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The arguments expressed by proponents of the legalization of physician-assisted suicide (PAS), do not in any shape or form stand up to the rigour of scrutiny necessary in a legal debate, and should therefore be dismissed altogether. English law as it stands currently reflects my position, and although the practice is illegal I will provide an informed alternative that the current UK government can take in addressing this issue1. This essay concerns the evaluation of the two strongest arguments supporting legalization, and the two strongest arguments against legalization. Before I delve into the arguments I will give some background to this controversial debate and also set the overall context of this essay. Each argument will be critically analysed and counter-arguments will be put forward.
Under UK law, the practice of PAS is punishable with upto fourteen years being locked up behind bars2. For over two centuries the morality of PAS has been deliberated upon within academic circles. However in the last century the debate has been most discernable when the jurisdiction doctors possessed over medical decision making has come under scrutiny, and with times of financial depression3, interest in PAS mirrors the reality that many people in western society feel entitled to pass away in a ‘decent manner’. The debate surrounding dying with a sense of grandeur has in some way become dichotomised. On one end of the aisle there are those who argue that PAS should be legalised, on the other end there are those who assert that palliative care is the ethical answer to care for the dying. The debate can be pictured as a lamentable dilemma for which there will never be a forthright answers that satisfies everyone. Terminology should be clarified from the onset when discussing legalization of PAS. A medical doctor who assists a patient to commit suicide by supplying fatal doses of drugs for self-use, at that person’s willing and capable request, then he or she is engaging in physician-assisted suicide.
Respect for patient autonomy is one of the major philosophical arguments used by proponents of legalization of PAS. In western society, autonomy is an imperative worth and shouldn’t be dismissed. There are four main principles of bioethics namely justice, non-maleficence, and autonomy5. Autonomy is the main ethical consideration underlying informed consent. For consent to be informed, patients rely on the information provided by their doctor. This right to autonomy or “self-determination” is considered to be one of the most important and fundamental rights of a patient. This is the right to direct the medical treatment a patient chooses or rejects. The Belmont Report states “respect for persons…divides into two separate moral requirement: the requirement it acknowledges autonomy and the requirement to protect those with diminished autonomy”6. It is a fundamental duty that doctors must uphold t autonomy when interacting with patients. Lawyers and philosophers have postulated that PAS should coexist with hospice and palliative care, and that a terminally ill patient not being entitled to the option of PAS has had their right of autonomy violated. Callahan D had said that in bioethics, autonomy occupies a place “at the top of the moral mountain” 8. In 2015 the Supreme Court held that established that the right of autonomy over treatment is enshrined in the common law. In this case, the appellant gave birth and as a result of complications during delivery, her son who was responsible for her case during pregnancy and labour. The appellant sought damages against the doctor who was responsible for her case during pregnancy and labour. The appellant sought damages against the doctor who was responsible for her case during pregnancy and labour.
The appellant claimed that5 her son’s injuries were attributable, in particular to the doctor’s failure to advise her about the risks that caused her son’s condition. The Supreme Court held “An adult person of sound mind is entitled to decide which, if any, of the available forms treatment to undergo, and her consent must be obtained before treatment interfering with her bodily integrity is undertaken. The doctor is therefore under a duty to take reasonable care to ensure that the patient is aware of any material risks involved in any recommended treatment, and of any reasonable alternative or variant treatments” 9. This means if PAS is available as a treatment choice then it is the doctors duty to advice and the patients right to decide. The patient has the right to decide what is best for him and her and their decisions must be respected. Another case involves Noel Conway, a 67 year old retired college lecturer. He was diagnosed with amyotrophic lateral sclerosis which is a form of motor neurone disease (9). According to the Guardian Newspaper, Mr Conway said that “Current law means that I will have no control of how my life ends and I will have to endure this nightmare for as long as it takes. As someone who has always been in control of his life and taken responsibility for himself, I find this quite unacceptable. I want to change the law to allow assisted dying so that I can be in control of my own death”(10) . Noel Conway and many others like him have tried to convince the courts that they should be allowed to have control.
When you look at the cases and their settings, it is hard to disagree with them.
Of all of the justifications for legalization of physician-assisted suicide, the relief of pain and suffering is one of the most agreed upon and publicly endorsed. Pain is the principal reason why patients see physicians but it is routinely undertreated. The International Association for the Study of Pain, defines the term pain as an “unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”(13). An experiment was conducted which showed that pain is undertreated, but also told us that a significant proportion of physicians support allowing PAS for the reasons of unremitting pain. of Here 3299 oncologists who are members of the American Society of Clinical Oncology participated in the experiment. 22.5% of those same oncologists supported physician-assisted suicide for a terminally ill patient with prostate cancer who had unremitting pain despite optimal pain management(14). Another experiment was conducted in the Netherlands to answer the question,how many people will have their needless pain and suffering relieved? The experiment relied on two factors , firstly, the proportion of all decedents that would euthanasia or PAS and secondly the proportion that would do so for reasons of unremitting pain.
For factor 1, according to the latest data. Approximately 2.4 percent of all Dutch decedents had a distinct dying process, were competent to request euthanasia or PAS, and died from euthansai or PAS(15). Factor 2 According to these same data, in only a third of cases did pain play any role in the patient’s decision to seek euthansai or PAS. Pain was the sole or dominat reason for euthanasia. Research also shows that patients with terminal cancer are thought to be at hugh risk of committing suicide. Patients with terminal cancer are thought to be at high risk of suicide due to pain, helplessness, exhaustion (16), or because further treatment or contact with the health-care system is not provided.(17) This study was organised by the palliative-care team of the Milan National Cancer Institute, which was notified of any case of suicide, defined as a self-induced injury or drug overdose resulting in death. 17 964 patients (9200 men) aged 61 years or less (33%), 62-72 years (35%), or 73 years or more (32%) were enrolled and five cases of suicide (0.027%) were recorded. Of these, two were women (breast cancer, melanoma) and three were men (bladder, lung, and unknown primary cancer site.) Mean Age was 65 years (range 50-76) and the duration of home care by the palliative care team was a median 30 days. Two patients jumped out of a window, two shot themselves, and one took an overdose of morphine. Patients were usually seen everyday, which makes the underestimation of suicide unlikely even if this occurred by drug overdose. These findings tell us that patients with cancer are at higher risk of committing suicide.
A serious objection to physician-assisted suicide concerns sliding down the slippery slope, toward total disrespect and contempt for human life. The argument holds that it is preferable to keep physician-assisted suicide illegal so as to raise a clear voice regarding the value and importance of human life, and to force physicians to think hard when they assume the responsibility of shortening life. The argument contains several warnings, but I will focus on two. The most obvious is that weak populations who are unable to protect themselves would be so severely harmed once physician-assisted suicide would be allowed.
The second is that patients may be coerced to use PAS for a variety of reasons which we will touch on. The essential slippery slope argument moves in the following way: take step A, and we shall be led to take steps B and C. Step A takes us onto the slope; steps B and C take us down it. In this form, a slippery slope argument is consequentialist in character: the consequences of taking step A are that we shall take steps B and C. However this matter is one of probability,, so that we need to believe it likely that we shall take steps B and C. If this probability is low, then fear of steps B and C may recede, if however, this probability is high, then the fear of steps B and C may well prevent us from granting the permissibility of step A, even if on other grounds it has passed moral muster. There are two points to notice about this essential form of a slippery slope argument. First, the argument is about the likelihood of disastrous slope consequences to passing: it is not an argument involving causal necessity. The claim is not that we shall be compelled by causal necessity to descend the slope, the claim is rather that if we take step A, then it becomes empirically very likely that we shall take steps B and C. Second, if a slippery slope is not a casual argument, neither is it a quasi-logical one. That is, the thought is not that one is inexorably led down the slope, say, of taking life as a result of line-drawing or boundary disputes, however real those disputes may at times be. What we require in the case of a slippery slope is some account, so to speak, of the mechanism that leads us down the slope and so that renders high the probability that we shall indeed go down it. For it is obvious that some uses of slippery slope are believed by no one.
Coercion of the patient is probably going to come from close relatives and family members either because of economic burdens or caregiving responsibilities. The bad news is that there is no hard evidence that will allow us to quantify the number of patients who die that may have been coerced to undergo PAS. There are however anecdotal accounts of such coercive pressures such as the Delury case. In this case a husband was found guilty of coercing his wife, who suffered from severe multiple sclerosis, to willingly end her life. Diaries that the husband had written contained evidence that his intention was to rid himself of the responsibity to care for his wife, there is also information that suggests financial pressures can lead to coercion. The SUPPORT study found that in 24 % of cases. Families of terminally ill patients lost most or all of their savings because of medical costs.
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