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Essay: The morality of physician assisted death and euthanasia

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  • Published: 23 March 2018*
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The debate surrounding the morality of physician-assisted-death (PAD) reflects a number of stark conflicts between and within fundamental moral principles. Front and center are the principles of autonomy and beneficence. The principle of autonomy sustains that “competent patients should be allowed to exercise their capacity for self-determination” and the principle of beneficence asserts that doctors “should not cause unnecessary suffering to those in their care” (Vaughn 9). In the context of the end of a patient’s life, the best course of action in line with these principles is often not clear. “Unnecessary suffering” is hard to define and sometimes cannot be avoided in any way besides allowing a patient’s life to end (if this involves cessation of life support it would qualify as passive euthanasia (PE)), but this “end” could also be considered suffering. Going further, a dying patient may explicitly ask for assistance in ending their own suffering by suicide (PAD) or in the extreme case may request that the doctor give them a lethal injection (active euthanasia (AE)). There are countless variations of cases like these. What is a doctor seeking to act morally to do in these complex situations? In this paper, I will emphasize the importance of examining cases individually and argue that passive euthanasia, physician assisted death, and active euthanasia are all morally permissible—if certain conditions are met.

To begin with, I will analyze the case of voluntary PE, which is arguably the least contentious. This is because a defense of voluntary PE can be grounded solely on the requirement of informed consent, whereas this is not possible in the cases of AE, PAD, or non-voluntary PE. The requirement of informed consent comes directly from the principle of autonomy and holds that physicians cannot perform medical procedures unless a patient knowingly and voluntarily agrees to them. In the context of PE, this means that “while patients who refuse treatment may become sicker, and sometimes will die… [this is] an unavoidable consequence of applying the doctrine of informed consent consistently and without exception” (NYSTF, 653). In other words, ethically considered, life-saving treatment is no different from non-life-saving treatment and cannot be administered to a well-informed patient who refuses it. Thus, voluntary PE can be considered morally equivalent to refusing to have a benign mole removed from fear of surgery—which is generally taken to be morally permissible. It’s important to note that this is also in line with the principle of beneficence, because, in general, competent patients are themselves best suited to decide the subjective matter of what is “best” for them. Therefore, when they give or do not give consent to an operation they are understood to be acting in their best interest. Thus, a doctor following these wishes can likewise be said to be acting in the patient’s best interest. Since the principle of autonomy and the principle of beneficence are preserved, voluntary PE, with informed consent, can be morally justified.

This argument neatly fits with voluntary PE, but obtaining consent isn’t always possible. This brings us to the more complex case of non-voluntary PE, which I will also defend as morally permissible—but with some restrictions. In cases of non-voluntary PE, an appeal to beneficence is needed to supplement the support of a patient’s autonomous actions. Some critics—who may even concede that informed consent justifies voluntary PE—interpret a doctor’s “beneficent” duty to be simply to preserve life, and thus condemn non-voluntary PE. However, I believe the principle of beneficence goes further. As stated by John D. Arras, it also implies a “solemn duty to alleviate pain and suffering whenever possible” (636). Of course, critics may often be right—preserving life typically does this. It does not do so in every case, though: “for many patients near death, maintaining the quality of one’s life, avoiding great suffering, [and] maintaining dignity…outweigh merely extending one’s life.” In these cases, then, the thought of losing dignity leads a patient to decide that “the best life possible for him or her with treatment is of sufficiently poor quality that it is worse than no further life at all” (Brock 614). Therefore, if the desire becomes strong enough, this decision is reached autonomously, and further treatment is determined to not likely improve the patient’s state, the principle of beneficence would accept this quality of life assessment, and not force a patient to extend their suffering if it’s not worth living through. This helps morally justify PE and presses the physician to act accordingly.

Most important in the context of non-voluntary PE is the fact that patients who cannot give consent to PE may also have had this desire, but have only lost the ability to communicate it. I believe it should still be respected in these cases. For example, in the 1990 case of Nancy Cruzan, who was left in a persistent vegetative state (similar to a coma) after a car accident, the parents urged the hospital to disconnect her life support after three years—stating that she would not have wanted to be kept alive in this way. In other words, the parents were referencing this desire to retain dignity. The parents knew Nancy extremely well, and throughout her life had been able to gain some insight into what she would consider a death with dignity. With this as evidence, they were able to convince the hospital to remove the life support, which I believe was a morally permissible action, given the emphasis on Nancy’s desires. However, in this case there is a much greater risk of abuse than in voluntary PE. PE would certainly be immoral in the case where a patient’s idea of a death with dignity excludes euthanasia. For this reason, I believe some restrictions are necessary. As the Supreme Court nicely summarizes, there exists an autonomous “‘liberty interest’ in refusing medical treatment… [that can] be exercised through a living will or by a designated surrogate… [states have] a legitimate interest in demanding ‘clear and convincing evidence’ of an incompetent individual’s preferences” (Vaughn, 605). I concur with basing the decision on sufficient evidence, because this is precisely what’s needed to determine what the patient in question would consider to be a death with dignity, which in turn is what’s most important according to the principle of beneficence. Thus, non-voluntary PE can be morally justified, if and only if it can be shown to support a death considered to be dignified by the patient in question, and there is sufficient evidence to determine that prolonging treatment would conflict with the patient’s consideration.

In the U.S., both forms of PE are generally accepted. PAD, however, is only allowed in five states. To argue for its moral permissibility, I will return to the principle of autonomy. As previously stated, the requirement of informed consent does not suffice in this case. A patient may consent to a fatal prescription of barbiturates, but if a physician does not prescribe it, nothing follows. In the case of PAD, the related right to self-determination is most relevant. In essence, this right holds that “certain decisions are momentous in their impact on the character of a person’s life decisions … [like] death, for example” and that “in a free society, individuals must be allowed to make those decisions for themselves.” Specifically regarding end-of-life issues, if deciding the conditions under which one dies is feasible, “most of us want [our] last act to reflect our own convictions … not the convictions of others forced on us in our most vulnerable moment” (Dworkin et al. 662). So, in order to fully respect the autonomy of patients who are not reliant on life-support and have decided they are ready for death, the option of PAD should be available to them. The choice may be li
kened to the similarly private choice of whom to marry, which if an external party were to constrain would seem like an immoral restriction of autonomy.

Opponents of PAD concede its morality in some cases, but most frequently condemn its general acceptance and legalization via a slippery slope argument grounded in fear of the social consequences. As Daniel Callahan states, “There are no good moral reasons to limit euthanasia once the principle of taking life…has been legitimated…there is no reasonable or logical stopping point” (625). In other words, once the practice is deemed permissible and society accepts it, the constraints on the practice may begin to seem arbitrary or subjective, so over time the practice may become easily accessible to people for whom it may not really be best-suited—like those who are curably depressed. This is certainly a major concern, but I don’t think we’re unable to address it. As humans, our moral reflections can help us determine the morality of our actions in specific difficult situations—not just in general. In this sense, “warnings of slippery slopes…insult our sensitivity by the suggestion that a society of individuals of good will cannot recognize situations in which their fellows want and need help and cannot distinguish such situations from those in which the desire for death is misguided” (Lachs, 632).

In light of this, I think it’s important to assess the moral justification of PAD on a case-by-case basis. To that end, I believe certain restrictions are necessary, because for the act to be moral it’s essential that the patient’s autonomous decision is genuine. A restriction to patients with a prognosis of six-months to live, as is the case in Oregon, is too arbitrary and does not target this moral consideration. I believe a policy based on demonstrable “intractable suffering,” such as the policy in Holland, is more adequate. Though this is largely subjective, “it is both possible and proper to take into account the objective circumstances that surround desires to terminate life. Physicians have developed considerable skill in relating subjective complaints to objective conditions” (Lachs, 633). If a competent patient deems their suffering “intractable,” they can show that their will to end it is not fleeting, and a doctor determines—through examinations, thorough interviews, and a second opinion perhaps—that their objective and subjective condition cannot be improved, then PAD would be morally justified and the patient should be able to move forward with it.

My defense of PAD based on the principle of autonomy and beneficence almost directly applies to AE, but some argue that the fact that physicians must inject the patient themselves undermines the value of the medical profession, as they are “killing” instead of “letting die,” and thus assert that AE is impermissible. However, this distinction is not what’s morally relevant. Dan Brock sets up a thought experiment to emphasize this. In one case a woman with ALS is taken off of life support by her doctor at her request (PE), while in another case her greedy grandson extubates her to cash in on his inheritance one day before the doctor was scheduled to do so (616). In this instance, the doctor’s actions seem moral, while the grandson’s do not, but it’s not because the grandson “killed” and the doctor “allowed to die”—they both performed the exact same actions. The true moral distinction lies in the fact that the physician has morally sound motivations—respect for the patient’s autonomy and an understanding that the patient’s genuine request signals the beneficence of the act—while the grandson is immorally motivated by his greed—to receive his inheritance quickly. Generalizing from this example, if a patient asks for AE and demonstrates their genuine desire to end their suffering quickly—instead of perhaps extending it via PE—and the doctor performs it with the intention of ending the patient’s suffering and valuing the patient’s self-determination, then the act can be morally justified and is still in line with the values underlying the medical profession. In cases of AE, though, I think doctor’s self-determination should also be respected, and if a doctor does not feel AE aligns with their moral responsibilities, the responsibility can be passed on to another doctor.

Ultimately, I believe PAD and AE should be treated like moral equivalents. For a policy to be morally sound, it should allow for the doctor and the patient to determine which alternative (PAD or AE) is most in line with the principles of autonomy and beneficence in each case, and should then be taken.

WORKS CITED

All of quotes I used come from the textbook:

Vaughn, Lewis. “Chapter 10: Euthanasia and Physician Assisted Suicide.” Bioethics: Principles,

Issues, and Cases, 2nd ed., Oxford University Press, 2013, pp. 594–677.

Specific Articles:

Arras, John D. “Physician-Assisted Suicide: A Tragic View.” Physician Assisted Suicide:

Expanding the Debate. Margaret P. Battin, Rosamond Rhodes, Anita Silvers. New York and London: Routledge 1998

Brock, Dan W. “Voluntary Active Euthanasia.” Hastings Center Report, vol. 22, 1992. 2.

Callahan, Daniel “When Self Determination Runs Amok.” Hastings Center Report,

vol. 22, 1992.

Dworkin, Ronald, et al. “Assisted Suicide: The Philosophers’ Brief.”

The New York Review of Books, 27 Mar. 1997

www.nybooks.com/articles/1997/03/27/assisted-suicide-the-philosophers-brief/.

Lachs, John “When Abstract Moralizing Runs Amok.” The Journal of Clinical Ethics,

vol. 5, 1994.

The New York State Task Force on Life and the Law (NYSTF), When Death Is Sought: Assisted Suicide and Euthanasia in the Medical Context. April 1997.

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