Ethicist-assisted suicide

Not long ago, the Dutch Parliament made the Netherlands the first country in the world to legalize euthanasia.  The Dutch have long been in the vanguard of tolerating the elective ending of life by doctors.  Physician-assisted suicide and voluntary euthanasia have been tolerated - if not legal - on an official basis in the Netherlands since 1993.

The new law, in essence, merely relieves Dutch prosecutors from having to review each case of assisted suicide and euthanasia that occurs in the Netherlands.  These life-ending practices have been technically illegal in the Netherlands, but if certain guidelines are met and each case is formally reported, no legal action has been taken. Over 2200 cases of the elective ending of life were reported to Dutch officials in 1999, but many more cases that went unreported are suspected to have occurred.  Those unreported cases were technically in violation of the law.  The new law legalizing euthanasia, according to officials, is supposed to "take euthanasia out of the criminal arena."

Patients' rights advocates hail the decision as a major step in favor of the patient's right to choose.

DrRich comments:

Most ethicists have been telling us for at least a decade that ethical arguments against physician-assisted suicide and euthanasia (two actions that, according to ethicists, are ethically equivalent) are doomed.  Our society has clearly embraced the notion of individual autonomy, and therefore has also embraced - in principle, at least - assisted suicide and euthanasia.  Allowing these actions is simply a manifestation of the individual's right to choose.  The latest move by the Dutch parliament merely formalizes what western society has already chosen. 

DrRich is not an ethicist, and would surely lose on points a debate with a real, university-trained ethicist. (I can't follow much of their arcane jargon or acrobatic twists of logic.)  (By the way, since we're supposed to behave ethically, isn't it unethical for ethicists not to speak plainly?)  But to me, the real issue is not purely an ethical one.  It's a practical one.  For, even if assisted suicide and euthanasia are ethical, what happens when you introduce these practices into a health care system in which the basic underlying operating principle is covert rationing?

In viewing the Dutch record, proponents of assisted suicide see a shining example of the societal benefits of permitting end-of-life autonomy of choice.  Opponents see a series of terrible abuses, including an utter disregard of the prescribed guidelines.  To DrRich, however, the most telling feature of the Dutch experience is the admission that thousands of cases of “active involuntary euthanasia” are occurring each year.  In other words, patients are being actively killed at the hands of their doctors without their permission.  All, it is said, are leading insufferable existences, and all are being euthanized solely for humane reasons.

What do the ethicists say about such a thing?  Not all agree, of course, but it turns out that it is fairly easy to derive an ethical argument in favor of involuntary euthanasia from the starting point of upholding individual autonomy.  That argument goes like this: the principle of autonomy demands that patients be allowed to refuse therapy; refusal of therapy is the ethical equivalent of voluntary euthanasia; since voluntary euthanasia is a right of individuals with intractable suffering, it follows that it would be unethical to withhold euthanasia from suffering individuals who are incapacitated, just because they are unable to give their permission. Hence, involuntary euthanasia is ethical for suffering patients who are unable to give their permission. 

Where this leaves us is at a place where others can decide for an individual both what constitutes intractable suffering, and when that individual is too incompetent to make such a determination for him or herself.  Where these “others” end up drawing the line on whether a person’s existence is of value or whether a person is competent, of course, can be influenced by all sorts of external factors.

In Nazi Germany, for instance, those external factors included a belief in the purity of the Arian race, and that belief led to horrible excesses.  We don’t have that belief today. 

What we do have is a hidden but undeniable imperative to ration health care, which means that potentially beneficial care is going to have to be withheld from somebody, somewhere.  Can we be sure that, once we start down the road of allowing patients to choose death, we will be able to withstand our external influences, and stay our hands from ending the suffering of some who might not be so sure of their choice or who are incapable of making a choice – especially when, by so doing, we will make more health care available to others?

Let us personalize this issue a bit.

Imagine yourself at age 75 in a hospital bed with a critical but potentially treatable illness.  Your doctor walks in, smiling.

If physician-assisted suicide and euthanasia are still illegal, you can be reasonably sure he’s smiling with confidence. He thinks he can cure you, and his smile tells you so. You relax. You feel better already.

But what if they are legal?  What would his smile mean then? He still might be smiling with confidence, of course.  But maybe he’s smiling as a means of beginning a conversation with you about some choices.  Maybe he’s about to pull up a chair, shake his head a bit, and say, “Well, you know, things don’t look so good this time, Charlie.”  He’ll pause, smiling wider now. “But the good news is, we can make it all pretty easy on you.”

Or worse, he might not say anything.  He might leave you guessing about how hard he’s really working to make you well. You’ve even heard – well, you’ve heard they don’t always tell you beforehand.

It’s hard to imagine anything more destructive to the trust between a doctor and a patient than knowing that your doctor, at some point, may shift from trying to cure you to trying to usher you into the next life as cheaply as possible (by encouraging suicide, by offering euthanasia, or by simply doing the euthanasia because you’re so incompetent you can’t see it’s the only thing to do).

If people want to commit suicide, and if the ethicists agree that assisted suicide is entirely okay, then let the ethicists do the assisting. I have relatively little to say against ethicist-assisted suicide. But leave the doctors out of it.

(For a full discussion of assisted suicide, click here.)

September, 2003

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