Assisted Suicide Should Be Permitted
Any issue that concerns human life is an important one deserving of our attention and opportunities where the different perspectives may be heard. The question of Physician-Assisted Suicide (PAS) made legal by the government is a question of a citizen’s freedom to control when that citizen would like to end his or her life. For patients who are terminally ill or suffering irreversible conditions that cause them suffering in ways they can no longer tolerate, the issue of freedom is most pertinent. This debate concerns a model of legalized PAS under certain conditions by a state that organizes a system of checks and balances to ensure that abuses and misuses do not occur.
The relationship between Law and Medical Ethics
At the core of a legalized physician assisted suicide (PAS) system is the principal that medical ethics should be governed and regulated by the professionals instead of lawmakers. A PAS system puts the expertise of the doctor and the experience of the patient at the forefront of the issue and views both perspectives rightly as the most credible in a given situation. The law cannot adapt to the specificity and multitude of ethical problems that arise on a situational basis. The law can only take into account circumstances that it foresees and can elaborate on. The highly personal and situational nature of this issue deems it insufficient for legislation, which exists outside the realm of the personal.
The foundation of medical ethics relies upon the understanding of the consent (when applicable) of the patient to the procedure and the discretion, judgment, and experience of the medical profession to whom the patient has entrusted their care. The basis of good and ethical health and health systems relies upon the integrity of this.
Laws are codifications of what morals exist in a society. Side Opposition wonders how exactly 'Medical Ethics' would be defined in the status quo anywhere in the world if these things were not defined through the law. Furthermore, most nations have ways in which the law can in fact be changed, thus giving law the ability to adapt to the specificity and multitude of problems that do exist in regards to health care.
Also, without the law then attempts to even test a society with PAS wouldn't exists anyway. Simply put, the law is what safeguards patients, doctors, and everyone else in the medical field, anywhere.
And still, any change in health care can directly affect not just what humans can do, but how humans think about being human (and, therefore, what rights and obligations humans should have). As issues of between medical ethics and the law come into play the importance of prudent use of law to protect health and safety becomes central. Finally, issues of social justice and resource allocation are presented more starkly in the medical care context than in any other context.
The Ethical Safeguards of PAS
To ensure that a system maintains the highest ethical standards, numerous safeguards will be implemented. To begin, The patient’s condition must be either a terminal one (meaning incurable) with no hope of recovery and death imminent (Two doctors must overlook the case to verify the diagnosis and prognosis) or suffering irreversible medical conditions that cause them suffering in ways they can no longer tolerate. Secondly, Euthanasia can only be undertaken at the request or with the permission of the patient (Oregon provides a good example by requiring two written requests at least 15 days apart, an oral request and other safeguards to ensure the capability of the patient to make such a serious decision. Also, two doctors must verify the decision-making capability of the patient.) Lastly, Doctors must perform the task of providing means and administering but only if necessary, otherwise the patient will self-administer.
In the medical profession, there is an unavoidable problem dealing with the prognosis of 'terminal' patients.
Many problems arise when physicians try to diagnose a disease that will be terminal or try to recognize the terminal phases of an illness. For example, a person who has recently been infected with HIV can be considered to have a condition that will be terminal, yet 10% to 17% of such persons are still without sequelae of immunodeficiency at 20 years. Cardiac disease is the leading cause of death in the United States , but persons with atherosclerotic disease are not considered to be terminally ill even though their deaths may occur at any moment.
This has much to do with why PAS is very hard to implement. These definitions will differ not just in the US, but in other nations around the world. At the point we recognize this to be true, proposition would be granting the right to PAS for some people, and yet not for others. This is why we look to palliative care, because, at the very least, the standards are clear.
Furthermore, we say that patients who are terminally ill may have a single disease process (such as a brain tumor) that will, in and of itself, cause death; they may have a disease (such as leukemia) that weakens them to the point where a second condition (such as pneumonia) may overwhelm and kill them; or they may have a combination of diseases, each of which makes the other incurable (for example, severe lung disease and cardiac disease). The prognosis will alter as the patient makes decisions about treatment of the primary disease or intercurrent illnesses.
But let's talk about Oregon: In the first year Oregon voters put PAS into law, 15 patients had undergone PAS. However, only four of the candidates had psychological or psychiatric consultations. Eleven others did not. Since the way in which PAS has been provided in a current system has not been shown to be systematic, it has shown to not be fair either. Surgeons don't operate without informing a patient of all their options, or doctors do not prescribe prescriptions without allowing for other options, yet PAS physicians have been able to let some patients undergo consulting while others don't have as much help. Because of this, PAS is inherently unfair on the basis that some patients will have access to more knowledge than others - this is important because all patients are attempting to make the same choice.
The Right to life, from Cradle to Grave
We believe strongly in the protection of the right to life for citizens and just as strongly in the right for citizens to choose when to die and hasten their demise to avoid unbearable pain. To withhold them of this essential right is by any definition, unethical. For example, Force-feeding patients against their will is a barbaric and unethical practice. It violates the consent of the patient and vilifies the patient’s own interests for the interests of the Other (be it a family, a hospital’s reputation, the law). Without an alternative, same patients choose to starve themselves rather than undergo medical treatment. Hector Rodas in Colorado also won the right in 1987. He was a quadriplegic. It took him 15 days to die and morphine had to be administered to kill the pain of fatal dehydration. Others have been known to survive as many as 33 days after they've decided to undergo such actions/inactions. Hallucinations ensued in the final days and relatives discussed how painful the deterioration was to watch.
This is immense pain that those who do not wish to use violent means/cannot use other means undergo in their desperation to escape suffering. The government takes away an alternative that would prevent pain. This is a violence enacted on its people through legislation. There is another option; we offer the good government that option. Simply put, governments should not be in the business of prolonging the pain of its citizens any longer then the citizens deem necessary and should abandon what seems to be sadistic policies that impinge on citizen’s right to die while watching them suffer immensely.
The rights offered to prisoners should be the rights of all: “Where a prisoner refuses nourishment and is considered by the physician as capable of forming an unimpaired and rational judgment concerning the consequences of such a voluntary refusal of nourishment, he or she shall not be fed artificially. The decision as to the capacity of the prisoner to form such a judgment should be confirmed by at least one other independent physician. The consequences of the refusal of nourishment shall be explained by the physician to the prisoner.”
Let us imagine the Nazi forces are marching into France. We offer our forces to resist, willing to die for the cause. There is no resistance, we are told. We know we will be taken to a concentration camp. We choose instead to end our lives nobly, in a humane way, and in humane conditions. The question would not be asked of us, “But could one have survived Auschwitz?” Some few did survive. Yet the dignity of the decision made to die on one’s own terms does not depend on counter factual worlds. The onslaught of a coming torture is sufficient reason to consider such a choice. This may be a torture imposed on a person by a government or organization, or it may be the ravaging force of a disease. The decision remains the same.
The state is capable, and at times better, to make decisions in regards to how people live their lives. We think there are clear brightlines in what a government says people can and cannot do. The state doesn't let children smoke cigarettes or drink alcohol, because it isn't a decision they are able to make on their own. Furthermore, the state doesn't let people walk around doing crack cocaine for the sake of their autonomy.
We also wonder what proposition would say to those who might have the consent to undergo PAS, but don't have full control of themselves anyway. We point them to mentally ill patients, who may believe, through their own consent, that they would like to undergo PAS, yet the state knows that decision is not legitimate because it was not one made with full knowledge. In regards to force feeding anorexics, we think the same logic applies. At the point where individuals cause harm to themselves, or even attempt to cause harm to themselves, the state has the right to step in.
Therefore, since we grant the state to protect the life of its citizens in every other capacity, we think the same should apply in standing against PAS.
We think, given the two points mentioned earlier, on top of current palliative care treatments, individuals cannot undergo PAS, and that the state has every right in preventing them from happening.
Also, in regards to prisoners, they give up being under the care of the state when they commit a crime against it. Therefore, the state does not have the same moral obligation is has to them as it does its citizens.
And as far as the Nazi example goes, they say, "the onslaught of a coming torture is sufficient reason to consider such a choice." We are confused by this. People could see death in general as a coming torture or the fact that death is imminent for anyone...does that mean everyone now has the right to PAS?
Quality of Life
We deem establishing and maintaining a proper quality of life should be a top priority on any good government’s agenda. Instead of prolonging or even creating pain and suffering for it’s citizens does not fit in this definition. Studies such as the one done in the Netherlands have empirically shown that patients actually found comfort in the assurance that their doctors would assist them to die if insurmountable pain that they could not handle were to arise. For those with terminal illnesses; apart from the physical pain, the mental anguish caused by simply watching and waiting for death to come. No one should have to go through this slow and torturous process. The surety that death will come and nothing, and absolutely nothing can be done about it. In addition, knowing that your loved ones are nearby going through the same process; simply bystanders watching you die. No one wants to see the people they care about suffer.
And so, if you are mentally capable of making the decision and quite sure of your decision, then why shouldn't you not go through this whole process and save all those involved from a substantial amount of pain?
The comfort provided by the knowledge that should one suffer unbearably, there is an alternative does not always rely upon the realization of that alternative.
This is exactly the same as the argument before it. We also have the same responses.
Discrimination in Palliative Care and how PAS can end it
Those who have terminal disease that are less common often face more suffering. Without the lobbies and charities behind diseases like lung cancer, brain cancer, etc., palliative care cannot provide the same Quality of Life that other better-funded palliative measures do. [“This study suggests that patients with end stage COPD have significantly impaired quality of life and emotional well being which may not be as well met as those of patients with lung cancer, nor do they receive holistic care appropriate to their needs.”
Those in the third world are the most discriminated against in the area of palliative care. They are denied basic analgesics because of their economic situation. “Morphine is a cheap, safe analgesic, yet most patients in developing countries are denied access to this drug.” Palliative care is also weakened in the Third World by “the lack of effective models for…delivery.” The palliative care options are often limited to those available to the family. Though physicians may be available, long-term palliative care is often ineffective as the physicians must respond to a large area of need and the constant support is left up to the family of the patient, who are limited in resources and training.
Minority groups are less likely to be given palliative care. Dalits, African Americans, and other minority groups are systemically given poor health care coverage and treatment. The result is that they face more emergency care rather than preventative and more inpatient non-palliative deaths. Without the option for PAS, minority groups often face alienated deaths in the institutions that have alienated them.In the case of the Roma people, both an ethnic and a lifestyle minority are discriminated against without access to PAS. Because of their nomadic way of life, the European healthcare system allows them to fall through the many cracks. When they plead for the right to die, they are denied PAS on “ethical” grounds. The European healthcare system, like many worldwide, is inherently biased to those who have a lifestyle of the majority, i.e. with a permanent residence.
A inequality in palliative care in places around the world is not enough to justify its circumvention. If anything, the option of PAS not only decreases the growth of the success some palliative care has been able to prevent, but it will prevent it's growth in the future as well.
Legalizing physician-assisted suicide is merely a part of the debate about improving end-of-life care. It cannot be viewed as a quick and easy fix, or a way to protect patients from inadequate care arrangements. Too many people still suffer needlessly, often because doctors and families just do not know how to serve people who are dying. The main problem lies with a lack of knowledge. Many suffer because doctors fail to provide adequate medication for pain. To legalize physician-assisted suicide would make real reform, such as better pain control, less likely. And ultimately hurts the growth of the medical industry. Without the reform of pain medication, patients end up with no prospects to live well while dying. In this scenario, making suicide an option is not offering a genuine choice but instead forcing a decision on the patient who again loses rights under this plan the affirmative have presented.
How to Save a Life
In addition, if there are those whose death is inevitable who would like to be put out of their suffering early, it means that doctors will have a chance to examine their vital organs to see if they can be donated. At later stages of many terminal illnesses, organs are severely weakened and, in some cases, failing - it may not be possible to use them at that point. This will help alleviate the long waiting list there is for organ donations. Thus permitting assisted suicide through euthanasia will not only put the victim out of his/her suffering earlier, but may also help save more lives. More than 102,389 men women and children are waiting for organ transplants in the US alone with only 14,203 eligible donors. PAS is an effective and ethical avenue to decrease this vast and fatal gap.
Regardless of whether or not a patient decides to under PAS, they have already made the decision to be an organ donor, or not, well before the procedure. There has not been a correlation shown between the number of people willing to be an organ donor if they underwent PAS (From the Oregon studies).
We would also say that a push for organs would decrease the amount of care given even with a PAS. Because now the focus is not on the patient but on their organs.
In the status quo, people who are registered donors are at times kept on life support against (against their will, something we though, the proposition did not like) to determine the organs sustainability for transplant.
Finally, if patients who have been cleared for PAS under the guidelines set out by the proposition, then they are already terminally ill, and thus, have failing organs already, not in good enough condition for transplant.
Rebuttal: Law and Medical Ethics
1) Opposition seems to live in an ideal setting where ethics and Law are synonymous. Unfortunately proposition does not find this to be a realistic understanding of our legal system. If laws truly where a precise barometer of ethics, the need to criminalize an action would not arise.
The proposition sees that laws sometimes fail to reflect the majority ethical positions, and other times fail to evolve alongside changing ethical notions. Countless examples of archaic laws overturned a century after the populace stopped caring for them proves this. Furthermore we believe that some law do come in clear contradiction with the majority ethical paradigms of a society, and are justified in doing so. For example laws permitting homosexuality are in fact against the majority's ethical stance regarding the issue, but they are codified to ensure the protection of a minority against this majority. We see existing models that allow a plurality of ethics and medical practitioners to work with legislators. (See Art. 19: [[http://portal.unesco.org/en/ev.php-URL_ID=31058&URL_DO=DO_TOPIC&URL_SECTION=201.html]])
2) The oppositions acknowledge that there is specificity and multitude of problems in regards to health care, but believe that the law can deal with these. They do not realize that laws cannot be changed over night, they can not be changed for individual cases, and they cannot be changed by medical health professionals and patients.
The government's position is that questions of medical ethics should not be solely determined by finite legislation. With the existing ban, legislators have made the ethical decision for medicine and for patients. This decision cannot have been based upon an individual assessment of every case: that is only possible for the patient and doctor to decide. Thus we believe that an overarching ban on assisted suicide is a majority view that has been imposed without consideration for individual circumstances, and without regard for the suffering of the minority. Removing this ban would allow the decision to be made at an individual level, and be in the hands of the patient and the doctor who are actually involved, rather than a blanket resolution.
3) The opposition correctly realizes that this law is not only about allowing an action, but altering our perception of the meaning of our humanity. But, they fail to elaborate on this and show us why legalizing PAS would alter this perception in a negative way.
What makes us human is how we value and prioritize autonomy and dignity. A large part of our humanity is choice, and control over our lives. Allowing PAS reinforces this perception, by allowing us to control our death, choose to do it with dignity and alleviate suffering in our final hours.
4) Again, the opposition identifies issues of social justice and resource allocation, which come into play very harshly in the medical context. They do not show us why these issues are harmed by permitting PAS.
The government believes that these issues are in fact being harmed in the status quo and are helped by PAS.
"The current two-tier system—a chosen death and an end of pain outside the law for those with connections and stony refusals for most other people—is one of the greatest scandals of contemporary medical practice. The sense many middle-class people have that if necessary their own doctor "will know what to do" helps to explain why the political pressure is not stronger for a fairer and more open system in which the law acknowledges for everyone what influential people now expect for themselves." [[http://www.nybooks.com/articles/1237]]
This option to alleviate ones pain is being restricted to those with influence and money. We believe permitting PAS across the board ends this two-tiered system and provides for greater social justice.
1) Proposition's rebuttal seems to be quite different than their first matter was. They tell us in their first "Law and Medical Ethics" point that "the law cannot adapt to the specificity and multitude of ethical problems that arise on a situational basis. The law can only take into account circumstances that it foresees and can elaborate on". But now they say that they acknowledge laws can change and that this justifies their model.
Our point here was that the law is very crucial to medical policy, let alone medical ethics. If anything, it seems as if both sides agree that the law is able to change, to an extent, for whatever situations may arise. (The homosexuality is a good example, one - we think - helps this side in regards to how adaptable the law is to a small populace) The only thing we would like both sides to acknowledge is that the Law plays a bigger role in medical ethics than what the proposition first led us to believe in their constructive matter, but we think they have given their first point here.
2) Proposition then changes their mind again and says that "The government's position is that questions of medical ethics should not be solely determined by finite legislation" What else would they be determined by? Prop just got done telling us that small groups use the law (homosexuality example) to make change, but not the law isn't sufficient? However, we would also add that there are more options that proposition lets on to change the law. Legislators can change state law and federal law, but there is also such a thing as civil suits.
Rebuttal: Ethical Safeguards
The opposition seems to believe that Highly trained Medical health professionals are incompetent, unable to analyze PAS requests on a specific case to case basis, and do not understand the patient or their medical condition any further than just the name of the patient and their one word diagnosis.
1) The laundry list of differing terminal illnesses that the opposition gives shows a lack of understanding of both the Standards set by the proposition, and the situations where PAS requests are received. People who are HIV positive, but are not suffering from full blown aid can hardly be said to meet the "imminent death" criteria that the government laid out. Similarly people suffering from atherosclerosis, are unlikely to opt for PAS until their suffering reaches extremely high levels, at which point they are eligible under the second option of the governments qualifications.
2) We fail to understand how the analysis of single disease, a combination of diseases or a meta disease affects the role of PAS. Yes the proposition gladly accepts that we are granting the right of PAS to some people and not the other. We don't want someone to walk into the doctor's office the day after they contract HIV and say "I will eventually die(as will all of us) why wait 40 years, please assist my suicide." We do, on the other hand, want people who face imminent death, and only face suffering in the period between the PAS request and the moment of death to be allowed to alleviate their unnecessary pain. The latter situation is the more realistic one, the one continually observed in the form of PAS requests (both in areas where it is legal or illegal) and the one that the government facilitates.
3) To point out that in the first year a system did not go without hitch is not sufficient amount of evidence to scrape an entire system. For instance, Medicad, the system that guarantees healthcare to low-income families in the US, has left approximately 60 percent of poor Americans not covered. By the opposition’s logic, we should just remove Medicad all together and allow the 40 percent whom do have coverage through the system to suffer.[[ http://www2.citizen.org/hrg/medicaid/assets/reports/2007UnsettlingScores.pdf%5D%5D Time and effort can efficiently fix these problems as it already has in Oregon in the status quo, this is why the opposition has attacked the system’s first year alone. If this system was so unfair then why would not only Oregon voters vote against an attempted repeal (60% majority)[[http://oregonvotes.org/nov497/other.info/m51abst.htm]] but also that the U.S Supreme Court decided to uphold the act in 2005?[[ http://www.law.cornell.edu/supct/html/04-623.ZS.html%5D%5D We don’t believe that Oregon Voters as well as the U.S Supreme court have any vested interest in keeping an unfair system running.
4) It goes without saying that trained medical professionals indeed are knowledgeable about the alternatives. We ourselves know them: hospice care or continued medical treatment in a palliative center, clinic, or hospital. For those who have non-terminal irreversible conditions, there may be no alternatives at all. Informing a patient of alternatives and their risks is a fundamental part of informed consent. [[http://www.ama-assn.org/ama/pub/physician-resources/legal-topics/patient-physician-relationship-topics/informed-consent.shtml]]
All of this shows that there is a fundamental flaw in the oppositions view of PAS cases, and government has a more realistic understanding of these. They offer a scenario where a doctor offers PAS to a patient without any previous knowledge about the patient and the patient's condition and then fifteen days later, after meeting the minimum ethical requirements, administers PAS. But:
a) A terminally ill patient is hardly one that has just popped out of nowhere and decided to go in for PAS - the patient most likely has been ill for some time (the chances of a patient who has been ill for a few days and is opting for PAS are very, very slim) and has a medical history, as well as an association with the hospital or numerous physicians/specialists. The 15-day period is just a measure to tie the loose ends on a decision that has probably been in consideration for weeks, if not months - patients are not going to take a decision like committing suicide lightly. Doctors at the hospital are likely to have known the patient's case for quite some time before the 15-day period.
b) The opposition is naive in thinking that the patient's sole source of advice will be a single (highly trained!) medical professional. The model itself provides for at least two consulting physicians. Furthermore, citizens trust the judgment of these professionals with good reason, but still know better than to decide the course of their lives based on one doctor's opinion. When it comes to a matter of life and death, does the opposition not believe patients will look for possible alternatives themselves with fierce energy and dedication? Even in the extremely unlikely event that the doctor (again, highly trained!) does not have knowledge of types of end-of-life care, the patient will use whatever it takes - the power and scope of the internet in terms of information gathering, advice from friends and family, or even contacts in the medical profession in this matter of life and death. If the patient is unable to do this alone, friends, family, and loved ones help.
The opposition's claims that 'doctors may not know the patients well enough' or 'they may make mistakes' are not enough to offset the fundamental right patients should have to control the course of their lives.
Opposition's problem with this point is not that some people are getting help while others are not. It's the way in which the proposition would like to administer that help that makes it unfair. We think putting a label on someone as 'already dead' undermines autonomy to begin with. That is why we don't want doctors to be able to to take that away. Furthermore we would add that if an individual, and their autonomy that the proposition likes to talk about so much, truly believe that their life in unbearable, why don't they have the right to PAS as well?
That is why we discussed the HIV example, because we would argue that a person with HIV is just as vulnerable to death as other terminally ill patients. We do point at though a person with HIV actually is considered terminal, regardless of what stage it is at. That is why we have a problem with defining what terminal is in some instances and when it is not. Proposition wants to guarantee a right for terminally ill patients, but now they say that the won't be an option unless a doctor "ok's" it. That has been our problem from the beginning. How is an individual's autonomy better protected in the hands of someone else?
They say "We don't want someone to walk into the doctor's office the day after they contract HIV and say "I will eventually die(as will all of us) why wait 40 years, please assist my suicide." We do, on the other hand, want people who face imminent death, and only face suffering in the period between the PAS request and the moment of death to be allowed to alleviate their unnecessary pain." But, they do allow for that to happen. They recognize that lives are worth living at times, regardless of whether or not a person has been diagnosed with a terminal disease longer than another person has. This is also the stance the opposition has been taking from the beginning.
At the point where some patients will be given the option to end their life, their negating their own autonomy. We do not believe that the state has that right to allow for that to happen. Furthermore, we add that if proposition allows for one person to have more autonomy than other individuals in regards to PAS, then you are negating the autonomy of other individuals with other diseases who may feel like the way to "end their suffering" as well.
Rebuttal: Right to Life
1) This debate has nothing to do with crack cocaine or cigarette use. Autonomy is a foundation of modern medical ethics, and informed consent is one of its tenets. We are discussing medical ethics, at the foundation of which is informed consent. They show their prejudice by assuming all "mentally ill" people cannot consent properly to a procedure like PAS. They ignore what kind of mental illness the person has, whether this causes them suffering, whether it impairs their judgment, whether they are undergoing treatment for it, etc. The attending medical professional would take all this into account.
2) The position of the opposition is that he state can make better decisions for individuals than they themselves can.What we see is a state that does not make decisions for individuals, but rather seeks to create conditions to allow individuals to make optimal decisions.
3) They further show this by their misunderstanding of the examples such as the prisoner example, we see outlined in "The World Medical Association Declaration of Tokyo. Guidelines for Physicians Concerning Torture and other Cruel, Inhuman or Degrading Treatment or Punishment in Relation to Detention and Imprisonment" the provision for prisoners who refuse food or treatment that their wishes be respected, but that the consequences should be explained to them. The opposition sees this as a relinquishment of the state's moral duty to prisoners. Clearly, the document is intending as outlining exactly what the moral duty is. It is this duty which all should be privy to.
4) In the "Nazi example", it’s not that death is imminent, but that the remainder of the life that is faced is inhumane and intolerable. If the only problem were imminent death, there would be no reason to hasten it. Instead, what we are concerned about is life and its quality. When the inhumanity of a single human life becomes intolerable, the right to end it should be available.
Opposition's position here is that the State can in fact make decisions for individuals when it comes to their safety. But even if we concede this point (which, we aren't) we would argue that by enacting their model, the government is still making a decision for people. Proposition thinks there is a difference between legislators and the people they represent. The impacts here are that now, in both a proposition and opposition world, the government is either allowing for individuals to look for other methods of care, or it is allowing them not to. Since we say that the state has protected people from other bad decisions in that past, it can do so here as well.
1) The opposition has characterized PAS as a "quick and easy fix" to the problems with palliative care around the world. They blame this problem on the ignorance of the people in developing areas where palliative care is non-existent or provided solely by the family. In the words of the opposition, "doctors and families just do not know how to serve people who are dying."
But on a less superficial examination of the situation, we find that "if you were a law-abiding citizen in, say, India or Sierra Leone or Sudan, and your wife was dying of cancer, it would be next to impossible to get any decent pain relief for her."
80% of the world's morphine, the commonest and cheapest of the palliative anesthetics, is consumed by six of the world's countries. Needless to say, these are not the developing countries of the world. When "4.8 million people a year with moderate to severe cancer pain receive no appropriate treatment" PAS cannot be considered as a quick and easy fix. It is the only viable alternative. ^2^ Even if we were somehow to miraculously change global markets and consumption so that these drugs were available to those in pain, we would not be able to prevent all suffering, as many of the patients come to clinics only in late-term suffering. In the posted article, we read of a woman who has breast cancer with a tumor that burst from her skin. They ask for real reform: we are the only reform that can be provided to those who currently suffer - those patients cannot wait the extra 5 years it takes to create, develop, test, and produce better pain relief medication. While they dismiss quick and easy fixes, those who are in immense pain need something quick and they need something easy enough for them to actually be able to get it. The opposition has not talked about what kind of reform they would actually provide, apart from a "better pain relief" option somewhere in the future. In the absence of any feasible concrete steps, proposed or otherwise, we claim that PAS is a reform to the state of palliative care in the developing world and an extremely urgent and necessary one.
2)The opposition believes that pain control in palliative care would be hurt by PAS. But patients' knowledge of the possibility of assisted suicide would make it more difficult for such doctors to "force a decision on the patient". That is the view of the Coalition of Hospice Professionals, who said, in their own amicus brief, ‘Indeed, removing legal bans on suicide assistance will enhance the opportunity for advanced hospice care for all patients because regulation of physician-assisted suicide would mandate that all palliative measures be exhausted as a condition precedent to assisted suicide.’” ^3^ As a fundamental part of our model, we have posited informed consent and provided regulations to make sure that it truly is informed consent. That a physician would be able to force PAS on a patient is an unfounded accusation.
3) In addition, the opposition makes the claim that allowing PAS will mean a compromise on better pain control that will ultimately hurt the medical industry. This is absolutely false - first, there will always be a continuing demand for pain control both with terminally ill patients (PAS is an alternative - not every single terminally ill patient will choose it!) and among other types of patients (where the demand will remain high) so doctors will continue to research pain control in order to find more effective methods of pain relief. Second, even if the demand does ebb temporarily, it does not mean doctors will stop researching more effective painkillers - after all, the field of medical research is not solely ruled by supply-demand economics; it is first and foremost an academic field, and academics often disregard 'demand' in their studies. Thus the idea that PAS will somehow stunt medical research is ludicrous.
We think, the line that proposition and they stance they are taking here, only gets more and more blurrier. Earlier they tell us that they are just fine with letting some people have PAS and others not. But now, they are not okay with the fact that some people have palliative treatment and others do not, so their plan is to then give some people the option to PAS and not to others. Hm. This is the underlying argument for the proposition. We think all of this, is very bad.
How are patient's and their autonomy being upheld in a medical system such as the one the proposition is attempting to enact?
Because we do not want to add yet another level of unfairness in the medical care (some with the option of PAS and others not) we feel that palliative care, regardless of the condition it is in in some nations should be the main focus. Proposition says that palliative care is an option and that they are just fine if doctors tell their patients about it, but for some reason they want the PAS option just in case. Opposition has already shown how these inequalities will exist in PAS.
If inequality exist in palliative care, the solution won't be to create inequality in PAS either. We think what the medical community should focus on, is very obvious here.
Rebuttal: How to save a life
1) While it is true that this benefit is only going to found from patients who have agreed to be organ donors and who opt for PAS, it does not mean the benefit is non existent. In status quo people who are willing organ donors are unable to do so because without the option of PAS, their organs are not in a state to be used by the time the palliative care gives up. These people's organs would be in working condition if PAS was administered to them, by their choice. So we are not arguing that number of people who opt for organ donation would necessarily go up, but that more people who chose to donate will be capable to donate working organs.
2) As for the opposition's claim that terminal illness disqualifies organs for organ donations, we disagree. The eyes of a patient with terminal cancer are still healthy eyes. The reason that PAS will help increase organ donation is that patients will be able to consent previous to their death (this reaffirmation of their organ donation actually strengthens rather than jeopardizes their consent) and thus the organs can be removed while blood still circulates through the body, before the tissues begin to die, and before more organs fail. Most organ donations can only occur if someone is seriously injured in an accident but dies once they are brought to a hospital. This is inadequate to meet the demand for organ donation.
3) The idea that the focus would shift from the patient to the organs and would decrease care given to these patients is ludicrous and insulting to the medical professionals. Organ donation is already existent in status quo, yet we don't see the doctor's give up and go for a coffee break everytime an accident victim who is a voluntary donor is admitted.
4) In the status quo people are kept on life support against their will to determine organ sustainability for transplant. This practice will not be affected in anyway by permitting PAS.
The only affect our law would have would be on people who are opting in for PAS, and also voluntary organ donors, and who can have their organs accessed before the PAS is administered. Since PAS is not administered the minute you request it, we don't see how these people would be kept on life support any longer due to being organ donors.
We would like to thank opposition for granting us that keeping someone on life support against their will is unethical. We think this is a point for our side. Whether the life support is artificial, like an oxygen tank, or natural, the life processes of the degenerating body, ignoring patient consent for a "greater good" goes against the dignity of the medical practice. With PAS, no one would be forced to stay on life support. In fact, it is just the opposite. In the definition of PAS we offered this is abundantly clear.
This is very different than the stance the rest of the proposition team is making. They tell us in not only their model, but the rest of their rebuttal as well, that individual WILL NOT be able to under PAS unless they have already reached a brightline of imminent death. This means they are terminal, this means that most of the organs are not working by this point. At the very least both proposition and opposition agree on what terminal is. To say now, "In status quo people who are willing organ donors are unable to do so because without the option of PAS" if false.
Furthermore we point out that the proposition did not address our argument that people make decisions to be donors much earlier in their lives. A normally healthy individual becomes a donor one day, dies, and guess what, his organs are still harvested. So if a terminally ill person who will opt for
PAS dies because his heart failed, then he can still donate his eyes regardless of whether or not he has a terminal illness. Just because a person undergoes PAS does not mean anything, whatsoever, in relation to organ donors.
Embracing death and the role of modern medicine.
Philosophers have always been unable to understand what exactly comprises death. Derrida in fact called death, a site of interminable confusion. Perhaps this inability to understand death is what causes us to be afraid of it; to avoid it for as long as we can; to think of it as the ultimate evil.
“For palliative care providers, however, the worst evil is a poor quality of life that is an obstacle to valuing the time that is left, rather than seeking to destroy the natural life-cycle.”
We believe this kind of belief exemplifies the human fear of death. When we read deeper into this mentality of the opposition, we see what it really says is “Life is sacred, extend it as long as you possibly can.” We on the proposition don’t support this ideal. We think that the worst evil is being forced to cling on to a failing life and spend the last living moments in pain, when you really want to progress your life painlessly to the next stage, death. We think death is just a part of life, and is a natural final stage of it. The proposition thinks its better to live life and enjoy it, extend is an far as you can without compromising on its quality, but when all that is left is an imminent death and a long period of suffering till you get there, it is a valid choice to progress it to the next stage and cut short the suffering.
Furthermore, when we look at the role modern medicine plays in out lives today; we see that PAS fits the role perfectly. Modern medicine allows choice and control to our race. As a species we are diseased, and have short natural lives. Modern medicine, and technology in general, helps us extend this life pleasurable, helps us control our body in situations we couldn’t before (Like unsuitable climates, artificial foods etc) and most importantly, alleviate the pain and discomfort caused by natural ailments. We get sick, we take medication. We break a leg, we get a fake one. When pediatrics and geriatric medicine to make the transition between the stages of life smooth and painless. It logically follows that we should extend this ideal of pain alleviation to making a painful biology process more pleasant and reducing the unnecessary tediousness and humiliation of a long drawn out end filled with suffering. If death is indeed just another, albeit the final, biological ailment the body throws at us, isn’t it the duty of modern medicine to allow patients the choice to reduce their suffering from it?
Opposition has acknowledge all of this from the beginning.
Our rebuttal to "Ethical Safegaurds" and "The Right to Life" can be cross applied here.
When Michelangelo was asked how he created his masterpiece David, he simply said “I saw David through the stone and I simply chipped away everything that was not David”. Since we on the proposition are on a similar pursuit as Michelangelo in creating a masterpiece, lets first look at what supporting physician-assisted suicide is not:
1) Supporting PAS is not supporting the end of palliative care. The opposition has stated time and time again how palliative care can be a good thing but just needs reform. This offers no direct clash with our plan and our line of argumentation throughout the entire debate. We recognize that palliative care as a viable option for patients, but we also have pointed out some of the pitfalls of palliative care and how PAS can be a benefit to those who have to suffer in these pits in some countries currently. Reform can be achieved in both PAS and palliative care under our plan. Fundamentally, we respect the preference of the patient to choose whichever option. The proposition is on the side of options and a death with dignity for citizens. We denounce the self-proclaiming moral arbiters that would force citizens to die only on the terms that they deem “natural” and “right” in the face of intense suffering and unbearable pain being felt by the patient.
2) Supporting PAS is not supporting the disproportional killing of coerced poor people and stigmatized groups. While this concern is certainly respectable, it is based simply on predicative fears. These fears have been discredited with the empirical evidence that we have provided from countries and states in which PAS is already supported. While we support these groups getting access to PAS, we certainly aren’t forcing them and neither is any outside party, as the data shows.
3) Supporting PAS is not supporting new cultural norms or ideologies that declare some lives are ‘not worth living’. What PAS promotes is that citizen’s are in control of the choice of how they want to end their lives. This idea finds opposition not in the prevailing attitudes of the people, but in the ideologies that someone or something should be in control other than the actual individual, whether it be the government, religion or someone’s definition of nature. It is time to break free from the shackles of these ideals into a world where citizens are individually empowered by supporting the right-to-die. Day by day more and more governments and citizens are recognizing this right and are strongly disavowing the antiquated positions that our opposition has argued for.
Now that we have removed what supporting assisted suicide is not, let’s look at what it is:
1) Supporting PAS is supporting a system that addresses the highly personal and situational manner of this issue while enforcing ethical safeguards that protect against any form of abuse to the utmost degree possible. Both sides agree that laws can indeed change, but when should these laws should change is where the debate lies. We refuse to maintain archaic laws in which the consent of the patient and expertise of the doctor is largely ignored. We believe that to support PAS is supporting a flexible and ethical system that can address this complex situation with the patient and doctor in mind and at the forefront.
2) Supporting PAS is supporting the idea that it is the state’s role to create conditions where citizens can make optimal decisions for themselves amongst viable options. We do not support an atmosphere where the state destroys options and makes the decision for its citizens, especially on the most sacred thing a person has, life.
3) Supporting PAS is supporting a system that not only ends lives more humanely, but saves lives as well. We are not advocating a vast increase in quantity but rather a quality increase in organ donation. We have stated that if these terminally ill patients are forced to live prolonged lives, vital organs will become increasingly weaker even if the disease does not directly affect specific organs. The system allows organ donation to be completed more efficiently, effectively and even at all in some cases.
The proposition offers quality of life over just mere quantity, choice on how to preserve this quality, and a way to preserve life of many people on organ donation waiting lists. We strongly believe we offer a far better system for these very reasons, masterpiece or not.
Moral Obligation to Protect
Ethical and moral arguments should begin not with beaurocracy, but rather with the principle of protection of the socially and economically disadvantaged. We as the opposition are greatly concerned that persons whose autonomy and well-being are compromised by poverty or by membership in a stigmatized social group, (such as women, persons with disabilities, ethnic, sexual, and other minorities, and ill older persons in general) will be coerced into assisted suicide. The pressure to choose suicide may not be explicit and personal, because persons who experience stigma may internalize a diminished sense of entitlement to resources, which could be twisted by a less than qualified psychologist to be a terminal illness. These suffering individuals may be the ones who most strongly argue for their own demise. The principle of individual choice in dying is viewed as a fictitious ideal in a highly stratified society, such as the United States, where access to basic health care is highly variable and dependent upon personal income and private insurance.
While we question just how “greatly concerned” the opposition is for the well-being of citizens in poverty and socially stigmatized groups since they didn’t even take the time to type out their own argument, we will address this argument nonetheless.
The fears of the opposition that assisted suicides would occur disproportionately among the poor, uneducated, women and the uninsured has not statistically been proven to be true in areas where assisted suicide is legal such as Oregon and the Netherlands. [[http://books.google.com/books?id=K-dST14hmwoC&lpg=PA56&ots=LNZMcnvHjn&dq=assisted%20suicide%20medicare&pg=PA56]]
In fact, a report actually revealed that, compared to all Oregon deceased during the time period the report covered, the median age for those who chose physician assisted suicide was actually less, the amount of formal schooling received was significantly more and every single person who chose this option had health insurance [[www.oregon.gov/DHS/ph/pas/docs/year8.pdf]].
The people whom are in fact being coerced are those being forced to suffer in states where assisted suicide is illegal and are being coerced to live by the hands of the legal construct. That being said, we believe that this argument is not a strong enough reason to violate one’s individual autonomy and self-determination to end one’s excruciating pain and suffering and based on predicative fears that have proven to be empirically false. The principal of individual choice in dying is indeed fictitious, we are all going to die. This debate is about people hastening their death through the means they choose and making sure this choice is sound through ethical safeguards.
A Lack of Responsbility
Ethical safe-guards may not be achieved in the time frame allotted by the affirmative. Oregon physicians, as well as the physicians of Netherland, have been given authority without being in a position to exercise it responsibly. They are expected to inform patients that alternatives are possible without being required to be knowledgeable enough to present those alternatives in a meaningful way, or to consult with someone who is. Meaning that physicians or mental health professionals are advising patients without a complete understanding of end-of-life care available to them, which again goes against the Hippocratic Oath all medical personal must take. They are expected to make decisions about involuntariness without having to see those close to the patient who may be exerting a variety of pressures, from subtle to coercive. They are expected to do all of this without necessarily knowing the patient for longer than 15 days, which is clearly not long enough to fully gain perspective on a person. Since physicians cannot be held responsible for wrongful deaths if they have acted in good faith, substandard medical practice is encouraged, physicians are protected from the con-sequences, and patients are left unprotected while believing they have acquired a new right, and ultimately defeats the purpose of legalizing PAS.
We believe this Argument and the rebuttal for the proposition's "Ethical Safeguards" argument can be clubbed together, and they have both been responded to together in "Rebuttal: Ethical Safeguards"
The Price They Pay
The opposition stands with critics of PAS who have found that once assisted suicide is accepted as an available option for competent terminally ill adults, it may be permitted for ever-larger groups of persons, including the non-terminally ill, those whose quality of life is perceived to be diminished by a physical disability, persons whose pain is emotional instead of physical, and so forth. Critics point to the fact that permitting euthanasia and assisted suicide, as is done in the Netherlands, does not prevent violation of procedures (e.g., failure to report) which occurs frequently in the medical profession, or abuse (e.g., involuntary euthanasia). It is further contended by the opposition that adequate safeguards are not possible. For example, requiring written requests to be repeated over a period of time, such as 15 days, and witnessed by two unrelated witnesses while simultaneously involving at least two physicians AND a psychiatrist's or psychologist's examination is unrealistic. Persons at the end of their lives typically have neither the energy nor the ability to meet such conditions. In addition, the option of assisted suicide for mentally competent, terminally ill people could give rise to a new cultural norm of an obligation to speed up the dying process and subtly or not-so-subtly influence end-of-life decisions of all sorts. Which ultimately costs the patient one of the three inalienable rights, the pursuit of Life.
1) Many people who choose PAS and are not terminally ill have a physical injury or disease attached to their emotional pain. For instance, Daniel James [[http://www.timesonline.co.uk/tol/news/uk/article4969423.ece]] was paralyzed from a rugby accident and Chantal Sebire [[http://uk.reuters.com/article/idUKL1918252520080319]]
whom had a swollen tumor in her sinuses that made her face severely disfigured. These people felt like prisoners to their own existence, their quality of life was in fact diminished not "perceived". We believe no person or government has a right to keep these people entangled in a web of suffering. We recognize that people can continue their lives even in dire situations, but we believe the government should not force them to continue a life of suffering.
2) The opposition says that a “violation of procedures” can occur, such as a failure to report. Unfortunately we do not live in a world where the medical practice can be absolutely infallible. This is more an argument against any sort of medical procedure, life saving or life ending because these problems are not unique to any medical procedure, whether it be perceived as simple or complex . Involuntary euthanasia is not a problem with our safeguards and able and competent doctors in place. Any doctor that would commit involuntary euthanasia with any form of consent from their patient would do so even without a legal PAS system because they have no regard for ethics.
3) Firstly, it seems the opposition is unclear as to why they object to the conditions that need to be fulfilled; because they are not stringent enough or because they are too stringent to be fulfilled by people who wish to exercise this right?
We are not exactly sure how our safeguards can be deemed “not possible” and “unrealistic” when they are the same safeguards put in place in the state of Oregon, which we have already stated in our opening arguments.[[http://www.leg.state.or.us/ors/127.html]] This is not a chimerical proposition as the opposition has dismissed it as but in fact an actual and real life working system that has been around for 11 years.
This system, under which in fact the right to physician assisted suicide has been exercised by hundreds of patients since the law was passed in Oregon.
4) Rights do not demand to be exercised. We support the inalienable pursuit of Life but we do not support force-feeding life to citizens whom declare that they no longer want to participate in this pursuit for the ethically justifiable reasons stated in our case. We also grant citizen’s freedom of speech but does that mean they we should ban silence? Where governments allow dissent, it would be ludicrous to demand that all citizens must dissent in order to exercise their right. Instead, any theory of rights must protect the exercising of rights as well as the citizen’s choice to not participate, to not exercise their right. The right to life has to be forfeited at some point, and we support the right for our citizens to choose when they want to forfeit it. We see this in the status quo already - governments have ceased to consider suicide a crime. Why should assisted suicide for terminally ill patients be any different?
The Worst Evil
A patient may accurately judge their current quality of life to be unacceptable, but adequate care would always increase their quality of life to the point where they would reconsider. In addition, there is also fear that accepting such thoughts as legitimate, rather than simply understandable, could comfort an ideology that considers some lives as being ‘not worth living’, even if the person living this life sees value in it. PAS limits the view of the patient to a mere biological mass. Palliative care providers emphasize compassion, and the will to care for the whole human being. The importance of caring for the whole individual rather than for an organ is underlined, as is the importance of interactions between psychological and physical suffering. For both PAS and palliative care, the worst evil is a poor quality of life. For palliative care providers, however, the worst evil is a poor quality of life that is an obstacle to valuing the time that is left, rather than seeking to destroy the natural life-cycle.
1) Legalizing physician assisted suicide does not mean that it will be forced on all suffering patients. The proposition strongly feels about the freedom of choice, but the opposition would like to eliminate options and funnel suffering people down a path they feel is the right one.
2) The only ideology that this supports is that a citizen's life and its value is actually in the hands of and defined by citizens instead of some separate entity. We don’t see any sort of logical connection with this slippery slope that they would like us to ride down.
3) We are not advocating an end to palliative care; we believe both systems can co-exist. What we recognize is that there are some huge pitfalls in palliative care (See: “Discrimination in Palliative Care and how PAS can end it” argument) and that PAS can fill these ethically and efficiently. Stating why palliative care may be a good thing doesn’t address why a PAS should not also be a viable option for patients.
4) We don’t believe that anything that is “natural” is always inherently good and anything that is unnatural is inherently bad, as it seems the opposition believes. If we are to agree with this line of argumentation then any sort of medication, treatment and surgery, such as chemotherapy, that can save lives should not be exist either because they also destroy this “natural life-cycle” that our opposition has defined for all of humanity. We don’t believe that they are as omniscient as they seem to think and feel that they are trespassing into very dangerous territory when they attempt to define just how people should die, and force conformation to that definition.
What do you think?