"My question is: Who has the right to tell me that I don't deserve this choice [to choose physician-assisted suicide]? That I deserve to suffer for weeks or months in tremendous amounts of physical and emotional pain?" (Maynard).  Brittany Maynard writes these questions in a letter to the general public shortly before she commits physician-assisted suicide (PAS), an action in which a terminally ill patient is prescribed a lethal medication by their doctor so that the patient can end his or her life when he or she sees fit. After Brittany Maynard was diagnosed with terminal brain cancer, she became the spokesperson for PAS, increasing support for legalization of PAS, an issue that is not widely known or debated in the American healthcare system. 

In America, PAS is primarily supported because it enables people to escape the inconceivable suffering caused by a debilitating terminal illness. Patients with terminal illnesses often deal with organ failure and immense pain that cannot be controlled with medication such as morphine. They are also unable to take care of themselves or participate in their usual activities. Supporters of PAS such as Brittany Maynard believe that patients like herself should have the end-of-life option to commit suicide rather than endure this suffering. Many approve this option because it does not require a patient to refuse to eat or to be in agony while suffocating after having a ventilator removed.

Many supporters believe that suicide is wrong; this understanding causes them to try to differentiate PAS from suicide. In an attempt to differentiate the two actions, supporters give various reasons as to why PAS is distinct, such as limited life span, horrific pain, and the loss of autonomy.  This idea that PAS is different has influenced all the governments that have legalized PAS, causing them make it illegal for those with mental illnesses to access PAS. Even though it may not be physically apparent to people around someone with depression, those with depression can suffer from immense physical and emotional pain. Why should governments discriminate against those who suffer from mental diseases by supporting those who have physical illnesses? Since the intentions of patients committing PAS are not distinctive enough to differentiate it from suicide, supporting PAS as a solution of physical diseases while mocking other suicides that are due to a mental illnesses is not only hypocritical, but it also merely perpetuates the misconceptions surrounding mental health and suicide that many Americans have. Thus, PAS should be criminalized. In my paper, I want to examine the symptoms and effects of depression. Then, I want to consider the requirements for PAS. I finally want to consider various arguments made that suggest that PAS is different than suicide to show that many of the arguments made for PAS are not true.

My best friend during high school struggled with depression. I could always tell when she was experiencing a depressive bout from the second she walked out of the house to the car. Her shoulders would be hunched; her face scrunched up in pain; and her pace was even slower than normal. On the way to school, she would be subdued and quiet. At school, she struggled to stay awake in classes. During lunch, she would apathetically sit in the corner and refuse to talk to anyone while eating almost nothing. Some days she would have to go home early due to headaches, and for as long as the depressive bout lasted, she was unable to fulfill all of her activities. After school, she never had enough energy to do anything more than lay in her bed or on her couch. She would be stuck in this vicious cycle for at least two weeks, but these bouts could often last a month or more. This story about my best friend in high school is just one of the thousands of stories of those who have depression.

Depression is a mental illness that affects thousands of Americans. It is estimated that 6.7% of American adults and 3.3% of American teens suffer from this mental illness ("Depression"). The symptoms and severity of illness vary from person to person, but some of the common symptoms are feeling sad or empty, substance abuse, fatigue, either sleeping too much or too litte, panic attacks, the inability to make decisions and concentrate, and sometimes severe physical pains that do not respond to treatment ("Symptoms of Major Depression"). Many people who have depression lose the ability to function normally, which can affect their quality of life. However, these people's suffering goes unnoticed, or the suffering has a taboo around it due to the misunderstandings about mental illnesses. 

A horrible, yet common, end result of depression is suicide, which is currently a widespread problem in America. According to SAVE, 42,773 Americans died due to suicide in 2014, and suicide was among the top ten causes for death in America that year ("Suicide Facts"). At the same time, the CDC estimates that only one out of twenty five suicide attempts are successful, meaning that tens of thousands more are treated for suicide attempts each year ("Suicide Facts at Glance"). There is a certain stigma that surrounds suicide because most people believe that taking one's life is wrong. Unfortunately, this stigma is often worsened because many do not understand mental health issues and their complications but instead view these deaths as pathetic and unnecessary. These deaths or attempts are often covered up and not discussed, which greatly prevents those with mental health issues from receiving the greater support and care that they need to prevent such deaths in the future. The aversion towards suicide is completely opposite from the support that people express for people who commit PAS, which simply magnifies the stigma on suicide and mental health issues,

Overtime, PAS has been legalized through very specific bills in a few states. In June of 1997, the Supreme Court ruled that the legalization of PAS would be determined individually by each state. A few months later, Oregon passed the Death with Dignity Act ("Physician-Assisted"). This act would later become the guideline for the three other states that eventually created bills of their own: Washington, Vermont, and most recently, California ("Physician-Assisted"). This Death with Dignity Act states that anyone who wants to attain life-ending drugs must have a doctor diagnose the patients with a terminal illness that will lead to their death within the next six months. The patients then must make two oral requests for the medicine at least fifteen days apart as well as a written request signed by two witnesses, one of whom is not a  patients' relative ("Death"). At this point, the patients must visit another doctor to ensure the diagnosis is correct. Then, both of the doctors must determine if the patients are capable of making decisions for themselves, such as a mental illness. If there are any signs of depression, the patients must receive a psychological examination, and if they are found to have depression, the patients may no longer receive the pills ("Death"). Only at this point are physicians allowed to give their patients the medication ("Death"). The patients then have the freedom to consume the pills whenever they want, and many ultimately decide to not take the medication. 

Even though it is not widely supported all over America, promotion for PAS is starting to rise. In just the past seven years, three states have legalized PAS following Oregon's initiative, the most recent being California in October 2015. Meanwhile, two state's Supreme Courts, those of Montana and New Mexico, have declared that no physician will be held legally responsible if the physician were to prescribe a terminally ill patient lethal medication ("Physician-Assisted"). Concurrently, the number of requests for lethal medication as well as the number of deaths due to PAS has increased dramatically over the past five years. According the Oregon Public Health Division, 218 patients requested lethal medication from their physicians in 2015, which is a 40% increase from the 155 patients who requested it in 2014 ("Oregon"). Of those that requested the medication in 2015, 132 patients actually took the medication, which is a 25% increase in deaths due to PAS from 2014 ("Oregon"). These numbers indicate that the ratio of requests for medication to the performance of PAS has significantly increased, meaning that more people not only request the medication but also end their lives. As more and more patients consider PAS an end-of-life option, the debate for PAS has become heightened. 

Because taking one's life has the aforementioned stigma associated with it, supporters for PAS often try to distinguish PAS from suicide, perpetuating the misinterpretation of suicide. One of the many examples is the quote from supporter of PAS, Scott Mendelson, who is a physician working with dementia patients. He wrote that people commit suicide do so due to "frivolous, temporary, or easily resolved problems. Safeguards are written into the Oregon law to prevent an individual who is psychiatrically ill from making an ill-conceived and irrational decision to end their life" (Mendelson). In his quote, Mendelson essentially infers that those who commit suicide do so for reasons deserving of ridicule, while those who commit PAS have a rational reason to end their life. Such statements as these perpetuate the misapprehension of suicide. He clearly shows that he does not understand what mental illnesses are and can cause. He is not aware  that those with depression suffer, nor does he appear to realize that this pain, and the challenges that it creates, is what most often drives those with depression to commit suicide. These challenges, which are explained below, are also often the reasons that people who commit PAS give to legitimize their choice, which indicates that PAS is nothing more than a legalized suicide. 

Over the past two decades, the primary argument for PAS has become intertwined with the argument that everyone, including patients with terminal illnesses, has the right to die with dignity. Dignity in life has come to contain many aspects of life, one of which is that everyone needs to be autonomous (Mendelson). Patients with terminal illnesses begin to lose body function, making them dependent on medicine to provide relief and other people to complete simple tasks like washing their hair. The fear of losing autonomy and becoming dependent on others is the second most common reason that terminally ill patients give for committing PAS in Oregon, totaling to about 91.6% of the 991 people died due to PAS ("Oregon"). 

However, losing autonomy is not a consequence unique to terminal illnesses, since those with depression can also become dependents. While their loss of function, and therefore autonomy, is not as obvious as those with a terminal illness, those who struggle with depression very often become dependent on medicines for proper function. For example, my best friend in high school was reliant on three different medications to be able to function normally. If she missed a dose, her mood was dramatically changed. Also, depression can even cause people to lose the ability to perform basic actions and become reliant on others to care for them. Even though such severe cases of depression do not seem to occur often, depression is actually "one of the leading causes of disability in the world" (Johnson). Thus, depression affects enough people to be comparable to the devastating terminal illnesses. Therefore, escaping an illness through PAS is no different than committing suicide to end the pain that stems from depression. 

Another aspect of life with dignity argument is that everyone should have to ability to be happy and to live life in a way they find enjoyable. My grandfather greatly relished working, spending time with friends, and doing activities with his grandchildren. When he contracted renal cell cancer, which is extremely rare and fatal, he soon could not do any of his favorite activities due to the rapid weakening of his body as well as the compromise of his immune system. Terminal illnesses cause many such symptoms, greatly limiting the patients' ability to live an enjoyable life. Oregon Public Health Division found that 96.2% of patients who committed PAS in 2015 chose to do so because they were "less able to engage in activities making life enjoyable" ("Oregon"). While legalizing PAS enables people to avoid a miserable life, this argument for dignity does not show the difference between PAS and suicide. 

Those who struggle with depression also encounter problems with living an enjoyable life. Depression can cause most people to experience extreme exhaustion ("Depression"), which can be so extreme as to prevent them being active. Suddenly, some people with depression can no longer spend time with friends or even leave the house ("Depression"). Depression also can also cause loss of interest in hobbies or activities, meaning that they can no longer enjoy any activity or be happy ("Depression"). Even though those with depression do not have physically obvious reasons for being miserable as those with terminal illnesses, those with depression can lead just as unfulfilling lives as those with terminal illnesses.

A third aspect of the death with dignity argument is that experiencing uncontrollable pain creates a sub-human life, which is considered undignified. Terminally ill patients experience horrific pain due to a host of symptoms, including tumors and slow bodily decay. As tumors press up again various parts of the body or certain body systems shut down, the patients endure more and more pain. While palliative care and pain medications can reduce the pain, they do not always give the patient enough relief (Drum). Instead, these patients experience horrific agony during the last part of their life (Drum). Another problem is that many patients cannot afford to pay for palliative care for the length of time that they would require the care (Drum). Therefore, they would have to go through the entire illness without the proper care to make them comfortable. Even though only 28.7% of people who committed PAS named fear of a painful death as a reason to do such an act, those who write articles, such as Kevin Drum, or create videos in support of PAS, such as Brittany Maynard, give the fear of pain as the reason for why they choose to commit PAS ("Oregon"; Drum; Maynard). However, the fear of pain is not specific to those with terminal illnesses; the reason that many of those with depression who kill themselves choose to do so because they to end the pain they feel.

Even though its symptoms are not immediately obvious, depression causes an immense amount of pain that is not always treatable. One of the primary difficulties of depression is that people experience an overwhelming pain that can be manifested in many ways. Some people can experience severe emotional pain, while others actually have physical pain that cannot be physically treated because it is caused by projections of the brain. While both of these pains can be treated by anti-depressants, the medication is not a cure-all. According to psychiatrist Steven Reibord in his article about depression as quoted by Opposing Viewpoints Online Collection, anti-depressants do not work for many of the patients who have severe depression and can even aggravate the situation ("Depression"). Similarly, any counseling received does not always help either ("Depression"). Therefore, there are people whom therapy does not help. Therapies for depression are also expensive, and many people cannot pay for the help necessary to relieve them from the excruciating pain for years, if not decades. In the same way that those with terminal illnesses suffer indefinitely until they die, some people with depression then have to face an extremely painful life with no hope of escaping the pain, and often those with depression suffer for much longer than those with a terminal illness. This often inescapable and enormous pain is what drives many people to choose to commit suicide. Thus, the argument that PAS is different because medical care does not always work does not differentiate the act of PAS from the act of suicide. 

 Another aspect of the argument for releasing a patient from pain is that PAS enables patients to maintain peace that living in extreme pain would otherwise prevent. Marvin Lim argues that PAS should ultimately be accepted because it is a way to allow a patient to die in a peaceful manner in the face of a terminal illness (Lim). When people are told they only have so long to live, many can come to terms with their impending death, which can give them a deep sense of peace. Being reconciled with ones' life and being prepared for death enables patients to feel dignified as their body is wasting away. However, uncontrollable pain can take this peace away because it can corrupt good memories and prevent patients from having enjoyable experiences for the remainder of their lives (Lim). Thus, Lim argues that terminally ill patients who have come to peace with dying should be able to commit PAS because it is a better end than experiencing a stressful death. Having the understanding that those who commit suicide do not come to terms with their life, Lim believes that this peace is the differing factor that makes PAS allowable while suicide should be shunned. 

However, those who are depressed can also achieve peace in the face of impending death. As mentioned above, depression causes immense emotional and physical pain, which makes peace and happiness almost impossible to achieve. Driven by their suffering, those who commit suicide often do so to release themselves from their anguish. Making this decision can often bring about peace. According to Suicide Awareness Voices of Education, people who commit suicide can appear happier and calmer after they have decided to commit suicide ("Symptoms and Danger"). Deciding to commit suicide gives people the knowledge that their life is about to end; thus, they also go through the aforementioned process to reconcile their life with their impending death, similar those who choose to commit PAS. This peace can be shown through various ways, such as making arrangements for their funeral, giving away prized possessions, or even saying goodbye to those that they love ("Symptoms and Dangers"). Following the train of Lim's argument, those who are depressed should commit suicide because they need to maintain the peace that comes from being reconciled with their life, just like the reason why Lim believes people are allowed to commit PAS. Otherwise, the pain will cause anguish of such magnitude as to male being at peace impossible. 

The slight difference between Lim's argument and the case of suicide is that the decision to commit suicide provides the people with peace, whereas Lim believes that the patients are at peace before they choose to commit PAS. Either way, the choice to commit suicide or PAS ensures the peace to be reconciled to one's life and to prepare oneself for death. Therefore, those whom commit PAS or suicide are doing so with the same intention, to maintain peace with their lives. Thus, there is no difference between the two actions. 

Since PAS has been shown to be nothing more than a specific type of suicide, the implication of committing PAS should be no different than committing suicide. meaning that PAS should have the same stigma attached. However, those who support and commit PAS are celebrated by the media, are backed by the government in some states, and even have the support of those in the medical field. Meanwhile, people try to cover up suicides because most Americans believe that suicide is something pathetic and weak, which indicates that many of them misapprehend mental illnesses and their effects. By legalizing PAS, America has only furthered this misconception, which harms the part of the population with mental illnesses. Therefore PAS should not be legalized. 

The fact that thousands of Americans and even state governments are willing to support people in killing themselves in one case while mocking those who do it in another situation that is strikingly similar is astounding and wrong. As shown above, the arguments to commit PAS can also be used by someone with mental illnesses to commit suicide. Thus, PAS should be understood as what it is technically named: suicide. This attempt to change the understanding of killing oneself is understandable since people do not want to be associated with the stigma that arises from depression and suicide, especially in the face of horrible illnesses such as terminal brain cancer. In order to justify the ability to commit suicide, those who support PAS have successfully convinced Americans that PAS is not suicide with the arguments mentioned above. In some cases, those who agree with these arguments may turn a blind eye and support such actions out of sympathy for those suffering. Alas, many more are unaware of the symptoms of depression, since these symptoms are not as blatantly visible as those with terminal illnesses; many also misunderstand the act of suicide as an act of selfishness or, as mentioned above, as something "frivolous" (Mendelson). Nevertheless, depression causes real problems, which are similar to those who have terminal illnesses, making PAS no different than suicide. Thus, legalizing PAS simply increases the misunderstanding of mental illnesses and suicide.

After coming to such conclusions, there are a few questions that arise. First, why are so many people not recognizing that the stigma on any suicide comes from the innate understanding that killing oneself is wrong? Second, why are so many people not providing care for those who are suicidal to prevent their deaths, no matter the underlying cause?  Third, if life is so valuable that suicide should be shunned, then how can PAS be legalized? Yes, criminalizing PAS would increase the stigma placed on suicide. But, the stigma is not what needs to change about suicide. The fact that people recognize that such an action is wrong is good because this knowledge will hopefully prevent them from doing it themselves. What needs to change is the misinterpretation of mental illnesses and suicide. As mentioned above, so many Americans completely misunderstand what mental health is. Many do not know what affects such illnesses have simply because such diseases do not have severe physical symptoms as those with a physical disease. Thus, three things need to happen. First, Americans need to educate themselves on mental health and learn what it actually is and its affects to remove the current misunderstanding about mental illnesses and suicide. Second, PAS should be criminalized. Those who have already received the prescription should be required to give up their medication and receive the medical care that a suicidal person would because they are suicidal. This step will also help to clear up the misconceptions about suicide. Thirdly, more care and support need to be given to those who are suicidal or have diseases that can cause such thoughts with the intention of preventing as many suicides as possible. Completing these three tasks would hopefully reduce the misunderstanding that Americans have about suicide as well as the high suicide rate in America, which are things that should have been the focus of all Americans years ago. 

