Howard Ball’s lead essay on this issue is clear and helpful. Yet I think the term “Physician Assisted Death” is evasive and euphemistic. Physicians have for centuries helped patients to die—that is, to endure the process that ends in their death. The question is whether physicians should help them kill themselves—and whether the law should allow physicians to do so. Thus I will use the term Physician Assisted Suicide (PAS). This raises a moral question (Is PAS morally right?), and a legal question (Should PAS be against the law?).
First the moral issue. Morality centrally concerns how our choices bear on the intrinsic goods of human persons—such goods as life and health, knowledge, friendship, and others. We ought to care for every person, and that means helping them to attain or preserve these intrinsic goods. Since these goods are the aspects of persons, to act directly against any of them is to act against the person herself. Human life is not something we have; rather, one’s life is identical with one’s concrete reality, that is, identical with oneself. So, a choice to kill a human being, even for a good end, such as to prevent suffering, is contrary to the love and appreciation for the person herself. This is true both of killing others and of killing oneself. Suicide and assisting suicide are objectively morally wrong because they are choices contrary to the intrinsic good of an innocent human person. (I say objectively morally wrong, to distinguish that from moral guilt: someone who makes a choice that is objectively wrong is not at fault for a morally bad choice if she thought what she was doing was right and was not at fault for this mistaken judgment—often referred to as an inculpably erroneous conscience.)
This does not mean, however, that we must always take all measures possible to preserve someone’s life, our own included. It can be morally right to forgo some means of preserving life, even foreseeing that this will result in dying more quickly than one otherwise would. Such a choice is quite distinct from intentional killing—say, choosing to kill oneself by swallowing lethal pills. A choice to forgo excessively burdensome treatment does not involve a failure of respect for the intrinsic good of life. Rather, it is a choice not to use certain means of prolonging life in order to avoid the burdens of that treatment.
This distinction between intentional killing and accepting death as a side effect is important because by our choices we not only select which external behavior will be performed, but we direct our will (the capacity for choosing and intending) toward or against human persons. If I choose to kill someone, then I direct my will against the life—the concrete reality—of a human person.
Some hold that human life is only an instrumental good—not good in itself but only a condition for realizing what is intrinsically valuable. And so they claim that near the end of life our “mere biological life” may be all that is left, and our personal life—our selves—is gone. But that is a mistake: we do not just have or inhabit bodies; rather, we are bodily beings. As I type this sentence I am directly aware that it is the same agent that moves his fingers (a bodily being) and that thinks what to say (a conscious being): it is one and the same being that is both conscious and bodily. And so one cannot justify euthanasia or PAS on the grounds that they destroy a “mere biological life.” To choose to kill the biological life of grandfather is a choice to destroy the one being that grandfather is. (This remains true even though grandfather’s soul—which is only a part of him—survives).
But, it is often objected, why should we not be able to relieve someone’s misery by helping her to die? Isn’t it the compassionate thing to do—as Howard Ball claims—to assist them to kill themselves? We should distinguish between the person who is suffering, and the suffering. When someone we love is suffering grievously we have a strong emotional response. However, what we are reacting to with emotional repugnance is, precisely, the suffering itself of someone who is dying, in severe pain, and gradually losing their vigor and faculties. But it is a different thing altogether to assert that, given that emotion, the best way to act—the best way of helping someone who is suffering a great deal—is to help her kill herself. We rightly abhor the pain and suffering, but not the person herself in that condition. It is right to try to remove the pain and suffering; it is not right intentionally to destroy the person, as a means of removing that pain and suffering.
The moral issue does not by itself settle the legal issue, to which I now turn. Proponents of PAS argue that people’s autonomy should be respected and so the law should allow PAS. It is true that a large degree of autonomy, that is, the absence of restraint on one’s choices and actions, is important as a means to leading a responsible life. But both law and medical practice recognize rightful limits to autonomy. The law requires drivers to wear seatbelts and motorcyclists to wear helmets. There are laws against prostitution, dueling, and the use of certain addictive drugs. All laws limit liberty or autonomy to some extent; the question is whether there is a sufficient public good at stake to limit the liberty at issue.
The protection of life has always been recognized as an essential component of the public good. Especially important is how the culture as a whole—which is profoundly influenced by the law—regards human life. If a culture regards human life as inviolable, that fact protects all of us; if not, then the most vulnerable among us—especially the elderly and the disabled—are in danger. A culture that condones PAS views life as merely conditionally valuable and so views the lives of many of the most vulnerable among us as mere burdens. The elderly, the dying, and the disabled in that type of culture will receive treatment far inferior to what they would receive in a culture that recognized their equal and inherent dignity.
Consider the laws that prohibit physicians from amputating healthy limbs or performing female genital mutilation. If laws prohibiting those procedures were rescinded and those acts became widespread, the message would be sent that these practices are not inherently harmful. Such laws are in place because physicians should perform surgery only to provide a real medical (or cosmetic) benefit to the patient—or at least not significantly harm the patient. In the same way, if the law against PAS were rescinded and PAS were widely practiced, that would send the message that in many cases a person’s life is simply not worth living. The message sent to the elderly and the disabled would be that they may very well lack inherent value. That itself would be a pressure—and not a very subtle one—on the elderly, and on many disabled, to opt for death rather than life. A person’s sense of self-worth is profoundly affected by the views of others in her life and so the sense of self-worth among the elderly, dying, and disabled would be profoundly harmed by the practice of PAS, leading many to despair and to request suicide out of undue deference to others.
Moreover, the logic of decriminalizing PAS for the terminally ill who are suffering grievously would lead inexorably to allowing (and encouraging) other types of killing. If the rationale for PAS is to respect autonomy, then why limit it to those are terminally ill? Why privilege the autonomy of those who are suffering and terminally ill above those who are suffering chronically? If the rationale for PAS is that a person is in misery or has allegedly lost her dignity—if, for such people, death is a benefit—then it will be impossible to deny this alleged benefit to those who lack decisionmaking capacity, those who are unconscious, or demented, or too young to have such capacity (as has occurred in the Netherlands with the open euthanasia of infants).
Thus, out of respect for life, and out of compassion and care for the elderly, dying, and disabled, PAS should remain illegal.