In a recent blog post, Scott Adams, cartoonist and creator of the popular Dilbert comic strip, talked about his dying father. At the age of 86, his father’s mind was mostly gone and his physical lifespan tenuous. His estate was paying $8,000 a month to provide essentially custodial health care. While the details of his father’s condition were never revealed, Mr. Adams’ grief was undisguised. His anger at his father’s prolonged suffering was raw and unfiltered.
Entitled "I Hope My Father Dies Soon," his blog post excoriated anyone opposed to the idea of physician-assisted suicide:
"If you’re a politician who has ever voted against doctor-assisted suicide, or you would vote against it in the future, I hate your [expletive deleted] guts and I would like you to die a long, horrible death. I would be happy to kill you personally and watch you bleed out. I won’t do that, because I fear the consequences. But I’d enjoy it, because you [expletive deleted] are responsible for torturing my father."
He blamed the government for making his father suffer by taking away the option of physician-assisted suicide.
Hours after the post was published, his father died. Hundreds of readers wrote in to offer condolences and support, and there were more than 5,000 votes on the comments that followed, most in favor of physician-assisted suicide. Many castigated the medical profession and hospitals in general for prolonging suffering at great financial expense, and boiled the issue down to one of mere greed. While I didn’t get through all of the comments, none of comments I read were from people who identified themselves as physicians.
There were a lot of unanswered questions behind this post: Why there was no living will or advance directive, no specifics about who had decision-making authority in the family, and what role (if any) palliative care had in the case or if pain control was an issue. In situations like this, sometimes legal decision-making authority is only part of the picture and end-of-life care gets complicated by family dynamics, financial, or religious concerns.
During the training year, my forensic program addresses state statutes and cases related to advance directives, the right to refuse medical care, and assisted suicide. We talk about the right to privacy and personal autonomy, as well as the potential abuse of assisted suicide. We talk about cases like Karen Ann Quinlan, Nancy Cruzan, and Terry Schiavo. We cover the Supreme Court cases that address constitutional issues related to euthanasia, and the legal reasoning behind historical prohibitions against suicide.
Presently only two states, Oregon and Washington, allow physicians to administer lethal medications to patients. Two state appellate courts have found that a law banning discussion of suicide methods was an unconstitutional restriction of free speech. In my state, it is a misdemeanor criminal offense to knowingly provide the means to commit suicide, and as recently as last spring, one local circuit court criminally prosecuted someone for this.
Recently the New England Journal of Medicine sponsored an online opinion survey about the issue. Readers from 74 countries weighed in, and two-thirds were opposed to the practice. Among American states, only 18 voted in favor of permitting it.
Surveys and case law do little to capture how painfully personal end-of-life decisions are. As Mr. Adams’ post illustrates, all of these intellectual discussions feel sterile when confronted with the real, acute misery of a suffering family. The next time this topic comes up in our training year, I’m going to include his post as suggested reading.
Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011). The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.