Educated at Yale, Georgetown, and Harvard, Daniel Callahan was a cofounder of The Hastings Center, the first institute for bioethics, in 1969, and served as its president from 1969–1996. Callahan’s interests in bioethics range from the beginning to the end of life, and in later years have focused on health policy and research policy with an increasing concern for global issues. He is the author or editor of some 40 books. Particularly influential has been Setting Limits: Medical Goals in an Aging Society, which launched an extensive discussion of intergenerational justice and the appropriate limits of health care for the elderly.
In the article excerpted here, Callahan responds to the claims of those supporting legalization of physician-assisted suicide in terminal illness. Callahan argues against this view on three grounds: that euthanasia and assisted suicide are evil, or more accurately, “morally mistaken”; that while physical pain and psychological suffering in the terminally ill are to be alleviated, assisted dying is not the way to do it; and that allowing physician-assisted suicide will risk wider killing based on “private standards of a life worth living”—the slippery slope argument. These are among the most prominent arguments in the case against legalization of assisted dying.
Daniel Callahan, “Reason, Self-determination, and Physician-Assisted Suicide,” in Kathleen Foley and Herbert Hendin, eds., The Case against Assisted Suicide: For the Right to End-of-Life Care. Baltimore and London: Johns Hopkins University Press, 2002, pp. 52–68. Biographical material in the introductory passage from The Hastings Center.
from REASON, SELF-DETERMINATION, AND PHYSICIAN-ASSISTED SUICIDE
Claiming the right to control our bodies and our lives is characteristically American. “Give me liberty or give me death” is a part of our history. It could thus well be said that the physician-assisted suicide movement represents the last, definitive step in gaining full individual self-determination: “Give me liberty and, if I want it, give me death.” As a movement, physician-assisted suicide seeks to reassure us that we can die as we choose and, with a physician’s expert help, be certain that we will die in the most technically expeditious fashion.
However mistaken in its direction and emphasis (as I will argue it is), a turn to physician-assisted suicide is a perfectly understandable response to the increased difficulty of dying a peaceful death, a dying ever more ensnared in technological and moral traps. First, there are all the cultural and medical obstacles now thrown in the way of simply allowing people to die from disease. Medicine tends to conflate the value of the sanctity of life and the technological imperative, rendering an acceptance of death morally suspect. Moreover, by increasingly judging all deaths to be events for which humans can and should take responsibility, we are blurring the distinction between killing and allowing to die; there is now every incentive to seek final and decisive control over the process of dying. Physician-assisted suicide seems to present the perfect way to do just that.
The physician-assisted suicide movement rests on two basic claims, secondarily supported by other considerations as well. Those claims are our right to self-determination and the obligation we all owe to each other to relieve suffering, but especially the obligation of the physician to do so. The movement’s deepest point might simply be understood as this: If we cannot trust disease to take our lives quickly or peacefully, and we cannot rely on doctors to know with great precision how or when to stop treatment to allow that to happen, then we have a right to turn to more direct means. In the name of mercy, physicians should be allowed to end our lives at our voluntary request, or, alternatively, be permitted to put into our hands those means that will allow us to commit suicide. We will then be assured a peaceful death, one that we have fashioned for ourselves. For the peaceful death no longer (and never assuredly and perfectly) given us by nature, we must shape, by our choice, a death of our own making.
This is a dangerous direction to go in the search for a peaceful death. This path to peaceful dying rests on the illusion that a society can safely put in the hands of physicians the power directly and deliberately to take life, euthanasia, or to assist patients in taking their own life, physician-assisted suicide. (I see no moral difference between them—just as the law in most places would see no difference between my shooting someone and my giving a gun to another so he or she can do it.) It threatens to add still another sad chapter to an already sorry human history of giving one person the liberty to take the life of another. It perpetuates and pushes to an extreme the very ideology of control—the goal of mastering life and death—that created the problems of modern medicine in the first place. Instead of changing the medicine that generates the problem of an intolerable death (which, in almost all cases, good palliative medicine could do), allowing physicians to kill or provide the means to take one’s own life simply treats the symptoms, all the while reinforcing, and driving us more deeply into, an ideology of control.
The suffering that leads people to embrace physician-assisted suicide can seem compelling: prolonged agony; a sense of utter futility; pain that can be relieved only at the price of oblivion; a desperate gasping for breath that, if relieved, will be followed again and again by the same gasping; or the prospect of months or years in a nursing home, or dependent on a trapped, overburdened family member. The possibilities of suffering, physical and psychological, should not be minimized, and I do not want to rest my resistance to physician-assisted suicide on any slighting of that kind. I can well imagine situations that could drive me to want such relief or feel driven to want it for others. The movement to legalize euthanasia and assisted suicide is a strong and, seemingly, historically inevitable response to that fear. It draws part of its strength from the failure of modern medicine to reassure us that it can manage our dying with dignity and comfort. It draws another part from the desire to be masters of our fate. Why must we endure that which need not be endured? If medicine cannot always bring us the kind of death we might like through its technical skills, why can it not use them to give us a quick and merciful release?
The Relief of Suffering: Virtues and Duties
No moral impulse seems more deeply ingrained than the need to relieve human suffering. It is a basic tenet of the great religions of the world. It has become a foundation stone for the practice of medicine, and it is at the core of the social and welfare programs of all civilized nations. Unless we have been brutalized, our feelings numbed by cruelty or systematic indifference, we cannot stand to see another person suffer. The tears of another, even a total stranger, can bring tears to our own eyes. At the heart of the virtue of compassion is the capacity to feel with, and for, another. With those closest to us, that virtue often leads us to feel the pain of another as if it were our own. And sometimes it is stronger than that: it is a source of intensified anguish that we cannot lift from another the pain we would, if we could, make our own. A parent feels that way about the suffering of a child, and a spouse or friend about the suffering of a loved one who is trapped by pain that cannot be moved from one body to another.
Yet for all the depth of our common response to suffering, and our general agreement as a civilized society that it should be relieved, the scope and depth of that moral duty are not clear, especially for physicians. The problem of physician-assisted suicide forces us to answer a hard question: Ought the general duty of the physician to relieve suffering encompass the right to assist a patient to take his or her own life if that is desired and seems necessary? The question can be put from the patient’s side as well: Is it a legitimate moral request for a patient to ask a doctor for assistance in committing suicide?
But there is an even more fundamental question that must be explored before turning to those questions: What should be done in response to such suffering? Is it simply a nice thing to relieve suffering if we can, a gesture of charity or kindness worthy of praise? We might say that our impulse of compassion is a good to be cultivated and expressed—that we will all be better off if we entertain that as an ideal in our lives together. Or is there more to it than that? Might it be that the relief of suffering is a moral duty, not just a noble ideal, to which we are obliged even if our sense of compassion is faint, even if what is asked of us might cause some suffering on our own part? How far and in what way, that is, does our duty extend in the relief of suffering, and just what kind of suffering is encompassed within such a duty?
One common answer to such questions is that we are, at the least, obliged to relieve the suffering of others when we can do so at no high cost to ourselves, and that we should do so when the suffering at stake is unnecessary. But that does not tell us much that is helpful, though it is surely important to repeatedly remind ourselves and others of such obligations. The hard cases are those in which the demands on us may be morally or psychologically stressful, and in which there is uncertainty about the significance of the suffering.
It is useful to distinguish two kinds of burdens. In one, the demand on us is to act, to do something specifically to relieve the suffering. That may mean giving our already overcrowded time just to be with someone in pain, someone whose first need is for companionship, for closeness; or providing otherwise needed money to improve the nursing care of a dying parent; or taking the trouble to find a better doctor, or hospital, for a spouse receiving poor care. Demands of that kind can be heavy, pressing our sense of duty to the limit; sometimes it can be unclear just where the limit is.
The other burden is subtler: the need to discern when suffering cannot, or should not, be wholly overcome, when our duty may be to accept the suffering of another, just as the person whose suffering it is must accept it. Many legitimate moral demands, for instance, will carry with them the possibility of suffering, and they should not for that reason be shirked. To take an unpopular position, to stand up for one’s rights, to remain true to one’s promises and commitments can all entail unavoidable suffering. A parent’s commitment to the good of a child may require, and probably will at times require, that for the sake of the child’s development the parent accept the need for the child to bear the penalties of his or her own choices and mistakes, and thereby to suffer as a parent is watching that happen. The same can be said of many other human relationships—those with friends, lovers, husbands, and wives. As bystanders to the suffering, we have to accept its unavoidability for the sufferer. We cannot relieve that suffering. The demand in some cases is to accept the suffering that another must endure, not run from it. Patience, loyalty, steadfastness, and fortitude are called for in accompanying the persons who must suffer, to help and allow them to do and be what they must, however heavy the burden on them and others. We are called on to suffer with the other, to be a supportive presence.
For just those reasons it cannot be fully correct to say that our highest moral duty to each other is the relief of suffering. More precisely, our duty is to enhance one another’s good and welfare, and the relief of suffering will ordinarily be an important way to accomplish that. But not always. What we need to know is whether the suffering exists because without it some other human good cannot be attained; and that is exactly the case with the suffering caused by living out one’s moral duties or ideals for a life.
Therein lies the ambiguity of the term “unnecessary suffering,” frequently invoked as the kind of suffering physician-assisted suicide can obviate. Suffering will surely be “unnecessary” when it serves no purpose, when it is not an inextricable part of achieving important human goals. Unavoidable necessary suffering, by contrast, is that which is the essential means, or accompaniment, of valuable human ends, and not all suffering is. Yet the real problem here is in deciding on our goals, and the hardest choice will be in deciding whether, and how, to pursue goals that may entail suffering. If we make the avoidance or relief of suffering itself the highest goal, we run the severe risk of sacrificing, or minimizing, other human purposes. Life would then be focused on avoiding pain, minimizing risk, and craftily eying all possible life projects and goals in light of their likelihood of producing suffering.
If that is hardly desirable in the living of our individual lives, it is no less problematic in devising social policy. A society ought, so far as it can, to work for the relief of pain and suffering; and that is to state a simple moral principle. But a more complex principle is needed: A society should work to relieve only suffering that is not an unavoidable part of living out its other values and aspirations. That means it must ask, on the one hand, what those values are or should be and, on the other, what policies for the relief of suffering might subvert society’s general values.
The most profound question we must then ask is this: If the suffering of illness and dying comes from the profound assault on our sense of integrity and self-direction, what is the best way we can—as those who give care, who want to do right by a person—honor that integrity? The claim of proponents of physician-assisted suicide is that the assault of terminal illness on the self is legitimately relieved, even mercifully and honorably so, by recognizing the right to self-determination to end that life.
Yet notice what we have accepted here. It is the idea that our integrity can be served only by the self-determination that brings death, by the direct implication of another in our death, and by accepting the implicit assumption that the suffering is “unnecessary”—meaningless, avoidable. To accept that comes close to declaiming that life can have meaning only if marked by self-determination, a strange notion indeed, flying directly in the face of human experience. That experience shows that a noble and heroic life can be achieved by those who have little or no control over the external conditions of their lives, but have the wisdom and dignity necessary to fashion a meaningful life without it. We would also be declaring that a life not marked by self-mastery, self-determination, is a meaningless one once burdened with unwanted suffering. It is not for nothing perhaps that modern medicine in its quest for cure has itself contributed to the harmful idea that all suffering is pointless, representing not life and its natural condition but the failure of medicine to overcome, or relieve, that suffering.
Is Self-empowerment Socially Neutral?
But might it not be said, in response, that permitting physician-assisted suicide would not involve taking a general position on the meaning of life, death, and suffering, but only empowering each individual and his or her physician-accomplice to make that determination? Would it not be, in that sense, socially neutral? Not at all. To establish physician-assisted suicide as social policy is, first, to side with those who say that some suffering is meaningless and unnecessary, to be relieved as decisively as possible, and that only individuals can determine what such suffering is; and, second, to say that such a highly variable, highly subjective matter is best left to the irrevocable judgment of doctor and patient. That is not a neutral policy at all, but one that makes a final judgment about what constitutes an appropriate, socially acceptable response to dying (the mutually agreed-on deliberate death of a person) and about social policy (the legitimation of physician-assisted suicide as a response to perceived threats of suffering and loss of self-integrity).
A great hazard of this approach is that it declares some forms of human suffering—but only those forms determined by private, variable responses—to be so beyond human help and caring that they are open only to death as a solution. It is, moreover, a striking break with both the medical and moral traditions of medicine to treat the desires and wishes of patients as if they alone legitimate a doctor’s skills. It is to make doctors artisans in the fashioning of a patient’s life (and in this case death), a role well beyond the traditional role of medicine, which has been to restore and maintain health.
There is little disagreement about the duty of the physician to relieve physical pain, even though there are some significant disputes about how far that effort should go. Of more pertinence to my concern here, however, is the extent of the duty of the physician to relieve suffering, that is, to try to relieve the psychological or spiritual condition of a person who as a result of illness suffers (whether in pain or not). I contend that the duty is important but limited.
Two levels of suffering can be distinguished. At one level, the principal problem is that of the fear, uncertainty, dread, or anguish of the sick person in coping with the illness and its meaning for the continuation of life and intact personhood—what might be called the psychological penumbra of illness. At a deeper level, the problem touches on the meaning of suffering for the meaning of life itself. The question here is more fundamental: What does my suffering tell me about the point or purpose or end of human existence, most notable my own? The questions here are no longer just psychological but encompass fundamental philosophical and religious matters.
The physician should do all in his or her power to respond, as physician, to the first level, but it is inappropriate, I contend, to attempt to solve by lethal means the problems that arise at the second level. What would that distinction mean in practice? It means that the doctor should, through counseling, pain relief, and cooperative efforts with family and friends, do everything possible to reduce the sense of dread and anxiety, of disintegration of self, in the face of a threatened death. The doctor should provide care, comfort, and compassion. But when the patient says to the doctor that life no longer has meaning, or that the suffering cannot be borne because of its perceived pointlessness, or that a loss of control is experienced as an intolerable insult to a patient’s sense of self—at that point the doctor must draw a line. Those problems cannot properly be solved by medicine, and it is a mistake for medicine even to attempt to solve them.
The purpose of medicine is not to relieve all the problems of human mortality, the most central and difficult of which is why we have to die at all or die in ways that seem pointless to us. The purpose of medicine is not to give us control over our human destiny, or to help us devise a life to our private specifications—and especially the specification most desired these days, that of complete control of death and its circumstances. That is not the role of medicine because medicine has no competence to manage the meaning of life and death, only the physical and psychological manifestations of those problems.
Medicine’s role must be limited to what it can appropriately do, and it has neither the expertise nor the wisdom necessary to respond to the deepest and oldest human questions. What it can do is relieve pain and bring comfort to those who psychologically suffer because of illness. That is all, and that is enough. When physicians would use medical knowledge, designed to help with that task, to directly cause death as a way of solving a patient’s problems with life and mortality itself, they go too far, exceeding their own professional and moral rights. There has been a longstanding, historical resistance to giving physicians the power to assist in suicide precisely because of the skill they could bring to that task. Their technical power to help death along must not be matched by a moral or legal authority to engage in physician-assisted suicide; that would open the way for a corruption of their vocation.
I do not claim that a sharp and precise line can always be found between the two levels of suffering, but only that some limits can be feasibly set to enable us to say when the physician has strayed too far into the thickets of the second level. For ordinary purposes, it remains appropriate to speak of the duty of the physician to “relieve pain and suffering,” but only as long as it is understood that this can be done to relieve only the problems of illness, not the problems of life itself. What life itself may give us, at its end, is a death that seems, in the suffering it brings, to make no sense. That is a terrible problem, but it is the patient’s problem, not the doctor’s. The doctor can, at that point, relieve pain, make the patient as comfortable as possible, and be another human presence. Beyond that, the patient must be on his or her own. Patients have no resource left but themselves at that point.
Suffering and Subjectivity
There is also another side to the issue. When physician-assisted suicide is requested, the doctor is being asked to act on the subjective suffering of another—variable from person to person, externally unverifiable, and always in principle reversible—with an action that will be objective and irreversible. As the human response to evil and suffering suggests, there is nothing in a particular burden of life, or in the nature of suffering itself, that necessarily and inevitably leads to a desire to be dead, much less a will to bring that about. That will and must always be a function of the patient’s values and the way those values are either legitimated or rejected by the culture of which that patient is a part. Suffering in and of itself is not a good clinical predictor of a desire to be dead, which is why depression or a history of previous mental health problems is a far better predictor of a serious desire for suicide than illness, pain, or old age is. Thus we face a complex double challenge: to determine if, under those ambiguous circumstances, we should empower one person to help another to kill him- or herself; and if so, what the moral standard should be for the one who is to do the helping.
Physician-assisted suicide is mistakenly understood as only a personal matter of self-determination, the control of our own bodies, not to be forbidden since it is only a small step beyond our no longer forbidding suicide. But unlike unassisted suicide, an act carried out solely by the person, physician-assisted suicide should be understood as a social act. It requires the assistance of someone else. Legalizing physician-assisted suicide would also provide an important social sanction for suicide, tacitly legitimating it, and affecting many aspects of our society beyond the immediate relief of individual suffering. It would in effect say that suicide is a legitimate and reasonable way of coping with suffering, acceptable to the law and sanctioned by medicine. Suicide is now understood to be a tragic situation, no longer forbidden by the law but hardly anywhere understood as the ideal outcome of a life filled with suffering. That delicate balance would be lost and a new message delivered: Suicide is morally, medically, legally, and socially acceptable.
All civilized societies have developed laws to reduce the number of situations in which one person is allowed to kill another. Most have resisted the notion that private agreements can be reached allowing one person to help another take his or her life. Traditionally, three circumstances have primarily been acceptable for the taking of life: killing in self-defense or to protect another life, killing in the course of a just war, and killing in the case of capital punishment. Killing in war and killing by capital punishment have been opposed by some, more successfully in the case of capital punishment, which is now banned in many countries, most notably in western Europe.
The proposal to legalize physician-assisted suicide is nothing less than a proposal to add a new category of acceptable killing to those already socially legitimated. To do so would be to reverse the long-developing trend to limit the occasions of legally sanctioned killing (most notable in the campaigns to abolish capital punishment and to limit access to handguns). Civilized societies have slowly come to understand how virtually impossible it is to control even legally sanctioned killing. Even with carefully fashioned safeguards, having legally sanctioned killing invites abuse and corruption.
Does it not make a difference that the absolute power is given, not to subjugate another (as in slavery), but as an act of mercy, to bring relief from suffering? No. Although the motive may be more benign than in the case of slavery as usually understood, that motive is beside the point. The aim in prohibiting physician-assisted suicide is to avoid introducing into society the inherent corruption of legitimated private killing. “All power corrupts,” Lord Acton wrote, “and absolute power corrupts absolutely.” It is that profound insight—a reflection on human despotism, usually justified initially out of good, empathetic motives—that should be kept in mind when we would give one person the right to kill another.
We come here to a striking pitfall of the common arguments for physician-assisted suicide. Once the key premises of that argument are accepted, there will remain no logical way in the future to (1) for long hold the line against euthanasia, to take care of those physically or psychologically unable to take their own lives; (2) deny euthanasia to any competent person who requests it for whatever reason, terminal illness or not; and (3) deny euthanasia and physician-assisted suicide to those who suffer but are incompetent, even if they do not request it. I am not saying that such a scenario will in fact take place, but only that the arguments given in favor of euthanasia logically entail the possibility. We can erect legal safeguards and specify required procedures to keep that scenario from coming to pass, but over time they will provide poor protection if the logic of the moral premises on which they are based is fatally flawed. The safeguards will appear arbitrary and flimsy and will invite covert evasion or outright rejection.
The Logic of the Arguments
Where are the flaws in these arguments? Recall that there are two classical arguments in favor of euthanasia and assisted suicide: our right of self-determination, and our claim on the mercy of others to relieve our suffering if they can do so, especially our claim on doctors. These two arguments are typically spliced together and presented as a single contention. Yet if they are considered independently—and there is no inherent reason they must be linked—they display serious problems. Consider first the argument for our right of self-determination. It is said that a competent adult ought to have a right to physician-assisted suicide for the relief of suffering. But why must the person be suffering? Does not that stipulation already compromise the right of self-determination? How can self-determination have any limits? Why are not the person’s desires or motives, whatever they be, sufficient? How can we justify this arbitrary limitation of self-determination? The standard arguments for physician-assisted suicide offer no answers to those questions.
Consider next the person who is suffering but not competent, perhaps demented or mentally retarded. The standard argument would deny euthanasia and physician-assisted suicide to that person. But why? If a person is suffering but not competent, then it would seem grossly unfair to deny that person relief simply because he or she lacked competence. Are the incompetent less entitled to relief from suffering than the competent? Will it only be affluent, middle-class people, mentally fit and able, who can qualify? Will those who are incompetent but suffering be denied that which those who are intellectually and emotionally better off can have? Would that be fair? Do they suffer less for being incompetent? The standard argument about our duty to relieve suffering offers no response to those questions either.
Is it, however, fair to euthanasia advocates to do what I have done, to separate and treat individually the two customary arguments in favor of a legal right to euthanasia and physician-assisted suicide? The implicit reason for joining them is no doubt the desire to avoid abuse. By requiring a showing of suffering and terminal illness, the aim is to exclude perfectly healthy people from demanding that, in the name of self-determination and for their own private reasons, another person can be called on to kill them or assist them in suicide. By requiring a show of mental competence to effect self-determination, the aim is to exclude the nonvoluntary or involuntary killing of those who are depressed, retarded, or demented.
My contention is that the joining of those two requirements is perfectly arbitrary, a jerry-rigged combination if ever there was one. Each has its own logic, and each could be used to justify euthanasia and physician-assisted suicide. But that logic, it seems evident, offers little resistance to denying any competent person the right to be killed, sick or not, and little resistance to killing those who are not competent, so long as there is good reason to believe they are suffering, There is no principled reason to reject that logic, and no reason to think it could long remain suppressed by the expedient of an arbitrary legal stipulation that both features, suffering and competence, be present. In fact, in its statutes on physician-assisted suicide, the state of Oregon requires a terminal illness only, not a condition of suffering also. The result, of course, has been to remove a potential barrier to physician-assisted suicide.
There is a related problem worth considering. If the act of physician-assisted suicide, conventionally understood, requires the uncoerced request and consent of the patient, it no less requires that the person to do the assisting have his or her own independent moral standards for acceding to the request. The doctor must act with integrity. How can a doctor who voluntarily brings about, or is instrumental in, the death of another legitimately justify that act? Would the mere claim of self-determination on the part of someone be sufficient? “It is my body, doctor, and I request that you help me kill myself.” There is historical resistance to that kind of claim, and doctors quite rightly have never been willing to do what patients want solely because they want it. To do so would reduce doctors to automatons, subordinating their integrity to patient wishes or demands. There is surely a legitimate fear, moreover, that if such claim were sanctioned, there would be no reason to forbid any two competent persons from entering into an agreement for one to kill the other, a form of consenting-adult killing. Perhaps the resistance also arises out of a reluctance to put doctors in the role of taking life simply as a means of advancing patient self-determination, quite apart from any medical reasons for doing so.
The most likely reason for resistance to a pure self-determination standard is that our culture has, traditionally, defined a physician as someone whose duty is to promote and restore health. It has thus been customary, even among those pressing for euthanasia and physician-assisted suicide, to hang on to some part of the physician’s traditional role. That is why a mere claim of self-determination, which requires no reference to health at all, is not enough. A doctor will not cut off my healthy arm simply because I decide my autonomy and well-being would thereby be enhanced.
What may we conclude from these still-viable traditions? To justify committing an act of physician-assisted suicide and still maintain professional and personal integrity, the doctor must have his or her own independent moral standards. What should those standards be? The doctor will not be able to use a medical standard. A decision for physician-assisted suicide is not a medical but a moral decision. Faced with a patient reporting great suffering, a doctor cannot, therefore, justify physician-assisted suicide on purely medical grounds. The doctor must believe that a life of subjectively experienced intense suffering is not worth living in order to feel justified in taking the decisive and ultimate step of killing the patient. It must be the doctor’s moral reason to act, not the patient’s reason (even though their reasons may coincide). But if the doctor believes that a life of some form of suffering is not worth living, then how can the doctor deny the same relief to a person who cannot request it, or who requests it but whose competence is in doubt? There is no self-evident reason why the supposed duty to relieve suffering must be limited to competent patients claiming self-determination—or why patients who claim death as their right under self-determination must be either suffering or dying.
There is, moreover, the possibility that what begins as a right of doctors to engage in physician-assisted suicide under specified conditions will soon become a duty to offer it up front to patients. On what grounds could a doctor deny a request by a competent person for physician-assisted suicide? It is not sufficient just to stipulate that no doctor should be required to do that which violates his or her conscience. As commonly articulated, the arguments about why a doctor has a right to assist in suicide—the dual duty to respect patient self-determination and to relieve suffering—are said to be central to the vocation of being a doctor. Why should duties as weighty as those be set aside on the grounds of “conscience” or “personal values”?
These puzzles make clear that the moral situation is radically changed once our self-determination requires the participation and assistance of a doctor. Executing our will is no longer a solitary act but a social act requiring two people. It is then that doctor’s moral life, that doctor’s integrity, that is also and no less encompassed in the act of physician-assisted suicide. What, we might then ask, should be the appropriate moral standards for a person asked to assist in a suicide? What are the appropriate virtues and sensitivities of such a person? How should that person think of his or her own life and find, within that life, a place for physician-assisted suicide?
Now I could imagine someone granting the weight of the considerations against euthanasia I have advanced and yet having this response: Is not our duty to relieve suffering sufficiently strong to justify running some risks? Why should we be intimidated by the dangers in decisive relief of suffering? Is not the present situation, where death can be slow, painful, and full of suffering, already a clear and present danger?
Our duty to relieve suffering—by no means unlimited in any case—cannot justify the introduction of new evils into society. The risk of doing just that in the legalization of physician-assisted suicide is too great, particularly since the number of people whose pain and suffering could not be otherwise relieved would never be large (as even most physician-assisted suicide advocates recognize). It is too great because it would take a disproportionate social change to bring it about, one whose implications extend far beyond those who are sick and dying, reaching into the practice of medicine and into the sphere of socially sanctioned killing. It is too great because, as the history of the twentieth century should demonstrate, killing is a contagious disease, not easy to stop once unleashed in society. It is too great a risk because it would offer medicine too convenient a way out of its hardest cases, those in which there is ample room for further, more benign reforms. We are far from exhausting the known remedies for the relief of pain (frequently, even routinely, underused) and a long way from providing decent psychological support for those who, not necessarily in pain, nonetheless suffer because of despair and a sense of futility in continuing life.
Reason, Rationality, and Physician-Assisted Suicide
Could it not be said, however, in those cases in which physicians cannot relieve the suffering of a patient, that suicide would be a rational act for that patient? “Rational suicide,” as it has sometimes been called, surely has a kind of initial plausibility. Death is a definitive way to rid oneself of suffering and, if life with the suffering seems not worth living, then it would seem rational to be rid of that life.
In trying to evaluate this line of thought, some distinctions are necessary. The first is the need to distinguish between the rational and the reasonable. In its most minimal sense, an act can be said to be “rational” if it is consistent with the premises behind it. It does not matter what the premises are as long as the conclusion logically follows. In that sense, if it is believed that life is not worth living, then it is rational to end that life. It was no less rational for the Nazis, operating on the premise that inferior groups stood in the way of some imagined superior race, to conclude that it would be best to eliminate them. This form of rationality might be called instrumental rationality: it is indifferent to the quality of the premises and is interested only in coming up with deductions or conclusions consistent with them. Given consistent deductions or conclusions, the criterion of “rational” has been met.
The notion of what is “reasonable,” however, is meant to deal with the failings of instrumental rationality. Good, reasonable premises can stand up to careful scrutiny. Being “rational” in the sense specified above is the easy part. Knowing what is a justifiable premise is the hard part. The history of moral and political debates has shown that rational errors, displaying bad and inconsistent reasoning, are possible but that far more common is disagreement about premises.
Hence, the important question is not whether suicide can be rational—it surely can be in the narrow instrumental sense—but whether it is a reasonable way for human beings to deal with suffering. There are good reasons to doubt this. One of them is the simple fact, which any physician (or even layperson) can readily verify, that there seems to be no correlation whatever between the suffering a person may undergo and a decision to commit suicide. Put another way, if suicide is seen as a rational way to handle suffering, why is suffering a poor predictor of suicide (and thus—one might speculate in the absence of any clear data on this point—of physician-assisted suicide as well)? Both the Dutch experience and the early evidence from Oregon suggest that suicide is most attractive to those who fear a loss of control—and that, as a general rule, the majority of people who commit suicide have some history of mental illness. That history hardly proves suicide to be irrational in any and all cases, but it does give credence to the view that suffering at the end of life is rarely a predictor of suicide—and one test of rationality is whether there is some general and observable consistency between the fact of suffering and the choice of suicide. There simply is no such consistency.
Why is that? I surmise that since life in general—and not just the end of life—can be filled with tragedy and suffering, it is generally judged unreasonable to use suicide as a way of coping with tragedy and suffering. On the contrary, whether it is death from cancer, or the loss of a beloved spouse, or a broken romance, or an economic failure, in almost every culture suicide has not been considered an appropriate response.
There are two likely reasons for this. One of them is that since suffering is likely to be part of every life at one or more stages, life should not end when it occurs. The other reason (and here I speculate) is that there is a kind of perceived or felt duty to bear suffering as a form of mutual human support. The kind of despair that suicide represents is a temptation for all of us when life is miserable. But my ability to put up with it, to show it can be endured, is helpful to my neighbor when he or she is miserable. We all suffer at one point or other, and we all need the witness of each other that we can get through it. If we are essentially social creatures, not simply isolated individuals, then our life with other people will affect the way we look at life; we will learn from them just as they will learn from us. Suicide is, in that sense, not a private act at all. Families have to live with its aftermath, even as do those who only collect the bodies of those who have committed suicide. We are all models for each other’s lives, even if we are not aware of it. A society that accepted suicide as a way of life would be creating a set of models: those who chose to reject the earlier tradition of solidarity in favor of a more contemporary tradition of self-determination and the evasion of suffering.
It is probably some such insight that lies behind the traditional religious rejection of suicide and not, as more commonly thought, the belief that God is the author of life and thus has the final say over its disposal. In any event, I judge it to be reasonable to resist suicide as a way to manage suffering and unreasonable to think about it solely in instrumental terms, that is, that it ends our lives and thus releases us from misery.
Curing One Evil with Another
Physical pain and psychological suffering among those who are critically ill and dying are great evils. The attempt to relieve them by the introduction of euthanasia and assisted suicide is an even greater evil, or to speak more accurately, is even more gravely morally mistaken, a softer notion that does not presuppose malicious motives. Those practices threaten the future security of the living. They no less threaten the dying themselves. Once a society allows one person to take the life of another based on their mutual private standards of a life worth living, there can be no safe or sure way to contain the deadly virus thus introduced. It will go where it will thereafter. The belief that physician-assisted suicide can be safely regulated is a myth—the confidentiality of the doctor-patient relationship makes it impossible to provide adequate oversight. Since we cannot know what goes on in the privacy of the doctor-patient encounter, we can never know whether, and to what extent, laws regulating physician-assisted suicide (and euthanasia as well) will be violated or ignored. The lack of any correlation between suffering and a desire for suicide means, of necessity, that physicians will have enormous discretion in assisting in suicide—but no way of knowing how to make a definitive evaluation of the extent of, or the legitimacy of, the suffering the patient reports.