A doctor's involvement in assisting a suicide does not conflict, in principle, with the basic aims of medicine. Helping the sick may involve a wide spectrum of activity, and assisted suicide may be one venue through which such help can be rendered. Choosing when and how a person will exit this life is a very personal decision. From this perspective, helping terminally ill patients to end their lives for the purpose of alleviating intense physical or mental suffering is both rational and compassionate.
I write as a family doctor, and even though retired, I still think like one and like to base my musings on a case history:
A highly placed diplomat with splendid prospects was married to, and deeply in love with, a very beautiful woman. He was a man of humble origins and could never quite understand how such a gorgeous and good woman could have agreed to marry him--his self-esteem was surprisingly limited considering the position he held.
One of his colleagues was jealous of him and fed this low self-esteem by suggesting that his wife might be having an affair. Gradually distrust festered and eventually, after being given some false evidence of infidelity, the diplomat strangled his wife. She screamed as he was killing her and instantly the room was filled with people who had heard her.
They were appalled and quickly made him realize that he had suspected her without justification.
Using a knife he had on his person he committed suicide.
Should the crowd standing around Othello, for he it was [in Shakespeare's play], have tried to stop him? Or was he entitled to make a decision that life would no longer be worth living without his wife, disgraced, and perhaps in prison for the rest of his life? And if a doctor, and in particular a psychiatrist, had been present, would he or she, as part of their professional duty, have been under obligation to stop him on the grounds that anyone contemplating suicide is ipso facto incompetent to make an autonomous decision?
It is part of the human condition to believe that living is better than not living, otherwise life makes no sense and gives us no purpose--unless, of course, we believe that this life is only a preparation for another.
If we accept that life is in general preferable to death, how does suicide fit in? In the United Kingdom, suicide has been legal since the 1960s, on the assumption that a fully competent individual can make an autonomous decision that no life is preferable to life.
Yet many people would argue that no one in their "right mind" would commit suicide--in other words, that persons planning suicide should be restrained from carrying out their plans, to have their autonomy overruled, in order to stop them. Jonathan Glover has written that one good reason for stopping someone from committing suicide is that it gives the person a second chance, but it is unlikely that Othello would have changed his mind, and many would think he did the right thing.
I have thought about this conundrum over the years, partly in connection with my clinical role as a doctor and partly from the point of view of my contact with psychiatry. My interest was particularly aroused by my colleague and friend, Keith Hawton, now one of the professors of psychiatry in Oxford, who spoke about his work on suicide in the United Kingdom perhaps 15 years ago--he continues to research in this area. Many learned books and papers have been written around this subject. My article, by a non-specialist, is aimed at triggering discussion rather than examining these issues in detail.
So I would like you to consider a number of diffuse but conflicting statements. Though suicide is legal, to assist someone to commit suicide is not. To give drugs to assist pain relief which have the secondary effect of hastening death is legal and generally considered acceptable (a demonstration of the concept of double effect, which will be considered later). We as doctors are exhorted by the U.K. government to reduce the incidence of suicide, and yet we need to respect the autonomous decisions of our competent patients. But a patient who commits suicide in hospital or prison is considered to have done so as a result of failure by staff to prevent it. In addition, we know that many suicides occur in people who are suffering from a relapsing condition such as depression, and that though suicide is an act involving an individual only, it almost invariably causes major trauma to relatives and friends.
I would like to use these statements as a way into considering suicide and physician-assisted suicide and just touching on euthanasia, from the point of view of both general medicine and psychiatry, and as a means for ascertaining how a standard ethical approach may or may not help.
The attitude to physician-assisted suicide and voluntary euthanasia has become more liberal latterly, especially in Holland but also in the United Kingdom. In August 2000, a case was reported in the British Medical Journal in which the High Court in London decided that a man aged 19, who was suffering from motor neuron disease, had the right to die when he could no longer blink with his left eye--his only means of communication. At the same time doctors and especially psychiatrists are charged by the government with a reduction in suicide rates, presumably on the assumption that anyone, or maybe the majority, contemplating suicide must be suffering from a psychiatric illness. Some are, mainly from depression, but many are not.
Is there a duty by the medical profession to prevent suicide in whatever form, or is this part of the "nanny state" interfering in the autonomous wishes of individuals?
Although suicide itself was legalized in the United Kingdom in 1961, a House of Lords commission in 1994 advised against any loosening of laws on euthanasia for fear of developing a "slippery slope" situation. In the interval, surveys have shown that there has been a softening of public opinion on the admissibility of both active euthanasia and "passive"--that is, the withholding of treatment for persons such as those suffering from a persistent vegetative state.
This public softening of attitudes that has taken place in the United Kingdom and more so in Holland has happened mainly in the context of those suffering from physical illnesses, and it depends on persons being either competent to make such decisions themselves or being so persistently unconscious as to require decisions to be made by others. The concept of competence, which requires the ability to comprehend and retain information and the ability to weigh up such information in order to come to a choice is particularly difficult to apply to patients with mental illness.
I would like now to consider three fundamental issues that emerge from what I have said already.
In general, humans exhibit a "will to live"--we are programmed this way. This implies that life, and the continuation of it, has value, and that the old-fashioned U.K. Coroner's verdict of "suicide whilst the balance of mind was disturbed" is an appropriate summing up of the situation: one would be mad to end life. Yet we seem to accept that those who choose to neglect themselves, for instance by not eating enough or living rough, are placing a lower value on life than on other priorities, as are those who indulge in dangerous sports or who consider that, without taking risks, "life would not be worth living." Similarly, a competent patient on a life-support machine is entitled to choose to ask for the machine to be switched off, so as to be "allowed to die"--and this is not classed as suicide. An element of free choice has entered.
The Judeo-Christian religious viewpoint is that life is God-given and that though we are also given free will, it is always wrong to (willfully) terminate our own life. Out of this conundrum has appeared the concept of the value of suffering--a concept I find myself totally unable to subscribe to. Paradoxically, too, the life of others may be taken in self-defense or during war.
If such a religious viewpoint is excluded, and the exercise of choice is within the frame, we have to think in terms of life having meaning, or value, to go on being worthwhile. This meaning may take the form of doing things we find give satisfaction--such as being a doctor or writing fiction or being involved in making the streets clean--or of being able to conduct relationships with others. All of these involve gaining the respect of people we are in contact with, which helps us to have respect for ourselves--to have value.
Even if such meanings are not present, there may be some hope that they will be in the future. The abandonment of hope leads to despair, which may then lead to the contemplation of suicide. But while terminal illness with the prospect of suffering may seem a reasonable justification, being jilted in a relationship at the age of 17 may not. The basic question then is whether the despair that leads to considering life not worth living is justified in the context of a normal perception of the world, or whether it arises because of some temporary distortion of perception, such as happens with mood swings or in mental illness. And who makes the judgement as to justification? In other words, who decides in the border area between rational thinking and mental illness?
The comment that "They must be mad to do it" suggests that anyone contemplating suicide must be suffering from a mental illness, and that it is for doctors, especially psychiatrists, to cure such illness. But are all those suffering from a mental illness, by definition, unable to make a competent decision? How much misery and despair should persons suffer before it is accepted that it is reasonable for them to make a decision to terminate their lives? As already mentioned, when considering physical illness, it would generally be accepted that persons suffering from a painful and incurable illness should be listened to and allowed to die if they wish--with passive if not active assistance from the doctor in charge. In a situation where someone is suffering from persistent lack of enjoyment of life, with no possible relief in sight, but with no clinical mental illness on board, should not the same consideration operate? Indeed, should not someone suffering from a recurrent mental illness that shows no sign of being controllable by medication, and that perhaps causes chaos to those around, be granted the "accolade" of "incurable illness" to justify the wish to die--of course if the wish is expressed during a normal period? As so often, [author] Saul Bellow has summed up the dilemma for the individual: "Maybe an unexamined life is not worth living. But a man's examined life can make him wish he was dead."
And even if some form of treatment is available, is it reasonable to force people to submit to it, even to take away their autonomy by forcefully hospitalizing them, if they do not wish to have treatment?
A much-quoted case which raised this issue, and many others with which I won't deal, occurred in Holland in the early 1990s. Mrs. Bosscher was about 50 years old and had been unhappily married for some 30 years. She lived for her two sons, and when one committed suicide and a few years later the other died of cancer, she felt that all purpose in her life had vanished and she made a suicide attempt, which failed. She then approached a Dr. Chabot for assistance--in fact for euthanasia, though I don't want to deal with that aspect at the moment. What is relevant to my present point is that after lengthy psychiatric assessment, only a "complex adjustment reaction" and no evidence of clinical depression or other psychiatric illness was demonstrated. She refused any attempt at psychological treatment. There was therefore no evidence that she was incompetent to make a decision that her life should be terminated. That Dr. Chabot administered a fatal injection is not the issue here. The issue is that she was suffering from continuing mental distress, from despair, and yet by normal assessment she was competent to make a decision that she wanted to end her life.
My own feeling is that, on the whole, autonomy should be allowed to trump.
Should doctors ever be involved in causing the death of patients, by commission or omission? And is the concept of "double effect" --the principle that determines when an action that has both good and bad results is morally permissible--a valid one? You will notice that I add the qualifying phrase "by commission or omission," because I would contend that there is really no fundamental difference between acts of commission and those of omission, if the same end result is achieved by two routes. A doctor may withhold antibiotics in a patient with terminal cancer, knowing that this will result in the patient's earlier demise, and because this is an act of omission it is considered permissible, even though the doctor knows full well that the patient's death is being hastened. Concepts in relation to the turning off of a life-support machine have evolved over the years. The well-publicised case of Tony Bland illustrates this. He was a young man who was injured in the Hillsborough football stadium disaster in 1989 and descended into a persistent vegetative state, thus making him incompetent to make a decision. It took a court ruling some years later to allow feeding to be stopped. This is in contrast to the case of the 19-year-old with motor neuron disease already mentioned--the difference, of course, being that the latter was competent to make a decision, thus allowing the doctors to actively switch off the machine.
In this area the law in Britain is easing, as are public attitudes, but to me the distinction between a doctor hastening a patient's death by active or passive means is not clear.
I would also like to deal with what I now consider to be the outdated concept of "double effect." The doctrine of double effect implies that one is allowed to take an action that may result in death if procuring death is not the primary intention of that action, but it is not allowable to take the same action with the primary purpose of causing death. For instance, one can prescribe a large dose of morphine to control a physically ill patient's pain, even though this may shorten the patient's life, but one cannot prescribe the same dose with the primary intention of killing the patient. [Moral philosopher] Baroness [Mary] Warnock maintains that this is very much an argument for "getting off the hook." Catholic theology maintains that it is never permissible to perform an immoral act in order to permit something good to happen, and that a clear distinction can be drawn between what is intended and what is a secondary--but nevertheless anticipated--result of an action.
A widely reported case has recently arisen in the United Kingdom in which a court was involved over the separation of Siamese twins. It was known that if they were separated, one would live and the other die. The court eventually gave permission and this is what happened. Although the death of the second twin was not the primary intent of the intervention, it was anticipated and directly caused by the surgeon's action. Therefore, to my mind, it cannot be excused on the grounds of double effect. If an excuse is required, it must be on the basis of weighing up of the consequences of the intervention and deciding that causing this death was acceptable.
To return, then, to whether it is ever permissible for a doctor to kill a patient, we have just seen one example of where it probably is. Perhaps the best way forward is to consider what doctors should be doing for their patients. Bartlett's Medical Quotations includes a folk saying in French which translated reads, "Cure sometimes, help often, comfort always." Hippocrates encapsulated it in "Helping the sick."
Those who are opposed to the involvement of any doctor in the purposeful termination of life argue that to do so would violate the moral integrity of medicine and that doctors should never be involved in intentional killing. In our society this is partly the aftermath of the horrific involvement of doctors in the eugenic and medical experimentation policies of Nazi Germany. As we have already seen, this argument does not wholly reflect what does happen at the moment. Though some argue that a universal moral order exists that decrees certain ways of behaving, others, myself among them, would strongly argue that what is expected of a physician in society is a social construct, sanctioned by the laws of that society and open to rational debate. I have already mentioned the shifting situation in Holland and to a certain extent in the United Kingdom. In Japan, neither of the major religions, Shintoism and Buddhism, prohibit suicide, and many literary works extol it as a way to atone for misdeeds. Interestingly, there are still strict laws in place against euthanasia and physician-assisted suicide, though individual judgements have breached these rules. In the United States, Oregon passed a law permitting physician-assisted suicide in 1997. Between November of that year and July 1998, there were eight doctor-assisted suicides there, though the federal government under President [Bill] Clinton expressed reservations. It is likely that the present [George W. Bush] administration's policies will be more negative.
The purpose of benefiting the sick may involve a wide spectrum of activity, and some would consider that it may involve stopping the suffering of a patient by terminating life, and that this suffering may cover both physical and psychological situations. I have heard it argued that patients would lose faith in doctors if they knew that doctors may sometimes terminate life, and yet on many occasions I have had patients pleading with me to do just that, to put an end to their psychological or physical suffering.
It could be that in a large area of patient care, doctors are not actually doing what patients themselves feel would be in their best interests. I know that in my own case this has to do with my own abhorrence of the possibility that I am purposefully killing someone. However, my rational self suggests that in principle, medical involvement in suicide, or for that matter euthanasia, does not conflict with the basic aims of medicine of helping the sick, though I am well aware of the strength of the "slippery slope" argument. It may even be that taking seriously the wishes of patients who suffer from incurable physical illness, or even despair, may actually enhance trust in the doctor-patient relationship. For myself--and this is my problem--I just wouldn't be able to be the person giving the lethal medicine. I agree with [Dr. Bernard] Baumrin in his contribution to Battin, Rhodes, and Silvers [1998 book Physician-Assisted Suicide], that if euthanasia were to be legalized, it should be administered by someone other than a doctor.
I don't know what I would have done if I had been present at the bedroom scene where Desdemona lay dead and Othello was stabbing himself. I guess, though, that I would not have tried to intervene. Should I have realized that I was party to causing death by omission and have felt guilty?