Thesis Statement: Under certain circumstances, physician-assisted suicide can be both morally and ethically acceptable.
The debate about physician-assisted death thus far has been clouded by imprecise, sometimes inflammatory use of language. The descriptive term “physician-assisted death” includes both physician-assisted suicide and voluntary active euthanasia. It emphasizes the physician’s role as an assistant to an action initiated by the patient. Doctors “killing” patients are technically correct, but it incorrectly suggests a physician-driven act and brings out uneasy visions of the Holocaust, in which a vicious abuse of physician power was used to systematically exterminate those who were deemed to be socially unworthy. (Ondrey, 2006) Nothing could be further from the intent of those who favor a limited reconsideration of public policy in the areas of assisted suicide and voluntary active euthanasia. Physicians are reluctant partners in assisted dying, motivated by the compassion they feel toward suffering patients who request their help and have no good alternatives.
The different kinds of suicide
Suicide is defined as the intentional taking of one’s own life, but its multilayered meaning emerges in a second definition which includes the self-destruction of one’s interests. In the medical literature, suicide is almost always viewed as an act of despair and self-destructiveness, the outgrowth of untreated depression and impaired rational thought. (Derek, 2007) Suicide in that context is something to be prevented, and physicians’ appropriate role is to use all their resources, including enforced hospitalization if necessary, to help patients regain their will to live. (Dowbiggin, 2002)
Suicide in the context of end-stage medical illness associated with irreversible suffering that can only end in death can have a different meaning. Many believe that suicide under such circumstances can be rational—it is hard to judge the wish for an end to intolerable suffering that can only end in death as irrational. Under such tragic circumstances, death can sometimes provide the only relief. The only question is, how much more one must endure until it comes. Yet, because patients with such severe medical conditions are usually sad if not clinically depressed, it can at times be difficult to determine whether emotional responses to their illnesses are distorting their decision-making. (Mcdougall, 2007) If there is any question that depression or other mental illness is coloring the patient’s judgment, then consultation by an experienced psychiatrist or psychologist is necessary to understand the full implications of an incurably ill patient’s request for assisted death.
In “assisted suicide,” a patient is still carrying out his act, but he is indirectly helped by an “assistant.” When the assistant is motivated by compassion for an incurably ill patient who clearly and repeatedly requests help, the act can be ethical and moral, if not legal. If the assistant is motivated by greed, or if there is uncertainty about the rationality or motivation behind the patient’s request, then the act of assistance becomes immoral, unethical, as well as illegal. (Ondrey, 2006) There is the little case-based legal definition for what kind of compassionate “assistance” might be considered illegal. For example, a physician might prescribe a potentially lethal supply of medication, along with information about what dose would be lethal and what dose would be medicinal. There the physician’s intention could be explicitly to give the patient the option of taking her own life, or it might be more ambiguous. (“Don’t take all of them or it could kill you.”) Do we want dying patients to have such information and choice, or should we perhaps protect them from themselves by depriving them of potent medication that might be used to take their own lives? It is very difficult to prosecute doctors successfully in the face of such ambiguity, especially if they are motivated by compassion for their terminally ill patients rather than self-interest. (Derek, 2007)
Many dying patients often have potentially lethal doses of medication at home that are being used to treat their symptoms. To withhold such medicine because of an abstract fear of suicide would be immoral and in violation of fundamental principles of comfort care. Unfortunately, some physicians continue to under-medicate potentially treatable symptoms of dying patients, in part out of vague fears about patient suicide, but probably as significantly by their fear of legal or professional investigation should their patient take an overdose. If the patient is suffering from a reversible depression that is distorting her judgment, then caution and conservatism must be exercised until the distortion is resolved. Yet undertreating a dying patient’s symptoms because of unsubstantiated fears about liability is unfortunately quite legal, though unethical and immoral.
Assisted suicide and the law
No physician or a family member has ever been convicted of assisting in the suicide of a severely ill patient with intractable suffering. Such acts appear to be looked upon by juries as acts of compassion not intended to be covered by the law. Yet the laws exist, and the threat of professional or legal repercussions is severe enough to prohibit many doctors from assisting their patients even when they consider the patients’ requests rational and compelling. These laws perpetuate and exaggerate the power differences between vulnerable patients and their physicians, and put patients’ fates more than ever at the discretion of their physicians.
In physician-assisted suicide, the patient commits the final act herself. The physician’s participation is indirect, and there can always be a reasonable doubt about the intention as long as the prescribed drug has other medicinal uses. Laws that indirectly promote loneliness and abandonment at death should be carefully reconsidered to ensure that they don’t have the unintended effect of further isolating and disempowering rather than protecting the dying person (Mcdougall, 2007).
Euthanasia is defined as the act of painlessly putting to death a person who is suffering from an incurable, painful disease or condition. Its definition suggests a quiet and easy death—a “good death.” Euthanasia is equated by some with “mercy killing,” and its mention raises worries about involuntary killing and progressive disregard for human life. (Dowbiggin, 2002) For others, the images of a painless escape from extreme suffering into death offer the promise of more compassionate and humane options for the dying. Unlike assisted suicide, where the legal implications have yet to be fully clarified, euthanasia is illegal in all states in the United States and likely to be vigorously prosecuted. It is also illegal in all other countries, though in the Netherlands it is explicitly left unprosecuted provided that specific guidelines are met.
“Voluntary” And “Involuntary” Euthanasia
Several distinctions are of critical importance in a serious discussion about euthanasia. The first is “voluntary” versus “involuntary,” and the second is “active” versus “passive.” “Voluntary” euthanasia means that the act of putting the person to death is the result of the person’s own free will. Consideration of voluntary euthanasia as an option, and the request for its use, must emanate from the patient and no one else. The patient’s rational thought processes must not be distorted by depression or other sources of cognitive impairment. Unlike assisted suicide, where the physician provides the means for the patient to subsequently use, in euthanasia the physician is the direct agent of death. (Gorsuch, 2006) Although voluntary euthanasia can potentially be as humane and morally justifiable as assisted suicide, it puts the physician in a very powerful position. Many physicians and policymakers feel great trepidation because of the potential for abuse (e.g., physician-initiated euthanasia on incompetent patients or in ambiguous situations) or error (e.g., the patient changing her mind at the last minute).
“Involuntary” euthanasia means that the person is put to death without explicitly requesting it. Although this could be an act motivated by compassion for a severely suffering, incompetent patient, there is too much subjectivity and personal variation in the definition of “suffering” to condone such “acts of mercy.” Involuntary euthanasia could also be used for completely immoral purposes (Dowbiggin, 2007) for example, on incompetent or even competent persons as an act of eugenics and social manipulation. Such abuses were witnessed in Nazi Germany, as we should never forget.
Involuntary euthanasia, even when compassionately motivated, should remain criminal and should be vigorously prosecuted and prohibited. Involuntary euthanasia is a fundamentally different act both morally and ethically from responding to a voluntary request for euthanasia by a competent patient who has no escape from his suffering other than death. Voluntary euthanasia is an area worthy of our serious consideration since it would allow patients who have exhausted all other reasonable options to choose death rather than continue suffering. Involuntary euthanasia, even when compassionately motivated, is extremely dangerous ground because of the inevitable subjectivity and personal variation of human suffering, and because of the potential for social abuse when one starts making such profound decisions on behalf of other persons who cannot express their wishes. (Mcdougall, 2007) Perhaps fully competent suffering persons should be given the possibility of making such decisions for themselves; but under no circumstances should we allow such decisions to be made on behalf of those who are incompetent.
“Active” And “Passive” Euthanasia
The distinction between “active” and “passive” euthanasia rests upon the assumption that it is ethically permissible for physicians to withhold or withdraw life-sustaining medical treatment at the patient’s request, and let the patient die passively of “natural causes.” Such “passive” euthanasia is based on the fundamental ethical principle that informed, autonomous patients have the right to refuse any medical treatments, no matter what the consequences. (Gorsuch, 2006) Yet, under circumstances of identical or even greater suffering where no life-sustaining treatment is being used, current law forbids the physician to take direct action designed to achieve the same end—even if it is rationally requested by the patient and would result in a more humane death. Passive euthanasia, along with the double effect of narcotic pain medicine, probably accounts for the vast majority of the estimated six thousand planned deaths in United States hospitals each day. How many times lines are secretly crossed and distinctions blurred in the care of these dying patients is simply not known.
An Important Distinction
Some ethicists believe that there is a fundamentally important distinction between active and passive euthanasia. Death is the intended outcome in both circumstances, but the physicians’ actions are directly causal in active euthanasia, whereas it is the physicians’ “inaction” in passive euthanasia that allows the patient to die of “natural causes.” (Gorsuch, 2006) By maintaining this distinction, the medical profession allegedly remains untainted by becoming an agent of death. Yet, in the cloudy world of patient care, these distinctions can become more illusory than real, and our attempts to remain ethically pure sometimes extract a considerable price from dying persons who have little left to give. Both active and passive euthanasia intends to finally allows the patient with no other good options to die in the most humane way possible (Dowbiggin, 2002).
One does not need to have a great deal of medical experience to find an example of passive euthanasia resulting in a very difficult death from “natural causes.” Take for example a patient with end-stage, metastatic lung cancer who is near death from respiratory failure. He has tried to prolong his life through chemotherapy and radiation, but is now losing weight, extremely short of breath, and nearing the end of the road. He has elected to forgo cardiopulmonary resuscitation and mechanical ventilation (breathing machine) and knows that his death is inevitable. He has even begun to look forward to death as an escape from his life, which now feels empty, devoid of future or hope (Dowbiggin, 2007). So far, most physicians and ethicists would be comfortable with this example of passive euthanasia, allowing the person to die “naturally” of respiratory failure rather than prolonging his death by putting him on a mechanical ventilator.
Yet suppose that this patient has an overwhelming fear of suffocation, and wants to go to sleep quickly and not wake up, rather than continuing the agony of gradual suffocation for days or even weeks before his inevitable death. His request is confirmed to be rational, and his family agrees that he should be spared this final struggle if at all possible. Since there is no life-sustaining treatment to discontinue, passive euthanasia does not provide help or guidance at this point. According to comfort care principles, his shortness of breath can be treated with narcotics in doses intended to limit the feelings of discomfort, but not to intentionally produce death. His shortness of breath and feelings of extreme anxiety is therefore treated with an infusion of morphine until he falls asleep and appears relaxed (Toledano, 2005). Yet periodically he awakens, thrashing and screaming from a terrifying feeling of suffocation. His morphine dose is appropriately increased to the point that he is relaxed enough to again lose consciousness, and no further. Unfortunately, a primitive drive to continue breathing sustains him whenever he drifts off into sleep. He alternates between periods of extreme agitation and a medicated sleep on the edge of death, where he lingers for over a week on gradually increasing doses of morphine before finally succumbing. Anyone who has witnessed such “natural deaths” cannot help but be troubled by their nightmarish quality.
The option of physician-assisted death, whether by assisted suicide or active voluntary euthanasia, would allow patients such as this an escape from meaningless torment before death. When death is the only way to relieve suffering, and inevitable regardless, why not allow it to come in the most humane and dignified way possible? Why is it considered ethical to die of “natural causes” after a long heroic fight against illness filled with “unnatural” life-prolonging medical interventions, and unethical to allow patients to take charge at the end of a long illness and choose to die painlessly and quickly? Most of us hope to be fortunate enough to experience a “good death” when we have to die and to be spared an agonizing ordeal at the very end. Many of us hope that if we do end up in such unfortunate circumstances, we can find a physician who will help us creatively explore all possibilities, including facilitating a relatively quick and painless death. Hopefully, we will never need it, but the possibility would be very reassuring.
- Ondrey James H. (2006) Physician-assisted Suicide (At Issue Series). Greenhaven Press.
- Dowbiggin Ian. (2002) A Merciful End: The Euthanasia Movement in Modern America. Oxford University Press, USA; 1 edition.
- Mcdougall Jennifer Fecio, Gorman Martha. (2007) Euthanasia: A Reference Handbook. ABC-Clio; 2 Edition.
- Dowbiggin Ian. (2007) A Concise History of Euthanasia: Life, Death, God, and Medicine (Critical Issues in History). Rowman & Littlefield Publishers, Inc.
- Toledano Henry. (2005) Euthanasia – Choice and Death (Contemporary Ethical Debates). Edinburgh University Press.
- Derek Humphry. (2007) The Good Euthanasia Guide: Where, What & Who in Choices in Dying. Norris Lane Press; 3 edition.
- Gorsuch Neil M. (2006) The Future of Assisted Suicide and Euthanasia (New Forum Books). Princeton University Press.