Last year, California completed installation of a $220 million suicide barrier net on both sides of the Golden Gate Bridge to discourage people from jumping. The net was also intended to break the falls of those who did jump. The net runs the entire 1.7-mile span of the bridge and has reduced fatal jumps from the bridge by 73%, as well as deterring many who may have changed their minds about diving to their deaths.
As a consequence of roughly 2,000 suicides by jump from the Golden Gate Bridge since its construction in 1937, the net was installed because even though individual autonomy is highly valued in California, there was a compelling state interest in preventing suicide.
Ironically, this state interest in preventing suicide is at cross purposes with the California legislative proposal to make physician-assisted suicide a permanent fixture in the state by eliminating any sunsetting of the state’s existing physician-assisted suicide legislation.
This seeming contradiction in California’s interest in preventing suicide can only be explained by the fact that medically assisted suicide is considered a special category, which California can tolerate and permit, because it provides individuals at the end of their lives with dignity and autonomy. This argument is simple and appealing and seemingly separates the terminally ill from bridge jumpers. Who could be against such an ostensibly compassionate approach?
For those who advocate dignity and autonomy, that is all that matters. Any other discussion of suicide is superfluous — whose life is it anyway? The current climate suggests this argument has prevailed in many states and Western European countries that have adopted or are adopting physician-assisted suicide. England is currently debating such a bill that is likely to be enacted, and physician-assisted death is legal in 11 states and the District of Columbia, with legislation pending in several more, including Illinois.
But physician-assisted suicide is a matter of more than simply individual autonomy. It requires societal acceptance of suicide — an apparent reversal in centuries of public policy and attitude — as well as the collaboration of the medical profession. In Canada, physician-assisted suicide is formally known by the anodyne term MAID, medical assistance in dying, and currently accounts for 5% of all deaths in the country. An equivalent figure in the U.S. would be 150,000 deaths annually — more than those caused by diabetes, lung, kidney or liver disease. This could not happen without a major shift in public opinion about suicide.
But consider the consequences that extend beyond the individual.
First, state-approved suicide puts at risk people who are weakened in some way and thus susceptible to suggestion or persuasion. Anyone who might benefit from such a death, for financial or other reasons, has a motive that no government can remove. Put another way, safeguards can never be guaranteed to protect people with disabilities, those with mental illness or depression, and patients with chronic but not terminal conditions. In Canada, a woman applied for and received MAID after not receiving affordable housing to help her deal with a chronic health condition.
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Such tragic stories are not uncommon. Years of experience in other countries demonstrate that legislative and procedural safeguards invariably erode.
Second, the profession of medicine will eventually be corrupted. Many who favor physician-assisted suicide, including some doctors, dismiss this as a possibility, but it is real and significant. Most physicians involved in assisted suicide have their patients’ best interests at heart, but not all: The doctor whose patient is incurable and maybe a bother may decide that agreeing to legal suicide serves both of them conveniently. And as medicine becomes more depersonalized and fewer people have a personal physician, physician motives will be increasingly called into question.
Legal philosopher John Finnis described the chill that a patient will feel “a new zone of silence. Can I safely speak to my physician about the full extent of my sufferings, about my fears, about my occasional or regular wish to be free from my burdens? Will my words be heard as a plea to be killed? As a tacit permission? And why does my physician need my permission, my request?”
Third, the inevitable intrusion of money, government and big business — it is indisputable that physician-assisted suicide, when substituted for palliative care or care for those with disabilities, will cost less. This will become an attractive feature to government medical officials, insurers, and the corporations and hedge funds that are moving into medical care. The implications for hospice care and care for those with disabilities or chronic illness are obvious: Legalized suicide is a cheap alternative to ongoing medical care.
In the industrialized West, the long-standing religious, moral and legal stigma surrounding suicide has largely disappeared. Notwithstanding the barriers erected at the Golden Gate, which speak to the state’s compelling interest in preventing suicide, that interest does not extend to physician-assisted suicide.
With the widespread acceptance of the concept, it is becoming futile to fight against legislation permitting doctors to assist in suicide. That argument is essentially over — this is a movement whose time has come, for good or ill. Policymakers should broaden the public debate by including the ominous ramifications that expanding physician-assisted suicide will have for society: detrimental implications for hospice care and care for those with disabilities, corruption of the medical profession and health care ethics, and abuse by corporate and government interests that will almost certainly ensue.
Society may sanction physician-assisted suicide, but the public should be aware of what to expect.
Dr. Cory Franklin is a retired intensive care physician. Victoria Tiller, who has a master of science in nursing, is a patient advocate.
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