'Assisted suicide' or 'aid in dying?' The semantic battle over SB 128

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As the California legislature considers whether to make it legal for doctors to provide lethal prescriptions to certain terminally ill patients, a related rhetorical battle is raging behind the scenes.  

It's a high-stakes fight over how to frame the debate over SB 128, also known as the "End-of-Life Option Act."

The crux of the issue is the use of the word "suicide" when describing the act.

KPCC is among the media outlets that refer to the practice as doctor- or physician-assisted suicide, which generally follows the Associated Press Stylebook. Opponents of SB 128, such as Californians Against Assisted Suicide also use those terms, while Compassion & Choices and the bill's other supporters strongly oppose that language. 

Compassion & Choices argues the word "suicide" should be banished from all discussion and reporting on the issue, on the grounds that a terminally ill person's ingestion of lethal medications to stop his suffering does not constitute suicide as it’s generally understood. 

Instead, the group maintains, "aid in dying" or "death with dignity" are more accurate descriptions of what happens when a physician provides the drugs upon the patient's request. 

Chicago-based health care attorney Miles J. Zaremski agrees. Zaremski, who for two decades has argued in courts nationwide on behalf of so-called "Death with Dignity" laws, says references to suicide are "sorely incorrect...because we're not dealing with the concept or notion of suicide at all." 

Zaremski and other supporters of SB 128 argue that "suicide" refers to a desperate act by a despondent, mentally unbalanced person.  And as such, they say, the word doesn't accurately depict  terminally ill people of sound mind who want to live, but given their imminent  - and possibly painful death - wish to have the option of taking a lethal prescription to die peacefully. 

But opponents say that's a false distinction.

"Suicidal people don't really want to die. What they want to do is escape what they see to be an intolerable situation," asserts Dr. Aaron Kheriaty, an associate clinical professor of psychiatry and director of the Program in Medical Ethics at the University of California, Irvine School of Medicine.

"When I hear proponents talk about candidates who would be appropriate for (physician-assisted suicide), I hear them describing the very same mindset," he says.

Zaremski insists that there are instances in which a person who takes his own life clearly is not committing suicide, such as when a soldier throws himself onto an explosive device to save his comrades' lives.   

"We’ don’t view that action as a suicide because there’s really no intent behind wanting to kill oneself," Zaremski says. "But we do know that action will cause immediate death."

Zaremski offers another example:  The people who jumped off the World Trade Center on 9/11.  He points out that the coroner on those cases didn’t determine them to be suicides; instead, they were deemed homicides caused by acts of terrorism.

Kheriaty says those examples illustrate a concept in medical ethics known as "the principle of double effect," a doctrine used to explain the permissibility of an action that has a foreseeable consequence that we don't intend.  

So the soldier doesn’t intend to die when he falls on the explosives, and the 9/11 jumper doesn’t intend to die when he jumps to his certain death, Kheriaty says. They are not in the same category as the terminally ill person who takes a lethal prescription, he argues, noting that even though the terminally ill patient may not want to die, he fully intends to do so.

"And when a physician prescribes a deadly dose of barbiturate medication for the patient to take home and ingest, the only purpose of the medication is to end that person’s life," he says. "Physician prescribed suicide is really what we're talking about here."   

Politically,  there's a lot at stake when the word "suicide" is used in this debate, says Jason Doctor, an expert in behavioral decision-making in health and medicine at USC's Leonard D. Schaeffer Center for Health Economics and Policy.

Doctor points to a 2013 Gallup Poll survey that found support for allowing terminally ill patients to receive fatal drugs hinged upon whether the word "suicide" was used in the questions asked of those surveyed. 

"This Gallup poll survey showed that there is nearly a 20 percentage point increase in support for assisted suicide when the word suicide is omitted and replaced with ending the patient’s life by some painless means," he says. 

But that gap has shrunk in subsequent surveys, to about 11 percent in Gallup's 2014 poll and about 2 percent in this year's survey.  Gallup cites the high-profile story of Brittany Maynard as a likely reason for the increase in support regardless of language.  Maynard, who was dying of brain cancer, opted to move from California to Oregon last year where she could legally end her life with doctor-prescribed drugs. 

Despite the recent uptick in support for the practice no matter how it's described, the semantics issue remains key to players on each side. In fact, Compassion & Choices is lobbying the AP to change its stylebook entry on the matter, according to one of Compassion & Choice's spokesmen.

The AP considers "medically-assisted suicide" or "physician-assisted suicide" to be the most value-neutral terms available to journalists, says David Minthorn, one of the stylebook's three editors.

Minthorn adds that it's acceptable to use more generic references that make no reference to “suicide," such as the phrase, "ending ones own life." But he says "death with dignity" and similar phrases should only be used by journalists when referring to the name of legislation or a law, such as Oregon’s "Death with Diginity Act."

This story has been updated.

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