Abstract
A governing principle in medical ethics is respect for patient autonomy. This principle is commonly drawn upon in order to argue for the permissibility of assisted dying. In this paper I explore the proper role that respect for patient autonomy should play in this context. I argue that the role of autonomy is not to identify a patient’s best interests, but instead to act as a side-constraint on action. The surprising conclusion of the paper is that whether or not it is in the best interests for the patient to die is a morally objective matter. This allows for the possibility that it can be in the best interests of the patient to die even if she autonomously considers it to be in her best interest to continue living. I argue that concerns about ‘mandatory’ euthanasia can be met when patient autonomy is respected as a side-constraint on action. Ultimately, this means that assisted dying is permissible, not because the autonomous patient views her suffering to be unbearable, but because it is in her objective best interests and she permitted it via her consent.
In this paper I use the umbrella term ‘assisted dying’ to cover both voluntary euthanasia (VE) and physician assisted suicide (PAS). This does not mean that the distinction between VE and PAS should be, or are being, elided. Indeed, one might argue that there is an important distinction between a doctor intentionally killing a patient (VE) and intentionally helping a patient to commit suicide (PAS). The decision to use this umbrella term is that the argument presented here applies to both VE and PAS.
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Notes
- 1.
Throughout this paper I use the term ‘best interests’ to narrowly refer to the promotion or protection of the patient’s well-being. A broader usage of the term might include values in addition to well-being, such as financial gains and legal obligations.
- 2.
- 3.
Little has been written on the diminishing relevance of patient autonomy in recent bioethics literature as related to assisted dying. The exception is Varelius (2006), which explores the proper ends of medicine in view of a growing distinction in the bioethics literature on objective characterisations of the goals of medicine and, on the other hand, respect for patient autonomy (Varelius 2006, 121–2).
- 4.
For a comprehensive overviews of objections to assisted dying see Brock (1993).
- 5.
This is not the only argument in favour of the moral permissibility of forms of assisted dying. A second important argument focuses on patient well-being and the moral demand to reduce patient suffering (Brock 1993, 206). However, this second argument is often directly linked to the argument from autonomy with the burden of the patient’s suffering being determined by the autonomous patient (Brock 1993, 207).
- 6.
An important caveat to this argument is that respect for patient self-determination does not require health care practitioners to assist in patient dying at the patient’s request (Brock 1993, 207). The argument from autonomy should thus be seen as a constraint on morally permissible assisted dying; it does not amount to the claim that it is morally obligatory to carry out requests for assisted dying.
- 7.
Here I focus on arguments based on the connection between self-determination and maximisation of patient well-being only.
- 8.
For a detailed overview of defences of the claim that respect for self-determination facilitates the attainment of maximal best interests see Bullock (2014, 4).
- 9.
Varelius (2006, 123) refers to this as ‘subjectivism’ about the goals of medicine.
- 10.
I would like to thank Jukka Varelius for raising this point in comments on a draft of this paper.
- 11.
These are moral, rather than legal, conditions. Advocates for the legalization of assisted dying similarly agree on the importance of determining that the patient is suffering and that she consents to the intervention (Young 2014a, b). This paper focus on the moral framework underlying these legalistic conditions. Specifically, I argue that the determination of whether or not the person is suffering or whether her life is overly burdensome is not reducible to the self-determining patient’s conception of her best-interests.
- 12.
The items on this list are not presented in any order of priority.
- 13.
Here, I use the term ‘subject-related’ in order to contrast my position with such subject-relative views that do not allow the ordering of items on the list to differ between individuals whilst remaining independent of their views on the matter (cf. Varelius 2003, 368 ff.).
- 14.
The above discussion on subject-relatedness is adapted from Bullock (2012).
- 15.
Note that this position is different to the claim that there are objective standards for determining the permissibility of assisted dying, such as ‘the patient is suffering’ or ‘the patient has an incurable illness’. Whilst these conditions are relevant for determining the permissibility of assisted suicide, on my account, it could turn out that it is not in the objective best interests of a patient suffering from an incurable illness to die. It could equally turn out that it is in the best interests of a patient to die (when suffering from an incurable illness) even if she would prefer to continue living.
- 16.
I do not detail the conditions here but it will plausibly include things like, being near the end of life, having a terminal condition and/or the experience of great suffering.
- 17.
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Bullock, E.C. (2023). Assisted Dying and the Proper Role of Patient Autonomy. In: Cholbi, M., Varelius, J. (eds) New Directions in the Ethics of Assisted Suicide and Euthanasia. The International Library of Bioethics, vol 103. Springer, Cham. https://doi.org/10.1007/978-3-031-25315-7_1
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