Ethics of Assisted Death: Part II

by Rebecca Gagne-Henderson PhD APRN ACHPN

Those who argue for assisted death do so without a thorough examination of all the ethical implications associated with this practice, and the ramifications it will have for the individual, the clinician, and society.

The most frequently cited ethical principle in the argument for assisted death is Autonomy. According to Beauchamp and Childress “Personal autonomy is, at minimum, self-rule that is free from both controlling interference by others and from limitations, such as inadequate understanding, that prevent meaningful choice” (1).  This definition is specific to medical decisions. Note that the definition does not require the action of another individual. What is it when an individual, in the name of their own autonomy asks another to participate in an abhorrent act?  One must recall that most people enter into these agreements to end their lives before they are suffering.  Rather than a call for mercy, it is a hubristic, selfish and narcissistic act in the folly of gaining control over death.  

Throughout time immemorial, murder has been condemned by every civilization. Under the common law murder is the unlawful killing of a human being with malice aforethought. In addition, under common law, manslaughter is unlawful killing without the intent to kill…INTENT…, there’s that word again. One could say this is a distinction without a difference; however, In CT, murder is codified as causing a person to commit suicide by force, duress, or deception (CGS section 53a-54a). Since 1969, in the state of CT, intentionally causing or aiding a person, other than force, duress, or deception, to commit suicide is classified as second-degree manslaughter (CGS section 53a-56). With the stroke of a pen, legislators will likely, arbitrarily change one of society’s most abhorrent crimes into a medical intervention.

This requires a definition of the word malice.  In a world holding to a principle as old as time and across all cultures that murder is bad, killing a person is evil, that is if you “believe” anything can be evil. Malice is frequently defined as “the threatening to do evil”.  That is the definition I have chosen for this post.  In a post-positivist world, killing could be interpreted as good or bad. If killing a person to end suffering is “good”, does it remain good if there exist alternatives to the killing?  What if we could provide excellent symptom management?  In the very rare instance when symptom management was not optimal, there is also the argument for palliative sedation.

The individual who believes providing the lethal drugs is a “good killing” may not be aware that they are not only threatening to do evil but are participating in evil. They have performed a type of mental Jujitsu to rationalize an act of Utilitarianism using the argument that it is in the interest of the patient’s autonomy. The opposite of autonomy is paternalism. That being another person interfering with your self-rule. In that case, each and every law is, by definition, paternalistic.  It is also true that most laws exist to protect other individuals and society from the action of others. Therefore, the question requiring reflection is “but what if their self-rule harms others”?  From the scientific literature and sociology, we know that suicide affects more than the person ending their own life.  

Suicide has never been considered a medical act. It has been a crime and a tragedy. Suicide has been associated with mental illness (2).  The keyword here is ILLNESS.  In fact, those with mental illness have a 15 fold incidence of suicide (3). It is a pathology, not a reasoned decision.

The literature shows that suicide does not occur in a vacuum.  What the science reveals is that when one commits suicide it is not infrequently followed by clusters of suicide, amongst friends, peers and family. Therefore, suicide is considered a contagion and has societal consequences (4-6).  This reckons back to the words of Aquinas: “…natural or moral rectitude in human actions is not determined according to what happens per accidens in one individual but according to what results for the whole species” (7).  (I highly recommend this cited article.  It is excellent and accessible.)  The theory of human rights leads us directly back to Aquinas as does much of Western thought (8). Western thought has been challenged over the past 200 years by German philosophy all springing from the work of Kant in the 1790s (9).  This thinking which embraces “the spirit of the age” has led to socialism, communism, eugenics, collectivism and euthanasia (10).  Not all German thought has been destructive. After all, where would we be without kindergarten?  In all seriousness, German philosophy is an unattainable idealism that disregards the nature of humankind, as well as liberty.

Back to the topic of suicide. We also know that what leads one to suicide is a condition of despair or demoralization. Demoralization has been studied for several decades in palliative care, and in the psychiatric milieu since the 1970s. It has been distinguished from the garden variety depression. It is known as an “expression of existential distress, demoralization is characterized by feelings of hopelessness and helplessness due to a loss of purpose and meaning in life” (11). 

Viktor Frankl, the Holocaust survivor who studied the existential purpose of life, developed the therapy known as logotherapy, and wrote the book Man’s Search for Meaning, describes despair as “the absence of meaning”.   What we know about demoralization is that it is a frequent and natural response when we encounter, face to face, and up close, our own finitude.  Facing impending and imminent mortality means there is little time left to meet the goals we have set for ourselves. We must say goodbye to the people we love and value, and we must face a frightful thing…the unknown.  Frankl also wisely said that “Those who have a ‘why’ to live, can bear with almost any ‘how’” (12).

It is also of the utmost importance that demoralization has been linked to suicide. Equally important is that the state of demoralization can be addressed through good palliative care and counselling. This process is known as Remoralization. How much better to die having spent time reviewing one’s life, developing a sense of meaning than cutting the tie to this mortal coil too soon. I have seen the process of Remoralization many times over the course of my career working with the dying.  My next blog will be an illustration of how this can happen by relaying a story of such a patient.

An argument from the pro-AD advocate would be, “but what if they don’t want to participate in Remoralization?”  My answer is that most people don’t know that Demoralization exists and that there is help for the condition.  Rather than encouraging the Final Exit, which is a form of abandonment, our efforts would be better spent helping one to find their meaning before they leave us.  Once they leave, they will have all the answers to every mystery of life.

1.         Beauchamp TL, Childress JF. Principles of biomedical ethics. . U.S.A.: Oxford University Press; 2001.

2.         Windfuhr K, Kapur N. Suicide and mental illness: a clinical review of 15 years findings from the UK National Confidential Inquiry into Suicide. British Medical Bulletin. 2011;100(1):101-21.

3.         Harris EC, Barraclough B. Suicide as an outcome for mental disorders. A meta-analysis. British Journal of Psychiatry. 1997;170:205-28.

4.         Cheng Q, Li H, Silenzio V, Caine E. Suicide contagion: A systematic review of definitions and research utility. PloS One. 2014;9(9).

5.         O’Carroll PW, Potter LB. Suicide contagion and the reporting of suicide: Recommendations from a national workshop. Morbidity and Mortality Weekly Report. 1994:9-18.

6.         Walling MA. Suicide Contagion. Current Trauma Reports. 2021;7(4):103-14.

7.         Coleman GD. Assisted suicide: an ethical perspective. 1987;3:267.

8.         Lisska AJ. Human rights theory rooted in the writings of Thomas Aquinas. Diametros. 2013;38:134-52.

9.         Bowie A. Introduction to German Philosophy: From Kant to Habermas: Polity Press; 2003.

10.       Gagne-Henderson R. The Palliative Provocateur [Internet]2022. Available from: https://palliativeprovocateur.com/.

11.       Robinson S, Kissane DW, Brooker J, Burney S. A review of the construct of demoralization: History, definitions, and future directions for palliative care. American Journal of Hospice and Palliative Medicine. 2016;33(1):93-101.

12.       Frankl VE. Man’s search for meaning: Simon and Schuster; 1985.