Autonomy and Ethics in Physician-Assisted Suicide

Introduction

What is the principle of autonomy, and what role does it play in physician-assisted suicide, treatment refusal, and truth-telling? Is the decision to receive help dying — prior to the body giving out — an absolute moral consideration, and what makes such a decision a good one? There are many more questions, all of them pertinent, surrounding the assisted suicide issue, and some will be presented and critiqued through the literature available on the topic.

The Role of Autonomy in End-of-Life Care

Phillip M. Kleespies has written a book called Life and Death Decisions: Psychological and Ethical Considerations in End-of-Life Care. In his review of the book, Dr. Jack Schoenholtz insists that at this time in American history "we leave the end-of-life decision to personal autonomy" (Schoenholtz, 2004, p. 1936). Schoenholtz reports that the book is mainly for the benefit of psychologists, who should be using their skills "in conflict management, to become important members" of the team consulting on a particular person's wish to die. Referencing Kleespies, Schoenholtz writes that presently too many psychologists are "locked out" of the team of "core hospice service providers." Schoenholtz appreciated that portion of the book but criticized Kleespies for not mentioning the "major national initiatives" studying the end-of-life milieu. What Schoenholtz most appreciated was the argument that psychologists should have a prominent place in these decisions, probably alongside hospice professionals.

"Accommodations invariably infringe someone's autonomy," according to essayist Jerome E. Bickenback, and so the issue "is not whether there is infringement" on autonomy, "but whether it is justified" (Bickenback, 1998, p. 129). In Canada, the term "safeguards" in reference to physician-assisted suicide means that "procedural techniques" are in place to ensure that "the potential suicide is competent, has made the decision freely and voluntarily," and that the person is truly terminally ill and in "unrelievable pain" (Bickenback, p. 130). Moreover, in Canada physician-assisted suicide can only be carried out legally if the person in question "is physically incapable of performing the act of suicide and has adequate opportunity to change his or her mind," which returns us to the concept of autonomy. Would it be immoral to deny the right to die to a person who meets these criteria? That is a question for the state, the doctors, the families, and the field of psychology.

As for Bickenback, he insists that autonomy should be "preserved," and that if a patient has the right to autonomy, "then there is no reason, indeed we have no right, to inquire into the motivation for the decision" (p. 130). He tackles the issue directly: "Respecting autonomy does not mean respecting the right of people to arrive at correct decisions that are in their self-interest and consistent with their welfare; it means respecting their right to make whatever decision they wish" (p. 130).

Absolute Autonomy and Its Implications

Essayist Francis J. Beckwith puts his views plainly from the outset, claiming that the "most significant and influential contribution" that bioethicists have made to the issue of physician-assisted suicide is "their affirmation that a fundamental principle of medical ethics is the principle of respect for autonomy (or patient autonomy)" (Beckwith, 1998, p. 223). The principle of autonomy has been pivotal, according to Beckwith, in "empowering patients and moving medicine away from physician paternalism" (p. 223).

Beckwith quotes Dr. Jack Kevorkian, who attended a luncheon at which Beckwith was present. When asked to articulate his "underlying philosophical belief," Kevorkian answered: "it's quite simple: Absolute personal autonomy. I'm an absolute autonomist. Do and say whatever you want to do and say at any time you want to do or say it, as long as you do not harm or threaten anybody else's person or property" (Beckwith, p. 223). Many observers view Kevorkianism "as an ethical aberration," Beckwith admits, but there is "reason to believe that absolute autonomy is becoming the primary dogma by which courts, especially the U.S. Supreme Court" operate (p. 224). He quotes from the High Court's decision in Planned Parenthood v. Casey: "Our law affords constitutional protection to personal decisions relating to marriage, procreation, family relationships, child rearing… [all of which relate] to personal dignity and autonomy…" (p. 224).

Conclusion

The issue of physician-assisted suicide — and all the arguments, sidebar stories, and opinions surrounding it — will not be settled anytime soon. When psychologists, doctors, lawyers, judges, ordinary lay people, clergy, and politicians are all involved in the milieu, no certain policy is expected to emerge. But one thing is clear: the current trend points to autonomy as a necessary part of any final decision in end-of-life care.