Introduction

Medical aid in dying is a controversial topic both in bioethics and medical ethics. It is an umbrella term for several practices including euthanasia and physician assisted suicide. Overall, this practice involves a wide range of methods a physician can use or be involved with to assist a willing patient with putting an end to their existence. Usually this decision is made on the grounds of unbearable suffering, but not necessarily so (Velleman 1999).

Aid in dying can be grouped under four cases:

First, during any instance of medical treatment patients can request that life saving treatment be discontinued, such as disconnecting ventilators. In the second case, patients can also request that no extraordinary means of life saving treatment be undertaken, for example objecting to resuscitation in the case of myocardial infarction. 

The above mentioned practices are legal in the US by virtue of patient autonomy and the fact that they involve extraordinary measures. There is also an implicit rationale that either of these measures merely lets nature take its course, thus the patient succumbs from their ailment not from the physician’s doing. Both of these cases fall under passive euthanasia. (Thomson 1999; Brassington 202; Hartogh 2017)

The third and fourth cases are more controversial. In the former, physicians prescribe patients with a dose of medication which they know to be lethal. The patient can later purchase the drug and elect to take it when they decide it is time for them to put an end to their days. This example properly falls under instances of physician assisted suicide or physician aid in dying (PAD). In this case the physician’s role is to assert of the person’s intentions, their ability to make an informed decision, and write the safe but fatal prescription.

Physician assisted suicide is currently illegal in the US, with the exception of the states of Oregon, Washington, California, Montana, Colorado, Vermont, New Jersey, Hawai’i, and the District of Columbia. (Dudgal et al 2019)

In the latter and most controversial case, it is the physician who directly intervenes and injects the patient with a lethal drug in order to induce death. This form of active euthanasia is illegal and criminalized in the US, however it is permitted in Canada, Colombia, the Netherlands, Belgium, Luxembourg and Switzerland. (Hartogh 2017; Dudgale et al 2019)

Proponents and opponents of aid in dying often disagree on where to draw the line. (Jansen et al 2019) The most liberal proponents favor allowing all forms of aid in dying, including active euthanasia, while more conservative ones may only show support for physician assisted death.

The main arguments in favor of aid in dying appeal to individual rights, autonomy, and self-determination, suffering, and the safety of medically underseen practices. (Holm 2015; Campbell 2015; Dudgale et al 2019)

Concerns and challenges to legalizing all forms of aid in dying include the social phenomenon of suicide contagion, issues with conscientious objection from physicians, the role and nature of the physician-patient relationship, the lack of adequate care at the end of life, and slippery slope risks for vulnerable populations such as the elderly and persons living with physical and mental disability (Campbell 2015; Dudgale et al 201; Kious and Batin 2019; Sulmasy et al 2017; Math and Chaturvedi 2012; Breitbart 2012).

Additional considerations for advocates on either side of this debate include the moral distinction between killing, in active euthanasia, and letting die, in passive euthanasia; however others have denied the moral weight of this distinction (Rachels 1975; Thompson 1999). 

Another point of contention lies in the applicability of the principle of double effect to cases of euthanasia and the nature of the physician’s involvement and intentions. (Thompson 1999; Begley 1998; Johnson 2002; Brown 2015)

Finally, it is important to note that concerns both pro and against aid in dying range widely from religious beliefs and conscientious dilemmas, to ethics, and public policy applications. 

Assigned Readings

The following papers were used to inform and ground the discussion:

Rachels, J. (1975). Active and Passive Euthanasia. New England Journal of Medicine. 292, 78-80. DOI: 10.1056/NEJM197501092920206

Thesis: Rachels challenges the conventional distinction between active and passive euthanasia by elaborating that there is no real moral difference between killing in itself (not to conflate with actual cases of killing) and letting die since the outcome and intent are the same.

Thomson, J. J. (1999). Physician‐Assisted Suicide: Two Moral Arguments. Ethics, 109(3), 497–518. https://doi.org/10.1086/233919

Thesis: Thomson challenges two arguments that divide opinions on physician assisted suicide and euthanasia. Her paper argues against the moral difference between killing and letting die and rejects consequential appeals to the Principle of Double Effect and distinctions in doctor’s intentions.

Velleman, J. D. (1999). A Right of Self‐Termination? Ethics, 109(3), 606–628. https://doi.org/10.1086/233924

Thesis:  Velleman rejects the principle that persons have rights to self-determination based on sole ground of benefits to obtain and harms to avoid. He appeals to the inherent value of persons and challenges the conventional focus of self-determination in favor of dignity to derive adequate practices of respect for persons.

Reflection Questions

  1. Rachels argues that in cases of active and passive euthanasia, the outcomes are the same (i.e. to die) and the intents are the same (i.e. to stop suffering), so there is no distinction between the two. How convincing is his view?
  2. Thinking about killing v.s. letting die and active v.s. passive euthanasia, is there morally preferable action? How to compare? Is there a morally relevant distinction or is it just a cultural difference, considering different practices in different countries?
  3.  What is the moral relevance of when and where you adopt either active or passive euthanasia? Is there any?
  4. Key considerations are consistency in thought and public trust. A useful analogy: hiring a hitman is not acceptable but killing oneself is, in some circumstances, acceptable.
  5. According to Velleman, only “consideration of dignity” counts in thinking whether one has the right to end one’s life. But what does “consideration of dignity” exactly mean? Why can’t avoiding pain be incorporated in the “consideration of dignity”? In other words, “consideration of dignity” can be, in practice, used as an umbrella term that encompasses a bunch of concerns a patient might have.
  6. In reality, it’s hard to disentangle self-determination (such as concern for dignity) and self-interest (such as avoiding pain). One possibility for a Kantian to make the distinction is that if the pain disables you think it is acceptable to choose to die as concern for dignity.
  7. Given the fact that Kantian dignity is based on personhood, how should we understand the “dignity” of those whose “personhood” is compromised (e.g. people with dementia)?
  8. How about minimally conscious patients? Their family often insists that they still have dignity and that their dignity is not diminished by their minimally conscious state. What conception of “dignity” is operating here?
  9. Does it really make sense to say “respecting dignity in me”? This way of understanding dignity seems paradoxical: how can something that is “in me” but seem “external” to me by demanding me to act in a certain way?
  10. Does the concern for dignity distract us from consideration of suffering? No, because consideration of suffering is encompassed by respecting dignity.

References and Additional Resources

Brassington I. (2020). What passive euthanasia is. BMC medical ethics, 21(1), 41. https://doi.org/10.1186/s12910-020-00481-7

Dugdale, L. S., Lerner, B. H., & Callahan, D. (2019). Pros and Cons of Physician Aid in Dying. The Yale journal of biology and medicine, 92(4), 747–750.

Jansen, L. A., Wall, S., & Miller, F. G. (2019). Drawing the line on physician-assisted death. Journal of medical ethics, 45(3), 190–197. https://doi.org/10.1136/medethics-2018-105003

Holm S. (2015). The debate about physician assistance in dying: 40 years of unrivalled progress in medical ethics?. Journal of medical ethics, 41(1), 40–43. https://doi.org/10.1136/medethics-2014-102288

Snyder Sulmasy, L., Mueller, P. S., & Ethics, Professionalism and Human Rights Committee of the American College of Physicians (2017). Ethics and the Legalization of Physician-Assisted Suicide: An American College of Physicians Position Paper. Annals of internal medicine, 167(8), 576–578. https://doi.org/10.7326/M17-0938

den Hartogh G. (2017). Two kinds of physician-assisted death. Bioethics, 31(9), 666–673. https://doi.org/10.1111/bioe.12371