Euthanasia and Physician-Assisted Suicide: An Ethical Analysis

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 referring to the withdrawal of life support systems and the latter to the active administration of some medicine or method that terminates 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 through deontological ethics, utilitarian ethics, and virtue ethics. Whereas both deontological and virtue ethics categorically decry any type of physician-assisted suicide, utilitarian ethics provides a more nuanced, flexible, reasoned, and pragmatic approach to addressing this difficult issue.

Euthanasia Through 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 is the physician's ethical duty to preserve the life of patients, even if it was not their wish to be kept alive.

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. First, if one believes that it is a "duty to preserve one's life" in any and all situations, then Kant's logic would imply that fighting for one's country is unethical, or that it would be unethical for a firefighter to save a child even at the cost of her own life. Second, Kant's reasoning rests on the assumption that "everyone directly wants to" preserve their life. The cases involving physician-assisted suicide and euthanasia exist precisely because not everyone does. Chronic suffering can reduce a person's life to nothing but pain, or if not pain, then other debilitating conditions—such as difficulty breathing—that make daily life unbearable for those living with serious illness.

However, the crux of deontological ethics is the principle of duty. For Kant, a person acts ethically when, and only when, that person acts out of genuine respect for duty and moral law. If the person acts begrudgingly, 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, therefore, that the patient want to preserve life—not merely because they have been told to do so. "For an action to have genuine moral worth it must be done from duty" (p. 9). If patients were prohibited from choosing physician-assisted suicide, they would be preserving their lives only because they had no alternative—not because they were acting ethically. Similarly, if a patient endured suffering for religious reasons, their motives would not qualify as ethically sound under Kant's rigid framework.

Furthermore, Kant claims that "to have a duty is to be required to act in a certain way out of respect for law" (p. 10). Euthanasia laws vary from state to state and from country to country. Deontological ethics proclaims to be universal, which makes it impossible to apply consistently given the wide variation in legal frameworks. Kant also argues that allowing euthanasia would reduce the physician to a mere tool—and deontological ethics expressly prohibit using a person 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 addresses whether it is morally permissible for a person to commit suicide when chronically ill or suffering. He concludes 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... [this] couldn't be a law of nature, and therefore would be utterly in conflict with the supreme principle of duty" (p. 24). The fundamental problem with Kant's deontological ethics is that it cannot account for the wide range of people and circumstances that arise in cases involving physician-assisted suicide.

Utilitarian Ethics and End-of-Life Decisions

Utilitarian ethics are grounded in the "greatest happiness principle" (Mill, 2017, p. 2). Utilitarianism is also a form of ethical consequentialism, in which the results of an action matter more than the motives prompting it. Central to utilitarianism is an emphasis on happiness—a concept that is difficult to define but which John Stuart Mill describes as "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). To prevent a person from dying with dignity is therefore to stand in the way of that person's happiness and wellbeing. To allow another person to suffer needlessly can be considered morally repugnant and cruel. A person should have the right to a life and death that are both dignified.

Applying utilitarianism directly to physician-assisted suicide, Singer (2003) also demonstrates why this ethical theory is the most reasonable one. Singer distinguishes between hedonic utilitarianism and preference utilitarianism. Hedonic utilitarianism is more simplistic, offering 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 holds 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" (Singer, 2003, p. 527). If a person's long-term vision is to close out their life with dignity and self-respect—and if dying is part of that plan—then dying might fulfill a far higher order of meaning than could be derived from abstractly fulfilling a moral duty to preserve life.

Utilitarianism is also the most apt framework for 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 among the world's most liberal euthanasia laws, the courts have upheld the rights of both patients and physicians to terminate life under reasonable circumstances. Considerable leeway is given to both patient and physician in a manner that respects their individual intelligence and decision-making capacity. It is considered entirely possible for a person to make the rational choice to end their life—contrary to what Kant had assumed.

Conclusion

Physician-assisted suicide does not need to be as challenging an ethical issue as it has been made out to be in the media or in the courts. A utilitarian perspective shows that euthanasia aligns 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 ultimately be brought into alignment with utilitarian ethics to provide a reasonable guideline for best practices in end-of-life care.

References

Aristotle. (1931). Nicomachean ethics (W. D. Ross, Trans.). 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 (pp. 411–415).

Singer, P. (2003). Voluntary euthanasia: A utilitarian perspective. Bioethics, 17(5–6), 526–541.