Moral issue of physician assisted suicide (PAS) is a very complex and controversial topic. One focus of the controversy is whether patient’s autonomy can be guaranteed and whether his true will be manifested. Mill’s utilitarianism, Kant’s deontological ethics and Aristotle’s virtue ethics each have different interpretations of the legalization of physician assisted suicide, with both support and the questioning of the lack of protection of patients’ autonomy. In my point of view, Mill’s utilitarianism best captures the depth of controversy in the moral issue of physician-assisted suicide because it has a stronger reality, objectivity and practicality and only by fully safeguarding the absolute expression of patients ‘ own will can the legalization of PAS have a more reasonable ethical basis.
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The legalization of physician assisted suicide (PAS) is a widely controversial topic all over the world. Physician assisted suicide is suicide assisted by a physician providing certain prescription or drugs. In summary, the supporters for allowing PAS, mainly on humanitarian and benevolent grounds, want to eliminate the pain of terminally ill patients going to death, while opponents are more worried about technology abuse, moral decline, and so on. Both supporters and opponents can find reasons. In learning a number of controversial views, I believe that it is the controversy over the autonomy of a patient that is the key point, i.e., whether patient’s autonomy can really be guaranteed. This paper presents my analysis from the angle of ethics.
The morality of PAS is to allow a patient to approach fast and painless death by his own choice. Autonomy is a human right, meaning one’s own decisions and actions should be respected by others, i.e., the freedom and autonomous choice of individual rights holders to exercise such rights should be respected. The key to the ethics of PAS is whether the doctor’s assistance with the patient to end his life is a decision made by the patient himself, which should be fully autonomous and voluntary. The main concern of physician assisted suicide opponents is that such “suicide” may not be the real will of the patient. Instead, the patient’s “autonomous” and “voluntary” requirement of physician assisted suicide is only a matter of illusion.
Mill’s utilitarianism argues that although death is usually bad, suicide may not be a wrong choice for terminally ill people in great pains and with a terrible quality of life. Mill’s utilitarianism seeks to maximize happiness and believe people should pursues greatest happiness. That is, regardless of the motive of a person’s behavior, the effect of an action on the maximum happiness value should be the only element to be take into consideration, i.e., those that can enhance the maximum happiness value are of moral right, otherwise they are not. If there is a negative value after the good of the quality of life of these patients is added to the bad one, it may be more in their interest to die early. In this case, death is not a bad result, but a good result. At the same time, it is important to consider the impact on others, most directly on the family and friends of the deceased. On one hand, rational judgment may not agree the patient to continue to live in such irreversible pains. On the other hand, a dying patient in no hope of recovery does need care services from friends and family members day and night, which is the exhaustion of energy. With financial and psychological burdens, the patient causes the friends and family members to bear great emotional pains and pressure. Therefore, to meet the requirements of the patient to end his life through physician assisted suicide is also a relief for his family. In addition, given the allocation of social and medical resources, particularly in developing countries, it would be to the overall interests of society to devote limited medical resources to patients in a possible hope of rehabilitation rather than those in no hope.
Utilitarianism can well explain the legalization of PAS, but remaining the question that whether such legalization might result in the fact that application for PAS may not be out of his own will but external pressure, which could be an ethical slippery slope. On one hand, to avoid the responsibility of medical care, or even to inherit something earlier, the patient’s family may imply or force him to apply for PAS just out of their own selfishness or disputes over interests in family relations. On the other hand, as utilitarianism has always made “the happiness of the vast majority” an ultimate moral goal, such a view from the perspective of “the vast majority” would make PAS not a compassionate choice but something to reduce the burden, and even the “palliative care” to alleviate illness will not be encouraged. Ethical slippery slope in the whole society might be possible. In summary, Mill’s utilitarianism can better explain the conformity of PAS to the greatest happiness of social interests from the perspective of morality.
According to Kant, whether an action is justified depends on motive and means, i.e. whether the action in nature meets the requirements of moral obligation. Obligation comes from good will, and good will originates from the inner rationality of a person, and the obligation is the order issued by a good will. In discussing the legalization of PAS, the theory of obligation has its inherent contradiction. On one hand, Kant believes that dignity is a kind of existence of humanity and is an internal value of people themselves, meaning we all have a value of being respected. No matter how a person is or what his or her living environment may look like, even under very poor circumstances and conditions, the one who exists as a rational himself is worthy of respect. Dignity is the highest human existence, and among all human rights and values dignity is of the supreme status. Every move we do and everything we expect should be based on human dignity. We are rational beings, and the combination of rationality and strong will makes our intrinsic value and dignity as well. For a person suffering from disease, his life is going to the end, his body and mind are under great pressure, and his quality of life is related to human dignity. In such cases, the patient’s choice of PAS will give him the dignity of death. In this sense, the theory of obligation affirms PAS because it is an autonomous choice to make people die in better dignity. On the other hand, Kant’s self-discipline principle and his view that “man is the purpose” negate such legalization. He believes that everyone should legislate for himself and be responsible for his choice. At the same time, people are the purpose, meaning that all human choices are designed to make people live better, thus killing themselves not only destroys their own lives but destroys their own personality, treating themselves as tools, and therefore it should be an unethical behavior. “He abandoned the value of man and made himself an object, and he could not expect others to see him as the value of the human being.” In this sense, his theory opposes the legalization of PAS.
At the same time, the theory of obligation holds that as long as people have good will and have a favorable motive for an action, the action is good even without any effect. In the course of PAS, the patient’s own resistance may not be expected to achieve the goal of alleviating pain but rather increase the pain. This is also the result of patient’s autonomy being limited to incomplete information, and in practice doctors’ assessment of the risk of lethal drugs is not all accurate.
Aristotle believes that people, by their very nature, have their purpose or the last reason to provide criteria for evaluating the activities and development of human beings. The ultimate goal is to be good. A man, according to his nature, is to achieve the best. Goodness is happiness, and everyone should pursue his own happiness. Happiness is to live a good life and act well. And the first condition that constitutes a happy life lies in virtue or merit, that is, happiness is the realistic activity of the soul that conforms to virtue. Virtues are not only a tool to achieve happiness but themselves constitutes a part of it, thus happiness must be determined according to virtues.
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Aristotle, like Mill, believed that people were essentially social or political animals, that their happiness was linked to each other, and that personal prosperity was connected to the prosperity of all. The emphasis on personal happiness is the essential pursuit of human beings, but he denied that a person without a virtue of justice can be happy, and the so-called justice is the balance and the happiness of others. Based on the above view Aristotle would oppose suicide, saying that death to escape poverty, lust, or some kind of pains is appropriate for cowardice but not for brave people, for escaping is weakness. He cited, for example, that if someone killed himself because of anger, though he did it voluntarily, it was a violation of the right reason when the law forbade it. Therefore, what he did was an act of injustice. But who did injustice to? The injustice was against the city-state rather than against himself, for he voluntarily suffered the consequences but no one else. Therefore, because he destroyed himself, the city-state punished him and depleted his honor since he did something unjust towards the city-state. However, physician assisted suicide is different. Provided one’s own life suffers from great pains and himself no longer has the ability to promote the well-being of society, and has become even a burden on society, which prevents him from making greater contributions, the choice of PAS will not endanger others and the public interest nor is to escape the burden. It is but a helpless but also the most compassionate choice, which should be derived from virtue in accordance with the requirements of virtues. Aristotle’s theory would be in a perplex where it is believed that a terminal patient’s choice of physician assisted suicide is a virtue, and such a requirement is a manifestation of a noble moral sentiment generally accepted by the society, so that the legalization of PAS and the right of individuals to decide on the time and way to end his life may result in moral kidnapping, i.e. even if the patient himself does not want to commit PAS, he may be forced to do so. It is in fact a denial of the right to life.
In conclusion, I believe Mill’s utilitarianism theory can best capture the depth of controversy in the moral issue of physician-assisted suicide. Here are the reasons. Utilitarianism has a strong reality, objectivity and practicality. Such theoretical advantages can overcome the limits of Kant’s obligation theory and Aristotle’s virtue ethics, especially being more practical in the choice of individual behavior. The way it judges on good or evil lies in the total amount of happiness, that is, to choose the better one out of the two benefits, and to choose the one of less effect out of two harms, is something we are familiar and easy to master. Utilitarian values on happiness, utility or welfare, in comparison with the concepts of obligation and virtues, proves intuitively rational, explainable, and flexible.
Of course, in using utilitarianism to justify the legalization of PAS we should also avoid the moral hazard that may arise in the course of implementation, and ensure the absolute expression of patient’s autonomy. Therefore, we should put such a limit concerning one’s exercise of autonomy to seek suicide on the premise that he is mentally justified, including acquiring complete information about his condition, the ability to judge his state and the state he will face, and that the patient’s decision is purely due to mitigating the pains caused by the disease, and he should not be affected by economic pressures, cultural traditions and public opinion. Finally, he has no alternatives to alleviate his pains as palliative care and hospice measures have been used. What’s more, will PAS be a negative value to society? Aside from the ethical depression, does physician assisted suicide cause harm to the rest of people? The answer is No. On the contrary, the further consumption of social resources if of no practical significance for patients who are terminally ill. In many developing or poor countries, the affordability of households or countries is limited. From this view, there is no obvious conflict between human rights and social values in doing physician assisted suicide, which might in turn highlight the social value. We have to point out that, from the view of these physicians to help commit physician assisted suicide, there is no violation of the individual rights of patients on morality and norms of society when doing physician assisted suicide.
- PETER JARET. Is Physician-Assisted Suicide Ethical?[EB/OL].(2016,4,26)[2019,04,30]
- Kant, Immanuel．Suicide, Lecture on Ethics[M], Louis Infield tr’dal$., Moral Problems in Medicine, Prentice．Hall lnc．, 1983：435．
- The Nicomachean Ethics,1097b~15
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