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The Last Word

For Wesley Smith, author of Forced Exit: The Slippery Slope from Assisted Suicide to Legalized Murder, the circumstances surrounding the death of Jana Van Voorhis provide a chilling example of a movement running amuck. "This is the secret that a lot of media has not reported much on," says Smith,...
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For Wesley Smith, author of Forced Exit: The Slippery Slope from Assisted Suicide to Legalized Murder, the circumstances surrounding the death of Jana Van Voorhis provide a chilling example of a movement running amuck.

"This is the secret that a lot of media has not reported much on," says Smith, an attorney whose opinions on assisted suicide, bioethics and myriad other topics have appeared in some of the world's most influential publications.

"Assisted suicide is not about terminal illness. That's a pretext, in terms of the political fight to get people to accept the concept."

Smith suggests that "none of us know what our limits are or how we might react to pain or what mental illness might do to us, which is why when someone is suicidal, the rest of us have an even greater obligation not to accept that person's definition necessarily."

He is unabashedly judgmental "about people who, pursuant to their own ideology, would facilitate these kinds of things, because a lot of people who could be helped, instead will be dead. I frankly think some of the people get off on this."

Smith's passion reflects the controversial nature of the hot-button topic. Clearly, good thinkers on all sides of the endless debate on assisted suicide seem to find themselves at each other's throats (metaphorically, at least most of the time) before too long.

It's not a new story: Suicide itself (forget assisted suicide) has raised ethical, legal, and religious issues for centuries.

The ancient Greeks considered it morally acceptable to commit suicide if you no longer considered your life to be worthwhile.

But in English common law, suicide was a felony punishable — no kidding — by burial in the public highway with a stake driven through the body and forfeiture of one's goods to the crown.

The stigma of suicide may have abated somewhat in our culture these days (no more stakes into dead people, and some families now at least try to come to grips with self-inflicted deaths of loved ones).

Still, it remains one of the most grievous sins for Catholics and many Christian denominations — "a grave injustice toward Him," as the Catholic Encyclopedia puts it.

Like Wesley Smith, Jacob Appel, a New York City-based bioethicist, has written extensively about assisted suicide.

Most recently, Appel wrote for the May-June issue of Hastings Center Report, considered the nation's most prestigious bioethics journal.

Appel analyzed a momentous ruling by Switzerland's highest court early this year that put mental illness on the same level as physical illness in terms of assisted suicide.

Since 1942, Swiss law has allowed anyone to help another person commit suicide as long as a physician has been consulted and the motives are not malevolent.

"It must be recognized that an incurable permanent serious mental disorder can cause similar suffering as a physical disorder, making life appear unbearable to the patient in the long term," the Swiss court wrote.

The judges noted that "a distinction has to be made between a death wish which is an expression of a curable, psychiatric disorder and which requires treatment, and a death wish based on a person of sound judgment's own well-considered and permanent decision which must be respected."

The case was brought by a suicidal 53-year-old man suffering from severe manic depression who wanted to acquire a lethal dose of phenobarbital without a doctor's prescription.

It isn't clear from news accounts whether the depressed man has done himself in.

Appel argued in his article that assisted suicide can be a rational decision by those suffering from psychological illnesses.

"If the offer is that an effective treatment may eventually be found but a person will have to suffer for some decades more until that happens," Appel writes, "then it might still be rational to prefer suicide."

Appel, by the way, is a professor at Brown University, a licensed attorney, an oft-published playwright, and is currently completing medical school. According to his Web site, he also is a licensed tour guide in New York City (in his spare time).

He tells New Times that the many nuances of the Jana Van Voorhis case raise cutting-edge questions.

"We don't know, in this case, whether, on the one hand, this woman was delusional — believed she had disorders she didn't have," he says, "or on the other hand, claimed to have disorders she didn't have in order to achieve an end she wanted, namely assisted suicide, or some mix in-between."

Appel says the Van Voorhis case "demonstrates why, if you're going to have some form of assisted suicide, you probably want it in the context of the medical system and people who are capable of making these evaluations and licensed to do it. That's because very well-meaning people who take someone at their face value could do a grave disservice to them and to the community."

He says the details surrounding the Phoenix suicide make things "not so clear where mental illness comes in, whether this woman was suffering and sort of stepped back from her suffering in a rational sort of way, said, 'I don't want to continue suffering psychiatrically,' versus: Her suffering was so severe, she couldn't think clearly enough to make a rational decision."

Appel is a fan of Oregon's controversial physician-assisted suicide law, which has been in effect since 1997 (voters passed the Death With Dignity Act by a narrow margin in 1994, but implementation was delayed by legal injunction).

Oregon remains the only jurisdiction in North America where doctors may, under strict guidelines, prescribe lethal overdoses for dying patients. (Twenty-one other states have failed to pass physician-assisted suicide laws since then, including, in recent months, California and Vermont.)

But it's still considered second-degree manslaughter in Oregon to intentionally "cause or aid" another person to commit suicide. However, New Times could find no instances of that law being applied there.

"Dying" under the Oregon physician-assisted suicide statute means a prognosis of six months or less to live, an arbitrary length of time that troubles University of Arizona philosophy professor Michael Gill.

In 2005, Gill published a thoughtful piece in support of the Oregon law in the aptly titled journal Mortality.

"Supporters of the Oregon law, and I'm one of them, often tend to speak of terminal illness as if it's an undeniable scientific fact," Gill says. "More and more, though, it's not so cut and dried. People are given diagnoses of terminal illness and they live for years . . . But I'm still pretty sympathetic toward people who would want assisted suicide and aren't terminal, such as people with Lou Gehrig's Disease who may live for some years but won't be able to administer their own drugs at the end."

Gill suggests, however, that "it's a safer bet not to allow assisted suicide for unbearable [mental] suffering and to only allow it for the terminally ill, even though some people undergoing unbearable suffering — metaphysical or mental — probably are going to tug at our heartstrings."

Barbara Lee, the president of Compassion and Choices, a right-to-die nonprofit based in Colorado and Oregon, says she doesn't use the word suicide "in the context of a mentally competent, terminally ill person who wants to die. We use 'aid in dying,' and that's one of the tenets that we rest our case on that we're not breaking the law.

"It's not an irrational, impulsive repudiation of life to think that way. It's a rational judgment about an imminent death. If I have the medication in my hand, I will know when the time is right because I will be on the verge of that precipice, at the bottom of which is not life."

Lee, whose resumé includes stints as a nurse, physician's assistant, attorney and managed-care executive, says that Compassion and Choices — which lists more than 30,000 members — would not have assisted with the suicide of Jana Van Voorhis, as did the more-radical end-of-life group Final Exit Network.

"Not if she wasn't terminal in the way we define terminal — six months or less to live," Lee tells New Times, adding that about 90 percent of the clients served by her group die in a hospice setting.

"But I want to point out the difference between suicide and aid-in-dying. Suicide is a repudiation of life. It's different whether it's the result of a mental illness or a chronic physical illness, but both still involve a repudiation of life.

"A person who asks for aid in dying is not repudiating life — and, in our view, it's not suicide because of that. Frankly, it's an affirmation of the life that has been lived. If these people could make a choice to live, they would take it in a heartbeat."

Lee says "there's an enormous amount of harm being done out there, and this episode in Phoenix is not the worst of it. The worst of it is the people who do not find Compassion and Choices, do not find a compassionate doctor, and who are faced with what they feel is an unbearable situation for themselves and their families, and take matters into their own hands with violent means."

Wesley Smith, who opposes all forms of assisted suicide, says that for Barbara Lee and others to studiously avoid using the word suicide is telling.

"If your movement needs to change the lexicon to get people to accept something, then there's something wrong with the movement," Smith says. "That's just verbal engineering to say a suicide isn't a suicide, a spoonful of sugar to help the hemlock go down. Beneath the sophisticated talk, beneath the word-engineering, are people that get so caught up with this that they lose all sight of what's right and what's wrong."

Smith says "the social stigma for the term suicide is important and it helps save lives."

He stresses that he doesn't criticize people "who may engage in this type of behavior — I mean the people who are suicidal, not the facilitators. And it's obvious that the woman [Jana Van Voorhis] needed mental help. It's very sad."

Jacob Appel sees Jana's case through a different prism than Smith. He says it matters ethically under any circumstance about the persistence of someone's request for assistance in committing suicide.

"It's the difference between someone saying every time there's a crisis, 'I wish I was dead,' such as the teenage girl who wants to die after her boyfriend breaks up with her," Appel explains.

"Someone who persistently, day after day, says, no thank you, I'd rather die, that kind of persistence would lend someone like me to think that this is much more the kind of case that we'd want to give that kind of autonomy [to choose to be assisted in a suicide]."

As for the decision by Final Exit Network's exit guides not to contact Jana's family ahead of time about her suicidal plans, Appel argues that "assuming the woman is otherwise competent, then it's a perfectly reasonable request not to tell the family. People ask their physicians all the time, 'Don't share this with my family. They'll think it's a terrible idea.'

"The reason it's an issue here is there are indications that the woman might not have been competent at all, and that probably would have called for some follow-up or a back out [by the exit guides]. This is why you don't want people taking the law into their own hands."

Appel says he's worried that the revelations published in "Death Wish" will tarnish the efforts of people like him, who strongly support the idea of physician-assisted suicide.

"I also think it's important to remember that the people who assist in suicides get no joy out it," he says. "They generally are well-intentioned and are doing it out of compassion, trying to help. Whatever the outcome of the [Van Voorhis] case is, I think we should temper justice with a lot of mercy."

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