When Your Doctor Becomes an Angel of Death
Physician-assisted death: To be or not to be?
Physician-assisted suicide (PAD) is quite a tricky topic to write about. This topic is plagued by many debates for and against, with both sides making very convincing points. That not everybody agrees on the topic isn’t surprising. Whenever a new topic or field is broached, there are bound to be arguments, disagreements, points, and counter-points by people on both sides of the aisle. This democratic and open discussion is a sign of a healthy society.
Think about any great strides we’ve made on our way to a civilized society — from ending the practice of burning witches at the stake, legalizing abortion, giving women the right to work and vote, and even institutionalizing democracy. Today, we consider these normal or even required in a civilized society, but this wasn’t the case some centuries ago. We had a lot of discussions, disagreements, and arguments leading up to their legalization. Arguments around these sorts of important topics centre around their morality, ethics, economic impact, and how they will shape our future society. The conversations surrounding these sorts of topics are usually heated because the stakes are high. All these things and more are true for PAD.
What is PAD? Why is it controversial? What are the ethical issues surrounding PAD?
These are some of the questions I will tackle in the paragraphs that follow.
What is PAD?
Imagine a person who is terminally ill and wants to end their life. Maybe they don’t see any more meaning to life, maybe are in unbearable pain, or maybe the illness will turn them into a vegetable and they don’t want that — for whatever reason, this person wants to end his/her life. This person walks to the doctor and asks for a mix of lethal drugs that they can use to end their life. The doctor gives them the drugs, and the patient takes these drugs and dies peacefully at a time of their choosing. This practice is what is called physician-assisted suicide.
Although the doctor provides the lethal drugs, the patient plays an active role. The patient’s role is to take/consume the drug, the final step in the process of self-immolation.
We must make a distinction between PAD and a closely related term, euthanisa. In Euthanasia, the physician plays an active role, either by acting or non-action that directly results in the end of the patient’s life. There is a distinction between active euthanasia, where the doctor intentionally administers the lethal drugs to end the life of the patient who is terminally ill, and passive euthanasia — where the doctor withholds a treatment that could prolong the patient’s life (see the possible reasons for withholding lifesaving treatment here).
I want to point out here that in medical circles, withholding life-prolonging treatment is standard medical practice, and is not considered euthanasia.
Although I have made this distinction between PAD and euthanasia, most of the discussion around assisted dying addresses both PAD and euthanasia under the same umbrella. PAD and euthanasia are trailed by the same objections on ethical grounds. In the pages that follow, I will use PAD, but it is worthy of note that the arguments that follow are also valid for euthanasia.
Make 2024 the year you focus on your mental health. You deserve to be happy and healthy. I am a medical doctor and clinical psychologist, and I can teach you how to improve your mental health. Subscribe to my free newsletter here.What are the ethical issues surrounding PAD?
Most of the conversation around PAD centres on the ethics of letting a person knowingly violate the principle of the sanctity of life by ending their own life.
Beneficence
A doctor is required to act in a way that benefits the health and welfare of his/her patients. This is the basic principle of beneficence. But how does a doctor promote the welfare of a patient who is on the brink of death and is under immense pain and suffering? When a patient who is faced with a terminal illness asks for PAD, the doctor has the option to refuse their request. But refusing the patient’s request means that the doctor abandons the patient to their disease, for the disease to take its natural course. Yes, the patient’s life is prolonged, but the patient suffers for the remaining course of his/her life and dies a painful death.
For people who are against PAD, the doctor’s job is to preserve the life of the patient at all costs. For the advocates of PAD, it would be more humane for the doctor to show compassion and mercy on the patient by relieving them of their suffering. Call this a mercy killing.
Nonmaleficence
Nonmaleficence is closely related to beneficence. “Do no harm” is the guiding principle for medical practitioners. For opponents of PAD, do no harm means that the doctor should try every possible thing in their power to keep the patient alive, even if it means keeping the patient in a vegetative state. With the strides we have made in medicine, modern medicine can prolong a person’s life without providing a cure for their underlying diseases. To answer the question of nonmaleficence, we have to ask ourselves if by prolonging a patient’s life, we aren’t just prolonging their process of dying. Imagine a patient who is in a persistent vegetative state with a grim prognosis; he/she breathes with the help of machines and is fed with tubes. Or imagine a patient who is terminally ill is in very excruciating pain. There is no hope that this patient will get better, but there is also no hope for any pain relief. By prolonging the lives of these kinds of patients, the doctor is prolonging their suffering. In this case, is the doctor doing more good or more harm?
Doctors swear a Hippocratic oath, to practice Hippocratic medicine. Hippocratic medicine is built on the principles of nonmaleficence and beneficence. Doctors are supposed to preserve life and use medical treatments “to help the sick according to my ability and judgment, but I will never use it to injure or wrong them”, according to the Hippocratic Oath. When a patient says that their life is not worth living anymore because of severe pain or whatever, is obliging the patient’s request for PAD a breach of the Hippocratic oath? On the other hand, does refusing the patient’s request for PAD and keeping the patient alive by all means injure or harm the patient?
It is important to observe that although the Hippocratic oath mentions doing no harm, it doesn’t specify what that means. However we choose to interpret the Hippocratic oath, it is a subjective interpretation that should be subject to our evolving culture, civilization, and improved understanding of medicine and what it means to live a good life.
The principle of double effect
Let’s say that I have a patient who is in terrible pain. I’ve tried everything I could to relieve his pain, but nothing works for this patient anymore. The pain is so bad that I can’t in good conscience bear to see him like this, and neither does the patient’s family or the patient himself. I have one last option to try but it’s a dangerous option. I could administer morphine in high enough doses to bring pain relief to this patient, but morphine in these doses will hasten the patient’s death. My primary aim is to give the patient some respite from his pain — which is a good thing. I do not intend to kill the patient. But I also know that by providing this pain relief, the treatment will eventually lead to his death. What do I do?
This is the core question of the principle of double effect. In most medical circles, administering treatment — to a good end — even if the doctor knows the treatment will hasten the death of the patient is seen as less a taboo than obliging the patient’s request to end their life consciously and voluntarily.
But if we are being moral absolutists, then we must ask ourselves serious moral questions. For instance, what is the difference — from a moral standpoint — between a doctor who obliges a patient’s request for PAD and a doctor who gives his patient pain-relieving treatment, knowing fully well that the treatment will kill the patient?
The risk of incorrect medical diagnosis
Doctors make mistakes all the time. We have all heard stories about a doctor diagnosing a patient with a disease and telling them they have X months to live. The patient ends up outliving the doctor’s diagnosis by years and even making a recovery.
No technological advance in medicine will completely eliminate the possibility of incorrect diagnosis. Opponents of PAD opine that since mistakes in diagnosis, prognosis, and even treatment, can cause unnecessary death, PAD should be outlawed in order to protect lives.
But the folks on the proposing side also make a good point. Patients who eventually ask for PAD don’t do it as soon as the doctor gives his/her diagnosis. Usually, they would have undergone conventional treatment for months on end but their condition keeps deteriorating. It’s only after trying every possible treatment and there is no hope for recovery that the patient starts considering their options for how they want to die. PAD is not a first or second resort. It is only used as a last resort, at a point when the patient has tried every conventional means to cure their illness or relieve their pain, but their illness keeps getting worse.
Opening the floodgates of abuse
Some illnesses can be stubborn to treat and expensive to maintain. If PAD is legalized and made broadly accessible, you cannot discount a situation where family members of a patient who is terminally ill manipulate the patient or put pressure on them to consider PAD and die sooner rather than later. Dying sooner will relieve the family members of their duty of care. Financial concerns may also pressure the patient to choose PAD so that they don’t saddle their families with a lot of debt from their prolonged treatment, which the family has to pay after their death.
Consider a world where PAD is legal. Unscrupulous doctors who make a mistake in patient treatment may pressure their patients into choosing death to cover up their mistakes. Even well-meaning doctors who have run out of treatment options might encourage their patients to choose death. For these doctors, death becomes the ultimate solution for every illness for which medicine cannot provide a solution.
These are serious concerns that cannot be arbitrarily dismissed. Opponents of PAD argue that by keeping PAD illegal, we avoid the trove of potential abuses that PAD would otherwise be confronted with. The only response to this is; is keeping PAD illegal the only viable solution to these potential abuses?
To proponents of PAD, illegalizing PAD might stop a few abuses, but it brings untold harm and suffering to patients who suffer from unbearable terminal illnesses and to whom PAD would be a respite from their torments.
The slippery slope
At what point does it stop?
If PAD is legalized today, it’ll be a huge milestone that will set a legal precedent. This legal precedent might make it easier and more acceptable to legalize an ethically or morally abhorrent act in the future. The best way to stop ourselves from arriving at this future is if we don’t take the first step of legalizing PAD in the present.
This argument, made by opponents of PAD is a strong argument that I struggle to find any counterargument for. However, people have made the slippery slope argument for all kinds of issues in the past. From legalizing abortion to equality for LGBTQ folks to fighting technological advancements like the Luddites, it is always easy to make the slippery slope argument. The slippery slope argument is one that makes use to face the question of what the worst-case scenario is, and what it means for the human race. But that’s the thing about worst-case scenarios; they almost never occur.
Democracy and a civic society that promotes open discussions have proven to be excellent tools for keeping worst-case scenarios at bay. It is good to be aware of the worst-case scenarios so that we can take steps to avoid them. But if we had to let the worst-case scenarios stop us from taking action all the time, our world today would be completely unrecognizable and we wouldn’t have half the progress and civilization we have today.
Discussion
The ethical issues surrounding PAD make it a hotbed for controversy. It’s a controversy that is made all the more interesting by the solidity of the arguments from both sides.
Although I am very much empathic to the points made by the opponents of PAD, some things don’t just add up.
Currently, patients have the right to refuse food and water. A lot of patients who are facing imminent death routinely refuse food and liquids to hasten death. A study found that these patients die a “good” death usually within 2 weeks. But the fact that patients have this right raises the question of justice. We are a society that prides itself on justice and equality. Comparative justice is built on the principle that like cases should be treated alike. If patients are legally allowed to hasten death by refusing food, liquid, and treatment, what about patients for whom refusal of these things will not be enough to hasten death, or at least not fast enough? For these patients, justice might mean that an alternative option should be provided to them to end their lives legally and with dignity when they choose to.
We can also extend the issue of justice to the family members of a patient who is terminally ill. Denying a patient who is terminally ill and is suffering the right to end their suffering might be unjust. But this also forces their family to endure a prolonged period of emotional distress. In a case where the patient has made their wish to end their existence, the family members have to live with the guilt of the knowledge that their relative is suffering and the powerlessness that comes with knowing that there is nothing they can do about it.
Perhaps the patient who really wants to die will find a way to kill himself/herself. But this patient will be obliged not to tell anybody — doctors and family members alike — because of the legal consequences. If this patient eventually goes ahead to commit suicide, they will die alone, and without the comfort of their family and loved ones who could have been by their side in their last moments here on earth.
Conclusion
There are many more concerns surrounding PAD. An exhaustive discussion of the possible moral and ethical arguments for and against PAD will take weeks to complete and will be fit for a book. It is not my intention to write this book. Without a doubt, the controversies surrounding PAD will continue into the foreseeable future. These controversies however are a good thing. They mean that at the very least, we are beginning to have a meaningful and serious conversation about assisted dying. This is usually the first step on the eventual journey to progress.
Usually, articles about PAD and euthanasia end with a plethora of advice and even platitudes on how to get assisted dying right. These articles would make off-the-shelf recommendations like suggesting that patients who request PAD should undergo psychological evaluation and be subjected to a waiting period, as well as other to-do lists of a tightly regulated PAD process. These recommendations are ubiquitous (see some here), so I will do you the favour of skipping them.
We view human life as sacrosanct. This view has 2 implications. On one hand, it is a subjective view that arises from a religious perspective and a long culture that was heavily influenced by religion. Recent advances in technology and science have taught us that human life is not that different or more special than other lives including animal life. The idea that human life is sacrosanct is a subjective view. All subjective views are subject to eventual change. At the very least, every individual should have the freedom to choose if they subscribe to the subjective view as well as the freedom to opt-out.
On the other hand, if human life is sacrosanct, then a human life that is in excruciating and uncurable pain, or a persistent vegetative state is a violation of the sacrosanct nature of life. Empowering this life with the tools it needs to end its misery is the ultimate expression of the sacrosanct and the ultimate sacrifice for its preservation.
Make 2024 the year you focus on your mental health. You deserve to be happy and healthy. I am a medical doctor and clinical psychologist, and I can teach you how to improve your mental health. Subscribe to my free newsletter here.