Perhaps no health care issue since Clinton's failure at health care reform has attracted as much attention in the media as the Supreme Court's long-awaited, unsurprising, and unanimous decision to deny a last right for the dying to physician-assisted suicide. The denial of this "terminal liberty" provoked a cascade of responses, an outcome the justices themselves requested. On the narrowly legal side, expert commentator after commentator pointed out that there are numerous directions available for generating new litigation, so that the judicial issue is far from closed. Respondents who write and talk about American politics observed that here was yet another sign of our times, in which key political decisions are being turned over from the federal government to the states.
Popular responses to the moral question repeatedly have shown that the theme of assisted suicide is, as anthropologists say, "good to think with" as a mise-en-scene for examining different and often much wider ranging issues in the social transformation of health care that is remaking the economic, organizational, and cultural aspects of medicine in America. For example, pundits and commoners alike have shrugged their shoulders at the moral irony the Court intensified by its argument that the availability of quality end-of-life palliation should be the real issue for patients and families. That is bizarre in a society in which more than forty million citizens have no health insurance, access to care overall has been made more complex and uncertain by managed care, and economic measures of outcome overwhelm assessment of the "quality" of the experience of illness and care, and in which there is little empirical or conceptual agreement on what end-of-life experiences should be like.
The public moral questioning, as reported in the press for example, turns frequently to a different but clearly closely connected matter: the increasingly stated fear that the effect of the managed care revolution is creating a degree of time and space compression that so limits physicians' autonomy as well as patient control that the very valuation of what is at stake in care giving and receiving (not just at end-of-life but in routine practice as well) has undergone a radical redefinition. This shift is expressed by many lay persons as a perceived transvaluation of clinical values into economic ones, and by practitioners as the shared perception that medicine has become a business like any other with issues of efficiency, cost cutting, and market share replacing concern with caring and even competence. Assisted suicide is only one item in a much larger inventory of criticisms and complaints.
The band of broadcast public opinion on physician-assisted suicide per se seems to me at least to be about as broad (and differentiated) as the spectrum of waves and channels of communication. Many patients claim that they plan to control how they die. How they will accomplish that is usually not clear, but the commitment of Americans to the idea of crafting an individualized death is impressive. For example, in France, where I am writing this report, the established institutions--the church, the medical profession, the huge and omnipresent state bureaucracy--seem hardly to be challenged over this question when compared with the United States.
Furthermore, more and more American physicians are willing to admit either in print or in live interviews that in practice they assist patients and family members in providing such personalized control not just for pain management but even for the timing of death. That palliative care, which includes speeding up the "natural process" of dying via narcotic analgesics that work by depressing respiration in those vulnerable to respiratory failure, is now collectively recognized as a euphemism can scarcely be challenged. At the very moment when the Supreme Court has authorized the dichotomy between "active" assisted suicide (denied) and "passive" palliation (allowed), few seem to believe there is such a clear-cut distinction. …