice to “be” in the fashion they would choose to be.  In the form of true existentialist heroes, they reject the idea of submission and hold tightly to the freedom and the responsibility to choose what they will be and how they will go.  They choose not to passively cast themselves forward toward a transformation that will steal their remaining freedoms.  Therefore in response to the claims of the Catholic Church and others that death with dignity is a devaluation of human life, it is true that in a meaningless life a “sub-man makes his way across a world deprived of meaning toward a death which merely confirms his long negation of himself” (de Beauvoir 45).  But this only emphasizes that those making use of death with dignity differ in that their deaths, taken into their own hands, do not confirm any such long negation of the self.  Rather they do quite the opposite; the choice of a terminally ill patient to take advantage of these laws in fact verifies the abundance of meaning that person found in his or her life.  Recognizing the loss of capacity to live and to savor a life that has meant so much, and choosing to leave life on their own terms—to the extent that one could do so with a terminal illness—they instead confirm their remaining autonomy in this last exercise of pure existential freedom.  Thus death with dignity legislation does not devalue certain lives; rather it places incredible value on protecting freedom in end-of-life choices for each and every individual facing terminal illness.  While the Church considers aid in dying merely a form of violence against oneself (a sin that would, to 14th-century Catholic Dante Alighieri, land a person in the seventh ring of Hell), clear distinctions between suicide and death with dignity remain.  Dante condemns the souls of the suicides to languish in the desire to reclaim the bodies they cast off.  One such soul explains “My spirit, at the taste of disdain, believing by death to flee disdain, made me unjust against myself” (Canto XIII, 70-72).  However, death with dignity does not match the deaths of these tree-souls who discarded their functioning, healthy, and fully living bodies.  Aid in dying for terminally ill patients is not an unjust act against oneself—rather the injustice here would consist of forcing oneself to wither and lose oneself entirely before submitting to a painful death.

Similarly, oncologist Katherine Morris, MD, who attended to Cody Curtis and befriended her before her death, describes learning to interpret the Hippocratic Oath in a new light.  She explains “‘First do no harm’ is going to be different for every patient.  Harm for some patients is saying, ‘No, no, no.  You’ve got to do this the way your body decides as opposed to the way you decide’” (Richardson, How to Die in Oregon). “Do no harm” means something different in certain cases.  Harm is not something limited to the physical being, but the freedom of the human person is something tied to the physical being.  So when the limits become too much for a terminally ill person, the idea of “harm” no longer holds the same definition.  Harm now becomes forcing that person to suffer through barely existing, in pain and very, very unfree to help him- or herself.  Harm now becomes disrespecting the patient’s values and dying wishes.  As death and dying issues rise to public attention through these laws and proposals, palliative care physicians take the opportunity to highlight the issues they see in end-of-life choices.  Stanford Medical Center Palliative Care physicians recently released an opinion that “we must have to be sure that our wishes are respected, no matter what they are…. those who provide for our health should provide comfort and support when and where we need it” (Lorenz).  Thus when these dying wishes include the preservation of personal dignity through the relative comfort of death with dignity, health care providers should be protected in offering dying patients an option they might want to pursue.

Choosing humane aid in dying should be an option for terminally ill patients whose freedom has otherwise been siphoned away by a debilitating condition.  Death with dignity laws, like Oregon’s and those modeled after it, simply provide the freedom for terminally ill individuals in pain to end their suffering on their own terms.  This very personal decision is rightly limited such that it can only be carried out by each patient of his or her own volition.  The loss of autonomy and loss of freedom, not coercion or pressure, have been shown to serve as the primary motivators behind use of death with dignity legislation.  Additionally, the several major principles supposedly violated by the death with dignity option—avoiding violence, preserving justice, valuing human life, and adhering to the Hippocratic Oath—are in fact upheld by protecting aid in dying.  Thus wherever citizens show interest in establishing and committing to the upright and honest application of death with dignity laws, they should be able to offer this form of relief as an option to those for whom a painful end looms near.



Works Cited

127 Oregon Rev. Code. Sec. 810.2.02.  Oregon State Legislature, 2013. Web. 23           Nov. 2015.

Alighieri, Dante, Darrell W. Robinson, and Robert M. Durling. Inferno. New           York: Oxford UP, 1996. Print.

Barone, Emily. “See Which States Allow Assisted Suicide.” TIME. Time                   Inc., 3 Nov. 2014. Web. 21 Nov. 2015

Beauvoir, Simone De. The Ethics of Ambiguity. Trans. Bernard Fretchman.               New York: Citadel, 1976. Print.

Brown, Edmund G., Jr. “Signing Statement: End of Life Option Act.”                      CA.gov. Office of the Governor, 5 Oct. 2015. Web. 26 Nov. 2015.

“Frequently Asked Questions.” DeathwithDignity.org. Death with Dignity              National Center, n.d. Web. 25 Nov. 2015.

How to Die in Oregon. Dir. Peter Richardson. HBO, 2011. Rental.

Kant, Immanuel. What Is Enlightenment?: Eighteenth-century Answers and                Twentieth-century Questions. Ed. James Schmidt. Berkeley: U of                          California, 1996. Print.

Lorenz, MD, Karl. “Vantage Point: It’s Time to Talk Honestly about                        Dying.” News Center. Stanford Medical Center, 16 Nov. 2015. Web. 23              Nov. 2015.

Sanburn, Josh. “Brittany Maynard Could Revive the Stalled ‘Death With                Dignity’ Movement.” TIME. Time Inc., 1 Nov. 2014. Web. 21 Nov. 2015.

Sartre, Jean-Paul. Existentialism Is a Humanism. Yale UP, 2007. Print.

Shelfer, Penny. “I Want to Control My Ending.” DeathwithDignity.org.                    Death with Dignity National Center, Aug. 2015. Web. 25 Nov. 2015