We’re Economist journalists /u/NatashaLoder, /u/HelenJoyce, and /u/MattSteinglass. We reported and wrote for the paper’s cover story this week on The Right to Die. You can also catch up with us on Twitter: @natashaloder @HJJoyceEcon @mattsteinglass.

Here’s our leader (free to read) explaining why the paper thinks legalising doctor-assisted suicide is the next great liberal cause: http://www.economist.com/node/21656182. Here’s our briefing on what we and other colleagues around the world found is a growing global campaign on the issue http://www.economist.com/node/21656122 We also polled 15 countries to find out what people thought about assisted dying, and under which circumstances they thought it should be allowed – explore the results here: http://www.economist.com/node/21656253 All three of us have been talking about this for months, between ourselves and with our colleagues. We’ve interviewed people who feel passionately on both sides of the story, and been told personal tales of extraordinary courage and adversity. We feel passionately about this.

UPDATE: Well, that's it for us - thanks all for the great questions, and hope we've engaged people in the issues. Thanks for reading! You can follow us on Twitter @HJJoyceEcon @NatashaLoder @mattsteinglass

Bios: Helen Joyce Natasha Loder Matt Steinglass

Proof: Tweet announcing the AMA from @TheEconomist and another tweet today

Comments: 77 • Responses: 15  • Date: 

CO_Ethicist7 karma

What's your best, succinct response to slippery slope concerns? I.e., what would prevent the gradual evolution of MD-assistance into MD-delivery, then voluntary euthanasia and eventually involuntary 'euthanasia'?

CO_Ethicist3 karma

Seem to be a lull, so I'll ask another... physicians and their professional societies often oppose physician-assisted dying because it is said to be contrary to the physician's basic role as a healer. The Hippocratic Oath seems to reject it explicitly, for example. Why do you think they are wrong? Or, to be more blunt, aill doctors who kill be as trustworthy as doctors who forswear killing?

helenjoyce6 karma

Hey there. The Hippocratic Oath is obviously central to the medical profession - but in its original wording it's not taken any more. And it has been reshaped before. For example it originally precluded abortion. And strictly, if you're not going to administer poison, you can't administer morphine for pain relief in high enough doses to ease end-of-life pain - it also shortens life. But a more meaningful answer is this: as medical technology has developed, it's enabled us to extend life but sometimes at a quality that the person living it doesn't want to endure. Doctors are trained to 'fight disease' and 'fight death' - but death, always, always wins in the end. The wisdom to know when to lay down weapons can shade into the wisdom to beat a tactical retreat. Does that make sense? I should say that as the editor responsible for this story - and our leader - I've been living this topic now for months. So many colleagues came and told me moving stories. And several told me of their parents' or spouses' deaths, and those terrible final days. When there was no hope whatsoever left of healing. But still the doctor is there, and still the doctor has a role.

CO_Ethicist3 karma

I expect this AMA is long over, but I just got back to see your reply and wanted to offer an FYI. A number of studies over more than 20 years have demonstrated that morphine used for pain relief in terminal patients does NOT shorten life - in fact, it generally extends it a bit. I'd be happy to supply references. You might be thinking about palliative terminal sedation, which presumably could shorten life (though that might not be true either: http://annonc.oxfordjournals.org/content/20/7/1163.abstract), but PTS is not accomplished with morphine.

natashaloder1 karma

Thanks for this link, will root around on this topic with interest. I've become extremely interested in how we die - beyond the question of doctor-assisted dying. We seem not to know how it's going to go till it happens to someone close to us. (Of course there's huge uncertainty for each of us individually, but if you look at childbirth, which is similar in that respect, no individual woman knows if she will have to have an emergency Caesarean, or a quick or slow delivery etc - but there is oodles out there about the various ways it can go, and how you can influence the odds, and you can find out how many women end up doing what. There's nothing similar for death.)

leonj2 karma

You prominently acknowledge the potential for abuse, and you suggest sensible safeguards, but I am still not clear on the kind of safeguards that can specifically address the issue of profit. In a country without an NHS, if the patient and his/her family has no money to pay for ongoing treatment, this will surely affect their own decisions and those of the people earning a living by providing the health services. Or in the case of a national health service, surely The Economist would expect to see doctors statistically approving more assisted suicides during an economic depression. Is there anything that can temper this?

natashaloder1 karma

I'm based in the US. Experience has shown that this is driven by patients requesting this and not the insurers. All that said, I would be worried about introducing this into a country where the rule of law was weak. Perhaps this is why citizens of Russia and Poland are against in our survey?

La_Fee_Verte1 karma

Citizens of Poland are influenced by religion that states life is only God's to be given and taken - hence their negative stance on in vitro, abortion and assisted suicide.

natashaloder1 karma

I'm sure you're right. But isn't it interesting that heavily Catholic France, and to a lesser extent Italy and Spain, didn't show similar attitudes?

shakerattleandrollin2 karma

What's the best argument against the right to die, and what's your response to it?

natashaloder1 karma

The best arguments against are FUD arguments, that essentially spread Fear, Uncertainty and Doubt. They sound like this: there are side effects you might choke on your own vomit, you might have feelings of panic, oh and the slippery slope argument. These have been very effective at frightening people.

The best response is that if it is legalized it can be regulated and we can avoid people doing it on their own. Also if doctor injects the meds the side effect rate is 3% (most of these are that it takes a little longer to die).

kevinyuill1 karma

Would you similarly support capital punishment for those prisoners who welcome it? 11% of prisoners do not contest their capital sentences. If they are suffering, presumably you support their right to die, too.

natashaloder2 karma

Oh, that is a really good one. Um.... I would ask a question. If society thinks that he is going to escape proper punishment then one would have to refuse surely?

natashaloder1 karma

OK, so I do think differently from Helen who is a bit more of a softy liberal than me. I think that if death is a means to escape punishment i.e. they want it. Then they don't have that "right" as they are a prisoner.

mylarrito1 karma

My dad's a doc, and he fears that old people will feel pressured to euthanize, as to no longer be a burden on society/etc. What are your thoughts on this scenario?

natashaloder1 karma

If I may, I'm going to give two answers. One is what seems like a strained analogy, but I hope is illuminating. And the other is a suggestion to read a very provocative essay by someone who's nothing to do with The Economist. Strained analogy: you know when people worry about people from poor countries paying traffickers to smuggle them into rich countries to do awful jobs, like sex work? Some people who want to combat this talk as if the problem is the traffickers - I see the problem as the awful conditions in the poor country they want to leave. by cracking down on people trafficking you are taking away one terrible option from the very few options available, all of which are terrible. So old people who feel under pressure to euthanise - their lives must be pretty awful. They must already be feeling that they are useless, lonely, no one cares for them, etc. To me that problem is not solved by making euthanasia illegal - that's like cracking down on trafficking without doing anything to solve the problems like civil war, oppression of women, lack of economic growth, that cause people to turn to traffickers. It's solved by making their lives better. the short answer is to read an essay that I'm not endorsing, but think you might find very interesting and provocative. John Hardig's "Is there a duty to die?" http://web.utk.edu/~jhardwig/dutydie.htm

leonj1 karma

Let's assume we have a patient that has been declared mentally competent by a doctor. Ok, from here, it seems you would base your support for this patient's right to assisted suicide on their liberty/autonomy (i.e. their personal value judgements), as opposed to any kind of scientific measurement of health/pain to describe a legal threshold. Therefore isn't it arbitrary to mandate doctors as key decision-makers at this point. Why should they have authority here?

natashaloder1 karma

Elaborating on what Matt says - we talked a lot about this in the editorial meetings. One of my colleagues, as we were discussing the leader in a meeting, said: what's the role of suffering for you here? the argument seems to be the same without it. He was right - at that point. We refined it by saying - we are not talking here about criminalising suicide or not - that really is a personal autonomy only question. We are talking about whether the entire machinery of the state, and in the last analysis a particular individual doctor, will be pressed into service. We are entitled to think that that should happen only in very special circumstances. And that someone who offers 'help to kill yourself' in a light or frivolous or careless manner is risking doing something better described as homicide.

starbird20051 karma

I notice that the editorial doesn't mention cost at all, yet in the US over 80% of household bankruptcies are caused by medical bills, a lot caused at a point in which its clear there's no hope of recovery.

Although one of your answers looked at the UK perspective (I assume because NHS funds are more limited and they do limit treatment based on some factors) I was wondering if you could look more at the US, and not from the perspective of the doctors but of the patient households.

Do you think this financial aspect will make it easier or harder for patients to consider dying in the US? As keeping some people alive will cause more harm to their family (we'll skip over the craziness of a healthcare system which leads to these large bills)

natashaloder1 karma

Such a hard thing to skip over, isn't it?! I see this issue as being on a continuum. Even in the US decisions are made on the grounds of cost, and insurers do limit treatment. Everyone can't have everything. In a way the question of medical-caused bankruptcies, and whether someone decides not to have treatment because they can't afford it, isn't at all predicated on doctor assisted dying existing. As you say it already happens a lot. Again, John Hardwig's essay, Is there a duty to die, is interesting reading (I'm not endorsing it, just saying interesting - it really challenged me to think, and you can't ask for more than that!) Honest answer to whether it makes it harder or easier - don't know. Seems to have made a difference only at the margins in Oregon - so few people have died, not even a thousand, under this law, in well over a decade. Which would suggest it would make very little difference. But logically when you add one more option you do do something to people's decision-making. Since end of life treatment in the US is a crazy scandal of agonising, torturous overtreatment - read Atul Gawande on this - it would be good to have something change there (should note Gawande is very troubled by assisted dying).

Methaxetamine1 karma

How will this affect life insurance? Would people be "paid to suffer" to get money?

natashaloder1 karma

I think Oregon has written into its law that insurers cannot discriminate in any way on whether people use the law. Which seems sensible. This issue simply didn't come up in our reporting, which suggests that though theoretically there might be consequences, they are possible to avoid with a well drafted law.

CO_Ethicist1 karma

Seems to be a lull, so I'll ask another... physicians and their professional societies often oppose physician-assisted dying because it is said to be contrary to the physician's basic role as a healer. The Hippocratic Oath seems to reject it explicitly, for example. Why do you think they are wrong? Or, to be more blunt, will doctors who kill be as trustworthy as doctors who forswear killing?

natashaloder1 karma

Medical Associations tend to be quite conservative. But I think that the response of the California Medical Association to the proposed legislation is quite informative. I'll paste a little from their press release:

Today, the California Medical Association (CMA) announced that it has become the first state medical association in the nation to change its position on the long-debated issue of physician aid in dying.By removing decades-old organizational policy, CMA has eliminated its historic opposition and is now officially neutral on Senate Bill 128 (Monning/Wolk), the End of Life Option Act.

“As physicians, we want to provide the best care possible for our patients. However, despite the remarkable medical breakthroughs we’ve made and the world-class hospice or palliative care we can provide, it isn’t always enough,” said Luther F. Cobb, M.D., CMA president. “The decision to participate in the End of Life Option Act is a very personal one between a doctor and their patient, which is why CMA has removed policy that outright objects to physicians aiding terminally ill patients in end of life options. We believe it is up to the individual physician and their patient to decide voluntarily whether the End of Life Option Act is something in which they want to engage. Protecting that physician-patient relationship is essential.” http://www.cmanet.org/news/press-detail/?article=california-medical-association-removes

natashaloder1 karma

Also in answer to your question about trust. That will depend on the doctor and the patient, surely? If I am desperate to die because I am in physical agony and my doctor could help but refuses, not much trust there for me. The doctor is supposed to heal, but if they can't heal because there isn't a cure does that mean they can't help? No. They give non-curative treatments all the time. So the role is to aid those in pain as well.

kevinyuill1 karma

Where exactly do you think the "line" should be drawn? Should a 21-year old lovelorn person be assisted in their suicide?

mattsteinglass1 karma

I think the line should be drawn well short of that, and in every country where euthanasia is legal, it would be. The requirement in the Netherlands for example is that the person be experiencing intolerable suffering with no hope of remedy. Breaking up is hard to do, but you eventually get over it.

kevinyuill1 karma

So you want to judge whether other people are really suffering or not? Isn't suffering completely subjective? How can we (especially in law) distinguish between "genuine" suffering and the kind you get over? Rather than leave the decision entirely up to the individual, is there not a patronising assumption within legalization of assisted suicide and euthanasia that doctor still knows best?

mattsteinglass1 karma

This issue comes up in borderline cases, but as the saying goes, tough cases make bad law. A person who has terminal liver cancer is probably really suffering if they say so. A paraplegic who can't stand their quality of life is probably really suffering if they say so. A person who has a bit of a persistent cough is probably not suffering intolerably; after two weeks they may say they're no longer suffering at all. You want a mechanism to avoid helping someone to commit suicide one day just because they're in a very dark mood that day. The way to do that is to submit the case to review by multiple physicians. If they can't get physicians to believe that they're suffering, they may simply have to end their lives themselves. No one has a right to have a doctor help them end their life, but if you are determined to end your life, it's pretty hard to stop you.

kevinyuill0 karma

Thanks for some refreshingly honest answers. But I want to press you on this point. Are you saying that those who are old, ill and disabled lead lives less valuable and, therefore, more disposable than the 21-yr old?

helenjoyce1 karma

No, not at all less valuable - different, and still theirs. Did you look at the op-ed from Steven Fletcher: http://www.economist.com/node/21656111 I'm really glad he doesn't want to die - he's obviously a very valuable member of society - an MP for 11 years, a shining example of what people can do in extreme adversity - if I had a terrible accident I hope and trust that my doctors and my friends and family would point to him and say - see, life continues, look what you can do. But if he had responded very differently to his awful accident (broke his neck 19 years ago, when he was 23) - could I therefore condemn him and say - you should have been able to cope better? Not at all. I've no idea how I'd cope myself - I suspect no one has until they are in that position. And respect for autonomy, and agency, mean that I have to respect his decision, and other people's decisions, about what their lives feel like. I have to say I can imagine deciding that life was not worth living in that situation. It sparks my claustrophobia - my throat is closing right now thinking of it. His life is not less valuable, but it is quite comprehensible that the person living that life might decide they don't want to. Which is the hard, direct answer to your brilliant question.

kevinyuill1 karma

I'm aware that I am monopolizing this thread, but I have so many questions. Again, to press you, are you not setting out two categories by legalizing assisted suicide - those whose lives we deem to be valuable enough to prevent their suicides and those whose lives are less valuable and, therefore, we will assist them?

natashaloder1 karma

Casehead's answer is really good. I'll elaborate a bit. I think that to say: I can't see why someone who has motor neurone disease might want to die before they become totally incapacitated - is just taking scrupulousness too far. Of course we can see how they might. Might, not must. People really don't know till it happens to them. So if someone in that sort of very difficult situation insists over a good while that they want to, and is clearly of sound mind etc, we can take it that they mean it. Much harder to look at someone who's life seems so comparatively easy, but who assures you that their intractable depression makes it not feel worth living to them. If we said no to this person we might be creating two classes of people, though not exactly along the lines that you sketch - more, people whose word we're willing to take because it seems sensible, and people whose word we're not willing to take because it doesn't. But when the suffering is harder to see or understand, or when our knowledge of mental illness suggests to us that asking the prognosis is not that gloomy - in other words that the condition may well shift - then we are in a very different practical situation. We offer something else - help, support etc - during a decently long waiting period

m0q-3 karma

Hi,

can you explain why this is so important to focus on instead promoting awarness of the Tr.Ta_Part?

natashaloder3 karma

Hello! Really excited to be here and looking forward to all the questions. So I'm going to take the question about the TPP (trade discussions). So The Economist is often thought of as a Business magazine but in fact we have a front half full of international reporting that covers everything from health to politics. The back half of the magazine also has a science, technology and books and arts section. We don't see a cover as either or. Assisted suicide is an issue the magazine is interested in and decided to back it. If you are asking me why, this week, we had the results of the survey in--which is news.

natashaloder1 karma

:)