Physician-Assisted Suicide
Michael A. Gillette, Ph.D.

In its recent decision, the Supreme Court of the United States ruled that there is no constitutional right to physician assisted suicide. The court did not rule that there is a compelling state interest in making all physician assisted suicide illegal, but merely that any justified claim to physician assisted suicide (PAS) would not be constitutional in nature. In short, each State is now free to make its own laws governing this practice.

While I have already commented in previous newsletters on the theoretical issues involved in PAS, I would like to take this time to make a practical argument. Even though I reject most of the standard arguments that are designed to show that PAS is unethical, I believe that it is still possible to show that at present, PAS is not a practice in which Virginia physicians can ethically engage.

The best way to practically discuss an issue like PAS is to normalize our approach and apply our standard assumptions about ethics. As a background assumption, I assert that, all other things being equal, competent patients have the right to make medical decisions that often conflict with commonly held values and with their physician's judgment. This fact is well illustrated by a patient's ability to sign herself out of the hospital against medical advice.

On the basis of the above stated initial assumption, I believe that an informed and competent patient's desire to end his own life can, conceivably, be a choice that is private and one which the medical establishment ought not to override. On the other hand, although a patient may have an important right to self-determination that cannot be easily overridden, that right may not be powerful enough to create obligations on the part of others to aid the patient in the exercise of his rights.

Some rights are rights to non-interference, and not rights to assistance. The right to determine that continued existence is undesirable is most probably just such a right. When a patient signs herself out of the hospital AMA, she is asserting her right to refuse care even if such a choice is likely to shorten her life. The patient's physician may disagree with the choice to leave the hospital and is therefore not required to sign a discharge order. The physician is not able, however, to overrule the patient's right to leave on her own responsibility unless a special circumstance exists. This standard approach to patients who make decisions that are viewed by health care providers as self-injurious can be applied to the issue at hand.

If a patient wishes to end his life, then that choice is a private matter which at most creates a protection from interference. Even in the extreme case of a competent and fully informed patient who wants to end his life, such a patient would have a right only to demand that no one interfere in his actions. There is no aspect of the practice of medicine that creates an obligation to assist such behavior. Therefore, a patient who desires to die may have a right to avoid intervention if competent, but no physician has an obligation to provide assistance.

So far it has been argued that physicians are under no obligation to provide assistance in ending a patient's life at her competent request. It remains an open question, however, as to whether rendering assistance is permissible. Can a physician provide PAS if she wants to? The answer to this question rests on a judgment regarding the medical standard of care.

In evaluating the force of a patient's request, I would argue that a patient cannot demand that care be provided in a way that is substandard. While patients are capable of demanding many types of care under many circumstances, they cannot ask that a doctor commit malpractice. One reason why a patient does have the ability to demand that an appendectomy be performed on his enflamed appendix for example, is that such care is indicated according to accepted medical and social standards. The same patient cannot demand that an appendectomy be performed in order to relieve him of his chronic migraine headaches, because such treatment modalities are contrary to medical standards. If PAS is more like an appendectomy for the enflamed appendix, then a patient can demand it. If PAS is more like the removal of a healthy appendix for irrelevant reasons, then the patient should be restricted from receiving it. If PAS lies somewhere in between, then a physician might provide the treatment on his own discretion.

Without having to argue that PAS is intrinsically immoral, we can clearly determine that it is contrary to the present standard of care in Virginia. The Health Care Decisions Act, which governs the refusal of life prolonging care in the Commonwealth of Virginia, clearly states that euthanasia is illegal. While it allows the intentional shortening of life under certain circumstances (such as the provision of palliative care that may compromise respiratory function), it clearly disallows the intentional bringing about of a patient's death when that death is not the side effect of a medically indicated procedure.

The status of the Virginia Statute, combined with clear evidence of a national debate on PAS, clearly indicates that although PAS might someday become the standard of care under specified circumstances, it is not the standard of care at the present time. Since this is true, PAS ought not to be provided until after the standard of care changes as a result of legislative initiative. On the basis of this conclusion, the provision of PAS at the present time in this State would be equivalent to malpractice. Therefore, a physician is morally prohibited from providing PAS even at a patient's request. Furthermore, given this analysis, a facility administration would be empowered by its duty to uphold medical standards of care, to restrict physicians from providing PAS within its facilities, even if the physicians in question desire to provide it.