As of 2016, the California End of Life Option Act offers legal protection to residents suffering from terminal illness who wish to access medical aid-in-dying, also known as physician-assisted suicide. But the law has hardly quelled the controversy. We spoke with Dr. Guy Micco, co-director of the Program for Medical Humanities at Berkeley who has had a long-standing interest in aging and death, about the ethical concerns in legalizing life-ending treatment.
What are the main arguments against allowing aid-in-dying?
Those who believe that we are only caretakers of our own lives, that this life is a gift from God, see it as morally wrong to hasten the end; for God is the only ‘One’ who can properly decide when we die.
Some disability activists find medical aid-in-dying (MAID) an affront to the dignity of those with severe disabilities whose lives might be seen by others as “not worth living.” Such an attitude leads to a discounting of the life of someone with a disability; further, it can be internalized by that person.
Some secular bioethicists, physicians, and others believe that physicians should never be in a position to take life. They point to the fact that good palliative care and hospice are very successful at controlling severe pain, shortness of breath, and other physical symptoms at end-of-life. Further, they may point out that there is a “slippery slope” in play: First, assisted death for the terminally ill, competent person. Then, assisted death for the non-terminally ill, competent person. Then, we move to assisted death for the person who cannot truly give their consent because of, say, dementia or coma. Finally, we become so inured to killing that we have involuntary euthanasia (killing against the will of the person), as seen in Nazi concentration camps.
How do you respond to the fear of a slippery slope?
The slippery slope argument was recently made anew in an editorial in the journal JAMA Internal Medicine (2020) by geriatrician and palliative care physician Diane Meier.
She points out the problem of imperfect safeguards, or the impossibility of safeguards, surrounding the extension of euthanasia beyond terminal illness for a consenting adult; further, she says that this is already happening in the Netherlands. Letters from Dutch physicians, in response to her editorial, claim this is not the case. But having watched the use of MAID in our community, I tend to agree: Safeguards, such as assuring a patient’s consent and desire for MAID, are in place. Abuses can be prevented. However, I do have a lingering concern as articulated by the disability community.
Which concerns do you think are most valid and why?
I am quite sympathetic to the view of disability activists: First give us the right to a decent life, then talk to us about a “right to die.”
Fear of severe disability and age-related illness is near-universal, including among physicians. This may result in “the unconscious projection of support for a hastened death” (Meier)—a version of, “Of course you want to die, no one would want to live like you’re living. Let us help you.” If the life of a person with a severe disability is thought not worth living, how easy might it be to push that person toward MAID? The same might be said regarding elders toward the end of their lives: “You’ve lived a good life. Why are you hanging on?”
More and better education for us all regarding disability, old age, and the meaning of “quality of life,” along with appropriate safeguards for MAID, go a long way toward alleviating my concerns. But in the end, the question is one for society to answer: Should the value of autonomous decision-making take precedence over safeguarding the lives of the most vulnerable? And, if so, what safeguards must be in place to prevent abuses?