The Value of Autonomous Choice in Physician-Assisted Suicide and Voluntary Active Euthanasia
In the wake of relatively recent technological advances in the field of medicine and health care, a number of questions arise concerning the general ethics of the use of these technologies. One of the most controversial aspects of these technological advances is their ability, in a number of cases, to prolong life indefinitely. Clearly, medicine does not claim to have the ability to stave off death in all cases, but in a significant number of situations, the question of the role of health care in prolonging or even terminating life becomes paramount, especially in the formation of public policy and in its legal ramifications.
The cases in which a discussion of the ethics involved in health care comes to the forefront often involve physician-assisted suicide and euthanasia. The keys to unlocking the arguments surrounding both of these issues involve an understanding of autonomous choice. In light of a discussion of the role of autonomous choice in these issues, it becomes clear that moral judgments can be made regardless of the legality of the actions of the participants. The morality of the action, however, is not entirely independent of its legality because of the effects on the health care community that a complicit ethical stand on both physician-assisted suicide and euthanasia might have.
An examination of the true effects of autonomous choice and its role in these two possible medical interventions yields the conclusion that an acceptance of autonomous choice creates a number of future, potentially infringing consequences, which would be nearly impossible to logically defeat if voluntary active euthanasia or physician-assisted suicide were deemed as morally acceptable. Not only does a problem exist within the realm of autonomy, but also in the legal ramifications of a moral acceptance of these two endeavors. Both problems seem to stem from the misguided acceptance of autonomous choice as a sufficient reason to terminate care, or as in the case of physician-assisted suicide, to terminate life, when unbearable suffering on the part of the patient is involved.
The most obvious difficulty in accepting the two procedures as morally correct involves the reasoning used by health care professionals who participate in the acts, whether legally or illegally. Most of these professionals, and much of the complicit public, argue that the physician’s relationship with the patient includes a respect for patient’s autonomy and duty to relieve their suffering. These aspects of the relationship are then extrapolated to justify the intervention of physicians in situations where a termination of health care will lead to death—voluntary active euthanasia—or where the physician actively aids in the suicide of the patient—physician-assisted suicide. This extrapolation proves problematic. Often, the desire to respect autonomy merges with the stated goal of relieving suffering to form a single justification: the autonomous decision made by a patient who suffers from a severe ailment to discontinue his or her life should be respected by the health care profession. To continue the point, it should not be considered morally wrong if the physician participates, in either of the manners discussed, in the termination of the patients life. Unfortunately, in this line of reasoning there lies an inherent logical flaw, which then precipitates a number of unwanted and morally questionable results.
The flaw stems from the union of the two ideas into one justification. Upon closer examination, this union becomes suspect in its validity because of the frail nature of the congruence of autonomous choice and the relief of suffering. The common view, as expressed by Daniel Callahan, illustrates the perceived link between the two notions: “It is said that a competent, adult person should have the right to euthanasia for the relief of suffering.” Logically, however, why should a competent adult, or if we assume that competence is inherent in maturity or adulthood, why should a competent person have to be suffering in order to have the right to euthanasia, or the right to request a physician-assisted suicide? If respect for autonomous choice represents the fundamental justification for physician intervention in death, why does it need the qualification of “suffering” to validate it? This question will be addressed later in the discussion.
Now, the second half of the justification must be examined. If the relief of suffering is determined to be at least one of the goals of medicine, though not necessarily the overriding goal, then why should an incompetent patient be deprived of a procedure that would lead to their death, and thus to a relief of their suffering? It seems that the aggregation of both arguments—respect for autonomy and the relief of suffering—serves only to weaken and dilute the individual arguments. To answer the previous question concerning the need to qualify the competent person as suffering to validate the justification, it seems that its inclusion serves to cosmetically enhance the image of euthanasia and physician-assisted suicide, and to prevent the inevitable decline into unwanted, morally questionable eventualities. Essentially, the flawed two-fold justification prevents a “slippery slope” digression into situations where the medical profession could be called upon to participate in instances where people without any ailments at all could request physician-assisted suicide, or where patients, unable to give competent consent could be euthanized to relive their suffering.
These two possibilities describe the fundamental problem involved in a legalization of either voluntary active euthanasia or physician-assisted suicide. While legality does not directly influence the moral assessment of an act, in this case, it plays an important role in its viability as an accepted practice. The legality of the procedures discussed does have an indirect influence on the assessment in the sense that it is the key to preventing the precipitation of the “slippery slope” consequences outlined above. Some might argue that the combination of the two stipulations prevents any slippery slope digression, and thus serve as a viable justification of either voluntary active euthanasia or physician-assisted suicide. If these stipulations remained intact, could not legislation permitting and regulating the two interventions be enacted without the danger of unwanted results? The answer seems to be emphatically negative for precisely the same reasons that preclude voluntary active euthanasia and physician-assisted suicide from being deemed moral: eventually, petitions for allowing the extreme cases the slippery slope argument presents would arise, using in their defense the argument that a relief of suffering would be attained, or more probably, that only competent consent would be necessary to enlist medical aid in the discontinuation of life.
Another counter-argument presents itself. What if autonomous choice is the only prerequisite for either voluntary active euthanasia or physician-assisted suicide? (In this situation, it seems that the term “voluntary active euthanasia” would no longer apply, since it commonly implies an underlying illness that would eventually act as the direct cause of death, but it is included here, in part, to emphasize the similarities between the two actions.) If one agrees with this line of thought, moral problems still arise concerning the involvement of the physician. Again, this is a type of slippery slope argument. It seems difficult to presume that, if public policy were structured in such a way as to allow for physician-assisted suicide on the basis of autonomous choice alone, physicians would not encounter a number of conflicts of interest, making their decisions to render these services suspect. Difficulties arise concerning the fees involved in such a health care service, especially in their source and allotment, and concerning the participation of physicians who morally reject the interventions. Would a physician or a medical institution receive payment based on services rendered, or rather as a stipend from the government? If physicians maintained the right to abstain from rendering these services, what stigmas would be associated with such an action? Essentially, in the worst case, these procedures may become mandated for physicians, violating their personal autonomy, or more probably, physicians who refused or participated in the procedure could face social repercussions that would be impossible to legislate against. The argument concerning the right to chose a physician-assisted suicide or voluntary active euthanasia arrives at an impasse if there are no outside parties, other than the patient, who concur with this choice and who will act according to the patients wishes. Asserting that a patient has a right to this choice makes dangerous headway into an infringement of the rights and ethical beliefs of the care-giver.
A final, more global point illustrates the extremity of the issues involved in assuming the right to voluntary active euthanasia or physician-assisted suicide. This point involves the fact that the decisions being made involve death, and more importantly, make certain gross assumptions about this irreversible state. In the quest to justify the two interventions, many argue that death serves as a relief to suffering, and therefore remains as a humane alternative to treatment. It seems though that this assumption is rather illogical. Without becoming mired in theological debate, it can be argued with reasonable success that science and medicine do not offer any substantive answers to the question of what lies beyond death, if anything at all. It could be argued that this is a personal question, involving the beliefs of the patient, but what are its effects on the validity of competent choice in this situation? Can a competent choice be made without any knowledge or evidence, or does the fact that everyone is on equal footing in this case allow for a relative competence? To indulge an understandably extreme, but intriguing point, could a patient or, more importantly, could a physician allow a patient to participate in a procedure where the levels of risk cannot be ascertained? Clearly, this point is curious and its argument extreme, and it is not offered as concrete refutation to the dilemma of autonomous choice, but rather as an intriguing aside to the connection between the relief of suffering and the enactment of an autonomous decision.
It seems clear that moral judgments can be made concerning the rightness or wrongness of an act regardless of its relation to the law, but it would be naive to argue that legislation and law do not, at times, influence the morality of a situation or event. Moral actions are deemed so in the context of society, and the framework of society is supported and protected by the law. If an ethical society is the goal of legislation, as it seems to be, then morality and legality are intertwined. Both actions and agents can be assessed as moral or immoral, but only the agents can be held responsible, in an attempt to ensure the prevalence of ethics. This is not to say that the law should enforce a theocracy. This would be a misunderstanding of the term “ethics.” The law would maintain an ethical society in which its members’ freedoms and liberties would be protected. In the case discussed here, voluntary active euthanasia and physician-assisted suicide constitute immoral acts precisely because of the inherent contradictions involved in the conditions under which they would occur.