A number of common and generally noncontroversial practices in the care of patients at the end of life lead to their deaths. For example, physicians honor a patient's refusal of medical intervention even when doing so leads to the patient's death. Similarly, with a patient's or surrogate's consent, physicians administer sedatives in order to relieve pain and distress at the end of life, even when it is known that doing so will cause the patient's death. In contemporary U.S. public policy, (...) these practices are accepted as ethical and legal while physician-assisted suicide (PAS) isrejected in current U.S. law and public policy. Some think, however, that if one accepts practices that are known to lead to a patient's death, then one cannot reasonably reject a patient's request for a lethal dose of medication so that she may kill herself (PAS). (shrink)

abstract Many have held that there is some kind of incompatibility between a commitment to good end-of-life care and the legalization of physician-assisted suicide. This opposition to physician-assisted suicide encompasses a cluster of different claims. In this essay I try to clarify some of the most important of these claims and show that they do not stand up well to conceptual and empirical scrutiny.

Opponents of euthanasia sometimes argue that it is incompatible with the purpose of medicine, since physicians have an unconditional duty never to intentionally cause death. But it is not clear how such a duty could ever actually be unconditional, if due consideration is given to the moral weight of countervailing duties equally fundamental to medicine. Whether physicians' moral duties are understood as correlative with patients' moral rights or construed noncorrelatively, a doctor's obligation to abstain from intentional killing cannot be more (...) than a defeasible duty. (shrink)

It has been argued that, on Kantian grounds, pedophiles, rapists and murderers are morally obligated to take their own lives prior to committing a violent action that will end their moral agency. That is, to avoid destroying the agent's moral life by performing a morally suicidal action, the agent, while he still is a moral agent, should end his body's life. Although the cases of dementia and the morally reprehensible are vastly different, this Kantian interpretation might be useful in the (...) debate on the permissibility of suicide for those facing dementia's effects. If moral agents have a duty to act as moral agents, then those who will lose their moral identity as moral agents have an obligation to themselves to end their physical lives prior to losing their dignity as persons. (shrink)

Commentary on re-opening dialogue between theological and secular voices in bioethics.

In this paper, we argue that promoting patient values is a legitimate goal of medicine. Our view offers a justification for certain current practices, including birth control and living organ donation, that are widely accepted but do not fit neatly within the most common extant accounts of the goals of medicine. Moreover, we argue that recognising value promotion as a goal of medicine will expand the scope of medical practice by including some procedures that are sometimes rejected as being outside (...) the scope of acceptable medical practice, such as certain forms of physician-assisted death. We then rebut some common and possible objections to this view. Our aim is not to argue that other accounts are mistaken—except when they argue for a single goal that does not include patient values—but rather to show that value promotion should play a more central role in discussions about the goals of medicine. (shrink)

The article examines the so-called slippery slope argument (SSA) against the legalization of active voluntary euthanasia (AVE). According to the SSA, by legalizing AVE, the least morally controversial type of euthanasia, we will take the first step onto a slippery slope and inevitably end up in the moral abyss of widespread abuse and violations of the rights of the weakest and most vulnerable patients. In the first part of the paper, empirical evidence to the contrary is presented and analyzed: None (...) of the forecasted regrettable trends can be elicited from the body of existing statistical data. Accordingly, we have no good reason to believe either that we already are, or are sooner or later going to be, sliding into a moral abyss. A related question is then considered: Would it not be wiser and safer to stick to the status quo and preserve the existing legal ban on AVE even if the risk of its abuse is uncertain and may well turn out to be relatively low? It is argued that such an appeal to precautionary reasoning fails to justify an outright legal ban on AVE for at least two reasons: (i) it grossly underestimates the hidden moral costs of current legal arrangements (competent terminal patients suffer both disrespect for their autonomous will and deprivation of the good of a timely death) and (ii) the ban is both too inefficient and disproportionate to qualify as a reasonable measure of precaution. (shrink)

Most people who defend physician-assisted death (PAD) endorse the Joint View, which holds that two conditions—autonomy and welfare—must be satisfied for PAD to be justified. In this paper, we defend an Autonomy Only view. We argue that the welfare condition is either otiose on the most plausible account of the autonomy condition, or else is implausibly restrictive, particularly once we account for the broad range of reasons patients cite for desiring PAD, such as “tired of life” cases. Moreover, many of (...) the common objections to an Autonomy Only view fail once we understand the extent of the autonomy condition’s requirements—in particular, the importance of one’s values for autonomous choices. If our view is correct, then the scope of permissible PAD is broader than is currently accepted in both the philosophical literature and the law, and therefore poses an important challenge to this widely accepted view on justified PAD. (shrink)

A US Department of Health and Human Services Final Rule, Protecting Statutory Conscience Rights in Health Care, and a proposed bill in the British House of Lords, the Conscientious Objection Bill, may well warrant a concern that—to borrow a phrase Daniel Callahan applied to self-determination—conscientious objection in health care has “run amok.” Insofar as there are no significant constraints or limitations on accommodation, both rules endorse an approach that is aptly designated “conscience absolutism.” There are two common strategies to counter (...) conscience absolutism and prevent conscientious objection in medicine from running amok. One, non-toleration, is to decline to accommodate physicians who refuse to provide legal, professionally accepted, clinically appropriate medical services within the scope of their clinical competence. The other, compromise or reasonable accommodation, is to impose constraints on accommodation. Several arguments for non-toleration are critically analyzed, and I argue that none warrants its acceptance. I maintain that non-toleration is an excessively blunt instrument to prevent conscientious objection in medicine from running amok. Instead, I defend a more nuanced contextual approach that includes constraints on accommodation. (shrink)

In the United Kingdom the law and medical guidance is supportive of women making choices in childbirth. NICE guidelines are explicit that a competent woman’s informed request for MRCS should be respected. However, in reality pregnant women are routinely denied MRCS. In this paper I consider whether there is sufficient justification for restricting MRCS. The physical and emotive significance of childbirth as an event in a woman’s life cannot be understated. It is, therefore, concerning that women are having their wishes (...) ignored, and we must ascertain whether the denial of agency is justifiable. To answer this question I first demonstrate that access to MRCS is a lottery in the UK. Second, I argue that there is nothing unique about pregnancy that displaces the ethical norm of respecting patents’ sufficiently autonomous choices. Thus, the starting presumption is that all informed choices regarding MRCS should be respected. To ascertain whether any restriction of MRCS is justifiable the burden of proof must be placed on those who argue that MRCS is ethically impermissible. I argue that the most common justifications in the literature against MRCS are insufficient to displace the presumption in favour of autonomous choice in childbirth. I conclude that MRCS should be available to pregnant women, and we must strive to reduce the lottery in access to choice. (shrink)

abstract Debate about physician‐assisted suicide has typically focused on the values of autonomy and patient wellbeing. This is understandable, even reasonable, given the import‐ance of these values in bioethics. However, these are not the only moral values there are. The purpose of this paper is to examine physician‐assisted suicide on the basis of the values of equality and justice. In particular, I will evaluate two arguments that invoke equality, one in favour of physician‐assisted suicide, one against it, and I will (...) eventually argue that a convincing equality‐based argument in support of physician‐assisted suicide is available. I will conclude by showing how an equality‐based perspective transforms some secondary features of debate about this issue. (shrink)

The chair of the ethics committee of a major medical center agonized over how he, as a physician, and his organization should deal with Initiative 119, which, if passed, would legalize physician involvement in active, voluntary euthanasia in Washington State. In the end, he said, he could not vote for aid-in-dying because, “However much I want to reduce suffering, I myself just couldn’t do it to one of my patients.” He spoke of a personal distaste for the potential act, of (...) a profound desire not to have to do it. It was not an ethical argument, but an honest and compelling expression of feelings.Why can’t this sincere man do it, even for patients who request such aid? In a 1991 poll, taken in Washington State prior to the vote on Initiative 119, 49 percent of the physicians surveyed supported the initiative, but 75 percent did not want to participate in aid-in-dying. (shrink)

In this chapter, I consider the idea that physician-assisted death might come into question in the cases of psychiatric patients who are incapable of making autonomous choices about ending their lives. I maintain that the main arguments for physician-assisted death found in recent medical ethical literature support physician-assisted death in some of those cases. After assessing several possible criticisms of what I have argued, I conclude that the idea that physicianassisted death can be acceptable in some cases of psychiatric patients (...) who lack autonomy ought to be taken into account in assessing the moral and legal acceptability of physician-assisted death. (shrink)

One of the most important questions in the debate over the morality of euthanasia and assisted suicide is whether an important distinction between killing patients and allowing them to die exists. The U.S. Supreme Court, in rejecting challenges to the constitutionality of laws prohibiting physician-assisted suicide, explicitly invoked this distinction, but did not explicate or defend it. The Second Circuit of the U.S. Court of Appeals had previously asserted, also without argument, that no meaningful distinction exists between killing and allowing (...) to die. That court had reasoned that if this were so, it would be discriminatory to allow persons on life support to end their lives by removing such treatment, while those who are not connected to life support would be denied similar access to death. (shrink)

In this paper I use William James's understanding of significance in life to show that for certain patients euthanasia and assisted suicide can be importantly meaningful acts that family, friends, and health care professionals must acknowledge and even, at times, aid in bringing to fruition. Dying with meaning is transformative. It reshapes the lives of others that are left behind, giving to their lives new groundings by engaging them in the meaning of dying for us. For the patient, dying with (...) meaning takes the seemingly formless void in the abyss of death and gives it a significant purpose in the last stages of life itself; it turns potential nothingness into actual significance. To the extent that we outsiders do not help the dying, we condemn terminally ill patients to a meaningless existence until they die. (shrink)

This paper engages with a specific problem concerning the relationship between descriptive and normative claims. Namely, if we understand that descriptive claims frequently contain normative assertions, and vice versa, how then do we interpret the traditionally rigid distinction that is made between the two, as ’Hume’s law’ or Moore’s ’naturalistic fallacy’ argument offered. In particular, Kripke’s interpretation of Wittgenstein’s ’rule-following paradox’ is specially focused upon in order to re-consider the rigid distinction. As such, the paper argues that if descriptive and (...) normative claims are not mutually exclusive, then we need a new framework with which to understand this relationship. In this regard, the paper borrows from concerns with vagueness, particularly using a degree-theoretic approach in terms of subjective probability, in an attempt to graphically figure out these differences. Consequently, the paper tentatively proposes the hyperbola model in which degrees of normativity and degrees of descriptivity could be expressed and measured. It is hoped, as a result, that this tentative proposal will contribute to deepening the debate on vagueness in general. (shrink)

A governing principle in medical ethics is respect for patient autonomy. This principle is commonly drawn upon in order to argue for the permissibility of assisted dying. In this paper I explore the proper role that respect for patient autonomy should play in this context. I argue that the role of autonomy is not to identify a patient’s best interests, but instead to act as a side-constraint on action. The surprising conclusion of the paper is that whether or not it (...) is in the best interests for the patient to die is a morally objective matter. This allows for the possibility that it can be in the best interests of the patient to die even if she autonomously considers it to be in her best interest to continue living. I argue that concerns about ‘mandatory’ euthanasia can be met when patient autonomy is respected as a side-constraint on action. Ultimately, this means that assisted dying is permissible, not because the autonomous patient views her suffering to be unbearable, but because it is in her objective best interests and she permitted it via her consent. (shrink)

As a new approach to the still unsettled problem of a morally significant difference between active and passive euthanasia, the meanings of the notion of killing are distinguished on the levels of causality, intention, and motivation. This distinction allows a thorough analysis and refutation of arguments for the equality of killing and letting die which are often put forward in the euthanasia debate. Moreover, an investigation into the structure of the physician's action on those three levels yields substantial differences between (...) the two ways of acting. As can be demonstrated, only a teleological notion of the organism is able to grasp the characteristic feature of active euthanasia. On this basis it is argued that an action against the organism as a whole must, on the interpersonal level, be at once directed against the patient as a person himself. (shrink)

We have always had the ability to commit suicide or request euthanasia in times of serious illness. Yet these acts have been prohibited by the Christian tradition from early times. Some Christians, as they see relatives and friends kept alive too long and in poor condition through the use of current medical powers, however, are beginning to question that tradition. Are assisted suicide and euthanasia compassionate Christian responses to those in pain and suffering who face death? Or are they ways (...) of isolating and abandoning them, of fleeing from Christian compassion, rather than expressing it?The Committee on Medical Ethics of the Episcopal Diocese of Washington recently issued a report addressing assisted suicide and euthanasia. These matters cry out for religious contributions and perspectives, the Committee believes. The group recognizes that religious voices should not determine public policy, but believes they should be heard as we develop a social consensus about assisted suicide and euthanasia. (shrink)

As a bioethical and social issue, euthanasia has become in the 1990s what abor- tion was in the 1960s. Around the world, a de facto taboo on open discussion of the practice is seemingly falling by the wayside, as recognition increases that “active” euthanasia is taking place in spite of social and legal prohibitions. Euthanasia, or more specifically physician-assisted suicide, has become the most visible bioethical issue of the present era; and in the United States the debate has taken on (...) a prominence and urgency unprecedented in our nation's history. (shrink)

In this short paper I will discuss the ambiguous and, even, controversial term ‘right to die’ in the context of the euthanasia debate and, in particular, in the case of passive euthanasia. First I will present the major objections towards the moral legitimacy of a right to die, most of which I also endorse myself; then I will investigate whether the right to die could acquire adequate moral justification in the case of passive euthanasia. In the light of the Kantian (...) tradition I will argue that since rights are understood as based upon duties, the right to die should also presuppose a corresponding duty, which to me could be either an imperfect, solidarity-related duty, or an autonomy-related one, at least as far as the unwanted prolongation of life is concerned. I will conclude with the view that the right to die could actually be considered a legitimate one in the case of passive euthanasia, when the application of life-supporting techniques is against the wishes and the best interests of the patient. (shrink)

This study tests how various kinds of trust impact attitudes toward euthanasia among the general public. The indication that trust might have an impact on euthanasia attitudes is based on the slippery slope argument, which asserts that allowing euthanasia might lead to abuses and involuntary deaths. Adopting this argument usually leads to less positive attitudes towards euthanasia. Tying in with this, it is assumed here that greater trust diminishes such slippery slope fears, and thereby increases euthanasia acceptance.

In biomedical ethics the principle of autonomy is closely connected with the moral and legal claim to informed consent. After World War II and the dramatic misuse of medicine in Nazi Germany, informed consent regulations were expected to help avoid similar misuse in the future, to help overcome the traditional medical paternalism, and to advance the liberty rights of patients and human subjects of research. With the rise of the new field of bioethics in the 1970s, the traditional beneficence-based model (...) of medical ethics shifted in the direction of an individual autonomy model. (shrink)

The original “Dutch Protocol”—the treatment model comprised of puberty blockers, cross‐sex hormones, and surgery—was intended to improve the mental and physical health of pediatric patients experiencing distress over their sexed bodies. Consequently, both researchers and clinicians have couched eligibility for treatment and measures of treatment efficacy in terms of the interventions’ effects on outcomes such as gender dysphoria, depression, anxiety, and suicide. However, recent systematic reviews have concluded that the scientific evidence supporting these interventions is uncertain, leading to significant international (...) differences in what treatments are offered to youth. Against this backdrop, a different argumentative approach has emerged in support of gender‐affirming care. This approach appeals not to reductions in patient morbidity or mortality but to patient autonomy, where medical intervention is pursued as a means to the satisfaction of a patient's “embodiment goals.” In this article, I raise objections to autonomy‐based justifications for pediatric gender‐affirming care, concluding that these arguments misunderstand the place of autonomy in clinical decision‐making and, consequently, put patients at risk of medical harm. (shrink)

Recently, debate over whether health care providers should have a protected right to conscientiously refuse to offer legal health care services—such as abortion, elective sterilization, aid in dying, or treatments for transgender patients—has grown exponentially. I advance a modified compromise view that bases respect for claims of conscientious refusal to provide specific health care services on a publicly defensible rationale. This view requires health care providers who refuse such services to disclose their availability by other providers, as well as to (...) arrange for referrals or facilitate transfers of care. This requirement raises the question of whether providers are being forced to be complicit in the provision of services they deem to be morally objectionable. I conclude by showing how this modified compromise view answers the most significant objections mounted by critics of the right to conscientious refusal and safeguards providers from having to offer services that most directly threaten their moral integrity. (shrink)

Opponents of voluntary euthanasia and physician-assisted suicide often maintain that the procedures ought not to be accepted because ending an innocent human life would both be morally wrong in itself and have unfortunate consequences. A gravely suffering patient can grant that ending his life would involve such harm but still insist that he would have reason to continue living only if there were something to him in his abstaining from ending his life. Though relatively rarely, the notion of meaning of (...) life has figured in recent medical ethical debate on voluntary euthanasia and physician-assisted suicide. And in current philosophical discussion on meaning of life outside the medical ethical debate on voluntary euthanasia and physician-assisted suicide several authors have argued that being moral and having a meaningful existence are connected to each other. In this article, I assess whether his intentionally refraining from causing the harm related to voluntary euthanasia and physician-assisted suicide would involve something to such a patient in the sense that it would promote the meaningfulness of his life. (shrink)

Some physicians refuse to perform life-sustaining interventions, such as tracheostomy, on patients who are very likely to remain permanently unconscious. To explain their refusal, these clinicians often invoke the language of “futility”, but this can be inaccurate and can mask problematic forms of clinical power. This paper explores whether such refusals should instead be framed as conscientious objections. We contend that the refusal to provide interventions for patients very likely to remain permanently unconscious meets widely recognized ethical standards for the (...) exercise of conscience. We conclude that conscientious objection to tracheostomy and other life-sustaining interventions on such patients can be ethical because it does not necessarily constitute a form of invidious discrimination. Furthermore, when a physician frames their refusal as conscientious objection, it makes transparent the value-laden nature of their objection and can better facilitate patient access to the requested treatment. (shrink)

This paper reports of a case where a physician conscientiously objected to prescribing PrEP to a bisexual patient so as not to “enable immoral sexual behavior.” The case represents an instance of conscience creep, a phenomenon whereby clinicians invoke conscientious objection in sometimes objectionable ways that extend beyond the traditional contexts of abortion, sterilization, or physician aid in dying. This essay uses a reasonability view of conscientious objection to argue that the above case represents a discriminatory instance of conscience creep (...) that should not be permitted. (shrink)

The Remmelink Committee published its report on medical decisions at the end of life in the Netherlands in September 1991. As a result, the Dutch debate about physician aid‐in‐dying has been broadened to include life‐terminating acts that have not been explicitly requested by the patient.

I have a hairstylist whose lover was very sick. I’d been seeing this stylist for ten years and we’re good friends. [His lover was] becoming an invalid, not able to get out of bed. He said “I hate to ask you this but would you mind writing a prescription to help us out?” [So] I wrote a prescription to a patient who I had never seen, and I sent it to him in the mail and I heard the next time (...) I went in to get my hair cut that it was the most beautiful experience that my stylist had ever had. It was Valentine’s Day and they had a lovely meal with champagne. And they held each other and then, you know, his partner took his pills and was released. (shrink)

In this paper I discuss a recent exchange of articles between Hugh McLachlan and John Coggon on the relationship between omissions, causation, and moral responsibility. My aim is to contribute to their debate by isolating a presupposition I believe they both share and by questioning that presupposition. The presupposition is that, at any given moment, there are countless things that I am omitting to do. This leads both McLachlan and Coggon to give a distorted account of the relationship between causation (...) and moral or (as the case may be) legal responsibility and, in the case of Coggon, to claim that the law’s conception of causation is a fiction based on policy. Once it is seen that this presupposition is faulty, we can attain a more accurate view of the logical relationship between causation and moral responsibility in the case of omissions. This is important because it will enable us, in turn, to understand why the law continues to regard omissions as different, both logically and morally, from acts, and why the law seeks to track that logical and moral difference in the legal distinction it draws between withholding life-sustaining measures and euthanasia. (shrink)

Our goal in this article is to explicate the way, and the extent to which, euthanasia can be voluntary from both the perspective of the patient and the perspective of the health care providers involved in the patient’s care. More significantly, we aim to challenge the way in which those engaged in ongoing philosophical debates regarding the morality of euthanasia draw distinctions between voluntary, involuntary, and nonvoluntary euthanasia on the grounds that drawing the distinctions in the traditional manner (1) fails (...) to reflect what is important from the patient’s perspective and (2) fails to reflect the significance of health care providers’ interests, including their autonomy and integrity. (shrink)

The chair of the ethics committee of a major medical center agonized over how he, as a physician, and his organization should deal with Initiative 119, which, if passed, would legalize physician involvement in active, voluntary euthanasia in Washington State. In the end, he said, he could not vote for aid-in-dying because, “However much I want to reduce suffering, I myself just couldn’t do it to one of my patients.” He spoke of a personal distaste for the potential act, of (...) a profound desire not to have to do it. It was not an ethical argument, but an honest and compelling expression of feelings.Why can’t this sincere man do it, even for patients who request such aid? In a 1991 poll, taken in Washington State prior to the vote on Initiative 119, 49 percent of the physicians surveyed supported the initiative, but 75 percent did not want to participate in aid-in-dying. (shrink)

I have a hairstylist whose lover was very sick. I’d been seeing this stylist for ten years and we’re good friends. [His lover was] becoming an invalid, not able to get out of bed. He said “I hate to ask you this but would you mind writing a prescription to help us out?” [So] I wrote a prescription to a patient who I had never seen, and I sent it to him in the mail and I heard the next time (...) I went in to get my hair cut that it was the most beautiful experience that my stylist had ever had. It was Valentine’s Day and they had a lovely meal with champagne. And they held each other and then, you know, his partner took his pills and was released. (shrink)

The COVID-19 Pandemic a stress test for clinical medicine and medical ethics, with a confluence over questions of the proportionality of resuscitation. Drawing upon his experience as a clinical ethicist during the surge in New York City during the Spring of 2020, the author considers how attitudes regarding resuscitation have evolved since the inception of do-not-resuscitate orders decades ago. Sharing a personal narrative about a DNR quandry he encountered as a medical intern, the author considers the balance of patient rights (...) versus clinical discretion, warning about the risk of resurgent physician paternalism dressed up in the guise of a public health crisis. (shrink)

We have always had the ability to commit suicide or request euthanasia in times of serious illness. Yet these acts have been prohibited by the Christian tradition from early times. Some Christians, as they see relatives and friends kept alive too long and in poor condition through the use of current medical powers, however, are beginning to question that tradition. Are assisted suicide and euthanasia compassionate Christian responses to those in pain and suffering who face death? Or are they ways (...) of isolating and abandoning them, of fleeing from Christian compassion, rather than expressing it?The Committee on Medical Ethics of the Episcopal Diocese of Washington recently issued a report addressing assisted suicide and euthanasia. These matters cry out for religious contributions and perspectives, the Committee believes. The group recognizes that religious voices should not determine public policy, but believes they should be heard as we develop a social consensus about assisted suicide and euthanasia. (shrink)

Contrary to the common view, this paper suggests that the Hippocratic oath does not directly refer to the controversial subjects of euthanasia and abortion. We interpret the oath in the context of establishing trust in medicine through departure from Pantagruelism. Pantagruelism is coined after Rabelais' classic novel Gargantua and Pantagruel. His satire about a wonder herb, Pantagruelion, is actually a sophisticated model of anti-medicine in which absence of independent moral values and of properly conducted research fashion a flagrant over-medicalization of (...) human problems. Ultimately this undermines the therapeutic core of medicine itself. We contend that PAS is a case of such over-medicalization and that its institution creates medicophobia. This article does not express an opinion about euthanasia in general. Rather, we claim that physicians should learn from the oath and from Rabelais that they should keep their practice to medical care and not to exploit their expertise and social privileges for the sake of ulterior motives, even when their patients desire those goals. (shrink)