September 1994 XVI/1
PHYSICIAN ASSISTED SUICIDE:
AN ETHICAL ANALYSIS OF PRESUPPOSITIONS
In a recent issue of the New England Journal of Medicine, a group of physicians, assisted by a lawyer and a philosopher, defend physician assisted suicide. (1) Realizing that physician assisted suicide is "outside standard medical practice," and that it could lead to the abuse of vulnerable patients and the degradation of the medical profession, the authors devote most of their attention to developing a complicated process of regulating the manner in which requests for assisted suicide are evaluated and monitored.
Before addressing the ethical arguments in the article itself, let us be clear about the subject matter. Usually, physician assisted suicide implies that a physician provides the material needed for the suicide to be carried out by the patient. For example, lethal doses of medication may be supplied which enable a person to kill herself or himself. While the physician does not cooperate physically in the suicide of the patient, the physician cooperates morally in the suicide by approving the act of suicide, even though reluctantly. Thus, physician assisted suicide is a moral participation in the killing of an innocent person. However, in the article under consideration, the authors also approve the active euthanasia on the part of the physician, that is, the physical termination of a patient's life a the patient requests it. The extension of assisted suicide (a less proximate and direct involvement in the death of a patient), to euthanasia (direct and intended killing) is logical because a moral cooperation in an assisted suicide can be justified then why not the direct act of killing? According to the authors, the reasons which justify the act of cooperating in suicide or killing a person without the person's physical participation in the act (active euthanasia) is the patient's right of self determination and the physician's responsibility to relieve pain (p. 119).
Finally, physician assisted suicide is not to be confused with the aggressive use of medication to relieve pain, which indirectly and beyond the intention of both patient and physician, might hasten the death of a suffering person. This form of aggressive comfort care for dying patients, as the authors acknowledge, is ethically acceptable and not under discussion in this article.
As is often the case, the article in question presupposes some vital facts or ethical theories and then draws conclusions without ever examining the presuppositions upon which the conclusions are based. The remaining part of this analysis will consider and evaluate three of these presuppositions upon which the article is based.
Presupposition 1. People suffering from intolerable pain which cannot be alleviated through comfort care, are capable of making voluntary decisions. In fact, a desire to commit suicide, even when one suffers from pain or has a terminal illness, is interpreted by experts as an expression of depression. How can a person make a voluntary request to kill oneself, or be killed by a physician, if he of she is in a depressed condition? Recently, when considering the feasibility of legislation to approve physician assisted suicide, the New York Task Force on Life and the Law rejected the proposal, offering a much more realistic response. It stated: "For purposes of public debate, one can posit "ideal" cases in which all the recommended safeguards would be satisfied: patients would be screened for depression and offered treatment, effective pain medication would be available, and all patients would have a supportive, committed family and doctor. Yet the reality of existing medical practice in doctors' offices and hospitals across the state generally cannot match these expectations, however many guidelines or safeguards might be framed. These realities render legislation to legalize assisted suicide and euthanasia vulnerable to error and abuse for all members of society, not only for those who are disadvantaged.
In sum, the presupposition that dying patients are capable of making voluntary decisions concerning suicide or direct killing, that is, decisions which are free from moral coercion, is simply unrealistic.
Presupposition 2: The second presupposition is: Physicians are the proper and exclusive agents for helping people cope with pain and approaching death. Thus, when physicians are unable to alleviate pain they have failed in their profession. To put it another way, the authors presuppose that in the presence of pain that cannot be alleviated through medical care the only alternative is patient or physician inflicted death. Even if we admit for the moment that pain cannot be controlled, an admission which many pain specialists are not willing to posit, (2) the assistance to cope with pain is available from many people besides those in the medical profession. Many people live with pain and in the face of death gain strength from their family and friends. Pain is not only a physiological phenomenon; it may occur at any level of human function: the physiological, the psychological, or the psychic level. A holistic evaluation of a dying person's situation requires a distinction between pain and suffering. A distinction not made in the article under study. Often people can bear pain if loved ones share their suffering. It seems that the assumption that only members of the medical profession are responsible and capable of helping people cope with pain and imminent death is short sighted. In addition, it bespeaks a latent paternalism which the authors of this article would loudly denounce in other circumstances.
The notion that the inability to relieve suffering constitutes failure on the part of the physician is also misguided. Who does not know that death is inevitable; who does not acknowledge that there will be pain and suffering in life that cannot always be overcome? Severe suffering and death are just as much a part of nature as birth and life. The nobility of the human person is found in coping with suffering if it cannot be overcome, not in surrendering to it through despair and suicide. Do you value people who give up in face of adversity.
Presupposition 3: The third presupposition concerns ethical theory. This presupposition which makes the intention of the agent the only source of ethical decision making could be stated as follows: An act which is unethical in itself, may become ethical by reason of the good intention of the person performing the action. Thus, lying or cheating on an exam, actions wrong in themselves, will be defended as morally good a the person who performs them may suffer the harm of embarrassment or failure a he doesn't lie or cheat. The desire to judge the morality of human acts by the intention of the agent and to ignore the moral object of the action itself occurs throughout history. In generic terms it is known as relativism. Elizabeth Anscombe, the great British philosopher, explained the distinction between the moral object and the intention of the agent in the following manner: "Whatever ulterior intentions you may or may not have, the question first arises: What intention is inherent in the action you are actually performing? What are you here and now doing on purpose? Whatever your ulterior aims, what one is here and now doing on purpose, precisely is called the object of the moral act." (3)
While the intention of the agent is one source of morality, the primary determinant of ethical or moral identity is the moral object. Anscombe describes it, the moral object is: "What you are here and now doing on purpose." The primary determinant of morality, the moral object, cannot be finessed or overridden by the intention of the agent. If this were so, there would be such a thing as an unethical or immoral human act because people always have, what seems to them at least, a good intention for their actions. Hence, there are some actions which are always wrong, no matter what the intention of the agent. Would if ever be ethically acceptable to sell children into slavery, even if the intention of the agent were to provide a better life for the children?
Clearly, the authors of this article consider physician assisted suicide usually to be unethical because they allow it only as a last resort. Moreover, they admit that any treatment whose purpose is to cause death "lies outside standard medical practice." The elaborate process calling for palliative care consultants and palliative care committees to assure that physician assisted suicide is carefully controlled also indicates that suicide and euthanasia are immoral by reason of the moral object. When the authors maintain that in order to eliminate pain or to respect the patient's right to self determination, a physician may assist a suicide or perform euthanasia, they are simply saying that one may do serious evil to achieve good.
The authors of the article under study maintain that through assisted suicide or euthanasia they seek to "relieve symptoms, and enhance the quality and meaning of life." This is double talk. As Leon Kass stated: "We cannot serve the patient's good by deliberately eliminating the patient." (4)
Kevin O'Rourke, OP
1. F. G. Miller at al, "Regulating Physician Assisted Death," NEJM July 14, 1994, p. 119ff.
2. A Jacox, at al., "New Clinical Practice Guidelines for the Management of Pain in Patients with Cancer," NEJM, March 3, 1994, p. 651.
3. Ethics, Religion and Politics Vol. III, (Oxford: Blackwell, 1981, p. 86.
4. "Is There a Right to Die," Hastings Report, Jan-Feb 1993, p. 34 ff.
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