What's Wrong with Physician-Assisted Suicide?

Charles J. Dougherty
Professor of Philosophy

1. The Arguments for It

Two arguments are commonly used in favor of assisted suicide. One is a compassion argument. Medical technology has made modern dying longer for the average patient, increasing suffering. Giving dying patients the authority to arrange their deaths can reduce this suffering. Timed properly, assisted suicide can maximize the enjoyment of life and minimize pain.

A second argument is based on autonomy. What is more personally mine than my life and my death? My ability to control my own destiny is complete only if I can arrange the end of my life when and how I choose. Taken together, the arguments from compassion and autonomy add up to a right of competent adults to have assistance in dying when they are terminally ill and suffering.

Involving physicians takes two more small steps. Physicians have the technical ability to achieve death with reduced suffering. Moreover, physicians are agents for their patients, charged to act on their behalf. When a patient's best interest dictates an expeditious death, a physician can and should act to achieve that end.

This, in outline, is the ethical case for physician-assisted suicide. To many Americans, the case is obvious and conclusive. What could be wrong with reducing suffering, enhancing autonomy, and doing both with professionals who can and should assist?

2. Reasons to Reject These Arguments

The short answer is the slippery slope created, a difficult ethical analysis to assess but one ignored at our peril in light of the unprecedented claims being made for physician-assisted suicide. Slippery slope analyses assert that consequences hardly anyone wants will follow with high probability from choices that some now consider desirable. Thus, it is morally best to avoid the first or crucial step to an inevitably bad result. Slippery slope logic is apparent in both the compassion and autonomy arguments.

Compassion is a spontaneous emotive response to suffering. Taken in itself, it is not bounded by considerations of competence or voluntariness. Many infants and children suffer. Persons with mental disabilities and dementia suffer. Perhaps some patients in comas suffer. If compassion is our guide and reduced suffering our goal, involuntary mercy killing lies at the bottom of this slope. Regulations, second opinions, substituted consent of others--all these may be brief stopping points on the slide but the destination is clear once compassion is linked to direct killing. Suffering justifies killing without the patient's knowledge or consent.

A similar slide bedevils the autonomy argument. If my life and death are truly my own, why should suicide and assistance in it be restricted to the dying who suffer? Why should it be restricted to the dying at all? Doesn't full autonomy entail a right to take my own life when and how I choose without needing permission from anyone, including physicians? At the bottom of this hill is an unconditional right to suicide.

The intersection of the compassion and autonomy arguments entails the moral acceptability of assistance in suicide when a patient is competent, terminally ill, and suffering. But the two main arguments on their own portend a future few would embrace: involuntary killing of incompetent patients who suffer (too much?) and an unconditioned right of the competent to suicide at any time for any reason. If that future is unacceptable and these arguments lead there--by however many steps and over whatever length of time--we ought to reject them now.

The role offered physicians in assisted suicide is troubling on its own. Certainly, physicians could assist at suicides. But this is nothing new. Physicians have had access to poisons since the beginning of Western medicine and have foresworn their use as incompatible with their commitments to heal and to care. Rejection of physician-assisted suicide is explicit in the Hippocratic Oath, for example.

Physicians are indeed agents for their patients. But this agency is bounded by a professional conscience that has rejected the killing of dying patients overwhelmingly and across generations. Drawing physicians into assisted suicide threatens to subvert this central aspect of the traditional ethos of medicine, with consequences none of us can begin to fathom.

3. What can be done?

The ethical arguments for physician-assisted suicide should be rejected. But the current demand for it cannot be ignored. Too many Americans have watched loved ones die long, painful deaths filled with technology but bereft of meaning. They have resolved not to endure the same. Physician-assisted suicide is their answer. If that answer is unacceptable, what alternatives are there?

Rejecting direct killing does not entail acceptance of all that medicine can do. Much of what can be done at the end of life is disproportionate in terms of the human gains and losses at stake. Patients and their families must be assured that it is morally acceptable to decline overly burdensome treatments and supported when they do. Medical technology must serve human values, not vice-versa.

Dying patients should have access to aggressive pain control. Too often dying patients are left with pains unmollified due to fatuous fears of addiction or concerns about lawsuits. Maximal comfort should be the goal. This includes the use of increasing levels of sedation, even where death is hastened, so long as the direct intent is patient care not patient death. These measures can be achieved. Advance directives and publicity about dying celebrities who have declined overly burdensome measures have made saying no increasingly possible for dying patients. More work is needed on pain control but there are hopeful signs here too.

A third measure is the most profound, hence the most difficult. Americans need a renewed religious interpretation of life, one that finds meaning in death. When death is the natural terminus of a life with a supernatural dimension, suffering and autonomy are transformed. The former becomes an opportunity; the latter, an illusion. Without this fundamental transformation, arguments for physician-assisted suicide will continue to appeal to many--in spite of the slippery slope they entail for us all.