Dying with Dignity

A Utilitarian Argument for Euthanasia and a Relativist Rebuttal

Originally written February 20th, 2010

Death is not a subject that most of us like to discuss.  But death is part of life and all of us one day will cease to be alive.  For those who are lucky, death will come in their golden years when they may drift away slowly and peacefully during sleep.  Unfortunately, many are not that lucky and are afflicted with illnesses that do not take their life, but prevent them from continuing to enjoy the life they have.  As the number of people who live to a very old age continues to increase and advances in medical science become more efficient in extending life, or as some would say, prolonging death, the issue of Assisted Suicide becomes of critical importance to society.  When pain and suffering are all that a person can look forward to, their individual free will and decision to die if they so choose should be respected and protected the same way that the Declaration of Independence protects our inalienable rights to life, liberty and the pursuit of happiness.  The main classic ethical argument for the legalization of Assisted Suicide is the utilitarian theory, while relativism counters said argument.  I intend to present both arguments and make a case for each.

Part I – The Utilitarian Argument for Assisted Suicide

                The states of Oregon, Washington and Montana have legalized Physician Assisted Suicide (PAS) by enabling doctors to prescribe lethal doses of medication to terminally ill patients.  However, in the rest of the country, the battle for a patient’s right to die with dignity continues.  The number of illnesses, diseases and conditions that could rob a person of their ability to live well and freely is numerous – cancer, MS, Lou Gehrig’s disease, and countless others.  “Consider the plight of those suffering from Alzheimer's. The afflicted can expect a slow, painful descent into advanced dementia.  The moderate memory loss that marks the onset in patients will, over the years, deteriorate into inability to recognize close family members, dress themselves or remember significant experiences.  Friends and family who are forced to witness their fall into oblivion suffer indescribably (Dincin, 2010).”  With such a grim and even terrifying outlook, it is not difficult to understand why some patients may want to choose to die sooner rather than wait for the devastating disease to take its course.  In cases where patients are competent, of sound mind, and determined about their decision, a respectful society should act to protect their right to choose their own fate.  The utilitarian would argue that decisions about one’s time and circumstances of death are extremely personal and private and just as we protect all persons’ right to privacy in all of their life decisions, so should we protect their privacy and autonomy in death decisions.

                There is also the question of justice and of fair and equitable treatment.  For some terminally ill patients, it is possible to request that any life-saving treatment be stopped as well as the cutting off of food and water supply in order to hasten death.  However, for many, treatment refusal is not sufficient to hasten death.  In many cases because their illness may not life-threatening, just debilitating, as with many neurological conditions or cases of paralysis only starvation would bring death and that in itself is also terrifying.  For those patients where the refusal of medicine or treatment is not enough to cause death, in the interest of justice, assisted suicide should be allowed in order to afford them equitable opportunity to choose.  Furthermore, compassion toward the needy and the suffering are some of humankind’s most admirable qualities.  Why should we deny our fellow citizens that compassion and understanding during their most critical and desperate hour?  Is it conscionable to refuse a friend, family member or neighbor the help they need to stop their pain and agony when there is no chance that they will recover?  If by denying a terminal patient in pain to die by their terms, what is the utility to society?  As the utilitarian argues that when it comes to the greater good, does this act produce the greatest good for the greatest number, given the various options available (Mosser, 2010)?

However strong society’s interest in preserving life may be, when a person no longer wants to endure the physical or psychological pain they are experiencing, it becomes unacceptable to place the state’s interest ahead of individual rights.  Unfortunately, the prohibition on assisted death and assisted suicide completely limits the individual liberty of patients and their families, denying them access to choices that would ease their pain and suffering.  Prohibition also accomplishes another important goal: silence.  The same way that drug prohibition is directly responsible for the lucrative black market, the prohibition on assisted suicide leads patients and families to seek questionable solutions outside the law.  In addition, it does not in effect prevent assisted death, but makes sure that it occurs in secret, by use of morphine drips or helium inhalation, preventing patients and families from having meaningful discussions with each other and their physicians about their choices.  The legalization of assisted suicide would promote open dialogue and pave the path toward greater understanding of the end of life processes and how to best help those who so desperately need it.

Part II – The Relativist Argument against Legalizing Assisted Suicide

With an issue this delicate it is important to remember that there are many serious considerations to be made that may indicate that assisted suicide should not be legalized.  The first is the sanctity of life.  Life is something sacred and not to be taken for granted or disposed of.  This is one of the most important of Christian values and it imbues every life with intrinsic dignity.  “I believe the rhetoric of the debate misappropriates the word “dignity.”  As used by those who want to legalize assisted suicide, “death with dignity” implies that people who are dying are not already dignified.  They are.  And that is not merely my assertion or some New Age platitude.  The preamble to the United Nation's 1948 Universal Declaration of Human Rights states that “recognition of the inherent dignity and of the equal and inalienable rights of all members of the human family is the foundation of freedom, justice and peace in the world.” This language formalizes an anthropological fact: the impulse to honor and care for our most vulnerable members - infants, elderly, injured, and ill - is part of our humanity (Byock, 2010)”  This is, of course, a textbook example of what relativism is.  It “regards values as determined by one's own ethical standards, often those provided by one's own culture and background (Mosser, 2010).”

There is also the argument that there is and should be an important distinction between passively letting someone die and actively killing them.  While the refusal or withholding of treatment is in essence simply letting a person die and letting nature take its course, which is justifiable, PAS equates to active killing and is morally reprehensible and illegal.  “A legal alternative to PAS is for the patient to stop eating and drinking; this is seen as a choice of stopping life-sustaining treatment.  If the patient is competent and physical, psychological, and spiritual symptoms have been managed, he or she has a right to exercise this choice.  When a person stops eating and drinking, death usually occurs in 1-3 weeks (Valente, 2004 cited in Lachman, 2010).  This is consistent with current law in most states, but does require support of caregivers (Lachman, 2010).”

There is also the important consideration that assisted suicide has a great potential to be abused.  It is conceivable that those who lack access to proper care and support may be pushed into assisted death and that we may end up sliding down a slippery slope where it becomes a cost-containment strategy.  If it is legalized, burdened family members, health care providers or insurance companies may encourage the option of assisted death.  Furthermore, associating PAS to the practice of medicine may lead to a significant and irreversible deterioration in people’s trust of the medical profession as a whole. 

The Netherlands and Belgium and the Netherlands are some of the European countries that have legalized Physician Assisted Suicide/Euthanasia (PAS/E).  A review of the book Death and Medical Power: An Ethical Analysis of Dutch Euthanasia Practice by physicians and philosophers Henk ten Have & Jos Welie, noted that the authors acknowledge that supporters of PAS/E have made a very convincing case.  But in spite of this, they still remain opposed to the practices of assisted suicide and euthanasia.  “Their opposition is based on a unique perspective of power in medicine.  They point out that scientific and technological advances in the past fifty years have given physicians real power over disease and death.  In response to this medical power, patients have sought their own empowerment - the authority to decline unwanted treatment and the right to demand euthanasia and assisted-suicide.  Paradoxically, in their view, by restricting the practice of PAS /E to physicians, Dutch courts and parliament have actually increased physicians' unilateral power rather than equalizing it between patient and physician.   For all the talk about patient autonomy, the actual decision-makers are physicians. Physicians’ assessment of whether a patient qualifies for PAS/E is a quality of life determination made, not by patients, but by physicians (Orr, 2009).”

When the power is concentrated solely in the hands of physicians and medical professionals, who are after all fallible human beings, there is concern that mistakes will be made.  As any doctor will admit, there is considerable uncertainty in the diagnosis and prognosis determinations for many patients.  Despite their best efforts, it is very plausible that doctors will make errors in diagnosis and treatment and may not manage a patient’s pain effectively or miss the occurrence of depression in a patient who is ill.  If assisted suicide is legalized, patients who could have had a chance to live additional fulfilling months or even years may be sent to a hasty death. 

Part III – Conclusion

Although there are compelling arguments against the legalization of assisted suicide, many can be properly addressed by enacting appropriate safeguards in the system to protect against mistakes and abuses.  But a more intrinsic dilemma is a about the moral questions concerning the sanctity of life.  Rubin (2010) states that “at present, traditional, Christian-based morality and an emerging secular morality centered on the value of self-fulfillment are in conflict within our society, a conflict that probably reflects a slow historical transition from the first to the second.  The intense debate about the morality of assisted suicide is one aspect of this conflict.  Blanket prohibitions of assisted suicide support one side of this debate, a side that happens to be allied with the Christian religion.  Consequently, these laws violate the Establishment Clause.”  The Establishment Clause is an explicit, well-developed constitutional provision that deals with the separation of church and state.  In addition, Rubin states that the argument is based on “specific historical experience of Western civilization and the idea that in our society, current laws against assisted suicide are in fact efforts to take sides in an ongoing controversy and impose a religiously based morality on those who would otherwise choose an alternative approach (Rubin, 2010).”

Furthermore, with regard to the distinction between passively letting someone die and actively killing them, the law is already clear in non-medical situations.  If a person locked another in a closet for one to three weeks without food and water and let them die, they would still be prosecuted for a crime, because preventing someone from living is essentially killing them.  Not to mention that the option to stop eating and drinking until one becomes weakened enough or dehydrated enough to cause death does not seem very much like a peaceful or humane way to spend our last days.  So the potential for abuse, although real is far outweighed by the fact that so many people who deserve to be treated with kindness and humanity may be subjected to unimaginable pain and suffering simply to avoid abuses that have not even materialized.  Also, there is the potential for abuse with any right or benefit that is given to citizens.  There are those who will use them to their advantage, but this does not prevent us from protecting these rights.  Just because some abuse the welfare system does not mean we should abolish it altogether.

It is also important to remember that when considering the potential impact to the medical profession with regard to patient trust and confidence, that this confidence has already been shattered.  By money-hungry doctors and by insurance company practices that instead of focusing on patient needs, are instead focused on numbers and profits.  And simply because there is a potential for error does not mean that we should eliminate the possibility altogether.  Like anything else in life and death, there is a potential for mistakes.  But the fact that doctors make mistakes does not stop us from seeking their help and looking for treatments that may help us be healthier or manage pain.  We all assume an inherent risk in everything we do because nothing in life, except gravity and the speed of light, is one hundred percent guaranteed.  Therefore, the correct response to these concerns would be to devise methods to reduce the potential for abuse and reduce the likelihood of mistakes, not eliminating the possibility entirely by complete prohibition.

As our society becomes more advanced it will be necessary to continue examining how we experience death.  Maintaining an open mind, focusing on justice and compassion, and remembering that our assumptions about death are a work in progress, will allow us to get closer to the answers we desperately seek.  “On a complex social issue like physician-assisted suicide, where people of goodwill differ so markedly on what is “right,” the law has limited ability to provide any satisfying moral resolution to the question.  In fact, even with more mainstream end-of-life laws, where we find some societal agreement, the law is a cumbersome tool in navigating complicated human questions.  The black-and-white of the written law is simply not that effective in making decisions in the massive gray area that is serious illness and dying in the modern medical-technological world.  It can give us rights, structure, and procedure, but not answers (Colby, 2009).”

The most important thing to remember is that while the right and the choice to die remain illegal, there can be no meaningful debate, and consequently no progress on this pressing issue.  Evidence from the three states where PAS has been legalized support this claim.  “The legalization of assisted death has been associated with substantial improvements in palliative care in Oregon, in areas including the appropriate training of physicians, the communication of a patient's wishes regarding life-sustaining treatment, pain management, rates of referral to hospice programs, and the percentage of deaths occurring at home.  Effective palliative care and hospice services may address many of the key reasons why patients request assistance in dying -- such as loss of autonomy, dignity, and the ability to care for themselves in a home environment -- and lead some to change their minds (Steinbrook, 2008).

This is key because if we do not have conversations with our friends, our loved ones and ourselves about what we would want at the end of our lives, chance are very high that none of us will get what we want.  It is only in the process of analyzing someone’s desire to die that we find out how to truly help them live, if that is indeed a possibility for them.  But if no amount of pain management or medicine or help can alleviate our loved one’s constant suffering, the only humane and ethical thing to do is to respect their decision and support them in carrying out their wishes.

References

Mosser, K. (2010). Ethics & Social Responsibility, San Diego, CA: Bridgepoint Education, Inc. 

Byock, I. (2010). Dying with Dignity. The Hastings Center Report, 40(2), 49.  Retrieved June 5, 2010, from Research Library. (Document ID: 2002792351).

Colby, B. (2009). Let's Talk about Dying. The Humanist, 69(3), 4-6.  Retrieved June 4, 2010, from ProQuest Religion. (Document ID: 1693011791).

Jerry Dincin. (2010, June 7). Death with Dignity: for those who suffer greatly, either choice – to live or to die – should be honored.  The Sun, A.13.  Retrieved June 7, 2010, from The Sun, Baltimore. (Document ID: 2051358921).

Lachman, V. (2010). Physician-Assisted Suicide: Compassionate Liberation or Murder?  Medsurg Nursing, 19(2), 121-5.  Retrieved June 5, 2010, from ProQuest Health and Medical Complete. (Document ID: 2024453181).

Orr, R. (2009). Easeful Death: Is There a Case for Assisted Dying, Death, and Medical Power: An Ethical Analysis of Dutch Euthanasia Practice/Euthanasia and the Law in Europe. Ethics & Medicine, 25(3), 188-189.  Retrieved June 4, 2010, from Research Library. (Document ID: 1890416741).

Rubin, E., (2010). Assisted Suicide, Morality, and Law: Why Prohibiting Assisted Suicide Violates the Establishment Clause. Vanderbilt Law Review, 63(3), 761,763-811.  Retrieved June 4, 2010, from ABI/INFORM Global. (Document ID: 2043375791).

Steinbrook, R. (2008). Physician-Assisted Death -- From Oregon to Washington State. The New England Journal of Medicine, 359(24), 2513-5.  Retrieved June 4, 2010, from Research Library. (Document ID: 1611103091).