The Ethical Bases of Medical Aid in Dying

Jean Mercier, Wayne Sumner, and Daniel Weinstock insist that the principles of respect for autonomy and compassion for our fellow citizens support physician-assisted dying.

The Quebec National Assembly has just finished clause-by-clause review of Bill 52, An Act Respecting End-of-life Care. As support for the bill extends across all of the major parties, it is very likely to soon become law.  In that case medical aid in dying will become legal in Quebec.

In recent weeks opponents of the bill have stepped up their fight, utilizing arguments of widely varying quality.  Some of those arguments are ethical, claiming that physician-assisted dying is simply wrong. This claim is usually supported by appeal to a principle of “the sanctity of life,” which forbids the intentional killing of innocent persons.  Physician-assisted dying is wrong, they argue, for the same reason that murder is wrong.

Our view is that, on the contrary, the case for allowing patients to choose medical aid in dying is strongly rooted in solid and widely shared ethical principles.

Oscar Bluemner, Smithsonian American Museum of Art

Oscar Bluemner, Smithsonian American Museum of Art

One of those principles is respect for the autonomy and self-determination of individuals, including the autonomy of patients at the end of life. This principle obliges us to respect the right of individuals to make their own decisions about their own lives.  It is embodied in the different charters of rights and freedom in Canada and serves as the basis of most of our democratic institutions. The principle of autonomy already governs most other aspects of our lives. Bill 52 would simply extend it as well to the final stages of life, to decisions about their own care made by patients who are suffering during the dying process.

Respect for autonomy might be overlooked as an ethical principle only because it is so ingrained in our daily occupations that we take it for granted. But those whose liberty and self-determination are disregarded in countries all over the world can attest to its importance. It is thus not surprising that the extension of autonomy and freedom of choice to end-of-life treatment is only debated and considered in democratic, open societies.

The second ethical principle supporting physician-assisted dying is compassion for our fellow citizens. Although contemporary palliative medicine is capable of alleviating most suffering at the end of life, it cannot prevent all of it. Some patients will continue to experience unbearable physical symptoms or psychological distress despite the best that palliative care can offer. This suffering is unnecessary, since it can be prevented by allowing patients the option of medical aid in dying. Forcing patients to undergo unnecessary suffering is not compassionate but cruel.

Those who advocate for the legal option of medical aid in dying have been quite consistent in calling upon these two principles, autonomy and compassion, in support of their efforts.

It should now be obvious why the opponents’ equation of physician-assisted dying with murder is mistaken. No one, of course, doubts that murder is wrong. But its wrongness is due to two important factors: the harm it does to the victim and its violation of the victim’s autonomy.  Neither of these factors applies to physician-assisted dying.

If a patient has made a voluntary request for medical aid in dying, having been fully informed of his prognosis and of all of the options available for end-of-life care, then a physician’s willingness to comply with that request cannot compromise the patient’s autonomy.  Murder substitutes the will of the perpetrator for that of the victim.  Physician-assisted dying respects the free will of the patient.

Murder harms its victims by depriving them of further life which would be of value to them.  But patients elect medical aid in dying when the only future they can foresee promises nothing but additional suffering.  In their own view of it, a continuation of life would have no value for them.  Far from harming them, a physician-assisted death would be a benefit for them.

There is therefore no analogy between medical aid in dying and cases of unjustified homicide.  In light of that, there is no ethical case against a law which would provide dying patients with this option.  And there is a very strong ethical case in favour of it.

Jean Mercier is a Professor in the Department of Political Science at Université Laval, Quebec City, Canada.

Wayne Sumner is a University Professor Emeritus in the Department of Philosophy at the University of Toronto, Toronto, Canada.  He is the author of Assisted Death: A Study in Ethics and Law (2011)

Daniel Weinstock is Director of the Institute for Health and Social Policy and a Professor in the Faculty of Law at McGill University, Montreal, Canada.

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