PHYSICIAN-ASSISTED SUICIDE, PRO AND CONPHYSICIAN-ASSISTED SUICIDE, PRO AND CON
Euthanasia And Physician-Assisted Suicide
There are two major reasons to oppose euthanasia. One is based on principle: it is wrong for one human to intentionally kill another (except in justified self-defense, or in the defense of others). The other reason is utilitarian: the harms and risks of legalizing euthanasia, to individuals in general and to society, far outweigh any benefits.
When personal and societal values were largely consistent with each other, and widely shared because they were based on a shared religion, the case against euthanasia was simple: God or the gods (and, therefore, the religion) commanded “Thou shalt not kill.” In a secular society, especially one that gives priority to intense individualism, the case for euthanasia is simple: Individuals have the right to choose the manner, time, and place of their death. In contrast, in such societies the case against euthanasia is complex.
Definitions are a source of confusion in the euthanasia debate—some of it deliberately engendered by euthanasia advocates to promote their case.1 Euthanasia is “a deliberate act that causes death undertaken by one person with the primary intention of ending the life of another person, in order to relieve that person’s suffering.”2 Euthanasia is not the justified withdrawing or withholding of treatment that results in death. And it is not the provision of pain relief, even if it could or would shorten life, provided the treatment is necessary to relieve the patient’s pain or other serious symptoms of physical distress and is given with a primary intention of relieving pain and not of killing the patient.
Secular Arguments Against Euthanasia
1. Impact on society. To legalize euthanasia would damage important, foundational societal values and symbols that uphold respect for human life. With euthanasia, how we die cannot be just a private matter of self-determination and personal beliefs, because euthanasia “is an act that requires two people to make it possible and a complicit society to make it acceptable.”3 The prohibition on intentional killing is the cornerstone of law and human relationships, emphasizing our basic equality.4
Medicine and the law are the principal institutions that maintain respect for human life in a secular, pluralistic society. Legalizing euthanasia would involve—and harm—both of them. In particular, changing the norm that we must not kill each other would seriously damage both institutions’ capacity to carry the value of respect for human life.
To legalize euthanasia would be to change the way we understand ourselves, human life, and its meaning. To explain this last point requires painting a much larger picture. We create our values and find meaning in life by buying into a “shared story”—a societal-cultural paradigm. Humans have always focused that story on the two great events of each life, birth and death. Even in a secular society—indeed, more than in a religious one—that story must encompass, create space for, and protect the “human spirit.” By the human spirit, I do not mean anything religious (although this concept can accommodate the religious beliefs of those who have them). Rather, I mean the intangible, invisible, immeasurable reality that we need to find meaning in life and to make life worth living—that deeply intuitive sense of relatedness or connectedness to others, the world, and the universe in which we live.
There are two views of human life and, as a consequence, death. One is that we are simply “gene machines.” In the words of an Australian politician, when we are past our “best before” or “use by” date, we should be checked out as quickly, cheaply, and efficiently as possible. That view favors euthanasia. The other view sees a mystery in human death, because it sees a mystery in human life, a view that does not require any belief in the supernatural.
Euthanasia is a “gene machine” response. It converts the mystery of death to the problem of death, to which we then seek a technological solution. A lethal injection is a very efficient, fast solution to the problem of death—but it is antithetical to the mystery of death. People in postmodern societies are uncomfortable with mysteries, especially mysteries that generate intense, free-floating anxiety and fear, as death does. We seek control over the event that elicits that fear; we look for a terror-management or terror-reduction mechanism. Euthanasia is such a mechanism: While it does not allow us to avoid the cause of our fear—death—it does allow us to control its manner, time, and place—we can feel that we have death under control.
Research has shown that the marker for people wanting euthanasia is a state that psychiatrists call “hopelessness,” which they differentiate from depression5—these people have nothing to look forward to. Hope is our sense of connection to the future; hope is the oxygen of the human spirit.6 Hope can be elicited by a sense of connection to a very immediate future, for instance, looking forward to a visit from a loved person, seeing the sun come up, or hearing the dawn chorus. When we are dying, our horizon comes closer and closer, but it still exists until we finally cross over. People need hope if they are to experience dying as the final great act of life, as it should be. Euthanasia converts that act to an act of death.
A more pragmatic, but nevertheless very important, objection to legalizing euthanasia is that its abuse cannot be prevented, as recent reports on euthanasia in the Netherlands have documented.7 Indeed, as a result of this evidence some former advocates now believe that euthanasia cannot be safely legalized and have recently spoken against doing so.8
To assess the impact that legalizing euthanasia might have, in practice, on society, we must look at it in the context in which it would operate: the combination of an aging population, scarce health-care resources, and euthanasia would be a lethal one.
2. Impact on medicine.9 Advocates often argue that euthanasia should be legalized because physicians are secretly carrying it out anyway. Studies10 purporting to establish that fact have recently been severely criticized on the grounds that the respondents replied to questions that did not distinguish between actions primarily intended to shorten life—euthanasia—and other acts or omissions in which no such intention was present—pain-relief treatment or refusals of treatment—that are not euthanasia.11 But even if the studies were accurate, the fact that physicians are secretly carrying out euthanasia does not mean that it is right. Further, if physicians were presently ignoring the law against murder, why would they obey guidelines for voluntary euthanasia?
Euthanasia “places the very soul of medicine on trial.”12 Physicians’ absolute repugnance to killing people is necessary if society’s trust in them is to be maintained. This is true, in part, because physicians have opportunities to kill not open to other people, as the horrific story of Dr. Harold Shipman, the British physician-serial killer, shows.
How would legalizing euthanasia affect medical education? What impact would physician role models carrying out euthanasia have on medical students and young physicians? Would we devote time to teaching students how to administer death through lethal injection? Would they be brutalized or ethically desensitized? (Do we adequately teach pain-relief treatment at present?) It would be very difficult to communicate to future physicians a repugnance to killing in a context of legalized euthanasia.
Physicians need a clear line that powerfully manifests to them, their patients, and society that they do not inflict death; both their patients and the public need to know with absolute certainty—and to be able to trust—that this is the case. Anything that would blur the line, damage that trust, or make physicians less sensitive to their primary obligations to protect life is unacceptable. Legalizing euthanasia would do all of these things.
Euthanasia is a simplistic, wrong, and dangerous response to the complex reality of human death. Physician-assisted suicide and euthanasia involve taking people who are at their weakest and most vulnerable, who fear loss of control or isolation and abandonment—who are in a state of intense “premortem loneliness”13—and placing them in a situation where they believe their only alternative is to be killed or kill themselves.
Nancy Crick, a sixty-nine-year-old Australian grandmother, recently committed suicide in the presence of over twenty people, eight of whom were members of the Australian Voluntary Euthanasia Society. She explained: “I don’t want to die alone.” Another option for Mrs. Crick (if she had been terminally ill—an autopsy showed Mrs. Crick’s colon cancer had not recurred) should have been to die naturally with people who cared for her present and good palliative care.
Of people who requested assisted suicide under Oregon’s Death with Dignity Act, which allows physicians to prescribe lethal medication, 46 percent changed their minds after significant palliative-care interventions (relief of pain and other symptoms), but only 15 percent of those who did not receive such interventions did so.14
How a society treats its weakest, most in need, most vulnerable members best tests its moral and ethical tone. To set a present and future moral tone that protects individuals in general and society, upholds the fundamental value of respect for life, and promotes rather than destroys our capacities and opportunities to search for meaning in life, we must reject euthanasia.
1. Margaret Somerville, “Death Talk: The Case Against Euthanasia and Physician-Assisted Suicide” (Montreal: McGill Queen’s University Press, 2001), p. xiii.
2. Ibid.3. D. Callahan, “When Self-Determination Runs Amok,”
Hastings Center Report 1992, 22(2): 52–55.
4. House of Lords. Report of the Select Committee on Medical
Ethics (London: HMSO, 1994).
5. H.M. Chochinov, K.G. Wilson, M. Enns, et al. “Depression, Hopelessness, and Suicidal Ideation in the Terminally Ill,” Psychosomatics 39 (1998):366–70, “Desire for Death in the Terminally Ill,” American Journal of Psychiatry 152 (1995):1185–1191.
6. Margaret Somerville, The Ethical Canary: Science, Society
and the Human Spirit (Toronto: Viking/Penguin, 2000).
7. K. Foley and H. Hendin, editors, The Case Against Assisted Suicide: For the Right to End-of-Life Care (Baltimore: The Johns Hopkins University Press, 2002).
8. S.B. Nuland, “The Principle of Hope,” The New Republic
OnLine 2002: May 22.
9. This section is based on Margaret Somerville, “‘Death Talk’: Debating Euthanasia and Physician-Assisted Suicide in Australia,” AMAJ February 17, 2003.
10. H. Kuhse, P. Singer, P. Baume, et al. “End-of-Life Decisions in Australian Medical Practice,” Med J Aust 166 ( 1997): 191–96.
11. D.W. Kissane, “Deadly Days in Darwin,” in K. Foley, H. Hendin, editors, The Case Against Assisted Suicide: For the Right to End-of-Life Care, pp. 192–209.
12. W. Gaylin, L. Kass, E.D. Pellegrino, and M. Siegler,
“Doctors Must Not Kill.” JAMA 1988; 259: 2139–2140.
13. J. Katz, The Silent World of Doctor and Patient (New
York: Free Press, 1984).
14. K. Foley and H. Hendin. “The Oregon Experiment,” in K. Foley, H. Hendin, editors. The Case Against Assisted Suicide:
Margaret A. Somerville is Gale Professor of Law and Professor in the Faculty of Medicine at the McGill University Centre for Medicine, Ethics, and Law in Montreal, Canada.