Argumentative Philosophy Revisions

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When, if ever, is it morally permissible for a physician to assist with a suicide?

Mariam Kobeissi

University of Michigan-Dearborn

Professor Dunne

Medical Ethics

March 26, 2023

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Issue

The questions regarding the permissibility of assisted suicide are incredibly challenging

in Bioethics because it interacts with the harrowing fact that every human will ultimately face,

and sometimes unwillingly. A patient’s decision to get assisted suicide is most controversial

because death is primarily considered negative. It becomes more complicated when a healthcare

organization is involved because among the many objectives of a hospital is preventing death

and reducing the death rates. This is among the reasons why assisted suicide is controversial.

When examining such a topic in bioethics, it is essential to acknowledge the various basic

principles, including beneficence, autonomy, justice, and non-maleficence. These principles are

the goal of understanding and coming up with the decision for such a case. However, depending

on the issue, some principles bear more weight than others. The principles provide a guiding path

in most cases but are often open to adjustment.

In the bioethical issue regarding assisted suicide regarding terminally ill patients who

consent and choose this path, the most relevant principles are autonomy and beneficence. Any

ethical model for arguing for and against assisted suicide becomes complicated because of the

attitude towards death in society and the thought that there is always another option, such as

helping, hopeful that the patient can heal, while others base their argument on religion. Another

thing that greatly complicates this issue is the feelings of both parties, including the patient and

their family. There is often the question about how the family feels, which might contrast with

how the patient feels because most patients choose assisted suicide because they perceive it as

the only relief for their suffering. They are often convinced that eventually dying will stop the

pain and suffering, but there is always a consideration for the family.

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Therefore, it is essential to consider the various ethical frameworks and nursing

principles when deciding on the permissibility of the matter. The healthcare field is built upon

strong ethical frameworks that every individual is expected to stand up to when deciding

regarding various medical dilemmas, including assisted suicide. The best way to move forward is

first to understand what assisted suicide means and the various frameworks underpinning this

framework. Physician-assisted suicide occurs when a physician facilitates the ending of a

patient's life or gives them the necessary information to perform the life-bending act by probably

providing the pill and information regarding a lethal dose; with full knowledge, the patient will

commit suicide. Based on this, this paper will outline the different arguments regarding the

permissibility of a physician assisting a patient in carrying out suicide. I will then outline my

argument and the possible objections. Overall, I argue that physician-assisted suicide is

permissible when there is patient autonomy and informed consent, which has not been forced on

them in any way.

Positions

One of the significant positions regarding physician-assisted suicide is that it is

permissible when considering the autonomy and informed consent of the patient. The human

doctrine of informed consent is that patients have the right not to consent, meaning to refuse

treatment1. According to the law perspective, this can be seen in cases such as inre Quinan. The

New Jersey Supreme Court ruled that there was a right to discontinue the kind of treatment

because there is a right to privacy outlined in the United States Constitution in Griswold v.

1 Snead, O.C., 2020. What it means to be human: The case for the body in public bioethics. Harvard University Press. (P.176)

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Connecticut and Roe v. Wade2. As long as the patient is considered competent to decide on their

healthcare and the decision to end their life. The United States Constitution grants a competent

individual a constitutionally protected right to refuse lifesaving nutrition and hydration3. In every

United States Jurisdiction, it is lawful for patients to turn down and discontinue unwanted

medicine, including the different measures meant to sustain life. The normative justification

principle is intended to protect the self-determination and autonomy of patients considered of

sound mind. When applied to competent people, this does not involve controversy in any way.

The only time that a challenge comes up is when it is applied to patients who are not considered

competent and of sound mind.

This was seen in re Quinlan, whereby there was a woman in a persistent vegetative state,

a phrase created in 1972 by Jennett and Polum to outline the condition where an individual is

awake but lacks detectable awareness. Patients within this state, who experience sleep and

waking without particular recognition of external stimuli or attention, might cry, scream, and

other actions, but according to diagnosis, they are not evidence of psychological awareness. In

this case, the New Jersey Supreme Court ruled that the patient's right to privacy, which

encompasses the freedom to refuse life-sustaining measures, should not be extinguished because

of her cognitive disability.4. In this situation, the court allowed her father to decide the decision

she would have made for herself if she had been in the right mind or what is considered

competent according to the law. The court authorized him to direct the ventilator withdrawal,

which had been confirmed by the hospital ethics committee and the physician that she had no

hope for restoration to a cognitive sapient state. The ventilation was withdrawn, but surprisingly,

2 Snead. (2020). P.178 3 Snead. (P.182) 4 Snead. (182)

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she continued to breathe independently and lived for another ten years. After this, jurisdictions

have long held the notion that this liberty to decline life-sustaining measures can be done on the

patient’s behalf with no capacity to decide on their own (P.181). If there is oral or decisive

written evidence expressing the patient's preferences, they should therefore be implemented.

According to Beauchamp & Childress, letting die is acceptable in the medical field under

two conditions, including when medical technology has become useless in the sense of its

medical efficiency and success and if the patients or their surrogates have validly declined a

medical technology5. This means it is only acceptable to let a patient die if the condition of

futility is satisfied or the valid treatment is refused. Therefore, if these two are not available in

such a situation, then a healthcare professional might be assumed to have killed the patient and

might also be considered negligence. In healthcare particularly, the act of killing has been

traditionally morally and conceptually associated with unacceptable actions. These medical

practice conditions make the connection justifiable, but killing is considered absolutely

unacceptable. Therefore, it is essential to identify the difference between killing and letting die to

base the concept of acceptability and unacceptability. Many medical scholars have construed a

physician’s intentional foregoing of medical technology as letting die if only the underlying

injury and disease cause the death6. When these physicians put aside medical technology, death

occurs naturally since natural conditions do what they would have done if the healthcare

professional had not started applying the medical technology to stop them or slow the process

down. Contrastingly, killing occurs when the individual acts rather than letting the natural

conditions cause the patient's death.

5 Beauchamp, Tom L., and James F. Childress. Principles of biomedical ethics. 2020. (P.19/44) 6 Beauchamp and Childress. (P19/44).

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To validate this perspective, it is essential to fully satisfy the argument that putting aside

medical technology is validly justified and authorized. If the physician putting aside the

technopop is unjustified and a person dies from the natural causes of the disease or the injury,

this would be considered unjustified killing and not justified as letting die. The validity of the

authorization is the factor that is used to justify the moral acceptability of this circumstance

based on this perspective. Therefore, patient autonomy and informed consent come into play.

Suppose a doctor removes a ventilator from a competent patient who wants to continue using it

and needs it. In that case, the action is unethical even if the doctor has only removed the artificial

life support and let nature take its course.7. The lack of authorization from the patient is an

essential factor identified in this setting. Therefore, it is vital to have authorization and validity

when letting die, or it turns into killing, which, even under the law, is unacceptable.

Although most of the arguments are founded on the principle of autonomy, there is a

critical view presented by Tollerson, who presents the various misunderstandings that exist in the

view of autonomy8. According to Cullin & Tollefsen, there are several misunderstandings

involved. The first one includes a misunderstanding that an autonomous choice is right.

According to one perspective, autonomy is singularly important since what makes a decision

right is autonomy. This is called the radical autonomy view. By radical, it does not mean the

people supporting it operate out of the political mainstream. Instead, it means that in this

perspective, the exercise of autonomy principally affects the nature of the decision, making the

right decision. The radical autonomy viewpoint has its roots in the writings of Immanuel Kant,

who believed that autonomy could only exist when a decision was made following the

7 Beauchamp & Childress. (P.20/44). 8 Curlin, Farr, and Christopher Tollefsen. The way of medicine: Ethics and the healing profession. University of Notre Dame Press, 2021. (P.84)

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categorical imperative: one should only act following a maxim when one can simultaneously

wish for that principle to become a universal rule.9. According to Kant, a will operating

following such a maxim was free and autonomous because it was not motivated by external

factors, such as a simple desire. Based on this view, the issue of the validity of autonomy in

assisted suicide comes up, developing the argument that autonomy as the answer to whether

assisted suicide is permissible or not is wrong because sometimes this autonomy might be flawed

by a simple desire thus flawed judgment.

Support

I hold that there are instances when physician-assisted suicide is permissible. I argue that

although individuals base their arguments on the emotions of others related to the patient, it is

crucial to set aside the idea of emotions, to handle the dilemma head-on. Based on the

deontological point of view, I argue that the situation of a physician assisting a patient in

committing suicide is permissible. The deontological theories are frameworks that posit that the

rightness of deeds cannot be determined significantly by their consequences but by their intrinsic

nature by a more considerable margin.10. Therefore, for an individual to be considered as having

acted morally, according to the deontological perspective, one is obligated to follow their moral

duties. Therefore, it is essential to consider the patient-centered ethical framework, specifically

leaning toward deontology.

Patient-centered deontology is a framework that is right-based instead of duty-based, as

with most deontological frameworks. It is the most appropriate point of view to determine the

9Curlin & Tollefsen (84). 10 Carvalho, Tiago Mesquita. "Lost in Translation? Ethics and Engineering Practice." In Portuguese Philosophy of Technology: Legacies and contemporary work from the Portuguese-Speaking Community, pp. 163-183. Cham: Springer International Publishing, 2022. (p.164).

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rightness of suicide based on the act rather than its consequences. The most valuable principle to

determine the permissibility of the act is the autonomy principle, as identified by Kant.11.

According to this principle, an individual must never be trusted as a mere means. People must

have a natural value that is not bestowed on them but is derived from nature because they are

free and rational beings that can direct their own lives, seek the satisfaction of their own needs

and decree their own rules on how they wish to live or die. Although at some point Kant might

view physician-assisted suicide as ethically correct, his autonomy principle is relevant to arguing

that it is morally permissible when the patient has provided informed consent.

I argue that as long as an individual is competent, their autonomy and informed consent

are essential enough to rule out the permissibility of the physician helping the patient die. For a

person to be competent, they must be mentally stable and of the appropriate age. This validates

that they are in the right state to think for themselves and make rational decisions regarding

ending their suffering. Every healthcare professional is mandated to respect patient autonomy.

As long as the patient is well informed about the ins and outs of the process and the prospects of

recovering and decides to be assisted to die, no evidence can be employed to prove that this is a

wrongful act. This aligns with Kant’s view of autonomy, whereby he posits that as long as an

individual has decided to take a particular action, the only thing that validates the rightfulness or

the wrongness of an action is the person's choice.

The action required when a physician assists a patient can die can vary because a doctor

can eliminate and forego any further treatment or provide a lethal dose that the patient can take

out of their own will to die and end their suffering. The agent of this physician-assisted suicide

11 Carvalho. (P.165)

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can be considered as the physician who facilitates either of these things. However, labeling the

agent as the physician brings down the value of the autonomy of the patient to choose this

assisted suicide. The source of the agent is the decision the patient makes to go through this

assisted suicide without being ousted or being lured by anyone. What therefore matters regarding

the situation whereby assisted suicide is when the patient’s decision is the agent of the action.

Therefore, I hold that physician-assisted suicide can only be permissible if the patient

chooses this path rather than being lured or pushed to do it by any other agent. The patient must

have contemplated the situation significantly ad made the right choice, according to them. This

means that this must be an independent choice. Only the patient is permitted to decide whether or

not they can get assisted to die unless they are incompetent and might need other people close to

them to resolve for them, based on their level of suffering and the hope that they will get better.

Therefore, the patient must come to this conclusion being well-informed and free without the

possibility of being pushed into doing it.

The perspective of considering the patient as the principle of autonomy supports the

agent because Kant values an individual as their own end in the view of a physician assisting

them to commit suicide. Here, the patient is exercising their own right to use assisted suicide,

which eventually makes their view ending when using the physician as their agent partly as their

means to reach this end. The ability of the patient to make their own end based on Kant’s

perspective is part of what enables the patient to possess the natural right worth since they are

free as rational individuals that can direct their own lives. Suppose the doctor or any other

individual argues against the procedure. In that case, they are disregarding the patient’s

autonomy and thus deciding paternalistically by limiting the freedom to choose, ultimately

diminishing the natural value that individuals possess.

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Overall, I argue that the instance where the patient’s autonomy and informed consent

must be upheld provides permissibility for a physician assisting a patient in ending their life as a

means to end their suffering. Kant’s view of autonomy highly inspires this. Therefore, by trying

to limit or restrict this action, one would limit the patient from exercising their inherent right to

make decisions regarding their care and medicine. Additionally, I argue that it would be

impermissible if the patient is not competent enough to decide on the end of life and

discontinuation of treatment. The subject of autonomy has long been discussed in healthcare and

continues to be held in other treatments and thus should be respected even in such a

circumstance. The rightness of choice to die can only be validated if the patient decides without

considering other people and their feelings.

Objections

One possible objection that could arise from my argument is that physician-assisted

suicide does not align with the role of the healthcare professional role as a healer, thus posing

significant risks. The physician is traditionally and continually to be seen as a healer. Therefore,

in every situation, they are supposed to actively practice their healing role and give the patient

hope that they will get better even though they have lost all hope. The American Medical

Association offers various ways physicians can aggressively respond to patients' needs during

the end of life situations. 12. For example, the AMA mandates that the physician should not

abandon the patient after determining the cure is impossible, offer good emotional support and

communication, and provide the right comfort care and appropriate pain control. Based on this,

an individual would object regarding the issue of patient autonomy, stating that the physician

12 Beauchamp and Childress. (p.3/25)

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should instead try to offer the maximum support they can provide to the patient to ensure that

they are no longer hopeless or in pain, including providing emotional support and pain control.

However, I would object to this view because regardless of the power the physician

might have to help alleviate the situation, the code of ethics also mandates that physicians respect

the patient's autonomy. I believe that even while a physician tries to support the patient in the

best way they can use these strategies, the ultimate thing to do is to respect the patient’s desire

and autonomy. The patient is the ultimate decision-maker regarding their care; therefore,

regardless of what the doctor says, their autonomy should be respected. By doing these things

and ignoring their autonomy, the physicians would be violating the patients’ medical rights.

Another objection would come from the second misunderstanding that posits that

autonomy is not always the greatest good, as individuals would normally view it.13. Besides the

claim that a choice reached by autonomy is correct in nature, the autonomy-first view refutes the

idea that it is always the greatest good. Autonomy only improves a person's situation insofar as it

is directed toward instances of these and other fundamental goods, as opposed to goods like

health, education, friendship, or religion, which are all the better in and of themselves. It can be

seen whenever someone makes a self-destructive choice that an autonomous choice is only good

when it is a decision for good. If a decision is not entirely informed by reason, even a good one

may turn out to be bad. Therefore, the objection would be that this would not offer the greatest

good. However, on this view, I contend that autonomy is seen as a means and not as an end. As

long as the patient sees it as the best choice for them, the rest of the people cannot determine its

13 Curlin and Tollefson (P.184).

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permissibility. Instead, it should be seen as a means. Overall, the patient’s choice is the most

important thing.

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Bibliography

Beauchamp, Tom L., and James F. Childress. Principles of biomedical ethics. 2020.

Carvalho, Tiago Mesquita. "Lost in Translation? Ethics and Engineering Practice." In Portuguese

Philosophy of Technology: Legacies and contemporary work from the Portuguese-Speaking

Community, pp. 163-183. Cham: Springer International Publishing, 2022.

Curlin, Farr, and Christopher Tollefsen. The way of medicine: Ethics and the healing profession.

University of Notre Dame Press, 2021.

Snead, O.C., 2020. What it means to be human: The case for the body in public bioethics. Harvard

University Press