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The Slippery Slope of Legalization of Physician-Assisted Suicide
The American College of Physicians (ACP) positionpaper on the legalization of physician-assisted sui- cide reaffirms the ACP’s opposition to this practice, even though it is now legal in several countries and U.S. jurisdictions (1). The ACP’s position deserves credit for its clarity and courage.
Among other achievements, the ACP paper identi- fies “euthanasia” and “medical assistance in dying” as euphemisms. These terms do what euphemisms are supposed to do: make a distasteful subject palatable, or at least discussable. The social process of change in ethical and moral standards makes bold use of such euphemisms. At one time, “mercy killing” and physician-assisted suicide were both illegal and un- thinkable. However, times are changing, and the changes have followed a recognizable pattern (2). First, the unthinkable becomes discussable although highly controversial. After a while, it is seen as acceptable un- der certain circumstances. As it becomes more familiar, it seems increasingly sensible and reasonable. Finally, it is established as a legal right. In this way, what was once unthinkable can eventually become policy, or even a duty (3).
Space limitations permit only a brief consideration here of arguments for and against medically assisted suicide. The argument in favor that is based on “non- abandonment” ignores a conscientious physician’s commitment to relieve suffering and to accompany sick and dying patients to the very end. We all should provide “medical assistance in dying” and not abandon our suffering patients. This argument also tends to stig- matize those who object to suicide as a solution to suffering.
The “slippery-slope” objection to medical suicide and euthanasia may be dismissed as alarmist, but it is not easily refuted. Euthanasia was legalized in the Neth- erlands in 2002, with multiple safeguards against abuse. However, in 2015, the Dutch government re- ported that hundreds of persons were put to death without their express consent or because of psychiatric illness, dementia, or just “old age” (4). In addition, the Groningen protocol has legalized infanticide in the Netherlands. In view of these developments, it is laud- able that Oregon, Canada, and other jurisdictions have built safeguards into their end-of-life legislation. How- ever, a slope still exists, and it may be fairly steep.
The argument based on intractable suffering ap- peals to a physician’s sense of empathy. However, if hard cases make bad law, they also may produce un- wise medical policies, and the argument surely greases the slippery slope. If intractable physical suffering is a justification for actively ending life, why should intracta- ble existential angst, a severe sense of personal alien- ation, or the helplessness and hopelessness of severe depression not be as well?
The principle of patient autonomy seems the weightiest of the arguments in favor of medical eutha- nasia or suicide, and with good reason. It alone of the 4 pillars of medical ethics can survive Western society’s transition toward a post-Christian antinomianism. Be- neficence would now be defined as whatever the pa- tient believes to be helpful. Nonmaleficence and justice would be whatever the patient says they are, absent external standards. Autonomy alone would stand unas- sailed and, by default, carry the day. Who is to say that what I want for myself is the wrong thing?
A person might say it is wrong if he or she recog- nizes an objective moral standard, namely that human life has intrinsic worth and dignity and that its value extends beyond the individual to the community. This might be true even if its owner doesn’t recognize it for a time or if others believe that one’s life is “not worth living.” Some hold that this moral standard (along with many others) can be known from nature or discovered by reason. Others reach it intuitively or find it in revela- tion, still others in all of the above. Of course, in a plu- ralistic society, not everyone believes in or will agree on objective moral standards, or which one prevails when they seem to conflict.
One may reply that the dignity and worth of human life are not absolute values. For example, it is recog- nized that some life-prolonging treatments are dispro- portionate or even futile. However, as the ACP position paper points out, neither is patient autonomy an abso- lute value. We do not always give patients whatever they ask for: A futile treatment? No. An illegal prescrip- tion? No. We therefore find ourselves weighing differ- ent considerations with regard to assisted suicide. Many will give considerable weight to the presumption that human life is intrinsically valuable, especially in view of what may happen if this value is held as less compelling than autonomy, or utility, or health care economics.
The weakest part of the ACP’s position against medical suicide is its objection on the basis that such provision lies outside the scope of medical practice. I disagree. If assisted suicide and euthanasia are right and good, physicians should willingly accede; if they are wrong, they should not be done by anybody.
With clarity and courage, the ACP has reaffirmed its opposition to physician-assisted suicide. Perhaps the vote was close; the tide of opinion may be turning, and the next iteration of the ACP’s position might be differ- ent. Autonomy and self-determination are ascendant, and there are warnings of intolerance toward those who object. Nonetheless, physicians opposed to the provision of euthanasia and medically assisted suicide should not be cowed by attempts to place them “out- side the mainstream.” Where these practices are legal, I believe that physicians should firmly decline to participate.
This article was published at Annals.org on 19 September 2017.
Annals of Internal Medicine EDITORIAL
© 2017 American College of Physicians 595
It is time to return to our duty at the bedside. Our compassion calls us there, as Dr. Edward Trudeau is credited to have said, “to cure sometimes, to relieve often, to comfort always,” but not to kill or to assist in or facilitate killing. With time, we will see whether our col- lective cultural conscience, including respect for the in- trinsic value of human life, can keep us from sliding down the slope. Otherwise, it will merely mitigate our speed as we descend.
William G. Kussmaul III, MD Media, Pennsylvania
Disclosures: The author has disclosed no conflicts of interest. Form can be viewed at www.acponline.org/authors/icmje /ConflictOfInterestForms.do?msNum=M17-2072.
Requests for Single Reprints: William G. Kussmaul III, MD, 5 Arrowhead Trail, Media, PA 19063; e-mail, w.kussmaul @verizon.net.
Ann Intern Med. 2017;167:595-596. doi:10.7326/M17-2072
References 1. Snyder Sulmasy L, Mueller PS; Ethics, Professionalism and Human Rights Committee of the American College of Physicians. Ethics and the legalization of physician-assisted suicide: an American College of Physicians position paper. Ann Intern Med. 2017;167:576-8. doi:10 .7326/M17-0938 2. Marsh L. The flaws of the Overton window theory: how an obscure libertarian idea became the go-to explanation for this year’s crazy politics. New Republic. 27 October 2016. Accessed at https: //newrepublic.com/article/138003/flaws-overton-window-theory on 21 August 2017. 3. Stahl RY, Emanuel EJ. Physicians, not conscripts— conscientious objection in health care. N Engl J Med. 2017;376:1380-5. [PMID: 28379789] doi:10.1056/NEJMsb1612472 4. Francis N. Netherlands—2015 euthanasia report card. Dying for Choice Web site. Accessed at www.dyingforchoice.com/resources /fact-files/netherlands-2015-euthanasia-report-card on 18 August 2017.
EDITORIAL The Slippery Slope of Legalization of Physician-Assisted Suicide
596 Annals of Internal Medicine • Vol. 167 No. 8 • 17 October 2017 Annals.org
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