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So what should we do about physician-assisted suicide?

We should not legalize physician-assisted suicide and euthanasia, and certainly not while we're covertly rationing healthcare.  The potential for abuse is simply too high. Institutionalizing and popularizing these procedures will carry too high a price for our society.  And the ultimate price we would pay, supposedly in the pursuit of individual autonomy, ironically, is a devaluing of the worth of the individual. This is indeed a particularly precious example of the corruptive nature of covert rationing.

Does foregoing assisted suicide mean we'll need to abandon our suffering patients? On the contrary, as we have seen, turning our backs on the "easy way" should cause us to redouble our efforts to find ways of relieving the physical and emotional suffering of patients approaching the end of their lives. We've already made a lot of progress in this area.  

But what about those rare cases where terminal patients really do have intractable pain despite all efforts, and are begging to be given final relief?  I concede that there may be times when assisting suicide is the only humane course of action.  In those rare cases, the physician may reasonably conclude that her fiduciary duty to the patient should cause her to take this action for the patient's benefit, despite the law and despite potential consequences. A substantial minority of American physicians admit to having taken such action on a patient's behalf at least once.  Whether you think these doctors are heroes or criminals, at least it can be said for them that they are taking a principled action, and are doing so at their own personal risk, on behalf of and in concert with their patient, to whom they owe a fiduciary duty to at least relieve suffering, if curing is impossible.

This sort of action, of course, depends on a trusting relationship between the doctor and the patient.  It is ironic that covert rationing, which is clearly one of the forces behind the push to legalize assisted suicide, is destroying the relationship between doctors and patients that makes such intimate, trust-based actions possible.

The end-of-life controversies - conclusion

The issues surrounding end-of-life medical care are of vital importance both to individuals and to society. Perhaps more than any of the other issues we have discussed in this book, the way we handle end-of-life care will determine what kind of a people we will become in the 21st century.

End-of-life activists like to remind us that they are fighting to preserve, at almost any cost, the autonomy of individuals at the end of their lives.  But even on its face, insisting on autonomy in end-of-life decisions presents something of a paradox.  For what is death if not the ultimate reminder that the right of self-determination is, at best, a temporary gift?

"Gift" may not even be the right word here. Perhaps a better word would be "necessity."  For the ideal of individual autonomy - an ideal I have celebrated and will continue to celebrate in this book as a founding principle of American society, as our preeminent ethical norm, and as an ideal that is well worth fighting to maintain - is ultimately not nearly the highest possible good.  Our reliance on individual autonomy is not some pinnacle of ethical thought, but is merely a palliative, a partial and inadequate (though necessary) compensation for having to live in an imperfect world.  So as we finally face our exit from this imperfect world, the ideal of individual autonomy necessarily loses much of its significance.

Giving the dying patient a sense of control over their last days is a humane thing to do, and we ought always to do it, to the extent we can do so without harming society.  But to throw all other considerations to the wind, to make the dying patient's autonomy the overriding concern that trumps all others, ignores reality, ignores other things the dying patient needs more than his autonomy, is harmful to society, and calls into question our real motives.

While giving the dying patient some sense of control may be important, it is not the most important thing at that time of life. Certainly we should optimize his autonomy within appropriate bounds, but instead of encouraging a hasty exit there are things we should be doing that really need to be done.  We should offer relief from physical and emotional pain, offer help in resolving remaining issues of family or personal conflict, and offer spiritual support. We should let the dying person know that he won't be abandoned, that we will be there for him until the end.  We should let him know that, because dying is part of the human condition we all share, the fact of his dying does not make him different from us; it makes him like us, and binds us together. We are embracing him, not culling him from the herd. It is by such an affirmation of that person's continuing (indeed, everlasting) importance, and not by coercing him (overtly or subliminally) to exercise false autonomy by taking the easy way out (if not for him, then for us), that we truly honor his value as an individual.  It's the ultimate acknowledgement of his true autonomy.

Covert rationing precludes any such trust-based end-of-life care. It destroys the trust between doctors and patients, and even between patients and loved ones. It makes any solution to end-of-life care that is dependent on mutual trust utterly impossible.  Covert rationing corrupts everything it touches.

Next - Covert rationing summarized