In recent years, a great deal of publicity has been generated about "assisted suicide," especially physician-assisted suicide. In Michigan, Dr. Jack Kevorkian has assisted a number of people in killing themselves; his actions have precipitated much legal maneuvering and intense discussions of medical ethics (Kevorkian, 1991b). The book Final Exit, written and published by Derek Humphry (1991) of the National Hemlock Society, includes specific instructions on how to commit suicide. In the state of Washington, Initiative 119, which would have legalized physician-assisted suicide for terminally ill people, was narrowly defeated by voters in November 1991. A similar measure was defeated in California in November 1992. People with acquired immune deficiency syndrome (AIDS) and their friends and families are openly discussing suicide and assisted suicide. Clearly, this is an issue that has captured the interest and energy of a large number of people.
As a profession, social work must come to grips with the ethical issues and controversies involved in this topic. In a variety of settings, social workers may encounter clients struggling with issues of life and death and perhaps considering suicide or assisted suicide. Social workers in direct service in medical-surgical hospitals, nursing homes and convalescent centers, hospices, and outpatient clinics will inevitably encounter these situations. In addition, social workers on hospital ethics committees may play pivotal roles with regard to assisted suicide in the years to come. This article explores various aspects of the issue of assisted suicide, especially in relationship to social policy.
SELF-DETERMINATION VERSUS CLIENT WELL-BEING
One of the central ethical positions of social work is self-determination. Loyalty to this conviction has led many social workers to support assisted suicide (Levy, 1992). After all, it is argued, if an adult chooses to end his or her life, is that decision not the ultimate manifestation of the individual's right of self-determination? The NASW Code of Ethics (National Association of Social Workers [NASW], 1994) states that "The social worker should make every effort to foster maximum self-determination on the part of clients".
However, another central social work value has always been the well-being of the client. Sometimes a client's self-determined wishes and his or her well-being are in conflict with each other, and this conflict makes it difficult for an ethical social worker to know how to proceed (Freedberg, 1989; Loewenberg & Dolgoff, 1992).
A small body of literature has grown up over the past several decades focusing on the possible conflict between a client's wishes and the social worker's conviction about what is best for the client. A brief review of this literature may shed some light on the issue of assisted suicide as a contemporary example of this dilemma.
Environmental Limitations to Self-Determination
Almost 30 years ago, Perlman (1965) wrote that self-determination was "nine-tenths illusion, one-tenth reality". She was referring to the numerous limitations to true self-determination that all of us face, and especially clients with limited resources. Everyone, she said, was limited by both inner constraints such as lack of ego strength and outer constraints such as limited alternatives. Nonetheless, she argued that self-determination was a goal that was an end in itself, not a means to some other end. To give up the elusive goal of self-determination meant to give in to a dehumanized view of people as animals or machines.
Perlman's (1965) external and internal limitations did not mean that clients might choose poorly, and thus place a social worker in a professional dilemma, but rather that modern psychology and modern science seemed to indicate that people are the products of numerous powerful forces they are relatively helpless to resist. Thus, genetics, environment, circumstances, and past experiences make up a social "determinism" that dictates our desires, needs, and preferences. Nonetheless, she stated that social work must attempt to foster self-determination whenever possible, because "as we do this we build into each man's sense of himself as a person and affirm his worth as a human being".
Focusing more specifically on the issue of the conflict between self-determination and the social worker's judgment about a client's best interest, Kapp (1988) argued that except for a few narrowly defined exceptions, social workers must resist the temptation to force services on elderly clients who refuse them. He too endorsed the intrinsic value of self-determination and argued that in the case of older adults, social workers should do everything in their power, in most cases, to heed the wishes of the client.
Legal Limits to Self-Determination
Kapp (1988) discussed the issue of competence. Legally, competence is defined as "the ability to understand the nature and consequences of a proposed course of action" (Robertson, 1985, p, 562). A client who is competent presumably possesses the ability to weigh the various factors in a given situation in the process of coming to an informed decision. Given that he or she is competent, an individual has the right to make his or her own decisions. He or she may accept medical care, for example, or refuse it. But competence is a vague concept, …