Bioethics Forum Essay
Has Physician-Assisted Death Become the “Good Death?”
“Death with dignity” for the past 40 years has meant, for many people, avoiding unwanted medical technology and dying in a hospital. A “natural” death at home or in a hospice facility has been the goal. During the last 20 years, physician-assisted suicide has been legalized for terminally ill patients in several states of the United States, and recently “medical assistance in dying,” which also includes active euthanasia, has become legal in Canada. How should we think about what constitutes a good death now?
There are signs of a cultural shift, in which physician-assisted death is not just a permitted choice by which individuals can control the timing and circumstances of their death but is taken as a model of the good death. A recent lengthy front page article in the New York Times recounts a case of physician-assisted death in Canada in a way that strongly suggests that a planned, orchestrated death is the ideal way to die. While I have long supported a legal option of physician-assisted suicide for the terminally ill, I believe that this cultural shift deserves critical scrutiny.
The print version of the article appears with the title, “The Death and Life of John Shields,” and subhead, “A parting gift.” A photo of Mr. Shields, who lived in British Columbia, takes up about a quarter of the front page. The article continues with an additional five full pages of text and photos, including a photo of Dr. Stefanie Green, the physician who performed the euthanasia, walking her dog on the beach. The online version is entitled, “At his own Wake, Celebrating Life and the Gift of Death.” While the author, Catherine Porter, keeps herself in the background, the detailed narrative makes it unmistakable that she was present during Shields’s “wake” in the solarium of a hospice facility on Vancouver Island and during the euthanasia act itself in Shields’s hospice bedroom. The effect is akin to a documentary movie of the planned death of Shields.
Shields appears to have been a genuinely remarkable man, with a rich life dedicated to helping others. I have no qualms about the legitimacy of Shields receiving physician-assisted death in view of his being a competent patient suffering from advanced amyloidosis, a rare painful condition causing progressive dysfunction, with a poor prognosis. If he had lived in nearby Washington State, he likely would have been deemed terminally ill, thus satisfying the legal criteria for physician-assisted suicide, in which he would have taken a lethal medication prescribed by a physician. That Shields’s was caused by a lethal injection given by a doctor may, for some commentators, make this case more ethically complex. My concern, however, is not with the ethics of this planned death or the physician’s role in it, but with the article’s prescriptiveness in describing his way of exiting life.
It is natural that Shields, coming from an Irish Catholic background, would have wanted to have a wake; indeed, he was a Catholic priest in his youth. Many of us imagine being present at our funerals, so why not be present at one’s “wake?” The New Age rituals orchestrated at the “wake” and euthanasia by Penny Allport, a friend and “life cycle celebrant,” reflected Shields’s attitudes and values. Each to his own. But this was not just Shields’s own life and death celebration. He had a journalist on board.
It seems significant that the New York Times—an arbiter of culture—devoted an extraordinary amount of attention to a planned, physician-assisted death and the rituals associated with it. There is a human interest story here, but the article had scant discussion of the ethical and policy issues raised by Canada’s form of legalized medical assistance in dying. Presented to the readers, in lavish detail, as the “Gift of Death,” with a very appealing protagonist, this article romanticizes the death of John Shields. More importantly, I see it as describing, and prescribing, a model for the good death in North America today. The article prominently features various quotes from Shields: “I think this is a mark of our humanity,” “What could be more meaningful than planning for the end of your life?” These are Shields’s own legitimate opinions, but I read them as being given a prescriptive force.
Physician-assisted death remains ethically controversial. The end of life is an arena for diverging values. Commitment to pluralism means recognizing a variety of good or legitimate ways to face death and dying. Presenting the planned death of John Shields as a model for dying in our era uncritically places a premium on the choice and control of the sovereign individual. Letting death happen, with the aid of palliative care, is no less good than making it happen. We should beware of prescribing a particular form of “death with dignity” as a model for the end of life and not acknowledging other perspectives.
Franklin G. Miller, PhD, a Hastings Center Fellow, is a professor of medical ethics in medicine at Weill Cornell Medical College.