Legistrothanatry: A New Specialty for Assisting in Death

LEGISTROTHANATRY: A NEW SPECIALTY FOR ASSISTING IN DEA TH ROBERT M. SADE* and MARY F. MARSHALLf The debate on physician-assisted suicide and voluntary euthanasia is still active and unresolved. Clear resolution in the near future seems unlikely, because moral visions of the acceptable and unacceptable are diverse, and arguments on practical grounds are supported by little data. Suicide itself is viewed by some as morally unacceptable, but most of that opinion is religiously based. Because we are a secular, pluralistic society, suicide should be viewed, if not as morally acceptable, at least as lying within an individual's moral purview and not subject to legal prohibition [I]. If suicide should not be subject to legal prohibition on moral grounds, then it seems difficult tojustify on moral grounds, prima facie, prohibiting assisted suicide or its close cousin, voluntary euthanasia. There is a fundamental difference, however, between suicide and assisted suicide: the former is ultimately chosen and executed by one person with a single set ofvalues; the latter draws in a second person with a second set of values. While the second person may be concerned only with the interests of the suicide subject, there is potential that he may act in his own interest, based on his own values, in encouraging and assisting suicide [2] . Thus, there is an important empirical question that looms larger under conditions of assisting suicide than suicide: to what extent and with what frequency is the act ofsuicide motivated by the best interests of the subject? Self-serving motivation by the assister may be an attendant risk of a permissive social attitude toward assisted suicide; debate on the subject has provided no clear answers because few unequivocal data are available. Objective evidence that the interests of second or third parties will frequently motivate assisters to encourage suicide would argue strongly for legal prohibition of assisted suicide; whereas evidence tìiat this will seldom occur *Department of Surgery and Institute of Human Values in Health Care, Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC 29425. fThe Program in Biomedical Ethics, Medical University of South Carolina.© 1996 by The University of Chicago. All rights reserved. 0031-5982/96/3904-097C401.00 Perspectives in Biology and Medicine, 39, 4 ¦ Summer 1996 | 547 would weigh toward a more permissive attitude that promises substantial benefits to some patients who have unrelievable suffering. Public support and opposition to assisted suicide have been roughly evenly divided: referendums in Washington and California have rejected and Oregon has passed, all by narrow margins, laws permitting assisted suicide. The concern that motivates much of the support of such initiatives is the desire to retain control of one's own destiny at the end of life, a desire that some feel may be frustrated by sophisticated life-sustaining technologies . We will assume, for the purpose of this discussion, that the benefits to suffering patients outweight the risks that suicide may be encouraged or provoked by a misguided or unscrupulous assister. If this assumption were correct, then perhaps assisting suicide should be permitted by law. If it should be legal, we may ask whether physicians should be the assistere . Some say they should, because physicians have access and expertise in the use of appropriate lethal drugs, and, more importantly, they have a responsibility to minister to all a patient's needs, including reliefofuntreatable suffering at the end of life [3] . Others argue they should not, because killing by physicians is contrary to their healing role and would undermine the trust that grounds the healing relationship between physicians and patients [4] . Moreover, they argue, there may be a steep slippery slope leading to involuntary euthanasia of incompetent persons when physicians are permitted to assist in or cause death [5] . We cannot resolve this ethical and legal debate here, because there are deeply held views on both sides of the issue and insufficient empirical data to clarify pertinent issues, such as the extent to which trust of physicians may actually be undermined. We would, however, like to propose an answer to the following perplexing question: if assisted suicide and voluntary euthanasia should be legal, and if physicians should not help patients to die, who should? Although curing...