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Physician-assisted Suicide

The Ethical Considerations of Physician-assisted Suicide Madeline Jordan Department of Biology; College of Arts and Sciences Abilene Christian University

With respect to physician-assisted suicide, several approaches to adjudicate an ethical position can be processed from the theories of , Kantian deontology, and . This paper explore these three positions with respect to physician-assisted suicide and the pros and cons of each. In conclusion, based on my and Christian beliefs, I will define why I reside with and why it leads me to a position that is against physician-assisted suicide at this particular point in my life.

Euthanasia has been a topic under euthanasia. The differences are withholding debate within our world for many centuries; or withdrawing of medication in order to but with medicine advancing quicker every allow the patient to die, which is passive; the day, euthanasia is more of a second is killing the person, which is active. concern with society and the medical Within each of the passive and active community as well. It has been a topic of categories of euthanasia, they are further concern that many different ethical theories broken down into either voluntary or have tried to tackle over the years, but non-voluntary/involuntary. Throughout my remains just as controversial, if not more, research, I have found that many researchers today. There is not only passive and active use the terms non-voluntary and involuntary euthanasia but whether each is involuntary, interchangeably; for the remaining length of voluntary, or physician-assisted as well. the paper, I will use the word involuntary. This paper begins by describing each Voluntary constitutes the patient verbally different type of euthanasia. It, then, goes on deciding that he or she wants to die. to talk more about voluntary active Involuntary constitutes the patient having no euthanasia as it pertains to physician- choice in the matter of whether they die or assisted suicide. Once physician-assisted live. suicide is established, the paper goes on to discuss the utilitarian, Kantian deontology Examples of Euthanasia and virtue ethical on this matter, Since each type of euthanasia has and the pros and cons of each ethical theory. been broken down, let us now look at an Finally, based on the research I have found, example of each. Involuntary active I will explain why I feel that my views euthanasia is the patient being injected with resonate with the virtue ethical theory. a lethal dosage of drugs by a physician without having the patient’s .1 Types of Euthanasia Involuntary passive euthanasia is the We must first look at the broad withholding or withdrawing of medical care category of euthanasia. When narrowing to a patient without consent. Voluntary down the various approaches to euthanasia, passive euthanasia is where the patient we see that they break down into two actively for the physician to separate categories: passive or active withhold or withdraw medical treatment in

1 Manning, 1998

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Physician-assisted Suicide order to allow the patient to die. Voluntary allows for the patient to have the right to active euthanasia is the patient’s consent choose what is best for his or her life. In this given to a physician in order to inject a case, it is whether he or she should live or lethal dosage of drugs to cause his or her die. Advocates for physician-assisted suicide death.2 This type of euthanasia will be also believe that no one should have to live discussed further throughout the paper, and through terminal , and that if the more specifically within the aspect of physician cannot alleviate the any other physician-assisted suicide. way, then aiding in death is acceptable.5 On the contrary, people who are against the Physician-Assisted Suicide actions of physician-assisted suicide believe We now turn our focus to physician- that it is not in the physician’s job assisted suicide. In the United States, six description to decide the fate of the patient, states have legalized physician-assisted even if patient consent is given; they also suicide; these include California, Colorado, believe that killing is intrinsically wrong.6 Oregon, Vermont, Washington, and Many physicians and people fit their beliefs Washington D.C. The state of Montana also on this matter within ethical theories. Ethical has legal physician-assisted suicide through theories help shape a person’s and a court ruling. The states that this option their behavior and actions in regards to their is only available to patients who are moral views. In order to understand how terminally ill or have a specific, limited life many people would determine their position expectancy.3 So, what is physician-assisted on physician-assisted suicide, we must suicide and how is it related to voluntary examine some of these ethical theories and active euthanasia? In physician-assisted determine their positions. suicide, the physician plays an important role in enabling the death of a patient.4 Rule and Act-utilitarianism Although the patient has given the physician The first ethical theory to be defined consent to help aid with the process by is and ’s prescribing the lethal dosage of medicine, utilitarianism. Utilitarianism, in all forms, the patient is actually the one who will lies on the weight of consequences rather administer it in order for him- or herself to than rules and it places emphasis on the die (typically by ingesting a lethal dosage of and bad rather than what is right or drugs). Therefore, physician-assisted suicide wrong.7 Though utilitarianism is usually is a type of voluntary active euthanasia. talked about as one big category, it is often broken down into many different categories, Arguments For and Against Physician- and within this paper we will be looking at Assisted Suicide the categories of rule-utilitarianism and act- So why is there such controversy utilitarianism. Rule-utilitarianism over the concept of physician-assisted an individual action is morally correct when suicide and why is it not widely accepted by it sides with the rules or codes that were everyone? People who argue for the use of already made on a utilitarian basis.8 It says physician-assisted suicide believe in the that a person should act in agreement with fundamental of . This the rule that brings about the largest balance

2 ibid. 6 Uhlmann, 1998 3 Yao, 2016 7 Ashcroft, Dawson, Draper, & McMillian, 2007 4 Degrazia, Mappes, & Brand-Ballard, 2011 8 Mandal, Ponnambath, & Parija, 2016 5 ibid.

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Physician-assisted Suicide of good over for everyone involved would feel that the killing rule is better to be within the situation.9 Act-utilitarianism is broken in order to bring about the better sometimes referred to as a type of situational consequences for everyone involved. When ethics. This means that a certain kind of applying both of these categories of action can be wrong within one setting but utilitarianism, we see that, more than likely, right within another. This situation is either most people who find that they agree with right or wrong considering which side brings both theories agree with physician-assisted the greatest amount of good for everyone suicide. involved.10 Pros of Rule and Act-Utilitarianism Rule and Act-Utilitarianism in Regards to Rule-utilitarianism and Act- Physician-assisted Suicide utilitarianism bring about strong points. In Consider a patient who is terminally regards to rule-utilitarianism, a valid ill and in a lot of pain. He or she wants a the theory presents is asking individuals to physician to help speed up his or her death make their decisions based off of rules that by prescribing a lethal dosage of drugs. A exemplify morality. Act-utilitarianism looks rule-utilitarian, in this situation, would at all sides of a situation before the decision consider raising the possibility of a justified is made. This is in order to maximize the exception to the rule of “do not kill.”11 In of all people involved in, which is most rule-utilitarian’s eyes, killing in self- good since they are not trying to maximize defense is seen to be a justifiable exception the utility of just themselves. Therefore, in to the rule of “do not kill.” Therefore, the the case of physician-assisted suicide, the rule-utilitarian that advocates for physician- physician would look at all who were assisted suicide believes that if the involved before consenting with the patient, terminally ill patient would be able to escape rather than just deciding based on the a prolonged painful death, others involved patient’s belief. would benefit as well. The hospital and physicians would benefit from not using Cons of Rule and Act-Utilitarianism unnecessary money that could go to another Though there might be pros to both patient who would ultimately live. The rule and act-utilitarianism, arguments can be family involved would benefit by not made for cons as well. With act- watching their loved one suffer anymore. utilitarianism, one is allowed to break a The patient should be allowed to be the moral rule, such as the case with physician- administration of the lethal dosage of a drug assisted suicide. However, there must be a since the consequences will bring about the reason to believe that breaking the rule will greatest balance of good over evil. cause maximum utility, or the perfect The act-utilitarian would agree with balance between good over evil for all the rule-utilitarian on this matter as well. involved. With this brings about the problem They agree that “do not kill” is a moral rule of a person taking one’s interest more into that should be followed, but if the terminally consideration over everyone else involved ill patient is in terrible pain, wishes to die, along with the breaking of a moral rule. and everyone else who is involved would Similar to act-utilitarianism is the rule- benefit as well, then physician-assisted utilitarianism, which says that moral rules suicide is justifiable. An act-utilitarian are subject to exception if the exception has

9 Op. cit. ref. 4 11 ibid. 10 ibid.

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Physician-assisted Suicide better consequences than the moral rule believes that this includes suicide, and that without the exception.12 Both theories suicide is not acceptable under any situation. believe that if the consequences of the In Jecker, Jonsen, and Pearlman’s work, results to exception are better than the moral they quote Kant saying, “…a system of rule itself, then the action is justifiable. So, nature by whose law the very same feeling with each individual that wants to undergo whose function is to stimulate the physician-assisted suicide, if their particular furtherance of life should actually destroy situation, in their eyes, has better results by life would contradict itself and consequently proceeding with the physician’s assistance, could not subsist as a system of nature.”16 then it is justifiable to do so. Since the Killing oneself is seen to go against Kant’s individual within the situation decides which moral principle of the categorical action produces the better consequences, imperative, and, therefore, is never to be shouldn’t there be a stipulation with each broken. Kant deontology also expresses the individual on what constitutes what a better of beneficence, which lies within the consequence entails? “imperfect duty to others” category. He believes that we are not only to treat people Kantian Deontology with respect but we are to further the The next ethical theory to be of others as well, but never at the discussed is Kantian deontology that was expense of a perfect duty.17 developed by . Kant believes that the is the Kant in Regards to Physician-assisted fundamental principle that is the basis of all Suicide moral responsibilities.13 The categorical In regards to physician-assisted imperative is based on two formulations, but suicide, based off of Kant’s as we will only be addressing one of these explained above, it would seem that Kant formulations. The one that is most would believe that there is no justification prominent within the context of this paper is for this particular action. Since Kant’s the second formulation, which says, “…treat perfect duties to others and self seem to say humanity... never simply as a means, but that no matter the situation killing is wrong, always at the same time as an end.”14 Kant it would seem that Kant would not ever be furthers this formulation by breaking it in agreement with physician-assisted down into four different duties. Of the four suicide. However, through the duty of duties, “perfect duties to others,” “perfect beneficence, the physician would be creating duties to self,” and “imperfect duties to happiness for the patient who wants to die. others” are the three that are relevant to our This, however, still goes against Kant’s topic of physician-assisted suicide. The categories of “perfect duties to others” and perfect duties to others include respecting “perfect duties to self”, which are to never others. Examples include not killing be broken according Kant’s belief in the innocent people, keeping promises, and not categorical imperative. lying. There is no exception, like utilitarian, in breaking these duties. They are simply off Pros of Kantian Deontology limits. With “perfect duties to self,” you are Kantian deontology brings about not to disrespect yourself either.15 Kant strong points when Kant points out that we

12 ibid. 15 op. cit. ref. 4 13 ibid. 16 Jecker, Jonsen, & Pearlman, 1977, p. 136 14 op. cit. ref. 6 17 op. cit. ref. 4

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Physician-assisted Suicide must respect not only ourselves, but others described previously, is not action-based. It as well. Kant believing that the notion of is concerned with becoming a good person respecting others and not treating a person rather than acting a certain way. Virtue strictly as a means to an end is a key point in ethics is looking to achieve what is humanly morality. This philosophy seems to be excellent rather than looking to maximize beneficial to everyone involved, not just the utility or consistently performing duties. patient.18 Another valid point that Kant Virtue theory does not care whether or not brings to the table is individual for the action brings about harm or benefits to everyone, and in this way he describes them the individual or a society, but it cares about as perfect duties to others in which a person, the person performing the action showing for example, is not to kill, which in turn virtuous behavior.22 It believes that actions causes you as an individual to not be killed show our inner morality and are what either.19 So any source of suicide or killing help shape that morality within us.23 is strictly forbidden, no matter the Therefore, a virtuous person carries circumstance. out the right action, and the right action describes a virtuous person. So, this brings Cons of Kantian Deontology up the question, what does virtuous behavior Just like utilitarianism, Kantian entail? Virtues are characterized by traits deontology critics argue that it brings about that are morally valued, which include, but some difficulties as well. Critics believe are not limited to, truthfulness, compassion, that often this ethical theory thinks too much courage, and .24 Virtue theory also about the individual and not enough about takes little consideration into rules and the community to the effect that the . This theory believes that community is often non-existent.20 Everyone cultivating enduring traits like honesty and is different and each person lives a different loyalty through education and role models life, but Kant does not believe this to be are a more reliable basis for a morally true. Kant believes that no matter what the correct action than from of situation a person is in, everyone should principles or rules.25 It often asks the come to the same conclusion when it comes questions of “Who am I?”, “Who ought I to specifically killing and suicide. We can become?”, and “How ought I get there?”26 come to this same conclusion with In conclusion, virtue theory relies heavily on physician-assisted suicide as well. This the individual person rather than a group or clarity is often misleading to some because what is best for everyone within a situation. it denies the role of the social in which this dilemma may occur.21 Virtue Ethics in Regards to Physician- Assisted Suicide Virtue Ethics In regards to physician-assisted The last ethical theory that will be suicide, I believe the theory would view this discussed is the virtue theory as seen to action as going both ways. If the physician emerge from . The virtue theory, is virtuous, which means that he or she unlike the other two ethical theories acquires the virtues as listed above, they are

18 op. cit. ref. 4 23 ibid. 19 op. cit. ref. 4 24 op. cit. ref. 4 20 Garrett, Baillie, & Garrett, 1993 25 op. cit. ref. 4 21 ibid. 26 Rozier, 2016 22 Koçyiğit & Karadağ, 2016

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Physician-assisted Suicide able to use their virtues of compassion and that they are doing it out of their virtuous mercy to help understand the pain that the behavior? I think that it is difficult to exactly patient is in. These virtues help guide the know the motivations of a physician and physicians in their decision-making and whether or not we can distinctly say that he actions in regards to helping their patients. or she is acting out of virtue. If our moral This theory would view that, in some compass were to be learned by education or physician’s eyes, aiding in the death of a a role model, like the virtue ethics theory patient, under which he or she could not live suggests, it would be difficult to know who anymore, to be a respectful, compassionate, the physician’s role model was. and benevolent response to a patient’s suffering.27 However, other physicians could Conclusion have these same virtues, and believe that Before I started this paper, I physician-assisted suicide is wrong. It’s understood very little of what euthanasia or difficult to draw conclusions on whether or even physician-assisted suicide entailed. I not this theory believes that physician- knew that there was major controversy assisted suicide is okay since it is strongly concerning this topic, but I had never looked based on the individual person and the way at each topic in light of the various ethical that he or she pursues his or her virtues. theories. In regards to the ethical theories presented within this paper, I find that I can Pros of Virtue Ethics accept parts of each of the theories in In favor of virtue ethics, we can see particular circumstances when it comes to that the other two ethical theories presented the topic of physician-assisted suicide. above often fail to face the fact that we often However, I also find that I can see the look at the character and motivation of a downside of each of these arguments as person and not just their actions. Another well. I cannot discount that each ethical point that is valid is virtue ethics does not theory presented within this paper, at least at just go along with a set of principles, but some point, has made me question my own rather learns from personal experience what beliefs on the matter, but it has also is morally correct. It has no clear cut rules furthered my knowledge on this particular that it should follow, which allows issue. Based on my research of the ethical individuals within this theory to have a little theories investigated, I find that I reside bit more space in his or her decision making. more with the virtue ethics aspect of being However, theory does call for the physician against than for physician-assisted suicide at to use the virtues that he or she has learned this particular point in my life. As a in order to help with the patient at hand, Christian, I believe that our virtues cause us rather than all of the people who are to act, and I believe that these virtues are involved in the situation. given to each of us from in the form of the Holy Spirit. On the matter of Christianity Cons of Virtue Ethics and physician-assisted suicide, Lammers Though we are able to see the and Verhey state, “We need not glorify or upsides of this theory, how are we to know seek suffering, but we must be struck by the that the motivation of a physician in the case fact that a human being who is a willing of a physician-assisted suicide is actually sufferer stands squarely in the center of virtuous? Are we to trust that if the Christian piety. Jesus bears his suffering not physician agrees to aid the patient in dying because it is desirable but because the Father

27 Huxtable, 2002

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Physician-assisted Suicide allots it to him within the limits of his and think in a different way. The reason why earthly life.”28 God nor Jesus said that we I am hesitant to be fully against physician- were never meant to suffer within our assisted suicide is due to instances where I human life, so I believe that this is where I could understand it being open for have to lean toward disagreeing with discussion, such as a patient with physician-assisted suicide. With this belief, I amyotrophic lateral sclerosis, or ALS. also state that I have no doubt that there are However, I feel that much more research holes within my argument, and that I believe and thought is needed before we can agree the Holy Spirit may give each of us some of with certain situations being acceptable in the same virtues but causes each of us to act regards to physician-assisted suicide.

Literature Cited Ashcroft, R. E., Dawson, A., Draper, H., & McMillian, J. R. (2007). Principles of health care ethics (2nd ed.). Chichester: John Wiley & Sons. Degrazia, D., Mappes, T. A., & Brand-Ballard, J. (2011). Biomedical ethics (7th ed.). New York, NY: McGraw-Hill. Garrett, T. M., Baillie, H. W., & Garrett, R. M. (1993). Health care ethics: principles and problems (2nd ed.). Englewood Cliffs, NJ: Prentice Hall. Huxtable, R. (2002) Death and compassion: a virtue-based approach to euthanasia. Journal of , 28(1), 278. Jecker, N. S., Jonsen, A. R., & Pearlman, R. A. (1997). : an introduction to the history, methods and practice. Sudbury, MA: Jones & Bartlett Learning. Koçyiğit, M., & Karadağ, E. (2016). Developing an ethical tendencies scale based on the theories of ethics. Turkish Journal Of , 9(2), 297-307. Lammers, S. E., & Verhey, A. (1998). On moral medicine: theological perspectives in medical ethics (2nd ed.). Grand Rapids, MI: Eerdmans. Mandal, J., Ponnambath, D. K., & Parija, S. C. (2016). Utilitarian and in medicine. Tropical Parasitology, 6(1), 5–7. Manning, M. (1998). Euthanasia and physician-assisted suicide killing or caring? Mahwah, NJ: Paulist Press. Orentlicher, D. (2014). Aging populations and physician aid in dying: the evolution of state government policy. Indiana Law Review, 48(1), 111-123. Rozier, M. D. (2016). Structures of virtue as a framework for public health ethics. Public Health Ethics, 9(1), 37-45. Ulhmann, M. M. (1998). Last rights?: assisted suicide and euthanasia debated. Washington, D.C.: Ethics and Public Policy Center. Yao, T. (2016). Can we limit a right to physician-assisted suicide?. National Catholic Bioethics Quarterly, 16(3), 385-392.

28 Lammers & Verhey, 1998, p. 659

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