Abstract
This paper aims to refute a common line of argument that it is immoral for physicians to engage in medical assistance in death (MAiD), i.e., the practices of euthanasia and physician-assisted suicide. The argument in question is based on the notion that participating in MAiD is contrary to the professional-role obligations of physicians, due to MAiD’s putative inconsistency with the ends of medicine. The paper describes several major flaws from which that argument suffers.
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Notes
It is worth noting that if terminal sedation indeed counts as a form of MAiD, then any arguments against MAiD per se will have to contend with the fact that terminal sedation is widely accepted as an ethical practice. And those who wish to argue only against physician-assisted suicide and euthanasia (and not against terminal sedation) will, on pain of inconsistency, be unable to base their position on the premise that such practices are instances of MAiD. That is a key reason why those opposed to physician-assisted suicide and euthanasia, especially for the reasons to be discussed in this paper, would be well-suited not to construe terminal sedation as a form of MAiD.
There can be legitimate debate about how “contrary” functions in this argument. For purposes here, the following characterization will do: an act X is contrary to an end E if, and only if, doing X makes it less likely that E is achieved.
Of course, in one sense all professions are “socially constructed”, in that they would not exist but for the societies that value and support them. We should distinguish between social construction as determining the existence of a thing, and social construction as determining the existence conditions of a thing. It should be relatively uncontroversial that the practice of medicine, as any profession, requires social-institutional support in order to exist. But on the essentialist view of the ends of medicine in question, the criteria for what counts as practicing medicine are not socially constructed—society does not determine those criteria, even if it gets to decide whether the practice of medicine, as a profession, is instantiated. In other words, if society “constructs” the practice of medicine existentially, then it can only do so in a certain way substantively, due to the essential nature of the practice itself.
To be sure, Pellegrino believes that MAiD does not serve the patient’s good because he believes that there are almost always more beneficial alternatives, including proper palliative care (Pellegrino 1992, 1998, 2001b). Thus, he concludes that “[w]ith the optimum and judicious use of those [palliative] measures, there are virtually no patients whose pain cannot be relieved” and that we can relieve that pain “without rendering the patient unconscious” (Pellegrino 1998, 73). This is at best an extremely contentious view. Indeed, given what we know about intractable pain and suffering at end-of-life, for some patients the only comparably beneficial alternative to MAiD is terminal sedation, viz. medicating patients into unconsciousness and allowing them to die either of their underlying illness or of dehydration (Cassell and Rich 2010; National Ethics Committee, Veterans Health Administration 2006). And it is dubious that that option would always be more beneficial to a patient than would MAiD (hence, presumably, Pellegrino’s desire to avoid relying on such an option). Moreover, Pellegrino seems to admit that palliative care will be insufficient in some cases, even if they are rare; thus, it would be difficult for him to deny that MAiD can serve the patient’s good (Seay 2005).
Ends of medicine that incorporate additional moral values, such as respect for patient autonomy or fairness, are also plausible. Perhaps the best way of understanding medical practice is that such a profession aims to promote well-being and respect autonomy (or: achieve the morally right balance of those values) through certain biologically efficacious techniques—techniques that are especially and primarily suited to healing (including prevention and care of illness and injury) but need not be. This view is expansive enough to allow for the practice of medicine to exist outside of an explicit “healing relationship”—consider, again, cosmetic surgery and sports medicine—and permits non-health-related well-being to be the target of medical practice insofar as the general techniques in question are those that are “especially and primarily” suited for promoting health. Additionally, including respect for autonomy separately within the ends of medicine is better able to account for cases in which patients’ choices are clearly not in their best interests yet should be honored in any case—without that addition, one would have to claim, contentiously, that any autonomous choice necessarily promotes one’s overall well-being. Finally, it is plausible that a “fairness qualifier” could be incorporated here, such that the practice of medicine aims to fairly or equitably accomplish its well-being- and autonomy-related goals. I thank an anonymous reviewer for raising these issues and for suggesting an “equity” addition to the ends of medicine.
References
American Medical Association. 2016. Chapter 5: opinions on caring for patients at the end of life. Code of medical ethics. https://www.ama-assn.org/system/files/2019-06/code-of-medical-ethics-chapter-5.pdf. Accessed September 24, 2022.
Baumrin, B. 1998. Physician, stay thy hand! In Physician-assisted suicide: Expanding the debate, edited by M.P. Battin, R. Rhodes, and A. Silvers, 177–181. New York: Routledge.
Blackman, R. 2015. Meta-ethical realism with good of a kind. European Journal of Philosophy 23(2): 273–292.
Brenan, M. 2018. Americans’ strong support for euthanasia persists. https://news.gallup.com/poll/235145/americans-strong-support-euthanasia-persists.aspx. Accessed September 24, 2022.
Brock, D.W. 1992. Voluntary active euthanasia. The Hastings Center Report 22(2): 10–22.
Cassell, E.J., and B.A. Rich. 2010. Intractable end-of-life suffering and the ethics of palliative sedation. Pain Medicine 11(3): 435–438.
National Ethics Committee, Veterans Health Administration. 2006. The ethics of palliative sedation as a therapy of last resort. American Journal of Hospice and Palliative Care 23(6): 483–491.
De Lima, L., R. Woodruff, K. Pettus, et al. 2017. International Association for Hospice and Palliative Care position statement: Euthanasia and physician-assisted suicide. Journal of Palliative Medicine 20(1): 8–14.
Ganzini, L., H.D. Nelson, M.A. Lee, D.F. Kraemer, T.A. Schmidt, and M.A. Delorit. 2001. Oregon physicians’ attitudes about and experiences with end-of-life care since passage of the Oregon Death with Dignity Act. JAMA 285(18): 2363–2369.
Geach, P.T. 1956. Good and evil. Analysis 17(2): 32–42.
Hall, M., F. Trachtenberg, and E. Dugan. 2005. The impact on patient trust of legalizing physician aid in dying. Journal of Medical Ethics 31(2): 693–697.
IPSOS/The Economist. 2015. Public attitudes to assisted dying. https://www.ipsos.com/en-uk/public-attitudes-assisted-dying. Accessed May 12, 2023.
Kass, L.R. 1975. Regarding the end of medicine and the pursuit of health. The Public Interest 40: 11–42.
———. 1985. Toward a more natural science: Biology and human affairs. New York: The Free Press.
———. 1989. Neither for love nor money: Why doctors must not kill. The Public Interest 94: 25–46.
MacIntyre, A. 2007. After virtue: A study in moral theory, 3rd ed. Notre Dame: University of Notre Dame Press.
Marcus, R.B. 1980. Moral dilemmas and consistency. The Journal of Philosophy 77(3): 121–136.
Miller, F. G, and H. Brody. 2001. The internal morality of medicine: An evolutionary perspective. The Journal of Medicine and Philosophy 26(6): 581–599.
Momeyer, R. 1995. Does physician assisted suicide violate the integrity of medicine? The Journal of Medicine and Philosophy 20(1): 13–24.
Pellegrino, E.D. 1992. Doctors must not kill. The Journal of Clinical Ethics 3(2): 95–102.
———. 1998. The false promise of beneficent killing. In Regulating how we die: The ethical, medical, and legal issues surrounding physician-assisted suicide, edited by L.L. Emanuel, 71–91. Cambridge: Harvard University Press.
———. 1999. The goals and ends of medicine: How are they to be defined? In The goals of medicine: The forgotten issues in health care reform, edited by M.J. Hanson and D. Callahan, 55–68. Washington DC: Georgetown University Press.
———. 2001a. The internal morality of clinical medicine: A paradigm for the ethics of the helping and healing professions. The Journal of Medicine and Philosophy 26(6): 559–579.
———. 2001b. Physician-assisted suicide and euthanasia: Rebuttals of rebuttals—the moral prohibition remains. The Journal of Medicine and Philosophy 26(1): 93–100.
Pellegrino, E.D., and D.C. Thomasma. 1988. For the patient’s good: The restoration of beneficence in health care. New York: Oxford University Press.
Populus/Yonder Consulting. 2015. Dignity in dying poll. https://yonderconsulting.com/poll-archive/dignity-in-dying.pdf. Accessed September 25, 2022.
Rachels, J. 1975. Active and passive euthanasia. The New England Journal of Medicine 292(2): 78–80.
Radbruch, L., C. Leget, P. Bahr, et al. 2016. Euthanasia and physician-assisted suicide: A white paper from the European Association for Palliative Care. Palliative Medicine 30(2): 104–116.
Seay, G. 2001. Do physicians have an inviolable duty not to kill? The Journal of Medicine and Philosophy, 26(1): 75–91.
———. 2005. Euthanasia and physicians’ moral duties. The Journal of Medicine and Philosophy 30(5): 517–533.
Sulmasy, L.S., and P.S. Mueller. 2017. Ethics and the legalization of physician-assisted suicide: An American College of Physicians position paper. Annals of Internal Medicine 167(8): 576–578.
Sulmasy, D.P., I. Finlay, F. Fitzgerald, K. Foley, R. Payne, and M. Siegler. 2018. Physician-assisted suicide: Why neutrality by organized medicine is neither neutral nor appropriate. Journal of General Internal Medicine 33(8): 1394–1399.
Urmson, J.O. 1968. The emotive theory of ethics. London: Hutchinson.
Woollard, F., and F. Howard-Snyder. 2021. Doing vs. allowing harm. Stanford Encyclopedia of Philosophy https://plato.stanford.edu/entries/doing-allowing/. Accessed September 25, 2022.
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Partial funding for this project was received through Duquesne University’s Presidential Scholarship Award.
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Vogelstein, E. Medically Assisted Death and the Ends of Medicine. Bioethical Inquiry (2023). https://doi.org/10.1007/s11673-023-10288-x
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DOI: https://doi.org/10.1007/s11673-023-10288-x