Does Physician-Assisted Suicide Go Far Enough?

Earlier this month, New York’s Medical Aid in Dying Law came into force. This historic piece of legislation allows terminally ill New Yorkers to legally request – and receive assistance – in ending their own lives. The law makes New York the fourteenth US jurisdiction to legalize physician-assisted suicide (PAS). It’s a surprisingly low number, given that an overwhelming majority (72%) of Americans are in favor of this policy. Indeed, the way in which most jurisdictions approach PAS demonstrates a stark inconsistency in our attitudes. The American Medical Association takes a firm position on physicians taking an active role in helping a patient to die, stating that the practice is “fundamentally incompatible with the physician’s role as healer” and “would ultimately cause more harm than good.” Yet, at the same time, doctors have the prerogative to – at a patient’s request – withhold life-sustaining treatment and allow their patient to die.

This inconsistency can be made more apparent with an example. Suppose that Beatrice has received a terminal cancer diagnosis. She has only six months to live – a period of time which will be filled with nothing but extreme and unrelenting suffering. Beatrice asks for her doctor’s assistance in ending her life, so as to minimize the amount of suffering she has to endure from her cancer. In most US jurisdictions, it would be impermissible for the doctor to fulfil her wish. Suppose, then, that Beatrice happens to contract a chest infection while in hospital. This infection will, without treatment, see her die within the week. Beatrice asks that her doctor not treat the infection, so as to minimize the amount of suffering she has to endure from her cancer. In this case, it is perfectly permissible for her doctor to fulfil her wish.

And therein lies the problem. Either Beatrice has a life worth living, or she doesn’t. If her life is worth living, then everything should be done to ensure her survival – including the treatment of her infection. If, on the other hand, she doesn’t have a life worth living (if, as is the case here, the remaining six months of her life will be filled with far more bad than good) then it seems that we should seek to alleviate that suffering in the least harmful way possible. Why is it seen as permissible to allow her to succumb to an infection (a process that will involve no small amount of suffering) but impermissible to administer a drug that will see her die a quick and painless death?

Philippa Foot has claimed that the important difference lies in who ends up being “the agent of harm.” Put simply, if we stand back and allow Beatrice’s infection to run its course, then it is the pneumonia that kills her. If, however, we take an active role in ending her life, then what kills her is us.

It’s a thorny problem – but not one I want to focus on here. Rather, the question I want to consider is this: If, like New York, we decide that terminal patients should be permitted to end their lives, does PAS go far enough?

Because here’s the thing: while fourteen US jurisdictions might’ve legalized PAS, none have gone so far as to permit euthanasia. What’s the difference? While PAS allows a doctor to provide the means of a patient’s death, the administration of those means is the sole responsibility of the patient. In cases of euthanasia, however, the means of death are both provided for – and administered by – the doctor.

New York’s law, for example, explicitly requires that a patient must self-administer their life-ending medication. Why does this matter? Well, suppose that due to the progressive nature of Beatrice’s disease, she is now physically unable to administer her life-ending drugs. Perhaps her hands shake. Perhaps she has serious difficulty swallowing. The problem is this: Under New York’s legislative framework, it is perfectly permissible for Beatrice’s doctor to provide her with the means of dying. Further, if Beatrice were in perfect physical health, she would be capable of administering those means, and bringing an end to her suffering. But because of her physical ailment, she cannot do as much. She is forced to suffer. Whether or not Beatrice is actually able to end her life is therefore determined not by the severity of her suffering, but rather by the (largely irrelevant) fact of whether or not she is physically capable of administering a drug. And this seems wrong.

There are other concerns too. Self-administration – especially by someone who is undergoing enormous suffering – is more likely to go wrong than administration by a trained professional. Concerns about the misappropriation and misuse of death-inducing drugs can also be mitigated by allowing doctors to take a more active role in assisted dying.

All of this is to say that legislation like New York’s might simply not go far enough. If we accept – as fourteen US jurisdictions have – the argument that there are those who should be allowed to receive assistance in dying, then we need to ensure that the process provided does not unjustly preclude otherwise worthy individuals on irrelevant grounds.