Physician Assisted Suicide Euthanasia

Introduction
Euthanasia, and all its variations including physician-assisted suicide, terminal sedation, and involuntary euthanasia, are among the most challenging issues in bioethics. The Hippocratic Oath, the classic ethical doctrine that guides medical practice, denounces euthanasia. However, the Hippocratic Oath is an anachronistic document that serves more sentimental and symbolic functions than pragmatic, ethical, or legal ones. Euthanasia and physician-assisted suicide are both defined as the “deliberate action taken with the intention of ending a life, in order to relieve persistent suffering,” (Nordqvist, 2017, p. 1). Other factors, such as the patient’s competency (whether the patient is unconscious, conscious, or conscious but mentally or psychologically impaired) need to be taken into consideration when determining individual cases. Likewise, there have been attempts to differentiate between passive and active euthanasia, the former of which refers to the withdrawal of life support systems and the latter to the active administration of some medicine or method that terminates the life. The application of ethical theories can also shed light on the different roles the patient and the physician play in determining whether euthanasia is appropriate. Euthanasia can be approached by deontological ethics, utilitarian ethics, and virtue ethics. Whereas both deontological and virtue ethics categorically decry any type of physician-assisted suicide, utilitarian ethics provide a more nuanced, flexible, reasoned, and pragmatic approach to addressing this tricky issue.
Euthanasia in Light of Ethical Theories
Deontological Ethics
Deontological ethics are ethics based on duty or moral imperative. The philosopher most credited for explicating deontological ethics is Immanuel Kant, who wrote extensively on the specific issue of the moral legitimacy of suicide. Kant concludes that preserving one’s life should always remain an ethical duty. It therefore follows that Kant would also have agreed that it would be the physician’s ethical duty to preserve the life of patients, even if it was not their wish to do so.
In Groundwork for the Metaphysic of Morals, Kant claims outright: “It is a duty to preserve one’s life, and moreover everyone directly wants to do so,” (p. 8). This statement is problematic on two levels. The first is that if one believes that it is a “duty to preserve one’s life” in any and all situations, then Kant would say that fighting for one’s country is unethical, or also that it would be unethical for a fireman to save a baby even if it meant losing her own life. The second reason why Kant’s reasoning is wrong is the assumption that “everyone directly wants to do so.” The cases involving physician-assisted suicide and euthanasia exist precisely because not everyone wants to preserve their life. Chronic suffering can cause a person’s life to become nothing but pain, or if not pain, then any number of other problems like difficulties breathing that make daily life unbearable for those who have a disease.
However, the crux of deontological ethics is the principle of duty. For Kant, a person is acting ethically when and only when the person acts out of a genuine sense of respect for duty, respect for moral law. If the person begrudgingly acts, then their motives signal a kind of moral depravity that negates the ethical validity of the action. Following from this, Kant states “he preserves his life without loving it, not led by any want or fear, but acting from duty,” (p. 8). It is important for the patient to want to preserve life, not because the patient has been told that is what they are supposed to do. ”For an action to have genuine moral worth it must be done from duty,” (p. 9). If patients were prohibited from taking advantage of physician-assisted suicide, they would be preserving their own life only because they had no other option, not because they were acting ethically. Also, if a patient were enduring suffering because of their religious laws, their reasons or motives for acting would not be ethically sound according to Kant’s rigid ethical reasoning.
Furthermore, Kant claims “to have a duty is to be required to act in a certain way out of respect for law,” (p. 10). Euthanasia laws do vary from state to state, as well as from country to country. The deontological perspective proclaims to be universal, which makes it impossible to actually apply given the great variation in legal frameworks. Kant also attempts to show that the physician would be used as a tool, and deontological ethics expressly prohibit a person from being used as a means to an end: “If he escapes from his burdensome situation by destroying himself, he is using a person merely as a means to keeping himself in a tolerable condition up to the end of his life. But a man is not a thing,” (Kant, 2017, p. 29)
Finally, Kant does address the issue of whether it is morally permissible for a person to commit suicide when chronically ill or suffering. Kant believes that doing so would be an affront to moral duty and therefore wrong: “For love of myself, I make it my principle to cut my life short when prolonging it threatens to bring more troubles than satisfactions... couldn’t be a law of nature, and therefore would be utterly in conflict with the supreme principle of duty,” (p. 24). The problem with Kant’s deontological ethics is that it cannot take into account the wide range of people and circumstances that might come into play when judging cases involving physician-assisted suicide.
Utilitarian Ethics
Utilitarian ethics are based on the “greatest happiness principle,” (Mill, 2017, p. 2). Utilitarianism is also a type of ethical consequentialism, in which the results of an action are more important than the motives prompting it. Also integral to utilitarianism is the emphasis on happiness. Happiness is difficult to definitively define but John Stuart Mill does a fairly good job saying, happiness is “pleasure itself together with freedom from pain,” (p. 4). The most enduring tenets of utilitarianism are outlined in Mill’s treatise Utilitarianism.
One of the colloquial phrases used to describe euthanasia is “death with dignity.” The state of Oregon, for example, passed a “death with dignity” act that legalized physician-assisted suicide. This act follows from utilitarian precepts that honor a person’s “sense of dignity,” (Mill, 2017, p. 6). In fact, Mill also believed that “dignity is essential to happiness,” (p. 6). Thus, to prevent a person from dying with dignity, a healthcare worker is actually standing in the way of a person’s happiness and wellbeing. To stand by and allow another person to suffer can be considered morally repugnant and cruel. A person should have the right to a life and a death that are dignified.
Applying utilitarianism directly to physician-assisted suicide, Singer (2003) also shows why this ethical theory is the most reasonable one. First, Singer (2003) does differentiate between hedonic utilitarianism and preference utilitarianism. Hedonic utilitarianism is more simplistic in that it offers a narrowly defined view of the happiness principle. Because life has ups and downs and no one is happy all the time, preference utilitarianism is more appropriately applied to physician-assisted suicide. Preference utilitarianism states that the “right act is the one that will, in the long run, satisfy more preferences than it will thwart, when we weigh the preferences according to their importance for the person holding them,” (527). If a person’s long-term vision is to close out their life with a sense of dignity and self-respect, and if dying is a part of that plan, then dying might indeed fulfill a far higher pleasure than which could be derived from the simplistic action of fulfilling some abstract moral duty to preserve life.
Utilitarianism is also the best way of framing euthanasia because of the ethical principle of autonomy. “If beings are capable of making choices, we should, other things being equal, allow them to decide whether or not their lives are worth living,” (Singer, 2003, p. 529). In the Netherlands, which has the world’s most liberal euthanasia laws, the courts have upheld the rights of both patients and physicians to terminate life under reasonable circumstances. Great leeway is given to both patient and physician in a way that respects their individual intelligence and decision-making capacity. It is deemed completely possible for a person to make the rational choice to end life, contrary to what Kant had assumed.
Virtue Ethics
Virtue ethics also offers insight into euthanasia, but not nearly as well as utilitarianism. The principles of virtue ethics are expressed cogently in Aristotle’s Nicomachean Ethics. While virtue ethics have great value in politics and family life, when it comes to euthanasia and end-of-life choices, it has no real value except to show that it is virtuous to act with compassion. For example, Singer (2003) refers to one Dutch case in which a senior wished to die not because of a terminal illness but just because he was tired of living. At 86 years old, the man requested physician-assisted suicide and received it. “The court recognised that the doctor had acted out of compassion,” thereby deeming the act fully legal (Singer, 2003, p. 535).
However, Aristotle himself believed that any form of suicide was cowardice and therefore far from being virtuous. Aristotle states, “dying to escape...is the act not of a Brave man but of a coward; because it is mere softness to fly from what is toilsome, and the suicide braves the terrors of death not because it is honourable but to get out of the reach of evil,” (Aristotle VII). Aristotle also points out that any type of suicide is bad for the entire community: “a certain infamy is attached to the suicide as to one who acts Unjustly towards the Community,” (IX).
Objection and Response
The deontological and virtue ethics perspectives do have something valuable to offer to the debate over euthanasia and physician-assisted suicide. To be sure, physicians are not always in the position of knowing when a patient is experiencing a temporary fugue or on a genuine and long-term suffering. It is critical that legislation regarding physician-assisted suicide set out specific parameters for how doctors can assess patients properly. Some guidance could be taken from the Dutch examples, which happen to be based on utilitarian ethics and not on either deontological or virtue ethics.
Oppositions to the utilitarian perspective on euthanasia are summarily weak. Some of those arguments are based simply on religious grounds. It is perfectly fine for a religious person to refuse the right to die with dignity, just as it is fine for a person of faith to refrain from an abortion. However, it is not fine for a person of faith to impose their faith on the rest of the citizens living in their midst. People who make their moral judgments independently of religious institutions have the right to decide for themselves what promotes happiness or the greater good. Furthermore, a physician who takes a compassionate and caring view of patients will come to see that it is morally virtuous as well as categorically correct to support patient perspectives on what constitutes health, healing, life, and death.
Conclusion
Physician-assisted suicide does not need to be as challenging an ethical issue as it has been made out in the media or in the courts. A utilitarian perspective shows that euthanasia will be in line with several of the most important ethical prerogatives in medicine, including the duty to treat patients with dignity and the duty to promote patient autonomy. Ironically, deontological ethics and virtue ethics can be brought in line with utilitarian ethics to provide a reasonable guideline for best practices.




References
Aristotle. (1931). Nicomachean ethics. (W.D. Ross, Trans.). Oxford, GBR: Clarendon Press. Retrieved from http://www.gutenberg.org/cache/epub/8438/pg8438.html
Kant, E. (2017). Groundwork for the Metaphysic of Morals. http://www.earlymoderntexts.com/assets/pdfs/kant1785.pdf
Mill, J.S. (2017). Utilitarianism. http://www.earlymoderntexts.com/assets/pdfs/mill1863.pdf
Nordqvist, C. (2017). What are euthanasia and assisted suicide? Medical News Today. https://www.medicalnewstoday.com/articles/182951.php
O’Neill, O. (1993). A simplified account of Kant’s ethics. In T. Regan (Ed.) Matters of Life and Death, 411-415.
Singer, P. (2003). Voluntary euthanasia: A utilitarian perspective. Bioethics 17(5-6): 526-541.