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Physician-assisted suicide

Aside from abortion, there is no controversy in medicine more contentious or polarizing today than that of physician-assisted suicide.  Proponents of assisted suicide usually invoke a prototypical scenario to illustrate their position: Consider the patient riddled with widely metastatic cancer, facing an all-too-slow but inevitable death, and suffering from severe, uncontrollable pain.  Does not such a patient have a right to ask his or her physician to give them the means to end their suffering once and for all?  And does the physician not have the right to respond to that human need without committing a crime?

It is an extremely compelling question.  Accordingly, this is the kind of scenario that has been posed to the public in most polls whose results appear to show that the majority of Americans are in favor of physician-assisted suicide. Few would argue that this terminal, pain-wracked patient does not have a right to expect his physician to do whatever it took to relieve his suffering.  Few would want that physician to deny the desperate pleas of the patient.  Most would believe it unethical for a doctor to deny those pleas.

Nonetheless, with good, compassionate medical care, this very difficult clinical problem ought to be rare; it should be manageable in most cases without having to resort to assisted suicide.  In the large majority of patients with terminal pain, symptoms can be controlled with pain medication, even though the medication may need to be given in very high doses or by novel routes of administration, and even though doing so may run the risk of hastening the patient's death.  This aggressive use of pain control measures in terminal patients is not only usually quite effective, it is also entirely consistent with professional standards of behavior. It honors the autonomy of the individual patient, and does so without impinging on the rights of society. Certainly there will be occasional instances where even extremely aggressive pain management fails to adequately control pain, and leaves the patient asking for death.  But with adequate, creative and aggressive pain control efforts, such instances are very uncommon.

Unfortunately, some doctors just don't understand pain management techniques, or are too afraid to use them, and as a result too many patients are suffering needlessly as their lives draw to a close.  However, it somehow does not seem appropriate to just go ahead and kill the patient as the first option in redressing this medical shortcoming. A better approach, one might think, would be to insist on improved physician education and clear professional standards for pain control.

While the argument for assisted suicide invariably centers on relieving the suffering of terminally ill patients with intractable pain, in actual practice these are often not the individuals who seek this remedy.  By and large these were not the patients who sought out Dr. Kavorkian, the famous assistant of the suicidal. Most who requested his assistance wanted to end their lives for other reasons, commonly because they suffered from disease-related depression, a debilitating sense of losing control over their own destiny, or fear of becoming a burden to their families.  Some did not even have terminal illnesses. This is a pattern that holds up in Holland, where assisted suicide and euthanasia are acceptable as a matter of public policy.  Intractable pain is the motivator in only a decided minority of Dutch patients who ask for assisted suicide.

Whatever the real-life usage of this "therapeutic option," however, there clearly is a vigorous and often passionate movement in the U.S. in support of physician-assisted suicide. Some of the impetus for this movement undoubtedly derives from a genuine belief that individual autonomy needs to be rescued from the clutches of the unrelenting, unfeeling, smothering bio-techno-medical machine. In others it probably derives from some underlying psychological disorder. (It seems possible to me that Dr. Kavorkian, for instance, might have broader ties to pathology than merely that it was his profession.)  In still others it may be a vehicle for a political voice.  And without a doubt there are more than a few supporters of assisted suicide who have gone through the trauma of witnessing a loved one experience nightmarish end-of-life medical care at the hands of amateurish physicians.

The debate over assisted suicide is fundamentally a debate over medical ethics. The clear majority of medical ethicists seem to have come down strongly in favor of this practice, since the right to assisted suicide is so clearly a win for the vitally important principle of individual autonomy.

But while I have stressed the importance of individual autonomy throughout this book (indeed, one of my major themes is that individual autonomy needs to be saved from the ravages of covert rationing), close examination of the ethical question suggests that in the case of assisted suicide, at least under our present paradigm of covert rationing, the unbridled endorsement of end-of-life autonomy threatens to lead us precisely to where none of us say we want to go - ironically, it will lead to the coercion and devaluing of the individual.

The ethics of physician-assisted suicide

The arguments advanced by professional ethicists regarding end-of-life medicine can be difficult to follow. This is too bad, since couching ethical opinions in jargon and arcane twists of logic places the rest of us in the position of having to accept the ethical bottom line without really understanding how that bottom line was reached.  It reduces ethics to "received knowledge," and elevates professional ethicists to a priesthood.  Advancing unintelligible ethics is, well, unethical.

In any case, once you cut through the argot, here is how most of today's medical ethicists seem to regard the issue of end-of-life autonomy in general, and physician-assisted suicide (and its close cousin, euthanasia), in particular:

Point 1) We as a society have already decided that the individual patient's autonomy is the deciding factor in making decisions on ending life.  We made this decision when we formally asserted the individual's right to refuse medical treatment (and to have treatment withdrawn), even life-sustaining treatments, and even if the disease for which treatment is being refused is curable. This was the critical ethical choice for us, and we have made it.  Thus, we have already decided that passive euthanasia - letting nature take its course - is ethical if the patient desires it.

Point 2) There is no ethical difference between "passive" and "active" euthanasia.  That is, there is no difference between "letting nature take its course" and helping nature along a bit.  In one case, the doctor acts to remove or withhold life-sustaining therapy, thus hastening death. In the other case, the doctor acts to administer the means of hastening death.  In either case, the doctor has taken an action that hastens death - the two acts are ethically equivalent.

Point 3) Once active euthanasia has been determined to be ethical, there are no remaining ethical grounds for objecting to the lesser question of physician-assisted suicide. If it is ethical for a doctor himself to act to hasten death, there can certainly be no objection to his handing the patient the switch that triggers the suicide machine.  

Conclusion) Since we have already asserted the right of the patient to refuse life-sustaining therapies, ethical consistency also requires us to allow both physician-assisted suicide and active euthanasia.

As nearly as I can tell, most ethicists believe the Supreme Court was wrong in 1997 when it denied a constitutional right to assisted suicide. Furthermore, many ethicists were scandalized that the Court made a clear ethical distinction between "letting nature take its course" and hastening death, especially since it did so in the face of nearly unanimous agreement of the ethics community to the contrary.

The bottom line is that, from the standpoint of most experts, the same ethical principle of individual autonomy that makes it acceptable for patients to refuse life-sustaining therapy also renders physician-assisted suicide (and active euthanasia) entirely ethical.  Thus, there is no generally accepted ethical barrier to either.

And here is the problem I have with the analysis medical ethicists have generally advanced on this issue. By admitting that patients have the right to refuse medical therapy (and how could we, by any stretch, do otherwise?), we have embraced the principle of individual autonomy apparently to the exclusion of all else, and have instantly triggered an elaborate chain of logic that finally requires us - in order to be ethically consistent - to sanction not only assisted suicide, but also active euthanasia and who knows what else.  There's got to be another side to the story.

The other side to the story is that the right to individual autonomy simply cannot be absolute, any more than any other ethical principle can be absolute.  Ethical principles, in fact, often live in a natural state of conflict with one another. When two valid ethical principles are in conflict, we call that an ethical dilemma; and the proper job of an ethicist is to help us think about ways of resolving these dilemmas. This is best done not by completely abrogating one of the conflicting principles (since both principles are, by definition, important), but attempting to achieve a reasonable balance between the two, aimed at optimizing the overall results. When a medical ethicist says, "Sorry, my boy, but individual autonomy is all there is to it, and all other considerations can go pound salt. We have no choice but to follow the principle of individual autonomy to wherever it may lead us," as I see it he is derelict in his duties. Such ethicists can be dangerous.

It is undeniable that in any culture, the rights of the individual will inherently be in conflict with the rights of society at large.  Which rights ought to predominate will vary from society to society, and even from time to time.  In socialist countries the rights of the collective virtually always have primacy over those of the individual.  In contrast, in the United States, by our very founding documents, the rights of the individual ought to predominate - but to be predominant is not the same as being unchecked.  

Clearly, the question of physician-assisted suicide presents us with an ethical dilemma.  For insisting on absolute individual autonomy in this case will significantly impact our entire society.  Before we fully endorse assisted suicide - opinions of medical ethicists to the contrary notwithstanding - we must perform a sober assessment of how the rights of society might be impacted by it.  And the cost to society simply cannot be adequately estimated without considering that in America, our society is one in which the covert rationing of healthcare is a fundamental fact of life.