Time to die
WHAT would it be like to live in an America where doctors routinely assisted terminally ill patients who wanted to commit suicide? Well, look around. That’s what it would be like. Every day, doctors in America assist terminally ill patients who want to commit suicide. In all but three states, this is illegal, so it’s impossible to know precisely how often it happens, because doctors can’t talk about it openly. The most widely cited study of the phenomenon is 15 years old. Based on interviews with 355 oncologists, it found that about 5% had performed euthanasia (directly injecting drugs to end a patient’s life) and 5% had performed physician-assisted suicide (PAS)—ie, providing the patient with drugs to aid them in ending their own life. Another study estimated that 4% of oncologists had performed euthanasia or PAS in the last year; estimates for other specialties are lower.
These feel to me like low estimates, basically because, of my few intimate acquaintances who are deceased, one died by PAS in a state where it is illegal. He had an unbearable, incurable condition and no real prospect of getting out of the hospital again, and the (uniformly excellent) physicians and staff involved didn’t give the impression that under the circumstances, helping him to end his life painlessly was anything shocking or extraordinary. I see no reason to believe that my experience is unusual. Because all of this takes place underground, though, there’s no way to know how common it is. More important, there is no way to institute reliable safeguards against ethical missteps, such as terminating a patient whose request stems from temporary depression. To regularise the process, Oregon, Montana and Washington have passed laws legalising PAS (or PAD, physician aid in dying, as it’s apparently known these days). The anxiety, however, has always been that legalisation may make the process more common, and that it may create gradual pressure on patients to request euthanasia or PAD in cases where they otherwise wouldn’t have.
The best data on this question come from the Netherlands, where euthanasia under clear “precautionary conditions” (zorgvuldigsheidseisen) has been legally tolerated since 2002. (Technically euthanasia is still illegal, but a doctor who meets the conditions can’t be prosecuted for it. The patient must request euthanasia twice orally and once in writing, mental health must be confirmed by a separate doctor, etc.) On Tuesday, the Dutch government published the results of its periodic report on end-of-life decision-making, the latest in a series it began in 1990 when euthanasia was still illegal, and it appears that legalisation has not led to an increase in cases. In 2001, just before the law was passed, euthanasia accounted for 2.6% of deaths in the Netherlands. In 2005 it actually fell to 1.7%; in 2010, the year of the latest data, it was back up to 2.8%, statistically indistinguishable from the pre-legalisation level.
What has changed is the number of cases of euthanasia without an explicit request from the patient. This has dropped dramatically since legalisation. Euthanasia without an explicit request happens when patients are too incapacitated to make a meaningful decision; the great majority of such cases involve extreme pain and no prospect of improved conditions, and in many cases patients have earlier expressed a wish to die under such circumstances. Usually the doctor administers medication that hastens the end of life in consultation with the patient’s family. In 1990, before legalisation, Dutch doctors ended the lives of some 1,000 patients without an explicit request, about 0.8% of all deaths. That number fell steadily to 300 in 2010, 0.2% of deaths, as legalisation made it easy and routine for doctors to discuss end-of-life decisions with patients before they become incapacitated.
Now, many American states are simply not going to legalise euthanasia anytime soon, for cultural and religious reasons, and that’s perfectly understandable. It makes sense to decide these issues at the state level because it provides some iterative flexibility to electorates that are more or less favourable to these reforms. But I would like to preemptively respond to the frequently heard objection that cultural differences make the experiences of other countries around these kinds of moral issues irrelevant. Things don’t work that way. Rather, cultures change, and so do laws. Legal and cultural shifts proceed together, and often require and reinforce each other.
In other words, it’s not always culture that changes the law; it’s often the other way around, or rather that the two processes simply can’t be disentangled from each other. For example, the other night I sat down with my wife and flicked on the TV, and we ended up getting sucked in by a middling Dutch weepie about a man who must reconcile with his domineering mother after she suffers a debilitating, irreversible stroke that leaves her unable to move or speak. As part of the normal progression of the drama, the family doctor visits and, in the presence of her children, asks her to reconfirm her request to receive euthanasia. She nods enough to make it clear. On a second visit, just after the son has burst out weeping and at last proclaimed his love for his mother, whose eyes overflow with tears, the doctor gives her an injection that puts her to sleep. It’s a corny death scene that is structured entirely by the state of Dutch end-of-life law as it has developed over the past decade. Culture and the law move in tandem. This scene couldn’t be played in an American film today, but it couldn’t have been played in a Dutch film 20 years ago. Who knows what death scenes will look like in American films in 20 years? Sure, Dutch actors do seem to have a bit of a specialty in cheesy portrayals of dying with dignity, but American audiences haven’t been entirely unreceptive.