Topics : Physician-Assisted Suicide

Terminology
Standard Arguments against Physician-Assisted Suicide
Standard Arguments in favor of Physician-Assisted Suicide
Physician-Assisted Suicide in the United States
Case for Discussion

A central question that faces the profession is the relationship of assisted suicide to the fundamental goals and values of the profession itself. As noted above, the A.M.A. holds that it is detrimental to medicine itself. There are other views. Some commentators have supported assisted suicide but still argued that it falls outside the domain of moral medical practice: they argue there ought to be others (non-physicians) who assist in death of this kind. Other commentators note that there is a plurality of views within the medical profession, and the goals of the profession ought to respect that diversity. The profession tolerates differences of opinion about, for example, the practice of abortion. Why should it not, goes the argument, also tolerate diversity in respect of physician-assisted suicide?

Terminology

Ethics has drawn up a specific vocabulary in order to clarify different kinds of action. A physician's involvement in the death of patients can fall into the following categories:

1. active, involuntary: the physician intentionally kills a patient contrary to the wishes of the patient
2. active, voluntary: the physician intentionally kills the patient in accordance with the wishes of the patient
3. passive, involuntary: the physician lets the patient die by refraining from interventions, contrary to the wishes of the patient
4. passive, voluntary: the physician lets the patient die by refraining from interventions which would be useless in any case, in accordance with the wishes of the patient

Medical ethics has traditionally accepted (d) as moral on the grounds that it is disease and not the physician who is doing the killing, treatment for the dying patient is thought to be pointless in any case, and a patient should not be subjected to interventions that bring about more harm than benefit.

The formally stated opinions of medical ethics have traditionally denied the legitimacy of (a), (b), and (c). For example, the American Medical Association has said: “. . . permitting physicians to engage in euthanasia would ultimately case more harm than good. Euthanasia is fundamentally incompatible with the physician’s role as healer, would be difficult to control, and would pose serious societal risks.” (Code of Ethics, 2.21)

In criticism of this tradition, some commentators have held that there is no meaningful distinction between “active” and “passive” involvement in a patient's death since physicians will always be “actively” involved in the outcome by reason of what they do or refrain from doing. That is, there is no pure “passivity” on the part of the physician. If this distinction between active and passive fails, these commentators go on to say, there is no morally relevant reason why physicians cannot assist patients who want to die. Respect for autonomy is thought to be the decisive issue.

1. suicide is wrong in and of itself even for the ill
2. it is incompatible with the healing goals of medicine
3. given appropriate palliative care, it is unnecessary
4. requests for death are induced by poor care and/or unrecognized psychological needs
5. the practice damages physicians by desensitizing them to human needs
6. it leads down a slippery slope to indiscriminate killing of the ill, weak, and disabled, among others

Taken either separately or in some combination, these arguments are often found powerful and convincing by physicians, moralists, and the public alike.

At present, the A.M.A. declares the profession entirely opposed to physician-assisted suicide: “Physician-assisted suicide is fundamentally inconsistent with the physician's professional role.” Instead of physician involvement in assisting the death of patients, the A.M.A. counsels physicians to tend assiduously to the pain and discomfort of the dying. “The use of more aggressive comfort care measures, including greater reliance on hospice care, can alleviate the physical and emotional suffering that dying patients experience.” [A.M.A. Code of Medical Ethics Reports 1994 (V), Report 59.] Some psychiatrists even hold that requests by patients for assistance in death are prima facie evidence of incompetence; these requests should not therefore be honored under any circumstances.

Contrary to the views expressed just above, some commentators fully accept the morality of physician-assisted suicide under limited circumstances, and there are political and judicial movements toward making the practice legal. It is widely known, for example, that the Netherlands legally tolerates physician-assisted suicide that follows certain guidelines. This practice was not the result of public referenda but the consequence of certain decisions by public prosecutors and judges.

As is the case with the case against physician-assisted suicide, certain arguments are repeated in these movements favoring physician-assisted suicide:

1. it protects people who do not want to suffer lingering, painful deaths
2. it is in keeping with respect for patient autonomy
3. it is defensible as policy because it respects social diversity
4. it protects against physician paternalism and unwanted treatment
5. it protects against debilitating conditions not easily managed by medicine
6. the state has no interesting in forcing the prolongation of life of someone in pain who wants to die

There is no moral or legal support for physician assistance in any kind of involuntary death. No serious advocate of physician-assisted suicide has argued that physicians must take part in assisting in death. Proponents of physician-assisted suicide recognize the right of individual physicians to decline to participate for religious or moral reasons. It is though sometimes argued that physicians should, regardless of their own moral views about assisted death, offer referral of patients to physicians who will help them in the desired way.

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Physician-Assisted Suicide in the United States

In 1997, the U.S. Supreme Court handed down two cases central to physician-assisted suicide: Vacco v. Quill and Gregoire v. Glucksberg. In those cases, the court determined that there was no Constitutional right to physician-assisted suicide, either on the grounds of equal protection or personal liberty. The court argued that both constitutional history and the trends of Western civilization generally worked against reading the Constitution that way. In its decision, the Court was sensitive to the prospect of unintended and unwanted consequences that might follow the recognition of a Constitutional right to assisted suicide. For example, the Court mentioned the way in which such a right might prejudice the fate of people with disabilities. Insofar as the state has the right to protect such people, the Court could not take away the tools necessary to that protection, including bars against physician-assisted suicide.

However, the court did not say that physician-assisted suicide could never be legitimate. The court noted that this question was too important to be decided once and for all through these cases, and it invited the states to reflect on the matter. In effect, the Court concluded that while there was no Constitutional right to physician-assisted suicide, the states of the Union could decide the matter for themselves.

In 1997, the state of Oregon did exactly that. After a long legislative process, a certain kind of physician-assisted suicide is legal in the state of Oregon. By following certain guidelines, physicians can prescribe overdoses to certain patients, without fear of legal action. According to the guidelines, the patients take the drugs themselves, so that physicians are not directly administering the lethal drugs. As might be imagined, the theory and the practice of physician-assisted suicide in that state are being studied closely by both advocates and proponents of physician-assisted suicide. It is too early to tell whether Oregon has paved the way for other states to accept some version of physician-assisted suicide, but states such as Washington and California have had various initiatives on the matter in the past.

It is worth repeating that it is illegal in all jurisdictions in the United States for physicians to directly administer lethal drugs to patients. Oregon permits physicians to prescribe drugs which patients them take themselves. For purposes of Oregon law, this is different from a physician injecting a patient with lethal drugs. Oregon is the only state that permits this practice, and the vast majority of states have laws that forbid assisting suicide in the way Oregon permits.

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Case for Discussion

Time for an End to Treatment?

Mr. Giovanni Mangioni, 81, has Alzheimer's disease and has lived in the same nursing home for the past 7 years. At this point he can no longer talk or walk, is incontinent of urine, and requires round-the-clock nursing care. Because of his general neurological dysfunction, he has virtually stopped eating and has begun to lose a significant amount of weight. The staff at the nursing home make the decision to feed him by inserting a thin, nasogastric tube known as a Dobhoff. Most patients tolerate this type of tube quite well, but a few find it quite uncomfortable. Whenever this tube is inserted in him, Mr. Mangioni repeatedly and vigorously attempts to pull it out, and he is usually successful. As a result, he is physically restrained and his hands are covered with mittens. He subsequently groans and struggles constantly against the restraints. Finally, a tube is surgically placed through his skin into his stomach (a gastrostomy tube) in the hope that he would be more comfortable and not require any kind of restraint. Unfortunately, he also dislodges that tubing.

Mr. Mangioni has no known family or friends. Faced with the challenges of caring for him, the health care team begins to think that they should no longer attempt to replace the tubing and that he should be allowed to die.

Study Questions

1. What are the main reasons that the health care team thinks they should no longer attempt interventions with Mr. Mangioni?
2. In what way, if any, does this case involve euthanasia? What kind of euthanasia is relevant to the kind of treatment plan proposed for Mr. Mangioni?
3. Do you think that the healthcare team would be justified to take active steps to hasten Mr. Mangioni’s death if he had left some advance directive authorizing them to bring an end to his life should he become as debilitated as he is now?

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