Death By Prescription

In November, a "right to die" proposition in California was defeated by a narrow margin. Washington voters rejected a similar bill last year. In other countries too (especially Holland), many people support the idea to which this phrase alludes. But there is something fundamentally wrong with the notion that we have "a right to die" and hence with everything based on that notion.

Right, a political concept, refers to the relationship of the individual to the state. Death, a biological concept, refers to a property that is inherent in, and the final destiny of, all complex living things. Since death is a fact of nature, like the setting of the sun, it is foolish to speak of a "right to die." Today, the phrase usually functions as a euphemism for "physician-assisted suicide"—or, in plain English, granting doctors the right to kill patients.

Having a right to kill, under certain circumstances, may be deemed either morally good or morally bad. But killing, even if it is legally permissible, cannot be morally neutral, as the controversy about abortion illustrates. Furthermore, like any moral agent who commits an act, a person who kills (himself or others) may be considered competent or incompetent. In a society based on Anglo-American principles of political liberty and personal responsibility, every adult is presumed to be competent until proven incompetent, just as he is presumed to be innocent until proven guilty. And like innocence, incompetence is a legal concept that must be based on a judicial determination.

Potentially, everyone can kill others or himself (or both). There are certain well-defined instances in which a person has the legal right to kill another—for example, the enemy in war, a criminal condemned to death, an aggressor in self-defense (when no other option would avail), a fetus during the first trimester of pregnancy. Paradoxically, the right to kill oneself is a murkier matter. Although suicide is no longer a criminal offense, most people find the idea of a "right to kill oneself" offensive, or at least distasteful. One reason for this is that the Judeo-Christian ethic condemns suicide. For centuries, it was treated as both a sin (an offense against God) and a crime (an offense against the sovereign), with harsh punishments visited on both the corpse and the family of the "offender."

Suicide is now considered to be the cardinal symptom, and the preventable result, of a treatable mental illness called "clinical depression." The medical view of suicide rests on an analogy with a disease, such as acute appendicitis, that if left untreated results in death but if properly treated does not. An inflamed appendix has a disposition to rupture, an outcome likely to be fatal (in the days before antibiotics, it always was). Timely removal of the inflamed appendix saves the patient's life. Similarly, depression is a disease that makes the patient disposed to try to take his own life, an "outcome" (what we call it is crucial) that may be fatal. Timely treatment of the depression saves the patient's life.

This analogy is persuasive to the extent that we accept the supposed similarities between the inflammation of a vestigial part of the intestine and the intention of a decision-making individual and ignore the differences between depriving a voluntary patient of his appendix and an involuntary nonpatient of his liberty. Regardless of the absurdity of viewing suicide as a disease (with a fatal outcome) rather than as a decision (one we may deem "irrational"), however, the fact remains that most people seem more terrified of the human potential for suicide than of the human potential for murder. As a result, although suicide is not illegal, a person diagnosed as "suicidal" may legally be deprived of liberty by confinement in a mental hospital.

In short, we entertain two mutually incompatible views of suicide. One is political: The decision to end one's life is an integral part of our fundamental right to control our fate. The other is medical: The decision to end one's life is a symptom of a mental disease, justifying coercive psychiatric intervention. Instead of confronting the conflict between these two views, we prefer to expand our repertoire of medical procedures, adding to it the acts of doctors "assisting" patients who want to kill themselves (and also those of doctors killing patients at their request).

Let us assume that the suicidal person is physically capable of swallowing a handful of pills. Why does such a person need a doctor to kill him or to help him kill himself—any more than he needs a doctor to give him a drink? One reason might be that he finds the task of killing himself distasteful or does not want to take responsibility for the act. Another is that the trade in the necessary instrument—in this case, the drug—is illegal. Hence we wish to grant physicians the privilege to prescribe, for psychiatrically approved patients, the drug useful for committing suicide.

Thus, the citizen needs the doctor not so much to kill him as to give him legal access to an otherwise illegal product. In an article offering "proposed clinical criteria for physician-assisted suicide," published last year in The New England Journal of Medicine, Rochester, New York, physician Timothy E. Quill and two colleagues write: "For a physician, assisting with suicide entails making a means of suicide (such as a prescription of barbiturates) available to a patient who is otherwise physically capable of suicide." This is reminiscent of Prohibition, when doctors were in the habit of prescribing whiskey.

Policy makers in Western societies say they are struggling to contain medical costs. Yet they endorse the medicalization of one of mankind's most basic moral choices, the choice to end one's life. Typically, physicians classify a person who wants to kill himself (or who they think wants to kill himself) as mentally ill, define his decision as a symptom of mental illness, and justify the use of psychiatric incarceration and coercive drugging as treatments. When physicians deem a person to be suffering from an incurable illness and intense pain, however, they define physician-assisted suicide, in the words of Quill et al., as an "extraordinary and irreversible treatment."

Preventing suicide is psychiatric treatment. Facilitating suicide is medical treatment. Viewing suicide as a moral choice, and the physician's participation in it as medical meddling, is professional heresy.

Contributing Editor Thomas Szasz is professor of psychiatry emeritus at the SUNY Health Science Center in Syracuse. He is the author, most recently, of Our Right to Drugs: The Case for a Free Market (Praeger).