Chapter 5 - The Ethical Debate
CHAPTER 5
THE ETHICAL DEBATE page 77
The ethics of assisted suicide and euthanasia are squarely
before the public eye. A steady drumbeat of media attention and
mounting concern about control at life's end have generated serious
consideration of legalizing the practices. Public discussion has
centered on the desire for control over the timing and manner of
death, amidst warnings about the potential abuse or harm of
overriding society's long-standing prohibitions against assisting
suicide or directly causing another person's death.
Concurrent with this public debate, but in many ways separate
from it, has been the discussion of assisted suicide and euthanasia
in the medical and ethical literature. In this debate, some assert
that both assisted suicide and euthanasia are morally wrong and
should not be provided, regardless of the circumstances of the
particular case. Others hold that assisted suicide or euthanasia
are ethically legitimate in rare and exceptional cases, but that
professional standards and the law should not be changed to
authorize either practice. Finally, some advocate that assisted
suicide, or both assisted suicide and euthanasia, should be
recognized as legally and morally acceptable options in the care of
dying or severely ill patients.(1)
An Historical Perspective
For thousands of years, philosophers and religious thinkers
have addressed the ethics of suicide. These debates have rested on
broad principles about duties to self and to society as well as
fundamental questions of the value of human life. Many great
thinkers of Western intellectual history have contributed to this
--------------------------------------------------------------------
(1) Through most of this chapter, arguments are schematically
presented as those of "proponents" of legalizing assistcd
suicide and euthanasia and "opponents" of legalizing these
practices. Each category groups together diverse views in order
to provide an overview of a debate marked by complex and nuanced
positions.
page 78 WHEN DEATH IS SOUGHT
debate, ranging from Plato and Aristotle in ancient Greece to
Augustine and Thomas Aquinas in the Middle Ages, and Locke, Hume,
and Kant in more modern times.(2)
Some views and practices surrounding suicide were rooted in
particular cultures and beliefs that have little relevance for
contemporary society. For example, in the warrior society of the
Vikings, only those who died violently could enter paradise, or
Valhalla. The greatest honor was death in battle; suicide was the
second best alternative.(3) Likewise, the ancient Scythians believed
that suicide was a great honor when individuals became too old for
their nomadic way of life, thereby sparing the younger members of
the tribe the burden of carrying or killing them. In other eras and
civilizations, the debate about suicide touched on values that
influenced the course of Western thought and still resonate to
contemporary perspectives on suicide.
The word "euthanasia" derives from Greek, although as used in
ancient Greece, the term meant simply "good death," not the practice
of killing a person for benevolent motives.(4) In ancient Greece,
euthanasia was not practiced, and suicide itself was generally
disfavored.(5) Some Greek philosophers, however, argued that suicide
would be acceptable under exceptional circumstances. Plato, for
example, believed that suicide was generally cowardly and unjust but
that it could be an ethically acceptable act if an individual had an
immoral and incorrigible character, had committed a disgraceful
action, or had lost control over his or her actions due to grief or
suffering.(6)
----------------------------------------------------------------------
(2) It is notable that the current debate about assisted
suicide, even among academic commentators, has drawn so little
from this rich history. For an excellent discussion of the
intellectual history of suicide, see B. A. Brody,
"Introduction," in Suicide and Euthanasia: Historical and
Contemporary Themes, ed. B. A. Brody (Dordrecht: Kluwer
Academic Publishers, 1989), 1. For an engaging literary history
of suicide, see A, Alvarez, The Savage God (New York: Random
House, 1971).
(3) Those who died peacefully in their beds of old age or
illness were eternally excluded from Valhalla, Alvarez,
54.
(4) According to one author, no Greek philosopher "cver
discusses euthanasia in our contemporary sense of the word." J.
M. Cooper, "Greek Philosophers on Euthanasia and Suicide," in
Suicide and Euthanasia, ed. Brody, 14. See also P. Carrick,
Medical Ethics in Antiquity (Dordrecht: D. Reidet, YJuwer,
1985), 127-31.
(5) A. Alvarez suggests that although suicide was
taboo, the Greeks tolerated suicide in some circumstances.
Noting the Greek practice of burying the corpse of a suicide
outside the city limits with its hand cut off, Alvarez argues
that this practice was "linked with the more profound Greek
horror of killing one's own kin. By inference, suicide was an
extreme case of this, and the language barely distinguishes
between self-murder and murder of kindred." Alvarez points out
that many suicides in Greek literature reflect acceptance and
even admiration of the act. Alvarez, 58.
(6) Plato, Laws, chap. 9, 854, 873; see Cooper, 17-19. Plato
also argued that, in most cases, suicide would represent
abandonment of one's duty and would violate divinely mandated
responsibilities. Plato, Phacdo, 62. In contrast to Plato,
Aristotle believed that suicide was unjust under all
circumstances, because it deprived the community of a citizen.
Aristotle, Nicomachean Ethics, chap. 5, 1138a; Cooper, 19-23.
CHAPTER 5 - THE ETHICAL DEBATE page 79
Unlike contemporary proponents of assisted suicide and
euthanasia, who regard individual self-determination as central,
Plato considered the individual's desire to live or die largely
irrelevant to determining whether suicide might be an appropriate
act. An objective evaluation of the individual's moral worthiness,
not the individual's decision about the value of continued life, was
critical.(7)
In contrast to Plato, the Stoics of the later Hellenistic and
Roman eras focused more strongly on the welfare of the individual
than on the community. They believed that, while life in general
should be lived fully, suicide could be appropriate in certain rare
circumstances when deprivation or illness no longer allowed for a
"natural" life.(8) The Stoics did not, however, maintain that
suicide would be justified whenever an individual loses the desire
to live. Unlike contemporary proponents of a right to suicide
assistance, the Stoics believed that suicide was appropriate only
when the individual loses the ability to pursue the life that nature
intended.(9)
Since ancient times, Jewish and Christian thinkers have
opposed suicide as inconsistent with the human good and with
responsibilities to God. In the thirteenth century, Thomas Aquinas
espoused Catholic teaching about suicide in arguments that would
shape Christian thought about suicide for centuries.
------------------------------------------------------------------------
(7) Plato's suggestion that medical treatment should not be provided
to severly ill and disabled patients reflects a similar objective
view. In the Republic (chap.3, 406-7), Plato argues that no
treatment should be provided to prolong the life of severly
ill or disabled individuals, because they represent a burden
to themselves and others. As with suicide, the individual's
subjective feelings about the merits of continued life had
no bearing on the appropriatness of continued medical treatment.
Interestingly, Plato did not apply this analysis to the
severly ill and disabled elderly, who, he argued, should be
permitted to live regardless of their ability to contribute
to the community. See Cooper, 13.
(8) Cooper, 24-29,36n.
(9) Some Roman Stoics such as Seneca, however, argued that the
individual should have broad discretion to end his or her own
life. He criticized those who "maintain that one should
not offer violence to one's own life, and hold it accursed
for a man to be the means of his own destruction; we should
wait, say they, for the end decreed by nature. But one who
says this does not see that he is shutting off the path of
freedom. The best thing which eternal law ever ordained was
that it allowd to us one entrance into life, but many
exits." In Carrick, 145.
page 80 WHEN DEATH IS SOUGHT
Aquinas condemned suicide as wrong because it contravenes
one's duty to oneself and the natural inclination of
self-perpetuation; because it injures other people and the community
of which the individual is a part; and because it violates God's
authority over life, which is God's gift.(10) This position
exemplified attitudes about suicide that prevailed from the Middle
Ages through the Renaissance and Reformation.(11)
By the sixteenth century, philosophers began to challenge the
generally accepted religious condemnation of suicide. Michel de
Montaigne, a sixteenth-century philosopher, argued that suicide was
not a question of Christian belief but a matter of personal choice.
In an essay presenting arguments on both sides of the issue, he
concluded that suicide was an acceptable moral choice in some
circumstances, noting that "pain and the fear of a worse death seem
to me the most excusable incitements."(12) Other writers employed
more theological arguments to challenge the religious prohibition on
suicide. In the early seventeenth century, for example, John Donne
asserted that while suicide is morally wrong in many cases, it can
be acceptable if performed with the intention of glorifying God, not
serving self-interest. Donne acknowledged the merit of laws against
suicide that discouraged the practice, but he argued that civil and
common laws ordinarily admit of some exceptions, suggesting that
suicide could be morally acceptable in certain cases.(13)
In the eighteenth century, David Hume made the first
unapologetic defense of the moral permissibility of suicide on
grounds of individual autonomy and social benefit. He asserted that
even if a person's death would weaken the community, suicide would
--------------------------------------------------------------------
(10) Thomas Aquinas, Summa Theologiae, II-II, 64; D. W.
Amundsen, "Suicide and Early Christian Values," in Suicide and
Euthanasia, ed. Brody, 142-44; T. L. Beauchamp, "Suicide in the
Age of Reason," in Suicide and Euthanasia, ed. Brody, 190-93.
(11) These principles continue to influence contemporary religious
and secular views about suicide. See the discussion below in
this chapter.
(12) G. B. Ferngren, "The Ethics of Suicide in the
Renaissance and Reformation," in Suicide and Euthanasia, ed.
Brody, 159-61. As Ferngren notes, suicide and euthanasia were
discussed a generation earlier in satirical works by Erasmus
and Thomas More, but it is unclear whether the authors intended to
advocate these practices. Ferngren, 157-59.
(13) Donne articulated these views in an essay entitled
Biathanalos, which was published only after his death. He did
not want it published during his lifetime, perhaps reflecting
his discomfort with views that challenged the prevailing
Christian ethics of his time. In Biathanatos, Donne
acknowledges that he battled his own urge to commit suicide.
"Whenever any affliction assails me, me thinks I have the keys
of my prison in mine own hand, and no remedy presents itself so
soon to my heart as mine own sword." In Ferngren, 169.
CHAPTER 5 - THE ETHICAL DEBATE page 81
be morally permissible if the good it afforded the individual
outweighed the loss to society. Moreover, suicide would be
laudatory if the person's death would benefit the group and the
individual. Hume did not advocate that all suicides are justified,
but argued that when life is most plagued by suffering, suicide is
most acceptable.(14)
Other philosophers of the Age of Reason, such as John Locke
and Immanuel Kant, opposed suicide. Locke argued that life, like
liberty, represents an inalienable right, which cannot be taken
from, or given away by, an individual.(15) For Kant, suicide was a
paradigmatic example of an action that violates moral
responsibility. Kant believed that the proper end of rational
beings requires self-preservation, and that suicide would therefore
be inconsistent with the fundamental value of human life.(16) Like
some contemporary opponents of assisted suicide and euthanasia, Kant
argued that taking one's own life was inconsistent with the notion
of autonomy, properly understood. Autonomy, in Kant's view, does
not mean the freedom to do whatever one wants, but instead depends
on the knowing subjugation of one's desires and inclinations to
one's rational understanding of universally valid moral rules.(17)
Essays advocating active euthanasia in the context of modern
medicine first appeared in the United States and England in the
1870s. In an 1870 work, schoolmaster and essayist Samuel D.
Williams argued that "in all cases of hopeless and painful illness
it should be the recognized duty of the medical attendant, whenever
so desired by the patient, to administer chloroform, or such other
anaesthetics as may by and by supersede chloroform, so as to destroy
-------------------------------------------------------------------------
(14) D. Hume, "On Suicide," in Ethical Issues in Death and
Dying, ed. T. L. Beauchamp and S. Perlin (Englewood Cliffs,
N.J.: Prentice-Hall, 1978),105-10; T. L. Beauchamp, "An
Analysis of Hume and Aquinas on Suicide," in Ethical Issues in
Death and Dying, ed. Beauchamp and Perlin, 111-21; Beauchamp,
"Age of Reason," 199-205.
(15) Ferngren, 173-75.
(16) See II. Kant, Grounding for the Metaphysics of Morals, 3d ed.,
trans. J. W. Ellington (Indianapolis: Hackett, 1993); and
the discussion in Beauchamp, "Age of Reason," 206-15.
(17) For Kant, the fundamental moral law was expressed in the
"categorical imperative": "Act only according to that maxim
whereby you can at the same time will that it should become a
universal law," or, in another formulation, "Act in such a way
that you treat humanity, whether in your own person or in the
person of another, always at the same time as an end and never
simply as a means." Ellington translation, pp. 30, 36-1 Ak.
421, 429.
page 82 WHEN DEATH IS SOUGHT
consciousness at once, and put the sufferer at once to a quick
and painless end."(18) Support for euthanasia at this time was
animated in part by the philosophy of social Darwinism and concerns
with eugenics -- improving the biological stock of the community.
In 1873, essayist Lionel A. Tollemache asserted that euthanasia
could serve the patient's interests and benefit society in
appropriate cases by removing an individual who was "unhealthy,
unhappy, and useless."(19)
Over the course of the following decades, essays discussing
euthanasia continued to appear in medical and popular journals. The
British Parliament debated a bill to legalize euthanasia in 1936.
In the United States, similar proposals were introduced in state
legislatures during the first half of the twentieth century,
including New York State in 1947. The Euthanasia Society of
America, an organization advocating such proposals, was founded in
1938.(20) Following World War II, however, the term "euthanasia"
became disfavored due to sensitivity about Nazi practices.
Distinguishing Assisted Suicide and Euthanasia
Contemporary discussion has not focused primarily on the
ethics of suicide itself, but on assistance to commit suicide and
the direct killing of another person for benevolent motives.
Actions that intentionally cause death are often referred to as
active euthanasia, or simply as euthanasia. Euthanasia performed at
the explicit request of a patient is referred to as "voluntary"
euthanasia. Euthanasia of a child or an adult who lacks the
capacity to consent or refuse is often termed "nonvoluntary."(21)
In addition, the terms "euthanasia" and "passive euthanasia"
are sometimes used to describe withholding or withdrawal of
life-sustaining treatment. For example, Roman Catholic authorities
------------------------------------------------------------------------
(18) "Euthanasia," in W. B. Fye, "Active Euthanasia: An
Historical Survey of Its Origins and Introduction into
Medical Thought," Bulletin of the history of Medicine 52 (1978):
498. Similar arguments were advanced in the 1936 debate on a
bill to legalize euthanasia in the British House of Lords; see
S. J. Reiser, A. J. Dyck, and W. J. Curran, Ethics in Medicine:
Historical Perspectives and Contemporary Concerns (Cambridge:
MIT Press, 1977), 498.
(19) "The New Cure for Incurables," in Fye, 499.
(20) J. Fletcher, Morals and Medicine (Princeton: Princeton
University Press, 1954); J. Fletcher, "The Courts and
Euthanasia," Law, Medicine and Health Care 15 (1987/98):
223-30.
(21) Involuntary euthanasia, performed over a patient's explicit
objection, has not been endorsed by anyone in the current
debate.
CHAPTER 5 - THE ETHICAL DEBATE page 83
often use the word "euthanasia" to refer to inappropriate
decisions to withhold or to stop treatment.(22) This report uses the
term "euthanasia" to refer only to active steps, such as a lethal
injection, to end a patient's life.
In assisted suicide, one person contributes to the death of
another, but the person who dies directly takes his or her own life.
Many individuals hold similar positions on assisted suicide and
euthanasia. Others find assisted suicide more acceptable, either
because of the nature of the actions or because of differences they
see in the societal impact and potential harm of the two practices.
For some, assisted suicide and euthanasia differ
intrinsically. A physician who writes a prescription for a lethal
dose of medication, for example, is less directly involved in the
patient's death than a physician who actually administers medication
that causes death. With assisted suicide, the patient takes his or
her own life, usually when the physician is not present.
Accordingly, factors such as the physician's intentions may be more
complex. In some cases, a physician may intend to make it possible
for a patient to commit suicide so that the patient feels a greater
sense of control, but may hope that the patient does not take this
final step. In addition, because the patient's own actions
intervene between the physician's actions and the patient's death,
the physician's causal responsibility may be less clear.(23)
Some regard physician-assisted suicide as less subject to
abuse than euthanasia. When assisted suicide occurs, the final act
is solely the patient's. It would therefore be more difficult to
------------------------------------------------------------------------
(22) The Vatican's 1980 "Declaration on Euthenasia" describes
euthanasia as "an action or an omission which of itself or by
intention causes death, in order that all suffering may in this
way be eliminated." In President's Commission for the Study of
Ethical Problems in Medicine and Biomedical and Behavioral
Research, Deciding to Forego Life-Sustaining Treatment
(Washington: U.S. Government Printing Office, 1993), 303.
Appropriate decisions to forgo extraordinary or
disproportionately burdensome treatment would not be considered
euthanasia, however. Ibid. This report does not discuss the
criteria that characterize appropriate decisions to forgo
life-sustaining treatment. The Task Force has addressed this
issue in previous reports. See New York State Task Force on
Life and the Law, When Others Must Choose: Deciding for
Patients Without Capacity (New York: New York State Task
Force on Life and the law, 1992) and Life-Sustaining Treatment:
Making Decisions and Appointing a Health Care Agent (New York:
New York State Task Force on Life and the Law, 1987).
(23) See R. F. Weir, "The Morality of Physician-Assisted
Suicide," Law, Medicine and Health Care 20 (1992): 116-26.
page 84 WHEN DEATH IS SOUGHT
pressure or convince a patient to commit suicide than to
secure agreement to euthanasia.(24) Further, a patient who requests
assistance in suicide but then becomes ambivalent could simply put
off the final step. By contrast, some patients would be too
embarrassed or intimidated to express uncertainty to a physician on
the verge of giving a lethal injection, or would be concerned that
the doctor might be hesitant to administer the injection at a later
time.(25)
Some note that the potential for intimidation or influence
stems not only from the doctor's actions in euthanasia, but also
from his or her presence at the time of death. Some individuals
therefore distinguish cases when a physician assists a suicide by
providing information or a prescription, which they believe should
be permitted, from instances when the physician is present at the
time of the suicide and directly aids or supervises the act, posing
a greater risk.(26) Others are not troubled by this risk, and
believe that the physician's presence could express caring and a
desire to accompany the patient in the final moments of life.(27)
For others, no decisive distinction can be drawn between
assisted suicide and voluntary euthanasia. Whatever differences may
exist do not justify a policy of accepting one practice while
forbidding the other. This view is shared by some who support
both practices and by others who oppose both.(28) Proponents of
------------------------------------------------------------------------
(24) D. E. Meier, "Physician-Assisted Dying: Theory and
Reality," Journal of Clinical Ethics 3 (1992): 35.
(25) J. Glover, Causing Death and Saving Life (Harmondsworth,
England: Penguin Books, 1977), 184. Howard Brody writes:
"There are psychological reasons to prefer patient control over
physician-assisted lethal injection whenever possible. The normal
human response to facing the last moment before death, when one
has control over the choice, ought to be ambivalence. The
bottle of pills allows full recognition and expression of that
ambivalence: I, the patient, can sleep on it, and the pills
will still be there in the morning; I do not lose my means of
escape through the delay. But if I am terminally ill of cancer
in the Netherlands and summon my family physician to my house to
administer the fatal dose, I am powerfully motivated to deny any
ambivalence I may feel." H. Brody, "Assisted Death - A
Compassionate Response to Medical Failure," New England Journal
of Medicine 327 (1992):1384-88.
(26) D. T. Watts and T. Howell, "Assisted Suicide Is Not
Euthanasia," Journal of ihe American Geriatrics Society 40
(1992): 1043.
(27) T. E. Quill, C. K. Cassel, and D. E. Meier, "Care of the
Hopelessly Ill: Proposed Clinical Criteria for Physician-
Assisted Suicide," New England Journal of Medicine 327 (1992):
1383.
(28) Among supporters of the practices, see E. H. Loewy,
"Healing and Killing, Harming and Not Harming,"
"Journal of Clinical Ethics3(1992):30; G. C. Graberand
J. Chassman, "Assisted Suicide Is Not Voluntary Active
Euthanasia, but It's Awfully close, "Journal of the American
Geriatrics Society 41 (1993):88-89. An opponet of
both practices likewise argues: "If the right to control the
time and manner of one's death - the right to shape one's
death in the most humane and dignified manner one chooses -
is well founded, how can it be denied to someone simply
because she is unable to perform the final act by herself?"
Y. Kamisar, "Are Laws Against Assisted Suicide Unconstitutional?"
Hastings Center Report 23, no.3(1993):35.
CHAPTER 5 - THE ETHICAL DEBATE page 85
the practices believe that the risks of error and abuse are
similar in both practices, and can be minimized with appropriate
safeguards.(29) Many who oppose both assisted suicide and euthanasia
agree that the practices pose similar risks, but reject these risks
as unacceptable.(30)
Most of those who emphasize the basic similarities between
assisted suicide and voluntary active euthanasia nevertheless
acknowledge some difference in degree between the two practices.
Some claim that while both should be allowed, assisted suicide would
be a preferable option in any particular case, in order to minimize
the possibility of error.(31) Others oppose both practices but view
active euthanasia as more problematic.(32) As discussed above,
American law draws a clear distinction between the two types of
action, treating euthanasia as a far more serious offense. In New
York and many other states, while both practices are felonies,
assisting suicide is generally classified as manslaughter, while
euthanasia constitutes second-degree murder.(33)
The Appeal to Autonomy
American society has long embraced individual liberty and the
freedom to make personal choices as fundamental values. These
values have always been pursued within a social context, accompanied
by commitments to promote the overall good of society and protect
vulnerable individuals from harm. For some, the exercise of
----------------------------------------------------------------------
(29) D. Brock, "Voluntary Active Euthanasia," Hastings Center Report
22, no.2(1992):10;Graber and Chassman, 88.
(30) Kamisar, 35.
(31) E.g., Glover, 184; 1-1. Brody, 1384-88. As Dr. Aadri
Heiner of the Netherlands describes his practice, "I will bring
a small glass bottle, and I will hand it over and say, "This is
for you.' he has [to] drink it by [him]self. ... And
that makes me very sure that it is his own wish." "Choosing
Death," Health Quarterly, broadcast March 23, 1993.
(32) See American Medical Association, Council on Ethical and
Judicial Affairs, "Decisions Near the End of Life," Journal of
the American Medical Association 267 (1992):2233.
(33) See chapter 4, p. 63.
page 86 WHEN DEATH IS SOUGHT
autonomy must also be balanced against other fundamental values
embraced by society, including our reverence for human life. The
current debate about assisted suicide and euthanasia also presents
questions about the way autonomy can best be realized, and the
manner in which the tension between autonomy and other ethical and
societal values should be resolved.
One strand of the debate about assisted suicide and euthanasia
has focused on whether the value of self-determination, which
undergirds the right to refuse treatment, provides the basis for a
right to assisted suicide or euthanasia as well. Would the
self-determination of severely ill patients actually be promoted in
practice if assisted suicide and euthanasia were legalized? Does
contributing to another person's death manifest respect for that
person's autonomy? Questions have also been posed about the impact
of legalizing assisted suicide and euthanasia on the
self-determination and well-being of individuals who do not seek out
these options.
Proponents
Proponents of assisted suicide and euthanasia maintain that
respect for individual self-determination mandates the legalization
of these practices. Individuals have a fundamental right to direct
the course of their lives, a right that should encompass control
over the timing and circumstances of their death. While few if any
advocates argue for an absolute right to commit suicide, most
believe that in appropriate cases suicide can minimize suffering or
enhance human dignity, and that people in these circumstances should
have the right to take their own lives.(34)
Proponents suggest that a physician's participation in
assisted suicide or euthanasia can support a choice embraced by the
patient, consistent with his or her own value system. Individual
beliefs about the meaning of life and the significance of death vary
greatly. For proponents, establishing assisted suicide and
euthanasia as accepted alternatives would respect this diversity.
As stated by one commentator:
There is no single, objectively correct
answer for everyone as to when, if at all,
one's life becomes all things considered a
burden and unwanted. If self-determination is
a fundamental value, then the great
variability among people on this question
makes it especially important that individuals
control the manner, circumstances, and timing
of their death and dying.(35)
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(34) M. Battin, "Voluntary Euthanasia and the Risks of Abuse,"
Law, Medicine and Health Care 20 (1992): 134; M. P. Battin,
"Suicide: A Fundamental Human Right?" in Suicide: The
Philosophical Issues, ed. M. P. Battin and D. J. Mayo (New
York: St. Martin's Press, 1980), 267-85. See also J. Arras,
"The Right to Die on the Slippery Slope," Social Theory and
Practice 8 (1982): 285-328, noting arguments on both sides of
this issue.
CHAPTER 5 - THE ETHICAL DEBATE page 87
Some proponents promote legalizing assisted suicide and
voluntary euthanasia as an affirmative step to grant individuals
further control over their dying process.(36) For others, the
decisive principle is the right to be free of state interference
when individuals voluntarily choose to end their lives.(37)When
differences on basic issues such as life and death go deep and
involve profound values, a tolerant, pluralistic society must allow
each individual to decide. Many believe that, even
if pain can be alleviated, the individual's right to control his or
her death should prevail.
"I wouldn't want to be kept alive that
way" has become a modern motto in American
society. Pain management and hospice care are
better than ever before. But for some people
they are simply the trees. The forest is that
they no longer want to live, and they believe
the decision to die belongs to them alone.(39)
Opponents
Some believe that assisted suicide and euthanasia can promote
autonomy, at least in some cases, but that the dangers of the
practices are overriding. For others, the value of human life
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(35) Brock, 11. See similarly R. Dworkin, Life's Dominion (New
York: Knopf, 1993), 208-11; C. K. Cassel and D. E. Meier,
"Morals and Moralism in the Debate over Euthanasia and Assisted
Suicide," New England Journal of Medicine 323 (1990): 751.
(36) Weir, 124. Dick Lehr reports that in every case of
assisted suicide that health care professionals discussed in
interviews, "patients were middle- to-upper class, accustomed to
being in charge." An oncologist who had assisted suicide stated
that "these are usually very intelligent people, in control of
their life - white, executive, rich, always leaders of the pack,
can't be dependent on people a lot." D. Lehr, "Death and the
Doctor's Hand," Boston Globe, April 26,1993.
(37) As stated by one philosopher, "One will need to live with
individuals' deciding with consenting others when to end their
lives, not because such is good, but because one does not have
the authority coercively to stop individuals from acting
together in such ways." H. T. Engelhardt, Jr., "Fashioning an
Ethics for Life and Death in a Post-Modern Society," listings
Center Report 19, no. 1 (1989): S9. See also J. Rachels, The
End of Life (New York: Oxford University Press, 1986), 181-82.
(38) Dworkin, 217.
(39) A. Quindlen, "Death:The Best Seller," New York Times,
August 14,1991, A19.
page 88 WHEN DEATH IS SOUGHT
outweighs the claim to autonomy, and argues decisively against
permitting suicide assistance or direct killing, even with
benevolent motives. Still others assert that seeking to end one's
life intrinsically contradicts the value of autonomy. Like the
"freedom" to sell oneself into slavery, the freedom to end one's
life should be limited for the sake of freedom.
Many reject euthanasia because it violates the fundamental
prohibition against killing. They understand this prohibition,
except in defense of self or others, to be a basic moral and social
principle. This view is expressed within the context of diverse
religious, philosophical, and personal perspectives.(40) Rooted in
religious beliefs about the value and meaning of human life, it also
resonates to and informs secular values and attitudes, including our
laws proscribing murder.
Assisted suicide is opposed by many for similar reasons;
although it does not violate the ban against killing directly, it
renders human life dispensable and implicates physicians or others
in participating in the death of the patient. Some emphasize that
assisted suicide and euthanasia are not simply nonintervention in
the private choice of another person. The participation of a second
person makes assisted suicide and euthanasia social and communal
acts, ones in which social, moral, and legal principles must be
considered.(41) A physician who assists a patient's death affirms,
----------------------------------------------------------------------
(40) See, e.g., R. M. Veatch, Death, Dying, and the Biological
Revolution, rev. cd. (New Haven: Yale University Press,
1989), 69-72. Among the Biblical statements of this prohibition
are Exodus 20:13, Deuteronomy 5:17, and Genesis 9:5-6. Many
religious traditions understand these statements as prohibiting
suicide and assisted suicide as well as direct killing. For an
overview of the attitudes of diverse religious traditions, see
R. Hamel, ed., Active Euthanasia, Religion, and the Public
Debate (Chicago: Park Ridge Center, 1991)- and C. S. Campbell,
"Religious Ethics and Active Euthanasia in a Pluralistic
Society," Kennedy Institute of Ethics Journal 2 (1992): 253-77.
On the significance of religiously influenced views for public
policy deliberations, see, e.g., S. Hauerwas, Suffering Presence
(Notre Dame: University of Notre Dame Press, 1986), 105; Joseph
Cardinal Bernadin, "Euthanasia: Ethical and Legal Challenge,"
Origins 18 (1988): 52-1 J. Stout, Ethics After Babel (Boston:
Beacon Press, 1988); D. Callahan and C. S. Campbell, eds.,
"Theology, Religious Traditions, and Bioethics," Hastings
Center Report 20, no. 4 suppl. (1990); S. L. Carter, The
Culture of Disbelief (New York: Basic Books, 1993).
(41) See, e.g., Callahan, 52-53; T. L. Beauchamp and J. F.
Childress, Principles of Biomedical Ethics, 3d ed. (New York:
Oxford University Press, 1989), 227. Many religious traditions,
including Roman Catholicism, challenge the notion of an
autonomous right to end one's life, appealing to the social
nature of human life and the mutual dependence of individuals in
society. See, e.g., Bernadin, 55. This point is also advocated
in secular terms.
CHAPTER 5 - THE ETHICAL DEBATE page 89
or at least accepts, the patient's choice, actively contributing to
the outcome.(42) Some believe that one person should never be
granted this power over the life and death of another, even a
consenting other; it is intrinsically offensive to human dignity, in
the way that consensual slavery would be.(43) Others are more
pragmatically concerned about the influence physicians would
exercise in the decision-making process.(44)
For some, assisted suicide and euthanasia are not inherently
incompatible with self-determination, but they believe that the
practices as applied in the daily routines of medical practice and
family life would undermine the autonomy of many individuals. In
many cases, a patient who requests euthanasia or assisted suicide
may have undiagnosed major clinical depression or another
psychiatric disorder that prevents him or her from formulating a
rational, independent choice. Other patients may feel compelled to
end their lives because they lack real alternatives, due to
inadequate medical treatment or personal support.(45) Offering
------------------------------------------------------------------------
(42) Opponents argue that the patient's request for suicide
assistance is not just a way to obtain drugs: The request might
represent a desire for companionship in pursuing a difficult
course of action; a wish for confirmation of a decision about
which the patient is unsure; inquiry of the physician's opinion
on an issue about which the patient is ambivalent; an appeal
for the physician's reassurance that he or she is committed to
the patient and believes that the patient's life is worthwhile;
or simply an expression of desperation and a cry for help. See,
e.g., E. D. Caine and Y. C. Conwell, "Self-Determined Death, the
Physician, and Medical Priorities: Is There Time to Talk,"
Journal of the American Medical Association 270 (1993): 875-76.
See also Glover, 183.
(43) As stated by Daniel Callahan, "No human being, whatever the
motives, should have that kind of ultimate power over the fate
of another. It is to create the wrong kind of relationship
between people, a community that sanctions private killings
between and among its members in pursuit of their individual
goals and values." 1). Callahan, "Can We Return Death to
Disease?" Hastings Center Report 19, no. 1 (1989): S5.
(44) Edmund D. Pellegrino argues that while the doctor appears
to place the initiative in the patient's hands and be merely
"open" to suicide under the right circumstances, the physician
actually retains control: "Ultimately, the determination of the
right circumstances is in the physician's hands. The physician
controls the availability and timing of the means whereby the
patient kills himself. Physicians also judge whether patients
are clinically depressed, their suffering really unbearable, and
their psychological and spiritual crises resolvable. Finally,
the physician's assessment determines whether the patient is in
the 'extreme' category that, per se, justifies suicide
assistance." "Compassion Needs Reason Too," Journal of the
American Medical Association 270 (1993): 874.
(45) See, e.g., Arras, 311-13; J. Teno and J. Lynn, "Voluntary
Active Euthanasia: Individual Case and Public Policy," Journal
of the American Geriatrics Society 39 (1991): 827-30;
H. Hendin and G. Klerman, "Physician- Assisted Suicide: The
Dangers of Legalization," American Journal of Psychiatry 150
(1993): 143-45; D. W. McKinney, "Euthanasia as Public Policy:
Rights and Risks," The Berry Street Essay, delivered in New
Haven, Conn., June 22, 1989, Unitarian Universalist General
Assembly, 9. See also the sections discussing suicide and
depression in chapter 1.
page 90 WHEN DEATH IS SOUGHT
suicide assistance, but not good medical care, could be especially
troubling for some segments of the population. As expressed by one
doctor who manages a Latino health clinic, legalizing assisted
suicide would pose special dangers for members of minority
populations whose primary concern is access to needed care, not
assistance to die more quickly.
In the abstract, it sounds like a
wonderful idea, but in a practical sense it
would be a disaster. My concern is for
Latinos and other minority groups that might
get disproportionately counseled to opt for
physician-assisted suicide.(46)
Diverse religious traditions oppose assisted suicide and
euthanasia because the practices violate the basic value of human
life, seen as God's gift. From the perspective of many religions,
suicide itself is not an ethically sanctioned choice. Many
religious traditions reject assisted suicide and euthanasia based on
their understanding of general values, including appreciation for
the life and value of each individual, the individual's
responsibility to the community, and society's obligations towards
all of its members, especially the poor and vulnerable. Many
religions understand life itself as something that is entrusted to
persons by God, entailing a sense of individual responsibility that
is often expressed in terms of "stewardship." Differing religious
perspectives also share a commitment to compassion for patients and
others who are suffering.(47) They believe that this compassion
should be expressed by offering care and companionship, not assisted
death or medical killing, to the severely ill.
As articulated in the 1980 Vatican Declaration on Euthanasia,
and affirmed in recent speeches by Pope John Paul II, the Catholic
Church firmly rejects assisted suicide and euthanasia.(48)
--------------------------------------------------------------------
(46) Dr. Nicolas Parkhurst Carballeira, Director of the
Boston-based Latino Health Institute, in Lehr, April 26, 1993.
A recent study found that patients treated at centers that serve
predominantly minority patients were three times more likely
than those treated elsewhere to receive inadequate pain
treatment. Elderly individuals and women were also more likely
than others to receive poor pain treatment. C. S. Cleeland et
al., "Pain and Its Treatment in Outpatients With Metastatic
Cancer," New England Journal of Medicine 330 (1994): 592-96.
(47) See, e.g., H. Arkes et al., "Always to Care, Never to
Kill," First Things no, 18 (1992): 4547; Hamel, ed., 45-77.
(48) Speaking in the United States in 1993, the Pope condemned
euthanasia, stating: "In the modern metropolis, life - God's
first gift, and the fundamental right of every individual, on
which all other rights are based - is often treated as just one
more commodity" "The Prayer Vigil," Origns 23 (1993): 184.
See also "Contributors to the Formation of Society: Ad Limina
Address," Origins 23 (1993): 486-87; "Veritatis Splendor,"
Origins 23 (1993): 321, par. 80.
CHAPTER 5 - THE ETHICAL DEBATE page 91
Similar views are expressed by representatives of all branches of
Judaism.(49) Many Protestant denominations, such as the American
Lutheran Church and the Episcopal Church, also oppose the practices
as ethically unacceptable.(50) The Unitarian-Universalist
Association, however, has expressed support for legalizing the
practices.(51)
Benefiting the Patient
Individuals suffer from diverse causes. They may experience
pain, physical discomfort, and psychological distress.(52) Relieving
suffering is widely recognized as a basic moral value and a goal of
medicine in particular.(53) The debate about euthanasia and assisted
suicide turns in part on a judgment about how to help suffering
individuals most effectively while protecting them and others from
harm.
-----------------------------------------------------------------------
(49) For further discussion of Jewish views on assisted suicide
and euthanasia, see, e.g., I. Bettan et al., "Euthanasia," in
American Reform Response, ed. W. Jacob (New York: Central
Conference of American Rabbis, 1983), 261-71; J. D. Bleich "Life
as an Intrinsic Rather Than Instrumental Good: The
'Spiritual' Case Against Euthanasia," Issues in Law and Medicine
9 (1993): 13949; B. A. Brody, "A Historical Introduction to
Jewish Casuistry on Suicide and Euthanasia," in Suicide and
Euthanasia, ed. Brody, 39-75; E. N. Dorff, "Rabbi, I Want to
Die: Euthanasia and the Jewish Tradition," in Choosing Death in
America (Philadelphia: Westminster/John Knox, forthcoming); D.
M. Feldman and F. Rosner, ed., Compendium on Medical Ethics, 6th
ed. (New York: Federation of Jewish Philanthropies of New
York, 1984), 101-2; I. Jakobovits, Jewish Medical Ethics, 2d ed.
(New York: Bloch, 1975).
(50) As stated in a report of the American Lutheran Church:
"Some might maintain that active euthanasia can represent an
appropriate course of action if motivated by the desire to end
suffering. Christian stewardship of life, however, mandates
treasuring and preserving the life which God has given, be it
our own life or the life of some other person. nis view is
supported by the affirmation that meaning and hope are possible
in all of life's situations, even those involving great
suffering." "Death and Dying," 1982, in Hamel, ed., 63. See
also Hamel, ed., 52-71.
(51) The 1988 Unitarian Universalist General Assembly issued a
statement resolving "That Unitarian Universalists advocate the
right to self-determination in dying, and the release from civil
or criminal penalties of those who, under proper safeguards, act
to honor the right of terminally ill patients to select the time
of their own deaths." In Hamel, ed., 68-69. This resolution has
been criticized by some within the Unitarian Universalist
Association, including Donald McKinney. McKinney.
(52) See chapter 3 for discussion of current approaches in pain
and palliative care. See also K. M. Foley, "The Relationship of
Pain and Symptom Management to Patient Requests for
Physician-Assisted Suicide," Journal of Pain and Symptom
Management 6 (1991): 289-97.
(53) See, e.g., R. S. Smith, "Ethical Issues Surrounding Cancer
Pain," in Current and Emerging Issues in Cancer Pain: Research
and Practice, ed. C. R. Chapman and K. M. Foley (New York:
Raven Press, 1993), 385-92.
page 92 WHEN DEATH IS SOUGHT
In the debate about assisted suicide and euthanasia,
compassion for patients in pain or with unrelieved suffering is a
common moral and social ground. Disagreement centers on how society
can best care for these patients, and the consequences for others if
the practices are permitted. The debate hinges in part on
assumptions about the number of patients affected, the availability
of pain relief, and the effect of legalizing assisted suicide and
euthanasia on the provision of palliative care. At the core are
basic differences about what compassion demands for suffering
individuals. Disagreement exists too about whether the availability
of assisted suicide or euthanasia would reassure or threaten ill and
disabled patients.
Proponents
Those who support euthanasia and/or physician-assisted suicide
believe that such actions are the most effective way to help some
patients experiencing intractable pain or intolerable psychological
distress. They regard these actions as essential to fulfill a
commitment to relieve suffering. Indeed, many feel that, in
appropriate circumstances, a physician's desire to act
compassionately towards his or her patient provides the strongest
rationale for the practices.
Contemporary advocates argue that, despite advances in
palliative medicine and hospice care, a small number of patients
continue to suffer from severe pain and other physical symptoms that
available medical therapies cannot reduce to a tolerable level.(54)
Studies have shown that large numbers of patients receive poor
palliative care; while state-of-the-art treatment could manage their
pain and discomfort, they are not receiving and are unlikely to
receive this care. In these cases, euthanasia or assisted suicide
would directly end the patient's suffering.(55)
In addition to physical pain and discomfort, patients
experience psychological and personal suffering, which is less
amenable to medical treatment. As articulated by several doctors,
"The most frightening aspect of death for many is not physical pain,
but the prospect of losing control and independence and of dying in
an undignified, un[a]esthetic, absurd, and existentially
unacceptable condition."(56) Some patients suffer because of losses
---------------------------------------------------------------------
(54) At least short of anesthetizing the patient to a sleep-like
state; see p. 93, n. 60.
(55) G. A. Kasting, "The Nonnecessity of Euthanasia," in
Physician-Assisted Death, ed. J. M. Humber, R. F. Almeder, and
G. A. Kasting (Totowa, N.J.: Humana Press, 1993), 2545; Weir,
123-24; Rachels, 152-54.
(56) Quill, Cassel, and Meier, 1383.
CHAPTER 5 - THE ETHICAL DEBATE page 93
that have already occurred or because of anticipated losses and
decline. Others may experience anxiety, loneliness, helplessness,
anger, and despair. Proponents of assisted suicide and euthanasia
assert that only the patient can determine when suffering renders
continued life intolerable.(57)
The number of patients who would receive assistance to commit
suicide or euthanasia is unknown. Most advocates assert that these
actions would be appropriate only in rare cases, and that relatively
few patients would be directly affected. They argue, however, that
many individuals who never use the practices would benefit. Some
patients would feel better cared for and more secure if they knew
that their physician would provide a lethal injection or supply of
pills if they requested these means to escape suffering.(58) Knowing
that assisted suicide or euthanasia is available would also reassure
members of society in general, including those who are not severely
ill. "While relatively few might be likely to seek assistance with
suicide if stricken with a debilitating illness, a substantial
number might take solace knowing they could request such
assistance."(59)
Opponents
Those who oppose legalizing assisted suicide and euthanasia
are also deeply concerned about the needs of terminally and severely
ill patients. They believe that society all too often abandons
these patients, adding to their suffering and sense of despair.
However, they reject assisted suicide and euthanasia as unacceptable
or harmful responses to these patients in need. They also believe
that the likely harm to many patients far exceeds the benefits that
would be conferred. Advances in pain control have rendered cases of
intolerable and untreatable pain extremely rare. In exceptional
cases in which symptoms cannot be controlled adequately while the
patient is alert, sedation to a sleep-like state would remain an
option.(60). Allowing assisted suicide or euthanasia, especially
----------------------------------------------------------------------
(57) Brock, 11; Weir, 123; Kasting.
(58) F. G. Miller and J. C. Fletcher, "The Case for Legalizcd
Euthanasia Perspectives in Bioloy and Medicine 36 (1993):163-64;
Quill, Cassel, and Meier, 1382.
(59) Watts and Howell, 1044-45.
(60) N. Coyle et al., "Character of Terminal Illness in the
Advanced Cancer Patient: Pain and Other Symptoms During the
Last Four Weeks of Life," Journal of Pain and Symptom Management
5 (1990): 83-93; Foley; Teno and Lynn. Watts and Howell
(1045), in advocating assisted suicide, write: "We concede that
there is another alternative: terminally ill patients who
cannot avoid pain while awake may be given continuous anesthetic
levels of medication. But this is exactly the sort of dying
process we believe many in our society want to avoid." In
contrast, Leon R. Kass states: "It will be pointed out [that]
full analgesia induces drowsiness and blunts or distorts
awareness. How can that be a desired outcome of treatment?
Fair enough. But then the rationale for requesting death begins
to shift from relieving experienced suffering to ending a life
no longer valued by its bearer or, let us be frank, by the
onlookers." "Neither for Love nor Money: Why Doctors Must Not
Kill," Public Interest 94 (1989): 33. Palliative care experts
report that while sedation seems objectionable to many healthy
individuals contemplating it in the abstract, most terminally
ill patients and families find it acceptable. Nessa M. Coyle,
R. N., Director, Supportive Care Program, Pain Service,
Department of Neurology, Memorial Sloan-Kettering Cancer Center,
oral communication, March 11, 1993. While continual sedation
can be an important option for patients in severe and
intractable physical pain, it is a less practical option for
patients whose suffering is primarily psychological and who may
have years to live. Quill, Cassel, and Meier.
page 94 WHEN DEATH IS SOUGHT
given the current state of palliative care, would deny patients the
treatment and support that should be a routine part of medical
practice. It also would lead to the death of some patients whose
pain could be alleviated.(61)
Health care professionals can do much to help relieve
psychological suffering by providing humane care and personal
support.(62) Opponents believe that assisting a patient's suicide or
performing euthanasia in an attempt to relieve psychological anguish
or despair will rarely serve the patient's interests. For some,
this is an evident contradiction; causing death can never constitute
a benefit.(63) Others maintain that assisted suicide and euthanasia
could alleviate psychological suffering in rare cases, but believe
that the advantages of allowing the practices are outweighed by the
potential harm to many other patients.(64)
Significant too is the concern that suicide should not be
pursued as a means to care for, or "treat," patients who suffer
--------------------------------------------------------------------------
(61) Reflecting on this danger in the United States, Alexander M.
Capron writes: "'The difficulties in developing caring and
creative means of responding to suffering discourage society as
well as health care providers from greater efforts. A policy of
active euthanasia can become another means of such avoidance...
I could not rid my mind of the images of care provided in our
hard-pressed public hospitals and in many nursing homes, where
compassionate professionals could easily regard a swift and
painless death as the best alternative for a large number of
patients." "Euthanasia in the Netherlands: American
Observations," Hastings Center Report 22, no. 2 (1992): 32.
(62) See, e.g., N. Coyle, "The Euthanasia and Physician-Assisted
Suicide Debate: Issues for Nursing," Oncolog Nursing Forum 19,
no. 7 suppl. (1992): 4445; and discussion above, chapter 3.
Most proponents of assisted suicide and euthanasia would agree
with this statement but still believe that the practices should
be available at the patient's option.
(63) As argued by Leon Kass: "To intend and to act for
someone's good requires his continued existence to receive the
benefit." Kass, 40.
(64) P. A. Singer and M. Siegler, "Euthanasia - A Critique," New
England Journal of Medicine 322 (1990): 1881-83.
CHAPTER 5 - THE ETHICAL DEBATE page 95
because of psychological reasons. Society has long
discouraged suicide as a remedy for psychological suffering, even
though many individuals who consider suicide are anguished and find
relief in the prospect of death.(65) Even for patients who are
suffering and seek assistance in ending life, complying with the
request may provide the wrong kind of "assistance," causing some
patients to end their lives prematurely. Two physicians report
that, while many hospice patients at times express a desire for
death, almost none make serious and persistent requests for active
euthanasia. They write:
New patients to hospice often state they
want to "get it over with." At face value,
this may seem a request for active euthanasia.
However, these requests are often an
expression of the patient's concerns regarding
pain, suffering, and isolation, and their
fears about whether their dying will be
prolonged by technology. Furthermore, these
requests may be attempts by the patient to see
if anyone really cares whether he or she
lives. Meeting such a request with ready
acceptance could be disastrous for the patient
who interprets the response as confirmation of
his or her worthlessness.(66)
Others note that even if all patients are assumed to make
rational and beneficial choices for themselves, giving patients the
option of choosing to end life would change the way they and those
around them perceive their lives. Specifically, a patient could no
longer stay alive by default, without needing to justify his or her
continued existence. The patient will be seen (by others and
himself or herself) as responsible for the choice to stay alive, and
as needing to justify that choice. Given societal attitudes about
handicaps and dependence, "the burden of proof will lie heavily on
the patient who thinks that his terminal illness or chronic
disability is not a sufficient reason for dying."(67)
-----------------------------------------------------------------------
(65) As explained by one sociologist who studied suicide: "It
is undeniable that all persons - 100 percent - who commit
suicide are perturbed and experiencing unbearable psychological
pain." E. S. Shneidman, "Rational Suicide and Psychiatric
Disorders,"New England Journal of Medicine 326 (1992): 889.
Two psychiatrists offer a similar opinion; see Hendin and
Klerman, 144.
(66) Teno and Lynn, 828.
(67) This argument is well developed by J. David Velleman,
"Against the Right to Die," Journal of Medicine and Philosophy
17 (1992): 665-81. While Velleman argues against establishing
a law or policy permitting euthanasia, he believes that some
patients would benefit from death and welcome euthanasia and
that in such cases rules against euthanasia should not be
enforced.
page 96 WHEN DEATH IS SOUGHT
Severely ill patients depend on others not only for physical
care, but for conversation, respect, and meaningful human
interaction. In some cases, family members may encourage patients
to "choose" the option of dying.(68) More commonly, even without
such pressure, a patient may assume that friends and family regard
the choice to remain alive as irrational or selfish. As expressed
by one commentator, "The patient may rationally judge that he's
better off taking the option of euthanasia, even though he would
have been best off not having the option at all. ... To offer the
option of dying may be to give people new reasons for dying."(69)
Many opponents believe that establishing an option of assisted
suicide or euthanasia would have negative consequences not only for
patients who receive assisted dying, but for many others who would
not use either practice. The option of assisted suicide or
euthanasia could distract attention from the care that some patients
might otherwise be offered. Especially if a patient's symptoms
persist despite initial attempts to alleviate them, the effort and
expense of more aggressive treatment and support may seem less
compelling.(70) Officially sanctioning these practices might also
provide an excuse for those wanting to spend less money and effort
to treat severely and terminally ill patients, such as patients with
acquired immunodeficiency syndrome (AIDS).(71)
Societal Consequences
Decisions about euthanasia and assisted suicide touch upon
fundamental societal values and standards. They entail questions
about why we value human life, when life may be taken, and what
obligations we owe to others. Legalizing assisted suicide or
euthanasia would represent a dramatic change, and is likely to cause
both intended and unintended consequences.
Those who favor or oppose legalizing assisted suicide and
euthanasia differ both in their prediction of societal consequences
-----------------------------------------------------------------------
(68) See Kamisar, 37; and also the concerns noted in M. P.
Battin, "Manipulated Suicide," in Suicide: The Philosophical
Issues, ed. Battin and Mayo, 169-82.
(69) Velleman, 675-76.
(70) A. J. Dyck, "Physician-Assisted Suicide - Is It Ethical?"
Harvard Divinity Bulletin 21, no. 4 (1992): 16.
(71) Donald McKinney argues that even if relatively few patients
avail themselves of the choice, officially sanctioning the
option may alter public perceptions, making improvement in
palliative care and increased social support for suffering
patients seem less urgent. McKinney, 7-8.
CHAPTER 5 - THE ETHICAL DEBATE page 97
and in the way that they evaluate possible outcomes.(72) They
disagree, for example, about the effect of the practices on
society's respect for the value of the lives of others, especially
those who are most frail and ill. They also differ about whether
expansion of a policy of voluntary euthanasia to include
nonvoluntary euthanasia would benefit or threaten vulnerable members
of society, and whether mistakes or abuses in a relatively small
number of cases would constitute a moral outrage or the unfortunate
but unavoidable imperfections of any human activity. Finally,
proponents and opponents disagree about how the burden of proof
should fall in deciding public policy. If the societal consequences
of authorizing assisted suicide or euthanasia are uncertain, should
society allow these practices until such time as harmful effects can
be proven, or should the practices remain prohibited unless society
can assure itself that they would not cause unacceptable social
harm?(73)
Proponents
Proponents believe that legalizing assisted suicide and
euthanasia would not produce harmful consequences for society as a
whole, and that potential dangers can be minimized by appropriate
safeguards. For example, some argue that, despite current
prohibitions, assisted suicide now occurs. Openly permitting
assisted suicide in accord with required safeguards might therefore
encourage physicians to communicate more freely with their patients
and to consult with professional colleagues. Mandated consultation
with a licensed psychiatrist would improve the diagnosis and
treatment of many patients who are depressed.(74) As a result,
allowing the practice in carefully defined circumstances would lead
to greater professional accountability and fewer cases of abuse.(75)
----------------------------------------------------------------------
(72) See Brock, 14.
(73) Similar arguments about potential consequences and the
"burden of proof" in the absence of unproven but probable risks
have been raised in the debate on Surrogate motherhood. See New
York State Task Force on Life and the Law, Surrogate Parenting.-
Analysis and Recommedations for Public Policy (New York: New
York State Task Force on Life and the Law, 1988) 73-74,116- 17.
(74) Some opponents, though, emphasize the difficulty of
diagnosing depression among severely ill patients, and argue
that mandated psychiatric consultation would fail to identify
some cases of depression. See chapters 1 and 8.
(75) Cassel and Meier, 751. Data on the number of cases of
assisted suicide and euthanasia currently occurring are
difficult to obtain, especially because the practices are
illegal. Information about cases of assisted suicide and
euthanasia has largely been presented in anecdotal reports.
See Lehr.
page 98 WHEN DEATH IS SOUGHT
Many who favor legalizing physician-assisted suicide see
little distinction between assisted suicide and euthanasia. Both
practices rest on commitments to respect autonomy and prevent
suffering. Some acknowledge that a practice of euthanasia with the
patient's consent is likely to lead to euthanasia for patients
incapable of expressing consent or refusal. They believe that
nonvoluntary euthanasia would be appropriate when it reflects some
information about the patient's own wishes or when it relieves the
patient's suffering.(76) Others accept euthanasia for patients too
ill or too young to decide for themselves because they see no value
in continued life for severely disabled individuals who irreversibly
lack the ability to experience life consciously or to relate to
others. Essentially, some believe that these individuals do not
"have a life" in the sense in which life is treasured.(77)
Advocates of legalizing assisted suicide and/or euthanasia
maintain that although some abuses will occur, the number of
inappropriate deaths would be small, and the opportunity to
alleviate suffering in other cases outweighs this cost. The
potential for abuse suggests the need for safeguards, but should not
preclude legalizing assisted suicide and euthanasia. For them,
claims about negative consequences for the medical profession or the
broader society seem uncertain and speculative.(78)
-------------------------------------------------------------------
(76) Brock, 20.
(77) See, e.g., Rachels, 24-33, 64-67, 178-80; P. Singer,
Practical Ethics (Cambridge: Cambridge University Press,
1979), 138-39.
(78) Concerns about the potential consequences of a change in
policy are often discussed in terms of "slippery slope"
arguments: allowing a given practice will tend to lead to
acceptance of other actions that are objectionable. A
logical or conceptual version of a slippery-slope argument
would claim that there is no distinction in principle between
two actions; for example, that if voluntary euthanasia is
allowed, there would be no principled basis for not allowing
nonvoluntary euthanasia. Causal or empirical versions of the
argument maintain that allowing a certain type of action
would tend to lead in practice to another, objectionable
action; for example, that if voluntary euthanasia is allowed,
society would be more likely to accept nonvoluntary
euthanasia. The empirical version of the argument can rarely
prove that a given result (e.g., nonvoluntary euthanasia) is
certain to follow. Those utilizing such arguments maintain
that they may nevertheless establish that allowing one type
of action poses a significant or unacceptable risk that the
problematic result will occur. See Arras; Beauchamp and
Childress, 139-41; W. van der Burg, "The Slippery-Slope
Argument," Ethics 102 (1991): 42-65; B. Freedman, "The
Slippery-Slope Argument Reconstructed," Journal of Clinical
Ethics 3 (1992): 293-97; B. Williams, "Which Slopes Are
Slippery?" in Moral Dilemmas in Modern Medicine, ed. M.
Lockwood (New York: Oxford University Press, 1985), 126-37.
CHAPTER 5 - THE ETHICAL DEBATE page 99
Some advocates of legalizing assisted suicide or euthanasia
favor prospective guidelines: for example, requiring that the
attending physician consult with colleagues and that the patient
voluntarily and repeatedly request assisted suicide or euthanasia,
receive psychological evaluation and counseling, and experience
intolerable suffering with no hope for relief.(79) Proposals also
stipulate requirements for the patient's medical condition: for
example, that assisted suicide or euthanasia would be allowed only
if a patient is terminally ill or has an incurable disease. Others
recommend that a panel or committee review the patient's request
before assisted suicide or euthanasia is performed.(80)
Under some proposals, assisting suicide or performing
euthanasia would remain a violation of criminal law, but guidelines
would specify types of cases that would not subject physicians to
any penalty. Physicians would be able to avoid punishment by
proving that they acted appropriately in exceptional circumstances;
a showing that the physician responded compassionately and
competently to a voluntary request by a competent patient would
constitute a defense to criminal prosecution.(81) Finally, some
advocates have suggested a trial period of voluntary active
euthanasia or measures to legalize the practice in a few states, in
order to gain data on the consequences of the practice.(82)
Opponents
For many, the potential for error and abuse in particular
cases, the risks to vulnerable individuals, and the profound effect
on society's values present the most compelling reasons against
allowing assisted suicide and euthanasia. Most immediately, the
practices create enormous potential for abuse in particular cases.
Some decisions to contribute to a patient's death may be
well-intentioned but hasty and possibly mistaken. In other cases,
patients may be pressured to consent to euthanasia when their care
is expensive or burdensome to others. As one commentator has
argued, "Advocating legal sanction of euthanasia at a time and in a
society where access to care is so limited and its cost so critical,
the so-called `right to die' all too easily becomes a duty to
die."(83)
------------------------------------------------------------------------
(79) Various safeguards are suggested in Hemlock Society
U.S.A., "Model Aid-in-Dying Act," 1993; M. Battin, "Voluntary
Euthanasia and the Risks of Abuse;" Weir, "Morality," 124-25;
H. Rigter, "Euthanasia and the Netherlands," Hastings Center
Report 19, no. 1 (1989): S31-32; Quill, Cassel, and Meier,
1381-82. For a discussion and critique of guidelines
proposed by Quill, Meier and Cassel, see chapter 6, pp.
14245.
(80) See, e.g., Brody, 1387.
(81) This is the way the law is structured in the
Netherlands, although most agree that physicians are not
reporting many cases of euthanasia despite the legal
requirement to do so.
(82) See, e.g., Brock, 20; Glover.
page 100 WHEN DEATH IS SOUGHT
Some warn that individuals who are disadvantaged or members of
minority groups would be especially susceptible to such pressures.
Others note the widely recognized failure of our health care system
to provide minimally acceptable health care to the poor and
disadvantaged. Especially in overburdened facilities serving the
rural and urban poor, the lack of available options may effectively
pressure patients into assisted suicide or euthanasia.(84) For some
opponents, cases of abuse, even if relatively infrequent, would
count decisively against a policy authorizing assisted suicide and
euthanasia.(85)
Opponents also believe that the practice would expand,
presenting even more profound dangers. A policy of allowing
assisted suicide or euthanasia only when a patient voluntarily
requests an assisted death, and a physician also judges that
assisted suicide or euthanasia are appropriate to relieve suffering,
is inherently unstable. The reasons for allowing these practices
when supported by both a patient's request and a physician's
judgment would lead to allowing the practices when either condition
is met.(86) The value of self-determination supports compliance with
any voluntary request by a patient with decision-making capacity.
Moreover, any serious request would reflect psychological suffering
that the patient considers unbearable. Suggested restrictions on
the practices, such as requiring that patients have a terminal or
degenerative illness, would be seen as arbitrary limits on patients'
autonomy.(87) In particular cases, and more broadly over time,
-----------------------------------------------------------------------
(83) McKinney, 9. Similarly, David Velleman asserts that some
patients will choose to die out of conccrn for the resources
of family members or society, and that to accept such a
"gift" can be problematic. "Establishing the right to die is
tantamount to saying, to those who might contemplate dying
for the social good, that such favors all never be refused."
Velleman, 678-79.
(84) As argued by John Arras, "Insofar as we sustain unjust
conditions, including profoundly inequitable systems of
terminal health care, we thereby heighten the impoverished
person's sense of being truly a 'dead end case.' By failing
to alleviate or eliminate those social conditions that would
make a quick death look relatively attractive, we become
deeply implicated in this choice for death." Arras, 312.
(85) Singer and Siegler maintain, "Even one case of involuntary
euthanasia would represent a great harm." Singer and
Siegler, 1883.
(86) See Dyck; Kamisar.
(87) As argued by Benjamin Freedman (293), societal acceptance
of decisions to forgo life-sustaining treatment began with
decisions made directly by terminally ill patients; over time
the courts and policymakers concluded that it is
inappropriate or infeasible to make such criteria decisive
for purposes of public policy. Daniel Callahan adds that it
would be difficult to enforce restrictions on euthanasia
because of the privacy of the interaction between doctor and
patient. Callahan, "When Self-Determination Runs Amok," 54.
Some express concern that legalizing assisted suicide and
euthanasia would render it more difficult to forgo
life-sustaining treatment. Restrictions on euthanasia might
be applied to decisions to forgo treatment, and all decisions
at life's end might become subject to overly intrusive
review. S. M. Wolf, "Holding the Line on Euthanasia,"
Hastings Center Report 19, no. 1 (1989): S13-15; McKinney,
4-6.
CHAPTER 5 - THE ETHICAL DEBATE page 101
assisted suicide and euthanasia would be provided based on any
serious voluntary request by a competent patient, regardless of his
or her medical condition.(88)
Opponents similarly argue that restrictions requiring the
patient's informed choice would be difficult to maintain. If
intentionally contributing to or causing death is an appropriate
course of treatment for suffering patients, then physicians should
be able to provide this treatment to patients unable to make the
request themselves.(89) The resulting policy of euthanasia for
children and incompetent adults is regarded as intrinsically wrong,
or as an option that poses an extraordinarily high risk of abuse.
Some believe that legalizing assisted suicide and euthanasia
would have a subtle but widespread impact on society. They fear a
general reduction of respect for human life if official barriers to
killing are removed.(90) Others are especially fearful of the effect
on the disabled and other vulnerable persons in society at large.
Instead of the message a humane society
sends to its members -- "Everybody has the
right to be around, we want to keep you with
us, every one of you" -- the society that
embraces euthanasia, even the "mildest" and
most "voluntary" forms of it, tells people:
"We wouldn't mind getting rid of you." This
message reaches not only the elderly and the
sick, but all the weak and dependent.(91)
--------------------------------------------------------------------
(88) Among others, Yale Kamisar asserts that, if assisted
suicide is allowed for patients with a terminal or
degenerative illness, it would seem unfair to exclude others,
such as a quadriplegic or severely injured accident victim.
He continues: "Why stop there? If a competent person comes
to the unhappy conclusion that his existence is unbearable
and freely, clearly, and repeatedly requests assisted
suicide, why should he be rebuffed because he does not
'qualify' under somebody else's standards?" Kamisar, 36-37.
In a recent case in the Netherlands, a court approved a
psychiatrist's assistance of suicide for a patient who was
depressed and experiencing psychological suffering, but had
no other medical illness. W. Drozdiak, "Dutch Seek Freer
Mercy Killing:, Court Case Could Ease Limits on Assisted
Suicide, Euthanasia," Washington Post, October 29,1993, A29.
(89) Callahan, "When Self-Determination Runs Amok," 54; Dyck,
17; Capron, 31. Some point to the Dutch experience as
evidence that the practice would expand. See the discussion
in chapter 6, pp. 132-34.
(90) See, e.g., Beauchamp and Childress, 141; Dyck, 17. -102-
page 102 WHEN DEATH IS SOUGHT
Some who oppose legalizing euthanasia believe that acts of
voluntary euthanasia are morally acceptable in exceptional cases,
such as when a terminally ill patient suffering from intolerable and
untreatable pain makes an informed request. On balance, however,
they conclude that conscientious objection and leniency in the
judicial process would be appropriate in these cases, but such
exceptional cases cannot justify explicit changes in the law or
moral rules that bar active and intentional killing. However strong
our compassion for patients in these rare circumstances, it cannot
support fundamental changes to society's moral code, with
potentially disastrous and irreversible consequences.(92)
Similarly, some argue that even if actions of assisting
suicide in particular cases are morally justified or excusable, it
would be difficult or impossible to craft a policy that resulted in
assisted suicide only in those cases. A policy that allowed
sensitive physicians to assist suicide indirectly in exceptional
cases, after lengthy discussions with a patient, would also allow
less thoughtful physicians to aid suicides after perfunctory
conversations. Accordingly, a former president of Concern for
Dying, an advocacy organization for patients' rights, suggests:
A deliberate act to assist someone in
taking her/his life -- however merciful the
intent -- should not be sanctioned by law.
Rather it should be left a private act, with
society able to be called in to judgment when
and if the motive should be impugned. This is
not a neat and precise system of justice to be
sure, but one that continues to afford the
least possibility of abuse.(93)
--------------------------------------------------------------------------
(91) R. Fenigsen, "A Case Against Dutch Euthanasia," Hastings
Center Reporl 19, no. 1 (1989): S26. Richard Doerflinger
similarly argues: "Elderly and disabled patients are often
invited by our achievement-oriented society to see themselves
as useless burdens. ... In this climate, simply offering
the option of 'self-deliverance' shifts a burden of proof, so
that helpless patients must ask themselves why they are not
availing themselves of it." "Assisted Suicide: Pro-Choice
or Anti-Life?" Hastings Center Report 19, no. 1 (1989):
S16-19. Hendin and Klerman assert that for society to
authorize assisted suicide would in effect endorse "the view
of those who are depressed and suicidal that death is the
preferred solution to the problems of illness, age, and
depression." Hendin and Klerman, 145.
(92) See Veatch, 73-75; J. F. Childress, "Civil Disobedience,
Conscientious Objection, and Evasive Noncompliance: A
Framework for the Analysis and Assessment of Illegal Actions
in Health Care," Journal of Medical Philosophy 10 (1985):
73-77.
(93) McKinney, 7.
CHAPTER 5 - THE ETHICAL DEBATE page 103
The Role and Responsibilities of Physicians
While any person can aid suicide or cause death, the current
debate about assisted suicide and euthanasia generally centers on
the actions of physicians. Long-standing medical tradition,
exemplified by the Hippocratic Oath, enjoins physicians not to harm
patients, and in particular not to "give a deadly drug to anybody if
asked for it, nor ... make a suggestion to this effect."(94) The
oath also commits the physician to employ therapeutic measures to
benefit the patient.(95)
The issues of assisted suicide and euthanasia confront some
physicians in a dramatic and deeply personal way, as they consider
how best to respond to a patient's suffering, or to an explicit
request for assistance in ending life. In these as in other cases,
some physicians feel a conflict between their personal commitments
and conscientious judgment in a particular case, and policies
designed to prevent harm or abuse for patients generally.
The debate about assisted suicide and euthanasia raises
complex questions about the duties of physicians and the goals of
the medical profession. What is a physician's obligation when a
patient requests assisted suicide or euthanasia? How does this
obligation relate to the overall goals of medicine? What impact
would the practices have on the social role of physicians and on the
physician-patient relationship? In response to the growing public
debate, the organized medical community has focused on the special
questions posed for its profession.
------------------------------------------------------------------------
(94) In T. L. Beauchamp and J. F. Childress, Principles of
Biomedical Ethics, 2d ed. (New York: Oxford University
Press, 1983), 330. ne Hippocratic Oath dates back to
approximately the fourth century B.C. Although doctors no
longer swear by the god Apollo, the oath has been regarded as
a central statement about the ethical responsibilities of
physicians throughout the history of Western medicine.
Nonetheless, not all aspects of the oath are universally
honored as prescriptions in contemporary medical practice.
For example, many physicians reject the oath's proscription
against abortion.
(95) Ibid. The oath specifies, "I will apply dietetic
measures for the benefit of the sick according to my
ability and judgment."
page 104 WHEN DEATH IS SOUGHT
Proponents
Physicians and others who advocate assisted suicide and
euthanasia believe that the practices are consistent with the
professional role and responsibilities of physicians. They assert
that the physician's responsibility to care for patients should be
understood broadly in terms of promoting patients'
self-determination and enhancing their well-being. Accordingly, it
would be appropriate for a physician to assist suicide or perform
euthanasia when these actions are chosen by and would benefit a
patient.(96) Others believe that "alleviating suffering, curing
disease, and not causing death are important and simultaneous
obligations."(97) If suffering can be eliminated only by causing
death, a physician would face conflicting obligations, requiring a
personal choice about which obligation is most compelling under the
circumstances.
Some proponents regard assisted suicide as less threatening to
professional integrity than euthanasia.(98) They believe that
removing rules against physician-assisted suicide would offer
physicians an important option in responding to the personal
experiences and values of each patient. In appropriate cases, a
physician's willingness to discuss this alternative and assist
suicide would demonstrate commitment to the patient throughout the
course of life, including the moment of death.
Some proponents maintain that physicians should have a special
role in contributing to patients' deaths because they have access to
drugs and the expertise to cause death quickly and painlessly.(99)
Other individuals, such as family members and friends, may be
reluctant to cause or contribute to a patient's death. In addition,
the moral authority of physicians enables them to aid patients
seeking to end their lives in less tangible ways.
Historically, in the United States
suicide has carried a strong negative stigma
that many today believe unwarranted. Seeking
a physician's assistance, or what can almost
seem a physician's blessing, may be a way of
trying to remove that stigma and show others
that the decision for suicide was made with
due seriousness and was justified under the
circumstances. The physician's involvement
provides a kind of social approval, or more
accurately helps counter what would otherwise
be unwarranted social disapproval.(100)
-----------------------------------------------------------------------------
(96) Brock, 16-17.
(97) Loewy, 31.
(98) Diane E. Meier argues that euthanasia and assisted
suicide "would likely have a substantially different impact
on the ethos of the medical profession." Meier, 35.
(99) See, e.g., Brock, 21.
(100) Ibid.
CHAPTER 5 - THE ETHICAL DEBATE page 105
Some urge that only physicians should be authorized to assist
suicide or perform euthanasia. Physicians can discuss the patient's
medical condition, explore alternative means for alleviating pain
and suffering, and determine whether the patient's judgment is
significantly impaired by psychiatric conditions. Physicians can
also use their technical skills to provide or administer a lethal
dose that leads to a rapid and painless death. Finally, limiting
the number of people authorized to assist suicide or perform
euthanasia would enhance accountability and protect against
abuse.(101)
Others frame the argument for assisted suicide and euthanasia
more broadly. Another person, such as a family member, might be
best able to help the patient achieve relief through death. The
patient may not have an established relationship with a physician,
or the patient's physician may be unwilling to comply with the
patient's request. In several prominent cases, family members or
friends, motivated by compassion, have assisted suicide or caused
death. According to some advocates, "mercy-killing" should be
established in general as an acceptable defense to criminal
prosecution.(102)
Opponents Many physicians and others who oppose assisted
suicide and euthanasia believe that the practices undermine the
integrity of medicine and the patient-physician relationship.
Medicine is devoted to healing and the promotion of human wholeness;
to use medical techniques in order to achieve death violates its
fundamental values. Even in the absence of widespread abuse, some
argue that allowing physicians to act as "beneficent executioners"
would undermine patients' trust, and change the way that both the
public and physicians view medicine.(103)
------------------------------------------------------------------------------------
(101) See, e.g., Weir, 125.
(102) Rachels, 2-6, 28-33,168-70.
(103) As expressed by a group of four physicians: "If
physicians become killers or are even merely licensed to
kill, the profession - and, therewith, each individual 104Sec
physician- will never again be worthy of trust and
respect as healer and comforter and protector of life in
all its fraility." W. Gaylin et al., "Doctors Must Not
Kill," Journal of American Medical Association 259 (1988):
2139040.See also McKinney, 6-8; D. Orentlichter,
"Physician Participation in Assisted Suicide," Journal
of the American Medical Association 262 (1989):1844-45.
Some physicians writing near the beginning of the
century expressed similar concerns. If part of the
doctor's role was to cause death in specified cases,
"his very presence would necessarily be associated
the idea of death. He would enter the sick room,
into which he should bring life and hope, with the
dark shadow of death behind him." "The Right to Die,"
in Reiser, Dyck and Curran, 491.
page 106 WHEN DEATH IS SOUGHT
Some believe that, while physicians may be motivated by
compassion in some cases, a physician abandons the patient in a
profound sense when he or she deliberately causes the patient's
death.(104) Others note that professionals such as physicians have
great power and enjoy significant discretion to use that power
prudently. Strict boundaries to prevent the misuse of power are
therefore necessary. General professional limits may in some cases
impinge on an individual physician's personal sense of vocation, but
are needed to maintain public confidence in the profession and guard
against abuse.(105)
Some object that assisted suicide and euthanasia would be used
as a "quick fix" of the kind that is too prevalent in contemporary
medical practice.
Having adopted a largely technical
approach to healing, having medicalized so
much of the end of life, doctors are being
asked ... provide a final technical solution
for the evil of human finitude and for their
own technical failure: If you cannot cure me,
kill me.(106)
Others note that relying on medical practices to assist
suicide removes a natural psychological barrier to the act, leading
some individuals to end their lives without facing the full
implications of the act.(107) Some believe that a judgment about
------------------------------------------------------------------------
(104) See P. Ramsey, The Patient as Person (New Flaven: Yale
University Press, 1970).
(105) Kass, 35.
(106) Ibid.
(107) A. Alvarez writes that "Modern drugs not only have made
suicide more or less painless, they have also made it seem
magical. A man who takes a knife and slices deliberately
across his throat is murdering himself. But when someone
lies down in front of an unlit gas oven or swallows sleeping
pills, he seems not so much to be dying as merely seeking
oblivion for a while." Alvarez, 137. Writing about ancient
Greece, Paul Carrick notes that the development of hemlock
contributed to a change in the conception of suicide, and to
an increase in the suicide rate. Carrick, 130.
CHAPTER 5 - THE ETHICAL DEBATE page 107
whether to assist suicide or perform euthanasia is not essentially a
medical judgment, and falls outside the parameters of the
patient-physician relationship.(108) They object to the notion that
physicians would be granted special authority to assist suicide or
perform euthanasia.
Some believe that assisted suicide or euthanasia performed by
physicians would be more problematic than similar actions by other
individuals. Because of the risks of abuse and threats to the
integrity of the medical profession, it would be particularly
objectionable for physicians to participate in these actions. A
group of four physicians writes: "We must say to the broader
community that if it insists on tolerating or legalizing active
euthanasia, it will have to find nonphysicians to do its
killing."(109)
Finally, some object in particular to the concept of killing
as a form of healing or death as cure, arguing that such views
resonate with periods in history when the medical profession was
used to end human life. While the practice of mass murder in Nazi
Germany differs from contemporary proposals for euthanasia, it began
with the active killing of the severely ill, and built on earlier
proposals advanced by leading German physicians and academics in the
1920s, before the Nazis took power. Like policies currently
advocated in the United States, these proposals were limited to the
incurably ill, and mandated safeguards such as review panels.(110)
----------------------------------------------------------------------
(108) "Are doctors now to be given the right to make judgments
about the kinds of life worth living and to give their
blessing to suicide for those they judge wanting? What
conceivable competence, technical or moral, could doctors
claim to play such a role?" Callahan, "When
Self-Determination Runs Amok," 55.
(109) Gaylin et al., 2140. For some, physician participation in
assisted suicide and euthanasia raises similar concerns to
physician participation in capital punishment: whatever an
individual physician's personal beliefs about the practice,
to act as a physician in a way that contributes to a person's
death would violate one's professional responsibilities. For
a recent statement on participation in capital punishment,
see American Medical Association, Council on Ethical and
Judicial Affairs, "Physician Participation in Capital
Punishment," Journal of the American Medical Association 270
(1993): 365-68. An argument for distinguishing between
physician involvement in capital punishment and physician
involvement in euthanasia may be found in Loewy, 29-34.
(110) Capron, 32-33; R. J. Lifton, The Nazi Doctors:
Medical Killing and the Psychology of Genocide (New York:
Basic Books, 1986), 45-50-1 Veatch, 66-67. Lifton, while
distinguishing Nazi "euthanasia" from euthanasia in the
Anglo-American context, traces the significance of concepts
such as "life unworthy of life" and "killing as a therapeutic
imperative" in removing social and psychological barriers
against killing and advancing the Nazi program of genocide.
"The medicalization of killing - the imagery of killing in
the name of healing - was crucial to that terrible step."
Lifton, 14-15, 46. See also the recent translation of Karl
Binding and Alfred Roche's 1920 work, "Permitting the
Destruction of Unworthy Life: Its Extent and Form," trans.
W. E. Wright, P. G. Derr, and R. Salomon, Issues in Law and
Medicine 8 (1992): 231-65.
page 108 WHEN DEATH IS SOUGHT
The Views of Medical Organizations
In recent years, professional organizations -- including the
American Medical Association, the American College of Physicians,
and the American Geriatrics Society -- have joined the public debate
about assisted suicide and euthanasia. The positions embraced by
these organizations share several elements. The organizations
consistently distinguish assisted suicide and euthanasia from the
withdrawing or withholding of treatment, and from the provision of
palliative treatments or other medical care that risk fatal side
effects.(111)
Professional organizations report that most pain and suffering
can be alleviated, but that some patients find their situation so
intolerable that they request assisted suicide or euthanasia.
Physicians should respond to these patients by exploring their
concerns, investigating whether the patient is suffering from
depression, and improving palliative care when needed. The
organizations generally recognize that assisted suicide or
euthanasia might be beneficial to a small number of patients. They
note, however, that such actions are illegal, and they express
concern that allowing these practices could damage the
physician-patient relationship and pose serious risks to vulnerable
members of society.(112)
Within the framework of this consensus, medical societies have
offered somewhat differing views. While not supporting assisted
suicide and euthanasia, the American College of Physicians Ethics
Manual does not explicitly reject all such actions. The manual
recommends that physicians respond to patient requests for
euthanasia or assisted suicide by seeking to ascertain and respond
to the patient's concerns.(113) In contrast, the American Geriatrics
----------------------------------------------------------------------
(111) American Medical Association; American College of
Physicians, "American College of Physicians Ethics Manual,"
3d ed., Annals of Internal Medicine 117 (1992): 953-54;
American Geriatrics Society, Public Policy Committee,
"Voluntary Active Euthanasia," Journal of the American
Geriatrics Society 39 (1991): 826.
(112) Ibid.
(113) As stated in the ACP manual: "In most cases, the
patient will withdraw the request when pain management,
depression, and other concerns have been addressed, but
occasionally the issue of physician-assisted suicide needs to
be explored in depth. However, our society has not yet
arrived at a consensus on assisted suicide and most
jurisdictions have specific laws prohibiting such action.
Physicians and patients must continue to search together for
answers to these problems without violating the physician's
personal and professional values and without abandoning the
patient to struggle alone." American College of Physicians,
955.
CHAPTER 5 - THE ETHICAL DEBATE page 109
Society strongly urges physicians not to provide interventions that
directly and intentionally cause the patient's death. It also
recommends that the current legal prohibition of physician
assistance to commit suicide and euthanasia should not be
changed.(114)
The Council on Ethical and Judicial Affairs of the American
Medical Association similarly states that "physicians must not
perform euthanasia or participate in assisted suicide." While these
actions may seem beneficial for patients in some sympathetic cases,
authorizing physicians to perform them would pose unacceptable risks
of allowing mistaken or coerced deaths. It could also gradually
distort both public perceptions of medical practice and the practice
of medicine itself.(115)
Killing and Allowing to Die
The debate about euthanasia and assisted suicide takes place
against the backdrop of changes in medical practice. Medical
developments have increased the number and range of treatment
decisions that must be made near the end of life. Decisions to
withhold and withdraw life-sustaining treatment in accord with the
patient's wishes and interests have become widely accepted in
principle, and to an increasing extent in practice. As a result,
many physicians have participated in decisions and actions to end
life-sustaining treatment, giving them a sense of control over the
timing and manner of a patient's death.
Some believe that such actions are essentially similar to
assisted suicide and euthanasia. They challenge the commonly
-------------------------------------------------------------------
(114) As set forth in the organization's policy statement,
"Active euthanasia might reasonably be preferred by a few
patients with intractable pain or other overwhelming symptoms;
however, the benefit of allowing this choice must be weighed
against possible abuse of euthanasia on the frail, disabled,
and economically disadvantaged members of society. The
American Geriatrics Society also expressed its concern that
allowing euthanasia could also lessen patients' trust in
physicians, and further weaken society's commitment to
provide adequate resources for supportive care. American
Geriatrics Society, 826.
(115) American Medical Association. The Committee on
Bioethical Issues of the Medical Society of the State of New
York articulates a similar position in "Physician-Assisted
Suicide," New York State Journal of Medicine 92 (1992): 391.
The National Hospice Organization has adopted a resolution
rejecting the practice of euthanasia and assisted suicide.
The resolution "reaffirms the hospice philosophy that hospice
care neither hastens nor postpones death," and advocates
hospice care as an alternative to euthanasia and assisted
suicide. Resolution approved by the delegates of the
National Hospice Organization, Annual Meeting, November 8,
1990, Detroit, Michigan.
The American Nurses Association has not issued a formal
position statement on assisted suicidc and euthanasia. Some
nurses have argued that ANA position papers would suggest a
position opposing euthanasia. N. Coyle, 44.
page 110 WHEN DEATH IS SOUGHT
accepted distinction between intentional killing, which is viewed as
always wrong, and allowing to die, which is accepted in many cases.
Many of those who reject this distinction support policies
authorizing assisted suicide and euthanasia.(116) The current debate
about assisted suicide and euthanasia poses questions about whether
killing and allowing to die are intrinsically different on ethical
grounds, and whether the practices should be distinguished for
purposes of social policy.
Against the Distinction
Some claim that forgoing treatment cannot be distinguished in
principle from taking affirmative steps to end a patient's life
because the intentions, motives, and outcomes are identical in both
cases. They argue that in each instance, the decision maker seeks
the patient's death and is motivated by compassion, and the same
result occurs.(117) Some supporters of assisted suicide and
euthanasia assert that society currently accepts decisions to forgo
life-sustaining treatment that effectively constitute killing; for
example, withdrawing a respirator or failing to provide artificial
nutrition and hydration.
Even if this characterization of current practice is rejected,
they argue, killing (or more generally, contributing to a person's
death) should not be seen as intrinsically immoral. Ending a
person's life is wrong in most cases because it deprives a person of
-----------------------------------------------------------------------
(116) Others who reject the distinction oppose decisions to
forgo life-sustaining treatment, as well as assisted suicide
and euthanasia. Discussion about distinguishing between
killing and allowing to die may be found in R. F. Weir,
Abating Treatment with Critically III Patients: Ethical and
Legal Limits to the Medical Prolongation of Life (New York:
Oxford University Press, 1989), 228-32, 261-68; J. McMahan,
"Killing, Letting Die, and Withdrawing Aid," Ethics 103
(1993): 250-79; J. Feinberg, Harm to Others (New York:
Oxford University Press, 1984), 159-63, 171-86, 257-59n; P.
Foot, "Morality, Action and Outcome," in Morality and
Objectivity: A Tribute to J L. Mackie, ed. T. Hondreich
(London: Routledge and Kegan Paul, 1985), 23-25.
(117) Rachels, 106-28, 139-43; Rachels, "Active and Passive
Euthanasia," New England Journal of Medicine, 78-80. See
also J. Fletcher, Humanhood: Essays in Biomedical Ethics
(Buffalo: Prometheus Press, 1979), 149-58. Rachels
describes two cases: Smith, who kills his 6-year-old cousin,
and Jones, who intentionally lets his cousin die, both in
order to gain an inheritance. He argues that as both acts
are equally reprehensible, the "bare difference" between
killing and letting die is morally insignificant. Others
have criticized such arguments as inconclusive at best. Even
if the two cases in the example are equally objectionable,
the difference between killing and letting die is significant
in other cases. For instance, a person is not morally
obligated to endanger his or her own health or spend a large
sum of money to save another person, but it would be morally
wrong for a person to kill someone actively in order to
safeguard his or her health or save that sum of money.
Beauchamp and Childress, 136-38; Feinberg, 167-68, citing H.
Maim, "Good Samaritan Laws and the Concept of Personal
Sovereignty," typescript, University of Arizona (1983), 11.
CHAPTER 5 - THE ETHICAL DEBATE page 111
the benefit of continued life, and violates the individual's rights.
However, in appropriate cases of assisted suicide or voluntary
euthanasia, the patient believes that continued life would not
provide a benefit (and, with euthanasia, waives his or her right not
to be killed).(118) Some patients decide to stop or withhold
life-sustaining treatment because they perceive life as a burden and
wish to die. In these cases, assisted suicide or euthanasia would
end the patient's life and suffering more quickly and effectively
than withdrawing or withholding treatment. As one philosopher
argues:
If one simply withholds treatment, it
may take the patient longer to die, and so he
may suffer more than he would if more direct
action were taken and a lethal injection
given. This fact provides strong reason for
thinking that, once the initial decision not
to prolong his agony has been made, active
euthanasia is actually preferable to passive
euthanasia, rather than the reverse.(119)
Finally, proponents of assisted suicide and euthanasia point
out that the potential for mistake or abuse exists for withdrawing
and withholding treatment as well. They argue that society has
addressed this problem with appropriate safeguards, and could do the
same for assisted suicide and euthanasia.
For the Distinction
Despite such claims, the distinction between killing and
letting die, in general and in the context of medical decisions, is
widely accepted and supported. Many insist that the nature of the
action in each case is different. Decisions to withhold or withdraw
treatment allow the natural course of the disease to continue. The
decision maker determines that certain treatments are not medically
appropriate or morally obligatory, and the physician refrains from
imposing interventions that legally would constitute battery.
Moreover, forgoing treatment does not always result in a patient's
immediate death; the patient may continue to live, as in cases of an
inaccurate prognosis. (120)
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(118) Rachels, Fnd of Life, 39-59.
(119) Rachels, "Active and Passive Euthanasia," 78-80.
(120) Beauchamp and Childress, 144; Weir, Abating Treatment,
316-18; Ramsey, 153. See also G. R. Scofield "Privacy (or
Liberty) and Assisted Suicide," Journal of Pain and Symptom
Management 6 (1991): 283.
page 112 WHEN DEATH IS SOUGHT
This distinction in the nature of the acts of killing and
allowing to die is accompanied by a difference in causation. In one
case, the decision maker seeks to cause death and employs direct
means to achieve this result. In the other, the decision maker
accepts but does not cause the person's death, which is caused by
the underlying illness or condition. Paul Ramsey, for example,
argues that forgoing treatment is not simply an indirect means of
killing. "In omission no human agent causes the patient's death,
directly or indirectly. He dies his own death from causes that it
is no longer merciful or reasonable to fight by means of possible
medical interventions."(121)
For many, the prohibition against actively and intentionally
killing innocent persons represents a basic moral and social norm.
Diverse philosophical and religious perspectives affirm this
view.(122) Some also contend that the psychological effect on
professionals and family are different in cases of killing and
allowing to die.(123)
For others, the crucial distinction lies in the different
consequences of policies of killing and of allowing to die. A
practice of accepted killing is more vulnerable to abuse in
particular cases, and poses a greater risk of harm to others in
society. Some focus on the role of the distinction in the context
of law and public policy. As articulated by the President's
Commission for the Study of Ethical Problems in Medicine and
Biomedical and Behavioral Research, the prohibition of active
killing is part of "an accommodation that adequately protects human
life while not resulting in officious overtreatment of dying
patients," and "helps to produce the correct decision in the great
majority of cases."(124)
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(121) Ramsey, 151. See also Callahan, "When
Self-Determination Runs Amok," 53-54; McMahan, 263, 271. The
two types of cases also tend to be characterized by different
intentions. See Weir, Abating Treatinent, 310-11; G.
Meilaender, "The Distinction Between Killing and Allowing to
Die," Theological Studies 37 (1976): 468-69.
(122) see pp. 88-91.
(123) This argument was put forward as early as 1884 in an
editorial in the Boston Medical and Surgical Journal:
"Perhaps logically it is difficult to justify a passive more
than an active attempt at euthanasia; but certainly it is
less abhorrent to our feelings. To surrender to superior
forces is not the same thing as to lead the attack of the
enemy upon one's friends. May there not come a time when it
is a duty in the interest of the survivors to stop a fight
which is only prolonging a useless and hopeless struggle?"
"Permissive Euthanasia," in Fye, 501-2.
(124) President's Commission, 70-73.
CHAPTER 5 - THE ETHICAL DEBATE page 113
Some argue that the negative effects of active killing on
those involved and on society are stronger, and the potential scope
of abuse wider, than with allowing patients to die.(125)
Additionally, patients have a strong moral and legal right to refuse
treatment. Respecting decisions to forgo treatment recognizes this
right to be let alone and the moral obligation not to impose
treatment coercively. In contrast, people do not have the same
basic right to active participation by others in achieving their
death. Society's refusal to allow another person to assist suicide
or to cause death directly does not impose the same burden on the
patient that would result from forced medical interventions.(126)
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(125) See the discussion of risks posed by euthanasia throughout
this chapter and in chapter 6.
(126) See, e.g., Veatch, 67.
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