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Self-Determination or Unethical Practice?
Academic affiliation: Oklahoma State University
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The debate of whether or not to legalize physician-assisted suicide and euthanasia is frequently referred to as the slippery slope, this term slippery slope refers to the assumption that if we as a society take one step down from the principle that physicians preserve life, then we will be unable to stop an escalation of physicians killing more and more patients. There are many ethical and legal concerns within this debate, both for and against physician-assisted suicide and euthanasia. The debate involves a countless number of issues/concerns, a few of which are: the physician's role, if any, within the guidelines of their sworn medical and ethical oaths; a physician's obligation to their patients; a patient's right to self-determination or autonomy; and concerns that legalization of physician-assisted suicide and euthanasia will lead to widespread abuse. This paper will focus on comparing these views/concerns within the slippery slope debate, both for and against the legalization of euthanasia and physician-assisted suicide (PAS). With that in mind, please note that within the debate many scholars have drawn a distinction between active euthanasia, which they define as the act of killing the patient, or PAS, and passive euthanasia, which they define as letting a patient die; although that will not be addressed in this paper due to the fact that some scholars state no distinction.
To begin, the view of the American Medical Association (AMA) is stated by Lonnie Bristow, former president: "physician-assisted suicide is unethical and fundamentally inconsistent with the pledge physicians make to devote themselves to healing and to life" (167). The AMA's view is supported by the Hippocratic Oath which states, "I will give no deadly medicine if asked, nor suggest such counsel…" (qtd in Feinberg 851). There are many within the debate that agree with this view of physicians being devoted to preserving life, although death is literally the final stage of life. However, Arthur Rifkin, Professor of Psychiatry at The Albert Einstein College of Medicine refutes the AMA and today's interpretation of the Hippocratic Oath stating, "We hear misguided claims that following the Hippocratic Oath would keep physicians from assisting in suicide" (11). Moreover, as Humphry agrees with Rifkin stating, "It is ironic that a profession, which prides itself on the Oath, does not require its members to take it. Indeed, physicians who have actually taken it are few and far between. Many physicians have never even read it, much less sworn to it" (175). There are other critics that agree with Rifkin and Humphry on this opposing end of the spectrum, who describe situations where "medical treatment could provide no benefit" (Doyal 1079) and where legally the physician can withdraw treatment, including food and water. Critics of the AMA's position against legalizing euthanasia and PAS such as Len & Lesley Doyal argue, "If death is in a patient's best interest then death constitutes a moral good" (1079). The latter of these views is reinforced by a statement issued by the ninth circuit judges stating, "We see no ethical or constitutionally recognizable difference between a doctor's pulling the plug on a respirator and his prescribing drugs which will permit a terminally ill patient to end his own life… .To the extent that a difference exists, we conclude that it is one of degree and not one of kind" (qtd in Fraser 123).
People who want to end their life before enduring long periods of suffering are not permitted to do so legally, although a doctor or patient representative can end a life legally by withdrawing treatment, including hydration and nutrition. The argument can be debated in favor of either side but, as Fraser summarizes, "It seems that the debate is actually about who gets to have input into decisions regarding death" (122). Another summation of the physician's role in euthanasia and PAS, offered by Shannon, is that "The role of the physician is also blurred: healer or killer, the one who seeks to cure or the one who terminates the patient to end suffering. The clear and active involvement of the physician in euthanasia or PAS marks a distinct shift in the traditional role of the physician." (18). Some would conclude that, "There is no legal remedy for that problem-rooted in their education and common practice-only better education and a long process of changing medical mores" (Callahan 8).
Another issue in the slippery slope debate, of whether or not to legalize euthanasia and PAS, is the question of where the physician's primary obligation lies: to the Hippocratic Oath; to the state law; or to the patient. Bristow's opinion is that "The physician's primary obligation is to advocate for the individual patient" (168). Rifkin agrees with Bristow and accentuates Humphry's statement, elaborating, "The spirit of the Hippocratic Oath says the physician should be devoted to the patient's interests. How we define those interests today should not be limited by our understanding of medicine over two millennia ago" (11). An example conflicting with Bristow and Rifkin's views lies in the memoirs of the first man to chose legal PAS in Australia, Bob Dent, which describes how without the legalization of PAS, he would have otherwise be left to suffer until "some omniscient doctor decides that I must have had enough and increases my morphine until I die" (qtd in Fraser 121).
Some people within the debate would argue that this implied obligation to the patient only seems to become a factor in decisions after the patient has become incapacitated, as described by Doyal "it is sometimes acceptable for doctors to stop life sustaining treatments when there are grounds for assuming that this is in the best interest of severely incompetent patients" (1079). To those in favor of euthanasia and PAS, both of the previous examples suggest that the doctor's obligation to the patient is hypocritical; applying only once the patient is no longer capable of offering their desires, suggesting that the doctor's primary obligation is to the law rather than to the patient. Another example of this perceived hypocrisy by those in favor of legalizing euthanasia and PAS is, when the AMA stated, "It is ethically acceptable for a physician to gradually increase the appropriate medication for a patient, realizing that the medication may depress respiration and cause death" (qtd in Batlle 2279).
Next, the slippery slope debate frequently refers to the autonomy or self-determination of patients, and yet the patient's autonomy has little influence on legal decisions regarding PAS. Many people for legalization of PAS and euthanasia believe current laws are interfering with individual rights to make rational decisions regarding one's own life, intruding upon autonomy. This lack of consideration related to autonomy in rendering legal decisions related to PAS and euthanasia, is modeled by Doyal's description of an individual case where "She faces a death that she believes will entail indignity and suffering and physically cannot kill herself. The court has denied her request that her husband be allowed to help her" (1079). Furthermore, the physician's opinions on PAS and euthanasia, even in extreme cases of suffering, are of little influence on legal decisions as an example by Fraser suggests, "two-thirds or more of Oregon physicians surveyed favored a patient's right to obtain a doctor's help in hastening death in certain circumstances" (122).
The absence of public support for autonomy, when related to euthanasia and PAS is demonstrated by another example from Batlle, stating "surveys have found that more than 90% of the public would endorse the withdrawal of life support in the case of terminal illness, there is much less support for active euthanasia and PAS" (2279). A description of autonomy, by Justice Benjamin Cardozo is, "Every human being of adult years and sound mind has a right to determine what shall be done with his own body" (qtd in Batlle 2279). Batlle agrees with Cardozo, giving a summation of how individual autonomy has been previously viewed within the legal system, which states, "the courts have generally held that an individual's right to self-determination, including choices about death, outweighs a societal interest in the sanctity of life."(2279). However, the Missouri Supreme Court stated that the state's interest in preserving life "outweighs any rights invoked" (qtd in Feinberg 850), refuting Cardozo. Materstvedt further refutes Cardozo with his description of the possible affects legalizing PAS and euthanasia will have on autonomy, when stating, "literally speaking, euthanasia and physician-assisted suicide will damage autonomy in the most fundamental sense by eradicating the very possibility of future autonomous acting" (391).
The final issue we will look at is concerns of abuse if euthanasia and PAS are legalized. An example of these concerns as described by Batlle is "bioethicists worry about 'disparate impact,' a legal term that refers to the possibility that the legalization of assisted suicide would lead to its disproportionate utilization among vulnerable populations like minorities, the elderly, and the poor" (2280). Furthermore, Callahan describes how many people on the opposing side of legalizing euthanasia and PAS believe, "the strongest case against it is the danger it poses to the poor and the weak. Those unable to defend themselves from coercion and social rejection" (8). However, Batlle states, "preliminary evidence from Oregon indicates no obvious biases based on age, sex, or education level. In fact, the only significant demographic trend over time was that PAS requesters tended to be better educated patients" (2280) which provides evidence to challenge Callahan's description of the dangers legalizing euthanasia and PAS may have on the less fortunate. Rifkin suggests, "A treatment of ultimate finality- physician-assisted suicide- must have the most stringent safeguards against misuse" (11). On behalf of the AMA, Bristow voices skepticism of Rifkins view when stating, "Despite attempts by some, it is difficult to imagine adequate safeguards which could effectively guarantee that patients' decisions to request assisted suicide were unambivalent, informed and free of coercion" (169). However, The United States Supreme Court believes "the risk that 'vulnerable people' will be exposed to 'indifference, prejudice and psychological and financial pressure to end their lives' is just as great when a patient seeks to terminate life saving treatment as when a patient seeks self-administering drugs to hasten death" (Feinberg 874), suggesting the opposite of the AMA's view and concurring with Batlle's example.
Putting all of these opinions into perspective, Doyal reflects, "Though this may be difficult, it cannot be impossible" (1080) and Ezekiel agrees with Doyal elaborating that, "Such systemic changes are neither easily nor quickly accomplished. They require breaking old habits and patterns of care and forgoing new infrastructures" (1377). Rifkin believes, "The history of human kind is a widening circle of compassionate and just concerns. We have recognized the need to free ourselves from the injustice of slavery, mistreatment of children, unequal treatment of women, and ethnic and religious bigotry. Now the horizon of concern has reached a group often treated as unfairly and sadistically as any of the foregoing groups: the dying. Let us grasp the chance boldly" (11-12) giving a final summation.
For now the slippery slope debate will continue, back and forth, between scholars like: Doyal; Ezekiel; Rifkin; and Fraser; in favor of legalizing euthanasia and PAS, to others who oppose legalization of euthanasia and PAS, such as: Callahan, Shannon, and the AMA. Whatever our decision is as a society, whether in favor of legalization, or opposition; my only hope, is that the decision is one that we can live and/or die by, because our decision will affect the level of self determination an individual will have over their own life, in the new millennium.
Batlle, Juan Carlos. "Legal Status of Physician-Assisted Suicide." Journal of American Medical
Association 289. 17 (2003): 2279-81.
Bristow, Lonnie R. "Assisted Suicide Is Not An Ethically Acceptable Practice For Physicians." Euthanasia opposing viewpoints Leone, Bruno, David M. Haugen, eds. San Diego Greenhaven P, 2000 166-171.
Callahan, Daniel. "Good Strategies & Bad." Commonweal 126. 21 (1999): 7-8.
Doyal, Len and Lesley Doyal. "Why active euthanasia and physician assisted suicide should be legalized." British Medical Journal 323.7321 (2001): 1079-80.
Ezekiel, Emanuel J. "Euthanasia: where the Netherlands leads will the world follow?" British
Medical Journal 322.7299 (2001): 1376-77.
Feinberg, Brett. "The Court Upholds A State Law Prohibiting Physician-Assisted Suicide." Journal of Criminal Law & Criminology 88.3 (1998): 847-876
Fraser, Sharon I. and James W. Walters. "Death-whose decision? Euthanasia and the terminally ill." Journal of Medical Ethics 26.2 (2000): 121-25.
Humphry, Derek and Mary Clement. "Physicians Should Be legally Permitted To Assist In Suicide." Euthanasia opposing viewpoints Leone, Bruno, David M. Haugen, eds. San Diego Greenhaven P, 2000 166-171.
Materstvedt, Lars Johan. "Palliative care on the 'slippery slope' towards euthanasia?" Palliative Medicine 17 (2003): 387-392.
Rifkin, Arthur. "Euthanasia Can Be Ethical." The Ethics of Euthanasia. Leone, Bruno and Brenda Stalcup and Scott Barbour, eds. San Diego Greenhaven P, 1999 9-12.
Shannon, Thomas A. "Killing Them Softly With Kindness." America 185.11 (2001): 16-18.
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