Euthanasia and physician assisted suicide: do the moral arguments differ?
A discussion paper from the BMA’s Medical Ethics Department
Physician assisted suicide
The main question raised in this paper concerns the existence of a moral difference between the role of the doctor in euthanasia and assisted suicide.
With euthanasia, a doctor by a calculated act or omission initiates a causal sequence that results in the patient's death. With assisted suicide, the doctor may either help or may fail to prevent a patient completing a course of action which results in his or her own death. In the former case, the doctor rather than the patient is ultimately in control even when it occurs with patient consent. In the latter, although the boundaries may sometimes appear blurred, the patient remains the agent (or the act ceases to be suicide). Once a doctor has provided the means or the information, the patient exercises control over whether or not they are used.
Patients facing predictable physical deterioration prior to death sometimes complain that they either have the choice of committing suicide prematurely while they are still able physically to do so, thereby sacrificing an unknowable amount of good quality life, or by miscalculation leave it too late to avoid a protracted decline. It is sometimes argued that having an escape mechanism such as a lethal drug would maximise their autonomy and enable them to prolong their lives.
Enabling competent people to end their own lives is perceived by many as entailing less responsibility and as being therefore less blameworthy than ending their lives for them. Others would argue that there is no significant moral difference between the two. The inclination to perceive a clear moral distinction, it is argued, may be attributed to other contingent factors, such as the fact that the motives of people who let others die are generally less malicious than those of people who kill. Motive rather than the act itself may sometimes lead juries to decline to convict health professionals who appear to have acted in good faith to terminate suffering.
In spite of the lack of a clearly articulated moral difference, health professionals appear to feel that a substantive distinction exists between terminating a patient's life and allowing patients to kill themselves. A 1996 UK random survey to which 1,000 health professionals (predominantly doctors) Go to reference 6 responded indicated that 51% of respondents would be willing to assist a patient to commit suicide (16% said they would only do so in terminal cases; 28% would do so in cases of extreme suffering; 7% would do so without precondition if the patient wished it; 37% said they would never do so).
The percentages of those in favour or opposed to a change in legislation to permit physician assisted suicide were very similar (55% in terminal or suffering cases; 10% without precondition if the patient wished it; 30% opposed to legal change).
Most respondents found physician assisted suicide preferable to euthanasia (43% in comparison to 19%) but a high proportion (38%) were undecided. The figures reflect some general trends claimed in other jurisdictions.
Whereas morality cannot be based on crude measures such as majority opinion or the vagaries of opinion polls, it is clearly important for the BMA to hear and respond to doctors' views and, above all, to strive to inform them. Evidence of attitudes such as those indicated in the survey also undermines the argument that well informed health professionals are fundamentally unwilling to play a role in euthanasia or assisted suicide.
One of the potentially noteworthy findings of the above-quoted survey, however, is that whereas there was little difference in the percentages of hospital doctors and GPs in favour of a change in the law (approximately 48% were in favour), a much greater percentage of pharmacists supported legal change (72%). They were also the group most willing to assist in suicide without any precondition of terminal illness or suffering (11.7%). The authors of the report conclude that "perhaps these results indicate a belief that their professional status might be enhanced if physician assisted suicide was to be introduced", raising the issue of whether altruistic beneficence is necessarily the motive behind a desire for change.
Whatever the motive of the person assisting, by definition "suicide" cannot occur without the patient's cooperation. If the patient does not actively consent to the act, it becomes either non-voluntary euthanasia or murder.
It could be argued, therefore, that assisted suicide may be less open to potential abuse than euthanasia because the patient's cooperation must be verified by witnesses at various stages which can be separated in time. The 1994 Oregon legislation, for example, permitted doctors to prescribe a lethal dose for competent patients with a life expectancy lower than 6 months. The patient had to make a witnessed written statement plus two separate oral requests with waiting periods of up to 15 days between requests. The patient had to be referred for counselling to a specialist if depression or a psychological disorder were suspected.
Although there can be no guarantees that such regulations will be followed in ever case, they do provide a clear framework for decision making. Some argue that the current prohibition of assisted suicide in Britain is more dangerous and haphazard.
As with euthanasia, it is known that some health professionals contravene the prohibition on assisting suicide. In the survey previously quoted, 12% of respondents said they knew a colleague who had helped a patient commit suicide and 4% said they personally had done so Go to reference 7. The Institute of Medical Ethics has argued that it would be unjust "if only some doctors, as at present, continued to relieve terminal suffering by assisting death in the privacy of the home, while others, especially in hospital, did not do this."Institute of Medical Ethics Working Party, Assisted death, Lancet 336 September 1990; 610-613.
Although some may argue that the scope for abuse is less with assisted suicide than with euthanasia because of the need for the patient's informed cooperation, a Canadian Senate enquiry of 1995 Go to reference 8 found the potential for abuse or undue influence to be unacceptable. In its current guidance on end of life issues, the BMA Ethics Department quotes the views of a Canadian doctor canvassed during that national debate:
"knowing my own weaknesses and recognizing the weaknesses I have seen around me in the practice of medicine, within hospitals, and within the health care system, I can simply say to those who would ask so eloquently for these freedoms that, on the ground, in the trenches where it matters, the first to die would be the weak and inarticulate, the defenceless, not the strong-willed, those possessed of unattractive situations or stories of particular hardship. It would be the ordinary people whose continued existence is resented by unsympathetic relatives or an unsympathetic health care system".
The same Canadian report points to an apparent societal anomaly in approach whereby:
"Canada has identified a suicide problem among its youth and we have responded 'How can we prevent it?' Canada has identified a suicide problem among Aboriginal people and we have responded 'How can we prevent it?' Canada has identified a suicide problem among people with disabilities and we have responded 'How can we assist them to kill themselves?' ".
This articulates a concern about the potential message which may be given to society about the value of the seriously ill and disabled if assisted suicide were to be legalised.
References
6 Of the 1,000 respondents, 21% identified themselves as hospital doctors, 12% GPs, 9% surgeons, 11% psychiatrists, 18% pharmacists, 27% anaesthetists and 2% others such as nurses. McLean S, Britton A, Sometimes a Small Victory, as above.
7 McLean S, Britton A, Sometimes a Small Victory, as above.
8 Of Life and Death, Report of the Special Senate Committee on Euthanasia and Assisted Suicide, Senate of Canada, June 1995.