A Primer on Physician-Assisted Suicide and Voluntary Active Euthanasia

Here’s a primer on physician-assisted suicide (PAS) and voluntary active euthanasia (VAE). Nothing I say here is meant to endorse anything that follows (though I am against both practices); rather, what is said here is to help the uninitiated get a better sense of the issues and polarities concerning arguments for and against PAS and VAE. 

There are two approaches to arguing in their favor. The first is based on compassion: some people near the end of life are in such a sorry state that the compassionate thing to do is to permit them to seek medical help so they can die a relatively painless death by ingesting lethal substances prescribed by a doctor or by having a doctor administer an injection of some lethal substance. The advantage of this view is that it limits PAS and VAE to the sick and dying; healthy people are presumably ruled out. The problem with this view, for those who want to limit euthanasia to the voluntary variety, is that consent from the patient is not necessary; non-voluntary euthanasia can also be justified on the basis of compassion alone and is thought to be compatible with the best interests of those who are unable to communicate their wishes. While such a practice is not officially permitted even in the Netherlands where both PAS and VAE are allowed, it has broad support among the nation’s euthanasia advocates, and it has been deployed by a sizable number of doctors.

The second approach is based on patient-autonomy. This has the advantage of ruling out non-voluntary euthanasia, which some see as being too risky to allow in practice. One popular argument in favor of PAS and VAE begins with the widely accepted practice of withdrawing life-sustaining treatment at patient request. Since life-sustaining treatment is necessary for vital functioning, and since we have the right to be free of it upon our request, it follows that no one can hinder us from negotiating the timing of our death. Why then should we be hindered from negotiating not only the timing, but also the manner of our death as well? It would seem there is not much of a difference between being helped by the doctor to withdraw life-sustaining treatment while being given comfort care through opioids that might hasten death, and being helped by the doctor to die by some dosage or injection of a lethal substance. The “bare difference” between these two practices does not negate the fact that both involve the doctor in the causality of death. Nor are the results changed in any negative way: in both cases the patient dies, and perhaps more comfortably in the one where the doctor directly causes death. Thus, the expansion of patient autonomy to die by the hand of a willing doctor should be allowed.

What about the case against PAS and VAE? The are two broad strategies: the first involves arguments from the patient’s side of things, and the second involves arguments from the doctor’s side. On the patient’s side of things, there are two types of patient-centered arguments. The first involves a rights claim such that the right of an innocent person not to be killed is inalienable. That is, one’s life cannot be signed away through informed consent. Thus, the patient is wronged even if the patient is killed upon the patient’s request just like one would be wronged if one were enslaved upon one’s request to be enslaved. Such things are incompatible with our status as rights-bearers. The second stems from the belief that human life is sacred or is of such a value that it is owed an amount of respect that generates a norm against killing it. On this view, it may not be unjust to administer PAS or VAE, but it would nonetheless be wrong, because both the patient and the doctor do not treat human life with the respect it is owed.

From the doctor’s side of things, there are again two types of arguments that emerge. The first generates a norm against killing the patient for any reason, because killing is deemed to be incompatible with the professional character of medicine. The ancient code of medical ethics spelled out in the Hippocratic Oath is ‘exhibit A’ in this school of thought. The first rule is to do no harm, and killing the patient is thought to be a paradigm example of harm. Consensual patient-killing is ruled out of bounds just as consensual sex with patients is ruled out of bounds; allowing such behavior is thought to jeopardize the profession and undermine trust between patient and doctor. Thus, doctors are to “always care and never kill” as the saying goes.

The second doctor-focused strategy is one which relates to society as well — the so-called “slippery-slope” argument. While it may be the case that there instances in which PAS and VAE are morally justified, creating a public policy that ensures that vulnerable patients will be protected from abuse is hard to formulate. Limiting PAS to only the terminally-ill (those with only 6 months to live) is thought to be arbitrary. Why not the chronically ill? By what criteria are patients deemed to be competent and who decides? It would seem impossible to have an unbiased opinion on the matter. In the Neatherlands, it has been observed that the psychiatrists who sign off on cases of VAE tend to be euthanasia advocates. Who could know if the wish for suicide is coming from a place of rationality or a place of depression, manipulation, or deception? Moreover, a desire for suicide should not be presumed to be evidence of mental illness if PAS is a permissible option. More psychiatric work needs to be done to determine if there is competence-threatening mental-illness at work. And perhaps the pain and suffering of the depressed should be recognized as driving a rational choice for suicide as well. Comfort-care-only workers and suicide prevention specialists have to shoulder the burden of proof that their patient’s want to live despite their diminished state — in fact, the terminally and chronically ill must shoulder this burden as well making it clear to everyone involved that they want to live. This burden, however, can become intolerable when family members, health care providers, insurance companies, and perhaps the state put pressure on them to end their lives. The risk of there being a conflict of interest from the medical and societal side of things is thought to be grave, and the mechanisms by which abuse could be ruled out are thought to be absurdly weak. Thus, it is thought that adequately regulating PAS and VAE would be enormously difficult if not impossible and the sort of abuses that lead to non-VAE and perhaps to involuntary active euthanasia are inevitable in any society that allows it.