Medical Mogul: Assisted Suicide

Recently in British news, and across the world, the argument over whether terminally ill patients are allowed to request assisted suicide, that is the administering of drugs to end their own life. This has been supported by Lord Falconer’s bill which proposes that doctors should be allowed to prescribe a dose of medicine that will end a terminally ill person’s life (a person who is judged by two clinicians to have less than six months to live). The debate occurs in government tomorrow and more than 130 peers have put their name down to speak. I apologise for the length of this post but the arguments are complex and depend on many things. Skip to the section you want to read.

Schools of Thought

This raises the question: how should we decide on matters of life such as this? I will briefly here consider two schools of ethical thought, although there are many others, skip this and the next paragraph if you wish to hear the main issues involved in the debate. Utilitarianism is the belief that we should do whatever brings the widest good and the smallest harm. This considers the intensity of pain and how long the pain lasts. This pain is not only direct pain but also includes a loss of dignity (described as “purity”). The number of people influenced by an action is then considered and the richness of a life is considered i.e. whether an individual life would lead to other pleasures. Finally, universalism considers the certainty that a cure will be found in time. When we consider this school of thought we can address the issue of assisted suicide (effectively active euthanasia) in a systematic way. First the pain. The pain may be great and may last for significant amount of time as a terminally ill person may not be able to control their body and may suffer as a result, this suffering may then be prolonged as their death may be gradual and may be characterised by the gradual shut down of organs. Thus, in contrast, assisted suicide would lead to “pain” in the fact that the body is directly dying yet wouldn’t offer physical pain that could be monitored by the patient, this “pain” is also quicker. Furthermore, dignity may be dramatically reduced if a terminally ill person is kept alive against their wishes, this is because they may not be able to perform basic tasks. Alternatively, assisted suicide could also reduce dignity because it is viewed by some to be “admitting defeat” therefore by committing suicide of any kind it is a rejection of your identity as a human and so may undermine dignity. Furthermore, the extent of introducing active euthanasia for the terminally ill would be undoubtedly great and whether this is beneficial is based on opinions I will discuss later. Finally the richness of life, this is difficult as it is very subjective and does depend on the type of illness and the influence it has over life. For example, an athlete who develops MND will lose control of his body and so this may be viewed as a great loss so the richness of his life, because he gained pleasure from training, would be greatly reduced. In comparison, Stephen Hawking is a scientist and so developing motor neuron disease didn’t affect his ability to ‘write’ books and continue his career so his pleasure was preserved.

Another school of thought is virtue ethics which was developed by Aristotle who believed that the effect on the individual character is more important than the action itself. Thus we should aim for eudaimonia (a type of life that results from perfect balance). This is a form of happiness that is based on patience, temperance and courage which are developed so that we can be happy and so is not in the interest of others. Thus this school of thought doesn’t consider the “extent” as utilitarianism does, but instead looks at the extent as merely a collection of individuals. This school of thought would argue that people suffering from terminal illnesses cannot be ‘happy’ (although this is clearly controversial) and that people should strive to preserve the values of a eudaimonian life. This may mean for example taking courage to end your life, or to have the patience to deal will illness and not resort to assisted suicide. This depends on interpretation.

In Support of Assisted Suicide

Now we come to the main issues and we will first consider the arguments for assisted suicide for the terminally ill. Some people argue that it is a human right to die and that because illness takes away the autonomy of the individual then death is the only autonomous decision left. This argument is particularly supported in that clinical guidelines advise clinicians to act in the interests of the patient and to appreciate each patient’s individual needs. This means that if a patient says they want to die, then this should be respected as opposed to being ignored and forcing the patient into schemes which clearly oppose what the patient wants. For example, a patient suffering from a terminal illness may state they want to die, in response a doctor, under current legalisation, couldn’t offer euthanasia and instead may deal with the problem by increasing support to the patient through nurses and hospices. This, although helping to alleviate the complaints of the patient is acting in precise opposition to what they originally wanted. This creates the image that the healthcare profession is disrespecting to patients and so this may humiliate and frustrate patients. In addition, supporters of the bill may argue that allowing the terminally ill to ask for assisted suicide is the most loving and compassionate response. This was presented by Lord Falconer who stated that his bill would lead to “less suffering not more deaths”.

This would also be viewed as more considerate as Stephen Hawking described current laws preventing the disabled asking for assisted suiced as “discrimination against the disabled to deny them the right to kill themselves that able bodied people have”. This is a particularly strong argument as it suggests that death is an individual choice and thus is a private matter that the individual takes responsibility for. Therefore this implies that only the sufferer can decide and so acting on behalf of the disabled to preserve their life when they do not want it, may be wrong because it undermines their equality and humanity. Furthermore, this argument draws on the inconsistency within society that people are legally able to commit suicide yet those who cannot move for example, do not have access to this law. Thus this discredits arguments against the bill which state that assisted suicide could lead to people being pressured into assisted suicide. This is because, arguably, people are already being restricted in their choice to be able to commit suicide. However, we cannot call this “discrimination” as discrimination is acting on prejudice and so because prejudice isn’t being used (indeed, it is attempting to act in the best interest of the terminally ill) then it is not discrimination. Instead, it is an issue of consent and practicality.

Finally, some believe that assisted suicide should be allowed as the end (the relief of suffering) is more important than the means (helping someone to die). Therefore this is based on situation ethics which argues that certain actions are only justified in certain circumstances which are based on personal judgement. Therefore the benefit and damage of the respective end and means depends on a variety of influences. Hence, because situation ethics is very personal then it is very subjective and so cannot be analysed fully.

Against Assisted Suicide

In regards to the views against the bill and assisted suicide the main argument is that it could lead to pressure from family for a person to commit suicide so that the choice doesn’t represent the individual’s personal wishes. This leads to the possibility of coercion and so this undermines the value of the individual and instead makes life disposable and discredits the value of life which is the basis of society (e.g. doctors always help to preserve life, fire fighters do not see the burn marks on a person and think “I’ll leave him to die in the fire” because of them). This view has been mainly presented by Tanni Grey-Thompson who stated that 61% of people in Washington State choose assisted suicide because of family pressure. Thus laws should protect public safety. There are many issues with this argument. Firstly, this figure is likely to be unreliable as for the figure to be true, people committing assisted suicide, quite obviously, would have to be living. Therefore the fact that many living people are saying that they are being forced into death without even identification by a consultant seems quite unlikely. Furthermore, another way of viewing the statistic, although more controversial and robotic, is that because people are choosing death because their family wants them to (and then reporting this, seemingly uncaringly to the media) indicates a lack of self-value: the “I may as well” argument. This is a much more risky argument as I don’t know whether the 61% of people were crying out for help or simply regarding it as a factor in their decision. Adding to this, however, there may be pressure from the NHS and assisted suicide risks clinic as viewing patients as potential costs. This is much easier to argue against as doctors are unlikely to suddenly abandon their duty of care and begin viewing patients as merely costs. Furthermore, as the patient has become more empowered in recent years with the formation of regulation and stricter guidelines, doctors may become even more cautious when dealing with active euthanasia as they would be worried about complaints. Hence, the seemingly reckless attitude implied by this argument is very unrealistic. Furthermore, as many people have said, there will be regulations and controls in place to prevent this pressure and so this will mean that any exaggerated pressure from doctors would be even further reduced as two doctors would be needed to verify it. Some here may argue that so is the case with abortion and yet we have widespread abortion anyway. To this statement I would say that in the issue of assisted suicide we would be dealing with clear and tangible lives, as opposed to the life of a foetus which is disputed. In this case no-one can dispute that a person is living and so the regulation would be tighter than abortion.

Another argument is that assisted suicide promotes a risk to the development of palliative (pain-relieving) care as less people use palliative care and so development slows. This again can be easily contradicted by splitting the argument into a list of points (P1-4) and a conclusion:

P1: More people choose euthanasia

P2: Less people depend on palliative care

P3: Less people needing care slows the rate of research

P4: Less research means less palliative care

Conclusion: Introducing euthanasia means less palliative care.

First let me address P2. This is not a sound point as due to a growing population the number of people requiring palliative care may grow. This is further amplified when only those who have a reasonable chance of death in 6 months would be able to claim assisted suicide and even then many still would not. Furthermore, many people choosing euthanasia may have previously depended on palliative care e.g. a person due to die in 12 months may go to a hospice for 6 months and then choose assisted suicide. This would mean that the same if not more people will depend on palliative care in the future. Points 3 and 4 are also not sound as palliative care is a growing area of medicine and a number of hospices are already established – they are unlikely to suddenly close. Adding to this in 2014 “there are 230 nurses specially trained in 82 districts. They are supplemented by clinical officers and even doctors to deliver Palliative care at the 131 facilities that are accredited. We also have 12 stand-alone health centre providing Palliative services” according to Ms Kiwanuka, minister of finance in Uganda. This is compared to the 120 specially trained nurses in 2011 in Uganda. Also, points 3 and 4 confuse the rate of improvement with improvement itself. Although, the rate of improvement may slow, improvement will undoubtedly continue as although research may be scarcer, offering patients the choice will lead to palliative care becoming more willing to offer leading support and care to patients to encourage them to continue living. It will become a ‘competition’.

Finally, some people who are against the bill state that doctors may simply estimate wrongly, an example of which is seen in Stephen Hawking. This, however, is rare and could be tackled by a system which allows patients to make the decision and then doctors affirming it. For example, a patient suffering from a terminal illness may state to a doctor that they would like to die, the doctor could then review the patient and if it is found that they could die in 6 months then assisted suicide could take place so that the patient is not influence by the diagnosis and instead makes the choice based on how they are feeling. In contrast a patient who enjoys life may never mention assisted suicide and so the doctor would not tell them how long they have left. This clearly is dishonest and undermines the right of the individual to information and so this method would have to be modified further.

My Verdict

Overall the issues are complex and depends on whether you believes that we all need rules and certain actions are always wrong or whether it depends and must be resolved by looking to the individual. In discussing the issues above, I believe that people should have the choice to die and assisted suicide should be allowed for the terminally ill but this is my opinion. Regardless of your viewpoint however it is clear that if assisted suicide is allowed, it would make doctors’ jobs a whole lot harder and would intensify the debate even more. If you want to give your opinion, I have created a survey in the top right.