A Global Struggle

Spain is only the sixth country in the world to recognize the right to death with dignity, and only the fourth in the European Union to do so. The passage of the law is notable as a victory for the global right-to-die movement — but it is also notable as a victory for the Left, one that should resonate for socialists around the world, including in the United States.

The history of assisted-suicide legislation in the United States starts in 1997, when Oregon approved the country’s first assisted-suicide law. But today, despite the support of 73 percent of Americans, the fight for death with dignity in this country has lagged. Just eight states and Washington, DC, have death with dignity statutes, and the issue is far from prominent at the national level. Perhaps not coincidentally, it is also not a top issue among US socialists. In 2016, at a forum hosted by the Leadership Council of Aging Organizations, Bernie Sanders — who comes from a state that has had an aid-in-dying law since 2013 — became the only presidential candidate at the time to support physician-assisted suicide. The news, however, didn’t garner much attention among supporters or journalists.

But as Spain’s example tells us, assisted suicide can be a winning issue for the Left — even in a country with a powerful religious right. As socialists gain strength in the United States on a platform designed to ensure a life of dignity for the working class, we would be remiss not to consider the end of life as a crucial part of that vision. After all, assisted suicide isn’t simply a matter of personal liberty — it’s also a class issue. Speaking during a parliamentary debate about the law in March, PSOE senator Francisco Javier de Lucas argued that the law’s purpose was to make a dignified death a “right, not a privilege.” Today, he said, such a death “is only available to those who can afford it.”

Indeed, certain people in countries where assisted dying is illegal have always had access to a dignified death regardless of local laws. As suicidologist David Lester put it, “The patricians can easily die from assisted suicide. They are rich, they are informed, and most importantly, they have ‘contacts.’ Meanwhile, the plebeians have to beg and find devious ways to find sufficient quantities of a painless medication with which to commit suicide.”

In Australia, where assisted dying is illegal in most states, many elderly people procured the premier end-of-life drug Nembuthal through the black-market drug website Silk Road. After US authorities closed the site in 2013, however, the privileged were still able to get the drug. Former cabinet minister Kip Enderby, for instance, took comfort in knowing he had jars of Nembuthal on hand for himself and his wife — “something you know is there when you really need it.” (They wouldn’t say how they procured their supply.) For other Australians — including the then 104-year-old Australian scientist and right-to-die advocate David Goodall — an appealing alternative to black market drugs awaits in Switzerland, where assisted suicide services are available for foreigners. But according to the right-to-die organization Exit International, as of 2018 only forty Australians were known to have made the journey. That makes sense: not everyone can afford a flight to Switzerland, not to mention the cost of assisted-suicide services, which run upward of 7,500 Swiss francs (US$8,000).

“The Weakest in Society”

Opponents of assisted dying often maintain that legalizing assisted dying is not about reducing suffering but rather about attacking a broad category of individuals, including people with low incomes, people with disabilities, members of racial minorities, and senior citizens. In Spain, MP José Ignacio Echániz of the conservative Popular Party told parliament that the country’s new law meant “the weakest in society have reason to fear.”

Similar arguments have pervaded debates in the United States, including those that involved California’s 2015 assisted-suicide law. Senator Ted Gaines, a Republican, argued against the California law, saying, “I’m not going to push the old or the weak out of this world.” This sentiment was echoed by Dr Aaron Kheriaty, director of the medical ethics program at the University of California, Irvine, School of Medicine. He claimed that despite provisions in the law designed to prevent coercion, low-income and underinsured patients would inevitably feel pressure to end their own lives, given that the cost of continued treatment would be far higher than the cost of end-of-life pills. “As soon as this is introduced, it immediately becomes the cheapest and most expedient way to deal with complicated end-of-life situations,” Dr Kheriaty said. Even Democratic politicians like Christopher J. Hale have grounded their opposition to assisted suicide in a sense of concern for “the poor, the lonely, and the excluded.” Instead, he’s argued, “focusing on expanding access to health care for every American at the end of their lives would be the progressive thing to do.”

But death with dignity and access to good palliative care are not mutually exclusive. In fact, the data shows they’re complementary. In California, 94 percent of the patients who received prescriptions for aid-in-dying drugs in 2018 had health insurance and 88 percent were receiving hospice and/or palliative care. Similarly, in Oregon and Washington, the patients who request and use physician-assisted death are overwhelmingly well-educated, well-off, insured, and receiving hospice care.

Though it’s clear that many people with access to health care will still elect to pursue assisted suicide, it would be a mistake to ignore the role that inequalities — including racial inequalities — play in medical decisions at the end of life. Let’s look again at the Californian case. According to the California Department of Public Health, roughly 88 percent of people using California’s physician-assisted death law were white. Part of the reason for that disparity is a failure of messaging. “The information that’s written right now is written primarily for a white audience,” said Kim Callinan, the executive director of Compassion and Choices, a national nonprofit that supports physician-assisted death. “We need to have messages and materials that will resonate given the culture and the community we’re trying to reach, from credible messengers in that community.”

Working to raise awareness about assisted-suicide laws in diverse communities is a good way to start remedying these disparities, but there are also deeper, systemic issues that need addressing. According to Stanford University geriatrician Vyjeyanthi Periyakoil, distrust — the result of a long history of racism in America’s health care system — keeps many people of color from talking with their doctors about death. They also tend to get diagnosed with terminal illnesses at more advanced stages — in part because they lack access to health insurance — which gives them less time to think about end-of-life options.

But as bioethicists Lindsey M. Freeman, Susannah L. Rose, and Stuart J. Youngner have argued, these failures of our health and economic system are not a reason to ban physician-assisted suicide. Rather, they’re a reason to “address the inequalities that exist in the U.S. health care system” in a way that “allows all people regardless of socioeconomic status to choose among medically viable options.” We can’t advocate for death with dignity, in other words, without also advocating for an equitable system of socialized medicine that supports a dignified life.

Spain, in that sense, has long been ahead of the curve. Thanks to the PSOE, it’s had universal health care since 1986. Socialists in the United States, however, are operating in a totally different context, in a country with a draconian health care system that doesn’t value human life. But socialists shouldn’t wait for Medicare for All to pass here before fighting for the right to die. María José Carrasco’s case makes it all too clear that people will continue to seek to end their lives whether the laws change or not. But we must insist that everyone — not just the wealthy — can do so without fear of punishment or pain.