"Philosophical problems arise when language goes on holiday."—Ludwig Wittgenstein
The recent death of Brittany Maynard has again focused attention on the vexing issue of...well, of what, exactly? Here, the language wars begin and philosophical analysis often ends. To begin simply with the facts: Ms Maynard, age 29, who suffered from terminal brain cancer, ended her life by taking a lethal dose of barbiturates, prescribed under Oregon law by a physician.[1] Now, as a physician and bioethicist, I have no intention of criticizing either Ms Maynard or the physician who wrote the lethal prescription. This brave young woman found herself in an unspeakably tragic situation, and both she and her physicians knew that further treatment would be futile. Most reasonable and humane people can readily understand why Ms Maynard and her prescribing physician acted as they did, even if many might choose different paths for themselves.
But here, the fabric of language begins to fray and unravel. In Oregon, the events that unfolded fall under the comforting rubric of "death with dignity."[1] Ms Maynard herself has been described as a "right-to-die advocate," as Daniel E. Slotnik's New York Times obituary put it.[2] Some advocates of this putative right argue that, when a terminally ill patient chooses to end his or her life, this should not be called "suicide"—a word freighted with pejorative connotations—but rather "self-chosen death." The linguistic twists and turns become even more tortuous when the role of Ms Maynard's physician is discussed. We find terms such as "voluntary euthanasia," "mercy killing," "physician-assisted suicide," and "physician-assisted dying" all competing in the linguistic marketplace.
The late psychiatrist and staunch libertarian, Dr Thomas Szasz, considered the term "physician-assisted suicide" to be a mendacious euphemism. For Szasz, the physician who writes a lethal prescription for a terminally ill patient is participating in a form of "legally authorized medical killing." In his book, Fatal Freedom, Szasz argued that—far from affirming a patient's autonomy—so-called physician-assisted suicide merely codifies the all-powerful authority of the physician. If anything, he argued, physician-assisted suicide should be termed "physician-controlled suicide," because it is the physician who determines which patients "qualify" for the procedure, and who prescribes the lethal drug.
Some advocates for the right to die insist that terminally ill patients also possess the "right" to have their doctors prescribe a lethal drug. But on this point, Szasz made a crucial distinction between rights and liberties. For Szasz, a right is a privilege or activity that requires others to assist or cooperate in some fashion; a liberty is something that we may exercise without imposing obligations on others. So, for example, if citizens have a right to vote, the government incurs an obligation to provide a mechanism for voting. In contrast, citizens may be at liberty to smoke, but the government has no obligation to provide cigarettes.
Szasz did not believe that suicide was a full-fledged right but rather a personal liberty. He argued that people ought to be "left alone" to commit suicide—but he did not believe that physicians ought to "assist" in killing their patients. These distinctions are critical to the debate now raging over Brittany Maynard's death. For example, one might argue that a mentally competent patient facing a terminal illness ought to be at liberty to end her own life, without asserting any right that would obligate physicians, or anyone else, to assist her. On the other hand, US courts have consistently upheld the right of mentally competent, terminally ill patients to refuse unwanted and futile treatments, such as the use of respirators, which merely prolong the dying process. Here, the operative term is "desisting," not "assisting."
Finally, there is the matter of "dignity"—a word whose Latin roots denote "worth" or "worthiness." It is certainly plausible that having some control over the time and manner of one's death could give a dying person a sense of "worth" or "worthiness." But it is far from clear that ingesting a lethal drug confers more "dignity" than other ways of bringing one's life to an end. For example, according to Dr Mohana Karlekar, director of palliative care at Vanderbilt University, voluntary stopping of eating and drinking (VSED) is a humane means of ending one's life peacefully, relatively painlessly, and without the need for medical authorization.[3] For other patients with a terminal illness, dignity may entail letting the disease take its course, bearing with the dying process, and receiving optimal palliative care—perhaps through home hospice arrangements.
The self-induced death of Brittany Maynard will, understandably, elicit many different reactions from physicians, patients, and the general public. But we need to be careful with the terminology we use when referring to self-induced dying, rights vs liberties, and the role of the physician in the dying process. "Death with dignity" should not become a politicized slogan, appropriated solely by those who advocate so-called physician-assisted suicide. Rather, dying with dignity is a deeply personal matter that physicians and patients must explore together, with care, respect, and compassion.
Suggested Reading
Ganzini L, Goy ER, Miller LL, Harvath TA, Jackson A, Delorit MA. Nurses' experiences with hospice patients who refuse food and fluids to hasten death. N Engl J Med. 2003;349:359-365.
Pies R. Merciful assistance or physician-assisted killing? Psych Central. September 30, 2012. https://psychcentral.com/blog/archives/2012/09/30/merciful-assistance-or-physician-assistde-killing/ Accessed November 11, 2014.
Pies RW. Do we need 'thanaticians' for the terminally ill? Medscape Psychiatry. September 26, 2012. https://www.medscape.com/viewarticle/771274 Accessed November 11, 2014.
Schwarz JK. Exploring the option of voluntarily stopping eating and drinking within the context of a suffering patient's request for a hastened death. J Palliat Med. 2007;10:1288-1297
Szasz T. Fatal Freedom: The Ethics and Politics of Suicide. Syracuse, NY: Syracuse University Press; 1995.
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Cite this: Brittany Maynard and the Loose Language of Suicide - Medscape - Nov 19, 2014.
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