Physician-Assisted Suicide

By Salem, Tania | The Hastings Center Report, May 1999 | Go to article overview

Physician-Assisted Suicide

Salem, Tania, The Hastings Center Report

Promoting Autonomy--Or Medicalizing Suicide

Why have physician-assisted suicide and voluntary active euthanasia taken on such vitality in recent years? Some authors stress the conjunction of powerful medical and cultural trends. The advances of modern medicine in association with its overwhelming bias to treat have engendered widespread and increasing fear. More than death itself, what seems frightening is the very real prospect of losing control over one's own dying process.[1] The reaction to this exorbitant sway of medicine has been nourished since the 1970s: patients' empowerment or, more generally, the liberal individualism that has vigorously extended into the medical system. In response, advance directives, health care proxies, and other devices founded on the right to forgo medical treatment aim to "protect" patients from physicians, medicine, and hospitals' institutional imperatives. From the perspective of this recent history, physician-assisted suicide and even voluntary active euthanasia are just one more necessary and justified step in this process. It is as if what modern medicine has expropriated from individuals could be returned to them through physician-assisted suicide: control over their own deaths.[2]

These considerations condense two widespread current assumptions in the debate over aid in dying. The first is that these practices are, for better or for worse, paradigmatic expressions of patients' autonomy. Although proponents and opponents evaluate very differently the adequacy and the limits conferred to self-determination in this context, they both endorse this general assertion. The second assumption is that physician-assisted suicide and voluntary active euthanasia are ultimate brakes on the unrestrained use of medical technology at the end of life. They are instruments to promote the "demedicalization" of death.

I propose to challenge these assumptions. I want to argue that physician-assisted suicide does not demedicalize death; rather, it medicalizes suicide. By this I mean it transforms a private act (suicide) into a medical event. Indeed, physician-assisted suicide implies not a resistance to but an extension of medical power over life and death. And second, that instead of asserting an individual's autonomy physician-assisted suicide is in fact an impediment to it.

My analysis accepts the liberal/libertarian presumption that one of the essential attributes of the individual is precisely the liberty to govern oneself free from external constraints. Despite my belief in both the indispensability and inevitability of social constraints,[3] as an analytic device here I will assume radical autonomy to be a moral goal. I will also assume that from the perspective of the physician-patient dyad, more than killing, "assisted suicide" is literally what the phrase states: suicide with assistance, not only because it is the patient who makes the request, but also because it is she who is responsible for the final deed.

Promoting Autonomy, Demedicalizing Death

Many of those who favor physician-assisted suicide analyze and support it in reference to free choice, individual rights, and moral autonomy.[4] This line of argument rests on a conception of autonomy primarily as "negative liberty": the right to act and govern oneself in accordance with one's own private beliefs, values, and choices without interference as long as one's behavior does not harm others.[5] Proponents assert that this right should encompass patients' control over the timing and circumstances of death up to and including assistance in suicide. So conceived as a "personal and intimate decision," the right to aid in dying refers to a sphere of self-determination that should be left free from any paternalistic interference, whether that interference emanates from the state, from doctors, from family members, or from religious or philosophical orthodoxies. Physician-assisted suicide is, in short, advocated as a "natural" extension of the constitutionally protected "right to privacy," and as a mere specification of the moral right to self-determination.

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