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The Right to Physician-Assisted Suicide
Rick Garlikov

“The Montana Supreme Court ruled on Thursday that state law protects doctors in Montana from prosecution for helping terminally ill patients die. But the court, ruling with a narrow majority, sidestepped the larger landmark question of whether physician-assisted suicide is a right guaranteed under the state’s Constitution.”   The New York Times By Kirk Johnson; Published: December 31, 2009

In this paper I wish to examine what kind of general right a right to an available medical service is, and what specific kinds of obligations it bestows on others (i.e., physicians, nurses, pharmacists, and other health care providers), if any.  In particular, I will discuss the right to physician assisted suicide[1] because it engenders serious objection by those who believe it is a morally wrong act which should not be done at all and which they believe therefore does not bestow an obligation on health care providers to perform.  In essence, I want to address the two questions I believe are presented by the Montana case: 1) Does a dying person have a moral right to hasten his/her own death? And 2) does a physician or other health care provider have a moral right or a moral obligation to assist a dying person who makes the request for medical assistance to hasten his/her death?

First, the right to do an act does not necessarily mean the act is right to do.  Nor does having the right to do something necessarily mean others are obligated to help you exercise that right.  There are rights that bestow obligations on others, but not all do.  E.g., the right to certain liberties means that others have at least a prima facie obligation[2] not to restrict your liberty; but the right to squander your talent and waste your opportunities does not mean it is right to do that or that others should help you do it.  One might have the right to stay in a hotel that has vacancies – thus bestowing a prima facie obligation on the hotel to rent the room to you.  But a hotel corporation has no obligation to build hotels or extra rooms in a town where you might wish to stay.  On the other hand, a right to a public education does bestow an obligation on communities, not only to provide access to available facilities, but to provide the resources and make certain there are such facilities available for everyone who is entitled to the right.

Second, rights are not necessarily absolute in a simplistic way.  Freedom of speech does not make it right to say just anything any time one wants to no matter what the consequences.  Freedom to travel does not necessarily mean free tickets on trains or airplanes; nor does it mean freedom to drive drunk.  Freedom in general does not mean serious crime, such as murder of innocent people, is allowed or that imprisonment or capital punishment is necessarily wrong for those who commit it. Liberty is not an unrestricted, “absolute” right.

I will try to make the case here that the right to specific medical treatment is right to exercise under and only under particular kinds of circumstances, and that it bestows obligations on health care providers under, and only under, particular kinds of circumstances.  Thus, even if the right to physician assisted suicide were to be a constitutional right, I will try to show that does not mean it is either right in all kinds of circumstances or that others are obliged to provide it in all kinds of circumstances, though it may be right and obligatory in some kinds of circumstances.

Third, medical necessities, like any other necessities, are not always possible or feasible to meet.  So no matter how desirable or important medical care is, it is not always available, and thus the right cannot always be exercised.  Clearly one does not have a right to medical treatment that is not available or possible or reasonable to receive.  One cannot expect a liver transplant if there are no voluntary donors available, if there are no surgeons available to perform it, or no adequate facilities available in order to perform it.

To the extent it is a political/governmental matter of how much resource to devote to providing medical training, equipment, and labor for any particular area, medical necessities will compete with other necessities for finite resources.  I do not wish to try to argue here for some order of economic prioritizing of necessities.  I do think an interdependent[3] society of relatively affluent means should rank making medical treatment (and other necessities) available for all above making available luxuries and conveniences, but in a free society, the social/governmental means for doing that should normally be ones of motivation and incentive (whether through moral/emotional/psychological exhortation and/or financial means) rather than through legal demands or requirements.   The main point though is that medical treatment is not normally necessarily the kind of right that takes resource and labor priority over all other rights in the way, say, that a war for self-defense against annihilation might.  The only time it might have such an economic or labor and resource allocation priority would be in the case of a seriously debilitating, disabling, or deadly, widespread epidemic or pandemic that puts everyone at risk.[4]

But the sociopolitical, economic issue of what services ought to be readily available is beyond the scope of this essay, and that is why I am limiting the major portion of it to the rights and obligations involved in readily or feasibly available medical services which could readily be performed if allowed, and if available health care providers are willing to perform them; services for which there are no economic or practical impediments, but at most only moral or personal ones.

Fourth, even if an act is wrong, people might still have a moral right to be the ones to determine whether to do it or not in those cases where autonomy is more important than consequences.  E.g., while one should not let a three year old determine whether it is safe to play near a busy street or best to go on a total ice cream diet, it may be preferable to let him/her wear his/her choice of outfits to preschool even if they may be somewhat embarrassing or foolish rather than to demand s/he wear what you want.  It may be better to allow children and others to make harmless errors than to control their every action.  It may be better for a society to be relatively free rather than to be a police state, even if a free society has a possibility of serious crime that a police state would prevent. 

Furthermore, governmental decisions are not always better than personal ones, and in some cases it might be better to allow any errors to be made by the person most directly related and/or affected by the decision, rather than by someone else, particularly someone in government or a hospital board who may not sufficiently appreciate the patient’s feelings and beliefs.  E.g., while it might be wrong or a mistake for a particular person to be removed from life-saving medical technology, it might be a morally preferable to allow the patient to decide in consultation with the physician rather than to require a court or legislature to decide such cases, particularly if the latter are as likely to make errors as the individual.  It is perhaps better that a person be a victim of his own mistakes than a victim of someone else’s.  The government might want to make sure that the physician, or a patient advocate, has some training to make, and to help patients make, morally reasonable decisions, or the government might require a reasonable methodology to try to insure truly knowledgeable and informed (not just formal) consent by the patient that includes all the relevant considerations s/he should take into account.  But beyond something like that, it is reasonable to believe that combined patient/physician autonomy is better than government regulation or control, unless it turns out to allow for a kind of abuse of patients that would be important for government to prevent.  If such an abuse were uncovered, government’s role would be to eliminate it without thereby taking control of the decision-making process itself.  I will say more about a reasonable decision-making process later.

The real questions are 1) what circumstances, if any, make it right for a patient to receive voluntary assistance from a health care provider in dying – whether it is a) the passive help of dying from the condition by removal of medical treatment or b) active assistance in dying from the application of a treatment that will hasten death, and 2) what circumstances, if any make it obligatory for an available health care provider to honor a patient’s request for such assistance.  Resources for this sort of thing are not usually a problem, since non-treatment requires relatively little cost or medical skill, and since actively assisting dying also requires relatively minimal cost or medical skill.

There are bad rationales given on both sides of these issues, and I wish to consider them first:

1) One is “playing God” when one helps someone die.  That is true, but irrelevant, since one is “playing God” by thwarting death or illness also, and in particular, one is “playing God” in the kind of cases under consideration by not helping someone die when they want to and instead forcing them to stay alive and have to suffer.  There is a great line in the movie Something the Lord Made, where a priest is arguing with the surgeon who is going to attempt the first open heart surgery, in this case on an infant.  The priest says the surgeon should leave the baby’s life in God’s hands and not tamper with it.  The surgeon, certain that the baby will die without medical intervention, says that although God may want to kill this child, he would prefer to save it.  In terms of being responsible for the outcome, one is playing God either way, since the option of what to do is within the power of the people making the choice.  The issue is not whether one should take the responsibility, since one has the responsibility already either way.  The issue is which option should one choose, not whether one should choose an option.  One does not eliminate a choice or responsibility by ignoring it or pretending it does not exist.

2) One should not hasten death because one should not intervene in the dying process.  That “begs the question” which is whether intervention is right or not in particular cases.  It doesn’t help to say “there should be no intervention because there should be no intervention”; that is just circular reasoning.  Moreover, it seems false or there would be no point in the practice of medicine at all.  Medicine is an intervention. The idea is to intervene, though normally it is to keep the patient alive.  But that is because it is normally considered that life is a good thing, if not only in itself, but as a means of being able to experience other good things such as joys and pleasure or insight and knowledge.  Unfortunately, medicine has reached a point where it seems there can be life without its being any good.  If so, medicine’s role in preserving life may have only been a special case of the general case of preserving the benefits of being alive.  When there are no such benefits, and when only harms exist, then the obligation to preserve life would no longer be in effect.  Also, medicine has ostensibly always had two roles: a) prolonging life and b) preventing suffering.  Unfortunately, in some cases those two roles conflict with each other because only death can alleviate certain kinds of suffering.  One must then decide which role has priority, and there is no obvious reason preserving life should be more important than alleviating suffering in all cases.  Clearly, under normal circumstances, alleviating suffering trumps hastening death; one doesn’t euthanize a patient for a case of intestinal flu that makes him wish he were dead.  But in certain end of life cases, the priority is not obvious.

3) Life is a miracle and an unqualified good.  Life does seem to be special and miraculous just in its complexity alone, but not to be an unqualified good.  Certainly we try to eradicate some viruses and bacteria or living things (e.g., cockroaches, rats, and rabid animals) that endanger human life.  But even human life is not an unqualified good, whether miraculous and special or not.  We do not create all the humans we could, particularly if we do not think we can give them and us an adequate quality of life.  If people could be indefinitely kept alive only by a means that allowed them to experience incessant pain and suffering and nothing else, I doubt many people would knowingly opt for that. A permanent living hell is not much better than hell in death.  Life is good as a means, not an end in itself.

4) A health care provider should not be forced to violate his/her conscience.  That is only true when one’s conscience is either correct or where the right act is not able to be adequately determined, and one of the possibly right options remaining is the one the health care provider’s conscience holds. We are trying to determine here what the conscientious decision ought to be, in order not to follow a “mistaken” conscience.

5) The patient should be able to decide what is best for him/her.  People do not always do what is in their own best interest.  They are not always right about what is in their own best interest.  They do not always act either rationally, wisely, or with full understanding of the consequences – even when they are able to state the consequences.  Sometimes temporary despondency creates mistaken priorities and choices, that one would realize and regret if given the opportunity to experience both options.  Unfortunately death is not a reversible option.  There are times that one should not make permanent choices to solve temporary problems.  Clearly teen suicide over a romance breakup is not legitimate grounds for suicide.  Neither is refusal of necessary treatment while in despair and pain from a bad automobile accident an autonomous choice that should be honored.  The decision to drive drunk should not be honored by those who can prevent it. 

In many cases, “mental competence” is the determining factor for honoring patient autonomy, but “mental competence” in general is not the right criterion; a mentally competent person can make a terrible decision in any particular case.  The question is whether the particular decision is fully informed and made rationally and without undue influence by temporary or blinding circumstances.  And the follow-up question is whether there can be a moral and practical feasible way to determine that.

6) The right to die with dignity.  Supposedly somehow dying by choice of time and method allows one to die with dignity, as exemplified in the comment by Justice James C. Nelson in a partly concurring opinion in the Montana Supreme Court in the above case (quoted in the same NY Times article): “This right to physician aid in dying quintessentially involves the inviolable right to human dignity — our most fragile right.”  I am presuming that the impetus behind this claim is the desire to avoid needing a significant amount of help in performing normal functions, particularly messy bodily functions, as the body (and sometimes the mind) deteriorates in a prolonged dying process.  I take this to be a form of emotional or mental suffering that is part of what one wants to avoid by dying, since it cannot be avoided otherwise at this stage of medical science.  Many people don’t want to be helpless (“don’t want to be a burden” as it is often put) or to be embarrassed by uncontrollable and/or unsightly physical symptoms and effects of their deterioration.  They don’t want to endure help with pressure sores, with breathing, with uncontrollable eliminations.  They don’t want to be poked and jammed with needles or tubes.  They don’t want to be dependent on machines to which they are hooked up.  They don’t want to be seen or “remembered” by loved ones in that state.

There are two replies to this, however: a) the acute sense of embarrassment and fear about that sort of death perhaps can be overcome without having to resort to death as the only remedy.  The dignity argument is not about the deterioration itself but about the fear and embarrassment or seemingly shameful loss of independence the deterioration and physical treatments for it causes.  So even if current medical practice cannot prevent the deterioration, there is no reason to believe the fear and embarrassment cannot be minimized or avoided.  And more importantly b) as a type of suffering that is desired to be avoided, the rebuttal I will give shortly to “the quality of life” argument will apply to this  argument as well.

7) The quality of life argument.  This is the claim that when life becomes painful or unhappy past a certain point, it is better to end it than to continue to suffer or to have to face and endure even worse suffering.  The suffering involved may be either physical pain or emotional pain, as in the embarrassment and distaste for being a burden in the above “death with dignity” argument.  This argument needs clarification, however, and it will not stand up as it is normally conceived upon such clarification.

There is a difference between pain and suffering, in that pain may cause suffering but need not.  One can ignore pain or at least not be so focused on it that it prevents one from doing things which are enjoyable in spite of the pain.  One can have pain without “suffering” from it other than in the sense of just having it.  “Yes, Mary is in a lot of pain but she doesn’t let it hold her back or get her down” is a typical way of expressing the difference between having pain and suffering from it.  As to suffering from indignity, many mothers have said after the experience of having babies that “once you’ve had a baby and experienced all the doctors, nurses, medical students, residents, etc. that see you and examine you you quit being embarrassed by some sort of sense of modesty about being seen naked that you had before.”  This is just one example of how embarrassment can disappear.  Another kind of case is where one gleefully tells others later about their most embarrassing moments – telling the stories with humor and without any embarrassment.  Many of these stories are about medical moments that were terribly embarrassing or scary at the time, sometimes even physically painful.  Sometimes the right word by a health care provider can even avoid the embarrassment and minimize the fear and to some extent even the pain.  When I went for a barium enema once, a young nurse or physician assistant or tech was in charge of my preparation.  Upon introducing herself, she said to me “For the next half hour, I am going to be your best, and most intimate friend.”  That immediately reduced all my anxiety because she defused the embarrassment and showed compassionate understanding.  One does not have to lose dignity just because one is in what seems like it will have to be a most undignified situation.

Furthermore, embarrassment and disdain are often arbitrary, culturally induced phenomena.  If a society venerated age in the way ours worships youth, it would not think any more badly of the infirmities of age than it does of the infirmities of infancy.  If we respected the accomplishments and wisdom in older people’s pasts as much as we anticipate the potential accomplishments in babies’ and toddlers’ futures, there would be no embarrassment or disdain for again needing help to live.

So rather than expressing the “quality of life” argument in terms of pain or loss of dignity or emotional/psychological embarrassment or discomfort, it should be stated in terms of suffering, since suffering is what we really want to avoid when possible.  But then the problem is that suffering by itself is hardly grounds for dying.  We suffer all the time without seeing the need to be euthanized or to commit suicide over it.  And most likely for most people, even people of significant financial means (some of whom commit suicide), if they had to add up the amount of time they spent suffering (or being unhappy or dissatisfied) versus the amount of time they spent happy, the balance would be staggering on the side of unhappiness and dissatisfaction.  Yet most people don’t want to kill themselves over that.  They don’t want to die because they have to fill out their taxes or pay them.  They don’t want to die because they have to go to some boring event with a spouse.  They don’t want to die because they have a cold or a backache.  They don’t want to die because they played a lousy round of golf and lost a bet.  They don’t want to die because their favorite team lost an important game.  They don’t seriously want to die (even if they are very depressed or sad) because they went through a bad divorce or breakup.  They don’t want to die because they have a long day at work that will be boring and then have to come home to do family chores that are not particularly interesting or exciting.  Even in mourning the loss of a dearly loved one, most people don’t seriously want to die immediately even though they may feel the loss very sadly and deeply.

There is, of course, a point at which suffering becomes so burdensome and so unbearable that death would be better, but it is not a matter of “quality” of life in the sense of relative quantity of happiness over misery or sorrow, or of having any unalloyed joy or happiness at all.  Life can be most hard and difficult and yet people can and usually do want to live in spite of that.  They may welcome death as a way of finally achieving peace, but yet not seek to hasten it – not just as the philosopher David Hume pointed out in his Dialogues Concerning Natural Religion because people fear death, but because they find that in spite of all their suffering, their lives are worthwhile to them.  There are things and moments they want to experience and find some sort of joy in anticipating and experiencing, even though temporary and not devoid of their other suffering.  It might be anything from wanting to live to see a grandchild born while one is dying a terrible death to wanting to figure out some problem that one has become focused on and perplexed by. 

It could be something as “trivial” as wanting to see whether one’s team wins a big game or as important as seeing one’s life work come to a kind of fruition or recognition one had always hoped for and sought.  It might be wanting to hold or to be embraced by a loved one or to have some meaningful conversation.  Even the end of life can have hopes and dreams and moments that make it worthwhile in spite of all the suffering one has to endure.  It is only when all that is finally lost and impossible to have restored or replaced or to achieve again, that life becomes not worth living, and dying may be a reasonable remedy for the suffering one would otherwise endure, but only if also one chooses to die under such circumstances.[5] 

It is, of course, murder to kill someone innocent who wants to live, even if s/he has nothing for which to live.  There are two criteria, on my view, for making it morally right to assist someone in hastening their death: 1) there must be nothing possible for which they would want to continue to live in the condition they will be (i.e., nothing that makes their living and suffering worthwhile), and 2) they want to hasten their death in the way and time the physician is to assist.

But that circumstance is far rarer than the ones usually described as lack of quality of life, which are normally those end of life circumstances where there is pain one is so focused on that despondency and hopelessness make one forget or ignore the possibility of looking forward to something worthwhile in a way that is not just verbally or conceptually understood but is felt in the emotions with anticipation and attention.  Many times we try to talk dying patients into having hope or telling them there are things yet for which to live, rather than fostering the desire for something that they can look forward to experiencing or concentrating their attention.  Arguing people into wanting to continue to live seldom works.  There are more emotional, psychological, and educational ways one has to foster attitudinal changes and give one something to anticipate[6]. There can be reason and desire to live for another day or a few more hours, just as there can be reason to live for fifty more years.  Yet we somehow feel that it is okay for a terminally ill person to hasten their death (with physician assistance) but know it is wrong for a teenager to commit suicide while despondent.  I think that is because we believe the teenager will still have time to find something that makes life worthwhile, but we mistakenly think that a despondent terminally ill person who is suffering cannot be helped to find something for which to live in the little time s/he has remaining.  In states and countries that allow physician assisted suicide, the patient’s condition must not only be terminal, but their natural death must be somewhat “reasonably” immediate.  That is, having only two years to live is not normally grounds for immediate physician assisted suicide.  Much of value can occur in those two years, even if a cure or treatment that will extend the time before death is not found.  But it seems to me that “time remaining” is not the relevant factor.  The relevant factor is whether it is possible or likely for the person to find (or be helped to find) something worth living for that makes up for all the suffering they have to endure – that somehow redeems their suffering.  That is what makes life valuable in general, and I see no reason it should be any different in the last few days than it is when one seemingly has all the time in the world.

With all the above as background, I now turn to the two questions: 1) Does a dying person have a moral right to hasten his/her own death? And 2) does a physician or other health care provider have a moral right or a moral obligation to assist a dying person who makes the request for medical assistance to hasten his/her death?

The first answer to the first question is that whether one should have the right or not is not as important as whether it is right for the person to exercise it in a particular case.  There are specific senses in which it might seem one does not have a right to suicide; for example, if one takes out an insurance policy that excludes payment of the death benefit for suicide (in the first year of the policy, for example), then one has no right to commit suicide in order to collect the death benefit.  But more precisely that means one does not have a right to have the death benefit paid if one commits suicide; and so one may still have the right to suicide.  Or if one wishes to commit suicide to abrogate some sort of legal agreement, there may legally and morally be no such right.  But again, more precisely put that just means one does not have the right to abrogate the agreement that way, not that one does not have the right to commit suicide. 

But I think a case can be made that if suicide is wrong in a particular case, then one does not have the right to commit it.  For example, if one is merely temporarily despondent, then others have a right to try to prevent it, and are not culpable for doing so.  Thus one does not have a right to commit suicide in such a case, for actual rights (as opposed to merely prima facie rights) cannot justifiably be violated by others.  If suicide were a right, it would be immoral for anyone to prevent a wrongful or mistaken suicide – which might be considered, for example, to be one that if not committed, the person was later glad s/he had not done. 

I believe the question of the right to commit suicide only arises in certain kinds of cases: those in which the suicide may be right because (if I am correct about all the above) 1) there is no possible way to make the suffering one has to face for the remainder of one’s life in any way worth having to experience; i.e.,  the suffering is not in any way redeemable, and 2) the patient wants to, and chooses to, hasten their death in the time and manner that is to be provided. 

The practical question then is whether and when the patient has the right to make that determination and thus to commit suicide. I think the patient should have the prima facie right, meaning that without some reason to the contrary that would either change the patient’s mind or clearly convince reasonable, compassionate, sensitive, knowledgeable, and understanding people the patient is mistaken and will feel differently later, the patient’s wishes should stand.  That means it cannot be a bureaucratic matter decided by either government or some sort of formal board somewhat removed from the patient and his/her condition and feelings.  And it cannot be a panel made up of people who do not understand that suffering can be endured for a greater purpose even in this earthly existence and who are thus, unfortunately, willing to terminate the life of anyone who is in pain or poor conditions.  Surveys show, for example, that even health care providers rank the quality of life of disabled patients far lower than the patients will eventually rank their own quality of life, and so even health care providers may sometimes be willing to discontinue life-saving treatment prematurely at the time of the injury when the patient is distraught and despondent.  Hastening death is a decision that requires knowledgeable, sensitive, impartial, unbiased judgment, and is not likely subject to formula or to panels or judges who simply have good intentions.

Suppose then there is a particular patient who has a right to hasten his/her death, and that has been duly and properly determined.  The question then is “does a physician or other health care provider have a moral right or a moral obligation to assist a dying person who makes the request for medical assistance to hasten his/her death?”

It seems to me that if the health care provider can hasten the death in the compassionate and relatively non-suffering way the patient desires, that s/he should have every right to do so, as should anyone who is asked to help do something that is right, in a manner that is right. I believe that normally it is wrong to restrict people from doing what is right.  But that is only true if the person assisting does not have a real prior, or overriding, obligation that would preclude him/her from assisting.  For example, I believe it is policy in the United States not to draft into military service a sole surviving child of parents who have lost their other children in military action.  I could be mistaken about that being a policy, but it is easy to imagine there could well be such a policy if there isn’t.  The reasons for it would be not to add further to the grief of parents who have already sacrificed (more than) their share of the conflict being waged, and also the utilitarian benefit of the surviving child’s being available to contribute to the parents’ financial and practical well-being and care.  If service in the military in this particular conflict is right, then it would still be wrong for the last child to be allowed to serve, if s/he has obligations to his/her family.

Or consider a much more trivial example of the same principle.  There are occasions in driving or in standing in a line where it might be right for another driver to seek to “cut in” without waiting his turn.  If you have time and can let him/her in front of you, that would typically be a right you would have.  However, it is not your right to do so if there are people behind you who have not consented to let the person cut into the line.

What I don’t think should count as a prior obligation is a mistaken or unreasonable agreement not to provide help in a case where someone needs assistance to do the right thing.  For example, suppose you promise to take your children to the zoo on a given day, and that it is right for them to go to the zoo.  But on the way there, the car in front of you gets into a horrific accident, and you are needed to help in a way that will be time-consuming (perhaps looking after children of the injured driver, or going with the injured person to the hospital, etc.) and prevent you from keeping the promise to take your children to the zoo.  I would argue that it is right for you to break the promise.  The promise was a prima facie obligation, and circumstances arose that overrode it.  If physicians took an oath not to hasten death, that should be regarded as merely a prima facie obligation that can be overridden by circumstances where death should be hastened, that may not have been recognized or considered at the time the oath was written or taken.

Now, some argue that if physicians take part in the activity of hastening death, it would undermine patient trust, and cause more harm overall than the amount of good that might be caused in a particular case of assisting a patient’s suicide.  I see no reason to think that particular reason will stand up because I think people understand that there are safeguards in place for it, and that they would have to request having their death hastened.  Moreover, people today do make out “living wills” stating their preferences – often asking not to be put/kept on extraordinary life-saving measures.  People also ask for DNR (do not resuscitate) orders.  And none of these people then fears being euthanized by their physician for a sore throat.  And in another instance that is somewhat similar, people trust veterinarians with their pets without fearing that the pet will be euthanized on the whim of the veterinarian, even though veterinarians do euthanize animals.  I do not believe this particular objection will stand scrutiny.

It is also held that doctors should do no harm, but that is not true for surgeons or for those who give injections of any sort that cause pain or medications that have unpleasant side-effects.  Some chemotherapy causes a great deal of harm, for example.  True, they are not doing (or they are at least trying to prevent) overall harm, but they are still doing harm, though for a good reason. If hastening death is the only way to alleviate non-redeemable suffering, and if alleviating such suffering is a right of the physician, then it is a case of utilitarianism where the means can justify the end in the same way that amputation or disfiguring surgery can be justified by the fact it saves or potentially saves the patient’s life.  Only in this case, this saves the patient from pointless terrible suffering rather than from dying.

If the above is correct, then health care providers will have a moral right to hasten the death of patients when such a death itself is right, unless there is some particular obligation a particular physician may have to the contrary, that will stand scrutiny.  But having the right to do something that is right does not mean one is obligated to do it.  For example, one has the right, if one is at the end of a long line, to let as many people as one wants cut in front of him or her.  But one has no obligation to let any of them in; and certainly one has no obligation to let all of them cut in, even if one has a full basket of groceries, and each of the people asking to cut in front of you only has one item.  One might be obligated to let in one or two people, if that, but not a large number.

Now it is my current view that if a health care provider is emotionally and/or morally disposed not to hasten any patient’s rightfully hastened death, s/he is under no obligation to assist in doing so, as long as, and only as long as, there are other means or persons available who are willing to assist the patient in the endeavor, and whose doing so will not abrogate other obligations they have to other patients or other people.  What I mean by that is that if Adamson is unwilling to assist patient suicide, but Smith is, Adamson is not obligated to help the patient hasten death as long as Smith can do it in a way that does not overburden Smith and does not detract from his other obligations, say to his other patients in terms of time spent on their cases or tending to their care.

But if no one else is available to help the patient hasten his/her death, then as long as Adamson is free to do it, Adamson has an obligation to the patient to help relieve his/her suffering in this way.  The reason for that is a population can support only so many health care providers, and one person’s being in a community first prevents others from being able to be there under normal circumstances.  This is true, for example of hospitals where communities grant what is essentially an area monopoly to a hospital in order to prevent competition that will divide up patients so thinly that all of the hospitals fail.  If a case can be made that patients have a legitimate expectation of medical care that is available and right for them to have, and one hospital’s or doctor’s being there at the time the patient needs that care means those who would have provided the care cannot be there, then that doctor or hospital, it seems to me, has an obligation to provide that care which their presence otherwise prevents being available to the patient.  In essence, it is wrong to refuse service one could provide if one is the reason the community does not have anyone else to perform the service.  Some careers are so important that it would be wrong for a professional to refuse service s/he could easily provide if his/her success is what is keeping others from being available to provide the service to the community.

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[1] I use the term “suicide” because it is the termination of a life that would otherwise last longer, even if only a little while longer; it is the hastening of death in some sense, and, as in the article quoted at the beginning, “physician assisted suicide” is the common phrase for this now.  Euthanasia would be another term, but the medical community that is opposed to hastening death does not consider that term any more neutral than suicide. It is not clear there is a neutral term for this. And many physicians still cling to the AMA distinction between passively allowing a patient to die by discontinuing extensive treatment and actively helping induce death by use of a treatment, even though that distinction cannot withstand scrutiny, and is like saying that letting a child run out onto a freeway by purposely letting go of his hand when you know he is headed that way is morally different from pushing him out onto the freeway.  Also, many health care providers argue, futilely, that giving drugs to alleviate pain, drugs which one knows will also hasten death, is somehow different morally from giving those same drugs in order to hasten death.  That would be like allowing as a justified defense in a murder trial  the defendant did not intend the victim to die when he threw him off the skyscraper roof, but just wanted him to have the thrill of freefall as in skydiving, even though it was known he would die because of it.  Whether a known effect of an act is “intended” or not, one is responsible for causing it.  “I didn’t mean to” is never a justification, and it is not even an excuse when you knew the consequence was inevitable.

[2] “Prima facie obligations” are ones that can be overridden, but only with good reason.  Without such a reason, the obligation is in force.  E.g., liberties do not grant license, and they can be justifiably socially, morally, or legally restricted when there is good reason to override the right – such as falsely yelling “fire” in a crowded theater, publicly slandering innocent people, or being rude and offensive, in the guise of “freedom of speech”.


[3] By “interdependent” society I mean one where each person’s work contributes to and depends on the work of others in a complex way that tends to be taken for granted but which shows up when economic or natural disasters occur that keep some people from being able to contribute to the economic system.  An interdependent society is different from something like a pioneer society where each person or family is relatively self-sufficient even if they trade with each other for convenience. I think a case can be made that we owe much more to others with whom we are interdependent or on whose labor we have depended and prospered than we owe to those with whom we do very little or nothing that affects each other.


[4] Whether rightly or wrongly, behaviorally preventable epidemics are not as universally accepted as requiring resource allocations to find cures or preventions for those who will not control their own behaviors and who thus put themselves at risk for the illness.

[5] This essay is about patient-requested, physician-assisted suicide, not medical mercy killing of a patient who has not previously, and cannot currently, make (known) the choice to die.

[6] Typically psychiatrists, psychologists, clergy, survivors (in case of serious disabling, injuries), and/or social workers are called in to try to get a patient to see they have more to live for.  While that may sometimes be effective, I think what is more likely needed is anyone who can understand how to see what might give that particular patient something to live for.  What one might find worthwhile to live for could be anything from a past love to a child to a pet to a whole new interest in some subject there would be reason to believe the patient would find stimulating.  It might be a challenging problem for the patient to think about and want to solve.  It could be a book or videos the patient might find interesting enough to want to read or watch and that might even be interesting enough to take notice off the pain or suffering.  It might be simply more understanding care-givers who just make the patient feel happier to be around. It might be pleasant music.  If nothing of any of that sort of thing is successful, then perhaps there really is no reason for the person to continue to be forced to live.