The issue of physician-assisted suicide (PAS) is a hotly contested one in the field of medical ethics. There are two main positions held on this issue; one contends that in the appropriate situation, suicide should be considered an acceptable solution in the case of terminally ill patients, and furthermore, that it is within the role of the physician to provide the patient with the means to kill themselves. The other argument generally argues against one or both of the aforementioned reasons in favor of PAS, maintaining that the physician should not be allowed to aid in the death of the patient. In an article by Yale Kamisar, the author argues against PAS, giving several key points as to why the practice should not be decriminalized. Although there are numerous arguments against the practice of physician-assisted suicide, ultimately, in consideration of the bioethical principles of autonomy, justice, beneficence, and nonmaleficence, PAS can and should be legalized.
Looking at the entire lifespan, if someone has lived a complete, full, and generally healthy life, have they not achieved the ‘standard of health’ that should be accorded to every individual? Similar to the debate with respect to universal healthcare, it is certainly reasonable to say that maybe not receiving treatment would be most fair to equalize the level of health among different people. Considering the principle of justice, is it unjust to use heroic measures to save someone who is dying when there are others who have a better prognosis/longer expected lifespan if they receive treatment? In general, heroic measures usually only prolong life but do not reverse debilitating terminal illnesses. Thus, it is reasonable to assume that the cost-benefit ratio of heroic measures to prolong life is relatively low, and that the funding directed toward this would have a more measurable positive effect in other areas of healthcare. Although this interpretation of standard of health is certainly not universally accepted, it provides a plausible and cohesive argument for why physician-assisted suicide should be legalized with respect to justice.
In addition to the principle of justice, respect for patient autonomy also lends to the argument for PAS. There are many situations in which, from an ethical standpoint, we could consider a person’s request for death as a reasonable solution, especially in cases of extreme patient pain and a grim outlook for the rest of life. What if the person wants to die but is incapable of killing themselves or wants the medical expertise of a doctor to ensure as smooth and painless a transition into death as possible? In cases where the patient can give informed consent (they know that they want, are cognizant of their actions and themselves, and have been provided with adequate information that has clearly been processed) and wants to die, their request should be acknowledged, or at least considered, out of respect for patient autonomy.
In certain cases, it is the doctor or patient’s family that raises objections to the practice of assisted suicide. With respect to consideration of the medical provider, the situation seems very similar to that of abortion; every physician is not obligated to perform abortions, but rather it is limited to those who do not raise personal ethical objections to the practice of abortion. Similar to abortion, the case of PAS need not mandate that every doctor be obligated to assist in patient suicide – doctors could decide whether or not they would be willing to help based on their own internal ethical considerations. On a similar note, although family members are allotted a role in the decision making process of the patient, valuing the consideration of the family over the patient with respect to suicide would be a violation of the patient’s right to autonomy.
Furthermore, this consideration still holds when applied to certain situations of patients who are not capable of consciously making their own informed decisions. In the case of patients who are not currently cognizant but have made an end-of-life plan, then the patient’s choice should be honored and respected. Regardless of the state of mind of a patient in this situation, if the person specified their wishes at the end of life at a time when they were cogent, then their decision should be followed out of respect for their autonomy. The considerations of the family should only be considered when the patient is incapable of giving informed consent and their end of life plans are unknown or unclear. Barring situations in which the desires of the patient is unknown, considering the wishes of the family over those of the patient is a clear violation of a person’s right to autonomy.
Moreover, there are also considerations for PAS that should be made with respect to the principle of beneficence. It is certainly appropriate to say that one of the primary concerns of healthcare providers should be to extend the lifespan of those they are responsible for treating. However, this is not the sole consideration of healthcare providers. They should also consider the quality of care they are able to provide and the quality of life the patient is experiencing. In many cases, it is true that extending the lifespan and augmenting quality of life can occur simultaneously, and are in the patient’s best interests. However, there are also cases in which prolonging the lifespan comes at the expense of improving the quality of life of the individual. It is also equally possible that, with consideration to both of the aforementioned standards of are, a patient’s deteriorating condition would suggest that death would be kinder to them than using heroic measures to keep them alive with an increasingly debilitating quality of life.
On another note, the argument for PAS is also very similar with respect for the principle of nonmaleficence. The principle of nonmaleficence maintains that doctors should seek to ‘do no harm’ to their patients. It is entirely possible that if a doctor’s intentional actions resulted in a patient’s death, then that would be considered an act of maleficence. However, it seems equally plausible that there are situations in which the doctor’s actions would still adhere to the principle of nonmaleficence. In consideration of patients with terminal illnesses, it is reasonable to see why the initial response to assisted suicide would interpret it as harm to the patient. However, the outlook of terminally ill patients is generally grim, and the palliative care used to treat it can only focus on reducing the severity of the symptoms, not curing or finding a long-term solution for the disease. With this in mind, using whatever means necessary to keep a patient alive could cause more harm than good, which suggests that PAS could be the best solution with respect to the principle of nonmaleficence.
In his article on PAS, Kamisar argues against physician-assisted suicide using several key points. One of these points is that while there are individual cases that motivate the argument in favor of PAS, as a whole society would benefit more from the criminalization of assisted suicide. He notes that the argument for autonomy is flawed because we are not simply individuals responsible solely for ourselves, but are connected to other people in multiple layers of society at many different levels. He further states that “permitting such assistance risks the unwilling or manipulated death of the most vulnerable members of society, and the erosion of the normative structure that encourages them, their families, and their doctors to choose life,” (Kamisar 116) suggesting that the risk to the marginalized would outweigh any good that could be done for those with debilitating terminal illness.
Kamisar further stakes his argument on the ethical considerations based on the nature of the doctor-patient relationship. Because of doctor-patient confidentiality, an ethics board would only know what the doctor says about the suicide, and wouldn’t hear the other side of the story. In his article, Kamisar quotes that “absent ‘an intrusion into the relationship between patient and doctor that most patients would not want and most doctors would not accept,’ no law or set of guidelines covering euthanasia (or assisted suicide) can protect patients.” (Kamisar 120) Thus, the author seems to indicate that unless the nature of doctor-patient privilege was fundamentally altered, PAS would result in the violation of the patient’s right to life and appropriate medical care.
The final major point the author argues is that PAS would not simply be limited to those who are terminally ill, because of the arbitrary line of what determines terminal illness. He states that while many people who are candidates for PAS will be terminally ill, there will also be many cases in which the line is not so clearly defined, saying that “this category may well come to encompass persons in the early stages of HIV infection or Alzheimer’s disease. It may also come to encompass patients suffering from prolonged and intractable depression who exhibit no other symptoms of physical illness.” (Kamisar 125) Thus, the author bases his argument in the fact that the line between who is eligible for PAS will continue to erode, until everyone would qualify for assisted suicide.
Although Kamisar raises some interesting points, the ethical evidence ultimately still suggests that PAS should be legalized. Yes, we are connected to other people, but this same principle holds true for every other decision we make in our lives as well. Every decision that we make for ourselves will also impact other members of society. Furthermore, it is unfair to say that PAS would unjustly impact the socially marginalized. Protection for people on the fringes of society should derive from social welfare that has the specific target of reducing stratification of different groups of people. With consideration to autonomy and beneficence, denying PAS to the socially marginalized simply denies them of more civil liberties, rather than protecting their inherent rights.
Doctor-patient privilege should remain sacred, as it is a fundamental aspect of our healthcare system. However, we already put a monumental amount of trust in our healthcare providers to make decisions that will improve our lives, and because of this there are safeguards in place to ensure that doctors don’t take advantage of their patients. It is paramount that doctors don’t abuse the bond they share with their patients, but protecting the patient from doctor abuse is the responsibility of the physician and independent medical review boards. The risk of doctor abuse of power will always exist, suggesting that the system itself would need to be revised in order to change this, rather than accepting or denying individual facets within it.
The argument of difficulty drawing a line in what merits consideration for PAS would be valid, save for the fact that the issue of where to draw a line is something that needs to be considered for almost all facets of healthcare. From abortion to genetic screening, and refusing standard treatment and even socialized medicine, the line of treatment is rarely clearly defined. However, the solution in these cases has not been to institute a blanket ban, but rather to maintain general policies and consider each case on an individual basis. Thus, it is fairer to say that a regulatory board and consideration of case-by-case bases is considered more standard than outright denying potentially ethically fraught practices. Therefore, although Kamisar raises several valid ethical objections to the practice of PAS, ultimately the practice should be legalized, out of respect for the principles of justice, autonomy, beneficence, and nonmaleficence.
Kamisar, Yale. “The Reasons So Many People Support Physician-Assisted Suicide – and Why These Reasons are Not Convincing.” Issues in Law & Medicine. National Legal Center for the Medically Dependent & Disabled, Inc. 1996. HighBeam Research. http://www.highbeam.com>. pp. 113-131