I’ve met many people as a result of Jessica Yu’s Oscar-winning documentary about me, Breathing Lessons: The Life and Work of Mark O’Brien, but some stand out from the rest. Wesley J. Smith is one of these. As I left the film’s premiere, I saw a big, bearded man wearing a black leather jacket coming toward me. I was a little frightened, and wondered if this was a retired Hell’s Angel. But when Smith introduced himself, he immediately put me at ease. He told me he had attended the premiere because he had enjoyed my newspaper articles on disability, and I was taken with his warmth, intelligence, and good humor.
Smith is an attorney, a radio talk-show host, and the author or coauthor of eight books, four in collaboration with consumer advocate Ralph Nader, including No Contest: Corporate Lawyers and the Perversion of Justice in America (Random House). Smith’s latest book, Forced Exit: The Slippery Slope from Assisted Suicide to Legalized Murder (Times Books/Random House), is a thorough critique of the movement to legalize physician-assisted suicide. As an attorney for the International Anti-euthanasia Task Force, Smith has traveled the country arguing against legalizing assisted suicide. He has even filed briefs before the United States Supreme Court, which in 1997 ruled that, although there is no constitutional right to physician-assisted suicide, the states are encouraged to continue the dialogue about legalization.
Smith visits me often now. He tells great stories about arguing with talk-show hosts and serving as Ralph Nader’s one-man entourage during the 1996 presidential campaign. I consider myself lucky to know him.
In addition to acknowledging my friendship with Smith, I must also admit my bias on this subject: Smith quotes me in Forced Exit, and I’m a member of Not Dead Yet, an organization of disabled people who actively oppose physician-assisted suicide. I can hardly remain neutral when Faye Girsh, president of the Hemlock Society, advocates lesser penalties for so-called “crimes of compassion” against disabled family members, and Jack Kevorkian writes approvingly of using us as unwilling subjects in medical experiments.
This interview was conducted in July 1998. Smith lives in Oakland, California, with his wife, San Francisco Chronicle columnist Debra J. Saunders. His e-mail address is firstname.lastname@example.org.
O’Brien: There is a libertarian strain in American thought that says, “I can do whatever I want as long as I don’t hurt anyone else. Assisted suicide is a private matter between me and my doctor.” What’s wrong with that?
Smith: This society was not created on the principle of doing what we want, when we want, and how we want. This society was created to promote what the Founders called “ordered liberty.” We have the right to individual choices, but those choices are made within the context of relationship and community. To say we have the right to have doctors help us die would destroy traditional medical ethics, so it is not harmless. The entire doctor-patient relationship is damaged — not to mention the harm to the person being killed.
I am not a libertarian. I believe society has the right to put certain limitations on individual behavior to protect not only the individuals themselves, but the greater good. For example, you cannot sell yourself into slavery, because it would not only degrade you as a human being, but degrade our society. If we had a class of people who were slaves — even if they had chosen to be slaves — by definition it would create an atmosphere of oppression. And it would also create a situation in which poor and desperate people might sell themselves as chattel to save their families from deep financial difficulty.
The main difference I have with libertarians is that I see our society as a forest, whereas libertarians see it as just a bunch of trees standing next to each other.
O’Brien: You say assisted suicide would hurt the doctor-patient relationship. How do doctors feel about the issue?
Smith: As individuals, doctors are as divided as the rest of society, but their professional associations are almost unanimously opposed. The World Federation of Doctors, the American Medical Association, and almost every state medical association are on record opposing assisted suicide. They see it as a profound danger to medical ethics and the physician-patient relationship.
O’Brien: How could legalization of physician-assisted suicide hurt all patient-doctor relationships when many doctors are opposed to assisted suicide?
Smith: I have three letters for you: HMO. Managed care is taking over the finances of medicine. In managed care, unlike in fee-for-service plans, money is made by cutting costs. Doctors are being put under tremendous pressure to reduce costs by reducing the level of care and seeing more patients. Doctors in some HMOs are limited to twelve minutes of “face time” with each patient. In some cases, 25 to 30 percent of doctors’ income depends on bonuses they receive for cost containment. And what “treatment” would be cheaper than assisted suicide? Think of the money HMOs could make if they didn’t have to pay to treat people with cancer, or multiple sclerosis, or any other chronic or terminal illness you can name, because the patient “chose” instead to be killed.
O’Brien: But not all doctors work for HMOs.
Smith: Not yet, but most doctors eventually will, because managed care is where we are heading. Beyond that, we have 43 million people without health insurance. Again, which would be cheaper: taking care of them with public dollars, or giving them “death with dignity”? Indeed, Oregon, which rations health care to poor people on Medicaid, now covers assisted suicide under its public plan. Yet poor people with advanced cancer can’t get curative treatment under that same plan. Also in Oregon, an HMO with only a thousand-dollar in-home hospice benefit has stated that it will pay for assisted suicide.
Once you legalize assisted suicide, you send the message that it is legitimate to kill people. If it is seen as legitimate, then the path of least resistance will lead us toward induced death.
O’Brien: Isn’t there a way assisted suicide can remain purely voluntary?
Smith: The term “voluntary” is relative. In many cases, people who say they want assisted suicide are clinically depressed or are receiving inadequate pain control. For example, according to the American Cancer Society, approximately 50 percent of cancer patients receive inadequate pain control. Eighty percent of AIDS patients receive inadequate pain control. And one study recently reported that a large percentage of elderly people in nursing homes die in terrible pain because they don’t receive enough pain medication. So if somebody who is not being treated adequately for pain — or depression — wants assisted suicide, I hardly think we can call it voluntary. In fact, we’d be saying that the solution to the problem of doctors providing inadequate care is for those same doctors to kill their patients. To me, that is nuts.
O’Brien: Doesn’t morphine sometimes hasten death?
Smith: Only rarely. When pain control is done correctly, it almost never has the side effect of hastening the patient’s death. There are board-certified pain-control specialists who know how to properly set dosage and increase it if necessary as the pain worsens. People do not become addicted or permanently doped up under those circumstances. Indeed, pain control, properly applied, makes a wonderful difference at the end of life. But a lot of people don’t know that. And a lot of us have seen loved ones die in agony with little or nothing done to stop the pain. That is why we have to win this assisted-suicide debate: to give the medical profession time to improve end-of-life care and the treatment of pain, and to make sure that in difficult cases patient care is transferred to pain-control specialists.
And even if a person dies before he or she otherwise would have because of pain-control medication, it’s not the same thing as euthanasia or assisted suicide, any more than when somebody dies on the operating table during heart surgery. It’s an unwanted side effect. And when assisted-suicide proponents say otherwise, they are intentionally blurring vital distinctions and definitions in order to sow confusion in the debate.
Compassion means “to suffer with.” True compassion means you stay with people in times of crisis; you stay with them until they get to the other side; you take some of their pain onto your own shoulders. Assisted suicide is just getting rid of the person in one fell swoop.
O’Brien: Speaking of proponents of assisted suicide, do you think their motives are all bad?
Smith: People’s motives are not as important as the actions they advocate. A proponent of assisted suicide could be Moses, and it wouldn’t make assisted suicide right. That said, I think the motives of those promoting this agenda are mixed. I think there is a difference between the true believers in assisted suicide, who view it in an almost quasi-religious way, and people who support it because they believe it is the compassionate thing to do. The latter are merely misguided, in my opinion. But I have studied this movement for more than five years, and I think that the primary motive of most of the people who drive its agenda is not compassion. That’s how they sell it, though, and they have been quite successful, because the media haven’t really looked beneath the surface and have taken a lot of what they proclaim at face value.
If you want an example of the right-to-die movement’s compassion, take a look at a recent case out of New York: Myrna Lebov was assisted in suicide by her husband, George Delury. Lebov was not terminally ill; she had multiple sclerosis. When her husband admitted feeding her a deadly dose of medication and then putting a plastic bag over her head, he claimed he was acting out of compassion, that she wanted to die because her life had been reduced to, in his words, “the mere biological.” But then the police discovered Delury’s diary. It turned out he’d been pressuring her for several months to kill herself. According to his diary, he told her she was a burden. He told her she was a vampire sucking the life out of him. He told her she was holding him down, that he had places to go and things to do, and she was keeping him from living a decent life.
How was this terrible abuse and crime against a disabled person treated by the New York Hemlock Society? The society went to Delury’s defense. It started a defense fund for him. The leader of the New York chapter said he was confident that Lebov wanted to die because, after all, “who would want to live in that condition?” Delury has become a hero of the right-to-die movement: he’s written a book and speaks all over the country.
So, although they proclaim themselves the epitome of compassion, when you scratch beneath the surface, the proponents of assisted suicide really believe that people with disabilities or terminal cancer or other equally difficult conditions are better off dead.
You know, compassion means “to suffer with.” True compassion means you stay with people in times of crisis; you stay with them until they get to the other side; you take some of their pain onto your own shoulders. Assisted suicide is just getting rid of the person in one fell swoop. I don’t see that as compassionate.
O’Brien: The words that are used in this debate, like choice and compassion, have long been used by the American Left and Democratic candidates. Do you think we are losing sight of the meanings of these words? Are their meanings becoming distorted?
Smith: Absolutely. I think they are being distorted with malice aforethought. We have reduced public-policy discourse to sound bites and slogans, and “choice” is probably the best sound bite ever created, because it implies freedom and individualism, which are as American as any characteristic can be. And “compassion” implies that you care.
But talk of compassion and choice should not blind us to the incredible complexity of this issue or to the forces that will be unleashed if we accept killing as a means of alleviating difficult circumstances. Once people look into the matter in depth and see the consequences and the abuses that already exist, they’ll begin to turn away from assisted suicide as an answer. But as long as discourse is kept to the shallow level of slogans and sound bites, it will be very difficult to get people to see the full picture. They see only a small piece of it. And the media are responsible for this. Their coverage is unbelievably shallow and lacking in context. They go from case to case, not looking beneath the surface, repeating that assisted suicide is “choice” or “compassion” or the only way to stop suffering, which is false.
O’Brien: You have had a better reception in the conservative press than in the liberal press. Do you think that has to do with the right-to-die movement’s co-opting the word compassion and painting people who oppose assisted suicide as anticompassion?
Smith: Yes, in many ways it does. I think the liberal press believes that, because certain people oppose assisted suicide — specifically, the religious Right — they have to be in favor of it. Talk about anti-intellectualism. People should decide based on the facts of an issue, not based on what Jerry Falwell’s position is.
O’Brien: You’ve actually been accused of being a spokesperson for the religious Right.
Smith: Which is funny, because I am a colleague of Ralph Nader. But that shows the shallowness of the assisted-suicide debate. Rather than deal with the facts I present, advocates of assisted suicide prefer to associate me with a group of people who are not well liked by many Americans. That is not intellectually honest, in my opinion.
O’Brien: I’m reminded of the sixties and seventies, when the Left allowed the Right to seize the flag and patriotism and some of the basics of American culture, like country music and baseball. It got to the point where, if you were on the Left, you had to hate country music and baseball. The Left painted itself into a corner.
Smith: That’s exactly right. There’s a deep schism on the Left between the Martin Luther King Jr.–and–Ralph Nader Left — which values protecting vulnerable and defenseless populations against oppression and believes in strong community and equality for all people — and, for want of a better term, the radical-individualist Left, which believes that freedom equals unlimited personal license in terms of behavior. And such radical individualism — whether from the Left or the Right — is a destroyer of community and results in social Darwinism. You end up with an empty, nihilistic, sterile society.
There’s a widespread prediction in medical journals that the next great epidemic to sweep the West is going to be depression. Why are we so depressed? I think it’s partly because we are losing the bonds that tie us, our commonality, and are beginning to look at some human lives as less valuable than others. This is reflected in our cultlike devotion to celebrities. The way to turn that around is to develop a community that values people on their deathbeds as much as it does people who have just been born, one that values journalist Mark O’Brien, who uses an iron lung, as much as it does baseball star Mark McGwire. It’s essential that, in terms of moral worth, we all be viewed as equally precious. Of course, we have different talents and abilities, but at a core level, either we are all equal or none of us is equal and we end up with oppression.
O’Brien: It seems that advocates of physician-assisted suicide look to doctors as the arbiters of moral questions. Why is that?
Smith: Physicians have no greater or lesser morality than anybody else, but they do have a wealth of medical knowledge: they know how the body functions, how to treat illness, how to alleviate symptoms, how to make people well. So their words are given greater weight. We trust them. If a doctor says to you, “No, you shouldn’t commit suicide; there are things we can do,” that has a strong positive impact. But if a doctor says instead, “Well, you have colon cancer, so I guess assisted suicide is the best way to go,” that has a devastating impact. It’s not a neutral statement that simply grants a patient “choice,” but a terrible validation of one’s worst fears.
There is a paradox here. People seem to want increased behavioral license, but they also want authority figures to tell them what they’re doing is OK. And they expect doctors to perform that role in assisted suicide. But we grant doctors that authority at our own peril. Their diagnoses can be wrong. And they have prejudices and biases, just like everyone else. What if a homophobic doctor tells a gay man with AIDS that only assisted suicide can prevent his suffering? That would be a deeply bigoted act, but one that could be covered with a veneer of supposed compassion.
O’Brien: At the turn of the century, doctors described people with polio as being morally depraved.
Smith: They also involuntarily sterilized people whose lives, the doctors felt, lacked worth. I am not talking about doctors in Nazi Germany, but here in the U.S. We had sterilization laws in many states long before Germany did. We said it was based on compassion, but it was really a matter of disdain.
Now, I want to make it very clear that I don’t believe people who support assisted suicide want to take disabled people, line them up against a wall, and shoot them. But I do think that they want to narrow the definition of a life that’s worth living, and if society as a whole ever agrees with them, we are heading down a path to the marginalization of the sick and disabled and, indeed, the premature ending of the lives of a lot of defenseless people. I mean, I already hear people saying, “Do you want to pay for their upkeep?”
It seems to me that our emphasis on suicide is misplaced. We shouldn’t be talking about helping people kill themselves when we are doing such a poor job of helping people get along in life.
O’Brien: Aren’t there any circumstances in which the state could permit assisted suicide without it turning into the murder of the poor, disabled, and elderly?
Smith: I don’t believe you can create a system that permits doctors to participate in killing patients without that system expanding beyond the original mandate, because if you say that killing can be good in one circumstance, it’s eventually going to be deemed good in many more. As for guidelines to protect against abuses, history has already shown that they don’t work, for a very simple reason: once killing is deemed beneficial, the guidelines are no longer seen as protections, but as obstructions.
O’Brien: What history are you referring to?
Smith: It’s happened in the Netherlands, for example, and in Australia. The Netherlands approved euthanasia in 1973. It wasn’t formally legalized, but doctors were told they wouldn’t be prosecuted if they followed certain basic protocols and guidelines. Since then, doctors there have gone from killing terminally ill people who ask for it, to killing chronically ill people who ask for it, to killing healthy but depressed people who ask for it, to killing babies with birth defects, who of course can’t ask for it. In 1990, Dutch doctors killed six thousand people who had not asked to be killed. (That includes patients who were intentionally given massive overdoses of morphine.) This is a tremendous number when you consider that only 130,000 people die each year in the Netherlands.
In Australia’s North Territory, assisted suicide was legal for a brief period, during which four people died under the law. It took one of them four weeks to go through the steps mandated by the guidelines, and some proponents were so upset by the delay that they immediately started calling for easing the guidelines.
Once you legalize assisted suicide, you change the public mind-set 180 degrees. It’s like 1984’s newspeak: killing is good; caring is undignified. It changes who we are at a soul level.
O’Brien: When did the idea of physician-assisted suicide develop?
Smith: There may be a few earlier instances, but assisted suicide in its modern form began in Germany in the late 1890s. It started with the idea that society is an organism and therefore has the right to decide, for its own good, who lives and who dies. This perspective was advanced shortly before World War I, when a German man dying of lung disease published an open letter asking for help in killing himself. He used the same argument we hear today: that it was his body, and why should he be forced to suffer? That letter sparked active discussion of the issue among German intellectuals, but debate was cut off by the outbreak of war.
In the devastation following World War I, two prominent Germans, Karl Binding and Alfred Hoche, wrote a book called Permission to Destroy Life Unworthy of Life. Binding was a famous law professor, and Hoche was a well-known doctor. Together, they proposed that there were three categories of people who could be euthanized: the terminally ill; people who would remain unconscious indefinitely; and “idiots” and the disabled, who were seen as burdens on society. Their book, published in 1920, became the intellectual foundation for the acts of euthanasia committed in Germany by the Nazis between 1939 and 1945.
O’Brien: Isn’t there a difference between assisted suicide, which at least implies that it’s the patient’s choice, and euthanasia in Nazi Germany, which was inflicted upon you whether you wanted it or not?
Smith: Assisted suicide, in my opinion, is a bridge between suicide and active euthanasia. It lets you believe that you are really killing yourself, even though a doctor does the actual killing. But there are other means to kill oneself that don’t require help. The real purpose of the assisted-suicide movement is to get people used to physicians “helping” people die.
According to Derek Humphry, who founded the Hemlock Society and wrote Final Exit, 25 percent of assisted suicides fail, resulting instead in vomiting, convulsions, or extended coma. He says the only two ways to ensure death in an assisted suicide are suffocation by plastic bag and lethal injection by a doctor. Some assisted-suicide organizations even sell suicide-bag kits. I bought one for forty-two dollars. It has a bag with a Velcro closure, a cotton terry-cloth band to put on your neck for comfort, and instructions on how to kill yourself. Of course, most people find the idea of suffocating a loved one with a plastic bag horrible. The intention behind selling these kits is to get people to use them and start telling horror stories about it. Then assisted-suicide advocates can argue that we have to move on to lethal injection to make sure people die “with dignity.”
O’Brien: Do you think it’s a good idea to disseminate practical information about how to commit suicide, so that there would be no need for assisted suicide?
Smith: It seems to me that our emphasis on suicide is misplaced. We shouldn’t be talking about helping people kill themselves when we are doing such a poor job of helping people get along in life. As the disability-rights organization Not Dead Yet says: don’t talk about death with dignity until we have life with dignity.
O’Brien: I wonder if the move toward physician-assisted suicide is a reflection of diminished religious belief and an increase in utilitarian ethics.
Smith: Support for assisted suicide may be a symptom of less involvement in religion, but that is not primarily how I perceive it. I see it as a sign of a breakdown of community, a breakdown of mutual cohesiveness. I think that people are looking for the return of community. We can be led in that direction by religion, but also by civic institutions: the hospice movement, for example. Many hospices have nothing to do with religion, yet they bring a profound sense of community to dying people and their families.
I also see the push for assisted suicide as a vote of no confidence in the health-care system, and as a symptom of a society that is, frankly, becoming decadent and developing an attitude that not only says, “If it feels good, do it,” but also, “If it feels bad, kill it.”
I think what’s really behind most people’s support for assisted suicide is not so much compassion as fear. I think people are afraid of being left to writhe in pain. People are afraid of losing control and being dependent. People are afraid of being a burden, and also of being burdened. And I think the way this issue plays out will tell us a lot about who we are as a society. We are either going to be a society that embraces each and every one, that says to all, “You are welcome, you are wanted, you are worthy,” or one that says, “You are welcome, you are wanted, you are worthy — if you have a certain quality of life; if you can live autonomously; if you aren’t dependent; if you don’t have pronounced difficulties caused by illness or disability. Otherwise, you’re in trouble.”
O’Brien: What are some recent developments in the debate?
Smith: Well, Jack Kevorkian just took out the kidneys of a quadriplegic he had helped to die and offered them to society. He effectively said the organs of disabled people are more valuable than the disabled people themselves. The organs were rejected, but only because they weren’t sanitary. There was little moral outcry. In other words, Kevorkian was criticized for failing to follow proper medical procedure, not for the inherent immorality of the act. There was even some minor editorial support for the idea of using the organs of assisted-suicide victims.
Eighty percent of Kevorkian’s victims have not been terminally ill. Most have been disabled. Several, upon autopsy, turned out not even to have been sick. If we have reached the point where we are saying to sick and despairing people that we don’t care whether they kill themselves — indeed, we’ll help them do it — oh, and by the way, we’d like their livers, then we are no longer a moral and ethical society. Once we say that not all human life is equally deserving of protection — including protection from self-destruction — then we create a caste system in which some people are second-class citizens who can be exploited for the benefit of others.
O’Brien: Yet so many people, when facing death or severe illness, say, “I wish someone would just shoot me.”
Smith: The medical literature says that there are three primary reasons why ill or disabled people ask for help ending their lives: The first is untreated or undertreated pain. The second is clinical depression, which is present in almost all cases. And the third is lack of family support.
It seems to me that if we legalize assisted suicide, we are only going to add a fourth reason why someone might want to die, and that is abandonment by one’s community. Legalizing assisted suicide would be an explicit statement that, when you reach a certain place in life, we as a society have no objection to your destruction, with or without the assistance of others. That message has the potential to make people feel as if they are selfish to want to go on living.
I think a more compassionate response, one that values all human lives instead of just some, is to engage in suicide prevention, just as we would for people who are suicidal because they are divorced, or their business has failed, or their reputation has been destroyed. There are thousands of people alive today who were once suicidal, but persevered because someone cared enough about them to help them stay in this world until the crisis passed. I think we should treat the suicidal urge caused by illness or disability in the same manner.
O’Brien: Have you ever known someone who was suicidal because of disability or terminal illness and later changed his or her mind?
Smith: Yes, I have. As a hospice volunteer, I met a man named Bob, who died this past summer of ALS, or Lou Gehrig’s disease. I visited him once a week for nearly twenty months, and we got to know each other very well. He told me that when he was first diagnosed, he’d become suicidal. He worried about being a burden to his family. He was very upset by his growing disability. He was essentially abandoned by his friends. I will never forget his words: “First my friends stopped visiting me, then they stopped calling me, and then they stopped calling my wife. I felt like a token presence in the world.” He told me that, if he could have, he would have gone to Kevorkian.
But eventually Bob came out of the fog and realized he wanted very much to live. He had been depressed, but he adjusted and wasn’t depressed anymore. He built a new life for himself, even though he was completely paralyzed. He wrote, he collected art, he invested on the Internet, and he watched his three children grow. He died a happy man and was glad he had not killed himself. Did he suffer? Yes. ALS is a terrible disease. But he transcended. Had assisted suicide been legal, he might have done it and missed out on what Bob himself called the best years of his life. And our society would have borne a moral responsibility for that. We would have robbed him of those years by agreeing with him that his life was not worth living. And all in the name of compassion.