Top

Published in:

01-09-2020 | Original Research

The Case for an Autonomy-Centred View of Physician-Assisted Death

Authors: Jeremy Davis, Eric Mathison

Published in: Journal of Bioethical Inquiry | Issue 3/2020

Abstract

Most people who defend physician-assisted death (PAD) endorse the Joint View, which holds that two conditions—autonomy and welfare—must be satisfied for PAD to be justified. In this paper, we defend an Autonomy Only view. We argue that the welfare condition is either otiose on the most plausible account of the autonomy condition or else is implausibly restrictive, particularly once we account for the broad range of reasons patients cite for desiring PAD, such as “tired of life” cases. Moreover, many of the common objections to an autonomy only view fail once we understand the extent of the autonomy condition’s requirements—in particular, the importance of one’s values for autonomous choices. If our view is correct, then the scope of permissible PAD is broader than is currently accepted in both the philosophical literature and the law and therefore poses an important challenge to the current consensus on justified PAD.

Of course, this is just another way of describing the right of informed consent, which is most often grounded in autonomy but can also be grounded in welfare. There is perhaps a worry here about cases in which patients autonomously forgo this knowledge. This is an important question, but it is beyond the scope of this discussion.

That welfare and autonomy are treated as separate values in bioethics is at odds with the way many philosophers discuss well-being, which often includes some type of autonomy condition. For examples, see Mill 1859, Kymlicka 1989, and Wall 1998. Sumner’s own theory of welfare includes autonomy (Sumner 1996). Because of this, someone might object to our approach by claiming that we can’t avoid welfare. By treating autonomy and welfare separately, we are not ruling out this account of welfare, and these accounts are not at odds with our argument, given that they give significant weight to autonomy.

One might worry that this definition begs the question: a medical condition is just whatever relies on medical skills, but these are defined in reference to the conditions they are aiming to treat. But this is not the case. For one thing, as patients seek out doctors for various treatments of whatever sort, doctors might develop new skills—that is, the two concepts might, and probably do, co-evolve. Boorse and Hesslow advocate for revising the way medicine usually identifies itself as a healing profession. Their arguments, and ours, require a change in that perspective.

There are also pragmatic and legal reasons for a terminal-illness condition. Pragmatically, it might have a better chance of being passed into law (Young 2007). Legally, R.A. Sedler argues that the state’s interest in preserving life doesn’t apply to those with a terminal illness: “A ban on the use of physician-prescribed medications by a terminally ill person to hasten inevitable death does not advance any conceivable interest in ‘preserving life’” (Sedler 1993, 24). Because we are focused on the ethical justifications for PAD, we will set aside arguments of this sort.

Callahan asks:

Are doctors now to be given the right to make judgments about the kinds of life worth living and to give their blessing to suicide for those they judge wanting? What conceivable competence, technical or moral, could doctors claim to play such a role? Are we to medicalize suicide, turning judgments about its worth and value into one more clinical issue? Yes, those are rhetorical questions. (1992, 55)

Pace Callahan, the point of the Autonomy Only model is that it removes the need for physicians to make such judgements. Their gatekeeping role is narrowed to determining capacity.

One might worry that we are here abandoning our point about Autonomy Only being less ableist than the Joint View, insofar as Autonomy Only might still create barriers to access for those with less commonly accepted conditions or values. It may be true that in practice Autonomy Only still allows for certain ableist judgements of this sort. But it should be clear enough that Autonomy Only does better on this front than the Joint View, which counts in no small way in its favour.

Aviv, R. 2015. The death treatment: when should people with a non-terminal illness be helped to die? The New Yorker, June 15.

Barutta, J., and J. Vollmann. 2015. Physician-assisted death with limited access to palliative care. Journal of Medical Ethics 41(8): 652.CrossRef

Bayne, T., and N. Levy. 2005. Amputees by choice: Body integrity identity disorder and the ethics of amputation. Journal of Applied Philosophy 22(1): 75–86.CrossRef

Beauchamp, T., and J. Childress. 2012. Principles of biomedical ethics, 7th ed. New York: Oxford University Press.

Bickenbach, J. 1998. Disability and life-ending decisions. In Physician-assisted suicide: Expanding the debate, edited by M. Battin, R. Rhodes, and A. Silvers, 123–132. New York: Routledge.

Boorse, C. 2016. Goals of medicine. In Naturalism in the philosophy of health: Issues and implications, edited by E. Giroux, 145–177. New York: Springer.CrossRef

Buchanan, A., and D. Brock. 1990. Deciding for others. Cambridge: Cambridge University Press.CrossRef

Callahan, D. 1992. When self-determination runs amok. The Hastings Center Report, 22,(2):52.

De Haan, J. 2002. The ethics of euthanasia: Advocates’ perspectives. Bioethics 16(2): 154–172.CrossRef

Donchin, A. 2000. Autonomy, interdependence, and assisted suicide: Respecting boundaries/crossing lines. Bioethics 14(3): 187–204.CrossRef

Downie, J., and S. Sherwin. 1996. Feminist exploration of issues around assisted death. Saint Louis University Public Law Review 15(2): 303–330.PubMed

Dworkin, R. 1994. Life’s dominion. New York: Random House.

Dworkin, R., T. Nagel, R. Nozick, J. Rawls, T. Scanlon, and J. Thomson. 1997. Assisted suicide: The philosophers’ brief. The New York Review of Books, March 27: 41–47.

Fletcher, G. 2016. The philosophy of well-being: An introduction. New York: Routledge.CrossRef

Ganzini, L. 2004. The Oregon experience. In Physician-Assisted Dying: The Case for Palliative Care and Patient Choice, edited by T. Quill and M. Battin, 165-183. Baltimore: Johns Hopkins University Press.

Grant, K. 2018. Medically assisted death allows couple married almost 73 years to die together. The Globe and Mail, April 18.

Gunderson, M., and D. Mayo. 2000. Restricting physician-assisted death to the terminally ill. Hastings Center Report 30(6): 17–23.CrossRef

Hardwig, J. 1997. Is there a duty to die? Hastings Center Report 27(2): 34–42.CrossRef

Hesslow, G. 1993. Do we need a concept of disease? Theoretical Medicine 14(1): 1–14.CrossRef

Ho, A. 2008. Relational autonomy or undue pressure? Family’s role in medical decision-making. Scandinavian Journal of Caring Sciences 22(1): 128–135.CrossRef

Huxtable, R., and M. Moller 2007. Setting a principled boundary? Euthanasia as a response to life fatigue. Bioethics 21(3):117–126.CrossRef

Jennings, B. 2016. Reconceptualizing autonomy: A relational turn in bioethics. Hastings Center Report 46(3): 11–16.CrossRef

Kagan, S. 2014. An introduction to ill-being. In Oxford Studies in Normative Ethics, Vol 4, edited by M. Timmons, 261-288. Oxford: Oxford University Press.CrossRef

Kymlicka, W. 1989. Liberalism, community, and culture. Oxford: Oxford University Press.

Li, M., S. Watt, M. Escaf, et al. 2017. Medical assistance in dying—implementing a hospital-based program in Canada. New England Journal of Medicine 376(21): 2082–2088.CrossRef

Mackenzie, C., and N. Stoljar. 2000. Introduction: Autonomy refigured. In Relational autonomy: Feminist perspectives on autonomy, agency, and the social self, edited by C. Mackenzie and N. Stoljar, 3–34. New York: Oxford University Press.

Marquet, R.L., A. Bartelds, J. Visser, P. Spreeuwenberg, and L. Peters. 2003. Twenty five years of requests for euthanasia and physician assisted suicide in Dutch general practice: Trend analysis. British Medical Journal 327(7408): 201-202.CrossRef

Maynard, B. 2014. My right to death with dignity at 29. CNN.com, November 2. www.edition.cnn.com/2014/10/07/opinion/maynard-assisted-suicide-cancer-dignity/index.html. Accessed 1 Apr 2020.

McLeod, C., and S. Sherwin. 2000. Relational autonomy, self-trust, and health care for patients who are oppressed. In Relational autonomy: feminist perspectives on autonomy, agency, and the social self, edited by C. Mackenzie and N. Stoljar, 259–279. New York: Oxford University Press.

Mill, J. 1859. On liberty. New York: Norton.

Miller, F. 2016. Should a legal option of physician-assisted death include those who are “tired of life”? Perspectives on Biology and Medicine 59(3): 351–363.CrossRef

Pearlman, R., and H. Starks. 2004. Why do people seek physician-assisted death? In Physician-assisted dying: The case for palliative care and patient choice, edited by T. Quill and M. Battin, 91-101. Baltimore: Johns Hopkins University Press.

Sedler, R.A. 1993. The constitution and hastening inevitable death. Hastings Center Report 23(5): 20–25.CrossRef

Steinbrook, R. 2008. Physician-assisted death—from Oregon to Washington state. New England Journal of Medicine 359(24): 2513–2515.CrossRef

Sumner, L.W. 1996. Welfare, happiness, and ethics. Oxford: Oxford University Press.

------. 2011. Assisted death. .

------. 2017. Physician-assisted death: What everyone needs to know. New York: Oxford University Press.

Thomson, J. 1971. A defense of abortion. Philosophy and Public Affairs 1(1): 47–66.

Wall, S. 1998. Liberalism, perfection and restraint. Cambridge: Cambridge University Press.CrossRef

Young, R. 2007. Medically assisted death. Cambridge: Cambridge University Press.CrossRef

Title: The Case for an Autonomy-Centred View of Physician-Assisted Death
Authors: Jeremy Davis
Eric Mathison
Publication date: 01-09-2020
Publisher: Springer Singapore
Published in: Journal of Bioethical Inquiry / Issue 3/2020
Print ISSN: 1176-7529
Electronic ISSN: 1872-4353
DOI: https://doi.org/10.1007/s11673-020-09977-8

2024 ASCO Annual Meeting

Springer Medicine

The Case for an Autonomy-Centred View of Physician-Assisted Death

Abstract

2024 ASCO Annual Meeting

Springer Medicine

Abstract

Please log in to get access to this content

Other articles of this Issue 3/2020

From Sufficient Health to Sufficient Responsibility

The Ethical Dilemma of Truth-Telling in Healthcare in China

No Man (or Woman) Is an Island?

Why We Never Eat Alone: The Overlooked Role of Microbes and Partners in Obesity Debates in Bioethics

Balancing Patient and Societal Interests in Decisions About Potentially Life-Sustaining Treatment

Culpable Ignorance, Professional Counselling, and Selective Abortion of Intellectual Disability