Jack Kevorkian also known as “Dr. Death,” a name given to him due to his efforts in helping over 130 terminally ill people commit suicide, was one of the first physicians to make euthanasia and physicians-assisted suicide (PAS) what it is today. Since the 1990’s his methods have been criticized by many due to evidence showing that some patients were not terminally ill. He was a pioneer and it is due to his efforts that PAS is becoming more accepted today. He invented different devices to perform PAS, note Dr. Kevorkian was not the one to “flip the switch” that began this lethal process, which took only six minutes; instead it was the patient, aware of the timer that would release potassium chloride after they became unconscious, who started the process.
Dr. Kevorkian wanted to give people the option choose between living in pain or putting an end to it in their own terms. This example attracts several issues regarding the morality of PAS and euthanasia. PAS and euthanasia are two different terms yet many regard them as the same in moral discussions.
Euthanasia is the term used for mercy killing and is not the same as suicide. There are different forms of euthanasia, which are passive or active and voluntary, involuntary or non-voluntary. The difference between voluntary, involuntary and non-voluntary euthanasia is exactly what it sounds like, voluntary patients grant permission to perform euthanasia, involuntary patients refuse permission to perform euthanasia, and non-voluntary patients are unknown because they are not in a conscious state to grant or deny permission.
Voluntary euthanasia on the other hand is with the consent of the patient to end his or her own life. The difference between active and passive euthanasia has to do with how the patient dies. Active implies that a specific action from the hands of the physician kills the patient, such as a medication. Passive euthanasia or withholding treatment, is when the patient knowingly dies from natural causes because he or she has denied medical treatment that could have kept him or her alive longer.
Many see passive euthanasia as something acceptable because no person or medical treatment in particular can be held accountable for the death of a patient, only natural death is responsible. There is debate about which of these labels PSA falls under. Some argue it is a form of passive voluntary-euthanasia because the physician is not physically assisting the patient with her death. However, a prescribed lethal dosage of medication is not a natural death for anyone; therefore others view PAS as active-voluntary euthanasia.
A third group sees physicians assisted suicide in a category of its own because the patient, takes it upon themselves to commit the actual act instead of relying on the hands of someone else. The question and main aim that will be addressed is whether PAS and euthanasia are morally permissible. I will first present a couple of arguments for and against these treatments. After discussing both sides of the argument, I will present my conclusion on the morality of physicians-assisted suicide and euthanasia. There are many arguments today that oppose physicians-assisted suicide and euthanasia.
Some of the arguments are specific to the United States because they depend on the structural limitations of our health care system. In this first chapter I will examine the two most prominent stances that argue against PAS and euthanasia. I will focus on Hippocratic Oath that every physician must follow. Then on how our society can provide better alternatives for end-of-life treatment. For many people in the United States there is an important moral distinction between the two terms ‘killing’ and ‘letting die’. The term ‘killing’ has a negative societal connotation.
According to philosophers Gert, Culver and Clouser, killing means, ‘causing death’1 and is not morally permissible, with the exception of self-defense and in United States capital punishment. Gert, Culver and Clouser argue that the doctor-patient relationship is based on the historic and social assumption that the role of doctors is to keep their patients alive and healthy. There is no wiggle room or exceptional cases to this ethical rule. Doctors cannot ‘kill’ their patients because this would be in direct opposition to their jobs as physicians.
This vision of a physician’s professional duty dates back to the Hippocratic Oath in ancient Greece that forbade its members—a portion of the physicians at the time—to kill any of their patients. It states: “I will neither give a deadly drug to anybody if asked for it, not will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art. I will not use the knife, not even on suffers of stone, but I will withdraw in favor of such men as are engaged in this work. ”2 The Hippocratic oath stablished the beginning of medical ethical standards that does not allow physicians to kill their patients. This excerpt is the focal point that many doctors and medical ethicists refer to as the foundation for their work. Although PAS today requires drugs that were not available at the time the Hippocratic oath was written, the passage nevertheless undermines the basic concept of assisted suicide. Since the Hippocratic oath restricts physicians from ‘killing’ their patients, it is necessary to create a distinction between ‘killing’ and ‘letting die’ because circumstances where patients are allowed to die do not qualify under the oath.
According to the arguments of philosophers Felicia Cohn and Joanne Lynn, there are better alternatives to PAS and euthanasia that do not involve sacrificing the patient’s life. However, in order to reach these alternatives, we need to redirect the focus of medical care in our country to concern ourselves more with the terminally ill instead of discarding. Due to the extent in quality of medical care that our country has at its disposal with options such as hospice care and palliative care, there should be no reason for doctors and patients to resort to killing.
Palliative care is medical treatment that reduces the pain and suffering of a disease, no matter if the disease is fatal or not. Treatment deals with the reduction of the symptoms of a disease and not with the disease itself. It is about making the patient with the disease as pain-free and suffering-free as possible. Hospice care is a more specific type of palliative care because it too does not treat or cure illnesses but its focal treatment is comfortable end of life treatment. Most patients who receive hospice care are usually dying from terminal illness such as HIV/AIDS and cancer or even simply old age.
This is the point in a patient’s illness that he decides to no longer receive treatment to cure an illness. Instead he accepts his death is near and hospice care is available to make it as comfortable as possible, both physically and psychologically. Cohn and Lynn argue that our health care system needs to rearrange its priorities to take better care for those with terminal illness. They say that currently there is insufficient care and attention paid to terminally ill patients. Once that is fixed, there will be no excuse or reason for PAS.
One of the main reasons patients seek PAS is to avoid the pains and physical suffering caused by terminal illness or to stop their current suffering. However, with medical technology today the standard of care has increased to encompass many means of dealing with suffering from physical pain. Physical pain is much more commonly treated today than it use to be with medicines such as morphine and services like around the clock nurse care. Therefore pain is not sufficient ground for PAS. Another aspect of hospice care is the psychological treatment of the patient’s family members.
The decision to withhold treatment is a difficult one to deal with as a family because the death of a loved one is a near and inevitable fate. Hospice-palliative care encompasses all aspects of comfort, physical and psychological for every member affected. These two general arguments represent opposition to physicians-assisted suicide and euthanasia. There are variations of more specific arguments from different philosophers, but they all maintain the general principles of better alternatives that eliminate the need for PAS or euthanasia, and the moral responsibility of physicians to keep their patients alive.
Just as there are arguments against PAS and the different forms of euthanasia, there are several groups of arguments about the moral acceptability of the practice and favor for their legalization in the United States. This position has two groups of arguments: a different perspective of physician and medical care’s beneficent responsibility; and the importance of the difference between pain and suffering. One of the main arguments against PAS and euthanasia is based on the societal standard of a physician’s responsibility to her patient.
The Hippocratic Oath denies that a physician can cause the death of her patient. However, Gregory Pence points out in his book Medical Ethics that at the time of its creation, the Hippocratic Oath only applied to a small number of physicians who belonged to an exclusive society. During this time there were many other doctors that morally permitted assisted suicide in their practice. In fact, it was common for a physician to assist in the death of a patient to ease their suffering and pain.
In the same way that there were different standards of moral practice in ancient Greece, there are different standards of a physician’s duty amongst American citizens today. There are citizens who believe is it equally as important for a doctor or medical staff to act on behalf of his patient’s desires, whether that be to continue treatment or assist in end-of-life treatment. In the article Physicians, Assisted Suicide, and the Right to Live or Die by Rosamond Rhodes, physician responsibility is not understood o strictly prevent death, but to act for the good of the patient. (17) Rhodes considers the duty of beneficence to be the most important and morally binding aspect of a physician duty. He defines beneficence as the moral obligation to act for the good of someone else. When it comes to the specific case of doctor-patient relationships, the duty of beneficence can mean several different things: 1) doctors have an absolute duty to prevent pain and death to their patients, doctors should do what is in the best interest for their patient while respecting their wishes.
Arguments similar to Rhodes’ introduce this second duty, which also considers respect for the patient as another important aspect of the doctor-patient relationship. Rhodes cites the American Medical Association’s Principles of Ethics regarding these two duties, “A physician shall be dedicated to providing competent medical service with compassion and respect for human dignity. ”18 In most medical cases patients and doctors do not have conflicting interests or desires. The standard situation or assumption is that an individual enters/stays in a hospital for medical treatment to get healthy.
However, in the case of PAS and voluntary-passive or active euthanasia, a patient no longer wants to keep on living. Rhodes argues that if we assume that a physician’s primary responsibility is beneficence and in that it must take into account the dignity of the patient, then a physician does not necessarily have two conflicting duties as it might first appear. Rhodes says that our medical care currently runs on a ‘needs-based’ system in that, “The more assistance a needy person requires, the greater the amount of assistance that must be given. (19) His examples include the degree of assistance a sick person is given based on her need. When a patient needs medication yet has the abilities to take the medicine on their own, a doctor prescribes a dosage and it is up to the individual to purchase and take the prescribed medication. When a patient is so sick she no longer has the abilities to take the medication or capacity to administer proper treatment such as surgery or hospitalization, the physician must meet the increased demand of treatment.
Similar to when physicians have the moral and professional responsibility of beneficence to meet patients’ needs for more extensive treatment due to pain and suffering, they are equally responsible under this duty to meet the needs of preserving patient dignity and/or respecting patient autonomy. 20 Rhodes argues that physicians should fulfill these three needs based on the moral and professional obligation of beneficence. Therefore, both PAS and euthanasia are morally justifiable acts when there are no better options available to fulfill the need of dignity and autonomy.
Although Rhodes is an advocate for PAS and euthanasia, he also believes alternatives must be exhausted before the final decision can be made. Such alternatives are psychological treatment to make sure patients are not depressed with a skewed desire or pain management options if that is the desired goal. With this said, it only furthers his reason why physicians are best fit to perform PAS and euthanasia; they are the most knowledgeable of medical history and alternatives for their patients. Many opponents to PAS and euthanasia make the claim that we have sufficient pain treatments with palliative-hospice care and other forms of medical care.
Morphine is a commonly used drug to treat severe physical pain; however, opponents fail to recognize the difference between physical pain and psychological suffering. In chapter 3 of Physician Assisted Dying by Pence, he establishes two arguments regarding pain and suffering as sufficient reason for PAS and euthanasia. The first is that suffering can be both a physical and mental experience for a patient. It is also far more difficult to treat mental suffering compared to physical due to the limits of medication. Forms of mental suffering can include but are not limited to helplessness, stress, exhaustion, terror, and loss.
These forms of mental suffering do not always mean that a patient is facing depression. This distinction is important to make because depression is not argued by any to be a reason for PAS or euthanasia. Since mental suffering is much more difficult to treat with medication than physical pain, it is should be reason enough for a patient to no longer wish to carry on. The second argument by Pence for pain treatment, if it is physical, is when pain management goes too far. The known risk of morphine with patients facing excruciating amounts of pain is that it can induce a coma.
Some patients would rather face death if their pain were so strong that it runs a high risk of putting them in a coma. There is no point to surviving in a vegetative state because the person has no brain function and cannot experience life like a human. Patients see PAS and euthanasia as a positive experience in this respect. In summary, the arguments in favor of PAS and euthanasia are strongly based on the assumed importance of patient autonomy and the patient’s evaluation for quality-of-life and dignity. Variables for this evaluation include physical pain, psychological suffering and expectations for medical treatment.
The patient is regarded as the most important judge in end of-life care while the physician is morally and professionally responsible—according to the beneficent role discussed by Rhodes—for assisting when needed. Physicians-assisted suicide and euthanasia are clearly commonly discussed topics in the medical ethics field. Technological advances in medical care and major causes of death in the United States are big factors in why patients live longer and suffer more in the end stages of life than they did in the past. With these developing ethical problems, our medical ethics need to be reevaluated to better deal with these recent changes.
The state of Oregon has made important moral reconsiderations by legalizing PAS with strict legal safeguards, but that is only the first step. More states need to allow their residents the autonomous decision of how to end their lives and Oregon legislature should be aware of the moral equality of PAS and euthanasia. I propose that the moral values we place on the physical actions of PAS and euthanasia are misdirected and that focus should instead be targeted at the reason for the action and the intended result of the action.
All the while, physicians are morally responsible to respect patient autonomy through their guiding professional principle of beneficence. Physicians also need to ensure that patients are capable, aware agents of their own decision to end life and act freely and rationally. With the proper legal and moral safeguards for PAS and euthanasia, there is no need to be concerned that society is going to fall down the slippery slope that will force the elderly, disabled or anyone unable to meet the standards of an agent to kill themselves.
Physicians-assisted suicide and voluntary-active euthanasia are practiced out of a physician’s professional concern for the well-being of his patient, and there are circumstances where ending life can be in the patient’s best interest. My argument is not that patients should kill themselves, but that it is morally right they have the option to end their lives or seek the best alternative to end-of-life care; this makes PAS and euthanasia morally permissible in medical practice.