Assisted Suicide: An argument as to why
clinicians should not kill their patients.
Brendan Leier PhD
Clinical Ethicist, UAH, Stollery, MHI
Dossetor Health Ethics Centre
Assisted Suicide
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Why now?
Early debate
Professions
Current conflicts of interest
Medicalisation of death
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What is the law?
241. Every one who
(a) counsels a person to commit suicide, or
(b) aids or abets a person to commit suicide,
whether suicide ensues or not, is guilty of an indictable
offence and liable to imprisonment for a term not
exceeding fourteen years.
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Why now?
• Gloria Taylor aka Carter v. Canada BC 2012
• Bill C384
• Education and pre-professional attitudes
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Early debate
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Medical paternalism
poor palliative care (technically & legally)
‘Right-to-die’ movements
Very reasonable expectations that one might expect a
loss of personal control and painful death.
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James Rachels (NEJM 1973)
The Conventional Doctrine (endorsed by the American
Medical Association):
In certain situations, passive euthanasia ("letting die") is
morally permissible. However, active euthanasia
(physician-assisted death) is never morally permissible.
Doctors can withhold treatment in many circumstances,
and does nothing wrong if the patient dies, but the
doctor must never, ever "kill" the patient.
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James Rachels (NEJM 1973)
• Rachels’s Thesis: active euthanasia is not any worse
than passive euthanasia
Definitions:
• Active Euthanasia = taking a direct action designed to
kill a patient
• Passive Euthanasia = deliberate withholding of
treatment that could prolong patient's life, allowing the
patient to die
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James Rachels (NEJM 1973)
Important assumption: THE JUSTIFICATION for "letting
die" is to reduce harm & suffering of the patient.
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James Rachels (NEJM 1973)
First argument against the conventional doctrine is that
many cases of "letting die" are WORSE (for the patient)
than is killing them. If the patient is going to die either
way, why is it morally permissible to dehydrate them to
death? Either way, the patient is dead. But the
conventional doctrine often adds a requirement of
suffering before dying.
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James Rachels (NEJM 1973)
Second argument is the Bathtub Example of Smith
and Jones. It demonstrates that some cases of letting
die are at least as bad as killing.
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James Rachels (NEJM 1973)
• Therefore, the "bare" difference between killing and
letting die doesn’t always make a moral difference.
• Therefore, in many cases where it is right to let a
patient die, it is also right to practice active euthanasia.
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Principle of Double-Effect
The doctrine consists of four conditions that must be
satisfied before an act is morally permissible:
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Principle of Double-Effect
• The nature-of-the-act condition. The action must be
either morally good or indifferent.
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Principle of Double-Effect
• The nature-of-the-act condition. The action must be
either morally good or indifferent.
• The means-end condition. The bad effect must not be
the means by which one achieves the good effect.
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Principle of Double-Effect
• The nature-of-the-act condition. The action must be
either morally good or indifferent.
• The means-end condition. The bad effect must not be
the means by which one achieves the good effect.
• The right-intention condition. The intention must be the
achieving of only the good effect, with the bad effect
being only an unintended side effect.
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Principle of Double-Effect
• The nature-of-the-act condition. The action must be
either morally good or indifferent.
• The means-end condition. The bad effect must not be
the means by which one achieves the good effect.
• The right-intention condition. The intention must be the
achieving of only the good effect, with the bad effect
being only an unintended side effect.
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Principle of Double-Effect
• The nature-of-the-act condition. The action must be
either morally good or indifferent.
• The means-end condition. The bad effect must not be
the means by which one achieves the good effect.
• The right-intention condition. The intention must be the
achieving of only the good effect, with the bad effect
being only an unintended side effect.
• The proportionality condition. The good effect must be
at least equivalent in importance to the bad effect.
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Profession
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Authority over a body of knowledge
Autonomous
Self-regulating
Fiduciary obligation
Eudaemonistic
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Dissenters
[6]
Medical practitioners disagree about the ethics of
physician-assisted death. There are respected
practitioners who would support legal change. They
state that providing physician-assisted death in defined
cases, with safeguards, would be consistent with their
ethical views. However, other practitioners and
many professional bodies, including the Canadian
Medical Association, do not support physician-assisted
death. Carter v Canada
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Trust
Four of the top five most trusted professions in the eyes
of Canadians reside within the health care sector, while
firefighters top the list of forty-one professions to come
out as Canada’s most trust profession studied,
according to a new Ipsos Reid poll conducted on behalf
of Postmedia News and Global Television 2012
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Trust
Nearly all (84%) Canadians Trust the Information
Given to them by Nursing Organizations While only
three in ten (30%) rate the Quality of Healthcare in
Canada as ‘Excellent’ or ‘Very Good’, Canadians
credit Frontline Workers for Major Responsibility of
Quality Care... Ipsos Reid poll
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Trust
•
Arguably the most important aspect of the therapeutic
relationship
• Profoundly asymmetrical nature, i.e. Trust-building vs
Trust-destroying
• Professionals are the stewards of trust
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Professional Discretion
The American Medical Association’s (AMA’s) Code of Medical
Ethics prohibits involvement of physicians in executions, permitting
only certification of death after someone else has declared it.15
State laws and regulations requiring the participation of a physician
imply much more extensive involvement, including measuring
chemicals, inserting intravenous lines, injecting drugs, monitoring
sedation, and intervening if the prisoner does not die after
injection.13,16 Healing the sick and alleviating suffering is the
primary role of physicians in US society. The central thread running
through the AMA’s Code of Medical Ethics is the physician’s
obligations to help and not to harm people.
Journal of the American Medical Association COMMENTARY By Lee Black, JD, LLM and Robert M. Sade, MD
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Professional Discretion
The ANA is opposed to all forms of participation by nurses in
capital punishment, by whatever means, whether under civil or
military legal authority. Participation in capital punishment is
inconsistent with the ethical precepts of justice, nonmaleficence,
and beneficence, and the values and goals of the nursing
profession. The ethical principle of nonmaleficence requires that
nurses act in such a way as to prevent harm, not to inflict it. The act
of participating in capital punishment clearly inflicts harm; nurses
are ethically bound to abstain from any activities in carrying out the
death penalty process. Nurses must not participate in capital
punishment, whether by chemical, electrical, or mechanical means.
2010 ANA Position statement: Nurses' Role in Capital Punishment
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Transfer of the burden...
A declaration that the impugned provisions unjustifiably
infringe s. 15 of the Charter, and are of no force and
effect to the extent that they prohibit physician-assisted
suicide by a medical practitioner in the context of a
physician-patient relationship, where the assistance is
provided to a fully-informed, non-ambivalent competent
adult patient who: (a) is free from coercion and undue
influence, is not clinically depressed and who personally
(not through a substituted decision-maker) requests
physician-assisted death;
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Transfer of the burden...
and (b) is materially physically disabled or is soon to
become so, has been diagnosed by a medical
practitioner as having a serious illness, disease or
disability (including disability arising from traumatic
injury), is in a state of advanced weakening capacities
with no chance of improvement, has an illness that is
without remedy as determined by reference to treatment
options acceptable to the person, and has an illness
causing enduring physical or psychological suffering
that is intolerable to that person and cannot be
alleviated by any medical treatment acceptable to that
person.
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Medicalneed
justified
suicide
‘competent’
justified
suicide
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Medicalisation of Death
• The Right to Die Society Canada (1992)
• Evelyn Martens trial 2004
• The ‘exit bag’
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Medicalisation of Death
In many a village in Mexico I have seen what happens
when social security arrives. For a generation people
continue in their traditional beliefs; they know how to
deal with death, dying, and grief.59 The new nurse and
the doctor, thinking they know better, teach them about
an evil pantheon of clinical deaths, each one of which
can be banned, at a price. Instead of modernizing
people's skills for self-care, they preach the ideal of
hospital death. By their ministration they urge the
peasants to an unending search for the good death of
international description, a search that will keep them
consumers forever.
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Medicalisation of Death
Like all other major rituals of industrial society, medicine in
practice takes the form of a game. The chief function of
the physician becomes that of an umpire. He is the
agent or representative of the social body, with the duty
to make sure that everyone plays the game according
to the rules.60 The rules, of course, forbid leaving the
game and dying in any fashion that has not been
specified by the umpire. Death no longer occurs except
as the self-fulfilling prophecy of the medicine man.61
Ivan Illich, Medical Nemesis (1975)
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Conflicts of Interest
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Conflicts of Interest
• DCD
• Allocation of Scarce Resources
• Value judgments, i.e. QOL, Disability, Ageism, etc.
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Conclusion
I would hope to tear the question of whether it is
reasonable/permissible/justifiable to end one’s life from
the expectation that, in the event that the government of
Canada and/or Canadian civil society determined it to
be legal to assist a suicide, professionals who provide
healthcare would bear the burden of determining
suicide criteria, applying suicide criteria, and finally
killing, or providing the means to kill, successful
candidates.
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Conclusion
I would argue that, in the tradition of all true professionals,
the candidacy of doctors, nurses, pharmacists, etc, for
participation in the practice of assisted suicide would be
determined by those professional bodies alone. I would
also argue that health professions should oppose the
participation of their members as a matter of principle,
fundamentally, the threat of the conflict of interest
created by a fiduciary being expected to simultaneously
advocate for a patient’s best-interest and at the same
time consider killing him or her.
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Conclusion
At a very minimum, I would argue that this will serve to
further undermine the ongoing and continual perception
of patients and families that clinicians already bear the
pressure of competing interests that undermine patient
care in some systematic sense. (i.e. resourceallocation, value judgments, biases against age,
disability, etc)
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Thich Quang Duc
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