Euthanasia and Physician-Assisted Suicide

Overview

Defining Key Terms

Let me begin by introducing some terminology. (If this terminology seems confusing, just roll with it. Philosophers debate how we should understand these terms.)

It is common to distinguish between euthanasia, physician-assisted suicide and terminal sedation. Terminal sedation is legal in all 50 states. Terminal sedation (or palliative sedation) is when a terminally-ill person is induced into an unconscious state for the purpose of relieving unbearable pain and suffering. This is the standard end-of-life care provided by Hospice. Those who condone terminal sedation but not euthanasia note that the doctor’s intention is performing terminal sedation is to relieve pain and not to hasten the death of the patient (euthanasia). (Philosophers who support patient’s rights find this to be merely a verbal distinction.)

It is also common to distinguish between passive and active euthanasia. Passive euthanasia is the cessation of extraordinary treatment at the patient’s request. The paradigm case here is removing life support and letting nature take its course. With active euthanasia the doctor plays a causal role in bringing about the death of a terminally ill patient. The paradigm case here is injecting the patient with a lethal dose of medication. Those who agree with passive euthanasia but not active euthanasia argue that the doctor’s intention in passive euthanasia is to honor the patient’s right to refuse treatment and not to hasten the death of the patient. Active euthanasia is wrong, some say, because it is the intentional termination of life and that doctors should not be in the business of killing patients.

It is also common to distinguish between euthanasia and physician-assisted suicide. In euthanasia the doctor plays a causal role in bringing about the death of the patient—either by removing life-sustaining treatment (passive euthanasia) or by pushing a lethal dose of medication (active euthanasia). Physician-assisted suicide is when the doctor gives the patient the means to end his or her life. Physician-assisted suicide is legal in five states (Oregon, Washington, Colorado, Montana and California). It is legal in these states for physicians to write a prescription for life-ending medication. The patient must take the medication himself or herself.

Oregon Death with Dignity Act

In 1994 Oregon became the first state in the U.S. to legalize physician-assisted suicide. After three years of legal challenges, the Oregon Death with Dignity Act became law. Residents of the state of Oregon who are terminally ill and within six months of imminent death (in the professional judgment of two physicians), who are competent of mind and who are in unbearable pain and suffering (by their own estimate) may request life-ending medication from their physician.

The newspaper article by John Schwartz and James Estrin tells the story of Arthur Wilson, 86 a World War II and Korean War veteran who has been diagnosed with a terminal illness. Wilson requested and received the lethal dose of medications, according to the Oregon law. His story is interesting: Wilson estimates that there is less than a 50 percent chance that he will ever use the medication; it’s that having the medication gives him a choice, a sense of control over his situation.

The core question in this module is this: Should terminally-ill, competent patients have the right to choose the circumstances of their death?

In the years immediately following passage of the legislation in Oregon, there was much fear-mongering:

· We can’t allow physicians to prescribe life-ending medication to terminally-ill patients because if they start prescribing the medication to terminally-ill patients they will start killing healthy patients, perhaps some against their will.

· People who are merely depressed may seek the “right” to die.

· The law will weaken physicians’ commitment to provide optimal care for dying patients.

· There will be widespread abuses, particularly with the nation’s poor and under insured.

In the 16 years since the Oregon Death with Dignity Act has been implemented, none of these fears have been realized. In fact, one of the biggest surprises since the legislation has been implemented has been the small number of patients who make use of the life-ending medication.

Dan Brock

Brock supports voluntary active euthanasia. He thinks patients who are competent of mind should have the right to choose the manner of their death. Two core principles in biomedical ethics support the right to choose: (1) the principle of autonomy, and (2) the principle of wellbeing.

The first is the principle of autonomy (also called the principle of self-determination). This principle gives patients the right to refuse unwanted treatment. Brock thinks this principle also gives terminally ill patients the right to choose the time and place of their deaths. The principle of autonomy says it is not the government’s place to make end of life decisions for competent adults. Such decisions should be left up to the individual.

The second principle that Brock appeals to in support of active euthanasia is the principle of wellbeing. Brock notes that this principle may at first seem to conflict with the principle of self-determination in cases where the patient requests euthanasia. But this conflict arises only for those who think that life is the ultimate good. But for people who are in unbearable pain, death can be more appealing than life. “Life is no longer considered a benefit by that patient, but has now become a burden” (p. 647).

As Brock notes, most of those who oppose euthanasia acknowledge that there are cases in which patients welcome death as the end of suffering. However, these critics argue that it is still wrong. Active euthanasia is the direct and intentional killing of an innocent human being. If killing innocent people is always wrong, then active euthanasia is also wrong.

Brock argues this line of reasoning is confused. He asks us to consider the case of a patient on a respirator. She is competent of mind and finds her situation unbearable. There is no chance that she will recover and breath on her own again. She is persistent in her request to be removed from the respirator, even though she knows that she will die. All agree that the patient has a right to refuse treatment. In this case, the physician has a duty to unplug the respirator. In this situation, the doctor is commonly said to have “let the patient die”.

But Brock asks us to suppose further that the patient has a greedy son. The son thinks his mother will never agree to pull the plug. He is afraid that his inheritance will be dissipated by a lengthy and costly hospital stay. So he goes into her room and turns off the respirator. She soon dies. When the hospital staff realizes what has happened, they confront the son. But he replies, “I didn’t kill her. I simply let her die.”

Brock’s point here is that if the son can’t use the excuse, “I simply let her die,” then the doctor can’t use this excuse either. The point is that the removal of the respirator was the direct cause of the patient’s death. Brock argues that some killings are ethically justified. When the doctor removes the respirator, he kills the patient. And this killing is ethically justified. Voluntary active euthanasia is the killing of a patient. But it is an ethically justified killing.

To generalize the point, Brock thinks there is no ethical difference between killing and letting die. Suppose, for instance, that I know you cannot swim. We are out on a boat. I push you into the water. You drown. Here we would say that I have killed you and not that I simply let you die. But suppose, next, that you slip and fall into the water. I refuse to toss out the flotation device. Here we might say that I let you die. In the first case we would say that I killed you. In the second case we would say that I let you die. It really doesn’t whether we describe it as “killing” or “letting die”. I have still done something (or failed to do something) that has resulted in the death of an innocent person. In both cases, I have acted reprehensibly.

Brock next turns his attention to the institutionalization of voluntary active euthanasia. Brock is a utilitarian. He asks whether the good outweighs the bad at the level of public policy. What are the good consequences of legalizing euthanasia? First, Brock notes that legalization would allow medical professionals to respect the patient’s right of self-determination. Competent adults have the right to make their own end-of-life decisions, free of coercion from their medical practitioners or the federal government.

Second, legalizing euthanasia would benefit a wider group of people. Polls show that the majority of Americans support active euthanasia. Most Americans think euthanasia should be an option for terminally-ill patients. Yet few report they would utilize euthanasia themselves. By legalizing euthanasia, people can rest assured that if they ever wanted it, euthanasia would be a legal option. Think back about the case of Mr. Wilson. He didn’t want to die. He wanted a sense of control over his death. Having the medication in hand gave him a sense of control that his failing health had striped from him.

Third, legalizing euthanasia would reduce the amount of pain and suffering people experience. This is the argument from mercy. There are patients who experience unbearable pain in suffering in their final weeks and days. Legalizing euthanasia would give them the option of a quick and painless death.

The fourth and final positive consequence of legalizing euthanasia is that once the patient has accepted the inevitability of death, a quick and painless death is more humane than a protracted death full of suffering. People who die quickly or die in their sleep are said to have a “good death”. People who suffer through a prolonged death from say, bone cancer, are said to be unlucky. For some people suffering from prolonged illness, euthanasia may be a more humane option.

Having reviewed the good consequences of euthanasia Brock turns his attention to the bad consequences of euthanasia. Since he supports voluntary active euthanasia he needs to explain why the bad do not outweigh the good. The first bad consequence of legalizing euthanasia is that it is contrary to the role of the physician. The fundamental job of the physician is to heal. Permitting physicians to perform euthanasia would be incompatible with their role as healers. Some philosophers go so far as to say that legalized euthanasia would undermine the trust society places in physicians. They say that the “moral core” of medicine is under attack. If doctors are permitted to kill, patients will fear going to the doctors.

But how convincing is this claim? Brock notes that if euthanasia were truly voluntary, then no rational agent would have grounds to fear. Another point Brock could have made is that the core duty of physicians is not to heal; the core duty of physicians is to inform patients of their condition and educate them about possible interventions. The patient, on this view, has the final say in selecting the course of treatment. Let me also point out that doctors have been killing since 1973. Yet it is far from clear that permitting abortion has undermined the moral core of medicine. Pregnant women still seek prenatal care despite the fact that there are doctors who perform abortions.

The second bad consequence of legalizing euthanasia is that it would weaken society’s commitment to providing optimal care to dying patients. As Brock notes, health care is constrained by cost. If euthanasia is significantly less expensive than prolonged treatment, then society might become less committed to providing expensive, long-term care to dying patients.

Is this a good objection to legalizing euthanasia? Brock doesn’t think so. He notes that in areas where euthanasia is legal, very few people actually use it. Note, also, that Brock only supports voluntary active euthanasia. If patient’s are refused appropriate palliative care and other treatment (in the hopes that they will opt for euthanasia) then this isn’t voluntary euthanasia. This is coercion.

The third bad consequence of legalizing euthanasia is that legalization may serve to weaken patient’s rights to refuse unwanted medical treatment. There are many in the medical field today who uphold patient’s right to refuse treatment but who also oppose euthanasia. If patient’s right to choose entails the right to decide one’s own death, then those who support the patient’s right to stop treatment may withdraw their support.

Brock finds this objection unconvincing. Patients’ rights to refuse treatment has been established by both medical practice and law. In countries that permit euthanasia, clear safeguards are set in place to prevent abuse.

The fourth bad consequence of legalizing euthanasia is that it would give patients yet another option, and sometimes more options can mean more stress. Typically, continuing on is a given. But if patients are given the option to “check out” denies them the default option of continuing on. Thus the option of euthanasia leaves some patients less well off. Brock rejects this objection on the grounds that the majority of Americans support giving competent patients the right to make their own choice. It would be odd if the majority of Americans supported a social policy that left them worse off.

The fifth and final bad consequence of legalizing euthanasia is that it would lead to abuse. As Brock notes, this is the most serious objection to voluntary active euthanasia. Critics who run this line of argument accept that there are cases where euthanasia is appropriate—where the patient is genuinely competent of mind, where the patient is in unbearable pain and suffering and the patient freely chooses euthanasia. But given the possibility of abuse, the state should not permit euthanasia in any case.

I want to note that Brock’s essay was published in 1992. Back then, there were questions about whether the safeguards put in place in states such as Oregon were sufficient to protect dying patients from coercion. Indeed, people back then thought that the uninsured and the underinsured would be subtly pushed into euthanasia as a means of defraying some of the cost of providing long-term palliative care. However, it has been 15 years since Oregon instituted the Death with Dignity Act. In that time there has not been a single case of coercion. The majority of patients who get the life-ending medication never use the medication. It is interesting that people who opt to get the script filled have higher than average education and higher than average income. This shows that it is not the poor who are availing themselves of this option; it is the upper middle class.