This document discusses key issues around assisted suicide and end of life choices. It covers: 1) Western culture traditionally viewed death as passive, but assisted suicide envisions a more active role in choosing one's own death. 2) There is a paradox - modern medicine gives more control over life but less control over the end. Assisted suicide aims to restore personal control and self-determination. 3) The document explores different types of euthanasia and assisted suicide, and the distinctions between killing and letting die. 4) Views of death and individual rights have changed, shifting the debate around assisted suicide beyond just relieving terminal suffering. Some argue assisted suicide could become a normal end of life

1. Assisted Suicide Key Philosophical Issue Parties in the issue

2. Meanings of Death [Mann, Meanings of Death]

3. Shifting Meanings of Death Western cultural tradition has assumed that people will have a passive relationship with their own deaths Dying of natural causes, Accidents, Battle Concepts legalizing assisted suicide envision the “normalization” of a more active relationship with out own deaths What will death mean for individuals to actively choose it?

4. Paradoxical social situation Unprecedented (in human history) control over the contours of our lives – those more privileged in the world can routinely control hunger, temperature, allergies, reproduction; replace body parts – death is merely the “final act of life’s drama” At the same time, many discover that we do not retain personal control over the end of one’s life within a high-powered medical context; medical technology can prevent death, and the ethics of medicine obligate doctors to more and more extraordinary procedures as death comes closer; in order to exercise people’s clear desires to not be caught up in what some feel is a meaningless life, they may require a right to assisted suicide to properly exercise self-determination in the face of a medical establishment

5. Physician Assisted Suicide, Euthanasia & Intending Death [Kamm]

6. Euthanasia A death that is intended (not merely foreseen) in order to benefit the person who dies; involves a final act or omission by someone other than the individual whose life is to be ended Passive Euthanasia – Death Is intended, and is caused by an act of omission Active Euthanasia – Death is intended, and is caused by an specific act

7. Assisted Suicide A death that is intended (not merely foreseen) in order to benefit the person who dies; involves a final act by the individual whose life is to be ended, as well as an assisting act by someone other than the individual whose life is to be ended [giving the patient a stimulant to keep him awake so that he can shoot himself is assisted suicide…] Passive suicide – refusing lifesaving medication because he intends to die Active – shooting oneself intending to die Passive Assisted Suicide – terminating treatment that sedates a patient who wants to be sufficiently away to shoot himself (omitting the act of giving the next dose of sedating medicine); a removal of a barrier to death is a passive act; rather than a way to induce death;

8. Killing / Letting Die distinction Killing is an active act Letting Die is passive Distinctions Active euthanasia is killing Passive euthanasia by omission is letting die Passive euthanasia by action (turning off a life support machine) can be a killing [if the life support was not initially provided by the actor] or a letting die [if it was] Once a person forms an intention to commit suicide, he can do so actively which involves killing himself, or by letting himself die passively (either by an omission or act which terminates life support) If a person actively or passively assists an active suicide, he assists in a killing; If he actively or passively assists a passive suicide, he assists a letting die

9. Is there a difference between killing and letting die? According to the Philosopher’s Brief …. No

10. The Social-situational view [Battin]

11. Three changes that affect matters of how we die First, a shift, since 1850s, in the way human beings die. Away from parasitic and infectious disease, to death in later life of degenerative diseases – especially cancer and heart disease. Dramatically extended lifespances, and deaths from diseases with extended downhill terminal courses Changes in religious attitudes about death Less likely to see death as divine punishment fo sin, or to see suffering as a prerequisite for the afterlife, or to see suicide as highly stigmatized and serious sin rather than the product of mental illness or depression Individual rights of self-determination Reinforced by civil rights attention to individuals in vulnerable groups; and especially to the terminally ill Thus, our current concern with PAS is not just a phenomenon resulting from the (temporary) disparate development of life-prolonging and pain-controlling technologies [eliminating the need for PAS], but as part of a sea change in attitudes about death in general

12. Just in past 25 years, terminally ill patients have gained abilities of self-determination about their own death: Right to refuse treatment, discontinue treatment, Stipulate treatment to be withheld at a later date Designate decisionmakers Negotiate with physicians over DNR Patient plays a prominat role determining the course of his or her dying process, its character and its timing; more willingness to respect patient’s wishes by family & physicians

13. Tip of the iceberg? Much as human beings have made dramatic gains in control over our own reproduction (pill is 35 years old!), we human beings are beginning to make dramatic gains in control over our own dying We still cannot keep from dying altogether (cyrogenis…) But by using directly controlled death, it is possible to control many of dying’s features: timing, place, cause, context, etc. Perhaps, if it becomes possible to control the time, place manner and context of one’s own death, assisted suicide will become the preferred manner of dying – morph from a culture which sees dying as something that happens to you, to a culture which sees it as something you do – a deliberate, planned activity – one’s final and culminative activity.

14. Planning for assisted suicide We usually think of PAS in the context of a dying situation a person who is terminally ill making a decision to forgo a relatively brief and pain-filled end-of-life period motivations likely to include preemptive elements (the desire to avoid some of the very worst things that terminal illness might bring about), as well as reactive elements (the desire to relive some of the symptoms and suffering already being experienced) aware of what might be missed – a number of weeks of continued life, the unexpected cure, remote change of spontaneous regression or remission, or even the possibility that the rest of life will not be any worse than the current state and aware that a very hard end of life may include important moments with family and friends a rational choice: balancing risks and possible benefits of an easy death now, versus a little more continuing life with a greater possibility of a hard death making a choice in the middle of things, as the physical, social and emotional realities of terminal illness engulf him; enmeshed in situation; caught in it, trapped between two bad alternatives – suffering or suicide.

15. Think of PAS outside of this context, in a living situation Decisions about how life shall end, and whether to elect PAS, from a distanced perspective Rather than assessing prospects from the pointing time late in the course of illness when things have gottn “bad enough” and are likely to get worse, do deciding (hypothetically) from a more generalized view of life See the overall shape of life, and make decisions about its end from this perspective Choices are conditional; if I get cancer, I’ll refuse aggressive treatment…

16. The difference between these two view is substantial In the first, deciding between 0 days and, say, 3 weeks of life In the second, deciding between expected death at, say, 72.5 years, or 72.6 years… With the full understanding that there is a 50 percent chance of moderate to severe pain at least 50 percent of the time during the last 3 days prior to death The choice is much clearer at a distance (in time), especially when the planned-death alternative includes other plusses – like a conscious culminating experience surrounded by family and friends, with final prayers and goodbyes…. We are not used to making decisions about death and dying outside of a dying context – our medical practices, our biothetics, and culture do not encourage this

17. But it may be that attention to PAS will cause a shift in social and cultural norms and practices We may accept as a rule a slightly abbreviated lifespan in which there is dramatically reduced risk of pain and suffering It may become the norm and be seen as rational to plan for an abbreviated lifespane and to plan the means for bringing it about We would plan for direct termination of life Could PAS become not rare, but a choice viewed as rational by many or most members of our culture? PAS is not a rarity or “last resort” but a normal course of action

18. What kinds of context-specific cultural practices would this entail? Planned funerals, ceremonies, invitations Practical supports – insurance, legal, death benefits, etc Cultural and religious practices that treat assisted dying as acceptable and normal (rituals and rites), preparation for death, pre-death funerals understood as ceremonies of leavetaking and farewell These social practices would function as positive reasons to choose a somewhat earlier, elective death – even when pain control is no longer an issue – More frequent practice of setting a date, for one’s own death?

19. Do we have any reason to think that PAS will be rare rather than the norm?