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The Right to Die

by Nomad Tue Feb 9th, 2010 at 08:51:17 AM EST

New discussion is brewing in the Netherlands to legalize assisted suicide, or euthanasia, for the elderly. Get ready for (American) conservatives proclaiming about the increasing Dutch perfidies and Holocaust parallels.

After all, since April 2002 euthanasia is an acceptable practice in the Netherlands. The crafted law works through “No, unless” principles: euthanasia is still a criminal offence, however, doctors who practice euthanasia are exempt from prosecution but only if they adhere to specific criteria. One of those criteria is that the person involved is incurably ill, suffering and has no further prospects of recovery.

But the Dutch euthanasia law says nothing about assisted suicide for people who prefer to choose their own time of death, and who are not ill. In those conditions, assisted suicide of anyone not explicitly under medical treatment will be considered a criminal offense. A new citizen initiative, coined “Out of Free Will”, was recently launched with the aim to be debated in Parliament. Before the proposal can be placed on the diary of Parliament it will need the support of at least 40.000 supporting signatures.

'Right to die' for elderly back at centre of Dutch debate - NRC Handelsblad

In an interview in the office of Dick Swaab (65), a leading member of the group and the managing director of the Netherlands Institute for Neuroscience in Amsterdam, three of the initiative’s prominent supporters explained why they felt suicide assistance should be made legal. Former minister and self-described feminist Hédy d’Ancona (72) said arguing the right to choose one’s time of death was a natural extension of her lifelong battle for emancipation. Legal scholar Eugène Sutorius (63) said he considered the right a cultural matter, and that he was looking for freedom to face death “in a stoic manner”, without fear of a legal system that qualified assisted suicide as a crime or the dread of ending up in a care facility resembling a prison. For neurologist Swaab, death is a rather straightforward matter. “Throughout the animal kingdom, individuals are simply replaced, rather than patched up endlessly,” he explained. Aging constitutes nothing more than “cells wearing through use,” Swaab said. His argument: when you feel you have no more life left in you, you should be able to say so, and act on it.

All three expressed enthusiasm about ageing. Everything becomes easier to put into perspective as time passes, they said. Sutorius called it an “immense pleasure”. D’Ancona referred to it as “a great phase of life.” But they also expressed fear of what is still to come. D’Ancona said the knowledge she would be unable to end her life when she wanted to left her with a “nagging feeling”. She said it took some of the enjoyment out of what was otherwise a pleasurable phase of her life. Sutorius too feared a moment would soon come when he would come to experience the drawbacks of ageing. “I do not want to outlive myself,” he said.

Suicide is not criminalized in the Netherlands, so one could still wonder: what’s the fuss? If people want to step out of life, they can. The trouble of course is that dying can be a messy affair, suicide doubly so. And as far as I'm concerned, I think there rest considerable taboos on the subject of preferring death above life at one point.

But assisted suicide, whether the assisting consists of aiding, giving directions, or delivering death-inducing medication, is in all shapes or forms considered criminal. The initiative now proposes to decriminalise this aspect for people - but only for those older than 70 years (an age cut-off which has been chosen somewhat arbitrarily). It is further proposed that:

this task be carried out by specially trained and certified nurses, psychologists or spiritual professionals who could verify the request for assisted suicide in a series of conversations with the elderly patient. Only after a second health care professional has confirmed the patient’s death wish would he be provided with lethal drugs. The sam caretaker would finally supervise the patient as he administrates these to himself.

The group paints the following scenario: The specialists should ensure that the patient is of sound mind and that his or her request is explicit, logical and consistent. The suicide assistants must make sure the death wish is more than a rash impulse, the product of depression or the symptom of another illness, and that the patient has considered the consequences of his actions for those that will survive him. Once the patient has taken his own life, the suicide assistant writes a report that can be reviewed by the municipal coroner. The case is then assessed by the regional euthanasia approval commission, which has already been instituted to oversee the application of the current Dutch euthanasia law.

IMO this reads as a rational, well-thought scenario which slots in with already existing legislation on euthanasia, and overall improves the final right of a human being: to die with dignity.

Whether this initiative will grow legs of course remains to be seen. Reading across the webpage I can almost sense the hackles rise of Christian-orientated politicians – of whom we’ve still a few too many in our present government. That aside, one wonders if the initiative will gain enough traction in the first place. Death is all too often a triviality not to worry about too much compared to the exciting vagaries of every day.

And now back to our daily programming...
by Nomad on Tue Feb 9th, 2010 at 08:55:28 AM EST
The same debate is happening in the UK at the moment. I think there have been two or three cases in the courts in the last 3 weeks that have hit the headlines.  It has opened up debate about assisted suicides.

British author Terry Pratchett is a significant supporter of this:

Sir Terry Pratchett says he is ready to be a test case for assisted suicide "tribunals" which could give people legal permission to end their lives.

The author, who has Alzheimer's, says he wants a tribunal set up to help those with incurable diseases end their lives with help from doctors.

A poll for BBC One's Panorama suggests most people support assisted suicide for someone who is terminally ill.

Sir Terry set out his ideas in Monday's annual Richard Dimbleby lecture.

'God's waiting room'

In the keynote lecture, Shaking Hands With Death, the best-selling author said the "time is really coming" for assisted death to be legalised.

by In Wales (inwales aaat eurotrib.com) on Tue Feb 9th, 2010 at 09:37:50 AM EST
[ Parent ]
that for the UK euthanasia for terminally ill is still considered a criminal offense - while the above proposal is pushing the envelope for a next (logical) step. Although it may be so far ahead of the curve, it will wilter. However, this particular discussion (assisted suicide for healthy elderly) has been a topic in the Netherlands since at least the early ninenties.

The idea that some people have a right to declare sacrosanct the life of other people appears increasingly silly to me...

by Nomad on Tue Feb 9th, 2010 at 11:16:19 AM EST
[ Parent ]
Very true.  The landscape here is becoming increasingly bumpy with a number of challenges to the legislation as it stands.

What I find ridiculous in the euthanasia debate is the huge concern that people have for elderly people who may find their lives being snuffed out against their wishes, and yet we treat our old people appallingly in life.  Dignity and respect appears to be off the menu to enable them to have a decent quality of life and then the anti-euthanasia camp use exactly the arguments of dignity and respect for campaigning against giving people choice over how their lives end.

by In Wales (inwales aaat eurotrib.com) on Tue Feb 9th, 2010 at 11:32:10 AM EST
[ Parent ]
In Wales:
huge concern that people have for elderly people who may find their lives being snuffed out against their wishes, and yet we treat our old people appallingly in life.  Dignity and respect appears to be off the menu

hardly an original thought, but isn't this entirely reminiscent of attitudes about abortion?

save the foetus!!!! possibly for a horrible life, but saved.

seems like fear of death is the main driver.

'The history of public debt is full of irony. It rarely follows our ideas of order and justice.' Thomas Piketty

by melo (melometa4(at)gmail.com) on Tue Feb 9th, 2010 at 01:15:10 PM EST
[ Parent ]
I had a discussion of this with my cousin in Tulsa a few years ago. She is a year older than I, not particularly "chruchy" but still generally a believer. At one point she responded that those decisions "were in God's hands". To which I responded that, from the way things seemed to work, either He didn't give a damn or He was doing a piss poor job. I doubt she was very shocked by my opinions, as my views about religion are similar to those of my father, who she knew and knew of.

I should probably check back with her on her attitudes today. My wife has long advocated legal euthanasia at will. An OD from sodium penathol is a whole lot more peaceful than about any other means imaginable. The true terror is a botched suicide that leaves one aware but helpless. A form of assisted suicide is legal in the state of Oregon and I suspect it will spread. But legalization will be opposed by the Catholic Church and most fundamentalists and, I have been told by the son of a suicide, that for observant Jews, suicide is one of the worst things they can do. I regard this shared belief that "God will decide" and that "life is good", regardless of the circumstances, as the biggest single culturally normative insanity of which I am aware.

"It is not necessary to have hope in order to persevere."

by ARGeezer (ARGeezer a in a circle eurotrib daught com) on Tue Feb 9th, 2010 at 01:56:59 PM EST
[ Parent ]
For myself, I oppose assisted suicide, unequivocally.  I find it very hard to maintain a belief, on the one hand, that the recent banking crisis, or the problems with American profit-oriented medical care are largely, if not entirely, due to perverse incentives and moral hazard, and then turn around and assume that such incentives and moral hazards would be absent in an institution that permits suicide as an acceptable option for people with problems. It's absurd on its face.
by santiago on Tue Feb 9th, 2010 at 03:19:21 PM EST
I would like to have the choice, and control over all of my life.  Sometimes quality of life deteriorates so much, and there is no dignity and nothing left but pain.  If I find myself there, I want a choice.
by In Wales (inwales aaat eurotrib.com) on Tue Feb 9th, 2010 at 03:30:58 PM EST
[ Parent ]
I hear you, but is it really that important to have to follow laws or have other forms of societal approval when exercising such a radical form of personal control over all of your life? Why not just obtain the medications or artifacts to kill oneself illegally instead of trying to alter the institutional protections that others currently enjoy? Or is personal dignity also tied to social approval and physical comfort so that if it's not legal and convenient, it's not sufficiently dignified?
by santiago on Tue Feb 9th, 2010 at 04:52:01 PM EST
[ Parent ]
I'm talking about situations where an individual is not able to physically carry out the act of suicide by themselves.  They need help but don't want anyone who assists them to end up in prison for it.  It would require the person to make a choice before reaching that stage or to still be 'sound of mind' when at that stage to give consent or to ask for assistance.  I won't pretend it isn't a huge grey area in terms of how you regulate such a thing.  

Anti-euthanasia campaigners point out the what if you have a relative who just wants to bump off their elderly Mum and Dad without their consent?  This happens in practice anyway, and often goes undetected as a 'natural death'.  That isn't choice anymore than being forced to live is.

I'd rather be able to have on record what my wishes are in a situation where my quality of life is too low to want to be here anymore.  How is that much different from people who have Do Not Resuscitate on their medical charts?

by In Wales (inwales aaat eurotrib.com) on Tue Feb 9th, 2010 at 05:35:16 PM EST
[ Parent ]
Those are good points, but I'm more worried about whether your medical system administrators want to "bump you off" in benign ways by being able to create a moral discourse around personal responsibility in opting for less expensive end-of-life comfort care, rather than burdening the state and your care providers with extending your problematic life.
by santiago on Wed Feb 10th, 2010 at 10:55:04 AM EST
[ Parent ]
Human Rights - everyone has the right to life.  For a public discourse to develop in favour of pressurising individuals to go before they are ready would involve continuous and systemic breaches of human rights legislation at all levels.  The UN exists to monitor prevent such abuse by states.

Given the uproar that ensues when euthanasia or assisted suicide is debated, I don't think it is likely for the state to develop a narrative along the lines of "don't you think it's time you toddled off now, you burdensome thing?"  It would be a severe breach of human rights to put pressure on people to die.

I suppose you can argue that the state does that with severely disabled babies by removing medical care that keeps the child alive.  Perhaps withdrawal of care for elderly people would be a similar approach but they certainly couldn't actively end a life and legally get away with it.  

The process of removing care and medical attention from either elderly or terminally/chronically ill people without their consent would be challenged (I hope).

One of the problems for the UK is that these issues are hidden and taboo.  You don't talk about death. You don't openly look at the options.  You don't admit that a burden has become too much and you need out - for both the ill person and anyone who is caring for them. It is the lack of openness I think that poses more of a risk for people.

by In Wales (inwales aaat eurotrib.com) on Wed Feb 10th, 2010 at 03:54:29 PM EST
[ Parent ]
I guess I don't share your optimism about the protective powers of rights-based discourse and social institutions in terminal matters of life and death (maybe I've been damaged by having read too much Foucault regarding something else I'm working on). After all, it's not as if severe, systematic breaches of human rights are really rare in modern society, or that UN has a particularly compelling record on influencing policy to mitigate human rights violations either, does it?
by santiago on Wed Feb 10th, 2010 at 04:28:59 PM EST
[ Parent ]
Human Rights - everyone has the right to life.  For a public discourse to develop in favour of pressurising individuals to go before they are ready would involve continuous and systemic breaches of human rights legislation at all levels.  The UN exists to monitor prevent such abuse by states.

Try to replace "life" in this case with "asylum if their country of origin is unwilling or unable to protect them against persecution."

Are you still optimistic?

- Jake

Friends come and go. Enemies accumulate.

by JakeS (JangoSierra 'at' gmail 'dot' com) on Wed Feb 10th, 2010 at 05:32:48 PM EST
[ Parent ]
I know the state can and could abuse power.  But it already does within the status quo. As it is, if I wished to die but needed assistance, I'd be jeopardising another person's freedoms if they were found to have supported me.  

The arguments are very similar on both sides of the coin.  Stay alive, face abuse and indignity and not have the choice to go.  Or have the choice to go and potentially be forced into taking that option sooner rather than later.

I don't think that my wish to make the choice to go when I am ready should criminalise someone else. But whether I stay or go, there is always the potential for wrongdoing.  

How common do you think it would be for people to make such a choice? As pointed out elsewhere people can choose to refuse medical intervention.  Choosing to cut short a prolonged period of pain and ill health is just one step on from that.

by In Wales (inwales aaat eurotrib.com) on Thu Feb 11th, 2010 at 07:00:41 PM EST
[ Parent ]
But then again, why should you have to break any laws and norms and be labelled an outlaw while acting in your personal interest? Why should one's name and people's memory of him / her be tarnished just because he / she has decided to end their life for purely practical and / or medical reasons?

Is not the right to live and consequently end your life as you see fit, as long as you do not harm others by your actions, an alienable right?

by hitchhiker on Wed Feb 10th, 2010 at 01:50:10 PM EST
[ Parent ]
I think you mean "IN-alienable" right, but you have a good question:  Why should a burden of inconvenience fall on the person preferring death to life?  

There are a number of ways to respond and think about that question, but a simple way to start is to ask what are your underlying assumptions?  It appears that you are assuming that providing a legal right to die to some people has zero impact on others who would prefer to live under the same, hopeless circumstances. That is, a right to die is independent of a right to live, even if both rights can be traced somehow to the flowery language of the US Declaration of Independence. I question that assumption because it appears to directly contradict everything else we (meaning most people who visit this site regularly) have already implicitly or explicitly professed to believe about how the world works. Namely, we progressives reject the neoclassical assumption of individual omnipotence and omniscience when making choices and acting on them, which underlie all arguments for greater privatization and a very minor role for the state in capitalist society.  

Instead we accept the institutional critique which underlies most "progressive" intellectual endeavors, such as feminism, critical theory, and most "pro-state" ways of approaching economics and other social sciences. In our framework for thinking, individuals have very limited power and knowledge about the world, so their choices are inherently biased by the language and institutional contexts in which they find themselves. "Bounded rationality" is the technical term for how progressive thinkers believe the world works.

So, if you don't believe that free-market economics is the default solution to a social problems such as inequitable distribution of medical care, then you are implicitly rejecting the idea that a truly individual choice to die is even possible.  An individual's options are necessarily bounded by the possibilities presented to that individual by language, values, and other social structures. (That's the essence of the progressive argument against Laissez-faire capitalism.) And if that is the case, then just changing a law to make death a socially acceptable option for hopelessly ill people must also affect, most likely negatively, the ability of similarly hopeless people to choose the socially more inconvenient path of living longer while burdening the community.

Put more simply, I don't believe that the myth of individualism is true. Individual welfare, everywhere and anywhere, is mostly dependent upon relationships with the larger community in which one finds oneself, and inalienable rights are one form of such a relationship in our current, rights-based political institutions.  Therefore, it's not possible to assume that a right to die is independent of a right to live. Rather a right to die necessarily diminishes a right to live, and vice versa.  

And this means, as I said elsewhere in this thread, that legal suicide is simply incompatible with social medicine. It might be compatible with a completely private system of medical care, the Laissez-faire utopia, but I don't believe such a utopia is possible, and you probably don't either.

by santiago on Wed Feb 10th, 2010 at 02:41:02 PM EST
[ Parent ]
That is right, I meant inalienable! Thank you!

As for the rest of your argument, while I can certainly see why you are worried that providing the legal  basis for terminally ill people to end their lives may have negative impact and prove counterproductive for people just as sick but not willing to stop fighting the disease(s) and die, I am struggling to see the rationality in arguments that advocate the widespread conviction that if one is suffering from immense pain and there is no hope for them, they should nevertheless be stuffed with all kinds of medicines and kept alive at all cost for the sake of not letting them die even if that be their wish!

by hitchhiker on Thu Feb 11th, 2010 at 09:59:19 AM EST
[ Parent ]
You already have the right to refuse treatment - including life-saving and -extending treatment.

The right to refuse medical interventions has been on the books since the Nürnberg Declaration in 1947. Which came about... for obvious historical reasons, shall we say.

- Jake

Friends come and go. Enemies accumulate.

by JakeS (JangoSierra 'at' gmail 'dot' com) on Thu Feb 11th, 2010 at 11:04:54 AM EST
[ Parent ]
I'm still too chicken to stipulate on paper that in case my personal health would deteriorate below a certain point, the medical experts can switch off the machines or medication. But I do support it. In the case of the Out of Free Will proposal, my adherence to maximum personal freedoms makes it hard to not be supportive. I will do everything it takes to prevent my elderly days from becoming horrible, but having my own choice to decide over my own death, and to be free of any judgement about  suicide through illegal means and/or means traumatizing for others, is entirely sensible.

A parallel between the financial world and euthanasia is off because there is strict regulation on cases of euthanasia, while the current crisis shows there should be strict regulation in the financial world. Good government works. The exisiting and clear regulation on euthanasia shows precisely what is so wrong with the financial markets.

by Nomad on Wed Feb 10th, 2010 at 05:57:47 AM EST
[ Parent ]
I don't think the financial industry comparison is too far off at all. While true that increasing the amount of regulation can reduce the opportunities to act on perverse incentives, Stiglitz (and Ken Arrow before him) won his Nobel prize partly for his work proving that regulation could never sufficiently correct for institutionalized perverse incentives. That becomes very problematic when dealing with issues of permanence, such as assisted suicide (or capital punishment).
by santiago on Wed Feb 10th, 2010 at 09:31:45 AM EST
[ Parent ]
what you would mean with "institutionalized perverse incentives" in the case of euthanasia.
by Nomad on Wed Feb 10th, 2010 at 11:36:45 AM EST
[ Parent ]
The medical system itself, and agents within that system, including health care administrators, providers (when they are not compensated in a fee for service format), and taxpayers/insurance-premium-payers, all stand to gain if someone opts for less expensive end-of-life care, which would include assisted suicide, than if someone opted for the more expensive care to prolong one's problematic life.  That's the textbook case of a perverse institutional incentive to encourage someone to die instead of living a while longer.
by santiago on Wed Feb 10th, 2010 at 12:34:37 PM EST
[ Parent ]
your response to InWales upthread:

your medical system administrators want to "bump you off" in benign ways by being able to create a moral discourse around personal responsibility in opting for less expensive end-of-life comfort care, rather than burdening the state and your care providers with extending your problematic life.

If that's a case of "institutionalized perverse incentives", this is a non-issue, as the initiative which leads to euthanasia lies solely with the patient - this is so in the Netherlands, and I expect it to be likewise in other countries. The initiative simply does not lie with medical staff, or insurance companies.

by Nomad on Wed Feb 10th, 2010 at 11:50:38 AM EST
[ Parent ]
<teabagger>[Death Panel™ Alert!]</teabagger>

En un viejo país ineficiente, algo así como España entre dos guerras civiles, poseer una casa y poca hacienda y memoria ninguna. -- Gil de Biedma
by Migeru (migeru at eurotrib dot com) on Wed Feb 10th, 2010 at 12:10:57 PM EST
[ Parent ]
The so-called "death panels" proposed in the US were actually a way to try to mitigate this recognized perverse incentive, by forcing government care providers to talk regularly with patients about what patients really wanted with the lives rather than what providers, biased by budget worries, might assume that patients want.
by santiago on Wed Feb 10th, 2010 at 12:42:55 PM EST
[ Parent ]
Why is it a "non-issue?" Unless you buy into the neoclassical assumption of social science that all actors are all-knowing and all-powerful agents (and I presume you don't because no one on this site really does given the disparaging things we all say here about "neoliberals" and "neoclassical" or "monetary"  economists) then you have to assume the corollary -- that institutional arrangements (e.g. market-oriented discourse, patriarchy, rights versus obligations, etc.) are the primary influences on individual "choices" to do anything.  

Terminally ill or otherwise hopeless people may choose suicide because they don't want to inconvenience others within a language framework that ascribes, to varying degrees, moral deficiency to people who use social resources without being able to pay for them. Saying that suicide is a normal option for care rather than the current radical option that it is can help to change language and institutions to bias people toward death.  I find that extremely problematic as our societies grow more and more dependent on community relationships instead of individual independence.

Legal suicide is incompatible with social medicine.  There just isn't any way around it that I can see.

by santiago on Wed Feb 10th, 2010 at 12:53:40 PM EST
[ Parent ]
Talk of "institutionalized perverse incentives" (even while well argued) is a strawman defense to block personal self-determination, because the thesis "Legal suicide is incompatible with social medicine" is disproven by simply studying the working model in the Netherlands, done in practice, not just in thought. Point me at medical excesses, or steadily increasing rates of euthanasia, and I can reconsider.

A Dutch patient doesn't easily get into the position before euthanasia is a legal option. I need to strongly underline that we are talking about terminally ill people.

For those people there rests little difference between terminal sedation and euthanasia, except that the first is often imposed through medical staff - unless specifically ruled out by the patient. The second is a determined choice only available when specifically requested by the patient. The choice of dying in this situation is crystal clear - either you drift out in an opiod induced stupour, or with a self-determined choice. That is, simply, the right to die - people who want to face their death themselves. That does not make it an easy choice. And not many choose for it, as Dutch numbers unambiguously reflect.

As it is, I'm proud to live in a country where citizens are granded that final important right of self-determination.

by Nomad on Thu Feb 11th, 2010 at 05:30:25 AM EST
[ Parent ]
my mother died in a london hospice, and it's basically the same approach, comfort and cessation of pain are prioritised over length of life, and if they are helped to the point of accelerating their demise, no-one will be anything but grateful, as their existence is no longer any benefit to anyone, least of all themselves.

the staff there were angels of mercy, and the atmosphere anything but sombre.

sounds like the dutch don't see a need to sequester this from normal medical practice, and why should they?

'The history of public debt is full of irony. It rarely follows our ideas of order and justice.' Thomas Piketty

by melo (melometa4(at)gmail.com) on Thu Feb 11th, 2010 at 06:44:42 AM EST
[ Parent ]
Well, it's pretty far from "proving" anything on this topic, but it is true that the Dutch evidence shows a decrease in the proportion of deaths attributed to euthanasia and assisted suicide since peaking in the mid-1990's when euthanasia was a hot topic in public discourse.  The evidence is somewhat different in Oregon, but there is a reporting controversy there and the policy is more recent as well, and I don't know what it is in Belgium.

I think a better argument in favor of legalization of suicide is related to something In Whales mentioned elsewhere in this thread. Euthanasia and suicide happen anyway, so perhaps legalization provides a degree of transparency which helps to mitigate the perverse incentives at least where they involve direct encouragement of others to choose death.  (It wouldn't help the larger issue of presenting suicide as a morally superior option to continued treatment in order to avoid inconveniencing others.  This isn't refuted by the Dutch experience and data either, because it doesn't show what the Dutch experience would have been if suicide and euthanasia were not already established parts of Dutch discourse by the 1980's when data on such things became available.)

by santiago on Thu Feb 11th, 2010 at 12:42:29 PM EST
[ Parent ]
I think it is good that this gets a discussion. Dying to often is put away until the last moment. But I think it would make the end of life easier if precautions are being taken.

Nnoone should be able to decide over me, on how I will have to die - nor should anyone be able to keep me from dying when my time has come. It depends on the circumstances and I do believe people should be able to die peacefully.

There are discussions on a international level:

World Federation of Right to Die Societies

The World Federation, founded in 1980, consists of 44 right to die organizations from 25 countries (July, 2009). The Federation provides an international link for organizations working to secure or protect the rights of individuals to self-determination at the end of their lives.
by Fran on Tue Feb 9th, 2010 at 05:52:37 PM EST

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