Ethics of Physician Assisted Suicide

Should we be allowed to take our own lives?

In many cultures ancient and not so ancient suicide has been seen as the best option in certain circumstances.  Cato the Younger committed suicide rather than live under Caesar.  For the Stoics there was nothing necessarily immoral in suicide, which could be rational and the best option (Long 1986, 206).  Conversely, in the Christian tradition, suicide has largely been seen as immoral, defying the will of God, being socially harmful and opposed to nature (Edwards 2000).  This view, to follow Hume, ignores the fact that by dint suicide being possible it is not against nature or God (Hume 1986).  Nevertheless, the idea of being allowed to take our own lives impinges on the ethics of public policy in a variety of ways.  Here we will briefly examine the case of physician-assisted suicide (PAS) where an individual’s wish to die may be aided by the action of another.

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Hume considered suicide to be ‘free from every imputation of guilt or blame’ (Hume 1986, 20) and indeed suicide has not been a crime in the UK since 1961 (Martin 1997, 451).  Aiding, abetting, counselling or procuring a suicide is however a special statutory crime, although few prosecutions are brought.  Recently the issue of PAS has brought the debate about ‘whether and under what conditions individuals should be able to determine the time and manner of their deaths, and whether they should be able to enlist the help of physicians’ (Steinbock 2005, 235).  The British Medical Association opposes euthanasia (mercy killing) but accepts both legally and ethically that patients can refuse life-prolonging treatment – this that they can commit suicide (BMA 1998).  Failing to prevent suicide does not constitute abetting (Martin 1997, 451) although PAS ‘is no different in law to any other person helping another to commit suicide’ (BMA 1998).  In Oregon, however, PAS, restricted to competent individuals who request it, has been legalised (Steinbock 2005, 235, 238).  A distinction should be maintained between suicide and (mercy) killing, acts in which the agents differ, though of course exactly where the line should be drawn is part of the problem.

The ethical arguments in support of PAS involve suffering and autonomy (Steinbock 2005, 235-6).  The first assertion is that is cruel to prolong the life of a patient who is in pain that cannot be medically controlled; the second, in the words of Dr Linda Ganzini based on her study in Oregon, involves the idea that ‘being in control and not dependent on other people is the most important thing for them in their dying days’ (quoted in Steinbock 2005, 235).  The logical outcome of these arguments is that, if PAS can be justified on the grounds of suffering or autonomy, why should it be restricted to competent individuals or the terminally ill?  Indeed the judge in Compassion in dying v State of Washington (1995) stated that ‘if at the heart of the liberty protected by the Fourteenth Amendment is this uncurtailable ability to believe and act on one’s deepest beliefs about life, the right to suicide and the right to assistance in suicide are the prerogative of at least every sane adult.  The attempt to restrict such rights to the terminally ill is illusory’ (Steinbock 2005, 236).

As noted above, religious disapproval of suicide has become less relevant an as arbiter of ethics and policy.  In democratic societies that might best be described as secular with a Christian heritage, the views of religious groups should not restrict the liberty of individuals in society (Steinbock 2005, 236).  Others argue that the role of the physician is to heal and help and not to harm, though supporters of PAS would say that death is not always harmful and assisted suicide is a help.  Indeed, in a country where PAS is not legal people who wish to die without criminalizing those who assist in their suicide may be driven abroad, as in the case of Reginald Crew who was dying of motor neurone disease and travelled to Switzerland for AS, dying in January 2002 (English et al. 2003, 119).  This may cause more harm through the stresses of dislocation and worry than allowing the PAS to take place. 

The two most serious concerns are that PAS would be abused and would lead to negative changes in society.  This could happen in many ways through vulnerable groups such as the poor, the elderly etc, being pressured into choosing PAS (Steinbock 2005, 237).  The BMA emphasises a concern for the message that would be given to society about the value of certain groups of people (BMA 1998).  This is part of a wider concern also expressed in a Canadian Senate enquiry of 1995 (BMA 1998) which points to a policy of suicide prevention amongst some vulnerable groups that would be rendered anomalous by seeking to ease suicide amongst the disabled.  However, the presentation is slightly disingenuous, since there is a difference in the reason for potential suicide that must be investigated. For example, seeking to prevent suicide amongst the youth may involve programmes of social inclusion or increasing life prospects, and this style of solution is not applicable in the case of those who may seek PAS. 

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In Oregon at least, it seems that fears about PAS have not materialised, and one doctor suspects that the relatively low use of PAS is indicative of it being too restrictive (Steinbock 2005, 238).  Users of PAS, rather than being the poor and socially vulnerable as predicted, tended to be middle class and educated, with younger patients more likely to choose it than the elderly, and most were enrolled in hospice care.  Issues about PAS and euthanasia need to be clarified and argued separately.  In the context of this issue at least, the question of whether suicide should be allowed is the wrong one to ask.  A starting point is to ask how competent individuals can be allowed to fulfil their wishes as to life and death issues without endangering other people, whether doctors or loved ones and whether all embracing legislation is feasible.

Bibliography

• BMA. 1998. Euthanasia and physician assisted suicide: Do the moral arguments differ? London: BMA.
• Edwards, P. 2000. ‘Ethics of suicide’, in The Routledge Encyclopedia of Philosophy. London: Routledge, 870-71.
• English, V. Romano-Critchley, G., Sheather J. and Sommerville, A. 2003. ‘Ethics Briefings’, Journal of Medical Ethics 29: 118-119
• Hume, D. 1986. ‘Of Suicide’, in Singer, P. (ed.) 1986. Applied Ethics. Oxford: Oxford University Press, 19-27.
• Martin, E.A. (ed.) 1997. A Dictionary of Law. Oxford: Oxford University Press.
• Steinbock, B. 2005. ‘The case for physician assisted suicide: not (yet) proven’, Journal of Medical Ethics 31: 235-41.