Compassion in Choices discusses the power of names
Earlier this week I posted a news item about the California Assembly’s most recent attempt to bring a Death with Dignity law to that state. The headline of the post (which I have since changed) referred to “assisted suicide”. I received a thoughtful email from Kathryn Tucker, Director of Legal Affairs at Compassion & Choices. She has given me permission to post it here:
I am contacting you to urge that as editor you consider the language/terminology used to discuss the choice made by a mentally competent terminally ill patient to self administer medication for the purpose of hastening death, in cases where the patient finds the dying process intolerable.
As you may know, this option is currently legal in the state of Oregon,under the Oregon Death with Dignity Act, and is widely practiced covertly in other states. The Oregon Department of Human Services, which is vested with responsibility to report on the Dignity Act, adopted a policy in October, 2006, that it will no longer refer to this as “assisted suicide” or “physician assisted suicide”. As recognized by a medical epidemiologist at the DHS, “[it] probably has not been correct for us to be using this language all along.” Kevin B. O’Reilly, Oregon nixes use of term “physician assisted suicide,” amednews.com, Nov. 6, 2006 (quoting Katrina Hedberg, MD, MPH, a DHS Public Health Division medical epidemiologist).
This is consistent with the Dignity Act itself, which clearly states: “Actions taken in accordance with ORS 127.800 to 127.897 shall not, for any purpose, constitute suicide, assisted suicide, mercy killing or homicide, under the law.”
Similarly, the American Public Health Association adopted a policy to this effect at its 2006 annual meeting, recognizing that “The term “suicide” or “assisted suicide” is inappropriate when discussing the choice of a mentally competent terminally ill patient to seek medications that he or she could consume to bring about a peaceful and dignified death.” The APHA policy emphasizes “the importance to public health of using accurate language” and, accordingly, urges: “That health educators, policy makers, journalists, health care providers recognize that the choice of a mentally competent terminally ill patient to choose to self administer medications to bring about a peaceful death is not “suicide”, nor is the prescribing of such medications by a physician “assisted suicide.””
The APHA further urges “That accurate, value-neutral terms such as “aid in dying” or “patient directed dying” be used to describe this choice.” APHA policy, “Supporting Appropriate Language Used to Discuss End of Life Choices”, 11/08/2006, LB-06-02.
Many of your readers will have expertise in mental health issues, and readily appreciate that “suicide” and the choice of a dying patient to hasten impending death in a peaceful and dignified manner are starkly different from a mental health perspective. Profound psychological differences distinguish suicide from actions under the DIGNITY ACT. As one psychiatrist recently summarized: “The term ‘assisted suicide’ is inaccurate and misleading with respect to the DIGNITY ACT. These patients and the typical suicide are opposites:
* The suicidal patient has no terminal illness but wants to die; the DWD patient has a terminal illness and wants to live.
* Typical suicides bring shock and tragedy to families and friends; DWD deaths are peaceful and supported by loved ones.
* Typical suicides are secretive and often impulsive and violent. Death in DWD is planned; it changes only timing in a minor way, but adds control in a major and socially approved way.
* Suicide is an expression of despair and futility; DWD is a form of affirmation and empowerment.” Lieberman, E.J.,M.D., Letters to the Editor, Death with Dignity, Psychiatric News, 2006 Aug. 41 (15):29.
A working group of the American Psychological Association has recognized: “It is important to remember that the reasoning on which a terminally ill person (whose judgments are not impaired by mental disorders) bases a decision to end his or her life is fundamentally different from the reasoning a clinically depressed person uses to justify suicide.” Brief of Amicus Curiae Coalition of Mental Health Professionals, WL 1749170 at 17, Gonzales v. Oregon, 126 S. Ct. 904 (2006) (No. 04-623); see also, Rhea K. Farberman, Terminal Illness and Hastened Death Requests: The Important Role of the Mental Health Professional, 28 Prof. Psychol.: Research and Prac. 544 (1997); Smith and Pollack, A Psychiatric Defense of Aid in Dying, 34 Community Mental Health Journal 547 (1998).
Medical experts have discussed in detail why the term “suicide” or “assisted suicide” is inappropriate when discussing the choice of a mentally competent terminally ill patient to seek medications that he or she could consume to bring about a peaceful and dignified death. AAHPM Policy on Physician Assisted Death, adopted February 2007, available at http://www.aahpm.org/positions/suicide.html (rejecting the term Physician Assisted Suicide as “emotionally charged” and inaccurate). See also, J. Straton, Physician Assistance with Dying : Reframing the Debate, 15 Temp Pol. & Civ Rts. L. Rev. 475(2006) (Co Director of Symptom Management and Palliative Care in Dept of Family Medicine at Univ Penn writes “The process of permitting people to actively end their life before their life-ending disease completely runs its course” ought to be referred to as “physician assistance with dying”, and resoundingly rejects the term ‘physician assisted suicide’. ); Charles McKhann, A Time to Die, the Place for Physician Assistance, Yale University Press(1999) (renowned oncologist and professor of medicine at Yale University, explores the language issue extensively).
The inappropriateness of the term “suicide” or “assisted suicide” has been recognized by legal scholars as well: “The word ‘suicide’ is well suited to the description of a distraught individual with his whole life ahead of him, who in a moment of despair, commits a completely senseless and utterly tragic act. In contrast, “suicide” is not well suited to describe an elderly cancer patient who in the final days of a horrible and agonizing struggle simply wishes to avoid more needless suffering and indignity. The first individual’s act destroys what could be a long and productive life. The elderly cancer patient does not extinguish the hope of a bright future, but rather avoids the last painful and undignified moments of a life already fully lived. …Use of the word “suicide…arouses the images of tragic loss of life in a situation where the tragedy may be the continuation of life.” J. Dallner and S. Manning, Death with Dignity in Montana, 65 Mont. L. Rev. 309, 314-15 (2004).
The American College of Legal Medicine, addressed this terminology issue at some length in an amicus brief submitted to the United States Supreme Court in 1997, where the question presented was whether mentally competent terminally ill individuals had a federal constitutional right to choose aid in dying: “the term “physician-assisted suicide” is arguably a misnomer that unfairly colors the issue, and for some, evokes feelings of repugnance and immorality. The appropriateness of the term is doubtful in several respects. First, neither the New York nor the Washington statute at issue in these cases contain the phrase “physician-assisted suicide.” Second, the word “suicide” itself is defined not only as the “taking of one’s own life” but also as the “destruction or ruin of one’s own interests.” Webster’s Third New International Dictionary, 2286 (1981). As exemplified in the discussion below, it seems inappropriate to characterize requests for treatment that ends life, made by suffering, terminally-ill patients, as any form of destruction or *5 ruination of their interests. Assuming a patient’s mental competence, and recognizing this Court’s long-held commitment to the principles of personal autonomy and free will (citations omitted), prescribing medication intended to end life in the subject context serves–not destroys or ruins–a patient’s interests. For these reasons, ACLM questions whether the subject statutes even apply to the situation in which a physician cares for a mentally-competent adult in the end-stages of a terminal illness with medical treatment intended to end life. Notwithstanding that fact, ACLM rejects the term “physician-assisted suicide,” and instead refers herein to the practice in question as “treatment intended to end life.” Brief Amicus Curiae of the American College of Legal Medicine, Vacco v. Quill. Finally, as advocates for terminally ill patients, some of whom choose aid in dying, we at Compassion & Choices know that use of emotionally charged terms such as “suicide” or “assisted suicide” to refer to the choice of a mentally competent terminally ill patient to seek medications to empower the patient to control the time of impending death is hurtful and offensive to patients, their family members, and their physicians.
We urge you to adopt a policy supporting use of accurate, value-neutral language on this sensitive topic. I would welcome the opportunity to discuss this with you.