V.

Ethical Issues

The fundamental ethical issue regarding assisted suicide is whether acts by physicians that help others kill themselves (or let others die) can be morally justified, not whether these acts should be legalized. Those who believe assisted suicide is morally prohibited maintain that it is impermissible for a doctor to kill a patient and that a defensible distinction exists between killing a person and letting a person die. However, this distinction has proved difficult to define and explain precisely. Those who support assisted suicide maintain that any distinction between killing a person and letting a person die that may exist is actually irrelevant to the question of whether assisted suicide can be justified. Advocates of assisted suicide note that it is generally agreed that killing is justified under some conditions—for example, in cases of self-defense. Therefore, they argue, correctly applying the label “killing” or the label “letting die” to a set of events does not, by itself, indicate whether an action is acceptable or unacceptable. Instead, supporters argue, rightness and wrongness depend on the justification underlying the action.

Medical ethicists agree that physicians may forgo treatment when a patient or the patient’s authorized representative refuses treatment. Thus, valid refusals justify physicians to “allow” a patient to die when the patient could be kept alive with treatment. Supporters of assisted suicide believe that some acts of assisting in bringing about death can be framed similarly to refusals of treatment. Such actions could then, in principle, be justified by a request of the patient. They contend that a patient’s request for a fatal medication is analogous to a patient’s refusal of life-sustaining medication. However, the traditional view in professional medical ethics is that a request for assistance in dying by a competent patient does not have the same authority and obligatory force in law and morality that a valid refusal of treatment has. Therefore, such a request does not justify an action of physician-assisted suicide.

Major medical professional organizations—including the American Medical Association (AMA) and the Canadian Medical Association (CMA)—maintain that physician-assisted suicide is not justified by a patient’s request under any circumstance. However, this conclusion is controversial. Others believe that whether physicians are either morally permitted or morally required to honor requests for direct assistance that will lead to death depends on the nature of the request and the nature of the patient-physician relationship.

One of the most critical issues underlying the question of justified killing in medicine is whether the act of assisting persons in bringing about their deaths causes them a loss or, rather, provides a benefit. If a person chooses death and sees that event as a personal benefit, then helping that person bring about death may neither harm nor wrong the person and may provide a benefit or at least fulfill the person’s last important goal. On the one hand, avoidance of intentionally causing the death of patients is a deep and primitive restraint encouraged by many reservations that society has long had about killing innocent persons. To change this perspective would seem to be sweeping and dangerous. Opponents of assisted suicide fear that doctors will become less committed to saving lives, that families may respond to financial pressures by subtly encouraging suicide, and that limitations in the resources of the healthcare system might dictate decisions of life and death. On the other hand, some people question whether physicians should be restricted by law and morality if they may benefit patients in ways other than just by healing and providing noncurative pain relief. See also Medical Ethics.