Yet another argument against physician assisted suicide

Years ago, I read a clever argument against physician assisted suicide that held that medical procedures need informed consent, and informed consent requires that one be given relevant scientific data on what will happen to one after a procedure. But there is no scientific data on what happens to one after death, so informed consent of the type involved in medical procedures is impossible.

I am not entirely convinced by this argument, but I think it does point to a reason why helping to kill a patient is not an appropriate medical procedure. An appropriate medical procedure is one aiming at producing a medical outcome by scientifically-supported means. In the case of physician assisted suicide, the outcome is presumably something like respite from suffering. Now, we do not have scientific data on whether death causes respite from suffering. Seriously held and defended non-scientific theories about what happens after death include:

1. death is the cessation of existence

2. after death, existence continues in a spiritual way in all cases without pain

3. after death, existence continues in a spiritual way in some cases with severe pain and in other cases without pain

4. after death, existence continues in another body, human or animal.

The sought-after outcome, namely respite from severe pain, is guaranteed in cases (a), (b) and (d). However, first, evidence for preferring these three hypotheses to hypothesis (b) is not scientific but philosophical or theological in nature, and hence should not be relied on by the medical professional as a medical professional in predicting the outcome of the procedure. Second, even on hypotheses (b) and (d), the sought-after outcome is produced by a metaphysical process that goes beyond the natural processes that are the medical professional’s tools of the trade. On those hypotheses, the medical professional’s means for assuring improvement of the patient’s subjective condition relies on, say, a God or some nonphysical reincarnational process.

One might object that the physician does not need to judge between after-life hypotheses like (a)–(d), but can delegate that judgment to the patient. But a medical professional cannot so punt to the patient. If I go to my doctor asking for a prescription of some specific medication, saying that I believe it will help me with some condition, he can only permissibly fulfill my request if he himself has medical evidence that the medication will have the requisite effect. If I say that an angel told me that ivermectin will help me with Covid, the doctor should ignore that. The patient rightly has an input into what outcome is worth seeking (e.g., is relief from pain worth it if it comes at the expense of mental fog) and how to balance risks and benefits, but the doctor cannot perform a medical procedure based on the patient’s evaluation of the medical evidence, except perhaps in the special case where the patient has relevant medical or scientific qualifications.

Or imagine that a patient has a curable fracture. The patient requests physician assisted suicide because the patient has a belief that after death they will be transported to a different planet, immediately given a new, completely fixed body, and will lead a life there that is slightly happier than their life on earth. A readily curable condition like that does not call for physician assisted suicide on anyone’s view. But if there is no absolute moral objection to killing as such and if the physician is to punt to the patient on spiritual questions, why not? On the patient’s views, after all, death will yield an instant cure to the fracture, while standard medical means will take weeks.

Furthermore, the medical professional should not fulfill requests for medical procedures which achieve their ends by non-medical means. If I go to a surgeon asking that my kidney be removed because Apollo told me that if I burn one of my kidneys on his altar my cancer will be cured, the surgeon must refuse. First, as noted in the previous paragraph, the surgeon cannot punt to the patient the question of whether the method will achieve the stated medical goal. Second, as also noted, even if the surgeon shares the patient’s judgment (the surgeon thinks Apollo appeared to her as well), the surgeon is lacking scientific evidence here. Third, and this is what I want to focus on here, while the outcome (no cancer) is medical, the means (sacrificing a kidney) are not medical.

Only in the case of hypothesis (a) can one say that the respite from severe pain is being produced by physical means. But the judgment that hypothesis (a) is true would be highly controversial (a majority of people in the US seem to reject the hypothesis), and as noted is not scientific.

Admittedly, in cases (b)–(d), the medical method as such does likely produce a respite from the particular pain in question. But that a respite from a particular pain is produced is insufficient to make a medical procedure appropriate: one needs information that some other pain won’t show up instead.

Note that this is not an argument against euthanasia in general (which I am also opposed to on other grounds), but specifically an argument against medical professionals aiding killing.

Two kinds of professions

Compare the metalworker and the swordsmith. The metalworker's profession is defined by a particular technique for achieving human ends: the production and modification of items made of metal. The swordsmith's profession, on the other hand, is not defined by any particular technique. It is, instead, defined by an end: the existence of a sword. The two sets of skills may overlap: both a swordsmith and an metalworker can make a sword of metal, and in so doing remain within their professional competency. But a swordsmith can remain within her professional discipline in producing a sword of horn, wood and flint (say, in an emergency when metals are unavailable), while the metalworker who made such a sword would not be working within her profession. On the other hand, the metalworker remains within her professional competency when she makes a metal spoon, while the swordsmith is not working as a swordsmith when she makes a spoon—even though she may be as qualified to produce a spoon as any metalworker, and more so than some.

We can in general distinguish means-defined professions and end-defined ones. Examples of means-defined ones: software engineer, electrical engineer, chemical engineer, metalworker, woodworker, machinist, applied mathematician, lawyer. Examples of end-defined ones: civil engineer, aviation engineer, swordsmith, bowyer, cabinet maker, physicist, pure mathematician, biologist, legislator. There will also be cases of professions defined both by and end means. Some of these result from specializations within a means-defined or an end-defined profession—and sometimes it will be unclear which way is the better way to look at it. Is a biomathematician an applied mathematician (means-defined) who uses mathematical methods for the sake of gaining biological knowledge, or is a biomathematician a biologist (end-defined) who uses mathematical methods to pursue the end distinctive of her biological profession (namely, biological knowledge)?

It may be that in all cases of end-defined professions there are some constraints on which means count as part of the distinctive activity of the profession. Thus, it may be argued not be a part of the civil engineer's profession to pray that the bridge not collapse, even though doing so promotes the end that defines her profession. However, it is not clear that this is so. It may be a prejudice to say that the civil engineer does not pray qua engineer.

Nonetheless, despite borderline cases, a basic division into professions primarily defined by a means or set of means, and those defined by an end or set of ends, seems helpful.

Does any of this matter? I think it can. For instance, consider this question: Is it the job of the physician, qua physician, to execute criminals? Assume that the case is one of the rare cases where capital punishment is morally permissible. As has been noted at least since the time of Plato, the physician's professional knowledge makes her the most effective person at both preserving life and taking away life. Moreover, her skills may particularly enable the taking away of life to be reliably painless. If the physicians's profession is primarily defined by means or techniques, then to execute painlessly falls under her profession just as much as to heal. If, on the other hand, her profession is defined in terms of ends, presumably the relevant end is something like the good functioning of the body, and this goal is not promoted by killing. And euthanasia is also not something that falls to the role of a physician.

I think our concept of a physician is a mix. When we talk of the crime of practicing medicine without a license, we are thinking of medicine as in part defined by a particular set of techniques. One does not count as practicing medicine without a license if one suggests to someone that she refrain from eating too many cheeseburgers or if one prays for her health. But only in part. If someone who is not a medical professional intentionally stabs someone else to death with a surgical knife, she would not, I suspect, be charged with practicing medicine without a license in addition to murder, no matter if she had pored anatomy books to figure out how to do the deed.

Still, I think, the primary focus in the medical profession is on the end. Consider that the physician remains within her medical role if the means she recommends to promote end of health involve pharmaceuticals, surgery, physical exercises, psychological exercises, the taking of a placebo, etc. Almost anything that in a morally acceptable way promotes health—with the possible exception of the supernatural—can legitimately fall within the scope of her medical recommendations. She might even diagnose that the patient's headaches are due to financial worries and recommend that the patient come up with a good budget. She would be going beyond her medical competence, I suppose, if she recommended a particular set of safe investments, but that may only be because recommending investments is not a skill that physicians typically have. (A particular practitioner of profession will not have all the skills that can fall under the professional role—the bowyer who cannot work in fiberglass can still be a competent bowyer.)

Moreover, most of the subdivisions within medicine, with the most obvious exception being surgeon, are end-based: the neurologist, the psychiatrist, the gastroenterologist and the pediatrician are each defined by which instances of the goal of health it is their special task to promote.

The pharmacist, on the other hand, is equally defined by means and by end. She does not act within her role if she prepares medication for an execution. It is, after all, her job to take solicitude for the health of the patient, ensure that she is not allergic to the drugs, etc. But she also does not act within her role if she performs surgery.

Euthanasia and the role of the physician

Consider this argument:

1. (Premise) It is not professional for a physician to perform a procedure when there is not sufficient scientific evidence or professional experience about the sequelae of the procedure for the patient.[note 1]
2. (Premise) There is not sufficient scientific evidence or professional experience about the sequelae of euthanasia for the patient.
3. Therefore, it is not professional for a physician to euthanize a patient.

In support of premise (2), note that a crucial thing to have scientific or professional evidence about in the case of a medical procedure is what kinds of things, if any, the patient will be conscious of after the procedure. Now, there is good reason—and perhaps we can consider it "scientific reason"—to think that after the patient is killed, it will no longer be the case that the patient will be conscious of the particular pain, discomfort or indignity that prompted the request for euthanasia. However, there is no scientific evidence or professional experience about whether the patient would or would not have other pains, discomforts or indignities. In fact, there is no scientific evidence or professional experience about whether the patient would or would not have any conscious experiences whatsoever after the procedure.

For an analogy, consider a neurosurgical procedure that could be performed on a suffering patient, which procedure would place the patient in a coma-like state. Suppose further that there was no scientific evidenece or professional experience as to which of the following hypotheses was true:

4. There are no conscious patient experiences following the procedure.
5. The patient is conscious after the procedure, and her conscious states are extremely unpleasant.
6. The patient is conscious after the procedure, and her conscious states are extremely pleasant.
7. The patient is conscious after the procedure, and her conscious states are neither extremely pleasant nor extremely unpleasant.

Surely, the physician who performs the neurosurgical procedure in a responsible way has to have grounds for thinking that (5) isn't the likely outcome for this particular patient. Moreover, for the procedure to be done professionally, those grounds have to be of the sort recognized by the profession—namely, they have to be scientific or based in professional experience.

Observe that the patient's belief as to what the outcome of the procedure would be will not suffice to render a procedure professional. Suppose there is no scientific evidence or medical experience as to whether morphine fights colon cancer. If I request morphine from the physician because I believe, on non-scientific and non-medical grounds, that it fights colon cancer, the physician would not be acting professionally in granting my request. This is true even if my non-scientific and non-medical belief is justified, or even if it is knowledge, say because I know that an angel told me that morphine alleviates colon cancer. It is the physician's professional expectations as to the major sequelae of the procedure that are relevant to whether the physician should perform a procedure or prescribe medication, not the patient's beliefs. Professional medical practice, as it is generally understood in our society, requires both the actual or presumed or proxy informed consent of the patient and the physician's professional judgment.

Could one argue that a physician could kill a patient because she justifiably believes on non-professional grounds that this would be good for the patient? Perhaps the physician justifiably thinks she has an excellent philosophical argument against an after-life or a conclusive theological-cum-empirical argument for the claim that this patient, if killed, would go to heaven. Here, one needs to distinguish three questions:

8. Whether a procedure is or is not professional.
9. Whether a procedure is or is not unprofessional.
10. Whether a procedure is or is not morally permissible.

My argument, I think, does show that killing the patient is not a professional medical procedure. It does not immediately follow from this that it is unprofessional. For instance, reading a fun novel is not (typically) a professional medical procedure, but the physician who reads a fun novel is not behaving unprofessionally (typically). Possibly, however, when we add to (1) that the procedure is "by the physician in her medical role", then we can strengthen the conclusion of (1) to say that the procedure is unprofessional. Nonetheless, there is a further question whether the procedure is morally permissible or not. There might be times when it is morally permissible or even obligatory to violate professional standards (and then perhaps obligatory for any licensing body to take one's license away). Whether euthanasia constitutes such a case is a question I haven't addressed in this post. (Of course, I think euthanasia is always morally wrong, but I think this on grounds other than 1-3: it's wrong because it's an intentional killing of a juridically innocent non-aggressor.)

Euthanasia, patient autonomy and the physician's task

In this post, I am not going to distinguish between a doctor's "helping" a patient kill herself and the doctor's killing the patient herself, since in both cases the doctor kills, in the former case in concert with the patient and the latter alone. To help an assassin pull the trigger or aim the gun is to be a co-assassin. There are two different kinds of reasons given for allowing doctors to kill suffering terminally ill patients: care and autonomy. Those who focus on care base their argument on the patient's suffering and the physician's task in relieving that suffering. One difficulty with justing the euthanasia on such grounds is that once one sees euthanasia as a part of the physician's task of relieving the suffering, then it would become the physician's job to euthanize an incompetent patient (an eight-year-old?) who is suffering, terminally ill and yet begs to live, but where either no proxy is available or the proxy consents, just as it would be the physician's job to do life-saving surgery on an incompetent patient who resists the surgery. But even a lot of supporters of physician-assisted suicide will say that this is going too far.

Suppose instead that we base the killing of the patient on autonomy considerations: the patient chooses to be killed. Here, it is not clear what role in the justification is played by the fact that the patient is terminally ill and suffering, except maybe an epistemic role in providing evidence that the patient is not insane to request killing. After all, if the point is that people have the right to make deep decisions about life and death matters, then it seems that it would be equally the right of a patient who is quite well physically and mentally but who wishes to avoid creditors to request being killed by a physician, whereas surely this is not a request a doctor should accede to.

Now, a defender of euthanasia might object that a limiting condition on a physician's following of patient instructions is the good of the patient, and the person seeking to escape creditors would do better to declare bankrupcy than to be killed. Thus, just as on the first view, euthanasia was justified by care with consent being a limiting condition, on this view euthanasia is justified by consent with care being a limiting condition. However, this is problematic in a different way: It misunderstands the doctor's role. While those who took the first view were wrong in thinking that care calls for killing, they were right that care is the doctor's task.

Consider a surgeon who removes a malignant tumor. It would surely be very strange to say: "In order to honor the patient's choice to determine what is and what is not a part of his body, Dr. Magrodska removed Mr. Jones' tumor." Surely the right thing to say is that Dr. Magrodska removed the tumor because it was malignant, with Mr. Jones' consent being a mere necessary condition (and one that could be satisfied in other ways were Mr. Jones to be incompetent). Professionals are not servants of their clients' wishes, and physicians are professionals par excellance.

Now, there may be things that only a physician is qualified to do and which are done primarily as a response to the patient's wishes. Certain kinds of elective cosmetic surgery are such. But I think it is correct to say that in such a case the physician is not acting as a physician. Rather, she is acting as a medically-trained beautician. And even there she risks losing her status as a professional altogether if she does not act from a belief that the surgery makes the patient more beautiful. That a task requires medical training does not make the task a medical one (not that killing people painlessly requires medical training—see my previous post). Someone with medical training may be needed as consultant for a film set in a hospital—but such consulting is not a medical task.

There is thus a tension between the aspects of care and autonomy in the justification of killing terminal patients. If one focuses on care, then consent becomes a mere limiting condition and one arrives at abhorrent conclusions about killing vociferously protesting children. But if one focuses on autonomy, then physician-assisted suicide ceases to be a medical task.

Physician-Assisted Suicide

Derek Humphry wrote, as part of a defense of Physician-Assisted Suicide (PAS):

The help of a physician [in PAS] is imperative, because loved ones and family members untrained in the medical profession are rarely able to help a loved one to die [...].

This idea seems a standard part of the arguments for PAS.[note 1]

But there are four ways of reading "able" in "able to help": morally, legally, technically or psychologically, as well as combinations of these. Hymphry is presumably not claiming that family members are morally unable to help, that it is wrong for them to "help", since it would be really weird to suppose that medical training somehow gives one permission to kill when before the killing would be immoral. Nor is he claiming that unlike physicians they are legally unable to kill, for instance because they would be charged with murder, since the legality of PAS is precisely what is at issue, and if PAS is illegal, then physicians are also legally unable to "help".

Probably the best reading is "technically able to help", given the mention of training. But on that reading, the claim is false. There are many highly reliable methods of basically instaneously killing a person, at least if the killer has a normal amount of dexterity and physical strength. At the expense of some gruesomeness, let's briefly mention shotguns and large axes. One might object that in those cases, it is not a matter of helping but a matter of doing the whole job oneself. But it is easy to give the victim a role, say having the victim pull the trigger with a string.

Perhaps, then, we should read "able to help" as "psychologically able to help". On this reading, medical training makes it psychologically possible to kill. This is scary in that it makes medical training be akin to military training, a regime that makes one into someone who is not merely technically but psychologically capable of killing, overcoming our innate resistance to killing (on the latter topic, see this fascinating book by Rachel MacNair). Besides, if psychological resistance is the issue, one doesn't need a physician, just an able-bodied psychopath.

Maybe the best reading of the quote from Humphry is to combine the technical and psychological. The technical skills of the ordinary person, just much as those of the physician, make possible multiple relatively painless methods of killing, but these methods are messy, and are likely to be traumatic for the perpetrator. The methods available to the physician are neater. I think, though, there is a more perspicuous way of putting the difference: The methods available to the ordinary person make it look like the family member has killed a person, while the methods available to the physician make it look like a medical procedure has been performed. But once we formulate it in this way, it seems that the main "advantage" of the methods available to the physician is that they hide what has happened—the destruction of a human body. And that, in turn, is no advantage at all, since it hides from the moral imagination the truth of the situation, thereby skewing the decision.

Objection 1: Humphry could simply be worried about cleaning up after a killing committed with an axe or a gun.

Response: That seems unlikely. Besides, if mess is the issue, someone formerly in the special forces could surely be hired to do a neat and instantaneous job. Physicians are not the only people with technical skills for killing.

Objection 2: Being killed medically is more dignified than being killed with a gun.

Response: I simply do not see this. Why should being poisoned by an injection administered by someone in a white coat be more dignified than being shot dead? After all, we think of soldiers in wartime as dying with honor and dignity when they are shot by the enemy. I think the issue is not that being killed medically is more dignified, but that being killed medically hides the truth about what is happening. And dying in such a sneaky way is, if anything, less dignified.

Final comment: If I am right, then a major reason for PAS is a desire to make killing look less like a killing. And that desire is illegitimate if PAS is morally permissible. At the same time, I think the presence of that desire reflects something good: it reflects a revulsion at killing. But to kill the patient in a way that hides the destruction of the body is not the right way to respond to that revulsion. The right way to respond to that revulsion is to recognize the dignity of human life, and to care for rather than kill the patient.