On Euthanasia, The Right to Die, and Physician Responsibility

The debate about euthanasia to follow centers around the position of the AMA, as given by the House of Delegates of the American Medical Association’s statement from December 4, 1973:

“The intentional termination of the life of one human being by another – mercy killing- is contrary to that for which the profession stands and is contrary to the policy of the American Medical Association.

The cessation of the employment of extraordinary means to prolong the life of the body when there is irrefutable evidence that biological death is imminent is the decision of the patient and/or his immediate family. The advice and judgment of the physician should be freely available to the patient and/or his immediate family.” [1]

The first part of this statement, namely, the intentional termination of life of one person by another, has commonly been referred to as active euthanasia. Removal of life support mechanisms is coined as passive euthanasia. While the debate remains open as to whether there is a distinction between the two[2], I shall retain the usage of these terms for the purpose of this article. I shall attack the AMA position in the following respects: [1] the doctrine is based on a distinction between killing and letting die that is incorrect [2] equally construed, this document relies on a distinction either between doing and allowing, which is also irrelevant, or between intended and foreseen consequences, which is equally irrelevant [3] that in many cases killing is much more humane than letting die (thus arguing that death is not always a harm), and [4] that supporting active euthanasia is compatible with the role of a physician, and moreover that the AMA position is internally inconsistent with regards to active and passive euthanasia, as well as physician-assisted suicide (which is defined as the physician providing a patient with the necessary means to terminate their own life).

The basis for the argument that passive euthanasia is sometimes morally permissible, while active euthanasia is always morally impermissible relies on a moral distinction between killing and letting die. What is at the heart of such a distinction? This has been a topic of numerous works, and cannot be treated exhaustively here. However, it is clear that if there is a morally relevant distinction between killing and letting die, there will be no pair of cases which differ only in that one is an instance of killing and the other an instance of letting die such that the killing is equal in moral reprehensibility to the letting die. What I mean here by equal moral reprehensibility is that our intuitions would lead us to believe that either case is morally worse than the other. If such cases can be found, then the distinction between the two may point to some morally relevant difference, but the distinction between killing and letting die cannot itself be the morally relevant factor. As a matter of fact, many such cases can be found. Consider the following example from James Rachels, where it appears that letting die is equally as bad as killing:

Drowning Cousin - Smith and Jones are two greedy men who want to get rich by killing a young cousin and inheriting his money. Both enter the cousin's bathroom intending to drown him and make it look like an accident. Smith drowns the boy. As Jones walks in, he delightedly sees his nephew fall and hit his head, falling face down in the water. Jones stands ready to drown the boy if necessary, but he doesn't have to. Thus Jones lets the nephew die, while Smith kills his nephew. [3]

The only relevant difference between the two cases, as Rachels points out, is that Smith killed the child and Jones let him die. It certainly appears that each is equally morally reprehensible in their actions. One could object that in the Smith case the cousin is aware he is being murdered, which likely causes more suffering than in the Jones case, but this seems unlikely to point to a moral distinction between the two. The case could be made even stronger if we can posit an example of where letting die is worse than killing. In fact, I believe that actively euthanizing a suffering patient who otherwise would have survived in pain for months to come is an example of such a case. However, since this is the thesis I am arguing for, I clearly cannot use it as an example.[4] I shall let it stand without an example of letting die being worse that killing, relying on the fact that because the two can be shown to be equal in certain cases is enough to show the distinction is not a morally relevant one.

If the killing/letting die distinction is not morally relevant, perhaps it points to something else that is, since we commonly find that in cases killing is worse than letting die. It seems that the distinction could be founded in two main ideas. The first is that it could be based on a distinction between doing and allowing, which is what is really morally relevant. However, I believe this is also incorrect. This is demonstrated in the Rachels example of Jones and Smith stated above. Jones allowed his cousin to die, and Smith killed his cousin. Yet we concluded that they were equally morally wrong. Another such example can be given for those whom are unconvinced by the first, an example in which allowing is clearly worse than doing. The example, as posed by Jonathan Bennett, is the following:

Metallic Dust – Henry is in a sealed room where there is fine metallic dust suspended in the air. If he keeps stock still for two minutes, some dust will settle in such a way as to close a tiny electric circuit that will lead to some very undesirable consequences (say the death of an innocent). However, if he moves he shall save this innocent by preventing the dust from settling.[5]

Consider now that we revise the case slightly, such that the upshot (outcome) is the same but the action of the agent is reversed. Thus, in this example, the agent must not move in order to prevent the death of an innocent, due to the fact that he prevents the same metallic switch from closing (say his foot covers the switch). He need only move and the switch will automatically close and an innocent person may die. The only difference between this and the former case is that in the first, he must act in a negative way by staying still (thus allowing the dust to settle) so that the result is the agent’s death, and in the second case he must move his foot, allowing the switch to close, and thus killing the innocent. It is clear to see that if the agent’s action (or inaction) resulted in the death of the innocent, we would condemn him equally. We would not consider the agent in case 2 as more morally responsible than the agent in case 1; we would have no rational justification for doing so. It seems then, that there is no morally relevant distinction between doing and allowing. Other examples are provided by Bennett, including pushing a car down a hill vs. stopping it from rolling down a hill with equal effort, etc. The point demonstrated here is that doing and allowing are morally neutral actions.

The second foundation on which killing/letting die may rest is on a distinction between intended and foreseen consequences. Perhaps this lies at the heart of what is wrong with killing and not wrong with letting die in most examples. The question: is there a difference between performing an action with the intent of a certain outcome or performing the same action with the almost certain foreseeable same outcome, but having the outcome as only a foreseen consequence of the action, not its purpose? Admittedly, many examples we encounter deal with these issues, and result in us judging the act of killing as worse due to its intended, and not merely foreseen, consequences. Yet it seems that in such cases, the rightness or wrongness of an action or an omission depends entirely on a range of factors that are external to and independent of the distinction between acts and omissions itself. Among these factors are knowledge of what is at stake, the agent’s power of whether the death occurs, the sacrifice to oneself necessary to prevent the death, the likelihood that the death will come about (the probability our foreseen consequences are correct), and the agent’s motivation. Rachels claims, and I concur, that what makes most cases of killing worse than most cases of not preventing a death is the presence of these extrinsic differences. In most cases of letting die, the agent would have had to make a greater sacrifice to prevent the death, the death was less than certain, and the agent was not motivated by malice. It still strikes one as odd that to foresee the imminent death of a person and allow it to occur is less morally reprehensible than to intend his death. Suppose that the Smith and Jones example were reframed such that Jones had not intended to kill his cousin, yet was happy when he drowned and refrained from easily helping. This again doesn’t seem to weaken the case that each acted in an equally morally incorrect way. The extrinsic fact that motivation was different in the two actions can’t point to an intrinsic difference in the two cases. Again, many other examples can be given in which acting with foreseen consequences can be equally as reprehensible as intending to cause those consequences.[6] [7]What is clear is that it is not the intended vs. foreseen consequences aspect that determines the moral difference in the examples. There may again be some morally relevant distinction, but it is not this distinction.

I shall now address my points [3] that in many cases killing is much more humane than letting die (arguing that death is not always a harm), and [4] that supporting active euthanasia is compatible with the role of a physician, and moreover that the AMA position is inconsistent with regards to active and passive euthanasia. The AMA states the following in their code of ethics, in section E-2.21, Euthanasia:

“Euthanasia is the administration of a lethal agent by another person to a patient for the purpose of relieving the patient’s intolerable and incurable suffering.
It is understandable, though tragic, that some patients in extreme duress--such as those suffering from a terminal, painful, debilitating illness--may come to decide that death is preferable to life. However, permitting physicians to engage in euthanasia would ultimately cause more harm than good. Euthanasia is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks.
The involvement of physicians in euthanasia heightens the significance of its ethical prohibition. The physician who performs euthanasia assumes unique responsibility for the act of ending the patient’s life. Euthanasia could also readily be extended to incompetent patients and other vulnerable populations.
Instead of engaging in euthanasia, physicians must aggressively respond to the needs of patients at the end of life. Patients should not be abandoned once it is determined that cure is impossible. Patients near the end of life must continue to receive emotional support, comfort care, adequate pain control, respect for patient autonomy, and good communication.” (I, IV) (Issued June 1994 based on the report "Decisions Near the End of Life," adopted June 1991 (JAMA. 1992; 267: 2229-2233); Updated June 1996.)[8]

The AMA claims, “ Permitting physicians to engage in euthanasia would ultimately cause more harm than good. Euthanasia is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks.” Is it true that a physician is violating his role as healer when he ends the life of a terminally ill patient in great pain at that patient’s request? I think not. Physicians uphold the Hippocratic oath, of which the first rule is to “do no harm”, and the second, to “know thy patient”. It is not at least obviously clear that the physician in question does harm, as he is following the wishes of the patient as well as alleviating an agonizing situation. One could claim that in every case death is a harm, but this position would seem to rule out that a physician is allowed to refrain from treatment unlikely to provide a reasonable quality of life and poor results when death is sure to ensue. After all, why not always perform procedures that offer any modicum of returned function, quality of life, or even hope for the patient? Perhaps the AMA could claim under this situation that death is always a harm and hold that refraining from treatments doesn’t do harm (it merely allows it).[9] However, this would mean that physicians could not act in a positive manner that resulted in a patient’s death. But as we shall shortly see, physicians are allowed to perform such actions (such as removing current life-support machinery – doing) under certain circumstances under current policy. It would also seem to fall back on the doing/allowing distinction questioned earlier in this paper. The AMA does not seem to hold the position that death is always a harm. In section E-2.20, Withholding or Withdrawing Life-Sustaining Medical Treatment, the following is stated:

“Physicians have an obligation to relieve pain and suffering and to promote the dignity and autonomy of dying patients in their care. This includes providing effective palliative treatment even though it may foreseeably hasten death.

Even if the patient is not terminally ill or permanently unconscious, it is not unethical to discontinue all means of life-sustaining medical treatment in accordance with a proper substituted judgment or best interests analysis. “[10]

Clearly the AMA is not considering death a harm in the case of palliative care that hastens death, nor in the case of passive euthanasia even “if the patient is not terminally ill or permanently unconscious”! Thus clearly, even if one allowed the false distinction between doing and allowing, the current policy is inconsistent. It should also be noted that in some cases the cessation of life-supporting treatment is actually intended to bring about the death of a patient, and that this action is allowed under the current provisions of the ethical policy. In such cases, even accepting the intended/foreseen distinction would not save us from moral reprehension.[11] Furthermore, the physician is acting in his role to know his patients wishes, and if the patient were deemed to be psychologically adept and not depressed, would be acting in regards to those wishes.

The claim that such policy would be difficult to control, or would pose a serious societal risk is implausible. Physicians are afforded a level of autonomy to apply their knowledge in the best way in which is in alignment with his patients wishes. Yet at the same time physicians are governed by hospital institutional review boards, which could review cases on an individual basis and determine the best course of action, including whether euthanasia is appropriate. There is also no reason to believe that such a policy of embracing euthanasia would lead to the deaths of “to incompetent patients and other vulnerable populations”. This would likely result only from the action of malicious physicians, and such individuals would likely act in such a way without such policy. Clearly being an incompetent patient implicitly contains being unable to have the psychological aptitude necessary to make a choice on such a matter, and would rule out such people from the option of euthanasia. And what of vulnerable populations? This is just unsubstantiated fear to think that a policy allowing individuals to decide to be lethally injected would be applied in such a positive manner. Euthanasia would be a merely reactive step to patient’s wishes, and one of many treatment options given to the patient.
The AMA states at the end of the excerpt “Patients near the end of life must continue to receive emotional support, comfort care, adequate pain control, respect for patient autonomy, and good communication.” Yet I don’t see how a policy refraining from allowing a person to decide to end their own life respects their autonomy, nor is an extremely painful death a humane treatment option. Many times aggressive pain therapy can do little to alleviate the discomfort of the patient. Physicians may be limited in the amount of a drug they may prescribe do to legal issues with adverse reactions or overdose, and the patient is left to hold the pain. The patient has the right to die[12] if he wants to, as long as it is a decision he has reached after consideration and in a state of psychological stability. That many in society share this attitude is supported by the fact that Oregon has legalized physician-assisted suicide, as well as the fact that the Netherlands has legalized physician-assisted suicide and euthanasia. The idea that preservation of life is the ultimate goal of any physician poses a unique problem in the question of euthanasia. I think this stems from some of the impertinent distinctions mentioned previously, and from a misunderstanding of the role of a physician. A physician should be allowed to administer lethal agents at the patient’s request; this is the humane thing to do, and this is the position that falls more in line with the values that guide physicians in our society.

Turning toward empirical considerations, it is reasonable that patients should be offered euthanasia among the treatment options to which they are entitled. A substantial number of physicians believe this is the case. For example, a study published in the New England Journal of Medicine:

“Of the 1355 eligible physicians who received our questionnaire, 938 (69 percent) responded. Forty-eight percent of the respondents agreed with the statement that euthanasia is never ethically justified, and 42 percent disagreed. Fifty-four percent thought euthanasia should be legal in some situations, but only 33 percent stated that they would be willing to perform euthanasia. Thirty-nine percent of respondents agreed with the statement that physician-assisted suicide is never ethically justified, and 50 percent disagreed. Fifty-three percent thought assisted suicide should be legal in some situations, but only 40 percent stated that they would be willing to assist a patient in committing suicide. Of the groups surveyed, hematologists and oncologists were most likely to oppose euthanasia and assisted suicide, and psychiatrists were most likely to support these practices.

Conclusions: The attitudes toward physician-assisted suicide and euthanasia of physicians in Washington State are polarized. A slight majority favors legalizing physician-assisted suicide and euthanasia in at least some situations, but most would be unwilling to participate in these practices themselves.”[13][14]

As can be seen, many physicians actually support a policy of euthanasia. Other studies support that a smaller percentage of patients would either appreciate euthanasia as one of their offered treatment options, or agree with it in concept.[15] While it is true that there are problems with adherence to safety guidelines[16], these could be worked out with coherent and well-enforced policy, and seem to be no greater than those problems that face other aspects of medicine (i.e. IRB review of research subject eligibility, etc.).[17] [18]

I think that Dr. Trevor Mudge, Vice President of the Australian Medical Association, hit it very close when he said that “the basis is that the risk to society of allowing for the first time one section of society to kill another without the balancing intent of saving other lives, which is the situation with the termination of pregnancy or capital punishment, if you believe in it, with just war and self-defense. In all those situations where society allows, if you like, a killing, the justification is the preservation of other lives. In euthanasia it is not. The risk to society and the risk to the security and confidence that the public have in the medical profession is simply too great.”[19] This is part of the discomfort people have to supporting euthanasia, and coupled with the general consensus that killing in general is wrong, and that specifically physicians should not be allowed to kill (because their perceived ‘primary directive’ is to “save lives” in all cases), the reasons against such policy are compelling, at least on the surface. However, once critically considered, the position is not as negative as it appears, is coherent, and it is thus greatly beneficial to a certain population of patients (such as those terminally ill patients suffering great pain) that euthanasia be an option. It is certainly within the scope of the role of a physician, and doesn’t violate the role of a physician in society. It respects patient’s autonomy and rights, and thus should be upheld. Dr. John Freeman succinctly sums up the discussion when he says, “It is time that society and medicine stopped perpetuating the fiction that withholding treatment is ethically different from terminating a life. It is time that society begin to discuss mechanisms by which we can alleviate the pain and suffering for those individuals whom we cannot help.”[20] I would add to this that it is time society and medicine seriously reflect on the legitimacy of active euthanasia, and finally make a decision in favor of patients and their right to die.

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[1] James Rachels, “Active and Passive Euthanasia”, from Bonnie Steinbock and Alistair Norcross, Killing and Letting Die, New York: Fordham University Press, 1994. 112

[2] See Thomas Sullivan’s Active and Passive Euthanasia: An Impertinent Distinction?

[3] James Rachels, “Active and Passive Euthanasia”, from Bonnie Steinbock and Alistair Norcross, Killing and Letting Die, New York: Fordham University Press, 1994. 115

[4] See James Rachel’s example of Jack, a suffering cancer patient who wished to be euthanized, in More Impertinent Distinctions and a Defense of Active Euthanasia.

[5] Jonathan Bennett, “Negation and Abstention: Two Theories of Allowing”, from Bonnie Steinbock and Alistair Norcross, Killing and Letting Die, New York: Fordham University Press, 1994. 239

[6] See Jeff McMahan, Killing, Letting Die, and Withdrawing Aid.

[7] Some discussion here could be devoted to the Doctrine of Double Effect and its refutations, but I will ignore these considerations in light of refraining the scope of this paper to the topic at hand. Also, since euthanasia cases don’t involve the foreseen death of one person as a consequence of saving another, this doctrine does not apply here.

[8] AMA Code of Ethics, http://www.ama-assn.org/ama/pub/category/8458.html

[9] A possibility I credit to Alastair Norcross

[10] Ibid, http://www.ama-assn.org/ama/pub/category/8457.html

[11] See the recent Terri Schiavo debacle as evidence, where it was upheld by a supreme court decision that the removal of a feeding tube was both constitutional and in the patients best interest, and the removal was done not just with death as a foreseeable consequence, but with the intention of ending Terri Schiavo’s life.

[12] Obviously there is substantial argument on whether a right to die exists, and for the purposes of this paper I have assumed that one does, though certainly utilitarian considerations could come into play in support of such a position, as well as pragmatic consideration, and analysis of rights we currently believe we have being analogous to a right to die. In any case, this paper is meant to show that the current policy prohibiting euthanasia rests on impertinent moral distinctions and is inconsistent with other ethical policies physicians’ support, not to posit an argument in support of the right to die. I am using the term here in the practical, autonomous way, as opposed to an absolute right. It also seems that, because the patients has a right to withdraw treatment and die, he has at least a prima facie right to die, but again, this is unnecessary to the current debate.

[13] Cohen J. S., Fihn S. D., Boyko E. J., Jonsen A. R., Wood R. W. Attitudes toward Assisted Suicide and Euthanasia among Physicians in Washington State. N Engl J Med 1994; 331:89-94, Jul 14, 1994.

[14] See also, Kavanaugh A., Wilson K. G., Chochinov H. M., Toffler W. L., Edwards M. J., Hamilton N. G., Edwards P. J., Robinson S. T., Bachman J. G., Alcser K. H., Doukas D. J., Lichtenstein R. L., Lee M. A., Nelson H. D., Tilden V. P. Attitudes of Michigan Physicians and the Public toward Legalizing Physician-Assisted Suicide and Voluntary Euthanasia. N Engl J Med 1996; 335:518-520, Aug 15, 1996.

[15] See Ezekiel J. Emanuel; Diane L. Fairclough; Linda L. Emanuel, Attitudes and Desires Related to Euthanasia and Physician-Assisted Suicide Among Terminally Ill Patients and Their Caregivers, JAMA, Nov 2000; 284: 2460 - 2468.

[16] See Ezekiel J. Emanuel; Elisabeth R. Daniels; Diane L. Fairclough; Brian R. Clarridge, The Practice of Euthanasia and Physician-Assisted Suicide in the United States: Adherence to Proposed Safeguards and Effects on Physicians
JAMA, Aug 1998; 280: 507 - 513.

[17] For more information, see Robert Young’s entry in the Stanford Encyclopedia on Voluntary Euthanasia, http://plato.stanford.edu/entries/euthanasia-voluntary/ , 2002

[18] Groenewoud J. H., van der Heide A., Onwuteaka-Philipsen B. D., Willems D. L., van der Maas P. J., van der Wal G., Clinical Problems with the Performance of Euthanasia and Physician-Assisted Suicide in the Netherlands, NEJM 2000; 342:551-556, Feb 24, 2000.

[19] Australian Medical Association media conference, May 26, 2002. http://www.ama.com.au/web.nsf/doc/WEEN-5GB4C5

[20] John Freeman, “Is There a Right to Die – Quickly?” Journal of Pediatrics, 80, no. 5 (1972), 904-905

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