On the practical side I know many doctors. My dad and sister are both physicians, and the former serves on the ethics board of his hospital. We talk about these issues often. They both echo, and tell me that most docs do, the APA sentiments on the hippocratic oath. But I don’t think I have been clear on the right-duty point. My point was not meant to be a practical one, it is a principled one. I am not asking the practical question as to whether there will be willing participants. The question is, do I have the right to oblige someone to help me kill myself? Hunt puts it this way, “In the end-of-life situation, if respecting individual choice isn’t honored then, then when?”

So Hunt wants to make it an issue of autonomy. That is a good starting point – patient autonomy is a well-established principle in medical ethics. But I would argue (and most in the profession agree) that patient autonomy generally only includes negative rights – their autonomy can oblige inaction. For instance, they are free (autonomous) to refuse medical treatment and free to refuse food and water. That negative right requires inaction; it is not lawful to force medical treatment or force feed an unwilling competent person.

But physician assisted suicide is quite different. Does my autonomy (“respecting individual choice”) extend to requiring that others help me achieve my ends? I say no. I don’t think you have a right to oblige others to help you kill yourself. Arguing that you do not have that positive right is not, in my view, an unjustifiable restriction on your autonomy. In other words, I do think your argument is a matter of “indulgence” (that I have a right to the things I want), and I don’t think your argument is valid because it relies on an ambiguity on the meaning of freedom/autonomy.

Here is an analogy: I have the right to free speech. That is a negative right, a right that requires the inaction of the state (the state cannot censor my expression). But my right to free speech is not a positive right, it does not oblige the state and others to give me a platform from which to speak. So I think you have a right to autonomous decision making with your life, and that right includes potentially obliging others to inaction. But that right does not include obliging others to actions which help you achieve your particular ends (in this case, death).

From the public policy point of view, on balance I think the state has more compelling reasons to not legalize PAS than to legalize it (potential for abuse, vulnerability of marginalized groups, devaluation of the lives of the disabled, increase financial incentives to limit care, near impossibility of effectively regulation and limiting the practice, pressure on patients, disincentives to medical innovation, etc).

The US Conference of Catholic Bishops has threatened to shut down Catholic hospitals (a huge part of our health care infrastructure) if FOCA is passed.

Doesn’t surprise me in the slightest; Catholics already demonstrated their willingness to withhold treatment that doesn’t fit with Church dogma. Condoms in Africa, anyone? You might describe this as the Church taking its ball and going home, except that “the ball” is pretty huge chunk of the world’s wealth.

I am hoping someone comes up with something better than ‘I should have a right to the things I want’

You can’t simply boil that sentiment down to simple indulgence; this amounts to poisoning the well on a perfectly valid argument. In the end-of-life situation, if respecting individual choice isn’t honored then, then when?

In general, I would only defend suicide for healthy individuals in rare scenarios like astronauts in space facing calamitous circumstance and horrific death — that kind of thing. We all know from the movies about the infamous “suicide pill” to be issued to spies at risk of torture and death, etc. Some parallels can be drawn to the medical cases as well. If a person’s prospect is merely torture and then death, suicide seems a rational option (contra Kant) — as Joe said and as testified in the video.

I’ll relent on the collateral damage debate. Since I have the very notion, I’m more than happy to call it killing.

And, I’m a “he” not a “she”.

“If I go through with it, I die, as I must at some point. If I don’t go through with it, my choice is essentially to suffer, and to inflict suffering on my family, and then die.”

I argue that if you are to die anyway, it is morally good to do so without causing those close to you more pain, and without stacking up huge medical bills to be paid by those you leave behind. The result is the same, but staying alive hurts others more than suicide does.

Aside on abortion, though I am not intending to derail the debate: there is currently debate about whether a doctor or a hospital could decline to perform certain procedures. FOCA (which Obama promised to sign but thankfully has not) would basically abolish conscience clauses and hospitals would not receive any federal funding (ie, medicare patients) if they refused to perform abortions. The US Conference of Catholic Bishops has threatened to shut down Catholic hospitals (a huge part of our health care infrastructure) if FOCA is passed.

Collateral damage is not really a case of ‘letting die’. Those that try to justify such things typically appeal to the doctrine of double effect (that one is morally responsible only for the things they intend, but are not responsible for unintended though anticipated effects). So the US military wouldn’t deny that their actions killed innocents (since some of their actions plainly do), instead they would just argue that they are not morally culpable fort those killings.

Enough of defending my view. Can someone make an argument for why suicide is morally good, and why assisted suicide is good public policy? I am hoping someone comes up with something better than ‘I should have a right to the things I want’. I am interested in hearing Hunt’s argument in particular. Most pro euthanasia and assisted suicide arguments are utilitarian, but she does not think we should make consequentialist arguments.

Your point about positive rights and compelling doctors to kill people is interesting in light of the abortion debate. As far as I know doctors are not compelled to perform abortions, yet women seem to have no trouble finding doctors willing to do it. Abortion as a procedure is probably in the job description for some Ob/Gyn positions, but it is not mandated by law that a doctor perform them.

Worth noting that there are plenty of non-religious, indeed purposely non-theological, arguments against suicide. See Kant, who tries to couch his moral philosophy in pure reason (something some SHAFTers, insofar as new atheism is just recycled enlightenment thought, might well be attracted to).

Regarding the right to die and the duty to kill. The right to die is a “positive right” rather than a negative one. A positive right is a right which obliges an action while a negative right is a right that obliges inaction. The right to die clearly is a positive right since it requires the action of another person.

I am not the one who makes this connection. People like Jacob Appel (an outspoken proponent of physician assisted suicide) make this point. If the right to die is not an empty right, the state will have to require that some physicians (who have a monopoly on prescribing medications) help to kill. The state could mandate this (and might need to, in light of the incredible resistance to the practice from doctors) as a prerequisite for having a medical license. I don’t know – and neither do you – if there will be willing doctors. But if there aren’t, and you have a positive right to die, then the state could mandate that a doctor help you kill yourself.

I’m not sure I follow your second point. Collateral damage – if it is justified at all (and I have serious suspicions that it is) – is a different matter altogether. Collateral damage is a killing, not a ‘letting die’. But I feel that I am missing your point here.

Sorry, I’m not finished mining this statement — because if there’s one thing humanity has shown beyond a shadow of a doubt is our capacity to both kill and “let die” and our command over the distinction, and our ability to carefully choose one from the other. In war we even have names for it, like “collateral damage.” I don’t think you can claim that there’s some kind of lapse in our general understanding.

I think you’re kind of showing your hand here. I don’t think you can get away from the gravitational field of your religious convictions, that all things death-related are up to God and not us. This is the pink elephant in all your remarks. I don’t mean to be disrespectful, but this disqualifies much of your argument. “Slippery slope” is not so much an argument here as it is a rhetorical fallacy. You’re also appealing to consequence when you say that “right to die” implies “duty to kill.” If that was a true proposition then it would be correct to invert it (modus tollens), but I don’t think it is a valid proposition. There will probably always be physicians who won’t want to end life, as there will be those who think it is the correct thing to do — just as today there are doctors unwilling to perform abortions and those who think it is correct. (I believe) it is more important to leave consequence out of it and ask whether the act itself is acceptable. This may be hard to do, since modern rhetoric concentrates heavily on arguing to consequences — to its detriment, IMO.

In any case, I don’t think terminal dehydration and PA suicide are similar. It might be useful to define some terms:
- Euthanasia can either be voluntary (proceeds from competent patient request), involuntary (proceeds against the will of the patient) or non-voluntary (involves an individual who is not competent to give consent). For our purposes, let’s just presume we are speaking of voluntary (though the slippery slope argument suggests that one quickly moves to other types upon permitting voluntary).
- VAE voluntary active euthanasia: physician kills the patient (administers a lethal dose)
- VPE voluntary passive euthanasia: physician allows the patient to die (“pulls the plug”)
- PAS physician assisted suicide: physician provides the means (information, prescription, needles, etc) for a patient to kill themselves

As you say, in the case of PAS the physician “merely gives the patient a prescription” and it is up to the patient to actually do the deed. But you act as if this is no small thing. But the APA disagrees, they see using medical knowledge to bring about death as a basic violation of the hippocratic oath and the meaning of their vocation. And while the physician does not do the actual killing, by providing the means they are clearly complicit in the act. The doctor is made to participate in the hastening of death where the cause of death will not be natural.

This leads to your next point. You ask how “pulling the plug” (VPE) is different than assisted suicide. A good question. But I think the view that there is no difference between the two involves a metaphysical confusion about causes.
Case A (VPE): Patient with terminal cancer. Doctor removes them from life-extending treatment (chemo, whatever). The patient dies. Cause of death: cancer.
Case B (PAS): Patient with terminal cancer. Doctor gives them a prescription for a lethal dose of morphine and instructs them on how to administer it. The patient dies. Cause of death: morphine overdose.

“Killing” and “letting die” are not the same. One is an act of commission and the other an act of omission. Now it might be the case that some acts of omission are also deserving of moral blame (if I pull the plug on someone against their will, for instance). But looking at the two hypothetical cases above, in the first case the cause of death is man and in the latter case the cause of death is the illness. No one, in Case A, would say “cause of death was the doctor pulling the plug”. What they would rightly say is, “cause of death was cancer.”

That we are tempted to think that these two things are identical suggests a deeper problem – the underlying conceit that man has conquered nature in such a way that all events are ultimately under his control and direction.

Battlefield assisted suicide seems very problematic. Almost no one – not even assisted suicide advocates – think that this should be allowed as an “on the spot” kind of choice. Psychological evaluations would be required to make sure the person is mentally and emotionally stable, for instance. Hard to see how you would satisfy all of the regulatory precautions on a battlefield.

One point of clarification here: people are free to kill themselves. Suicide is not illegal (and it would be pretty hard to punish!). The question here is whether or not people have a right to insist that other people (physicians) assist them in killing themselves. Again, people can already choose to die through terminal dehydration. This right is well-established based on the principle of autonomy that is pretty basic to medical ethics.

I think your point about hospice care makes a lot of sense, but aren’t there cases where all the morphine and counseling in the world still leave the patient trapped in a bed, either in agonizing pain or only a very hazy consciousness? Are there never cases where one’s quality of life is so low that it’s too much to ask a person to go on? And what about cases (say on an isolated battlefield in a war) where access to good end-of-life care simply isn’t possible?

And I think assisted suicide and euthanasia are unnecessary. Following the APA, I believe that if adequate palliative and hospice care were provided, no one need suffer the horror stories of excruciating pain in terminal illness. We should put more resources to this end, and many doctors probably need better training.

I don’t think people need help dying, but in some cases they do need help seeing that their lives have meaning even in their suffering. It is a strange (and, Kant would say, irrational) thing to eliminate suffering by killing those who suffer.

I would also point out that, even if someone disagrees about the meaning of life and suffering, to demand assisted suicide (to say you have the “right to die”) implies that someone has the duty to kill you (or to help kill you). I think it is morally wrong to participate in this dehumanization, and I am against any public policy that would require it. This is the APA’s view, which is not driven, it seems to me, out of self-protection from litigation but from the Hippocratic Oath and the very meaning of their vocation.

Look, people don’t have a right to everything that they might want. It is as simple as that.