Final Act: Sorting out the Ethics of Physician-Assisted Suicide

Article excerpt

The question of whether a physician should assist a patient with an intolerable terminal condition to end his or her life has been debated since the practice of medicine began. Philosophically, it's been a toss-up: Plato, Thomas More, Francis Bacon, David Hume, and Jeremy Bentham approved; Aristotle, Thomas Aquinas, Roger Bacon, John Locke, and Karl Marx did not.

In the United States, patients now generally have a legal right to refuse treatment, and physicians can honor advance directives and surrogate decisions. So physicians currently with, hold or withdraw treatment--respiratory support, CPR, dialysis, sometimes nutrition and hydration--thereby allowing patients to die. Studies indicate that, as of 1991, roughly half of the deaths in hospital settings in nonemergency cases involved some form of withholding or withdrawing of treatment. A 1989 study reported that 85 to 90 percent of critical-care physicians -are withholding or withdrawing life-saving or life, sustaining treatment from some patients.

The "legalization" of euthanasia in the Netherlands has been widely discussed and often misinterpreted in the United States. As recently codified by the Upper Chamber, Dutch law now makes euthanasia illegal except in cases where the patient has explicitly requested it and there is no medical alternative for the relief of his or her condition. All cases are to be reported to a medical examiner who, in turn, reports them to a civil prosecutor who makes a decision concerning whether the criteria for exemption from prosecution were fulfilled. Reports in the American press of widespread involuntary euthanasia are therefore misleading. These reports are based on the Remmelink study, which was undertaken by a committee appointed by the Netherlands government. The Remmelink study counted as cases of involuntary euthanasia any instance in which life-support systems were withheld or withdrawn without the direct and explicit consent of the patient (as discussed above, a practice which is already far more widespread in the United States). Ironically, the Dutch actually appear to be less troubled by physician-assisted suicide when there is an explicit request by the patient but more troubled by the practice of withholding treatment and allowing a patient to die without such a request.

Many physicians and philosophers here draw a distinction between active and passive treatment and take the position that it is morally acceptable to allow a person to die "naturally" but unacceptable to do anything that hastens the process or brings about death. This is the kind of moral double-think that can give medical ethics a bad reputation. A number of years ago, philosopher James Rachels posed the following hypothetical situation: suppose Jones, who stands to inherit a fortune if his six-year-old nephew dies, goes into the bathroom while his nephew is in the bathtub and holds the boy's head underwater until he drowns. Now suppose another man Smith, who also stands to inherit a fortune if his six-year-old nephew dies, intends to do the same thing; however, as he enters the bathroom his nephew slips, knocks himself unconscious, and falls face down in the water. Smith simply lets nature take its course: he says a little prayer and leaves it to God. Is Smith's action morally acceptable, Rachels asked, because it is passive, while Jones' action is wrong because it is active?

Rachels' conclusion--that it makes little sense to distinguish between passive and active euthanasia--is even more evident today as medical practice has evolved. Consider two other cases. Jones is dying of multiple sclerosis; his condition has deteriorated to such a degree that he has lost all control of his bodily functions; he can no longer move without assistance and finds this condition intolerable. The dying process, however, has become a drawn-out affair, putting him and his family through prolonged misery. He begs the physician to help him end his life as peacefully and quickly as possible. …