I don’t find Ross Douthat’s case against physician-assisted suicide very convincing. If there’s a right to suicide for the dying, he worries, what’s to stop the mentally ill from choosing suicide, or the recently paralyzed? The answer, of course, is that they already can. As many bereaved survivors can tell you, a formal right to suicide isn’t a necessary precondition to the act. The question is not suicide, yes or no, but suicide, assisted or not?

You could even argue that the option of physician-assisted suicide might reduce suicides: The promise of a painless and safe death, one with no chance of failure and no grisly spectacle for loved ones, might be enough to persuade people who want to swallow a bottle of pills now to wait and begin working with a doctor instead. That creates time between the intention and the act, and that’s time in which the individual might reconsider, and time in which a professional caregiver is going to attempt to help them find treatments to ease their pain.

But for all that some of the arguments for physician-assisted suicide are convincing, this article by Ezekiel Emanuel continues to give me pause. Emanuel shows that unbearable physical agony is almost never the reason patients give for seeking euthanasia. “My own recent study of cancer patients, conducted in Boston, reveals that those with pain are more likely than others to oppose physician-assisted suicide and euthanasia,” he writes. “These patients are also more likely to say that they would ask to change doctors if their attending physician indicated that he or she had performed physician-assisted suicide or euthanasia. No study has ever shown that pain plays a major role in motivating patient requests for physician-assisted suicide or euthanasia.” Depression and other forms of mental distress — which are, of course, a sort of pain — are by far the more common motivator.

Emanuel also worries that the option of euthanasia will lead to worse care for the dying, and perhaps even subtle coercion on the part of loved ones and medical professionals who can no longer bear to see a patient suffer, or, more worryingly, can no longer afford to treat their suffering. “Broad legalization of physician-assisted suicide and euthanasia would have the paradoxical effect of making patients seem to be responsible for their own suffering,” he writes. “Rather than being seen primarily as the victims of pain and suffering caused by disease, patients would be seen as having the power to end their suffering by agreeing to an injection or taking some pills; refusing would mean that living through the pain was the patient’s decision, the patient’s responsibility.”

That may seem alarmist now, but give euthanasia 15 or 20 years to become commonplace, and abuse, or at least overuse, is much easier to imagine. “To recognize a legal right to physician-assisted suicide or euthanasia transforms the practices into routine interventions that can be administered without the need for a publicly acceptable justification.” So though I don’t buy into Douthat’s concern that legalizing physician-assisted suicide will give the suffering too much existential choice, I do buy into Emanuel’s concern that it’ll give the people around them too much choice, and that the long-term consequences of that are unsettlingly unpredictable.

In the end, Emanuel says, the proper policy is to “affirm the status of physician-assisted suicide and euthanasia as illegal” while making it possible for doctors to prove that this or that case was extraordinary enough to be the exception. “Such a policy would recognize that ending a life by physician-assisted suicide or euthanasia is an extraordinary and grave event,” which is probably as it should be.