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The final publication is available at the Springer website
Right to Die
Raphael Cohen-Almagor
University of Hull, Hull, UK
In Henk ten Have (ed.), Encyclopedia of Global Bioethics
DOI 10.1007/978-3-319-05544-2_386-1
# Springer Science+Business Media Dordrecht 2014
Abstract
This entry opens with a concise history of the right to die movement. Then it provides a
conceptual framework, explaining key terms that are often utilized by those who
advocate physician aid-in-dying: liberty, autonomy, dignity, respect, concern, quality of
life and suffering. Contra quality of life considerations, arguments relating to the sanctity
of life are presented. Reflecting on whether the physician’s role includes also
termination of life, guidelines are suggested that balance between patient’s wishes and
our shared concern to prevent abuse, explaining that while physicians cannot be
obligated to end life, those who accept that patients do have the right to die may come
to their assistance.
Key words: autonomy, dignity, ethics, euthanasia, physician-assisted suicide (PAS),
physician’s role, quality of life, suffering
Introduction
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Consider the following scenario: A patient suffers from an incurable disease and great
pain. The agonized patient loses hope and expresses a desire to die. Consequently,
she asks for the physician’s help. Those who believe life is intrinsically valuable object
to taking life and to providing aid-in-dying. They believe that end-of-life issues are
decided by nature; these are not decisions that people should take. However, this
objection ignores the autonomy of the patients’ concerned, and their explicit wishes. In
these contexts, a patient clearly says: “I would like to die. I would rather die in these
circumstances because I lost the zeal for life. Just hanging on there is not enough. I
want to live, not just to survive.” A number of questions arise: Can life be intrinsically
valuable independently of the interests of the individual? Does the state have the right
to impose continuation of living on patients who wish to die? Should the medical
profession provide aid-in-dying? These are the questions we face.
When speaking of the right to die, usually people refer to gravely ill patients who have a
certain perception of themselves within a subjective time framework. These are people
who appreciate their past, are unhappy with their present condition, and wish to have a
short future as the prospect of continued living under the challenging circumstances is
not appealing. While people cannot decide the moment when they come to the world,
some people wish to decide the moment they depart the world. To make a strong
argument for the right to die, people resort to the concepts of liberty, autonomy, dignity,
respect, concern, quality of life and suffering. Those who endorse physician aid-in-dying
accentuate respect for the patient’s autonomy and freedom of conscience as well as
opposition to coercion of any form. They speak of physicians’ requirement to respect all
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legitimate concerns and needs of their patients. Those who reject physician aid-in-dying
raise concerns regarding potential abuse, the possibility that patients who do not wish to
die might be killed, and the risk to vulnerable populations, especially children, elderly
patients, poor patients, demented and other incompetent patients. They also speak of
the limitations on physician’s duties. These duties include healing, relieving suffering,
providing care and comfort for the patients. These duties, so the opposition claims, do
not include the duty to end life.
This entry opens with a concise history of the right to die movement. Then it discusses
the above concepts and offers guidelines that strike a balance between the patient’s
wishes and our shared concern to prevent abuse, explaining that while physicians
cannot be obligated to end life, those who accept that patients do have the right to die
may come to their patients’ assistance.
History and development: background of the right to die movement
The Netherlands is one of the most liberal societies in the world. Its underlying values
are peace, freedom, openness, tolerance, and compromise. During the 1960s, the
Netherlands was transformed from a conservative, tradition-bound country into a society
of social and cultural experimentation. The Netherlands took a prominent place in the
sexual revolution, the legalization of prostitution and abortion, the acceptance of non-
addictive drugs, the democratization of educational institutions, and the questioning of
religious authority. The process of secularization that started in the 1960s gradually
undermined the status of traditional institutions. The student revolution of 1969 had a
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profound effect on the country as the social movement rebelled against traditional
values, autocracy and established hierarchies. Societal relationships also changed to
the effect that the social distance between ordinary people and people in power
positions declined. As such, ordinary people developed expectations about their role
and influence in society and their ability to affect matters concerning their lives (Griffiths,
Bood and Weyers, 1998).
The essential moral foundations that were established included the shifting of the focus
to autonomy and individuality, emphasis on individual choice, and liberation from
collective morality. The religious view of the sacredness of life was abolished and
replaced by secular moral views. The discussion on morality has revolved since then
around the rights of the individual, including issues such as contraceptives, abortion,
suffering, and ending life. The increased democratization of society and the emphasis
on individual control thus made the practice of euthanasia more open and available
(Cohen-Almagor, 2004).
In 1969, Jan Hendrik van den Berg (1978), a renowned psychiatrist, published his book
Medical Power and Medical Ethics. The book discussed the tragic conditions of various
patients, who were described as victims of medical power. Had they lived 100 or even
50 years ago, they would have been allowed to die in peace. These days, however,
they are being kept alive simply because the capacity to do this is available, regardless
of the patients’ best interests. Van den Berg suggested granting patients a dignified
death. His book started in earnest the debate on the right to die that culminated in 2002,
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when the Netherlands became the first country in the world to legally allow euthanasia.
The Dutch experience has influenced the debate on euthanasia and death with dignity
around the globe, especially with regard to whether physician-assisted suicide (PAS)
and euthanasia should be legitimized or legalized (Youngner and Kimsma, 2012).
In 1980, the World Federation of Right to Die Societies was founded. It has 53
organizations from 26 countries, all working to protect the right of individuals to self-
determination at the end of life (see http://www.worldrtd.net/). The same year, 1980, in
the United States, Derek Humphry founded the Hemlock Society in order to help
patients who suffer from incurable diseases to die peacefully. In 1991, Humphry
published Final Exit: The Practicalities of Self-Deliverance and Assisted Suicide for the
Dying which provides guidance on assisted suicide. The book made it to the top of the
New York Times bestseller list.
Conceptual framework
The right to die movement emphasizes the patient’s liberty, her autonomy to make fatal
choices at the end-of-life, the patient’s desire to maintain her dignity and the medical
team’s effort to see that the patient’s dignity is preserved. The right to die movement
speaks of our shared commitment to show respect and concern for vulnerable patients at
the time of need, the importance of quality of life considerations, and the avoidance of
suffering. Patients who are in a state of irremediable and unbearable suffering are no
longer able to appreciate and enjoy life. Some of them, especially those who are
autonomous and strong willed, may wish to decide the moment of their own death.
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Responsible and conscience supporters of the right to die share with those who oppose
that right deep and unequivocal concern about the crucial need to prevent abuse. After all,
matters of life and death are most significant and thus necessitate erecting ample
monitoring and control mechanisms to see that the right to die is not transformed into a
duty to die. The medical profession is not immune to paternalism, when some people
around the patient’s bed believe they know better what the patient’s best interests are,
better than the patient herself. This is a dangerous tendency against which vulnerable
patients need protection.
Liberty
Liberty is required in order to enable people to discover, from the open confrontation of the
ideas that are cherished in their society, their own views, their beliefs, and their future life
plans. Liberty enables autonomy, self-rule, and self-direction. Accordingly, the view is that
individuals should be left to govern their affairs without being overwhelmingly subject to
external forces. We are said to be free when our acts are not dominated by external
impediments, thus enabling us to form judgment, to decide between alternatives, and to
act in accordance with the action-commitments implied by our beliefs. Patients, it is
argued, should be at liberty to end their lives if they so choose.
Autonomy
The notion of autonomy assumes some degree of rationality. It involves the person’s
ability to reflect upon beliefs and actions, and the ability to form ideas about them, so as
to decide how to lead one’s life. The term ‘autonomy’ is derived from the Greek autos
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(‘self’) and nomos (‘rule,’ ‘governance,’ or ‘law’). By choosing among conflicting options,
individuals consolidate their opinions more fully and review the ranking of values for
themselves. Obviously, in order to be able to exercise autonomy, agents need to have a
range of options to choose from, some may be of significance to the agents, others may
not. Having options enables individuals to sustain activities that they regard as worth
pursuing, and to decide what is worthwhile and what is not. Those who support the
autonomy-based approach do not perceive life itself as an absolute virtue. Life allows us
to attain certain goals. When patients reach the conclusion that life no longer has
meaning to them, they should have the right to opt for death.
Two clarifications are in order. First, autonomy enables us to develop certain capabilities
and to cancel others. People may choose a path that negates further self-realization,
regarded as valuable to the extent that it outweighs other capabilities with which they are
blessed. Second, an autonomous choice does not have to be the best one available. It
presupposes that the agent exercises some extent of rationality, but not perfect rationality.
The emphasis is not on deciding the "best" objective options, or on holding the "true"
objective opinions, but on the way in which we come to make the decisions and to hold our
subjective opinions (Cohen-Almagor, 1994).
Dignity
The term ‘dignity’ is derived from the Latin noun dignitas, which means: (a) worthiness,
merit; (b) greatness, authority; and (c) value, excellence. The noun is cognate with the
adjective dignus (worthy), from the Sanskrit root dic and the Greek root deik, which
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have the sense of ‘bringing to light,’ ‘showing,’ or “pointing out” (Bayertz
1996). Human
dignity is the inherent value of personhood by virtue of being human.
When people endorse death with dignity, the focus is on the dominion of the patient
over her body. Should life be preserved at any cost? Two principled opinions are
expressed. One emphasizes the sanctity of life and sees its maintenance as a
substantive intrinsic value. Christian theologians and Jewish law (Halachic) thinkers are
among those who associate themselves with this opinion. The other emphasizes the
autonomy of the patient and her right to formulate a judgment whether or not to continue
living. This view is espoused by prevalent liberal thinking. When using the term ‘death-
with-dignity’ liberals refer to both (1) timing of death: people should be allowed,
whenever possible, to choose the time of their departure; and (2) the way people die:
with the help of medical professionals, people should be able to control the process of
dying, maintaining autonomy at the end-of-life, not being humiliated, and perceiving
themselves with honor. The concept of dignity refers to a worth or value that flows from
an inner source. It is not given from the outside but rather is intrinsic to the bearer of
dignity (Cohen-Almagor 2001). The World Medical Association Declaration of Helsinki
(1964) holds that “It is the duty of the physician in medical research to protect the life,
health, privacy, and dignity of the human subject”. The Universal Declaration of Human
Rights (1948), the International Covenant on Civil and Political Rights (1966), and the
International Covenant on Economic, Social and Cultural Rights (1966) also emphasize
the inherent dignity of the person.
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All people have a right to dignity. Dignity is something that must be accorded to every
person from birth, some say from the moment of conception. We are endowed with
dignity and have the right to be treated with dignity. Furthermore, dignity involves not
only objective but also subjective notions. It is the source from which human rights are
derived, and it also refers to one’s own feelings about oneself. To have dignity means to
look at oneself with self-respect, with some sort of satisfaction. It means to feel human,
not degraded. A subjective concept of the self refers to how a person conceives of her
life, her achievements, and her place in the world. This subjective evaluation is affected
by the individual’s self-respect, relative to the abilities she believes she possesses, and
relative to her peers and surroundings.
More specifically and with reference to the role of physicians, preserving dignity means
helping patients to feel valuable. The physical move from the familiarity of the home to
an unfamiliar hospital entails the transformation from a ‘person’ to a ‘patient.’
Sometimes the patient is perceived by physicians as a mere ‘case,’ stripped of
personality, representing an interesting disease to be studied, or a valuable research
tool. Hospitals and the medical staff are supposed to care for the patients but
sometimes, especially in research hospitals, it seems that the reverse is the case:
patients are in hospitals for the benefit of the medical staff. The shift from a ‘person’ to a
‘patient’ to a mere ‘case’ betrays human dignity. The preservation of one’s dignity
involves, inter alia, listening to the patients’ complaints, helping patients cure their
diseases, or at least assisting them in controlling their pain, responding to their distress
and anxieties, making an effort to relieve them, demonstrating sensitivity to the physical
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indignities that occur in severe illnesses, making the patient sense that she is a human
being and not an infant, a case study, or worse, a body that occupies a bed and
consumes resources. Patients can feel vulnerable because their self-respect is
undermined by their deteriorating condition. Maintaining the patient’s dignity requires
physicians as well as the patient’s loved ones (those around the patient’s bed who are
important to the patient, who truly care for the patient and want her best interests) to
help patients retain at least some of their self-respect. The aim is to secure dignified
living in severe health conditions.
Respect and concern
According to Kant (1785), to respect a person is to treat her as an autonomous human
being acting in accordance with moral law. The assumption is that humans are moral
and Kant’s demand is that people act in accordance with the Categorical Imperative. In
formulating his deontological Categorical Imperative, Kant recognized that each person
had an inviolable and inalienable dignity, which was the reason for respecting persons.
Kant (1785) wrote: “Act on maxims that can at the same time have themselves as
universal laws of nature as their object”; that gives us the formula for an “absolutely
good will”. The Categorical Imperative refers to the will itself, not to anything that may
be achieved by the causality of the will (Guyer, 2005).
People respect others as autonomous human beings who exercise self-determination to
live according to their life plans; we respect people as self-developing beings who are
able to expand their inherent faculties as they choose, that is, to develop the capability
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they wish to cultivate, not every capability that they are blessed with. In turn we respect
people in order to help them realize what they want to be. Each individual is conceived
as a bearer of rights and a source of claims against other persons, just because the
resolution of the others is theirs, made by them as free agents. To regard others with
respect is to respect their right to make decisions regardless of our opinions of them.
We assume that each course of life has intrinsic value, at least for the individual, and we
respect the individual's reasoning, so long as she does not harm others. Respect for a
person means perceiving of the other as an end rather than as a means to something.
As Kant explains (1785), persons are not merely subjective ends whose existence has
an effect on our actions; instead people exist as ends in themselves. An objective end,
Kant maintains, is one for which there can be substituted no other end, for otherwise
nothing of absolute value would be found anywhere.
Kant’s line of reasoning is supplemented by our emphasis on the notion of concern.
People not only respect people but also care for them. Kant wanted to base his
reasoning on logic, attempting to exclude emotional worries, but we acknowledge that
persons’ acts are often dictated by emotions. Human nature enables us to rationalize
but it might be influenced by emotional drives. Thus it is not sufficient to speak only of
respect (Cohen-Almagor, 2001).
The notion of ‘concern’ signals the value of well-being: we ought to show equal concern
for each individual’s good. ‘Concern’ does not demand giving equal weight, utilitarian
fashion, to the welfare of a stranger as to the welfare of a person’s children (Griffin,
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1986). Instead, it means giving equal weight to a person’s life and autonomy.
Yet again, the debate revolves around the importance assigned to a person’s
independent decision making. Those who endorse the Respect for Others Argument in
objection to the ‘sanctity of life’ model understand this argument in more specific terms
that relate primarily to the autonomy of the gravely ill patients. The defense of personal
liberties is founded on the assertion that we ought to respect others as autonomous
human beings who exercise self-determination to live according to their life plans; in
turn we respect persons in order to help them realize what they want to be. That is,
respect for human beings involves the presupposition that others should be allowed to
make their own decisions, based on their conception of what is good and just.
Accordingly, each person is viewed as speaking from that person’s point of view, having
perceived interests in her own way. We may be asked to give our opinions, or decide to
express our views anyway; nevertheless, in many instances we recognize the other’s
right to make choices. This notion of autonomy is crucial in our considerations. The
medical profession is required to respect the wishes of certain incurably ill patients.
Quality of life and suffering
Advocates of the autonomy model say that the consideration of human dignity might
lead us to think at times that life is no longer an attractive option. A theme that is
frequently reiterated in this discussion is ‘quality of life’ (Harris, 1985; Kuhse, 1987). The
lack of some standard of quality legitimizes, even necessitates, so it is claimed, allowing
patients the option of forgoing life if they so wish. Life qua life is not that important but
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rather what one does with one’s life. Life in earnest is important, not just the mechanical
processes that define life in the superficial meaning of the term. That one’s heart is
beating and that one is able to breathe are not sufficient reasons to maintain life.
The phrase ‘quality of life’ has many positive connotations when used in a general
social context. For instance, we speak of improving the quality of lives by various means
including diverting public transportation away from crowded neighborhoods, and making
efforts to decrease air pollution. People seek to promote their quality of life by
purchasing newer and bigger houses, cultivating their gardens, going abroad, engaging
in leisure activities. People use the phrase ‘quality of life’ when describing the different
ways they promote their comfort, their status and their tranquility. Likewise, in medicine,
the phrase ‘quality of life’ has positive connotations, for example, in rehabilitation,
cosmetic treatments, psychiatry, and psychology. However, when dealing with end-of-
life issues, ethicists who support euthanasia apply ‘quality of life’ considerations in a
negative sense more often than in a positive one, meaning that they do not seek to
improve the patient’s life but to end it (Kuhse and Singer, 1985). They refer to certain
patients and categories of patients, arguing that their lives lack significant measure of
quality and therefore should not be maintained. The terms ‘quality’ and ‘life’ in this
context are contradictory and competing, designed to justify the termination of life.
Quality of life does not constitute a single criterion upon which we judge a person’s
deeds. The criminal law does not address the quality of life. Different penalties do not
exist for a murderer, based on the quality of the life of the victim. One would be appalled
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if a murderer argued in her defense that “this guy was a useless creature, led a dull life,
and was miserable; therefore, no great loss had occurred.” Similarly, we would be
deeply disturbed if a physician would claim that “there is little point in investing
resources in patient A because she is seventy-five years old, and her prospects of
leading a valuable life are slim.”
That is to say that quality of life is a subjective term. What is important is not how we
assess the patient’s condition but how the patient assesses her own condition. Neither the
medical team nor the patient’s family can decide that “her life is not worth living”. This call
should be reserved only to the patient. Similarly, suffering is a subjective term. It may stem
from multiple existential, physical, mental, and spiritual sources such as pain, depression,
distress, hopelessness, dependence, loss of control, loss of sense of dignity, and anxieties
of burdening others. What one may consider as unbearable suffering might be considered
by another as bearable. When patients perceive their condition as dehumanizing,
humiliating, degrading, painful, beyond their abilities to endure; when patients believe that
their condition is not worth living, physicians and others should not coerce them to
continue living. This kind of medical paternalism cannot be justified. As we should not
coerce physicians to do something that is contrary to their conscience, we should not
coerce patients to live when they wish to die. Coercion qua coercion is morally repugnant.
Physicians should not desert patients when they need them the most.
Research has shown that the majority of patients dread death. Most patients prefer to cling
to life. However, for some patients death is not the worst thing that can happen to them.
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Suffering is. Upon experiencing refractory, intractable, irreversible physical and/or mental
suffering that they deem unacceptable, they realize that the end-of-life is nearing and may
lose the zeal to continue living. Concern and care for the patient dictate that physicians
should not ignore the patient’s wishes.
Fear of abuse
The question of how we can (or should) protect a patient’s autonomy is of major
importance. People who believe that rational patients should have the right to arrange
their own deaths, with the help of willing physicians, often appeal to autonomy as
justification. But those who object to this idea claim that people who really want to stay
alive might be killed, maintaining that leaving the decision in the hands of the patient’s
family and/or medical team might negate the patient’s autonomy. All agree that it is of
utmost importance to maintain trust between physicians and patients but while some
accentuate that trust means also depositing life in the hands of the physicians for them
to end it at the patient’s request, others assert that once such deposit is granted to
physicians, the trust between them and their patients might be undermined. Physicians
are in the healing profession, not killing.
Physicians might abuse the power they possess. Such fears can be avoided by paying
careful attention to the fine details when formulating concepts and regulations and by
using explicit wording that does not allow abusive interpretations. The fear of abuse and
the desire to grant patients with control over their lives until the very last moment are
good reasons to restrict assistance in dying to physician-assisted suicide (PAS). From
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Belgium, The Netherlands, Switzerland and Oregon we learn that the majority of
patients who opted for death were cancer patients. It can be assumed that they were
capable of activating a lethal needle administered by a qualified physician.
At the same time, a voice of extra caution is raised in conducting mercy killing, criticizing
death campaigns such as those of “Dr Death”, Dr Jack Kevorkian (1991), a pathologist
who had no qualifications to examine the medical files of those who approached him for
aid-in-dying. Kevorkian celebrated patient’s autonomy to the extreme without the
necessary safety valves and control mechanisms. Upon becoming a missionary for his
cause, Kevorkian killed patients who could have been cured. Aid-in-dying is a very risky
business when those promoting it become missionaries of their cause.
At the end-of-life, the fear of abuse is very tangible. If physicians were allowed to assist
gravely-ill patients to die, pressure might be exerted on old and weak patients whose
relationships with their families are not close. Appropriately, UNESCO Universal
Declaration on Bioethics and Human Rights (2005) has emphasised the physician’s
requirement to respect the patient’s personal integrity and the need to protect
vulnerable populations. With lax standards of due care, the delicate framework of trust
between patients and physicians would crack and practically be replaced by a
completely different set of norms. Patients would no longer believe that physicians and
nurses would do their best to help them stay alive. Explicitly or implicitly, physicians and
nurses might communicate that they expect special gratitude for assisting patients to
live. Patients might feel obliged to seek assistance to die in order to avoid further
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burdens on their beloved people as well as on the medical staff. There is also the fear
that the right to die, accorded to patients who are able to decide, will - at some point -
be expanded to patients who are not able to decide for themselves.
Sanctity of Life
Fear of abuse lead many people to oppose any quality of life considerations in treating
patients at the end of their lives. Many scholars fear the effects that entertaining
physician-aid-in-dying might have on the medical profession, changing its culture and
norms in a way that would undermine the patient’s best interests. Some of these
scholars promote ideas related to the sanctity of life (Novak, 1989; Pellegrino and
Faden, 2000). Often times, their reasoning is based on religion.
The monotheistic religions uphold the belief that God created life and death and we
must not take His place (Cohen, 1998). It is not a proper or appropriate role for medical
staff to end human life that had been given and sanctified by God. The proper role for
medical staff is to save life and not to destroy it (Gill, 1998; Misbin, 1992). The Christian
tradition emphasizes the following pertinent guidelines:
A. Life is a God-given gift. It is given to people “in trust.” Hence people do not own their
lives. Life is a gift over which we are to exercise stewardship, not dominion. That
stewardship demands that we be responsible for life - its protection and enhancement.
We will in turn be held accountable before the Creator not only for how we protected
and developed our individual lives, but for all life. Man cannot do with life as he wills
(Wallace and A. Eser, 1981).
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B. All human life is equal because every human creature is a creation of God.
C. Because God created human life, even the most miserable of lives is worth living
(Pellegrino and Thomasma, 1996).
D. Life is holy per se. God granted the respect, value, and sanctity of the human being
to people, and they are not subject to human measurement. Life is not sacred because
of something it includes, because of its content. Rather life is sacred because God
created it: God is holy, and He has sanctified life. Human life has worth because Christ
died to redeem it, and it has meaning because God has eternal purpose for it.
1
E. The life which God gives man is quite different from the life of all other living
creatures, inasmuch as man, although formed from the dust of the earth, is a
manifestation of God in the world, a sign of his presence, a trace of his glory. Man has
been given a sublime dignity, based on the intimate bond which units him to his Creator:
in man there shines forth a reflection of God himself. Life is the Lord’s image and
imprint, a sharing in his breath of life (Ramsey, 1950).
F. Life is indelibly marked by the truth of its own. By accepting God’s gift, man is obliged
to maintain life in this truth, which is essential to it. To detach oneself from this truth is to
condemn oneself to meaninglessness and unhappiness, and possibly to become a
threat to the existence of others, since the barriers guaranteeing respect for life and the
defense of life, in every circumstance, have been broken down.
G. People must not “play God” by determining when someone should die (O'Rourke and
Boyle, 2011).
1
. According to Islamic law, God is the author of life and ‘owns’ us. Since we do not own our lives we
cannot take them. See Charlesworth, 1993.
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There are many similarities between the Christian and the Jewish points of view
(Pellegrino and Faden, 2000). Both Judaism and Christianity affirm creation as the
necessary background for their respective revelations. Both share beliefs about the
sanctity of human life, the integrity of the family, and the right to a variety of individual
and cooperative achievements. One of the basic theological affirmations that is shared
by the Judeo-Christian ethic is that persons are created by God for the primary purpose
of being related to God (Novak, 1992; Holwerda, 1976). The Judeo-Christian ethic
integrates the virtues of faith, hope, and charity, with principles of medical ethics, based
on beneficence, justice, and the best interests of the patient. The notion of a person
includes not only the soul, spirit, cognitive and intellectual capacities, but also a living
body. Human life is intrinsically good and valuable, and society is obliged to respect a
living body irrespective of the person’s cognitive capacities. Notice that when speaking
of intrinsic values we do not speak of interests. Life qua life is valuable, without paying
attention to the person’s interests. In this view, taking one’s life by one’s own hands (or
with the help of others) is considered to be wrong in itself. Even if people have
deliberately chosen to die, it is nevertheless bad for them to do so. Euthanasia is
perceived as an insult to the sanctity of human life. It is also an insult to God, usurping
His authority (Cohen-Almagor and Shmueli, 2000; Dorff, 2004).
My independent research has shown that in Jewish and Catholic hospitals, most of the
patients cling to life and do not ask physicians to assist them in dying. This issue is
simply not part of the hospitals’ culture. Patients who may wish such help are more
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inclined to seek assistance in Protestant hospitals where sanctity-of-life considerations
are weighed against patient’s autonomy and quality-of-life considerations.
Physician-assisted suicide, not euthanasia
In euthanasia, the control lies with the physician who administers the lethal injection and
kills the patient. In physician-assisted suicide, the control lies with the patient. Ordinarily,
the physician prescribes the lethal medication, mixes it in a pudding or a yogurt, and
then the patient takes the last act and kills herself. To prevent abuse, and to ascertain
that the patient’s right to die does not open the road for medical paternalism where
physicians may play God, it is suggested limiting aid-in-dying to physician-assisted
suicide (Cohen-Almagor, 2001). Below is a set of guidelines which reflects the general
state of the art concerning the right to die. This set integrates some of the pertinent
guidelines that were adopted in Oregon, where physician-assisted suicide is legal, in the
Netherlands and Belgium where euthanasia is legal, in Switzerland where assisted
suicide is practiced, and in the Northern Territory of Australia, where physician-assisted
suicide was legal for a short period of time.
Specific Guidelines for Physician-assisted Suicide
Physicians are best equipped in terms of knowledge and expertise to provide aid-
in-dying. It is the only profession that could come to aid patients who insist on
their right to die. The medical profession is in flux. The rapid scientific and
technological progress, the rise of chronic disease, the ability to keep chronic
patients alive for many years, and the democratization of knowledge are all
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important in the shaping of medicine. The medical profession should be attentive
to wishes of all patients, and strive to accommodate their wishes.
Physicians should not suggest assisted suicide to the patient. Instead, it is the
patient who should have the option to ask for such assistance. Any reluctance
shown by patients regarding this issue should be honored and respected.
Initiation by the physician might undermine the trust between patients and
physicians, conveying to patients that the doctor is giving up on them. Such an
offer might undermine the will to live and to explore further avenues for
treatment. The GP may present before the patient the range of available options
without manipulation, and with due respect for patient’s life and wishes.
The request for physician-assisted suicide should be voluntary and come from a
competent adult, 18 years of age or older, who suffers from an intractable,
incurable, irreversible disease. The decision should be made by the patient and
not the family or as a result of family pressures. Some families can make the
decision to end life because they feel overwhelmed by the patient’s illness. Many
people cannot cope with the fact that their loved one is dying. For these reasons,
the PAS decision has to be reached without any pressures. The patient should
state this wish repeatedly over a period of time. This recommendation is similar
to the one invoked in laws and guidelines in Oregon, the Netherlands, Belgium,
and Australia.
It is the task of social workers to examine to what extent the patient is affected by
external pressures. The decision-making process should include a second-
opinion in order to verify the medical diagnosis and minimize the chances of
22
misdiagnosis, as well as to allow the discovery of other medical options. A
specialist who is not dependent on the first physician should provide the second
opinion. It is advisable that the identity of the consultant be determined by a
committee of specialists who will review the request for physician-assisted
suicide.
At times the patient’s decision might be influenced by severe pain, and therefore
the role of palliative care can be, and is, crucial (LaPorte Matzo and Witt
Sherman, 2009). The attending physician should inform the patient of all feasible
alternatives, including comfort care, hospice care and pain control.
The patient must be informed of her situation, the prognosis for recovery or
escalation of her disease, and the degree of suffering that may be involved.
There must be an exchange of information between physicians and patients. The
laws in Belgium and Oregon contain these provisions.
Sometime prior to the performance of PAS, a physician and a psychiatrist should
visit and examine the patient. They will verify that this is the genuine wish of a
sound mind person, and that the individual is not depressed, being coerced or
influenced by a third party to end her life. The conversation between all
physicians and the patient should be recorded and held without the presence of
family members so as to avoid familial pressures.
The patient must be able to rescind her decision to pursue physician-assisted
suicide at any time and in any manner, as it was the case in Australia and is the
case in Oregon and in Belgium.
23
PAS may be performed only by a physician in the presence of another physician.
Family members should not be allowed to administer assisted-suicide (or
euthanasia) as this might lead to abuse. The decision-making team should
include at least two physicians and a lawyer who will examine the legal aspects
involved and ensure there is protocol in place which will prevent possible abuse.
Perhaps a public representative should also be present. This extra caution
should ensure that the right to die with dignity does not become a duty. It will
contribute to reporting of cases. The physician who provides aid-in-dying should
be the one who knows the patient best, having been involved in the patient’s
treatment, taken part in the consultations, and verified through the help of social
workers, nurses and psychologists that PAS is the true wish of the patient.
Physician-assisted suicide may be conducted in one of three ways, all of which
should be discussed openly and decided upon by the physician and the patient:
(1) Oral medication; (2) Self-administered, lethal intravenous infusion; (3) Self-
administered lethal injection. Some medication may be difficult or impossible for
patients to ingest because of nausea or other side effects of the illness. The only
exception in which the physician would be allowed to administer the lethal
injection would occur in the event that medications have been provided and the
patient’s dying process is lingering on for long hours. Euthanasia may be allowed
only after the failing of physician-assisted suicide, or if the patient cannot
physically administer the medications to herself.
Physicians may not demand a special fee for the performance of physician-
assisted suicide. There must be no financial incentive to perform or assist with
24
the procedure since the motive for PAS is humane. There should be no special
payment that might cause commercialization or promotion of such procedures.
There must be extensive documentation in the patient’s medical file, including the
disease diagnosis and prognosis by the attending and the consulting physicians;
attempted treatments; the patient’s reasons for seeking PAS; the patient’s
request in writing or documented on a video recording; documentation of
conversations with the patient; the physician’s offer to the patient to rescind her
request; documentation of discussions with her beloved people, and a
psychological report confirming the patient’s condition. This meticulous
documentation is meant to prevent exploitation of any kind -- personal, medical,
or institutional. Each report should be examined by a coroner following
completion of the physician-assisted suicide.
The drugs required to end one’s life are known. As a control mechanism
pharmacists should be required to file a report every time lethal medications are
sold. Then it would be possible to track down the medication to the physician,
and keep track of how many times physician-assisted suicide was performed.
The practice of medicine should be deontological rather than utilitarian.
Physicians have certain duties to fulfill, including relieving patient’s suffering,
respecting patients and caring for them. Patients should always be regarded as
ends in themselves, never as means. Patient’s autonomy and preferences
should be respected as much as possible. At the same time, physicians should
not be coerced into taking actions that conflict with their conscience. No coercion
should be involved in the process.
25
A medical association committee should be established to investigate underlying
facts of reported cases, to explore whether there were cases which did not
comply with the guidelines, and to inquire whether there were unreported cases.
Significant sanctions should be taken to punish health-care professionals who
violate the guidelines, fail to consult with other physicians or to file reports, or
engage in involuntary termination of life without the patient’s consent or with
incompetent patients. Physicians who fail to comply with the guidelines should
be charged, and procedures to sanction them should be enforced by the medical
disciplinary tribunal. The sanctions should be significant and include revocation
of the physician’s medical license.
An annual report should be published documenting all cases of aid-in-dying. The
reports should be made available to the public. Discussions and debates about
their findings should be promoted and encouraged.
Conclusion
People, as autonomous moral agents, deserve to be treated with dignity. To treat a
person with dignity requires respecting her choices and life-decisions. If a person who
suffers from an incurable disease decides that her life is no longer worth living, we
should respect that decision. The medical profession should not rush to end life, but
upon careful examination and upon satisfying certain criteria, physicians may provide
aid-in-dying.
26
There may come a point when the belief in the importance of human dignity may lead to
the conclusion that physician-assisted suicide should be considered an option. Most
people find some meaning in their lives even when they are severely impaired, bed-
ridden, limited in movement, and in constant need of help. An independent, active and
energetic person with desires and ambitions, who becomes in her own eyes dependent
upon others, who reaches the conclusion that her life has become a burden to herself
and the people she loves, might lose her sense of humanity as well as her self-respect,
and this might lead her to lose interest in life and to choose death.
People should give equal consideration to the interests of others and grant equal
respect to a person’s life objectives so long as they do not deliberately undermine the
interests of others by interfering in a disrespectful manner. This line of reasoning should
be supplemented by our emphasis on the notion of concern, which is seen as the value
of well-being. We should give due weight to a patient’s autonomy and decisions at the
end of one’s journey.
Cross-References
Related entries from within the Encyclopedia of Global Bioethics:
Abuse: Elder Abuse
Applied Ethics
Assisted Suicide
Autonomy
Benefit and Harm
27
Bioethics: Medical
Coercion
Compassion
Consultation
Death: Good Death
Ethics
Euthanasia: Active
Euthanasia: History
Euthanasia: International Debate
Euthanasia: Passive
Human Dignity
Human Rights
Life: Quality of
Medicine and Ethics
Mercy
Pain
Palliative Care
Paternalism
Patient Rights
Quality of Life
Respect for Autonomy
Suffering
Vulnerability
28
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View”, Theoretical Medicine and Bioethics, Vol. 21, No. 2 (August): 117-137.
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29
Dorff, Elliot N. (2004). Matters of Life and Death: A Jewish Approach to Modern Medical
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30
LaPorte Matzo, Marianne and Deborah Witt Sherman (eds.) (2009). Palliative Care
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Further Reading:
Beauchamp, Tom L., and Childress, James F. (1994). Principles of Biomedical Ethics
(New York: Oxford University Press).
Bosshard, G., Broeckaert, B., Clark, D. et al. (2008). A role for doctors in assisted
dying? An analysis of legal regulations and medical professional positions in six
European countries, J. Med Ethics 34: 28-32.
Duwell, Marcus et al. (eds.) (2014). The Cambridge Handbook of Human Dignity: Inter-
disciplinary Perspectives (Cambridge: Cambridge University Press).
Jackson, Emily and Keown, John (2012). Debating Euthanasia (Portland: Hart).
Pellegrino, Edmund D., Schulman, Adam and Merrill, Thomas W. (eds.). (2009). Human
Dignity and Bioethics (Notre Dame: University of Notre Dame Press).
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Smith, Stephen W. (2012). End-of-Life Decisions in Medical Care (Cambridge:
Cambridge University Press).