COMMENTARY

Terminally Ill Woman Chooses Suicide, May Influence a New Generation

Arthur L. Caplan, PhD

Disclosures

October 28, 2014

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Brittany Maynard

I'm Art Caplan, and I'm at the Division of Medical Ethics at the New York University (NYU) Langone Medical Center in New York City.

The debate in the United States over physician-assisted suicide recently took a very interesting turn. A young woman, 29 years old, named Brittany Maynard announced that she intends to take her own life. She has moved to Oregon, which has legalized physician-assisted suicide, to carry out those plans.

Brittany has a fatal form of brain cancer, a glioblastoma, that can't be cured. Her doctors have told her that she has literally months to live and that her ending is going to be very tough; she's going to suffer and she's going to lose control over many bodily functions because this cancer will get into her cerebellum. It will kill her, but along the way it's going to leave her with loss of control of her body. She has taken a look at that situation, and the newlywed, whose wedding pictures are all over the Internet, has said that she doesn't want to die that way. She wants to be able to control her dying, and even if she is put in a hospice or offered palliative care, that's not the way she wants to go.

She knows she is terminally ill. She has gone to Oregon. She has said that she will have her new husband with her. Her family and her family physician are going to come to Oregon from her original state of California. They will assemble on a fixed date and she will take the pills.

In one way, the case of Brittany Maynard doesn't add anything new to the debate about physician-assisted suicide. Proponents say it's something that you ought to have the right to do, that physicians have a duty to help people who are terminally ill end their last days or spend their last days in a way that they find acceptable, even if they could go to hospice or receive palliative care. For some people, it's not enough. For some, it's not dignified enough. Doctors have a duty, they would argue, to help people die in a respectable manner, in the way that they want to. Others, critics, would say that it's too easy to abuse this. People are going to end their lives because they worry about being a burden to others or spending other people's money rather than having it spent on the college tuition of their son or grandchildren. They wind up spending it on medical care instead. They don't want that. They would like to die now.

Fear of the Slippery Slope

We have seen in such countries as Belgium and The Netherlands the slippery-slope phenomenon of going down the road from the terminally ill to people who are just suffering from a poor quality of life. In both Belgium and Holland, it is now legal to say, "I'm suffering too much. I may not be terminally ill, but I have psychiatric conditions or physical disabilities. You should let me die." People have received assisted suicide in those countries. Those in the disability community, some in the religious community, and many physicians say, "I can't be involved with that. If that's the kind of slippery slope we're going to go down, then we shouldn't legalize it here."

Brittany Maynard, because she's young, vivacious, attractive, a newlywed, has a dog, and is a very different kind of person from the average middle-aged or older person who has to confront issues about terminal illness, changes the optics of the debate. Now we have a young woman getting people in her generation interested in the issue. Critics are worried about her partly because she's speaking to that new audience, and they know that the younger generation of America has shifted attitudes about gay marriage and the use of marijuana, and maybe they are going to have that same impact in pushing physician-assisted suicide forward.

That seems to be the reason that she is commanding so much attention. She may change the politics here. Right now, only three states have legal physician-assisted suicide. Oregon and Washington have had it for a while. Vermont legalized it recently. New Mexico and Montana have court opinions that indicate that it wouldn't be against the law to do physician-assisted suicide in those states, but they don't have policies in place for doing it.

The Oregon Experience

Probably the most interesting argument about legalization is the experience of Oregon. They have had this practice for 14 years, with many safeguards. Only the terminally ill can use physician-assisted suicide. Only doctors who certify to doctors that you are terminally ill can qualify you. All deaths are reported to the police. You have to have a psychiatric psychological evaluation. You have to ask for the pills at least three times over the span of a month, and it's up to you to take the pills.

Of interest, very few people in Oregon have actually requested the pills in the past 14 years—less than 2000—and more than one third have never taken the pills even though they requested them. Just having them available seems to have given some people the motivation to go on and face a rough end. Even though they requested the opportunity, they didn't use the pills.

Oregon's experience has been without abuses. The critics of Oregon tend to be outside of Oregon. They don't tend to be from the state. The state isn't changing its policies. The media haven't discovered any instances in which people were rushed to their death or somebody said, after the fact, "I really think this was a horrible thing and I wish we hadn't gone that way. I wish we hadn't chosen it." I find that very convincing. It is possible to have physician-assisted suicide without going down the slippery slope. Whether it's something that every physician would want to get involved in, I'm certain that isn't so. But it turns out that there are enough physicians who do get involved in Oregon and Washington so that the practice has been able to move forward and the demand has been relatively small.

Of interest, most people don't want to use this way to die. They are happy to try hospice. They like having palliative care. But they want to live as long as they can for the most part, even with a lot of suffering and even with a lot of managed pain.

Brittany Maynard may change this debate. My forecast is that we are going to see more push to put these laws in front of state legislatures and to get them on state ballots. We are going to see more states move in this direction. That ultimately may be her legacy to the physician-assisted suicide debate.

I'm Art Caplan, from the NYU Langone Medical Center.

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