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Last Updated: Thursday, 11 May 2006, 08:08 GMT 09:08 UK
The ethics of assisted suicide
By Daniel Sokol
Medical ethicist, Imperial College London

On Friday the House of Lords will debate Lord Joffe's private member's bill, Assisted Dying for the Terminally Ill.

If passed, the bill will allow terminally ill adults in unbearable pain to receive medical help in dying.

Many objections to physician-assisted suicide are based on religious prohibitions.

These can only be countered by refuting the religion itself - a notoriously hard thing to do - or by arguing that religious teaching actually permits the act.

I shall not employ either of these arguments.

Harm is, at least in part, a subjective notion

Religion-based reasons will not persuade the secular folk, and hence many objectors usually replace or supplement their arguments with non-religious reasons.

Some of the secular reasons against physician-assisted suicide (PAS) appear speculative or ill-informed.

Initial doubts

They remind the historically aware of the initial reactions surrounding practices which are now widely accepted (for example, human dissection, considered an affront to human dignity in Hippocratic times, and vaccination, considered unnatural and a thwarting of God's will in the 19th and 20th centuries).

Some reasons, however, are more convincing.

If we allow assisted suicide of any sort, we undermine the value of life itself
AM Costley, Carmarthen, Wales

One such reason is that PAS will change the way members of the public view doctors.

In the public's mind, doctors will become part-time executioners.

We cannot predict if this will occur, but even if it did at first adversely affect the public's perspective, it is not a sufficient reason to reject the bill.

People's views can, and do, change.

If physician-assisted suicide is morally acceptable, then the fact that people might frown upon it does not alter the morality of the act.

Hippocratic Oath

Another common argument about PAS, especially amongst doctors, is that it violates the Hippocratic dictum: 'first, do no harm'.

If we strictly adhered to Hippocratic teachings, abortion should also be abolished

This principle was insightful in Hippocratic times when doctors mostly did more harm than good - magic and superstition were rife, and efficacious treatments few - but not in this scientific age.

The oath is now out of date. If we strictly adhered to Hippocratic teachings, abortion should also be abolished, for the Oath says "Neither will I give a woman means to procure an abortion".

It is therefore wrong slavishly to revere - as some still do - the Hippocratic Oath.

If taken literally, the only way doctors could 'do no harm' would be by declining to treat all patients.

Even simple medical procedures, such as taking a blood sample or injecting a local anaesthetic, entail some risks to the patient.

Many procedures and treatments require doctors to inflict harm in order to bring about some good.

In an appendectomy, the surgeon cuts open the patient's abdomen (a harm) to remove the troublesome appendix (a benefit).

Balance of good

As the ethicist Professor Raanan Gillon points out, doctors have a duty not to cause net harm.

In my view, physician-assisted suicide can be compatible with love, kindness and compassion

Is PAS a net harm to the patient who wants it?

Those in favour of the act will argue that helping a terminally ill patient to die is a benefit, not a harm.

Harm is, at least in part, a subjective notion.

What is beneficial or harmful to a particular patient is determined to some extent by the patient's perception.

If I choose to donate a kidney to my sick brother, no one would rightfully accuse the surgeon of having harmed me by removing the organ.

Overall, the operation would benefit me in spite of the physical harm.

Respecting a patient's autonomous wishes can itself constitute a benefit.

Thus it is far from clear that allowing doctors to help patients end their lives infringes the dictum 'first, do no (net) harm'.

An answer to the morality of PAS can be found by reflecting on the essence of medicine. This is no easy task.

Paracelsus, in the 16th century, wrote that medicine was grounded in love. More recently, Sir William Osler stressed the importance of humanity, which consists in showing 'tenderness and consideration to the weak, infinite pity to the suffering, and broad charity to all'.

He reminded doctors to keep a 'clear head and a kind heart'.

When the late Jean Bernard, the distinguished French haematologist, was asked by a journalist a few years ago: "technology aside, on what is medicine based?", he replied "on love, on compassion, since medicine will always be about man".

In my view, physician-assisted suicide can be compatible with love, kindness and compassion.

The real difficulties lie in regulating the practice to limit the possibility of abuse and, once that is overcome, in summing up the courage to do what is morally right in the face of anticipated abuse and opposition.

  • Daniel Sokol is the co-author if Medical Ethics and Law: Surviving on the Wards and Passing Exams.


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