Those who defend physician-assisted suicide often seek to distinguish it from active euthanasia, but in fact, the two acts face the same objections. Both can lead to abuse, both implicate the physician in the death of a patient, and both violate whatever objections there are to killing. Their moral similarity derives from the similar roles of the physician.
It is an oddity of the roaring debate over physician-assisted suicide that those who advocate legalizing physician-assisted suicide sometimes simultaneously argue against legalizing active euthanasia. Indeed, recent papers by Margaret Battin and by Timothy Quill, Christine Cassel, and Diane Meier argue for precisely such a distinction, drawing on some considerations about the different consequences of the two practices. In this paper I examine these and other arguments that active euthanasia is morally more problematic than physician-assisted suicide, and I conclude that none of these arguments is sound. For all that they have shown, the case for legalizing active euthanasia is morally indistinguishable from the case for legalizing physician-assisted suicide.
If this is right, then our understanding of the morality of active euthanasia and physician-assisted suicide will be enhanced by considering them together. In particular, the moral lessons of legalizing active euthanasia in Holland are directly applicable to the debate over legalizing physician-assisted suicide in the United States, although we nonetheless must take account of significant differences between the health care systems of the two countries. Thus if, as Herbert Hendin has argued, active euthanasia has been widely abused in Holland, we should certainly be aware of the risk of similar abuses of physician-assisted suicide in the United States, especially since the differences between the two countries--such as the lack of universal health care and of close physician-patient relationships in the United States--are likely to exacerbate this risk.
To establish the moral equivalence of active euthanasia and physician-assisted suicide, two strategies are possible: showing that the same arguments that purport to justify physician-assisted suicide would also justify active euthanasia, or showing that objections to active euthanasia would count equally against physician-assisted suicide. I will adopt the latter strategy.
The Slippery Slope
Both of the recent defenses of physician-assisted suicide raise the fear that legalizing active euthanasia would, in contrast to legalizing physician-assisted suicide, create too great a danger of abuse. In opposing legalizing active euthanasia in the United States, Battin says:
This is a country where 1) sustained contact with a personal physician is
decreasing, 2) the risk of malpractice action is increasing, 3) much
medical care is not insured, 4) many medical decisions are financial as
well, 5) racism is on the rise, and 6) the public is naive about direct
contact with Nazism or similar totalitarian movements. Thus, the United
States is in many respects an untrustworthy candidate for practicing active
Physician-assisted suicide, in contrast,
leaves the fundamental decision about whether to use [the means to end the
patient's life] to the patient alone ... [T]he physician is involved, but
not directly; and it is the patient's choice, but the patient is not alone
in making it.
Similarly, Quill, Cassel, and Meier point out that
[i]n assisted suicide, the final act is solely the patient's, and the risk
of subtle coercion from doctors, family members, institutions, or other
social forces is greatly reduced. The balance of power between doctor and
patient is more nearly equal in physician-assisted suicide than in
euthanasia. The physician is counselor and witness and makes the means
available, but ultimately the patient must be the one to act or not act. …