| by NICHOLAS DIXON Those who defend physician-assisted suicide often seek to distinguish it from active euthanasia, but in fact, the two acts face the same objections. Both can lead to abuse, both implicate the physician in the death of a patient, and both violate whatever objections there are to killing. Their moral similarity derives from the similar roles of the physician. It is an oddity of the roaring debate over physician-assisted suicide that those who advocate legalizing physician-assisted suicide sometimes simultaneously argue against legalizing active euthanasia. Indeed, recent papers by Margaret Battin and by Timothy Quill, Christine Cassel, and Diane Meier argue for precisely such a distinction, drawing on some considerations about the different consequences of the two practices.[1] In this paper I examine these and other arguments that active euthanasia is morally more problematic than physician-assisted suicide, and I conclude that none of these arguments is sound. For all that they have shown, the case for legalizing active euthanasia is morally indistinguishable from the case for legalizing physician-assisted suicide. If this is right, then our understanding of the morality of active euthanasia and physician-assisted suicide will be enhanced by considering them together. In particular, the moral lessons of legalizing active euthanasia in Holland are directly applicable to the debate over legalizing physician-assisted suicide in the United States, although we nonetheless must take account of significant differences between the health care systems of the two countries. Thus if, as Herbert Hendin has argued,[2] active euthanasia has been widely abused in Holland, we should certainly be aware of the risk of similar abuses of physician-assisted suicide in the United States, especially since the differences between the two countries--such as the lack of universal health care and of close physician-patient relationships in the United States--are likely to exacerbate this risk.[3] To establish the moral equivalence of active euthanasia and physician-assisted suicide, two strategies are possible: showing that the same arguments that purport to justify physician-assisted suicide would also justify active euthanasia, or showing that objections to active euthanasia would count equally against physician-assisted suicide. I will adopt the latter strategy. The Slippery Slope Both of the recent defenses of physician-assisted suicide raise the fear that legalizing active euthanasia would, in contrast to legalizing physician-assisted suicide, create too great a danger of abuse. In opposing legalizing active euthanasia in the United States, Battin says: | |
This is a country where 1) sustained contact with a personal physician is
decreasing, 2) the risk of malpractice action is increasing, 3) much
medical care is not insured, 4) many medical decisions are financial as
well, 5) racism is on the rise, and 6) the public is naive about direct
contact with Nazism or similar totalitarian movements. Thus, the United
States is in many respects an untrustworthy candidate for practicing active
euthanasia.[4]
| | Physician-assisted suicide, in contrast, | |
leaves the fundamental decision about whether to use [the means to end the
patient's life] to the patient alone ... [T]he physician is involved, but
not directly; and it is the patient's choice, but the patient is not alone
in making it.[5]
| | Similarly, Quill, Cassel, and Meier point out that | |
[i]n assisted suicide, the final act is solely the patient's, and the risk
of subtle coercion from doctors, family members, institutions, or other
social forces is greatly reduced. The balance of power between doctor and
patient is more nearly equal in physician-assisted suicide than in
euthanasia. The physician is counselor and witness and makes the means
available, but ultimately the patient must be the one to act or not act. In
voluntary euthanasia, the physician both provides the means and carries out
the final act, with greatly amplified power over the patient and an
increased risk of error, coercion, or abuse.[6]
| | They also refer to the same economic concern that Battin mentions: | |
[I]n the United States access to medical care is currently too inequitable,
and many doctor-patient relationships too impersonal, for us to tolerate
the risks of permitting active voluntary euthanasia.[7]
| | The central claim in both of these papers is that peculiarities of the health care system in the United States--in particular, the lack of universal access and the absence of close physician-patient relationships--create a real danger that active euthanasia would be overused were we to legalize it in this country. Social and economic pressures, and not an authentic desire to die, may motivate patients' requests for active euthanasia. In contrast, the argument continues, we may safely legalize physician-assisted suicide because of the crucial difference that it places control firmly in the hands of the patient who wants to die. When patients themselves are the ones who perform the final act to end their lives, their actions are more likely to be autonomous and not unduly influenced by external pressures. Autonomous decisions by patients are intrinsically desirable and are less susceptible to abuse. These slippery slope objections to active euthanasia seem to me to pose serious obstacles to its legalization in the United States under current conditions. My point here, however, is that they count just as powerfully against legalizing physician-assisted suicide, for the degree to which the patient who commits physician-assisted suicide is more in control of her destiny than the patient who is given active euthanasia is negligible. It is true that in active euthanasia the physician administers the coup-de-grace, usually a lethal injection, whereas in physician-assisted suicide the patient herself administers the injection or drinks the lethal solution, but this difference in causation has no significant effect on the patient's control over either situation. In voluntary active euthanasia, just as in physician-assisted suicide, the physician's participation is dependent on the patient's voluntary request. At any point in the process, from the time that discussions of active euthanasia first occur to the moment when the physician gives the lethal injection, the patient is free to change her mind and call a halt to the proceedings. The only moment when the patient has more control over her destiny in physician-assisted suicide than in active euthanasia is the split second between the insertion of the needle and the depression of the plunger. In physician-assisted suicide, the patient can change her mind at the last second and pull the needle out before depressing the plunger, or take the cup away from her lips without drinking it. In contrast, in active euthanasia, once the physician has inserted the needle for the lethal injection, the patient may lack the time to yell "stop" and abort the procedure. However, the chance of such last-second changes of heart seems too remote to count as a significant reason for preferring physician-assisted suicide to active euthanasia. The slippery slope objections make no reference to last-minute dramatics. They refer, instead, to the social and medical context in which the decision to request active euthanasia or physician-assisted suicide is made. Deliberation and discussion about this request are likely to originate many months before any action is taken and are likely to continue until the final scene. During this entire process, right up to the final split second, the patient has just as much control over her destiny in active euthanasia as in physician-assisted suicide. Consequently, the objections tell just as powerfully against physician-assisted suicide as against active euthanasia. Their force is that people may be coerced into making nonautonomous requests to die, requests that reflect social and economic pressures rather than their own authentic desires. These pressures are equally troublesome whether the physician or the patient is the one who takes the final step that causes the patient's death. Perhaps I have been taking the claim that physician-assisted suicide gives the patient more control too literally. The sense in which the patient has more control may be symbolic, in that the patient who is willing to be the direct agent of her own death gives a more unambiguous demonstration of her desire to die. But while this may be a good reason for preferring physician-assisted suicide over active euthanasia when both are a live option (since it seems reasonable to encourage an able-bodied patient who wishes to die to, as it were, put her money where her mouth is and carry out physician-assisted suicide rather than seek euthanasia), flatly to forbid active euthanasia on this ground would unfairly exclude those who have made equally reflective, autonomous requests to die but are physically unable to commit physician-assisted suicide. It would also exclude patients who are physically able to commit physician-assisted suicide but prefer to die by a particular method of active euthanasia--such as a barbiturate to sedate the patient followed by a lethal injection of curare. This peaceful way of dying is not feasible as a method of physician-assisted suicide because the sedation caused by the barbiturate would diminish the patient's ability to effectively self-administer the lethal injection. Even when the barbiturate and curare are combined in a single injection, many patients will prefer that it be performed by someone who is proficient in the use of needles. Yet patients who prefer to die by this method may desire death just as firmly as those who commit physician-assisted suicide. Another pragmatic reason for preferring physician-assisted suicide over active euthanasia is that physician-assisted suicide relieves the physician of being the immediate cause of the patient's death, which must be stressful even for physicians who favor active euthanasia. But since even in assisting suicide physicians play an active role in causing the patient's death, that practice must also be a wrenching experience. Both practices run counter to their instinct to preserve life. Consequently, the difficulty that physicians may experience in carrying them out does not provide a significant moral wedge between them. In short, then, if the slippery slope objections to physician-assisted suicide can be met, then although physician-assisted suicide may sometimes be preferable on the pragmatic ground that it provides compelling evidence of a patient's desire to die, we should also make active euthanasia available to those who are either physically unable to commit physician-assisted suicide or who prefer methods of death that cannot easily be self-administered by patients. Except in the case of highly unlikely last-second changes of mind, patients who are voluntarily euthanized have just as much control over their destiny as those who commit physician-assisted suicide, and it is inconsistent to favor legalizing physician-assisted suicide while opposing active euthanasia on the ground that it can be abused. Causal Differences Since we are unable to distinguish morally between active euthanasia and physician-assisted suicide in terms of their consequences, we need to look elsewhere to support the distinction. Perhaps the key lies in the causal difference between active euthanasia and physician-assisted suicide: in active euthanasia the physician is the immediate cause of the patient's death, whereas in physician-assisted suicide the patient herself provides the coup-de-grace. Indeed, despite Rachels's celebrated argument that no intrinsic moral difference exists between killing and letting die,[8] there are those who maintain that the causal difference is morally relevant.[9] While the euthanasia/suicide distinction is different from the active/passive distinction that Rachels and his opponents debated--after all, the doctor does a lot more in physician-assisted suicide than stand back and let the patient's illness take its natural course--the doctor's role in active euthanasia is certainly more active than in physician-assisted suicide. Is this difference sufficient to create a moral wedge between active euthanasia and physician-assisted suicide? On the surface, the active/passive distinction is of little help, even if we assume for the sake of argument that it is morally relevant. In passive euthanasia, the doctor figuratively stands back and lets nature take its course, but in physician-assisted suicide she is to varying degrees actively involved in killing the patient. At the very least, she gives the patient information on how to commit suicide. More commonly, she also provides the lethal solution, either by handing it to the patient or by writing a prescription. Dr. Kevorkian plays the most active role imaginable in physician-assisted suicide, since he hooks the patient up to his "suicide machine" and she merely flips a switch. In general, the only part of the causal sequence that a physician cannot perform in physician-assisted suicide is the final one, the act of ingesting or injecting the poison. By analogy, the person who plans a bank robbery, the hold-up guy; and the gang member who retrieves the cash from the bank's safe all share responsibility for the theft, even though the one who takes the money to the getaway car is technically the primary agent of the crime, since he is the one who carries the money off the bank's premises. Anyone who plays a significant, even if not sufficient causal role in producing an event--and a physician plays just such a role in a patient's assisted suicide--shares responsibility for that event. As Feinberg has pointed out, when we assign responsibility for an event we select from among its causal antecedents one or more that are particularly interesting for our purposes.[10] For instance, we are unlikely to cite stable features of the environment, such as the law of gravity, as the cause of a plane crash, even though they may be necessary conditions of the crash. We are more likely to cite an unusual intervention, such as pilot error or a stalled engine. Nothing requires that we identify the most recent causal antecedent as being responsible for the event. The pilot's error is followed by the pull of gravity, and retrieving the cash from the bank vault is followed by carrying it to the car, but we do not hesitate to cite pilot error and opening the vault as major causes of the plane crash and of the bank robbery, respectively. Similarly, even though the patient's own participation is necessary at the end for her to commit suicide, the physician's central role in the causal sequence gives her a major share of responsibility for the patient's death. There is another reason why the causal distinction between active euthanasia and physician-assisted suicide does not support a moral distinction. If we were to rank the doctor's role in bringing about the patient's death on a passive-active scale, with passive euthanasia at one end and active euthanasia at the other, even the most passive kind of physician-assisted suicide, in which the physician only provides information about suicide, is considerably more active than passive euthanasia, in which by definition the doctor does nothing to bring about the patient's death. When the physician also supplies the poison, and especially when she is present to guide the patient in injecting or ingesting it, her participation moves further toward the active end of the scale. Supporters of physician-assisted suicide presumably agree with Rachels that the active/passive distinction is not morally relevant, and this is what permits them to support the practice despite the active role that doctors play in it. It seems strange, then, for them to oppose active euthanasia on the ground that in active euthanasia physicians are slightly more involved in the patient's death than they are in physician-assisted suicide. Why does the active/passive distinction suddenly become so important, when a much larger difference on this scale was not considered morally relevant when comparing physician-assisted suicide with passive euthanasia? Supporters of physician-assisted suicide who oppose active euthanasia could concede that physicians play a major causal role in and share responsibility for the patient's death in physician-assisted suicide, but nonetheless insist that the relatively minor difference in the physician's causal role in active euthanasia and physician-assisted suicide is crucial. Granted, the physician's participation in physician-assisted suicide is a necessary condition for the patient's death and the physician knows and intends that the patient will perform the coup-de-grace. But because the patient, not the physician, injects or drinks the lethal dose, the physician does not kill the patient. Being substantially responsible for someone's death is not the same as killing her. Physician-assisted suicide is, after all, suicide. Of course, whether or not the act of killing the patient is inherently wrong is precisely what is at issue in the debate over active versus passive euthanasia, and simply to assert that active euthanasia is wrong because killing the patient is more problematic than either passive euthanasia or physician-assisted suicide would beg the question. An argument is needed to explain exactly why the fact of killing makes active euthanasia worse. We can formulate just such an argument by exploiting Bernard Williams's concept of integrity. Williams introduces the concept by way of a story about a man who chances upon a firing squad in a South American town. Twenty innocent people are about to be executed, but if he agrees to kill one of them himself, the others will be set free.[11] From a utilitarian point of view, no doubt seems to exist that he should agree to kill one of the prisoners, thus saving nineteen lives. The fact that it would be an agonizing decision, that whether he should kill the prisoner is not at all obvious, indicates that utilitarianism has left something important out of the moral picture. This something is the man's own moral integrity. Utilitarianism is concerned only with consequences, but moral agents are especially concerned about the morality of their actions, the purity of their own moral slate. When a harm has to occur, whether it is we or other people who perform that harm is not a matter of indifference to us. And this suggests a distinction between active euthanasia and physician-assisted suicide: even though both practices have the same result, the physicians involved intend the same results, and in both cases the physicians are deeply involved in causing death, the fact that only in active euthanasia does the physician actually kill the patient makes it more problematic than physician-assisted suicide. However, the disanalogies between Williams's persuasive case against utilitarianism and the attempt to distinguish physician-assisted suicide from active euthanasia are only too apparent. First, if an agent's personal involvement in a morally questionable practice is especially problematic, then physician-assisted suicide seems to be impugned just as much as is active euthanasia, for while the visitor to South America is unwillingly thrust into a situation that he did not create, a doctor participating in physician-assisted suicide voluntarily plays an active, central causal role in the patient's death. Second, and more importantly, in both options open to the visitor to South America an undisputed injustice occurs: either one or twenty innocent people are executed. Even if saving nineteen lives is in the end the right thing to do, the visitor will agonize because by killing one he will be the immediate agent of an injustice, thus threatening his own moral integrity. In contrast, in active euthanasia, whether the patient's voluntary death is an injustice is precisely the point that needs to be proven, not assumed. Whether a doctor's participation in active euthanasia is a violation of her integrity depends on whether the act is wrong, so we cannot without circularity use the concept of integrity to prove that it is wrong. The Wrongness of Killing So the argument has come full circle, and we have yet to find a good reason for morally distinguishing between physician-assisted suicide and active euthanasia. What we need is an independent reason for thinking that killing the patient is wrong even though helping the patient commit suicide is not. Two traditional arguments against active euthanasia purportedly turn on precisely such special characteristics of killing. One of these arguments is based on the premise that killing is wrong because human life is sacred, or because human life has an absolute secular value. Unfortunately, whatever the merits of this argument as an objection to active euthanasia, it fails to achieve the goal of morally distinguishing active euthanasia from physician-assisted suicide. If killing is absolutely wrong, then so is helping to kill someone. When a homicide occurs after a mugging, we often charge all of the muggers with murder, not only the one who fires the bullet. Even when we reserve the heaviest punishment for the murderer, we still regard assisting the murderer as a serious crime deserving substantial punishment. If opposition to legalizing active euthanasia is based on the alleged absolute wrongness of killing, then a similar argument also calls for banning physician-assisted suicide. A second traditional argument against active euthanasia is that when physicians directly kill their patients they violate their traditional role as healers. But once again the argument fails to morally distinguish active euthanasia from physician-assisted suicide. Setting aside doubts about whether active euthanasia really does violate doctors' traditional role--Dan Brock, for instance, has formulated a persuasive reconciliation of active euthanasia with the "moral center" of medicine[12]--any objections to active euthanasia that exploit conceptions of doctors' traditional role also extend to physician-assisted suicide. If the objection to active euthanasia is that doctors should heal, not kill, then helping to kill patients is also impugned, since it is just as much (or as little) at odds with healing patients. These two traditional arguments prove, at most, that if active euthanasia is wrong, physician-assisted suicide may not be quite as wrong. Neither one of them succeeds in showing that physician-assisted suicide would be justifiable, and any moral wedge that they create between active euthanasia and physician-assisted suicide is insignificant. Here as before, the objections to active euthanasia apply equally to physician-assisted suicide. The only reason for preferring one to the other is the purely pragmatic consideration that the willingness to commit suicide gives compelling evidence of the patient's desire to die. But this does not justify withholding euthanasia from patients who clearly demonstrate a desire to die. Fairness requires that if we legalize physician-assisted suicide, then we also make active euthanasia legally available to patients who are physically unable to commit physician-assisted suicide or who prefer to die by lethal injections that cannot easily be self-administered. Acknowledgments I am grateful for their helpful comments to my colleague Ron Massanari, to audience members at the 1997 American Philosophical Association Pacific Division meeting, where this paper was first presented, and to referees for the Hastings Center Report. References [1.] Margaret P. Battin, "Euthanasia: The Way We Do It, The Way They Do It," Journal of Pain and Symptom Management 6, no. 5 (1991): 298-305, and Timothy E. Quill, Christine K. Cassel, and Diane E. Meier, "Care of the Hopelessly Ill: Proposed Clinical Criteria for Physician-Assisted Suicide," NEJM 327 (1992): 1381-83. Page numbers of quotations from these papers are from their reprints in Biomedical Ethics, 4th ed., ed. Thomas A. Mappes and David DeGrazia (New York: McGraw-Hill, 1996). [2.] Herbert Hendin, Seduced by Death: Doctors, Patients, and the Dutch Cure (New York: Norton, 1997). [3.] However, Ronald Dworkin has argued that Hendin's criticisms of the Dutch system are questionable, and that we can, in any event, take simple precautions to prevent the occurrence of similar abuses if we legalize physician-assisted suicide in the U.S. See "Assisted Suicide: What the Court Really Said," New York Review of Books 44, no. 14 (1997), pp. 43-44. My point in referring to the Hendin-Dworkin debate is not to take a position on it, but merely to present it as an instance of meaningful debate arising from the kind of comparison between the practice of active euthanasia and physician-assisted suicide that we should encourage if my thesis about their moral equivalence is correct. [4.] Battin, "Euthanasia," p. 399. [5.] Battin, "Euthanasia," p. 400. [6.] Quill, Cassel, and Meier, "Care of the Hopelessly Ill," p. 401. [7.] Quill, Cassel, and Meier, "Care of the Hopelessly Ill," p. 401. [8.] James Rachels, "Active and Passive Euthanasia," NEJM 292, no. 2 (1975): 78-80. [9.] See, for instance, Daniel Callahan, "Can We Return Death to Disease?" Hastings Center Report 19, no. 1 (1989): 4-6. [10.] Joel Feinberg, "Sua Culpa," in Doing and Deserving: Essays in the Theory of Responsibility (Princeton, N.J.: Princeton University Press, 1970), pp. 200-207. [11.] Bernard Williams, "A Critique of Utilitarianism," in Utilitarianism: For and Against, ed. J.J.C. Smart and Bernard Williams (Cambridge: Cambridge University Press, 1973), pp. 98-99. [12.] Dan Brock, "Voluntary Active Euthanasia," Hastings Center Report 22, no. 2 (1992): 10-22, at 20. Nicholas Dixon, "On the Difference between Physician-Assisted Suicide and Active Euthanasia," Hastings Center Report 28, no. 5 (1998): 25-29. Nicholas Dixon teaches courses on ethics, logic, epistemology, and metaphysics in the philosophy department at Alma College, Michigan. He specializes in applied ethics and his current research interests include the morality of boxing, the nature of shame, and the relationship between pride and modesty. |
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