(Getty/The Washington Post/Annie Flanagan)
Most Americans believe that physician-assisted suicide, or as some movement advocates prefer, medical aid in dying, is morally acceptable in circumstances such as extreme pain and suffering during a terminal illness. Even in the face of his own terminal brain cancer, Dr. Michael Adams disagreed. The Washington, D.C., physician wrote compellingly to the Health and Human Services Committee of the district’s council then considering death-with-dignity legalization: “Patients deserve respect, comfort, [and] freedom from pain…particularly at the end of life,” he wrote. Adams cited his firm belief in his vocational calling and oath, writing that patients “die with dignity” when their physicians attend to bodily and existential matters, not when they violate “the trust patients place in [them]” by “provid(ing) treatment which would intentionally hasten death.” Dr. Adams died six months later. By year’s end, physician-assisted suicide was legal in Washington, D.C.
As the U.S. population grows older and more racially and ethnically diverse, physician-assisted suicide advocates and the legislators who champion their cause sense increasing success. The New York Times recently reported that more than 70 million Americans, or 22 percent of the nation’s population, can now access physician-assisted suicide. But race and religion impact views on the morality and legalization of the practice. Compared to most whites, African American Protestants and Latinx Catholics are less likely to agree that physician-assisted suicide is morally acceptable and are much less likely to support legalization. Among whites, only evangelicals report less than 50 percent moral acceptance of the practice, and only in extreme cases. The dissonance between U.S. racial demographic trending, lower moral acceptance from non-whites, and the trending legalization of the practice, begs for closer examination of the politics of race and religion in physician-assisted suicide.
As with many aspects of healthcare, physician-assisted suicide is regulated within each state. In the 10 jurisdictions where the practice is legal, these laws follow similar content and procedural patterns. They allow a qualifying patient to request that a physician write a prescription for medication that the patient can take at the time of their choosing to ease their transition to death. Qualifying patients have a prognosis of six months or less to live and are qualified residents of the jurisdiction where the statute exists. A second physician must confirm the diagnosis and prognosis. Both physicians must also agree that the patient understands that she is requesting a prescription that will cause death. A medically qualified patient must make a verbal request; meet a waiting period, typically 15 to 20 days; then make a written request. Many states require an additional, briefer waiting period before the prescription can be written. Finally, the patient must be able to ingest the medicine on her own, without the help of a physician, a family member, or other caregiver. These laws also establish annual public health reporting about patients who were approved for this end-of-life process.
These annual public health reports enlighten us about the types of patients who access legal physician-assisted suicide. Mostly, they are seniors, have a cancer diagnosis, and are more highly educated than the average U.S. citizen. As many as one-third of approved patients ultimately do not ingest the medications. Sometimes approved patients die from the qualifying terminal illness before they have a chance to take the medication. Some patients want the prescription for reassurance. Occasionally, the outcome for a patient is simply unknown. These annual reports also show that there are racial and ethnic differences in the demographics of patients who access physician-assisted suicide. Like Oregon, where the practice has been legal since 1997, the first states to legalize physician-assisted suicide have population demographics less diverse than the nation overall. It took until 2015 for the practice to become legal in three more states. However, since 2016, physician-assisted suicide laws have gone into effect in jurisdictions with more ethnic diversity, including California, Washington, D.C., and Hawaii. Legalization in these states provides the opportunity to examine the effects of access and usage among ethnically diverse populations. With a large population and racially and ethnically diverse, California provides a good test case. There, as in Oregon, most who choose physician-assisted suicide are white. In California, 88 percent of the patients who accessed the law in 2018 racially identified as white in a state where just under 37 percent of the population identifies as non-Hispanic white. Asians accessed physician-assisted suicide at one-half their representation in the California population, and Latinx at one-tenth. This data raises more questions. First among them: What accounts for such vast racial and ethnic difference in requests for physician-assisted suicide? What are contributing social and cultural factors?
The legalization effort is a national political movement that uses template legislation to normalize a seldom-used practice, one supported by Americans with resources, political power, and privilege. Health and healthcare are not simply the apt use of medical knowledge, but a sociocultural process in which culture, including religious beliefs, and social position are too often overlooked, although they shape practices and expectations about health and healthcare and impact health outcomes. Physician-assisted suicide, then, becomes a healthcare choice for the cultural one percent.
Scholars who research health inequity document the disparate healthcare experience and health outcomes of black and brown Americans in comparison to white Americans. Researchers have examined the history of exploitation and medical racism, failures of healthcare ethics, and their combined legacy of higher levels of distrust of the medical establishment among black Americans. The Institute of Medicine’s landmark report, Unequal Treatment, presents evidence that for patients of color, individual and systemic level encounters in healthcare can contribute to their disparate experience with implications including harsher treatments, such as amputations, and lower quality recommendations, such as for routine pain mediation. Autonomy is the moral core and rallying rationale of the physician-assisted suicide movement; it focuses on the right of an individual patient to control their body until the end of life. However, patients from social groups with a disparate healthcare history may carry the burden of their social group context in addition to their personal, individual moral considerations and healthcare decisions. The movement’s logic essentially suggests that these patients suspend reasoned distrust and believe that justice will prevail in their most vulnerable moment as an individual. For black and brown Americans, health equity is more relevant political activity than the right to die as they choose.
Physician-assisted suicide legalization advocates represent their interests as the right to determine the method and quality of their death, and to educate the public on end of life options. Some advocates view the disproportionately low usage of the practice by patients of color as evidence of unfounded fears that vulnerable persons would be coerced into an early death or exploited by the availability of the legalized practice. Arguments in the professional and lay legalization discourse are built around an ideal of control. Many patients say they do not wish to be a burden. In brief, these well-intentioned ideas are grounded in individualism as the core cultural value in America. Morality emerges from cultural and societal values. At a time when the U.S. population is aging and browning, and the healthcare system is in a heightened state of flux, it is relevant to ask: Who benefits from the political pursuit of physician-assisted suicide legalization? And why now?
The complexity of the contemporary physician-assisted suicide discourse is too often oversimplified as a binary conflict: People who object to legalization on religious grounds are accused of relying on “ancient traditions,” as though ancient wisdom has nothing to offer contemporary humans. In the oversimplified construct, the religious opposition wants to impose their morality on others, forcing patients for whom death is inevitable to suffer against their will. Conversely, advocates are depicted as brave secularists who demand to “die with dignity.” In this rhetorical construction, the legalization debate diminishes Americans who continue to develop their moral reasoning through a range of religious values. This argument falsely suggests that people who oppose physician-assisted suicide decline to exercise reason and that those who support legalization are not religious practitioners. This fails to acknowledge that religion and culture remain the heart of collective thought and activity for many people who understand the individual within a social context and see individualism as only one part of their American identity.
One national organization recently established councils to promote education and end of life options, planning, and rights among members of the African American and Latinx communities whose perspectives are less favorable to physician-assisted suicide; these councils include members of the communities they seek to reach. Such inclusivity is laudable only when it seeks first to understand and not just to be understood. However, for communities of color, this mission misses the point. Given the clear differences in lifelong health outcomes, justice would focus not only on an individual’s suffering but on disproportionate suffering of social groups including racial and ethnic minorities and the poor. For instance, white and black women experience a similar rate of breast cancer diagnoses (125 and 122 per 100,000, respectively), but black women (27.3/100,000) have a higher rate of death from it than white women (19.6/100,000). Racial gaps are even worse in pregnancy-related deaths. There is danger in continued distrust of the medical establishment, a distrust which will not improve when the same hospital-based physicians who are responsible for giving medication to help patients die—as a treatment service—are also responsible for informing other patients that there is nothing more that can be done for them. Such inconsistency of care is consistent with the healthcare history of peoples of color in the United States.
Everyone wants a good death. But everyone also wants a life of dignity and equity, before that good death.
Terri Laws is a professor of African and African American studies and religious studies at the University of Michigan-Dearborn. She teaches courses in medical ethics and African American religious experience.