Ethical Issues in Terminal Health Care
by Ed Newman
Published in the Truth Seeker (Volume 121 No. 5)
Medical advances have created ethical dilemmas which no previous generation of doctors has ever faced. New life-sustaining techniques and practices are forcing physicians to ask questions that never needed to be asked before. Foremost of these is: "How far do we go to save a life?"
Other questions challenge ethical traditions which have been in place for centuries. "When suffering is immeasurable and a patient's condition terminal, should doctors be permitted to end a patient's life?" "Should doctors take an active role in hastening a patient's death?"
Today, more than ever, the push is on to "change the rules." Dr. Kevorkian, while deplored by most medical professionals for his methods, is heralded as a hero on many fronts for bringing this issue into the public square. By all accounts a time of decision is upon us. When a fully conscious person requests death, should a physician -- contrary to the Hippocratic oath -- assist the person in dying?
It is the purpose of this brief article to present a concise overview of the primary arguments for and against the legalization of physician-assisted suicide. Without a careful consideration of the concerns on both sides, we can find ourselves saddled with ill-conceived policies that do not serve our best interests and will not be easily dislodged.
There are four primary arguments for legalizing physician-assisted suicide. They are:
l. The Mercy Argument, which states that the immense pain and indignity of prolonged suffering cannot be ignored. We are being inhumane to force people to continue suffering in this way.
2. The Patient's Right to Self-determination. Patient empowerment has been a trend for more than twenty-five years. "It's my life, my pain. Why can't I get the treatment I want?"
3. The Economics Argument, which notes that the cost of keeping people alive is exceedingly high. Who's footing the bill for the ten thousand people being sustained in a persistent vegetative state? Aren't we wasting precious resources when an already used up life is prolonged unnecessarily?
4. The Reality Argument runs like this: "Let's face it, people are already doing it."
The combined effect of these four arguments is persuasive. And many people I talk to have been persuaded by them. They can't imagine why we have waited so long to make this an alternative treatment option. The need for legalized physician-assisted suicide is self-evident, they conclude.
But then, as I present the arguments in opposition to these apparently self-evident truths, I invariably hear an "A-ha!" and an "Oh!" and "Well, I never considered..."
And so we give ear to the reverse side of the coin.
There are a variety of arguments against legalizing physician- assisted suicide. Here are the most widely cited concerns:
l. Medical doctors are not trained psychiatrists. Many, if not most, people have wished they could die rather than face some difficult circumstance in their lives. Doctors who are given authority to grant this wish may not always recognize that the real problem is a treatable depression, rather than the need to fulfill a patient's death wish. Perhaps Bob Liston's posting in the General Debate Forum of America Online said it best when he wrote, "I know many individuals with significant disabilities: quadriplegia, post-polio survivors, persons with MS, etc. A number of them have tried committing suicide in the past and are now thankful that a mechanism wasn't in place that would have assured their death, because they got over whatever was bothering them at the time and are happy with life again."
2. How will physician-assisted suicide be regulated? This is Carlos Gomez's forced argument, developed after investigating the Netherlands' experience, and presented in his book Regulating Death. "How will we assure ourselves that the weak, the demented, the vulnerable, the stigmatized -- those incapable of consent or dissent -- will not become the unwilling objects of such a practice? No injustice," Gomez contends, "would be greater than being put to death, innocent of crime and unable to articulate one's interests. It is the possibility -- or in my estimation, the likelihood -- of such injustice occurring that most hardens my resistance for giving public sanction to euthanasia."
3. The "Slippery Slope" Argument. A Hemlock Society spokesperson acknowledges this to be the strongest argument against legalization. In ethical dialogue, it is conceded that there are situations when an acceptable action should not be taken because it will lead to a course of consequent actions that are not acceptable. Our attitudes toward the elderly, people with disabilities and the devaluation of individuals for the "higher good of society" should be reflected upon. How long will it be before our "right to die" becomes our "duty to die"?
4. The "Occasional Miracle" Argument. Sometimes remarkable recoveries occur. Sometimes diagnoses are far afield of the reality. Countless stories could be told. I know a few first hand. How about you?
5. Utilitarian versus sacred view of life. This is probably a subset of the Slippery Slope argument, focusing on our cultural shift in attitude toward what it means to be human. Huxley's Brave New World vividly demonstrates an aspect of this argument. We need to be reminded of the role social engineers, doctors and geneticists played in 1930's Germany. Are we important only as long as we are making a contribution to society? Or is value something inherent in our being human? History has shown that when we devalue human beings, we open the door to abuse. The U.S. Supreme Court, in its Dred Scott decision, declared that blacks were not persons. This devaluation helped permit slavery and inhumane treatment of blacks to continue.
6. What effect will this have on doctor/patient trust? People who traditionally rely on their doctors to provide guidance in their health care decisions may become confused, even alarmed, when one of the treatment options presented is the death machine at the end of the hall. According to Leon R. Kass, distinguished M.D. from the University of Chicago, the taboo against doctors killing patients, even on request, "is the very embodiment of reason and wisdom. Without it, medicine will have lost its claim to be an ethical and trustworthy profession." Kass asserts that "patient's trust in the whole-hearted devotion to the patient's best interests will be hard to sustain once doctors are licensed to kill."
7. What about doctors who don't believe in killing? Will they be required by law to prescribe a treatment [death] they don't believe in?
Clearly, the ethical dilemmas surrounding terminal health care will be with us for years to come. There are more than seventy million baby boomers in this country, most of whom are currently grappling with the issue of aging parents. And in the decades to come we ourselves won't be getting any younger.
Ironically, our current situation is due in large part to the successes of medical science, not its failures. More people live longer today than ever in history because we have eliminated many of the diseases that once terrorized us as a society.
But some of the problem is due in part to our love affair with technology. When machines, tubes and computers take over, compassion and common sense sometimes seem to suffer. Fortunately, there seems to be an increased awareness of the intrusiveness of technology. Living wills, ethics committees and hospice care are all responses to this awareness.
How we choose to die in America is a complicated subject that needs clear thinking and a fair discussion of the ethical and technical dilemmas surrounding it. But let's keep in mind that even if we agreed that death technologies are wrong, this would not be an endorsement of the notion that people must be kept alive for as long as possible at any cost.
Any information in this article pertaining to legal or medical matters is not to be construed as professional advice. Copyrights remain the property of the authors.
A variation of this article originally appeared in The Senior
Reporter in the summer of 1992.
Part One: Issues and Their Implications
Part Two: Ethics Committees
Part Three: Local Perpsectives on the Right-to-Die Debate
Part Four: Patients Have Rights, But Doctors Have Rights, Too
Part Five: The Pros and Cons of Physician Assisted Suicide
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