thesis about assisted suicide

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Should assisted dying be legalised?

• Thomas D G Frost 1 ,
• Devan Sinha 2 &
• Barnabas J Gilbert 3  

Philosophy, Ethics, and Humanities in Medicine volume  9 , Article number:  3 ( 2014 ) Cite this article

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When an individual facing intractable pain is given an estimate of a few months to live, does hastening death become a viable and legitimate alternative for willing patients? Has the time come for physicians to do away with the traditional notion of healthcare as maintaining or improving physical and mental health, and instead accept their own limitations by facilitating death when requested? The Universities of Oxford and Cambridge held the 2013 Varsity Medical Debate on the motion “This House Would Legalise Assisted Dying”. This article summarises the key arguments developed over the course of the debate. We will explore how assisted dying can affect both the patient and doctor; the nature of consent and limits of autonomy; the effects on society; the viability of a proposed model; and, perhaps most importantly, the potential need for the practice within our current medico-legal framework.

Introduction

Over the past two centuries, the United Kingdom has experienced rapid population growth associated with a substantial decline in mortality from acute infectious diseases and poor nutrition [ 1 ]. As the average life expectancy has increased, so too have the rates of debilitating chronic illness – particularly coronary artery disease and cancers [ 2 ]. These diseases require years of treatment instead of the mere days to weeks that medicine once operated within [ 2 ]. Although healthcare systems have sought to adapt to such changes, aiming to prevent and treat such disease wherever possible, debate has arisen regarding those patients in the latter stages of chronic, incurable, terminal conditions [ 3 , 4 ]. Moreover, there is increasing recognition that the patient must be at the centre of health care decision-making, such that outcomes must be tailored to their individual needs and views. By extension, assisted dying might seem a logical step to help achieve these goals within the realm of end-of-life decision making [ 5 ]. Several jurisdictions, notably Oregon (1997) and the Netherlands (2001) have already legalised assisted dying in some form. These factors have contributed to ongoing legislative discussions within Parliaments for almost a decade, with current opinion polling suggesting a majority of medical practitioners and the public in favour of physician-assisted suicide [ 6 ].

Viability of assisted dying in practice

In the UK, a model for assisted dying has been developed from the legal structure found within the Assisted Dying Bill introduced by Lord Falconer in the House of Lords in 2013 [ 7 ]. Assisted dying could only be considered under circumstances in which a patient of legal age is diagnosed with a progressive disease that is irreversible by treatment and is “reasonably expected to die within six months” [ 7 ]. Registered medical practitioners would make such decisions for patients with terminal illnesses. Addressing the technicalities of ‘assisted dying’ requires distinction between ‘physician-assisted suicide’ (offering patients medical actions or cessation of actions by which they can end their own life) and ‘euthanasia’ (whereby the medical practitioner actively induces death). In light of the strong hostility of the medical profession towards active euthanasia, this proposed model, as with previous attempts to legalise assisted dying, permitted only the former [ 8 – 10 ].

However, there is concern that such distinction may be unrealistic in practice because medical practitioners could find themselves with a patient who had failed to successfully end their own life and was subsequently left in a state of greater suffering. Were such a patient no longer able to give consent, a heavy burden would then be placed on the physician regarding how to proceed. Moreover, the practice of physician-assisted suicide might be deemed discriminatory, for example by giving only patients with good mobility control over their own method of death.

The Assisted Dying Bill 2013 included the provision that any terminal prognosis must be confirmed and attested by a second registered practitioner. The strictness of such criteria has parallels to a similar double-physician requirement when procuring a legal abortion under the 1967 Abortion Act. The stated aims of the provision in both cases are as follows: first, to check the accuracy of the prognosis upon which the decision was being made; second, to ensure that the situation meets the required criteria; and third, to check that such a decision was taken by the patient after full consideration of all available options [ 11 , 12 ]. By having a second independent doctor, the legislation ensures that all three checks are met without prejudice or mistake.

Problematic for any protocol for assisted dying is the fact that estimates of life expectancy in terminal prognoses are erroneous in 80.3% of cases [ 13 ]. Furthermore, the accuracy of such prognoses deteriorates with increased length of clinical predicted survival. Forecasts of survival times are based largely on past clinical experience, and the inherent variability between patients makes this more of an art than a science. This brings to concern both the accuracy of any prognosis meeting the six-month threshold and the validity of requests for assisted dying based partly or wholly on predicted survival times. Whilst the majority of errors in life expectancy forecasts are a matter of over-optimism and hence would not affect either of those two concerns, many cases remain unaccounted for. Overly pessimistic forecasts occur in 17.3% of prognoses; hence we must decide whether the one in six patients making a decision based on an inaccurate prognosis is too high a cost to justify the use of this system. Patients requesting an assisted death often cite future expectations of dependency, loss of dignity, or pain [ 14 ]. If the hypothetical point at which the progression of their illness means they would consider life to be not worth living is not, as informed, mere weeks away but in fact many more months, then this information would have resulted in a different decision outcome and potentiated unnecessary loss of life.

Whilst the presence of a second doctor would be expected to mitigate such forecasting errors, the anchoring bias of the initial prediction may be enough to similarly reduce the accuracy of the second estimate. It is prudent to question the true independence of a second medical practitioner, and whether this second consultation could become more of a formality, as has now become the case with abortion [ 15 ].

Another challenge for an assisted dying system would be to recognise whether patients requesting death were legally competent to make that decision. Consider that any request for suicide from a patient with clinical depression is generally categorised as a manifestation of that mental disorder, thereby lacking capacity. It is arguably impossible to separate out the natural reactions to terminal illness and clinical depression. Indeed, there is evidence that major depressive disorders afflict between 25% and 77% of patients with terminal illness [ 16 , 17 ]. Any protocol for assisted dying must first determine what qualifies as a ‘fit mental state’ for a terminal patient.

The need for assisted dying

It could be argued that a doctor’s fundamental duty is to alleviate forms of suffering in the best interests of the patient. The avoidance of physical pain, as an obvious manifestation of suffering, might explain why assisted dying would be both necessary and within the duties of a doctor to provide. The evolving principle in common law known as the ‘Doctrine of Double Effect’ offers a solution to this problem [ 18 ]. This legal judgement stated that “[a doctor] is entitled to do all that is proper and necessary to relieve pain even if the measures he takes may incidentally shorten life”. This entails that a protocol already exists for patients searching for an escape from chronic pain. Furthermore, numerous retrospective studies have revealed very little correlation between opioid dose and mean survival times: one study of over 700 opioid-treated patients found that the variation in survival time from high-dose opioid treatment is less than 10% [ 19 – 21 ]. It can therefore be said that pain alone, if appropriately managed, should never be cause for considering assisted dying as an alternative.

By contrast, the ‘Doctrine of Double Effect’ might be seen as a subjective interpretation that has been applied unequally due to a lack of specialist training or knowledge [ 22 ]. Despite this, the principle can be easily understood and poor awareness can be remedied by improvements in medical education and standardisation of protocols. Moreover, should we choose to accept arguments for assisted dying that are based upon inadequate administration of pain medication, we set a precedent for conceding shortcomings in palliative care and other end-of-life treatments. Offering hastened death could become an alternative to actively seeking to improve such failings.

Whilst much has been made of the ‘pain argument’ here, the call for assisted dying is rarely this simple. Many patients also suffer a loss of dignity, often due to their lack of mobility – the inability to relieve oneself without help is a potent example. Beyond this are additional fears of further debilitation and the emotional costs of dealing with chronic illness, both for the patient and for their relatives and friends. A study of terminal patients in Oregon showed that these were the most significant reasons behind requests for assisted suicide, the next commonest reason being the perception of themselves as a ‘burden’ [ 14 ]. Clearly, we could seek to provide balanced, compassionate medical care for these patients, and still fail to address these points.

Developments in healthcare and technology may reduce this emotional burden, but remain an imperfect solution.

Rights of patients and limitations of their autonomy

J.S. Mill’s pithy dictum describes autonomy as follows: “over himself, over his own body and mind, the individual is sovereign” [ 23 ]. Not only has the sanctity of bodily autonomy profoundly influenced the development of liberal democracies, it has also provoked a holistic shift in making our healthcare systems more patient-centred – “care that meets and responds to patients’ wants, needs and preferences and where patients are autonomous and able to decide for themselves” [ 5 ]. The ethical principle of controlling the fate of one’s own body is inherently relevant to the debate on assisted dying. It is difficult to reconcile that citizens may have the right to do almost anything to and with their own bodies– from participating in extreme sports to having elective plastic surgery – yet a terminal patient cannot choose to avoid experiencing additional months of discomfort or loss of dignity in their final months of life.

Expectation of individual liberty has been codified in law. The right to bodily autonomy has been interpreted to be included under Article 8 - the right to privacy - of the European Convention on Human Rights (ECHR) and subsequently the Human Rights Act (HRA) [ 24 , 25 ]. Moreover, the ECHR underpins the right of individuals to ‘inherent dignity’ [ 26 ]. Hence, if an individual feels that dignity is unattainable due to the progression of a terminal illness, then taking recourse though assisted dying ought to be a legitimate option.

Conversely, there are two notable oversights in this interpretation of a right to assisted dying as an extension of the principles of bodily autonomy:

First, it would be wrong to view individual liberty as absolute. The HRA allows for exceptions to Article 8 on grounds of ‘health or morals’ [ 25 ]. The principle of autonomy is not inviolable. Governments have limited such privileges for the protection of individuals and society, for example by criminalizing the use of recreational drugs or the selling of one’s own organs. The preservation of life by denying assisted dying could fall within this category.

Second, the right of autonomy is not necessarily intrinsic to human beings but, as Kant argued, is dependent on our ‘rational nature’ [ 27 ]. This concept sees autonomy as an exercise of ‘evaluative choice’ [ 27 ], requiring rationality on the part of individuals to appreciate the nature of options and their consequences. To achieve true autonomy, there must be sufficient information to make those rational decisions; this is the basis of informed consent and why it is a fundamental duty of a doctor to offer a patient an informed series of treatment options [ 28 ]. The logistical issue is that doctors are unable to advise patients regarding the point at which their situation becomes less preferable to being dead. No doctor (or individual) has any knowledge or experience of what ‘death’ may be like. Hence, in this case, the idea of exercising true autonomy through informed consent might be considered meaningless.

Legalising assisted dying by attempting to establish an absolute right to bodily autonomy may undermine other individual and group rights. Vulnerable patients may feel pressured into assisted dying because of social, emotional, or financial strains placed on family and/or friends. This is exemplified by the trend showing that the proportion of patients stating ‘relief of burden’ on others as the reason for requesting assisted dying has risen from 17% to 25% in Oregon since legalisation [ 29 ]. One could even consider the risk of assisted dying becoming an expected choice rather than a free one. Thus, assisted dying may erode the elemental right to life of terminal patients as the value of their life becomes tied to relative costs to society and to those around them.

Moreover, by creating one class of individuals for whom life is expendable, that particular view may be extended by society to all groups possessing such attributes (e.g. the permanently disabled). There would be a definite risk to the rights of these vulnerable groups in the form of society being less willing to provide for their health and social care.

It is often raised that the limited legalisation of assisted dying would inevitably become extended in scope, but this is not necessarily a flaw. Even if the right to determine the manner of death were later extended to a wider group of people, posterity may reflect positively on such a change, just as extending the franchise to women ultimately led to legislation demanding equal pay.

Effect on health professionals and their role

‘To act in the best interest of the patient’ is often cited as a central duty of the doctor [ 28 ]. This concept of ‘best interest’ guiding the doctor’s action has seen the development of two important ethical principles: beneficence and non-maleficence. Beneficence mandates that the actions of the doctor must be aimed to bring about benefit (clinical improvement) for the patient, usually measured in terms of reduced morbidity or mortality; non-maleficence requires that the doctor not carry out treatment that is likely to cause overall harm the patient [ 30 ]. These traditional ethical imperatives on a doctor both conflict with intentionally hastening the death of a patient, and a resolution of this tension would require redefining what constitutes ‘acting in the best interest’.

A further dimension is the potential reluctance of health professionals to engage in a practice that contravenes their own ethical beliefs, particularly as this would affect doctors who never entered training in the knowledge that assisting patients to die would be an expected duty. This is certainly no argument against the introduction of assisted dying; indeed, a recent survey of a cohort of NHS doctors found that 46% would seriously consider requests from patients to undertake steps to hasten death [ 31 ]. It merely expresses the point that any early model would have to account for the fact that an initial 54% of the doctors in the NHS would be required to advise qualifying patients of assisted dying as a legitimate option, despite disagreeing with it in principle.

Furthermore, doctors who agree ethically with this practice may find themselves facing conflicts of interest. It is expensive to treat chronically ill patients, particularly in the final months of life [ 32 ]. Moreover, it would be difficult for commissioners to ignore the fact that the sustained treatment of one individual could deprive many others from access to surgery or access to novel drugs. Such an argument does not suggest that doctors or any other hospital staff would treat this practice without appropriate respect or care; rather it acknowledges the need for appropriate rationing of care and questions the intentions of service providers. The perception of an ulterior motive could negatively impact patient trust. One survey showed that a reasonable minority of patients (27%) – and particularly particularly the elderly – believe that legalising assisted dying would lessen their trust in their personal physician [ 33 ]. The costs of weakened trust in the doctor-patient relationship could far outweigh the benefits of assisted dying, particularly given the importance of trust when treating a chronic patient for an extended period of time.

There is no doubt that assisted dying would empower some patients to maximise control over the timing and manner of their own death. Such expression of autonomy would surely solidify moves towards a patient-centred approach to healthcare. However, the capacity for such consensual requests remains in doubt. Clinically, the patient’s state of mind and the reliability of diagnostic predictions are of issue; philosophically, the idea of informed consent for death is contradictory. The implications for patients, physicians and society have been weighed extensively within this article. The central tenet throughout has been the balancing of an individual’s right to escape a circumstance that they find intolerable, alongside the consequential changes to their other rights, and the rights and responsibilities of third parties. Ultimately, the challenge is for us as a society to decide where this balance lies.

About the debate

The Varsity Medical Debate was started in 2008 with the aim of allowing students, professors and members of the polis, to engage in discussion about ethics and policy within healthcare. Utilising the age-old rivalry between the two Universities, the debate encourages medical students from both Oxford and Cambridge to consider and articulate the arguments behind topics that will feature heavily in their future careers.

The debate was judged on the logic, coherence, and evidence in arguments, as well as flair in presentation. Although the debaters may not have necessarily agreed with their allocated side, the debate format required them to acknowledge a particular school of thought and present the key arguments behind it. Oxford, who opposed the motion, was awarded the victory in the debate; however, this does not mean that the judges believe that position ought to become public policy.

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Acknowledgements

For Cambridge University: Hilmi Bayri (Trinity), Alistair Bolger (Jesus), Casey Swerner (St Johns).

For Oxford University: Devan Sinha (Brasenose), Thomas Frost (Lincoln), Collis Tahzib (Lincoln).

Martin Farrell (Cambridge).

Baroness Finlay: Professor of Palliative Care Medicine and former President of the Royal Society of Medicine.

Dr. Roger Armour: Vascular Surgeon and Inventor of the Lens Free Ophthalmoscope.

Mr. Robert Preston: Director of Living and Dying Well.

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All authors planned and elucidated the layout. TDGF and DS drafted the manuscript which was critically edited and added to by BJG. All authors have read and approved the final draft.

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Frost, T.D.G., Sinha, D. & Gilbert, B.J. Should assisted dying be legalised?. Philos Ethics Humanit Med 9 , 3 (2014). https://doi.org/10.1186/1747-5341-9-3

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DOI : https://doi.org/10.1186/1747-5341-9-3

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Arguments for and Against Physician-Assisted Suicide

The right to legally end your own life is a heavily debated issue..

Posted September 16, 2020 | Reviewed by Gary Drevitch

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Although September is designated National Suicide Awareness Month, there are those who think about suicide 12 months of the year. They may be survivors of suicide loss—the family and friends of those who have taken their own lives—or they may be people who often contemplate suicide or have already made attempts. Articles and anecdotes of suicide published during the month of September and at other times most often focus on prevention. But there’s another side to the story.

Many people believe that ending one’s own life is a human right, particularly for those who are terminally ill and suffering from indescribable pain or impairment. In the United States, however, it is only a right for those in the nine places where physician-assisted death is now legal when strict guidelines are followed. In Oregon, Washington, Vermont, Maine, Hawaii, California, Colorado, New Jersey, or the District of Columbia, eligible, terminally ill patients can legally seek medical assistance in dying from a licensed physician. In all of these places, a physician can decide whether or not to provide that assistance. At the same time, other states—Alabama, Arizona, Georgia, Idaho, Louisiana, New Mexico, Ohio, South Dakota, and Utah—have, in recent years, strengthened their laws against assisted suicide. In 2018, for instance, Utah amended its manslaughter statute to include assisted suicide.

In a nutshell, it works like this: The patient orally requests legal medical assistance in dying from a qualified physician. That physician must assess and confirm the patient’s eligibility and also inform the patient of alternative treatments that provide pain relief or hospice care. At that point, a second physician must confirm the patient’s diagnosis and mental competence to make such a decision. If deemed necessary, either physician can require the patient to undergo a psychological evaluation. The patient must then make a second oral request for assistance. Once approved, the original physician writes a prescription for lethal medication (usually a high-dose barbiturate powder that must be mixed with water) that the patient can self-administer when and where they choose, as long as it is not in a public place. Some people never fill the prescription or fill the prescription but never take the medication. Those who do generally fall asleep within minutes and die peacefully within a few hours.

Several organizations have been formed to both support and oppose physician-assisted dying for moral, ethical, and legal reasons. Groups such as Death with Dignity and Compassion and Choices are in favor of what they call “medical aid in dying” and work to provide assistance and lobbying efforts to initiate legal “right to die” programs in every state. They support patient autonomy and choice, particularly in the case of terminal illness. To these groups and their supporters, most of whom come to this side of the issue as a result of agonizing personal experience, death with dignity is a human rights issue and those who are suffering are entitled to a peaceful death.

On the other side of the debate, groups like the Patients Rights Council and Choice Is an Illusion work to tighten laws against euthanasia and medical aid in dying. They fear a complete lack of oversight at the moment of death, as well as normalization of the process to the degree that patients will feel they must relieve their families of the burden they are inflicting by living with their illness. They are concerned that decisions will be made by others on behalf of those too ill to speak for themselves. These groups believe the job of a physician is to find ways to eliminate patients’ suffering, not the patients themselves. They do not believe a physician is qualified to make the decision to assist in ending a life.

In the end, no group really wants assisted suicide to be the final answer, but those who favor medical aid in dying see little recourse for those living with unbearable chronic pain , who are terminally ill, and who have no hope of improving the quality of their lives because medical science has not yet caught up with our modern potential for longevity.

Compassion and Choices: https://compassionandchoices.org/

Death with Dignity: https://www.deathwithdignity.org/

Patients Rights Council: http://www.patientsrightscouncil.org/site/

Choice is An Illusion: https://www.choiceillusion.org/2019/04/in-last-ten-years-at-least-nine-…

Susan McQuillan is a food, health, and lifestyle writer.

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Patients’ and caregivers’ attitudes towards patient assisted suicide or euthanasia in amyotrophic lateral sclerosis-a meta-analysis

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• Ioannis Mavroudis 1 , 2 ,
• Pavlina Alexiou 3 ,
• Foivos Petridis 4 ,
• Alin Ciobica   ORCID: orcid.org/0000-0002-1750-6011 5 , 6 , 7 , 8 ,
• Ioana Miruna Balmus 9 ,
• Bogdan Gireadă 10 , 11 ,
• Irina Luciana Gurzu 12 ,
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Assisted suicide and euthanasia are long debated topics in amyotrophic lateral sclerosis (ALS) patients care. We conducted a meta-analysis to evaluate the attitudes of ALS patients and their caregivers toward physician-assisted suicide (PAS) and euthanasia. Also, we were interested to identify the factors associated with the positive or negative attitude of patients and caregivers towards PAS/euthanasia. A thorough search of the online databases (PubMed, Cochrane Library, and Web of Science) was conducted and eligibility criteria according to the PRISMA guidelines were used to include the studies in the current meta-analysis. The assessment of the quality of the selected studies was carried out using a pre-specified set of criteria by Cochrane. The studies that were selected for this meta-analysis suggested that the expression of the wish to die is more likely correlated with depression, anxiety, hopelessness, and lack of optimism. The overall prevalence of considering PAS/euthanasia significantly varies in a dependent manner over the cultural, legal, and societal factors. In this context, we found that the opinion on this topic can be deeply personal and may vary widely among individuals and communities. Lower quality of life and lower religiosity were associated with a positive attitude toward PAS/euthanasia. On the other hand, patients who are more religious are less likely to choose PAS/euthanasia. Gender does not appear to play a significant role in determining attitudes towards PAS/euthanasia in ALS patients. Other factors, such as education and psychological state, could also be important. In conclusion, end-of-life decisions in ALS patients are complex and require careful consideration of individual values, beliefs, and preferences. Understanding the factors that influence a patient's attitude towards PAS/euthanasia can help healthcare providers to offer appropriate care and support for these patients and their families.

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Ioannis Mavroudis

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Pavlina Alexiou

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Foivos Petridis

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Alin Ciobica

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Mavroudis, I., Alexiou, P., Petridis, F. et al. Patients’ and caregivers’ attitudes towards patient assisted suicide or euthanasia in amyotrophic lateral sclerosis-a meta-analysis. Acta Neurol Belg (2024). https://doi.org/10.1007/s13760-024-02578-x

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Breaking News

Gorsuch on euthanasia and assisted suicide – and abortion?

In 2004, Neil Gorsuch was awarded a doctorate in legal philosophy by the University of Oxford, the British institution where he studied as a Marshall Scholar. Gorsuch’s doctoral thesis on euthanasia and assisted suicide served as the basis for his 2006 book, “The Future of Assisted Suicide and Euthanasia.” At Gorsuch’s confirmation hearing that year , Sen. Lindsey Graham asked Gorsuch about his writings on assisted suicide and euthanasia, noting that Gorsuch had been “prolific.”

Gorsuch assured Graham that his “personal views” would have “nothing to do with the case before” him in any situation. Having said that, though, Gorsuch added that his writings on assisted suicide and euthanasia had “been largely in defense of existing law” and were “consistent with the Supreme Court’s decisions in this area and existing law in most places.”

When Gorsuch first began his studies at Oxford in the early 1990s, euthanasia and assisted suicide were both high-profile and controversial issues. In 1997, in Washington v. Glucksberg and Vacco v. Quill , the Supreme Court rejected challenges to the constitutionality of state laws banning assisted suicide. But, Gorsuch emphasized in his book, the justices who concurred in that ruling left open the question whether such laws would be unconstitutional in the specific cases of adults who were terminally ill. “Thus, far from definitively resolving the assisted suicide issue,” Gorsuch suggested, “the Court’s decisions seem to assure that the debate over assisted suicide and euthanasia is not yet over—and may have only begun.”

Gorsuch’s prediction appears to have mostly missed the mark: The debate over assisted suicide and euthanasia largely subsided in the years following the publication of his book. Assisted suicide remains illegal in 44 states, while all 50 states ban euthanasia, and there have been few signs that the issues could make their way to the Supreme Court anytime soon. But Gorsuch’s book on assisted suicide and euthanasia nonetheless remains relevant, not only for what it tells us about his views and his writings more generally, but also for what (if anything) we might be able to glean from the book that might shed more light on his views on abortion.

Much of Gorsuch’s book is devoted to an exhaustive (but not exhausting) survey of the history of assisted suicide and euthanasia, the legal and ethical arguments in favor of the two, and court cases – in the United States and the United Kingdom – dealing with the right to die. Gorsuch is sharply critical of experiments with allowing assisted suicide and euthanasia in the Netherlands and Oregon. In the Netherlands, Gorsuch observes, “it appears that, for every three or four acts of voluntary euthanasia, the Dutch regime generates one case of a patient being killed without consent.” Moreover, he continues, euthanasia and assisted suicide are often motivated less by the desire to alleviate pain or respect patient autonomy than by a physician’s subjective belief that the patient’s quality of life is “degrading” or “hopeless.”

And in Oregon, which allows “capable” adults with terminal diseases to request medication to end their lives, the law does not require physicians to refer patients who want to commit assisted suicide to mental health professionals. Gorsuch cites data raising the possibility that other factors, such as depression or isolation, rather than terminal illnesses, may be driving assisted suicide in Oregon. Reporting requirements in the state are minimal, he adds, such that “Oregon officials admit that they have no idea how often state law is violated, and no way to detect cases of abuse and mistake.” Given the many flaws in the two regimes, he points to the potential costs if assisted suicide and euthanasia were legalized more broadly – particularly the prospect that they could lead to pressure, “real or imagined,” for the poor, minorities and the elderly to commit assisted suicide, in part because of the high costs of health care in the United States.

Although Gorsuch was correct at his confirmation hearing that his book defends existing laws prohibiting assisted suicide and euthanasia, the book offers an alternative ground to justify them: “the idea that all human beings are intrinsically valuable and the intentional taking of human life is always wrong.” Dubbing his rationale the “inviolability-of-life principle,” he characterizes it as a “middle path” between two extremes – on the one hand, the idea that life is “the most important good that must always be maintained” and, on the other, the idea that a person could die or be killed based on someone else’s judgment about his quality of life.

Gorsuch’s “middle ground” would, he takes pains to emphasize, still allow terminally ill patients to refuse or discontinue treatment; it would also allow medical personnel to prescribe high doses of morphine or other painkillers when death is near. The “critical, rational moral line,” he explains, is intent. When medical personnel and the patient’s family are seeking to relieve the patient’s pain, or the patient doesn’t have a “suicidal impulse” but opts to discontinue or refuse treatment “out of a recognition of the inevitability of death,” doctors should be permitted to prescribe painkillers and discontinue treatment even when they know that death will result and may even be accelerated. But, he cautions, doctors cannot do these same things when they do so with the intent to cause the patient’s death.

Allowing doctors to prescribe an overdose of morphine or discontinue care with the intent to relieve a patient’s physical suffering, even knowing that it will also result in death, but not allowing it with the intent to cause death may seem like a somewhat artificial distinction. But, in Gorsuch’s view, the distinction would also solve a constitutional conundrum: If – as essentially all states allow – patients can refuse care or discontinue treatment, why shouldn’t they also have a right to a doctor’s assistance in committing suicide? Although other efforts by scholars and lawyers to distinguish assisted suicide and euthanasia from the right to refuse treatment fall short, Gorsuch contends, “an intent-based distinction may work sufficiently well to withstand a constitutional equal protection challenge. Assisted suicide and euthanasia differ from the right to refuse in that they necessarily entail an intent to kill and, with it, the judgment that a patient’s life is no longer worth living. Such an intention may be present in a decision to refuse treatment, but, I suggest, it need not be.”

Gorsuch devotes an entire chapter to an analysis of Planned Parenthood v. Casey , the Supreme Court’s 1992 decision reaffirming a woman’s right to an abortion, and Cruzan v. Director, Missouri Department of Health , the court’s 1990 decision upholding the state’s refusal to allow the parents of a woman in a “persistent vegetative state” to terminate treatment on her behalf. The question for Gorsuch is whether the two cases support an interest in autonomy, protected by the Constitution, that could in turn support a right to assisted suicide and euthanasia. In his view, they do not. He maintains that the court’s decision in Casey should be read more narrowly, pointing to the portion of the decision in which a plurality of the court argues “that the doctrine of stare decisis , or respect for long-settled law, required continued adherence” to the court’s 1973 decision in Roe v. Wade , which recognized a woman’s right to terminate her pregnancy.

In a footnote, Gorsuch stresses that his analysis in his book is limited to assisted suicide and euthanasia; he has no intent “to engage the abortion debate.” But he doesn’t stop at that. Instead, he acknowledges that “abortion would be ruled out by the inviolability-of-life principle I intend to set forth if , but only if , a fetus is considered a human life.” Gorsuch then seems to pull back again, reminding his readers that in Roe the Supreme Court “unequivocally held that a fetus is not a ‘person’ for purposes of constitutional law” – suggesting, perhaps, that the issue has already been taken off the table. However, when Gorsuch makes the same statement elsewhere in the book, he again cites Roe , but he also cites a dissent by Justice Byron White, for whom Gorsuch clerked. Gorsuch characterizes the White dissent as “arguing that the right to terminate a pregnancy differs from the right to use contraceptives because the former involves the death of a person while the latter does not.” Gorsuch may not share White’s view, but his decision to include it is somewhat curious given what he has elsewhere described as the court’s “unequivocal” holding.

Is Gorsuch’s reference to the White dissent a veiled hint into his own views on abortion or merely an effort to give equal time to an opposing view? It is impossible to know for certain, and we aren’t likely to learn anything more at his confirmation hearing. If Gorsuch is confirmed, we may have to wait for the next challenge to laws regulating abortion to reach the Supreme Court.

Posted in A close look at Judge Neil Gorsuch’s jurisprudence , Nomination of Neil Gorsuch to the Supreme Court

Recommended Citation: Amy Howe, Gorsuch on euthanasia and assisted suicide – and abortion? , SCOTUSblog (Mar. 16, 2017, 5:29 PM), https://www.scotusblog.com/2017/03/gorsuch-euthanasia-assisted-suicide-abortion/

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H.Con.Res. 109: Expressing the sense of the Congress that assisted suicide (sometimes referred to using other terms) puts everyone, including those most vulnerable, at risk of deadly harm.

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118th CONGRESS

H. CON. RES. 109

IN THE HOUSE OF REPRESENTATIVES

May 23, 2024

Mr. Wenstrup (for himself, Mr. Correa , Mr. Murphy , Mr. Cartwright , and Mr. Smith of New Jersey ) submitted the following concurrent resolution; which was referred to the Committee on Energy and Commerce

CONCURRENT RESOLUTION

Expressing the sense of the Congress that assisted suicide (sometimes referred to using other terms) puts everyone, including those most vulnerable, at risk of deadly harm.

Whereas suicide means the act of intentionally ending one’s own life, preempting death from disease, accident, injury, age, or other condition;

Whereas assisting in a suicide , sometimes referred to as death with dignity, end-of-life options, aid-in-dying, or similar phrases, means knowingly and willingly prescribing, providing, dispensing, or distributing to an individual a substance, device, or other means that, if taken, used, ingested, or administered as directed, expected, or instructed, will, with reasonable medical certainty, result in the death of the individual, preempting death from disease, accident, injury, age, or other condition;

Whereas society has a longstanding policy of supporting suicide prevention such as through the efforts of many public and private suicide prevention programs, the benefits of which could be denied under a public policy of assisted suicide;

Whereas assisted suicide most directly threatens the lives of people who are elderly, experience depression, have a disability, or are subject to emotional or financial pressure to end their lives;

Whereas the Oregon Health Authority’s annual reports reveal that pain or the fear of pain is listed second to last (25 percent) among the reasons cited by all patients seeking lethal drugs since 1998, while the top 5 reasons cited are psychological and social concerns: losing autonomy (92 percent), less able to engage in activities that make life enjoyable (90 percent), loss of dignity (79 percent), losing control of bodily functions (48 percent), and burden on family friends/caregivers (41 percent);

Whereas the Supreme Court has ruled twice (in Washington v. Glucksberg and Vacco v. Quill) that there is no constitutional right to assisted suicide, that the Government has a legitimate interest in prohibiting assisted suicide, and that such prohibitions rationally relate to protecting the vulnerable from coercion and protecting disabled and terminally ill people from prejudice, negative and inaccurate stereotypes, and societal indifference ;

Whereas clearly expressing that assisted suicide is not a legitimate health care service, Congress passed, with a nearly unanimous vote, and President Bill Clinton signed, the Assisted Suicide Funding Restriction Act to prevent the use of Federal funds for any item or service, including advocacy, provided for the purpose of causing, or assisting in causing, the death of any individual such as by assisted suicide, euthanasia, or mercy killing;

Whereas a handful of States have authorized assisted suicide, but over 30 States have rejected over 200 attempts at legalization since 1994;

Whereas States that authorize assisted suicide for terminally ill patients do not require that such patients receive psychological screening or treatment, though studies show that the overwhelming majority of patients contemplating suicide experience depression;

Whereas the laws of such States contain no requirement for a medical attendant to be present at the time the lethal dose is taken, used, ingested, or administered to intervene in the event of medical complications;

Whereas such State laws contain no requirement that a qualified monitor be present to assure that the patient is knowingly and voluntarily taking, using, ingesting, or administering the lethal dose;

Whereas such State laws contain no requirement to secure lethal medication if unwanted or if death occurs before such medication is used;

Whereas such State laws do not prevent family members, heirs, or health care providers from pressuring patients to request assisted suicide;

Whereas such States qualify some patients for assisted suicide by using a broad definition of terminal disease and going to die in six months or less that includes diseases (such as diabetes or HIV) that, if appropriately treated, would not otherwise result in death within six months;

Whereas it is extremely difficult even for the most experienced doctors to accurately prognosticate a six-month life expectancy as required, making such a prognosis a prediction, not a certainty;

Whereas reporting requirements vary by State, but when required, rely on prescribing physicians or dispensing pharmacists to self-report;

Whereas such reporting is neither conducted by an objective third party nor of sufficient depth and accuracy to effectively monitor the occurrence of assisted suicide;

Whereas there is an astounding lack of transparency in the practice of assisted suicide to the extent that State health departments and other authorities admittedly have no method of knowing if it is being practiced within the bounds of State laws and have no funding or authority to make such a determination;

Whereas some State laws actively conceal assisted suicide by directing the physician to list the cause of death as the underlying condition without reference to death by suicide;

Whereas the confidential nature of end-of-life decisions makes it virtually impossible to effectively monitor a physician’s behavior to prevent abuses, making any number of safeguards insufficient;

Whereas the cost of lethal medication is far less costly than many life-saving treatments, which threatens to restrict treatment options, especially for disadvantaged and vulnerable persons, as has happened in several known cases and presumably many more unknown in which insurers have denied or delayed coverage for life-saving care while offering to cover assisted suicide;

Whereas access to personal assistance services such as in-home hospice and palliative care, home health care aides, and nursing care or assistance is regretfully limited and subject to long waiting lists in many areas, placing systemic pressure on patients in need of such personal assistance services to resort to assisted suicide; and

Whereas for all these reasons, assisted suicide undermines the integrity of the health care system: Now, therefore, be it

That it is the sense of Congress that the Federal Government should ensure that every person facing the end of their life has access to the best quality and comprehensive medical care, including palliative, in-home, or hospice care, tailored to their needs and that the Federal Government should not adopt or endorse policies or practices that support, encourage, or facilitate suicide or assisted suicide, whether by physicians or others.

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• v.83(3); 2016 Aug

Non-faith-based arguments against physician-assisted suicide and euthanasia

Daniel P. Sulmasy

1 The Department of Medicine and Divinity School, The University of Chicago, Chicago, IL, USA

John M. Travaline

2 Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA

Louise A. Mitchell

3 Catholic Medical Association, Bala Cynwyd, PA, USA

E. Wesley Ely

4 Department of Medicine, Division of Pulmonary and Critical Care, Vanderbilt University School of Medicine, Nashville, TN, USA

5 Veteran's Affairs Geriatric Research Education and Clinical Center (GRECC) of the Tennessee Valley Healthcare System, Nashville, TN, USA

This article is a complement to “A Template for Non-Religious-Based Discussions Against Euthanasia” by Melissa Harintho, Nathaniel Bloodworth, and E. Wesley Ely which appeared in the February 2015 Linacre Quarterly . Herein we build upon Daniel Sulmasy's opening and closing arguments from the 2014 Intelligence Squared debate on legalizing assisted suicide, supplemented by other non-faith-based arguments and thoughts, providing four nontheistic arguments against physician-assisted suicide and euthanasia: (1) “it offends me”; (2) slippery slope; (3) “pain can be alleviated”; (4) physician integrity and patient trust.

Lay Summary: Presented here are four non-religious, reasonable arguments against physician-assisted suicide and euthanasia: (1) “it offends me,” suicide devalues human life; (2) slippery slope, the limits on euthanasia gradually erode; (3) “pain can be alleviated,” palliative care and modern therapeutics more and more adequately manage pain; (4) physician integrity and patient trust, participating in suicide violates the integrity of the physician and undermines the trust patients place in physicians to heal and not to harm.

Introduction

In its first issue of 2015, The Linacre Quarterly published the text of a secular debate held at Vanderbilt University School of Medicine ( Bloodworth et al. 2015 ), hoping it would re-kindle interest in formulating arguments and contribute to increasingly common discussions in society about physician-assisted suicide (PAS) and euthanasia. As that paper was offered to engender dialog, it was hoped that other reflections would follow. As it happened, around the same time that the Bloodworth publication was being prepared, a debate was held by Intelligence Squared U.S. ( Intelligence Squared 2014a ) on legalizing physician-assisted suicide featuring Professors Peter Singer and Andrew Solomon “for” and Doctors Daniel Sulmasy and Ilora Finlay “against” the legalization of PAS. 1 Herein we build upon Doctor Sulmasy's opening and closing arguments from that debate, supplemented by other non-faith-based arguments and thoughts intended to further this conversation, focusing on objections to legalizing these practices. In this manuscript, we will thus review the Bloodworth article, present the Intelligence Squared opening and closing statements “against PAS” and then expound upon four key arguments against PAS: (1) “it offends me”; (2) slippery slope; (3) “pain can be alleviated”; (4) physician integrity and patient trust.

Before getting into Doctor Sulmasy's debate points, it is worthwhile to recount some points raised in the Bloodworth article ( Bloodworth et al. 2015 ). While the debate points presented at Vanderbilt were well-received, common criticisms to some of the assertions made in that piece are worth consideration. For example, one of the main bases for Doctor Ely's argument against physician-assisted suicide and euthanasia involved an appeal to natural law. 2 Such appeal to natural law does not presuppose belief in God. The knowledge of natural law is discernible by reason and so it is not fundamentally theistic. While it is true that the Catholic Church in particular has made prominent use of natural law in formulating its ethical positions, natural law is not essentially rooted in any faith tradition (see, for example, Anderson 2005 ; Finnis 2001 ; Goyette, Latkovic, and Myers 2004 ; McInerny 1993 ; Veatch 1971 ). Nonetheless, appeal to natural law is commonly mistaken as an appeal to theism, which many in a secular society dismiss out of hand because of this misperception. These critics often forget the use of natural law reasoning by the founding fathers of the United States. The Vanderbilt debate, for instance, referenced the Declaration of Independence, which is a quintessentially natural law-based set of governing principles. Lastly, the references in that debate to C.S. Lewis from The Abolition of Man were placed strategically and without necessary dependence on Lewis's explicit arguments for theism as the ground of the natural law, and hence morality. Lewis's approach leaves natural law vulnerable to the charge of theism by those who do not accept an ultimate or transcendent justice or goodness as the rule and measure of human actions. Lewis's position regarding the theistic basis of natural law is not, however, widely accepted by natural law scholars, the authors of this paper, or the Catholic Church.

The Bloodworth article was, as billed, a mere starting point. Doctors Sulmasy and Finlay developed a sophisticated, philosophical “devil's advocate” approach that was ultimately successful. They discerned optimal premises for making the case against physician-assisted suicide and euthanasia to avowed non-theistic practitioners of medicine. It is thus our privilege to publish here Doctor Sulmasy's points to continue building the case towards truth in respecting human life nearing its end in the context of the practice of the vocation of medicine. In the tradition of St. Thomas, we take four strong arguments for PAS that arose during the debate (patient autonomy, no slippery slope, unalleviated pain, physician's duty) and argue against them. We base our arguments in reason, with the conviction that the truth in a principle can be discerned and its implications drawn out to a logical conclusion, and an error can be shown to have a contradiction at its heart.

Doctor Sulmasy's Opening Statement 3

I am a physician. Part of my job is to help people die in comfort and with dignity. But I do not want to help you, or your daughter, or your uncle commit suicide. You should not want me to. I urge you to oppose physician-assisted suicide: it represents bad ethical reasoning, bad medicine, and bad policy. I am going to concentrate on the first of these lines of argument. Ilora will take up the latter two.

We strongly support the right of patients to refuse treatments and believe physicians have a duty to treat pain and other symptoms, even at the risk of hastening death. But empowering physicians to assist patients with suicide is quite another matter—striking at the heart not just of medical ethics, but at the core of ethics itself. That is because the very idea of interpersonal ethics depends upon our mutual recognition of each other's equal independent worth, the value we have simply because we are human. Some would have you believe that morality depends upon equal interests (usually defined by our preferences) and advance utilitarian arguments based on that assumption. 4

But which is morally more important, people or their interests? As Aristotle observed, small errors at the beginning of an argument lead to large errors at the end. 5 If interests take precedence over people, then assisting the suicide of a patient who has lost interest in living certainly is morally praiseworthy. But it also follows that active euthanasia ought to be permitted. It also follows that the severely demented can be euthanized once they no longer have interests. They can also freely be experimented upon as excellent human “models” for research. It also follows that infanticide ought to be permitted for infants with congenital illness.

Many would see these conclusions as frightful, but this is not just a slippery slope. They all follow logically from arguing for assisted suicide on the basis of maximizing personal interests. So if you do not believe in euthanasia for severely disabled children or the demented, you might want to re-think your support for assisted suicide. At least if you want to be consistent.

People often argue that they need assisted suicide to preserve their dignity, but that word has at least two senses. Proponents use the word in an attributed sense to denote the value others confer on them or the value they confer on themselves. But there is a deeper, intrinsic sense of dignity.

Human dignity ultimately rests not on a person's interests, but on the value of the person whose interests they are; and the value of the person is infinite. I do not need to ask you what your preferences are to know that you have incalculable worth, simply because you are human. Martin Luther King said that he learned this from his grandmother who told him, “Martin, don't let anybody ever tell you you're not a Somebody” ( Baker-Fletcher 1993 , 23). This some-bodiness, this intrinsic worth or dignity, was at the heart of the civil rights movement.

It does not matter what a person looks like, how productive the person might be, how others view that person, or even how that person may have come to view herself. What matters is that everybody, black or white, healthy or sick, is a somebody . Assisted suicide and euthanasia require us to accept that it is morally permissible to act with the specific intention-in-acting of making a somebody into a nobody , i.e., to make them dead.

Intentions, not just outcomes, matter in ethics. Intending that a somebody be turned into a nobody violates the fundamental basis of all of interpersonal ethics—the intrinsic dignity of the human.

Our society worships independence, youth, and beauty. Yet we know that illness and aging often bring dependence and disfigurement. The terminally ill, especially, need to be reminded of their value, their intrinsic dignity, at a time of fierce doubt. They need to know that their ultimate value does not depend upon their appearance, productivity, or independence.

You see, physician-assisted suicide flips the default switch. The question the terminally ill hear, even if never spoken, is, “You've become a burden to yourself and the rest of us. Why haven't you gotten rid of yourself yet?” A good utilitarian would think this a proper question—even a moral duty.

As a physician who cares for dying patients, however, I am more fearful of the burden this question imposes on the many who might otherwise choose to live , than the modest restriction imposed on a few, when physician-assisted suicide is illegal.

Assisted suicide should not be necessary. Pain and other symptoms can almost always be alleviated. As evidence, consider that pain or other symptoms rarely come up as reasons for assisted suicide. The top reasons are: fear of being a burden and wanting to be in control ( Oregon Public Health Division 2015 , 5).

You may ask, “Why shouldn't I have this option?” And yet we all realize that society puts many restrictions on individual liberty, and for a variety of reasons: to protect other parties, to promote the common good, and to safeguard the bases of law and morality. For example, we do not permit persons to drive when drunk, or to freely sell themselves into slavery.

Paradoxically, in physician-assisted suicide and euthanasia, patients turn the control over to physicians, who assess their eligibility and provide the means. Further, death obliterates all liberty. Therefore, saying that respect for liberty justifies the obliteration of liberty actually undermines the value we place on human freedom.

Doctor Sulmasy's Closing Statement

I have been on talk shows and received call-in questions from patients who ask how I can be opposed to physician-assisted suicide when they are getting sick from chemotherapy, suffering complications from the big IV they have in their neck, have intense pain, and are spending more time in the hospital than outside it. But I ask them, why are you still getting chemotherapy? Why not have the IV removed? Why not ask for hospice or palliative care to control your pain? Why not just stay home? You should have no need for assisted suicide. 6 Most supporters of physician-assisted suicide want what opponents want—respect for their dignity and attention to their individual needs.

But we are all human beings—fragile, interdependent, and connected in bonds of mutual respect and support. Suicide is always an act of communication and has profound interpersonal implications. Many persons who raise the question of suicide are really testing the waters, asking us if we care enough to try to stop them. When we do not stop them, or even say, “I'll help you,” we confirm their deepest fears and make it difficult for them to see an alternative. And when the suicide happens, physicians and families must live for the rest of their lives with fact that they did not try to intervene.

We should not construct a society that makes assisted suicide easy or common. We should re-direct our energies towards making sure that all patients get the kind of care we all want—helping us live to the fullest even as we are dying. Vote for that kind of high quality, compassionate care at the end of life, and the sort of moral world that makes it possible, by voting No on physician-assisted suicide.

Debate Result and Some of the Arguments

Doctors Sulmasy and Finlay won the debate according to its rules, by persuading the most members of the live audience to change their minds. While the live audience in New York City began the debate with 65 percent in favor of legalizing assisted suicide, only 10 percent opposed, and 25 percent undecided, after the debate, 67 percent were in favor but 22 percent were opposed to legalization. The unofficial online polling changed from 5 percent opposed to legalization before the debate to 51 percent opposed as of March 21, 2016. (See the Results tab at Intelligence Squared 2014a )

In the rest of this article we highlight and expound upon some of the arguments against physician-assisted suicide gleaned from the debate and from the audience comments and questions following it: (1) “It offends me”; (2) the slippery slope; (3) “pain can be alleviated”; and (4) physician integrity and patient trust. We take care not to frame them within a faith-based context. While we believe that faith-based arguments are strong, our intention in arguing from reason is that all too many people are quickly dismissive of faith-based arguments. Our aim is to advance the conversation from this perspective. As noted earlier, the hope is to have new and other iterations of the pro-life arguments readily available to reach as broad a swath of people as possible, believers and non-believers alike.

“It Offends Me” Argument

Certainly everyone should strive not to be offensive to others, but whether one is offended or not, partly depends upon the person potentially offended. To offend someone is to attack, violate, or cause resentful displeasure to a person. This presupposes that the one offended recognizes the attack, violation, or resentment, and so the argument vis-à-vis assisted suicide is that when one willfully kills oneself, or requests to be killed, every other human being should rightfully be offended. Why? Because subsumed in the action of one killing oneself (or requesting to be killed) is the implied announcement that one's life (human life) is somehow not as valuable as it otherwise would be if one were not in a position to seek one's death (For to value life contradicts the act of killing, and if one values life, one does not commit suicide or ask to be killed.). To assert that one values human life, and at the same time to commit suicide is contradictory and illogical. So, to kill oneself (willfully, i.e., to distinguish this form of suicide from suicide in association with mental illness or other clinical pathology) necessarily devalues human life. And, because we are all human beings, therefore, every human being is (or should be) resentful of his or her life being devalued.

Now some may grant that killing oneself is an expression of devaluing life, but only that individual person's life, and no one else's, arguing therefore, that there is no basis for one's willful suicide (or its request) to be offensive to anyone else. The fundamental problem, however, with this reasoning is that human beings are relational (natural law). It is part of the essence of being human to exist in a relationship to another. According to Thomas Aquinas, the third precept of the natural law is “an inclination to good, according to the nature of his reason … thus man has a natural inclination … to live in society” ( Aquinas 1948 , I–II, q. 94, a. 2). And Aristotle viewed a particular relationship, that of friendship, to be a virtue and “most indispensable for life” ( Aristotle 1962/1980 , bk. 8, ch. 1). Indeed the very origin of an individual necessitates the relationship of two other human beings—a mother and a father—and a human being exists in relationships with others by his or her very nature. Human beings then are always, and essentially a part of a community of persons, and as such because of this connection with others (as part of humanity), when another person kills him- or herself or allows him- or herself to be killed, life for every other human being is cheapened (devalued). Such an action says to some degree, that life is not worth it; and although the effect on others may be seemingly miniscule, the more it happens the greater the effect on others (like compounding interest on money). Moral actions very much and very often have consequences for others, even when there appears to be no connection. 7

The Slippery Slope Argument

One of the issues brought up in the debate over physician-assisted suicide is the slippery slope argument: If physician-assisted suicide is made legal, then other things will follow, with the final end being the legalizing of euthanasia for anyone for any reason or no reason. The experience of other countries shows that this is not theoretical. The Netherlands is an example of the slippery slope on which legalizing physician-assisted suicide puts us. In the 1980s the Dutch government stopped prosecuting physicians who committed voluntary euthanasia on their patients ( Jackson 2013 , 931–932; Patel and Rushefsky 2015 , 32–33). By the 1990s over 50 percent of acts of euthanasia were no longer voluntary. This is according to the 1991 Remmelink Report, a study on euthanasia requested by the Dutch government and conducted by the Dutch Committee to Study the Medical Practice Concerning Euthanasia ( Euthanasia.com 2014 ; Patients Rights Council 2013a ; Van Der Maas et al. 1991 ). In 2001 euthanasia was made legal. And in 2004 it was decided that children also could be euthanized. According to Wesley Smith, in a Weekly Standard article in 2004, “In the Netherlands, Groningen University Hospital has decided its doctors will euthanize children under the age of 12, if doctors believe their suffering is intolerable or if they have an incurable illness.” The hospital then developed the Groningen Protocol to decide who should die. Smith comments,

It took the Dutch almost 30 years for their medical practices to fall to the point that Dutch doctors are able to engage in the kind of euthanasia activities that got some German doctors hanged after Nuremberg. For those who object to this assertion by claiming that German doctors killed disabled babies during World War II without consent of parents, so too do many Dutch doctors: Approximately 21% of the infant euthanasia deaths occurred without request or consent of parents. ( Smith 2004 )

Euthanasia in the Netherlands went from illegal but not prosecuted, to legal, to including children . And it is not stopping there ( Schadenberg 2013 ). Now, in 2011, Radio Netherlands reported that “the Dutch Physicians Association (KNMG) says unbearable and lasting suffering should not be the only criteria physicians consider when a patient requests euthanasia.” The association published a new set of guidelines, “which says a combination of social factors and diseases and ailments that are not terminal may also qualify as unbearable and lasting suffering under the Euthanasia Act.” These social factors include “decline in other areas of life such as financial resources, social network, and social skills” ( RNW 2011 ). So a person with non-life threatening health problems but who is poor or lonely can request to be euthanized.

In another example of the slippery slope to which physician-assisted suicide leads, in 2002 Belgium “legaliz[ed] euthanasia for competent adults and emancipated minors.” In February of 2014, Belgium took the next step:

Belgium legalized euthanasia by lethal injection for children…. Young children will be allowed to end their lives with the help of a doctor in the world's most radical extension of a euthanasia law. Under the law there is no age limit to minors who can seek a lethal injection. Parents must agree with the decision, however, there are serious questions about how much pressure will be placed on parents and/or their children. ( Patients Rights Council 2013b )

Some say that the US state laws concerning physician-assisted suicide are very restrictive and so there is no chance of erosion such as has happened in the Netherlands or Belgium ( Intelligence Squared 2014b , 34). Yet, if there is no moral or philosophical basis for PAS laws in the common good, then there is no telling how far changes to PAS laws will go in the future, and no stopping the changes.

“Pain Can Be Alleviated” Argument

In medicine, we talk much these days about a “good death,” not necessarily one that is completely free of suffering, but a dying process in which we are attendant to pain and symptom management, optimize clear decision making, and affirm the whole person in as dignified a manner as possible. Importantly, this can often be effectively accomplished through incorporation of palliative care services. Palliative care is a healing act adjusted to the good possible even in the face of the realities of an incurable illness. Cure may be futile but care is never futile ( Pellegrino 2001 ). With appropriate utilization of palliative care, far fewer patients would be driven by fear to request that physicians actively end their lives via PAS/E.

Proponents of assisted suicide and euthanasia posit the scenario of uncontrollable pain as a straw man for advancing their cause. Such proponents apparently view death as the ultimate analgesic. In fact, in medical practice today, pain relief is almost always possible given modern therapeutics in analgesia and the medical specialty of pain management. Since pain can be alleviated, there is no basis to assert a need for PAS because of intractable pain. This may explain in part why many requests for PAS are no longer related to or initiated because of intolerable pain, but because of fear of such intolerable pain. Further, closely related to a patient's fear of intolerable pain, and sometimes associated with a patient's fear of being abandoned ( Coyle 2004 ), is a patient's request for PAS because of not wanting to burden others. This too poses a curious contradiction, for on the one hand there is not wanting to be a burden on a loved one, and on the other hand a fear of being alone and abandoned. Such a contradiction, once considered and coupled with the fact that pain can be addressed successfully through optimal palliative care implementation, enhances the power of this argument against PAS/E.

The Oregon law was enacted on the basis of intolerable pain — no one should be forced to endure pain that is uncontrollable and unendurable. Most of us can sympathize with that, but the law is not restricted to pain, and it is not pain that is the top reason people choose physician-assisted suicide in Oregon. The state's “Death with Dignity Act Annual Report” for 2014 shows that the top reason is “losing autonomy” ( Oregon Public Health Division 2015 , 5). Concern about pain was not even the second or third reason: “Less able to engage in activities making life enjoyable” and “Loss of dignity.” It was ranked sixth out of seven, above only financial concerns, and included not only “inadequate pain control,” but also “concern about it.” These patients were not necessarily in uncontrollable pain themselves, however they were concerned about it (as are we all). But even that concern did not rank high on their list of reasons that they wanted to commit suicide. Even if the line drawn is unbearable pain, how can that be restricted to only physical pain? Who can judge that mental anguish is not unbearable pain? Or that economic distress (or anything else that causes anguish) is not unbearable pain?

Physician Integrity and Patient Trust Argument

When a patient asks a physician to assist in killing him- or herself, not only is there disrespect shown to the physician's integrity, but a contradiction is created. Asking a physician to participate in PAS undermines the principled ethic and integrity of the physician whose noble profession is defined as one of compassionate service of the patient who is vulnerable, wounded, sick, alone, alienated, afraid; and undermines the integrity or wholesomeness of the patient, who him- or herself is in desperate need of trying to achieve. To ask and expect a physician to participate in the destructive act of suicide violates both personal and professional integrity of the physician, and leaves both the patient and the physician at risk for moral confusion about what is good, true, and beautiful about the human person.

The threat of euthanasia posed by legalizing PAS also undermines trust between physician and patient.

Both euthanasia and physician-assisted suicide would undermine the medical profession by eroding the trust of patients in their physicians as caregivers. If doctors were permitted to engage in practices that harm their patients, then patients would never know if their doctors were truly acting in their best interests. ( Austriaco 2011 , 148)

Will your doctor kill you if he or she thinks you are too ill or in too much pain or unconscious? The Oath of Hippocrates has guided physicians for twenty-four hundred years. The Oath states,

I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice…

I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. ( Tyson 2001 )

Even with all the advances in medicine over the last one to two hundred years, the public perception is still that the Hippocratic Oath is an important indicator that the patient in his or her vulnerability can put trust in the physician ( Lederer 1999 , 102). Euthanasia by health-care professionals undermines that trust.

Lack of trust is not just something that may or may not happen if euthanasia is legalized. It is happening in countries that have legalized euthanasia. Austriaco points out that “many Dutch patients, before they will check themselves into hospitals, insist on writing contracts assuring that they will not be killed without their explicit consent” ( Austriaco 2011 , 148). As stated earlier, in the 1980s the Dutch government stopped prosecuting physicians who committed voluntary euthanasia on their patients. By the 1990s over 50 percent of acts of euthanasia were no longer voluntary. This has had a deleterious effect on the relationship of patients to health-care professionals. An article in 2011 in the Telegraph , a newspaper in the UK, stated that “Elderly people in the Netherlands are so fearful of being killed by doctors that they carry cards saying they do not want euthanasia” ( Beckford 2011 ). The Dutch elderly mistrust their own doctors.

Trust is not the only issue concerning the integrity of medicine: PAS also calls into question the very ends of medicine to cure and to care. Christopher Saliga, a nurse, explains that

One can rightly say that in Oregon, the balance has shifted such that respect for autonomy currently has greater weight among the principles hanging in the balance than it had prior to the legalization of assisted suicide. As a result, the contradictory patient outcomes of life and death via continued care or willful suicide respectively are considered equally valid. ( Saliga 2005 , 22–23)

Medicine and the medical profession traditionally aimed at curing and healing. Assisting in a suicide is neither cure nor healing. It pits the medical profession against itself: curing and caring versus killing.

We offer the following table of the salient points comprising the non-faith-based arguments against PAS (Table  1 ).

Table 1

Concluding remarks.

As the secular world pushes more and more the agenda of personal autonomy and relativism, breeches of long-held ethical standards and our oath as physicians are increasingly apparent. On this topic of PAS and euthanasia, it is worth pointing out that in the practice of critical care medicine at the highest level of academia, there are now movements to endorse “shortening of the dying process” (SDP), which is a euphemism for physician-assisted suicide at best, and in effect, a synonym for murder when unilaterally committed by a health-care professional in the absence of legal approval. In fact, in one Belgian statement, the authors endorsed using medications to end patients’ lives even in the absence of suffering ( Vincent et al. 2014 , n. 6), a practice that was found offensive and actively rebutted by a group of Dutch physicians ( Kompanje et al. 2014 ). Such SDP is a practice that was reported by 2 percent of physicians in seven European countries ( Sprung et al. 2003 ), but which is felt by 79 percent of physicians to be wrong and intolerable even if allowed by law ( Sprung et al. 2014 ). With such active conversations occurring, especially now that the Canadian Supreme Court has recently ruled in favor of physician-assisted suicide, it is more important than ever to be adept with defense of life arguments, which are also arguments in defense of the healing profession of medicine at large.

All is not lost in medicine just because we have no cure and see a patient's life nearing its end. This represents a time in which we as physicians must focus, as Edmund Pellegrino taught, on elevating human dignity and the preservation of self-worth for each and every patient:

To care, comfort, be present, help with coping, and to alleviate pain and suffering are healing acts as well as cure. In this sense, healing can occur when the patient is dying even when cure is impossible. Palliative care is a healing act adjusted to the good possible even in the face of the realities of an incurable illness. Cure may be futile but care is never futile. ( Pellegrino 2001 )

We invite others to contribute to this ongoing debate, and to continue the dialog, hoping that some of it will be captured on the pages of this journal.

Biographies

Daniel P. Sulmasy, M.D., Ph.D., is the Kilbride-Clinton Professor of Medicine and Ethics in the Department of Medicine and Divinity School; associate director of the MacLean Center for Clinical Medical Ethics in the Department of Medicine; director, Program on Medicine and Religion at the University of Chicago.

Deacon John M. Travaline, M.D., is a professor of Thoracic Medicine and Surgery at the Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA.

Louise A. Mitchell, M.T.S., M.A., is associate editor of The Linacre Quarterly , and an adjunct professor of bioethics.

E. Wesley Ely, M.D., M.P.H., is a professor of Medicine and Critical Care at Vanderbilt University, the Vanderbilt Center for Health Services Research, and associate director of Research for the Tennessee Valley VA Geriatric Research Education Clinical Center in Nashville, TN, USA.

1 Intelligence Squared U.S. is a program which presents prominent figures before a live audience debating important timely issues of our time. More information can be found at http://intelligencesquaredus.org .

2 In essence, the natural law expresses the original moral sense which enables man to discern by reason the good and the evil, the truth and the lie. Catechism of the Catholic Church (2000), n. 1954 .

3 Doctor Sulmasy's opening and closing statements are printed verbatim. A few notes and references have been added. For the transcript, see Intelligence Squared (2014b) .

4 See Singer (1993 , 13–14, 21–26, 57, 94–95).

5 Aristotle. On the heavens (I.5, 271b9–10), in The Basic Works of Aristotle , ed. Richard McKeon (New York: Random House, 1941), 404.

6 The authors' understanding of palliative care is that it is present first and foremost to help the patient (and family) live maximally in the face of life-threatening illness and, in that sense, can provide great benefit to the patient and loved ones well before he or she is imminently dying. Whenever it is deemed appropriate in the course of a patient's life and dying process, the palliative care team's focus on “iving maximally” may be best achieved by coordinating activities to optimize the patient's comfort, function, relationships, healing, dignity, and preparation for natural death.

7 Further, if we were to develop this line of reasoning in a faith-based model, it would involve the notion that there is no such thing as a private sin.

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