Assisted Suicide: Some Ethical Considerations

Proc. of the Conference on Euthanasia, The Royal Society of Health, London, 1973

Publ. in International Journal of Health Services, 6/2 1976, pp. 321-330

THERE is no certainty in ethical opinions; and those who differ can find no ways by which either can be convicted of error. In logic and mathematics there is proof and disproof, and no two mathematicians are ever in disagreement about the correctness of a theorem. Science explores the realities of the external world. Although, as Karl Popper has shown, we can never prove the truth of our hypotheses, we can often show that they pass muster or that they are erroneous or inadequate. By proposing hypotheses and then, by way of experiment or observation, eliminating those that do not work, we engender a self‑corrective additive process, so that our knowledge and our understanding of nature grow cumu­latively. In the field of ethics the best we can do is to be explicit about our premises, and then show that they lead to certain conclusions. Those who dispute the conclusions may be able to refute the argument; but even if they cannot it is still open to them to deny the premises. I should like to persuade the reader to accept my con­clusions. I shall not be able to do so if his basic assump­tions are very different from mine. But even in that event the discussion will be justified if it leads to greater clarity about the foundations on which we take our stand.

THE BASIS OF ETHICAL JUDGMENTS

THERE ARE two main families of ethical systems, deontological and consequential. Deontological ethics asserts certain universal rules of conduct. In the past these rules have derived their power to bind from beliefs that they were given by God. No human authority is sufficient to maintain such universality; and if it is a church that speaks, it is in God's name. Maintained over the centuries, indoctrinated into the minds of children, the rule becomes a tradition of great weight. However, as the face of the deity seems to change in the mind of man, or to retreat into a pre‑cosmological past before ever the big bang started the whole hurly‑burly, the traditions gradually wither at the root, and come to be questioned.

    Deontological ethics is the ethics of duty. The conduct prescribed is held to be good in itself, regardless of the consequences. Fiat just itia ruat coelum asserts for the man of law just such an absolute duty, beyond question and needing no empirical justification. Another set of absolute rules is given to the Christian in the decalogue, including the sixth commandment 'Thou shalt not kill'.

    One of the troubles about these categorical rules is that they are so rigid that they have to be broken from time to time; and there is, of course, no rule to say when they may be broken and when not. When exceptional circum­stances arise the man of good will is left without any valid rule, or forces himself to obey a rule although it offends against his conscience and rational judgment. Man justifies himself to kill in war, in self‑defence and in other special circumstances. The sixth commandment becomes open to question. It commands respect only in so far as it accords with the general system of values of society, or for the individual as far as it corresponds with the inklings of his conscience. More and more the worth of the cate­gorical imperative gets valued by the consequences to which it is seen to tend.

    A further disadvantage is that deontological ethics distorts the human problems with which it is faced. It has to express them in its own over‑simple terms, in a lan­guage which cannot compass the complexities of the problematic situations. Perhaps the most serious de­ficiency of this system of ethics is that it is so limited in its application. It disregards by far the greater part of the range of human problems, which it then conceives as ethically indifferent. But all human activities have an ethical dimension. If we are blind to this we shall mis­conceive the problems, find only superficial answers and fail to take into account the long‑term consequences of our decisions.

    Consequential ethics maintains that moral acts are right or wrong depending on their consequences; within the span of human judgment, then, the purposes aimed at and the consequences that might be anticipated by rational consideration of the circumstances. The means must be justified by the end in view. Indeed, what else could justify the means? "No act is anything but random and meaningless unless it is purposefully related to some end or object" [1]. This still leaves us in the position of having to make an ethical judgment of the ends.

    The dilemma is more apparent than real. If we abandon with the categorical imperatives the religious dogmas which were their foundation, we are indeed reduced to general formulations of human and temporal values which are invariably unsatisfactory, e.g. "the greatest good of the greatest number", or "the promotion of the health, happiness and welfare of mankind", or "the loving care of the whole of the earthly paradise which is now our dominion". But when it comes down to concrete instances, it is not the unsatisfactory general formulations that bother us. We nearly always agree easily enough whether ends in view are good or bad. Health, vigour, happiness and the enlargement of freedoms are what we all desire, and as we must live in social amity, for our neighbours no less than for ourselves. All the problems arise when we have to decide whether the means proposed are the right ones, whether they may not have ill conse­quences which would outbalance the ultimate good, whether the ill consequences are not more probable than the good ones.

    Consequential ethics deprives us of any divine cer­tainty. It sets us to face the entire range of the human predicament without shift or evasion. We have to get along as best we can with all our fallibility, and we cannot lay any part of our responsibilities on the shoulders of God. We have to face real issues instead of ones that have been artificially distorted.

DEATH AS THE PARTNER OF LIFE

WHAT ARE the consequences of death, for the individual and for the community? It is only death, inescapable for all and death after a limited span of years, that keeps a community in a healthy and vigorous state. Death is an equal partner with new birth in the renewal of life. With­out this elimination, the living communities of plants, animals and man would be clogged in their own wastes. It is the cycle of birth and death that has provided the possibility of evolution, with higher life forms emerging from more lowly ones, and man climbing upwards from the subhuman hominid. It is the same cycle that has given man the variety of his culture, growing from barbarism into increasing awareness of the spiritualities of life.

    Death, then, is a healthful process, and, no less than life, should be in every way encouraged and supported by national health services. Socio‑medical services which do not restore the vigour of life, but only postpone death, are plainly working against the interests of the commu­nity and should be regarded as antisocial. By providing the fatally sick with such long‑term supports and make­shift prostheses as kidney dialysis machines we are multi­plying the numbers of our sick and dying. If patients start taking three or four years to die, instead of as many months or weeks, their numbers must go up to a much higher population level. From the standpoint of society, it is the duty of the dying man to die. As Germaine Greer [2] has said, "dying is after all a service to the community, and ought to be honoured as such."

    From the point of view of the single suffering human being, death must be seen as the great benefactor and comfort of mankind. Surely everyone knows this in his heart. In the country of Luggnagg, as Jonathan Swift relates, Gulliver met the struldbrugs, wretched indivi­duals condemned to immortality, and carefully preserved by the State in ever‑advancing feebleness, decrepitude and dementia. His hideous prophecy has now been brought to reality in our welfare state, where in psychogeriatric wards poor aged bodies, deprived of their souls, go on for one, two and three years in second childishness and mere oblivion, spoon‑fed, incontinent, no longer even aware of their own identity. All the horror lies in such an end­lessly protracted downward progress, when one has to do the job of dying day after day, month after month, and year after year. Death itself, the end of dying, is a momentary event, painless and benevolent.

THE MITIGATION OF DYING

IN ANY fully humane society, research would be en­couraged into the processes of dying and the mitigation of their subjective effects. There is no biological reason why man should not be able to look forward to dying, not in suffering but in a state of bliss. The pleasure centres of the brain are there only waiting to be mobi­lized. It should be perfectly possible to block off all unpleasant afferent stimulation, while the mind is set free to wander in Elysian fields before dropping into a dream­less sleep. Such experiences and the means of producing them should be studied in the normal, so that we would get informative accounts after the return to wakefulness. People ought to be able to have two or three trial runs in the course of a lifetime, to let them get to know for them­selves how delicious it can be to die.

    This is not the way things are. As has been reported in the British Medical Journal [3], a very high proportion of the dying have to go through pain, breathlessness, im­pairment of consciousness, depression, anxiety, vomiting, bedsores and incontinence, before they are safely out on the other side. This is a disgrace. It is wholly preventible; it is entirely unnecessary; and it is completely pointless. But it can only be corrected if society as a whole gives a mandate and an absolute imperative to the community's health workers that such things must not be.

    They may not wish it; they may not even believe it; but why are health workers so cruel to the dying? Is it because, by dying, they are showing the futility of those self‑imposed duties? If a doctor tries to keep a patient alive for ever he will fail and fail disastrously. The patient pays the cost of this failure. In proving the doctor wrong, he arouses every kind of defensive reaction; and guilt and frustration become the guardian angels of the bedside, instead of serenity and compassion.

     On 15 September last, at Helsingborg in Sweden, King Gustaf VI died at the age of ninety, one month after a stomach operation. It was a terrible undertaking to inflict a major operation on a man of that age, and difficult to justify. The time had clearly come for him to die, and the most compassionate line would have been to help him over the last critical step with the most solicitous atten­tion to his ease, comfort and peace. Instead, he was kept going through one hopeless crisis after another before he died. We can be sure that King Gustaf's doctors were men of the highest skill and integrity. I have no doubt they are good men. But by countless examples history has warned us that the noblest men in the grip of false beliefs will commit terrible cruelties. What these doctors did, they did because they believed it was their duty. In medicine, there is an insane categorical imperative, which calls for the preservation of human life at any cost. The consequence of such a course of action is the infliction of unnecessary, prolonged and pointless suffering; but if one obeys a categorical imperative one takes no account of consequences. As Voltaire said, those who believe absurdities will commit atrocities.

NEGATIVE EUTHANASIA

THE PRACTICE to which the Swedish doctors felt them­selves obliged to conform is not universal; but it seemsto be very general in all hospitals and to dominate intensive care units. Hence it is that eminent physicians [4] have advised that the place to die is at home. The patient who dies at home is not, indeed cannot, be subjected to such ordeals as was the King of Sweden. The general practitioner will very likely not engage in support meas­ures that would only postpone the end, and will give some help to let the patient slip away undisturbed. If the relief of pain or distress calls for medication which actually hastens the end, this too is allowed. Such a conduct of the case is sometimes called 'negative euthanasia'.

    It is only hospital doctors obsessed with the life­preservation ethic who have any objection to negative euthanasia. The Archbishop of Canterbury [5] has said that doctors are not in duty bound to prolong the lives of patients whose cases are hopeless. "The religious‑ethical defense of negative euthanasia is far more generally accepted by ministers and priests than medical people recognize or as yet even accept .... Indeed, not only Protestant, Catholic, and Jewish teaching take this stance; but it is also true of Buddhist, Hindu, and Moslem ethics." [6] Part of the medical profession is quite out of step with the informed laity; and there is no reason other than professional bigotry why negative euthanasia should not be standard medical practice, in hospital and out.

    It is important in the eyes of the priest or minister that a man should make a good end. He should be aware that his end is near and prepare his soul to meet it. This is surely what everyone would desire for themselves. Such an end is compatible with negative euthanasia, but it is not compatible with the desperate fight for life that so many hospital workers think necessary. One cannot die with dignity if the deathbed is turned into a battle‑ground.

    Eminent medical men, leaders of the profession, when called to consider the predicament of the dying, call for ,,an aggressive attitude towards the disease" and they say that "hope must never be allowed to die" [7]. They recom­mend "a conspiracy of silence" [8] to prevent the patient from guessing his future.

    Such attitudes show an ignorance of human psychology which is disastrous in its effects. Hope that is constantly aroused and as constantly defeated is only a mental torture. If, for the hopeless, hope is annihilated, the way is made open to calmer and more appropriate emotions: resignation, an acceptance of the inevitable, serene con­templation of a lifetime now accomplished, joy that at last there will be an end to suffering, thoughts of others to whom farewells are due, last acts of kindness for which there is still time, and the fulfilment of religious duties if that is one's wish.

    How is it, one may ask, that medical men who are dedicated to friendship to mankind, can take it upon themselves to deny us these boons? Perhaps the reason may be found in past history. Medicine is not only what it is, a science and an art, but also what it has been, a mystery. It is ancient tradition that only medical men can understand that mystery. Not only is it so deep that the lay would never understand it; it is also so sacred that to reveal it to the uninitiated would be a sort of blasphemy So it comes that 'Doctor knows best', and that 'Doctor' may think himself entitled to take decisions on the patient's behalf which the patient cannot be trusted to take for himself. So comes the 'conspiracy of silence'.

    It is high time that the mystery of medicine died a natural death. This musty cobwebbed thinking is stuff for witchdoctors. Medical men must in all humility accept their position as the patient's servant and not his master. They do not do anything he might ask which would be against the law; they should not do anything against their professional ethics; they need not do anything that is against their professional judgment. But they have no right to take decisions out of his hands. They are his agents. Their authority derives only from him. It is only by his permission that they touch his body at all. They betray their trust if they deny him information; they are guilty of a professional crime if they lie to him. It is their job to see that he is fully informed of everything con­cerning his case which is within their knowledge and which he might need to know to manage his affairs. If the information is unpleasant or ominous, then it becomes their task to break it gently and little by little.

    But they must not conceal it. Doctors who have dared to break the ice have found it, after all, not so difficult to talk to patients about the threat or the certainty of impending death, and have found them pathetically grateful for such frankness. It is their cowardice rather than the patients' that stands between them. If they are open with their patients they can spare them unnecessary fears. If they listen to them they can learn much, perhaps even to match their courage.

SUICIDE

"THE TOWN in which I live contains many who long to die", wrote the Rev. Dr. Leslie Weatherhead [9]. In England and Wales there are about six and a half million people over the age of 65; and the numbers of those who survive the ages of 70, 75 and 80 are still very considerable. Many of them do survive under crippling difficulties; and doctors in general practice will confirm Dr. Weather­head's view that there are many who long to die, and many, now past caring, for whom a merciful release is earnestly hoped for by their relatives. Most of the patients in geriatric wards are old people who have come there to get something put right and then to go home again. Nevertheless doctors who work in these wards will tell you that about one in ten of them would think it easeful to die pretty soon. As one gets older and older the compensations of life diminish, the distresses increase, energy ebbs away, and one's hold on life weakens. It becomes easier and easier to depart. Even those who still get a great deal out of their lives would not mind calling it a day, if thereby they did not leave behind a sorrowing partner nor leave some needful task undone.

    This attitude of mind is so foreign to people who are still enjoying health and vigour that they cannot imagine it, cannot feel themselves into it, and cannot give it their sympathy. The young have no understanding for the old; and those who are well have no conception of what it is to be deathly ill. Lack of understanding leads to un­intended cruelty. Consider for a moment the old and infirm, for whom every succeeding year brings new troubles and distresses, new incapacities and new humili­ations; those who have lost the last soul who loved them and now are for ever alone; those who are in the grip of advancing disease, which will surely kill them only after some months of suffering. All around them they see the hard‑eyed kind people who tell them that life is good, that they have a duty to go on, that they must never give up hope, that they will be looked after.

    When others will not or cannot help us, we can still help ourselves. The law allows us the recourse of suicide. Nevertheless there is a very powerful social taboo against this act. It may cause distress to a family that has not been prepared for it; and society as a whole, in its lack of understanding, is likely to regard it as a rejection and react with anger and hostility. It is accordingly very im­portant that such a decisive act should be well considered and properly prepared for. Those who intend suicide should soften the blow for their relatives by letting them know that this is a possibility that may have to be borne in mind. Then, of course, all one's affairs should be put in order, debts paid, private papers destroyed, one's estate adequately disposed by will. It is very important that the method of death chosen should not put anyone else at risk, or even to trouble or inconvenience. Such violent deaths as jumping in front of a train are indefen­sible. Law and custom being what they are, it is not possible to arrange for a family gathering when one takes one's leave. Farewells will have to be made by letter. If the method of death chosen is an overdose of hypnotic, adequate time must be allowed for the drugs to have their lethal effect. Forty‑eight hours of absolutely guaranteed freedom from interference should be arranged for. This way of dying is very lonely; but it is society that has made it so.

    However the best laid plans are subject to accident, and an unexpected intervention might occur. For such an eventuality it is as well to warn off officious‑minded persons from intruding on one's privacy. The following form is suggested, to be signed and placed where it cannot fail to be seen:

NOTICE

TO WHOM IT MAY CONCERN

    I have decided, for reasons of health and age, to exercise my lawful right to bring my life to its end, and I hope that my last wish will be treated with proper respect.

    I absolutely forbid anyone to lay hands on me or interfere with me in any way while I remain alive, and I warn anyone who is minded to disregard this notice that treating or even touching a person against his will is in law both a criminal and a civil offence. I hereby instruct my personal representatives to initiate proceedings against any person who attempts unsuccessfully to resuscitate me, and if the attempt is successful I shall take action myself.

    I am of sound and contented mind, and having now made my peace with life and death in my own way I ask to be allowed to die in my own time.

Signed            Dated

 

    It is of course grotesque that such expedients should have to be considered. Everybody must die one day. The only rational way is to choose one's own time, when one has had enough of living and wishes to be gone. If a man claims the right to end his life, this is a lawful act and must be allowed. I believe it should be allowed to all without any exception. We should, indeed, aim at a future society in which death is self‑chosen and only comes on, demand, in which everyone lives as long as he wants to and no one any longer: a future in fact in which suicide is the norm, and the rare alternatives only accident or an unheralded sudden bodily failure.

    In such a utopian society it would still not always be possible for the helpless and incapacitated to undertake the whole of the needful arrangements. Some assistance would be quite commonly required. It should not, then, be unlawful‑as it is in this country at present‑for a disinterested party, say the family doctor acting in good faith, when it has been specially and earnestly asked for, to put the means required within his patient's reach. In Switzerland assistance in suicide is only unlawful if made with selfish motives. If the Swiss can trust themselves with a law to permit assisted suicide, it should not be beyond our civic courage to follow their lead.

 

REFERENCES

[1] Fletcher, Joseph (1973). "Ethics and euthanasia", in To Live and to Die: When, Why and How, ed. Robert H. Williams. New York (Springer‑Verlag), pp. 113‑122.

[2] Greer, Germaine (1972). article, Sunday Times, 3 December.

[3] Rees, W. D. (1972). "The distress of dying". British Medical Journal, 3, pp. 105‑107, 8 July.

[4] Smithers, Sir David (1973). "Where to die". ibid, 1, 34‑35. 6 January.

[5] Reported in The Times (1971, 3 May).

[6] Fletcher, Joseph (1973). loc. cit.

[7] Gibson, Ronald (1973). 'Supporting the patient in the home' British Medical Journal, 1, 35‑36, 6 January.

[8] Anderson, W. Ferguson (1973). 'A death in the family': a pro­fessional view'. ibid, 1, 31‑32, 6 January.

[9] Correspondence, The Times (1970, 17 April).