The Philosophy and Application of Assisted Suicide

Transcription

1 The Philosophy and Application of Assisted Suicide By: Andrew Koshorek In a perfect world every problem would have a solution, or perhaps have multiple correct solutions that every person could agree on. Regrettably, this world is not a perfect one, but instead one where often the correct solution cannot be adequately defined. Many solutions that could be considered correct may be impossible to implement or enforce due to a lack of resources, or resistance from those who would stand to lose something from it. Some questions may never be addressed to the satisfaction of everyone involved. It is the duty of those who have the power to make and enforce policies to attempt to make decisions based upon a complete body of evidence, balancing the competing issues of morality and pragmatism. This is a daunting task. Luckily, we have the tools of philosophy and ethics to assist us in making these decisions. The medical community often has to make decisions regarding life and death situations. Coming up with a medical course of action that will satisfy all involved is particularly difficult, as these situations can inspire strong emotions and challenge religious or philosophical beliefs about the nature of life. The best that a medical professional can do is to choose a stance that can be supported with philosophical and ethical arguments and to be consistent when practicing that policy. The moral and ethical issues involved with the use of assisted suicide and euthanasia are difficult ones. Currently there are few official policies that are in place to help physicians and pharmacists tackle this difficult moral issue. The purpose of this paper is to review the philosophy, morality and legal complications involved with the issue of assisted suicide; to illustrate patients with a terminal illness should have the right to choose the manner in which they die and that strict administrative and legal guidelines are needed to insure that this power is not abused. In order to truly understand the concept of euthanasia first it must be defined. The Merriam-Webster online dictionary traces the etymology of the word to the Greek for easy death. It is defined as follows: the act or practice of killing or permitting the death of hopelessly sick or injured individuals (as persons or domestic animals) in a relatively painless way for reasons of mercy. 1 Though it is not implied in the definition, it is generally accepted that those who are performing the act of mercy are doing so at the behest of the hopelessly sick or injured individual. The term assisted suicide muddles an already complicated issue by associating euthanasia with the broader definition of suicide. Suicide is the act of voluntarily ending one s own life. While euthanasia, when performed at the request of the patient, is a form of suicide, as the patient dies voluntarily; the term suicide does not include the requirement that the person who dies be hopelessly sick or injured, nor does it state that the death must be relatively painless. The term suicide encompasses all forms of self-termination, often cases of teenagers who may have emotional or social problems that they feel are too difficult to deal with. Most of the people that commit suicide do so for reasons that the majority of people do not understand. Those who kill themselves as a result of emotional or mental issues are typically neither hopelessly sick nor injured, they merely require time to heal, social and emotional assistance and perhaps pharmaceutical interventions. Many of them may have clinical depression, a disease that can be treated relatively easily using a combination of medications and counseling. This clearly illustrates that there is a subtle difference between the definition of suicide and euthanasia. Though the term assisted suicide has become safely lodged in the popular argot, it is important to clarify that those permitted to use this option would have to be diagnosed Page 1 of 16

2 with a terminal illness, to have failed all attempts at curative therapy and only have a short time left to live without intervention. Those patients who are eligible for hospice care would also be likely candidates for assisted suicide. There are two types of euthanasia. Active euthanasia is the deliberate killing of a terminally ill person for the purpose of ending their suffering. 2,3 Often called a mercy killing, this form of euthanasia is currently only legal in the Netherlands and Belgium. Passive euthanasia is withholding further treatment until the patient dies of the illness. 2,3 The act of inaction lets nature take its course. This type of euthanasia is quietly practiced in every country in the world and sending a patient to an end of life hospice could be construed to be a form of passive euthanasia. Perhaps the most common form of passive euthanasia that one sees in regard to terminally ill patients is the provision of large doses of morphine with the knowledge that it may likely cause severe respiratory depression and consequently, death. 2,3 Though technically this morphine is given as a pain killer, the end result is frequently more final. Given a choice, most people would probably choose to die gracefully of old age in a bed surrounded by loving friends and family. This vision of death and dying is romantic at its best and dangerously unrealistic at its worst. The body is programmed to try its utmost to continue living even if this means excruciating pain and discomfort for its owner. No one can say exactly why our bodies slowly deteriorate. Our bodies are continuously exposed to environmental and behavioral abuse. Through all of this mistreatment our bodies continue to function despite all the burdens heaped upon them. Is it any surprise then that when our bodies succumb to the ravages of time, they go not with a whimper but with a bang? Those who are lucky enough will die quickly and with little pain, but many are destined to experience the slow and painful progression of cancer. Though a contemporary cancer patient has many options available to prolong his or her life and may even have available curative methods that will completely eradicate tumorous cells, there are still those patients whose cancer, despite the best efforts of therapists, metastasizes and disseminates throughout their body. The use of radiation and chemotherapy are never pleasant for the patient even in the best of circumstances, causing a number of extremely unpleasant side effects. A cancer that has metastasized and colonized other organ systems is virtually impossible to surgically remove and difficult to target with radiation and chemotherapy. At this stage in the disease the amount of radiation and chemotherapy required to treat the spreading tumor would most likely injure or kill the patient. At this point most doctors will notify the patient and their family that there are no further treatment options available and will recommend that the patient be admitted to a hospice in order to ease their passing. Though many families opt to take care of the terminally ill patient themselves in order to let them die in a familiar environment the use of a hospice takes a substantial burden off of the patient s already grieving family and the ready access to medical care around the clock assures that the patient will receive the appropriate therapy to deal with problems as they arise. The treatment that is given within a hospice is known as palliative care and indicates that the disease itself is no longer being treated; instead the signs and symptoms resulting from the progression of the disease are being minimized in order to maximize the patient s comfort. Hospice care is designed to ease a terminally ill patient s passage into death and free their family from menial tasks involved in their care in order to allow them time to grieve. Having had a number of my grandparents diagnosed with cancer that eventually metastasized I have first hand experience of how agonizing those last months can be for the patient and the family. After being told that they are terminal the cancer patient begins the long process of dying while their bodies slowly fail. In the beginning the patient feels a near constant fear of death, alternating with anger over the Page 2 of 16

3 unfairness of their situation; they see the pity and sadness in the eyes of their loved ones and feel guilt for putting them through this while at the same time loathing themselves for that pity. As the disease continues to progress they slowly lose their ability to perform tasks around the house and the pain increases. When most people are sick and in pain they know that their pain is transient or will at least decrease eventually; they take comfort in the knowledge that one day the pain will be less. The terminal cancer patient does not have the comfort of knowing that one day their pain will decrease, it will only increase in severity as time goes by; the only end in sight being their eventual demise. They begin the agonizing balancing act between how much pain they can stand and dosing themselves into an unconscious fugue with painkillers. Inevitably, they lose the ability to do even basic tasks such as use the bathroom and are forced to withstand the indignity of lying in their own waste until someone else removes it. They have to learn to accept the idea that their loved ones will often already view them as dead. All patients eventually succumb to the promise of oblivion and release from the intractable pain brought about by painkillers like morphine. After this their lives consist of a drug induced stupor punctuated with brief moments of lucidity, tainted by an echo of their excruciating pain, barely kept at bay by their medications. They may no longer be able to speak clearly or move and may be plagued by hallucinations brought about by high doses of painkiller and never-ending pain. For many families it becomes difficult to visit these pale echoes of their loved ones and often the visits become less frequent and sometimes cease all together. In their fleeting moments of clarity the patient will often find they alone and this will drive home the unpleasant fact that, to their family, they are already as good as dead. Inevitably the patient will eventually pass on and along with their grief the family will feel a guilty sense of relief that the suffering of their loved one has finally come to an end. This paints a grim picture for the futures of patients who are diagnosed as terminal, but it is important to remember that this sequence of events reflects a worst case scenario. For many patients their passage into death may not be as unpleasant. Perhaps they may have wonderful families and friends that take care of them. Perhaps they have faith in a higher power that gives them comfort at their last moments. Maybe the course of their disease is not as aggressive and palliative treatment is successful in alleviating their symptoms without depressing their mental functions. Though the course of every patient is unique it is important to realize that all of these patients suffer to varying degrees, there is no end in sight and no chance for them to ever recover from their disease. This is not the romantic vision of death that so many place their faith in; this is the cold reality. The root ethical question that must be addressed when dealing with a case of a terminal patient in intractable pain is the moral rectitude of suicide. If it can be determined that suicide is morally permissible in certain circumstances then by correlation assisting another to commit suicide could also be morally permissible. After determining the answer to this question, the next challenge would be to determine the circumstances under which such an action would be morally permissible. It would be difficult to apply science or mathematical thought to this question as it is not an objective question that can easily be quantified, but instead a subjective and emotional question. Questions of what is morally right and wrong can only be effectively answered using the tools of philosophy. Each philosophy gives a different framework to assist in the answering of difficult questions involving the morality of an action. Most of the different schools build their framework around a set of rules or truths that are generally considered to be absolute and universal. Asking questions within each of the different philosophical frameworks may assist one in determining if an action is ethical. If one asks the same ethical question using different philosophies one may often end up with two very different answers. Debate is Page 3 of 16

4 inevitable. This is the Achilles heel of philosophy; if one analyzes a question long enough it eventually loses any relevance it may have had to the original problem through a serious of endless cyclic arguments. Nevertheless, philosophy remains the most useful tool for those who decide what is ethical and thus which actions are right and wrong. For the sake of being thorough, the key maxims behind a number of popular philosophies will be illustrated in an effort to explore the different facets of the problem. Perhaps it may then be possible to determine if these philosophies will provide a valid framework to answer the question of suicide s morality. It is important to remember that these are simple summaries of complicated philosophies and not representative of their totality. Egoism is the belief that any action which makes one happy is right. 4 Using this philosophy, one sees that if dying would make one happy then it is right. Few would argue that this point of view is not absurd in its selfishness. A society of egoists would be a society of sociopaths with no regard to how their actions would affect others. Within the framework of this philosophy even a sadist who derives happiness from causing others to suffer is morally right. This philosophy is virtually useless in answering ethical questions for any society so we will not consider it any further. Ayn Rand, a philosopher and successful author created a philosophy that is based on the principles of egoism known as Objectivism. Objectivism states that it is right to act in a way that is rationally in our own self interest, even if this action does not necessarily make us happy. 4 An example of this would be a heroin addict who decides to quit using heroin even though continuing its use it would make her happy. The principle of looking out for number one is often a popular one in many societies and makes a great deal of sense in a real world context. In this framework committing suicide would be right if it was in one s best interest. This philosophy could be used to support and condemn suicide as there would be much debate over which action is in a terminal patient s best interest. In general most people who support this philosophy do not believe that suicide is ever in a person s best interest as it gives them no further options. However, the person who is most qualified to determine what is in the patient s best interest is obviously the patient themselves, thus assisting a consenting patient to commit suicide would be a right action. Though it is more relevant to our question than egoism, this philosophy is somewhat mercenary in nature and its maxims seem somewhat contradictory to the moral tenants of medicine; which could be summarized by saying that one should help others before one helps themselves. It would be difficult to use this philosophy to come up with an adequate argument for or against suicide without exposing ourselves to constant debate. Hedonism states that only pleasure has intrinsic value; all other things have extrinsic value insofar as they are productive of pleasure. 4 Things that cause pain are bad and have no worth unless they will eventually cause greater pleasure. In the case of a terminally ill patient who will only experience pain by continuing their existence it would be morally right to painlessly end their life to avoid further suffering. Hedonism is more or less a diluted shade of egoism and so is difficult to apply to real life situations. Consequentialism (Actual Consequentialism) states that the effects of an action are what determine whether or not an action is morally correct and disregards the methods that are employed in achieving it. 4 A summary of this view would be the ever-popular political phrase the end justifies the means. This philosophy is almost as absurd as egoism as it places no boundaries on the cost versus gains ratio. If little Johnny had his heart set on making the baseball team and Johnny s dad knew that there was no way his son was going to be picked it Page 4 of 16

5 would be morally acceptable under consequentialism for Johnny s dad to go and reason with the coach and get Johnny on the team, or simply run over some of the other kids on the team with his car in order to open up a few places on the team for Johnny. Both actions result in Johnny making the team and being a happy little boy therefore both courses of action are good. This would be patently ridiculous. Virtually any action could be justifiable using this philosophy so it is useless for us to use it as a tool to answer our question about suicide. With a few minor adjustments however consequentialism becomes utilitarianism, a valid and widely respected philosophy that can be applied to real world situations. Libertarianism is a philosophy that states that one should be free to do as they please as long as it doesn't harm others, unless of course they give their consent to be harmed. 4 This philosophy is popular enough in the United States to warrant the formation of a political party to support it. One can see that many of the tenants of this philosophy are present in the American constitution. In the United States people are generally allowed to live their lives as they see fit as long as they don t cross the line. The rights to free speech, the right to bear arms and a freedom to choose one s religion could all be seen as extensions of the libertarian philosophy. Libertarianism is about freedom with the only boundaries being to not interfere with another s freedom. The right to swing my fist ends where another man s nose begins is a quote by Oliver Wendell Holmes that adequately describes the libertarian viewpoint. Libertarianism obviously supports the option that people have a right to commit suicide if they so desire and subsequently to request assisted suicide. The freedom to choose the way in which one lives ones life also gives one the freedom to choose the manner in which they die. This would be a valid philosophy to use in an argument supporting assisted suicide but it does have the limitation that there is virtually no room for social restraint within its framework. Many of these unrestricted freedoms could easily have unforeseen consequences in the future. In a society in which everything is right until it goes wrong it would be difficult to make laws and policies until after the fact. Some restriction must be put in place in advance to assure society runs smoothly. Many people around the world believe in divine command. In fact some countries around the world, most notably those in the Middle East, also use divine command as a basis for their secular laws. Divine command states that you should do as the creator tells you. 4 Those who disobey these divine orders literally have hell to pay. In most religious dogmas the creator or creators are immortal, all knowing, infallible and incredibly powerful. In fact they are so powerful and intelligent that lowly humans are often incapable of understanding the basis of reasoning behind many of the commands and tenets dictated by these beings. Even if some commands may seem irrational to us they are part of a grand plan and it is wrong of us to question them. Our only duty is to follow them to the letter. Since the creator is infallible one would expect that these tenants would never change though they often do evolve slightly over time. Typically religious tenants such as the Ten Commandments usually do their best to promote ethical actions in people that benefit society and their fellow man. Throughout the course of history, evil and misguided people have often twisted religious tenants to serve their own needs, most currently leaders of terrorist cells who convince deluded people that killing innocents in a suicidal blast gives them the assurance of passage into heaven. At present the various forms of Christianity are still the predominant religious denomination in the United States. Ostentatiously the United Sates government has a separation of church and state though in practice it is often difficult to keep one apart from the other. Christian religious dogma has a substantial impact on the drafting laws and the moral views of our nation. The Christian view on suicide is generally a negative one. Though the bible does not specifically condemn suicide Page 5 of 16

6 itself most Christian scholars believe that Thou shalt not kill one of the Ten Commandments forbids killing anyone, including oneself. 5 Though the true meaning behind many of the Ten Commandments is often debated, virtually everybody agrees that this one is pretty succinct and not open to interpretation. The majority of Christians see suicide as a sin for a number of reasons. It violates the Ten Commandments ( Thou shalt not kill, in this case yourself). 5 Life is a gift from God which should not be disrespected. 5 Suicide can be seen as an expression of self-hatred, and the Bible says we are to "love our neighbors as ourselves." 5 Suicide is viewed as a selfish act that usurps the rights of God to decide when one s life ends; furthermore it does not serve the needs of Christ as there is one less Christian in the world to spread the word of Christ. 5 Since the philosophy of divine command by definition believes that it is the only correct philosophy and brooks no adversaries, it could be used to effectively argue against suicide, particularly if the terminally ill patient was a Christian themselves. Cultural relativism states that which actions are right or wrong varies according to the beliefs of each culture. 4 In this age of politically correct behavior this outlook is a popular one. However from a purely moral standpoint this philosophy could be used to justify virtually any behavior within a society as long as the majority of a society accepts it. The belief that when the majority of a society agrees and participates in an action that it is right has caused a number of catastrophes throughout history. The expansion of Nazi Germany and their extermination of the Jews is an obvious misuse of this philosophy. The use of slaves from Africa by the United States prior to the Civil War was taken to be acceptable behavior for many years though now few would argue that such behavior is acceptable under any circumstances. In many ways it is just a sugar coated extension of the philosophy of might equals right, which is a philosophy that is difficult to justify for any moral individual. Rules created using majority rule are not necessarily the most ethical, merely the most popular. Many times individuals that attempt to support a moral path are very unpopular with the majority. Within the framework of Cultural relativism the act of suicide would be considered a right action as long as it was popular or accepted by the majority of the culture. In a country with as diverse a cultural milieu as the United States it would be difficult to justify the use of cultural relativism as a basis for the determining the morality of assisted suicide as it could then be forced upon a minority culture that did not agree with it. Utilitarianism and Deontology are two different ethical viewpoints. These philosophical doctrines are the most accepted and commonly used by contemporary law makers and leaders. The two philosophies, while not by nature diametrically opposed, often disagree on whether or not an action is ethical. Both doctrines strive to base their frameworks on rational thought and pure morality. Both philosophies have been used by both those who object to assisted suicide and those who support it. Generally proponents of assisted suicide use the utilitarian view to support their views and their opponents usually use deontology to support their views. A simple summary of utilitarianism would be to say that an action is good if it maximizes the utility for a certain group of people, typically the human race as a whole. 4 It is a blend of consequentialism and universal hedonism. A more colloquial statement that summarizes utilitarianism would be to say that an action is right if it maximizes the overall happiness of all people. Combine consequentialism s the end justifies the means and universal hedonisms a good action is one that brings pleasure to the most people and you get utilitarianism: The good of the many outweighs the needs of the few- or if you prefer the tongue in cheek version- you can t make an omelet without breaking a few eggs. An Page 6 of 16

7 individual dying from terminal cancer and in intractable pain will have a difficult time enjoying old activities that previously gave them pleasure and they are guaranteed terrible pain for the rest of their existence. An unpleasant action in the form of suicide will have a good result, preventing months of pain and indignity, thus satisfying the requirements for a good action from a utilitarian viewpoint. Preventing the slow march towards death that awaits a cancer patient and his or her family would also minimize the family s suffering as they would not have to witness the slow decay of a loved one. I wish to be thorough in my analysis and at the risk of sounding callous I would point out that the death of a terminally ill patient would also greatly decrease the burden, both resource and financial, on both the medical community and the patient s family. Assisted suicide would prevent a great deal of suffering, both physical and mental for the patient and his or her family, as well as free up resources like hospital beds and medical staff to allow them to be used to treat those who have a better prognosis. All of these are good ends, even if the means to achieving them happens to be suicide. There will still be pain, sadness, grief and guilt (unavoidable a situation such as this), but they could be minimized with properly performed euthanasia. Rationally, utilitarianism can be used to prove that suicide, assisted suicide and euthanasia can be an ethical and moral act under the right circumstance. In utilitarianism, decreasing the amount of misery in the world is an ethical act. The policy of killing, at their own request, hopelessly ill patients who are suffering great pain would decrease the amount of misery in the world therefore, such a policy would be morally right. Although the use of utilitarianism to support assisted suicide is logically valid it feels emotionally distasteful. It would be too easy to ignore the patient s wishes entirely and perhaps perform euthanasia on a recalcitrant patient for their own good. 6 Pleasure and pain are difficult if not impossible to quantify and this philosophy begs for justification by quantifying such values. In the end utilitarianism, though it is often used to do so, falls far short of proving that assisted suicide can be a moral act and it instead makes those who support it using this framework sound like callous machines. Accepting this premise would imply that it would be morally right to violate the rights of individuals whenever it served to decrease the amount of suffering in the world. Making laws base on utilitarianism would be like trying to make dying and death more efficient. 6 This would be distasteful to the extreme and would open the floodgates for the abuse of this practice. 6 In my humble opinion the philosophy created by Immanuel Kant in the 18 th century which is appropriately known as Kantianism is one of the most rational and logically defendable of all philosophical views. Kant is considered to be the father of deontology, making ethical choices that are based off of more than just the consequences but that also take into account duties and rights. In this article I will delve more deeply into the roots of this philosophy and illustrate how it can be used to show that assisted suicide can be an ethically and morally correct decision. Immanuel Kant was born in 1724 in Kaliningrad, a country that at that time existed between Poland and Lithuania bordering on the Baltic Sea. 7 Kant was fascinated by ethics and extensively studied two popular philosophies that were relatively new at that time, empiricism and rationalism. Kant felt that each study had merit but had fundamental flaws in their methods and content. 7 Kant published a number of works but by far the most famous and influential were his papers involving ethics. His first paper The Foundations of the Metaphysics of Morals published in 1785 provided a framework for what would eventually become Kantianism and deontology. He later published a work titled The Critique of Practical Reason in 1787 which Page 7 of 16

8 was an attempt to reconcile his philosophical theories and the practical world. In this paper I will be focusing on illustrating Kant s view on what makes an ethical decision. Kant asked the question, how do we tell right from wrong? To Kant rational thoughts and actions are good and irrational thoughts and actions are bad. Rational is the same as moral. 7 Kant declared that Nothing can possibly be conceived in the world, or even out of it, which can be called good, without qualification, except a good will. 8 In other words, the sole feature that gives an action moral worth is not the outcome that is achieved by the action, but the motive or will that is behind the action. 4,7 Kant argued that we can never justify good actions by their end result as we can never be sure in advance that an action intended to be good will result in a bad action and vice versa. Kant argues that a man who runs over a little girl and then calls 911 just because he wants to receive credit for saving the girl did not perform a moral action. Though the man s actions resulted in the girl being given medical treatment, a good outcome, it was not done for the right reasons, only to avoid harsher consequences. If the man had called 911 because he wanted the girl to receive medical attention and to admit guilt then he would have performed a moral action. Both actions resulted in the little girl receiving medical care but only one action was moral due to the fact that it was performed with good intentions towards the little girl, while the other was not. Kant also stated that Intelligence, wit, judgment, and the other talents of the mind, however they may be named, or courage, resolution, perseverance, as qualities of temperament, are undoubtedly good and desirable in many respects; but these gifts of nature may also become extremely bad and mischievous if the will which is to make use of them, and which, therefore, constitutes what is called character, is not good. 8 This statement shows that even virtuous qualities can be used with evil intent. Kant believed that the most important ability of the human species is its rationality, the ability to reason and act according to rational principles. In order to establish rules for determining what intents and actions are ethical one he created the categorical imperative. Kant said that the categorical imperative was to "Act only according to that maxim by which you can at the same time will that it should become a universal law, 8 meaning that the best way to test an action is to ask oneself what would happen if ALL of society acted as though this action was a maxim for all people. A hypothetical example will be valuable in understanding this idea: Judy has a difficult test in her law class on Monday but she has a chance to spend the weekend going camping, binge drinking and flirting with totally hot guys. Judy has a great idea to solve this problem, on Monday she will wear a long skirt and write all of the answers to the test on her legs so that she can pull up her skirt a little and read them during the test. Her teacher just falls asleep whenever he s proctoring a test anyway. As Judy starts looking for a permanent marker she vaguely recalls one time in philosophy when her teacher was talking about Kant s categorical imperative and she decides to apply it to this situation to see if she is being ethical. The action that Julie is planning on doing is: CHEAT. What if society took this as a Maxim? Everyone would be cheating all the time and the relevancy of testing would become meaningless. Grades would mean nothing as they would no longer reflect how much was learned. Tests would no longer exist and cheating would become impossible. Cheating could not exist without tests, thus cheating could never be a universal law. Judy cheating on her test would be immoral. It looks like she may have to miss out on a fun weekend. Kant believed in what he called the duality of human nature. Kant says that animals are only capable of what he calls sensuous thought and thus are only capable of chains of causal actions. 7 Animals are creatures of stimulus and response and are guided by instinct thus they cannot be blamed for any of their actions as they are only reactionary and there is no will behind Page 8 of 16

9 them. Human beings have a sensuous side but also have the unique ability for rational thought. The ability to make rational decisions allows humans to originate an action not just react to a stimulus. 7 Our actions are neither wholly determined by natural impulse, nor are we free of nonrational impulse. Those people who learn to make rules for themselves using rational thought to overcome sensual impulses reach autonomy. 7 Autonomy is the ability to take control of your own life and live under rules we set for ourselves. When a person manages to overcome their sensual impulses and create rules for themselves and to live their life by them they gain what Kant calls dignity. 7 To Kant the most important thing that a person can have is autonomy and dignity. 7 Everyone has the capacity for autonomy but not everyone achieves dignity. Good actions cannot come from impulse or natural inclination as there is no will behind them and thus neither good nor bad intent. Kant states that "A man reduced to despair by a series of misfortunes feels wearied of life, but is still so far in possession of his reason that he can ask himself whether it would not be contrary to his duty to himself to take his own life. Now he inquires whether the maxim of his action could become a universal law of nature. His maxim is: From self - love I adopt it as a principle to shorten my life when its longer duration is likely to bring more evil than satisfaction. It is asked then simply whether this principle founded on self - love can become a universal law of nature. Now we see at once that a system of nature of which it should be a law to destroy life by means of the very feeling whose special nature it is to impel to the improvement of life would contradict itself, and therefore could not exist as a system of nature; hence that maxim cannot possibly exist as a universal law of nature, and consequently would be wholly inconsistent with the supreme principle of all duty". 8 He also states that he who contemplates suicide should ask himself whether his action can be consistent with the idea of humanity as an end in itself. If he destroys himself in order to escape from painful circumstances, he uses a person merely as a mean to maintain a tolerable condition up to the end of life. But a man is not a thing, that is to say, something which can be used merely as means, but must in all his actions be always considered as an end in himself. I cannot, therefore, dispose in any way of a man in my own person so as to mutilate him, to damage or kill him. 8 These quotes indicate that Kant is against suicide in the case of despair and misfortunes. Kant claims that the Maxim for suicide is "From self-love I adopt it as a principle to shorten my life when its longer duration is likely to bring more evil than satisfaction." 8 Basically Kant sees suicide as an act of self-love and that self-love prompts us to improve our lives. It is contradictory to suppose that we can improve life by destroying it so suicide is wrong. He also states that by committing suicide a person destroys his humanity/freedom and acts instead on sensuous impulses to avoid further misery; since humanity/freedom is the most important thing to Kant he says that suicide is using humanity as a means to an end which is wrong. Human beings should never be used as a means to an end. As if Kant s objections to suicide are not confusing enough he then goes on to say that self-sacrifice is good, "there are many circumstances under which life ought to be sacrificed. If I cannot preserve my life except by violating my duties towards myself, I am bound to sacrifice my life rather than violate these duties... Yet there is much in the world far more important than life. 8 This quote states that it is better to sacrifice one's life than one's morality. To live is not a necessity; but to live honorably while life lasts is a necessity". Kant says that it is desirable to take ones life if it will prevent one from violating their duties toward themselves. Kant seems to believe that to kill oneself for selfish reasons, such as the avoidance of suffering, is not moral. Page 9 of 16

10 Conversely, if a person kills themselves in order to preserve their duties towards themselves and others it is an ethical act. If you die to benefit yourself, it is wrong. Dying for duty is right. Neo-Kantians are modern-day disciples of Kant s philosophy. These individuals strive to figure out ways to use the Kantian framework in order to solve modern day ethical problems. As with any topic as intricate as philosophy, there are is great dispute over the interpretation of Kant s words. Though the majority of neo-kantians believe that Kant disagreed with suicide to escape suffering, there is dispute over whether or not Kant would have disagreed with the assisted suicide or euthanasia of terminally ill patients. 9 Neo-Kantians that believe Kant would have agreed with the idea of assisting with the death of a terminally ill patient justify their claims using the following arguments: Near the end of their lives in a hospice a terminally ill patient dying of a disease like cancer is in incredible pain and is also almost always on doses of pain killers that are sufficiently high to push the patient either into delirium or make them insensate. They alternate between a drug induced reverie and moments of intense pain and terror. To Kant the most important things for a human being are autonomy and dignity. Neo-Kantians argue that cancer patients near the end of their lives have effectively lost their autonomy from the mindnumbing pain and drugs. 9 They have few choices left to them besides whether to sit in pain or to take more drugs. Their existence has become totally controlled by the sensual side of the duality of human nature. Their life is all about pain and their reaction to it. With the loss of autonomy comes the inevitable loss of dignity. Dying from cancer is not a dignified process. Since uncontrollable cancer permanently robs a terminally ill patient of his dignity and autonomy, which are the most important things to a human being, it could be considered that the patient has the duty to sacrifice himself in an attempt to prevent their loss. Following this line of thought, a medical professional such as a physician or a pharmacist would also have an ethical duty to not allow the terminal disease to forever rob a patient of dignity and autonomy if they request it, to allow such a thing to happen would be unethical behavior for a medical professional. 9 As death is their only way to escape from the pain, they often long for it. Terminally ill cancer patients do not want to die; their real wish is for their pain and embarrassment to end, the fact that death is the only way that they can escape this state is inconsequential, if there were any other options there is no doubt that they would take it. Kant states that it is rational thought that separates humans from animals. One could argue that a terminally ill patient within the grip of pain and drug induced stupor has lost the ability for rational thought. Kant says that we have a duty to ease the suffering of an animal because it cannot choose to stop its own suffering and does not have the ability to understand why it suffers. To let a creature that no longer understands why it is in pain live on dehumanizes those that allow it to happen. 4,7 How is this any different from the situation of a human who no longer is aware of anything but suffering and cannot choose to do anything but suffer? My grandfather died of metastatic bone cancer over a prolonged period of time. Near the end of his life he told me something that will always stick with me: they wouldn t treat a dog like this. He felt as though he had to work to die. This phrase, directly from the mouth of a dying man, illustrates the moral acceptability of euthanasia, in preserving the dignity of a patient in his twilight hours. Of all approaches covered thus far, I believe that neo-kantianism, libertarianism and to a lesser extent, utilitarianism, can all be used effectively to support assisted suicide and euthanasia in patients that are terminally ill and in intractable pain. Using a combination of these philosophies, one can justify the following statements: terminally ill patients have the right to Page 10 of 16

11 choose the manner in which they die. Many methods of prolonging the life of a terminally ill patient to the bitter end leave them with little dignity. Self-dignity is an important part of a person, and allowing a disease to rob that dignity without their consent is unethical. It is unethical to allow the government (or any other third party) to decide how someone chooses to live their life, and concordantly, to decide the manner of their death. Though suicide is a thing that must be lamented and generally discouraged it should not be decreed a criminal act by legislative and judicial bodies. Though many religions frown upon suicide as a sin it is not proper or professional behavior to impose one s value system on another person who may or may not believe as you do. Though there are many tools available for a person to take one s own life, there are prescription drugs that are available that can allow a person to ease their passing without pain or cognition. The pharmacist has access to compounds that ease ones passing into death in as dignified a manner as possible. There is little difference between hospice care and assisted suicide. Both are essentially drug assisted passage into death; the only difference is the time it takes. Individuals who qualify for hospice care, expected to live for a few months in a drug induced fugue, should have the option to quickly and painlessly end their lives. As a nation, the United States places great emphasis on freedom of thought and decision. It is considered an inalienable right that people should be allowed to live their lives in the manner that they desire, so long as their actions do not infringe upon the liberty of others. It is here where government regulations come into play, and it is here where the debate grows most fierce. Where is the line drawn? It is thus important to look at assisted suicide and euthanasia from a legislative and judicial point of view, the spheres of government that apply to this gray area. In legal terms assisted suicide is distinguished from euthanasia by who performs the action that results in the death of the patient. In the case of euthanasia, another person administers the lethal substance or removes the life sustaining equipment. 3 In assisted suicide, the patient is supplied with a method to take their own life by another party. 3 As stated previously, the Netherlands and Belgium are currently the only jurisdiction in the world which has laws that specifically permit euthanasia and assisted suicide. 3 Oregon currently permits assisted suicide. 3 Australia s Northern Territory approved a euthanasia bill in 1995 which went into effect in 1996 but it was overturned by the Australian Parliament one year later. 10 In Vermont, Alabama, Idaho, Maryland, Massachusetts, Michigan, Nevada, South Carolina, and West Virginia, euthanasia has been criminalized by common law. 11 Vermont has taken this one step further and has proposed a bill that would make it illegal to cause or to assist anyone in committing suicide. 11 The penalty would be no more than 20 years in prison and no more than a $3,000 dollar fine other states have statutes explicitly criminalizing assisted suicide. In 1997 Oregon passed the Death With Dignity Act, which legalized assisted suicide by a medical professional but specifically prohibited euthanasia where a physician or other person directly administers a medication to end another's life. 3,12 Certain requirements must be met in order to qualify for protection under the Death With Dignity Act. Patients must be residents of Oregon and be over 18 years old. 3,12 They must have the capacity to communicate health care decisions. 3,12 They need to have been diagnosed with a terminal illness that is decided to be irreversible and terminal within 6 months. 3,12 A second physician must be consulted to confirm the diagnosis and the patient must be made aware of palliative and hospice care that could be alternative options. 3,12 An expert in psychology must confirm the patient s ability to make decisions. 3,12 The patient must be requested to notify their next of kin of their decision but are Page 11 of 16

12 not required to do so. 3,12 Every step along the way is documented and the patient must sign multiple forms of consent. Despite its availability, in the first year after the Death With Dignity Act was passed, only 23 patients were given lethal injections and only 15 died as a direct result of these injections. 12 Some patients may not have taken the injections and in others the suicide attempt may not have been successful. The guidelines for both assisted suicide and euthanasia in the Netherlands and Belgium are generally much less stringent than those found in the Oregon legislation. The Netherlands in particular has been the subject of many studies evaluating its guidelines for euthanasia. Physicians in the Netherlands have very few restrictions on how they go about the practice of assisted suicide, and the guidelines dictating its use are incredibly vague. Doctors cannot be prosecuted as long as they have fulfilled the following guidelines set by the Royal Dutch Medical Association in ,13 The patient makes a voluntary request. 3 The request must be well considered. The wish for death is durable. 3 The patient is in unacceptable suffering, and the physician has consulted a colleague who agrees with the proposed course of action. 3 The patient's death cannot inflict unnecessary suffering on others. 3 Only a doctor can euthanize a patient. 3 The unacceptable suffering mentioned above does not necessarily have to be physical pain but can be psychological pain as well. 3 Later on, a corollary was added stating that the patient should be in a terminal state but is not required to be so. The definition for terminal given is ambiguous at best: the concrete expectancy of death. 3 Technically, every human being who is currently alive has the concrete expectancy of death. The bottom line is that to be a candidate for induced death the patient only needs to be in a state of unbearable suffering of either a physical or mental nature. 3 There are no rules against encouraging a patient to kill themselves, and unbelievably, there are few guidelines about which patients are eligible for euthanasia. The approved method of euthanasia is administration of a lethal injection. Though it is generally assumed that patients who are subjected to euthanasia have consented to it, are terminally ill and in intractable pain, studies have shown that a disturbing number of patients neither requested to die nor were many of them diagnosed with any terminal disease. 13 Incredibly, a small number of patients have been euthanized when no medical diagnosis was present besides a possible case of depression and a persistent wish for suicide. 13 The Remmelink report revealed that in a 12-month period, 2318 Dutch patients received euthanasia after a persistent, voluntary request. The same study concluded that around 1030 additional terminations-of-life occurred without explicit and persistent requests. 13 Although the Netherlands has a reporting system for physicians to record their assisted suicides, official surveys of Dutch doctors under conditions of immunity and anonymity revealed that only 41% of euthanasia and assisted suicide deaths were reported. 13 Dutch doctors are arguably the most experienced medical professionals in the world in administering lethal injections and reports have shown that even under their expert application one out of five patients experiences complications and may survive the injection with serious adverse effects and possible pain as a result. 13 The legalization of assisted suicide in the U.S.A. without very stringent guidelines would inevitably open the doors for those few who would abuse this ability. 6 There would be the potential for patients to be coerced either by the doctor, their family or even the insurance company to kill themselves. 14 There is a very real and disturbing chance that doctors themselves would be pressured by insurance companies like HMOs to engage in assisted suicide to save the company money. 14 The terminal diagnosis could have been made by an incompetent doctor and Page 12 of 16