Physician-Assisted Suicide and Euthanasia Life is a precious gift that is to be received from the Creator with gratitude. It should be cherished, preserved, and enhanced in every way possible. But when the potential for meaningful, joyful, desirable life has been thoroughly exhausted and every effort made to prevent the inevitable, we should make it legally possible for the merciful to show mercy to the dying who request intervention to end their suffering. The only appropriate way to make this claim is with deep humility and in fear and trembling. We must always stand in awe and reverence when life itself is at stake. As Dr. Timothy Quill has said, anyone who thinks this question has a simple or obvious answer has not thought very deeply or seriously about the matter. Those who oppose the legalizing of physician-assisted death make arguments and voice fears that are formidable indeed. Nevertheless, I conclude that the stronger case rests with those who advocate the legalizing of assisted death under carefully regulated conditions. This paper consists of several parts. First, I present the main arguments for and against assisted death. While the current controversy centers on providing medicines or other means that patients can use to end their lives (physician-assisted suicide) I also make a case for physician-administered death (voluntary active euthanasia) in which the doctor gives a lethal injection or other medicines that cause death. I use the term assisted death to cover both. After that I offer more extended treatments of the major objections and make the positive case. In Part 1, I reject some of the common objections made against it. In Part 2, I state arguments in favor of the practice. Finally, I contend that the dilemmas, ambiguities, complexities, and tragedies involved in these life and death issues point to a religious resolution beyond everything that law, medicine, and morality can provide. Part 1 Arguments Against 1. It violates Medical Ethics. The Hippocratic Oath expressly forbids the giving of deadly medicine to anyone who asks. This ancient document also requires doctors to swear by Apollo and all the gods and goddesses. It also forbids the taking of fees for teaching medicine. This tells us that we have to judge each tenet by its own merits and not regard it as a final authority in all matters. The American Medical Association has consistently condemned physician-assisted suicide as an unethical practice. Nevertheless, attitudes may be changing. According to recent surveys a majority of doctors in some areas -- 60% in Oregon, 56% in Michigan, and 54% in Great Britain -- favor the practice in extreme circumstances. Specialists in medicine and ethics are not in agreement on the question. 2. It undermines trust between doctor and patient. We expect physicians to heal and preserve life, not to kill on request. I reply that I want to be able to trust my doctor to do what is best for me in every situation, including assisting me to die with dignity if life becomes an intolerable burden, and I choose not to live any longer. I would not ask a doctor to do anything illegal, but if law permitted physician-assisted death, I would not want to be abandoned in my final hours. The trust issue, then, works both ways. A doctor may be as likely to lose the confidence of patients by not consenting to their request for assistance in dying as by consenting. 3. It is God's place to decide the time and place of a person's death. I reply that assisted death is a moral issue that has to be resolved on the basis of principles we use to deal with every other question about right and wrong, not a special case. Moreover, the implication of this objection is that we should never interfere with the course of any life-threatening condition. If a person is bleeding to death from an accidental cut, should we not just watch and let death occur? To intervene would challenge God's prerogative to determine the time and place of death. In some cases this objection is made by proposing that to take innocent life is "playing God." Anyone who makes this claim ought to state the criteria that tell us when human action is about to encroach on divine prerogatives and on what basis this claim is made. Otherwise, it remains an empty assertion that contains nothing one can argue against rationally. It is not a self-evident, self-defining premise that settles the question merely by being invoked. Sometimes when one person accuses another of "playing God," the charge appears to be based on intuition or a feeling and is not associated with explicit principles or careful reasoning. 4. It is a slippery slope. If we permit even the most limited forms of assisted suicide, the argument goes, we might eventually be killing off the handicapped, the poor, the elderly, abnormal babies, and anyone else who becomes inconvenient. In this extreme form it is surely groundless, given the values that prevail in our society. Nevertheless, we should be deeply concerned about this and see to it that proper safeguards are instituted. However, the idea that one should not make a reasonable choice now because it might lead to other measures later is not a sound basis for policy making unless (1) subsequent moves are inevitable and (2) are clearly wrong. Neither is necessarily the case. The guard against slippery slopes is the virtue, character, and good sense of the majority of our citizens. Our hope is that reasonable people know when to draw a line between going far enough and going too far. It is not at all clear that where the line is presently drawn is where it ought to be drawn. 5. It is killing. Nearly everyone agrees that sometimes it is permissible to cause the death of another. The question in each case is whether the action is justified under the circumstances. The same is true of assisted death. 6. The patient may be depressed temporarily or may undergo a change of mind. Depression, when present, should be treated. Patients should be given sufficient time and counseling to enable them to make sure their decision represents their deepest wishes. But at some point we have to decide whether patients are to be permitted to be the authors of their own destiny or not. 7. It violates the crucial difference between passive and active procedures. The argument is that there is a decisive moral difference between (1) letting nature take its course by ceasing or withholding treatment in hopeless cases when death is close and certain and (2) taking active steps that deliberately hasten death. I reply that this distinction in and of itself is not morally crucial. To put the focus here misses a far more important point. The proper question is this: What is the best thing to do under certain extreme circumstances? The answer may be: (1) cease futile treatment, or (2) do something that will bring about a merciful death that shortens the time of intolerable, unnecessary suffering. The patient may legitimately request either one, and we may morally comply. Death occurs in either instance, and human choice and agency are involved in both. 8. A misdiagnosis could occur, or a miracle cure might happen. Perhaps, but keeping this in mind implies that we should be extremely cautious not that we should never act under any circumstances. Besides, the possibility of an unexpected recovery or a misdiagnosis implies that we must do absolutely everything in our power to extend life as long as possible. Hence, we would never cease or withhold treatment even though the case looked hopeless if so doing hastened death ever so slightly. 9. Ending life to relieve suffering interferes with the role that suffering plays in God's plan. The extreme view that all suffering is sent by God to serve a purpose implies that we should never do anything to relieve suffering of any kind. It is true that suffering may lead to spiritual gains and moral maturity, but not all suffering does. In any case, most people would agree that it is our duty to relieve suffering to the extent that is possible, especially that which is excruciating and robs life of it s meaning and joy. If this is the case, one can reasonably argue that in some extreme cases relieving suffering takes priority over extending life. 10. Personal autonomy is not absolute. We wisely do not allow people to do anything they want, even if the consequences will affect them most or altogether. We do not allow people to duel with lethal weapons. We do not permit people to sell themselves into slavery. And, so the argument goes, we do not have a right to have other people kill us or assist us in committing suicide. Deciding what choices should be wisely left to individuals and which options should be forbidden by law is difficult for any society. We have been divided over the abortion question for many decades. Often society changes its mind. Once certain sexual practices between consenting adults were forbidden. Now we recognize that this was an unnecessary and unwise intrusion of the government into private affairs. My argument is that when it comes to the ultimate matter of choosing death to relieve unbearable suffering for which there is no remedy, it is time for the state to stop interfering with a decision made by the person whose life and death are at stake. The choice should rest with the only person who is experiencing the intolerable agony that cannot be relieved. 11. Bad consequences would follow. Guidelines would inevitably be violated. Mistakes would be made. Patients might feel guilty for staying alive and choose death to lift the financial burden or the strain on loved ones. Families out of desperation and emotional exhaustion might give up too quickly and give their support to ending the misery of a relative. Some patients might conclude that their lives were not valued if society provided a way to kill them. Doctors might feel less obligation to provide the best possible care if administering death were available as a solution to the agonies of life. Society might be tempted to put less priority on providing needed assistance for the disabled, the poor, and minorities and let the choice of death make things easier and cheaper. We might all become less sensitive to suffering and more callous about death once we got used to the idea of choosing death as a way out of life's tribulations. So the list goes. These dangers must be taken seriously, and steps taken to prevent them if assisted death becomes legal. Let us notice that no arrangement is free from abuse. Many of the pressures that might be felt by patients and families or urged on them by institutions already exist with regard to the approved practice of withdrawing life-sustaining treatment. Since doctors can administer heavy doses of pain medicine that hasten death, the present system allows for covert instances of assisted death. Fewer abuses might occur if current practices were open to scrutiny and regulation. Far from lessening efforts to manage suffering, the option of assisted death might well inspire greater efforts to make life tolerable for patients so that they would not want to die. The main abuse now existing, however, is that by denying terminally ill patients a choice in hopeless situations, we consign those whose misery cannot be relieved to pointless, needless agony. Part 2 Arguments For Deciding what is right is especially difficult when the permissibility of deliberately ending a human life is involved. In these extreme situations the normal rules of morality are stretched to the breaking point. Self-defense against a would-be murderer, killing enemy soldiers in war, capital punishment for the most horrendous crimes, intentional suicide by a spy to prevent torture or a coerced disclosure of vital military information, killing a berserk man who is systematically murdering a line of hostages -- all these instances pose questions that severely test our moral wisdom. Nearly everyone would agree that in some of the cases listed it would be legitimate to end a life deliberately. This fact tells us that killing a person is not always and necessarily regarded as wrong. It all depends upon the circumstances. Now enters the question of physician-assisted death. I want to make a cautious argument that under some carefully limited circumstances, it is permissible for a physician to assist a person hasten death to end unwanted, intolerable, unnecessary suffering. This includes providing medicines or other means the patient can use to commit suicide or by directly administering medicines that end the patient's life. 1. In some situations the choice of the patient takes priority over other considerations. Consider a person with an incurable illness or severe debility such that life has become so racked with pain or so burdensome that desirable, meaningful, purposeful existence has ceased. Suppose that person says, "My life is no longer worth living; I cannot stand it any longer; I want to end it now to avoid further pain, indignity, torment, and despair." In the end after all alternatives have been thoroughly considered, I believe this person has the right to make a choice to die and that it ought to be honored. We would want to urge consultation with physicians, clergy, lawyers, therapists, family, and others so that such a serious and irreversible decision can be made after sufficient time has passed and every alternative thoroughly weighed. We have obligations to others and should take their needs into account. The state has an interest in protecting life. But, in the end, individuals should be given wide latitude in deciding when life has become an unendurable hardship. 2. The role of the physician is to do what is best for the patient, and in some extreme situations this may include hastening death upon the voluntary request of the dying. Many doctors protest that they are committed to preserve and enhance life, not to end it deliberately. If the role of the physician is defined solely in terms of healing, then, of course, this excludes assisting someone to die. This is the wrong way to go about defining the scope and limits of the doctor's proper function. I suggest that the question should be put this way: What is the best thing I can do to help my patients in whatever circumstances arise, given my special knowledge and skills? In nearly every case the answer will be to heal, to prolong life, to reduce suffering, to restore health and physical well being, i. e., to preserve and enhance life. But in some extreme, hopeless circumstances, the best service a physician can render may be to help a person hasten death in order to relieve intolerable, unnecessary suffering that makes life unbearable as judged by the patient. This would be an enlargement of the physician's role, not a contradiction of it. 3. Sometimes ending suffering takes priority over extending life. Assisted death is so troubling because it involves an agonizing conflict between values. Life is a wonderful gift full of the promise of pleasure, joy, happiness, and love. But circumstances may turn it into a heartbreaking, hopeless burden filled with suffering, pain, and despair. We desire to live, but in some situations death may be preferable to the continuation of an intolerably burdensome existence. If some person comes to that dreadful conclusion, what is our duty? The moral imperative forbids us to kill, but it also enjoins us to be merciful. We have a term that puts the dilemma before us -- mercy killing. While insisting that we must make every effort possible to guard against abuse, I sorrowfully conclude that, at a patient's request, it may sometimes be more merciful and loving to end suffering than to extend a joyless, unendurable life. 4.When death becomes preferable to life, everyone would benefit if it were legal to show mercy. Compassion and benevolence demand that we legalize assisted death for the sake of the afflicted and those who love them. The most powerful argument in favor of physician-assisted death comes from the families of those who have witnessed loved ones die in extreme agony. When medical science has done all it can and death has not yet brought merciful relief, family members suffer a sense of powerlessness and despair as they watch in horror someone they love dearly writhe in torment as they wait and hope for a quick end to their awful suffering. That these extreme cases are rare is indeed fortunate, but it does not render less important the appalling plight of whose who must live -- hopeless and helpless -- through such distress. It would benefit everyone if choosing death in hopeless, intolerable situations were allowed under defined circumstances that prevent abuse. The most forlorn of all are those who agonize over whether to take action in violation of the law to end the life of someone dear to them who pleads and prays for death. A few in desperation, unable to stand it any longer, take a gun or a pillow and do what they dread and hate to do but must do in order to bring relief to a parent or child or spouse who is glad for the intervention but is fearful of the legal consequences for those who have shown them mercy. You have seen them, or heard them, or read about them. Their faces are sometimes hidden and their voices are disguised as they tell their sad stories. They must witness in secret to what has happened because the law condemns their compassion and calls them murderers. Yet they loved the deceased with all their hearts and were moved to do the dreadful deed out of pure benevolence. Physicians are more fortunate in that they can take refuge in the principle of the "double effect" and write on the death certificate the cause of death. Many of us have heard doctors report that they have, out of compassion and mercy, given heavy doses of morphine to relieve the intolerable distress of patients who are near to an inevitable death, knowing full well that the result will be to hasten the end. Somehow this is all right, since the primary aim is, we say, to relieve suffering and not to kill, but it would not be right, we are told, to do the very same thing with the primary aim of hastening death, while getting the secondary result of comfort. Why do we force good people full of love, mercy, and compassion to such extreme measures to bring an end to hopeless torment when no cure or relief is possible for the dearest people on earth to them? Why do we force physicians to justify their mercy in hastening death by denying that they did it for that reason, when we all know what is really going on? There are times when we need to rethink received wisdom by subjecting our principles, codes, and traditions to a fresh exposure to real life experience. Sometimes ideals that are designed to protect and enhance life may actually degrade life and be the source of unnecessary suffering. So it is I believe with the prohibition of physician-assisted death under any and all circumstances. We can provide an opportunity for patients in certain extreme and rare cases under strictly regulated conditions to manage their dying without endangering our reverence for life. In so doing we can provide a way to be merciful to the dying without branding those who show mercy as criminals. We can avoid the agony of family members and of physicians who must do in secret what love and compassion urge upon them and thus serve the dying while honoring the living. In many circumstances of the sort discussed here, human beings confront limits to their wisdom. We make decisions in the presence of objective uncertainty and conflicting values. Tragedy and ambiguity pervade the scene. No solutions are foolproof, infallible, or free from the possibility of abuse despite good intentions or because of ill intent. Sometimes every possible course of action makes us uneasy. We can continue to subject our own convictions to the scrutiny of others whose criticism we trust in the hope that deeper insight will dawn regarding what love bids us do for each other when life becomes a burden rather than a blessing. Meanwhile, our final recourse is to the mercy of God, who has pity on us pathetic, error-prone creatures.
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