Morality of Death with Dignity Acts

In this paper I will tentatively argue that physician assisted suicide laws promote well-being & self-determination and that this law is consistent with the harm principle. First, I will introduce the “Death with Dignity Act,” (DDA) and alike laws in question. Then I will discuss Brock’s principles for medical practice of well-being and self-determination, and Mill’s view of permissible government intervention as they relate to the morality of assisted suicide laws. Finally, I will discuss alterations to the stipulations of the DDA that can make laws regarding physician assisted suicide more morally sound.

Relevant Stipulations of the Law that are Morally Sound Are As Follows:

I will provide numbers for these stipulations to refer to them later with greater efficiency and clarity.

(1) Delayed Approval: Before writing prescription, physicians must wait 15 days after an initial request made by the patient, and 48 hours after a written request. Two written requests and 1 oral requests must be made by patient.

(2) Access To Information: Physicians must inform a patient of their formal prognosis & diagnosis, and other relevant options or alternatives to assisted suicide.

(3) Capacity & Non-Coercion: A patient must have decision-making capacity, be acting voluntarily (without coercion), and be making an informed choice.

(4) Sanity Stipulation: If physicians recognize that the patient has impaired judgement or does not meet the criteria stated above, then the physician must refer the patient to counseling for further psychological analysis.

(5) Terminal Diagnosis & 6-Month Prognosis: Patient must be diagnosed as terminal and given a prognosis of 6 months or less.

Physician Assisted Suicide Laws Promote Well-Being & Self-Determination

First, before I introduce suggestions for additional stipulations, I will argue that physician assisted suicide laws are morally sound using Brock’s two principles for moral healthcare. Brock argues that physicians should respect the self-determination of competent patients and promote their well-being (Brock 1992, 392). Self-determination, interpreted as autonomy, should be understood as the ability of an individual to make decisions and be free to act in accordance with their conception of a good life and values of their own. (Brock 1992, 391). Well-being should be understood as a personal conception of what is satisfactory or preferable.

To exemplify how respect for self-determination promotes well-being, I will give the case of the high school student, Roger.

Roger is finishing high school and is contemplating what he would like to do after high school. Many urge him to go to college, but Roger feels that college is not for him. He would rather travel the world, work in the towns he visits to fund his travels and learn how people live in their respective places in the world.

Roger will be practicing self-determination if he is free to pursue his dreams of travel. He may never achieve them due to external factors, such as injury of financial trouble, but he nonetheless is free to act in accordance with what he thinks is valuable and good for him. He may make less money or not live up to living standards of his loved ones, but Roger may nonetheless be happy with his choices because they were his. If his parents respect his self-determination, they would support him doing what he thinks is best for himself. This shows that his parents respect his critical faculties and respect that his conception of what is good is what will ultimately influence his well-being. They may attempt to inform him of other paths in life and suggest he explore other relevant options, but these suggestions do not disrespect his self-determination. In other words, Roger’s parents respect that Roger is the only person who can judge his own well-being, and by supporting him in his preferences, they are promoting his well-being. This is how respect for self-determination promotes well-being.

Respect for Self-Determination & Well-Being Applied to Medicine

Applied to medicine, a physician who respects the self-determination of a patient will respect a patient’s wish to perform or not perform a procedure. By doing what the patient believes will make their life better, the physician will be promoting the well-being of the patient. There is a limit to this respect for self-determination, of course. The physician’s self-determination must also be respected. If a patient requests a procedure that opposes the physician’s values or is contrary to the physician’s conception of what is good, then the physician should not be coerced into doing the requested procedure. If this patient can be proven to be competent, not coerced, and mentally stable then the patient should be free to seek out those who will perform the procedure that, in their own opinion, promotes their well-being.

Determination of Patient Competency

Brock argues that a patient’s requests for end-of-life decisions should be respected if a patient is competent (Brock 1992, 391). This determination of competence has been explored in other studies at length. I don’t think it necessary to fundamentally describe competence. I will appeal to almost universally accepted conceptions of competence as informed consent and decision-making capacity.

I will briefly speak on informed consent, understood legally as competency (President’s Commission 92). To judge a patient’s capacity, physicians must first determine if a patient has decisional capacity. Decisio- making capacity may be judged differently for different decisions. For example, preference for food or a preference for life-ending action have drastic differences in the gravity of their outcomes. The latter creates an everlasting and irrevocable change to a patient’s life while the former is clearly less morbid and ever-lasting. To determine which decisions may justify intervention by physicians, I will appeal to Mappes & DeGrazias’ guidelines in Biomedical Ethics for how best to judge self-determination.

Mappes and DeGrazia discuss the implications of decisions more in depth when discussing the power of physicians to limit self-determination. This topic, called paternalism, has been discussed at length, but I will refrain from speaking about paternalism to finely focus on the judgement of decision-making capacity. Mappes and DeGrazia layout the following view regarding diminished capacity. A person is incompetent when they lack intellectual reasoning ability, is ignorant of relevant facts, or is not free to exercise reasoning abilities with action. When a person is incompetent and the decisions in question create outcomes that cause serious, irrevocable harm, limits on self-determination are justified (Mappes & DeGrazia 1996, 33).

DDA Promotes Self-Determination & Well-Being:

The “Death with Dignity Act” law enables patients to be free to make a final decision regarding their life and well-being. The Capacity & Non-Coercion and Access To Information stipulations ensure a patient is competent, not coerced, and informed of other options. If a patient feels that their well-being would be improved by a decision to end their life, then this action should be enabled by a physician who is willing to facilitate the service.

The Delayed Approval stipulation requires a patient to make several requests to prove their commitment and require a patient’s mental health to be evaluated. These stipulations would be supported by Brock because they require a patient to prove they are competent, not coerced by an outside force, and the stipulations respect the self-determination and well-being of the patient.

Duties Physicians Have to Society & the Harm Principle

Next, I will argue that John Stuart Mill would tentatively support these assisted suicide laws as they are. I will use Mill’s harm principle, which is justified by Mill’s interpretation of utilitarianism, to show that government intervention is not permissible in physician assisted suicide. Then I will show that Mill’s view of direct vs. indirect harm shows that, in most cases, suicide does not cause harm. Finally, I will argue that the duty a physician has to society does not make assisted suicide immoral.

Harm vs. Indirect Harm

Mill argues power should be exercised over individuals against their will only when they directly harm others (Mill 1859, 13). Mill argues that government intervention over people is only permissible to prevent harm to others. To Mill, harm is caused when a person’s interests are “affected prejudicially,” causing a reduction in their ability to act or think independently (Mill 1859, 69). Examples of harm inflicted on persons are physical injury or death, coercion or deception, financial loss, and physical restraint against their will.

Harm Principle’s Utilitarian Justification

Mill justifies this principle by appealing to utilitarianism as the ultimate ethical principle (Mill 1859, 14). Utilitarianism is the ethical theory that states actions are right if they maximize the good. To Mill, utility is maximized when individuals act on their volition and are free to do and act as they prefer, so long as they do not harm others. Mill believes that when “permanent interests of man” are promoted or protected, the utility of man is optimized (Mill 1859, 14). Permanent interests are those that unchanging with cultural norms and essentially human. They are interests such as the freedom of thought, action, and association that promote autonomy.

Examples of Indirect & Direct Harm With Utilitarian Justification

The government may not justify action against man to prevent indirect harm. When the outcome of an action does not violate the rights of others, government intervention is impermissible. A man may not directly harm another by stabbing them with a pitchfork out in the pasture. The government should prevent this physical attack on another person. On the other hand, a man may directly stab himself with the pitchfork. The government should never intervene to prevent harm to one’s self. To exemplify indirect versus direct harm, I will give the example of a landowner which this self-harming man that I just described works for. This landowner depends on the man to pitch hay on his land. The landowner may experience a deficit of labor from the man’s self-laceration. This is not harm. To Mill, there is no indirect harm unless they have a duty to society that protects the rights of man. A person can never injure another indirectly unless they have a duty to protect the “progressive interests of man,” or uphold the utility of man.

An example of this is a physician. A physician has a duty to protect citizens from dying from external causes. If a physician is incapacitated from morphine injections he procured from the overstocked medicine cabinet, which he self-administered to satiate his addiction, people may die without his care. In this circumstance indirect harm is equivalent to direct harm. Nothing the physician did to himself was harmful. His addiction is not harmful. His stealing is not harmful (if the syringes aren’t needed to directly save other patients). The government should not intervene due to the seemingly unsustainable habits of the physician as a person. Though, because the physician has a duty to society to heal and provide care to it citizens, the government should intervene with the physician over the physician to protect indirect harm caused to the citizens.

Role Based Duties Don’t Interfere with Physician Duties

Some have tried to used Mill’s description of role-based duties to show that physician assisted suicide is immoral. They argue that if physicians condone or facilitate suicide, then the role of physicians as healers and caregivers may deteriorate into a role of death-mongering (Brock 1991, 392). I will show that the role of physicians is to enhance well-being, and promote self-determination, which prevents harm and does not contradict duties physicians have to society.

Gaylin argues that patients may begin to distrust their physicians if bringing death was a skill in the physician’s repertoire (Brock 1992, 391). Though, I think it clear this would not happen if patients are the only ones who may request assisted suicide. The Capacity & Non-Coercion Stipulation ensures that patients are autonomous in their decisions and that physicians are merely facilitators of patient desires. If the universally accepted principles of self-determination and well-being are promoted in medicine, then physicians who facilitate self-determining acts of assisted suicide are enhancing the well-being of patients. The slippery slope that physicians will become death-mongers will never materialize should physicians respect patient self-determination.

Mill would argue the role of physicians is to protects the rights that are relevant to medicine. Mill would think that physicians have an obligation to society to uphold the rights of patients to not be confined against their will, be coerced, have contracts broken, endure financial loss not protected by rights, or endure physical harm or death caused by others. The latter right is the most relevant. It may seem that physicians are breaking their obligations to patients by assisting in death, but Mill would not think so. Mill argues that people have absolute control over their body so long as they do not harm others, including patients and physicians, and the utility of man is optimized when people act according to their principles. If patients desire end-of-life prescriptions, they are not coerced, and proven to be sane, then physicians who merely assist with utility-enhancing acts according to patient principles are not breaking their obligations to society.

Harm Principle Applied to Death with Dignity Laws:

At a fundamental level, considering the outcome of the Death with Dignity Act, individuals are enabled by the law to do with their body as they prefer. In all circumstances, except for those with a duty to uphold the progressive interests of man, people should be able to do with their body as they desire. Mill would support any legislation that promotes utility of man, including the liberty of action, thought, and liberty to plan one’s life.

Committing suicide will never harm another person directly unless they have a duty to those around them, as mentioned before. Thus, without direct harm to others, the government has no jurisdiction to prevent this person from committing the act.

Mill would also argue that the “assisted” part of the law does not contradict the duty physicians have to society as a caretaker and life-saver. If patients are ultimately the only one’s responsible for their decision to commit suicide, then the physician is not committing harm to anyone. As an example, a samurai who wants to preserve his honor and desires to commit hara-kiri, a form of ritual suicide, asks for a tantou blade from his samurai senpai. When the samurai commits honor suicide with the tantou provided by his senpai, the samurai committed the act. The senpai did not commit the harm against the samurai. Even if the senpai had a duty to teach the samurai how to live and protect himself, both progressive interests of man, the samurai’s suicidal actions are his own. There is no indirect harm in this circumstance. Similarly, a patient who asks for medical aid in dying, and is provided it by a physician, is acting out of volition and with a desire to lead or end their life as they see fit.

Stipulations that Should be Altered to Increase Accessibility

Now I will speak about which stipulations should be altered and offer suggestions that would make physician assisted suicide laws more moral.

(5) Oral, Written Request: Patients must make two oral requests, and 1 written request.

(6) Self-Administration: Laws require patients to self-administer the lethal drug.

Stipulations that Should Be Included in 1 Form or Another that Aren’t Currently:

(7) If the service is provided to a patient in 1 part of the state, then the location where the patient can access the service in the relevant domain of the law should be conveyed. This will be referred to as the equal access stipulation.

Accessibility

Oral, Written Requests

These stipulations should be altered so that patients who prove their capacity for reasoning and understanding can also make requests for PAS, even if requests don’t come in an oral or written format. Written and oral requests require patients to communicate with their mouths and use fine motor controls to sign their name. These require physical abilities that terminal patients are likely not to have. This clause impedes paralyzed patients or those with severe parkinsonian symptoms or supranuclear palsies, for example, from accessing physician assisted suicide (supranuclear palsy is a rare brain disorder causing paralysis and speech problems, among other ailments).

Currently, patients may be judged to not have adequate capacity to make drastic changes to their well-being, considering oral and written communication are a hurdle for PAS access. In other words, if a patient cannot speak or write, they will be impeded from accessing PAS because they don’t have the capacity to communicate in traditional ways. Decision-making incapacity should only be judged if a patient acts or expresses desires to alter their well-being in ways that they have not previously expressed (Presidents Commission 92). Thus, if a patient is not acting unexpectedly and is in alignment with previously expressed desires and can communicate these desires to physicians using any accepted format of communication for the disabled, PAS should accept these patients.

Self-Administration

Patients should also be able to request administration of end-of-life medications by those they choose. Patients with disabilities are clearly excluded from suicide assistance since their physical disabilities can likely make it impossible to bring the medicine to their mouths to consume. Like previously described, if a patient’s is determined to have decision-making capacity, and acts in alignment with previously expressed desires, then a patient should be able to access PAS.

With the advent of eye-tracking, voice synthesis technology, along with rudimentary forms of sign language, palsy-stricken or paralyzed patients can often prove their capacity. Appealing to widely accepted opinions of autonomy, if a patient has shown higher order capacities for understanding and decision-making, then a patient’s self-determination is only respected if they are free to act, so long as they do not harm other people. This should apply to all patients who are shown to have capacity.

Equal Access

If a patient with capacity desires PAS in a state where DDA laws exist, but a physician or hospital refuses to provide PAS, then the hospital or physician should provide a patient with relevant information on locations where the service can be provided. The President’s Commission suggests that health-care professionals and institutions provide information and assist patients in obtaining information regarding a patient’s condition (President’s Commission 92). By conveying this information to patients or their caregivers, physicians are respecting a patient’s self-determination and promoting a patient’s well-being without providing the service that may be incompatible with their professional values (Brock 1996, 392).

I also think there is a normative claim to make for the validity of this equal access stipuation. Many people would think it fair to say patients or any person should be not be impeded from accessing a service that is offered in their relevant domain (a state boundary, in this case) because the people around them dislike the service for moral reasons. Say I desired my appendix to be removed, but the local hospital felt that appendixes should not be removed since their God had created the human form in his image. No such removal of organs is justified in their opinion if there is no pain or evidence of appendicitis. If the hospital is unaware of other locations, and pleads ignorance, then this may be excused. Though, when a hospital is aware of other locations where a service may be provided, and the hospital won’t provide the service for religious or ethical reasons, then this is not justification enough to withhold information from me.

This does a disservice to my self-determination and reduces my liberty of action. Appealing to widely understood concepts of autonomy, liberty of action is reduced when information is withheld from patients (Mappes & DeGrazia 1996, 25). Therefore, information that could be provided to patients to enhance their autonomy that is withheld is a form of coercion. Consequently, there should be a stipulation to reduce this form of coercion.

Concluding Statements

Physician assisted suicide laws are morally permissible since they promote self-determination, enhance well-being, and are justified by the harm principle. Disabled patients should have access to PAS if their capacity can be determined with some form of accepted communication. Additionally, patients should be provided means of consuming end-of-life medication even if they are physically unable to self-administer the medication. Lastly, patients should be provided with information on where to access PAS if their local physician or hospital doesn’t provide the service and the hospital is aware of other locations.

Citations:

Mill, John Stuart. 1859. “On Liberty.” Chapter 1: “Introductory.” no. 6-18. Chapter 4: “Of the Limits to the Authority of Society over the Individual.” no. 69-86.

Brock, Dan. 1996. “Voluntary Active Euthanasia.” In Biomedical Ethics, 4^th Edition, edited by Thomas Mappes and David DeGrazia, 391-392. New York. McGraw-Hill Inc.

Mappes, Thomas A. and DeGrazia, David. 1996. Biomedical Ethics, 4^th Edition. 25-35. New York. McGraw-Hill Inc.

President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. “The Values Underlying Informed Consent.” In Biomedical Ethics, 4^th Edition., edited by Thomas Mappes and David DeGrazia. 1996. Biomedical Ethics, 4^th Edition. 89-94. New York. McGraw-Hill Inc.