Philosophy 220

1. Philosophy 220 Voluntary Active Euthanasia and Physician Assisted Suicide

2. Suicide: Some Definitions • Suicide is the intentional and voluntary ending of one’s own life. • Though there are significant questions about the moral status of suicide, our focus in this section addresses a narrower concern: assisted suicide. • Assisted Suicide refers to situations where individuals assist another person in committing suicide, usually because something about the person’s situation prevents them from completing that act on their own. • We are specifically interested in the concerns raised by the possibility of physicians assisting individuals in this way. • Though some people equate physician-assisted suicide with voluntary active euthanasia, there are others who insists that they are importantly different.

3. Brock, “Voluntary Active Euthanasia” • The aim of Brock’s essay is to defend the moral permissibility of VAE, in those instances where the patient exhibits the requisite competence. • His defense rests on two fundamental moral values: • Individual self-determination (autonomy) • Individual well-being • The basic argument is that these principles jointly support the claim that patients should have the right to make decisions about their medical care and inasmuch as VAE is consistent with these values, VAE is a morally permissible choice for patients to make and doctors should respect this choice.

4. Two Moral Values • When we consider the two values at the heart of Brock’s argument, we can appreciate their centrality not only to our thinking about patient rights, but to many basic moral intuitions. • The first value speaks to our status as moral agents. Assuming competency, we generally agree that people have a right to define their own conception of a good life, at least to the degree that it affects them. • This is what Brock is calling self-determination. • The second value addresses our relationship to other self-determining agents. The basic idea is that to the extent that we are involved with others, we should be guided by a concern for their personal well-being. • To paternalistically interfere with their self-determination, we need very good reasons to think that we are making them better off than they would be if they chose for themselves.

5. What about Physicians? • One serious objection raised against VAE addresses the moral concerns and obligations of the physicians potentially involved in the process. • Clearly, if a particular physician is morally opposed, they should not be forced to participate. • More significantly, it has been argued that VAE is directly opposed to the principled core of the code of ethics under which doctors operate, undermining the trust and confidence patients have in doctors. • Brock responds by noting that just the opposite may very well be the case. In a system which supports VAE, patient autonomy and well-being would be recognized as paramount values, and patients would rightly believe that their interests we of fundamental importance to their doctors.

6. Doerflinger, “Assisted Suicide: Pro-Choice or Anti-Life?” • Richard Doerflingeris Associate Director for Pro-Life Activities for the United States Conference of Catholic Bishops. • He references the religious context of his position at the beginning of his essay, but his argument is moral rather than religious. • Doerflingerobjects to the permissibility of assisted suicide (including active euthanasia) on two bases: • The standard pro-choice appeal to autonomy is at odds with itself. • Pro-choice advocates fail to appreciate the risks of a slippery slope towards allowing wrongful practices of killing.

7. Pro-Choice? • Though more familiar to us from the debate about the moral and legal status of abortion, the label ‘pro-choice’ has been employed by advocates and critics of assisted-suicide to reflect the focus on self-determination highlighted by people like Brock. • At first pass, Doerflinger notes that such a focus seems incompatible with the idea that human life has intrinsic value. • Instead, it seems that life has only a subjective value: valuable only if the subject of the life values it.

8. Reprising the Argument from Self-Determination • Doerflinger summarizes this position as the claim that we should respect the wishes of patients contemplating asking for assistance in ending their life because humanity or personhood has a dignity that demands respect for individual freedom. • They claim that suicide is the “ultimate” exercise of self-determination, and thus deserves not only respect, but the assistance of others. • This has led some, (most notably the members of the Hemlock Society) to advocate a constitutional “right to die.”

9. A Constitutional (but not moral) Contradiction • According to Doerflinger, this argument departs from American traditions on liberty. • The inalienable human rights described in the Declaration of Independence are: “life, liberty, and the pursuit of happiness.” • These rights are importantly nested. Liberty allows for the pursuit of happiness and life allows for liberty. • “Safeguards against the deliberate destruction of life are thus seen as necessary to protect freedom and all other rights” (318c2). • If this is right, suicide is not a fundamental exercise of liberty, but its contradiction. • “If life is more basic than freedom, society best serves freedom by discouraging rather than assisting self-destruction” (ibid.).

10. A Moral Contradiction? • Though this argument is aimed at positions like that articulated by the Hemlock Society, Doerflinger suggests it has broader implications. • Advocates of assisted suicide tend to prioritize the avoidance of suffering over and above freedom. • Freedom (and life itself) is viewed as instrumental to the value of happiness (the avoidance of suffering). • On this system, someone who is suffering and yet chooses to live could be seen as irrational. • But, Doerflinger insists, this prioritization is ultimately incoherent. It puts one choice (the choice for death) over all other choices that the choice makes impossible.

11. Back to the Slope • In addition to this conceptual argument, Doerflinger also highlights some possible dangers flowing from the acknowledgement of the permissibility of assisted suicide. • Amongst the concerns he highlights are: • possible changes in legal doctrines and definitions of “terminal illness” • possible prejudice against citizens with disabilities • alterations in the character of the medical profession • the negative influence of the human “will to power” • While acknowledging the limitations of these slippery slope arguments, he insists that cumulatively they give us reason to pause in the face of legally (or morally) approving of assisted suicide.

12. Watts & Howell, “Assisted Suicide is Not Voluntary Active Euthanasia” • Watts and Howell think that the common assumption that assisted suicide should be understood as a form of euthanasia (VAE) is mistaken, and that once they are distinguished, it becomes apparent that criticisms of VAE do not hold against assisted suicide (at least in some forms). • They define VAE as the “administration of medications or other interventions intended to cause death at a patient's request” (324c1) • Assisted suicide, by contrast, is “provision of information, means, or direct assistance by which a patient may take his or her own life” (ibid.).

13. 3 Levels of Assistance • Once we define assisted suicide in this way, it becomes apparent that not all assistance is the same. • The most minimal form of assistance is providing information to patients about means of suicide. • A more substantial form is providing the means of suicide. • Finally, physicians could supervise or directly aid in the suicide itself.

14. Some Possible Concerns • Watts and Howell recognize that assisted suicide can raise some possible concerns but they ultimately argue that these concerns are misplaced. • That assisted suicide will lead to abuse of vulnerable persons • That it will undermine trust between patients and physicians • That it will weaken societal resolve to increase resources allocated to care of the dying • Far from leading to these possible consequences, they insist that normalizing physician participation in end of life decisions might actually lead to an overall decrease in suicide rates.

15. Conclusion • Watts and Howell ultimately defend “limited” physician-assisted suicide. • More specifically, they support legislation and policies which would allow for providing information and providing the means of suicide. • They draw the line at supervising or directly aiding the act, on the basis of the potential abuse of power or influence of attending physicians.