The History and Philosophy of Physician-Assisted Suicide

On October 27th, 1997, physician-assisted suicide officially became legal in Oregon (the first US state to approve this process and make it legal) with the Oregon's Death with Dignity Act, but only after four years of delay, controversy, and fight as the act suffered injunction and reversed ruling. The Death with Dignity Act passed allowing a physician that is either a Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.) to prescribe medications to hasten death to patients that have a terminal illness as well as a prognosis of six months or less to live (“Physician-Assisted Suicide Fast Facts”). 21 years later in 2018, this act, still dripping in controversies, has officially become legal in seven US states including Colorado, Hawaii, Vermont, and Washington as well as well as in the District of Columbia.

Physician-assisted suicide requires patients to be terminally ill, have less than six months to live, and for two physicians to confirm the patient’s prognosis and that they are mentally capable and acting voluntarily (“Death​ ​with​ ​Dignity”). If patients are thought to have a psychiatric disorder or depression, they are required to be sent to a mental health provider who needs to determine that the patient is does not have impaired judgement in their decision to die caused from a disorder (“Death​ ​with​ ​Dignity”). It is also required that the patient is informed of alternatives such as hospice, the patient's request must be made both in writing (which needs to be witnessed by at least two informed individuals) and also orally (at least 15 days after the initial request) (“Death​ ​with​ ​Dignity”). Patients are also able to change their mind at any time and are required to take the medication themselves (“Death​ ​with​ ​Dignity”).

On February 9th, 2018, Oregon Health Authority released their annual report. The report stated that as of exactly 20 years after the Death with Dignity Act was made legal, 218 people have received these deadly prescripts from 92 physicians (“Oregon Death with Dignity Act: Annual Reports”). The document stated that “As in previous years, most patients were 65 years or over (80.4%); had cancer (76.9%); were on hospice at the time of death (90.9%); died at home (90.2%)” (“Oregon Death with Dignity Act: Annual Reports”). The document also stated that “During 2017, the estimated rate of deaths under the law was 39.9 per 10,000 total deaths in the state” (“Oregon Death with Dignity Act: Annual Reports”). Since 1998, the year in which the first person in Oregon took medication prescribed under the law, a total of 1,545 patients have received the prescription, of whom 991 (64.1%) ingested it and died (“Oregon Death with Dignity Act: Annual Report”s). It has also been shared since the first person legally took the medication in Oregon in 1998,a total of 1,545 patients have been given this prescription, but that only 991 (64.1%) ingested it and died (“Oregon Death with Dignity Act: Annual Reports”).

Jack Kevorkian, also known as Dr. Death, is the pinnacle mascot of conversations and controversies surrounding the topic of physician-assisted suicide. Having gained international attention in 1990 when he helped a 54 year old women in the early stages of Alzheimer’s disease to kill herself using a machine of his he called Mercitron machine (Bernstein). Over the next three years, Kevorkian was present as over 20 more deaths, and throughout his life aided and assisting in the suicides of more than 100 patients (Bernstein). From advocating in the opening of suicide clinics to carrying out medical experiments on death row inmates, it is no wonder than Kevorkian later was served two jail sentences in 1993 for violating the state’s law and later in 1998 charged with first degree murder for administering a lethal injection to a patient without a medical license (Bernstein). Despite all of this, Kevorkian is a large reason why the Death with Dignity Act was created in 1997, and he is also a big reason why the act still remains so controversial. People do not like to look at or think of death let alone suicide, and Jack Kevorkian was a walking reminder of what this act represents and could allow.

Immanuel Kant, philosopher and author of the book Groundwork of the Metaphysic of Morals takes on this intriguingly gruesome topic in the debate surrounding the morals of this suicidal act. “One person, through a series of evils that have accumulated to the point of hopelessness, feels weary of life but is still so far in possession of his reason that he can ask himself whether it might be contrary to the duty to himself to take his own life. Now he tries out whether the maxim of his action could become a universal law of nature. But his maxim is: ‘From self-love, I make it my principle to shorten my life when by longer term it threatens more ill than it promises agreeableness’. The question is whether this principle of self-love could become a universal law of nature. But then one soon sees that a nature whose law it was to destroy life through the same feeling whose vocation it is to impel the furtherance of life would contradict itself, and thus could not subsist as nature; hence that maxim could not possibly obtain as a universal law of nature, and consequently it entirely contradicts the supreme principle of all duty (Kant 38)” In other words, one of our inclinations is to take care of ourselves and to make ourselves happy. The principle that Kant formulates is that in order to make myself happy I am going to end my life. He says that this is a contradiction of terms as it is our nature to preserve ourselves which is one of the first principles of self love or self care (self preservation) (Kant). This shows us another way in which bad categorical imperatives get made. To determine if ending one’s life is a moral thing to do, you would have to will it to be a duty for everyone everywhere and always, which would not be a moral or logical thing to do (Kant). This is the guide that Kant lays out for us, allowing us to not necessarily be able to say for certain what a categorical imperative is, but instead simply to test the matter. Kant would say it is wrong is because we can’t universalize it. If a physician assisted one to take their life Kant would argue is situational and can not ever be categorical because there is no way to tell with 100% certainty that you are not terminally ill. However, it must also be taken into account that this is in direct opposition with what the law states today (that the patient must have prognosis of six months or less to live in order to be administered the lethal medication). We are essentially left with the conundrum that while these patients are given their prognosis that is created and made legal on the idea and basis that the science and probability is exactly correct and they than in fact also meet the probable percentage they were supposed to fit into, it is nevertheless impossible to know for 100% certainty what would have happened to said patient once the outcome has been tampered with by aiding in the suicide. The probability of that person’s death may be extremely high and calculated as to when it is expected to happen, but by changing the person's natural time of death you are essentially creating a paradox allowing us to never know for certain when that person would have actually died, with the only conciliation being that at least that person did not suffer.

As for the second test Kant puts this scenario through, “In order to remain with the previous examples, First, in accordance with the concept of the necessary duty toward oneself, the one who has suicide in mind will ask himself whether his action could subsist together with the idea of humanity as an end in itself. If he destroys himself in order to flee from a burdensome condition, then he makes use of a person merely as a means, for the preservation of a bearable condition up to the end of life. The human being, however, is not a thing, hence not something that can be used merely as a means, but must in all his actions always be considered as an end in itself. Thus I cannot dispose of the human being in my own person, so as to maim, corrupt, or kill him” (Kant). This too leads Kant to say it is wrong to take one’s own life because you are using the physician-assisted suicide as a means to an end which therefore isn’t rational. You wouldn’t be respecting your own rational nature.

Another philosopher, Plato, also tries to bring light to the morals of taking one’s own life (whether assisted or not), and he would argue that it is morally wrong to commit suicide if a god has not indicated some necessity to do so. Born on May 27th, 427 BC in Athens, Greece, Plato lived in a time and society brought up on what we now call “Greek mythology” (“Greek mythology is the body of myths and teachings that belong to the ancient Greeks, concerning their gods and heroes, the nature of the world, and the origins and significance of their own cult and ritual practices” (Wikipedia)). In the eyes of people from Plato’s time, the gods were men’s guardians and men their possessions. Plato would argue that physician-assisted suicide is moral as long as the man is terminally ill because that would mean that death was already the will of the gods “Man is a prisoner who has no right to open the door of his prison and run away. A man should wait, and not take his own life until God summons him” (Phaedrus). According to Plato, if that man is not terminally ill, he must wait for his natural death in order to be compliant with the gods. When looking at Plato’s view, it must be remembered that for those who base their morals off the world and themselves, morality is subjective. But for those such as Plato who believe in a religion of some sort, morality is not subjective or opinionated, but instead to them their morals are fact as what morals to have is handed to them in whatever god their religion follows. Plato would also probably suggest and categorize that the desire for physician-assisted suicide would be because it would be because we desire it only for its consequences, the escape of pain and decreased time of having to wait for the inevitable. The consequences for the desire is also the reason why Death with Dignity was made legal and why people who advocate for it do so.

According to Aristotle on the other hand, this would be a subjective topic and that mode action must be aimed at some good therefore it may be wrong in some circumstances and moral in others (Aristotle). Humans are rational animals with the ultimate goal of happiness and to achieve it follow the golden mean which is the control between excess and deficiency (Aristotle). In order to control the golden mean we must exercise rational judgement (Aristotle). Moral actions must be voluntary actions (Aristotle). If a rational person can not achieve happiness due to a terminal illness or disease physician-assisted suicide should be a an option for them. If their conditional state prevents them from pursuing happiness they should be allowed to make that choice.

John Stuart Mill, author of Utilitarianism, says that utilitarianism is based off of actions being in proportion as they often promote happiness, but wrong as they often produce the reverse of happiness (Mill). Mill says that happiness is pleasure and the absence of pain (Mill). He explains how we can take different amounts of and types of pleasure (Mill). Mill later explains that happiness is basically what creates our existence and that all people ever actually want it happiness which is why all of people’s desires are simply a way to hopefully attain happiness (Mill). Essentially, while I do understand why why Mill, Kant, and some other philosophers may take Mill’s argument to explain why taking one’s life is a contradiction to itself, I (along with more than likely those that created and legalized the Death with Dignity app) can look at Mill’s definition above, see “happiness is basically what creates our existence”, and understand that by Mill’s definition of what creates our existence, those people in agonizing pain with such a short time left to live that have requested this physician-assisted suicide, they have already ceased to exist, long before they inject that deadly dose.

If you consider that everyone subconsciously or unconsciously sees everyone as whether they help or hurt our desires, that we evolved to hope for the best but to expect the worst, wanting to avoid the bad but also expecting and having a negativity bias, that we add emotions, intentions, and dispositions to everything we do, that suffering is always made up of either change of loss, comparison with others, or preoccupation with ourselves, and that we are always either involved in a goal-seeking activity, trying to get something, acquire something, avoiding threats, or spacing out. Essentially, all of these different things that I just listed that make us human also make us dispositioned to view physician-assisted suicide as a negative thing. Especially when keeping in mind the branch of philosophy ethical egoism that teaches that every act we do and emotion we feel is rooted in our own self interest, whether tied up with the collective happiness or not. This branch of philosophy, along with simply the word “ego” or “selfish”, has a very negative connotation in the minds of those unfamiliar with this concept. However, keeping this concept in mind, it is understandable that people disagree with physician-assisted suicide when they are biologically dispositioned to instinctively want to protect oneself and all those they hold dear. Not for the sake of those that they hold dear, but for fear of the pain of losing them. The only way to understand the reason behind this act is to put oneself completely aside and to realize the pain that the dying person in this position must be in in order to even be considered for this deadly process. Another crucial step to understanding why such an act could become legal and people would choose to die this way, would be to put aside religion. Given that research done by Alper and Aleksandra shows that 77% of people in the US are religiously affiliated, and that most of these religions are against committing any kind of suicide, it is easy to see why this may be a difficult concept to grasp and feel at peace with for most people.

Despite the commonly shared views of Aristotle, Kant, and Plato depicting physician-assisted suicide as immoral and illogical, and despite the controversy brought on by Jack Kevorkian a.k.a. Dr. Death, the number of people vouching for physician-assisted suicide today more than ever still continues to fluctuate as it’s legalization spreads. As for the reason why it’s still undecided and people still do it, proponents of the Death with Dignity movement find value in concepts like personal liberty and they believe that everyone should be free to make decisions about their own lives and their own deaths. Which is ironic considering people can’t decide whether or not to keep normal suicide legal and whether or not to make abortions illegal or legal. Not to mention, the debate talking about how we don’t make the choice to be born. But alas, if you are suffering from a terminal illness that will kill you in less than six months and don’t mind disagreeing with some ancient philosophers, just move to Oregon and you will be taken care of. Unfortunately not by Jack Kevorkian (a.k.a Dr. Death) however, as he now lives up to his nickname having finally taken his turn journeying into whatever afterlife you believe in when he died in early 2011 from thrombosis….painlessly, at an old age, naturally, and when the time was right.

Works Cited

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