In medical ethics, there is a growing conflict between two important principles: autonomy and dignity. In an important way, autonomy and dignity are virtues derived from different worldviews. Autonomy owes much to the secular/materialist view of man, whose very existence is the product of an autonomous struggle for existence. Dignity owes much to the Judeo-Christian understanding of man, who is created in the image of God. Certainly there is overlap; advocates of autonomy obviously have some respect for dignity, and advocates for dignity have some respect for autonomy. But the differences in approaches to ethics are real, and are of great consequence.
The differences are particularly clear and important in the issue of physician-assisted suicide. Oregon has passed a law allowing physician-assisted suicide, and a similar statute was recently passed in Washington State. Physician-assisted suicide is even more common in Europe, with some nations such as Switzerland attracting ”suicide tourists”. Bioethicist Jacob Appel has even endorsed physician-assisted suicide for some healthy people who request it.
Proponents of physician-assisted suicide generally invoke autonomy as the primary justification for medical cooperation in suicide. Of course, the reality is that our autonomy is always constrained, given our nature. We are naturally constrained by many things, and autonomy must be understood in light of those constraints. There are really two kinds of patient autonomy in medical ethics: negative and positive.
Negative autonomy is the right to be left alone. The right to negative autonomy is radical, and is accepted by all bioethicists. The right of a competent adult to refuse medical care is universally acknowledged.
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Positive autonomy—the right to obtain a specific medical treatment-- is another matter entirely. All ethicists implicitly acknowledge that the right to positive autonomy is severely limited. A patient in my office with a brain tumor has a right to a very limited range of treatments. The options only include treatments accepted by the medical profession as appropriate to brain tumors. My patient has a right to brain surgery, or to radiation therapy, or to chemotherapy. He does not have a right to countless other medical treatments, such as amputation, antibiotic therapy, liposuction, a heart transplant, etc. Positive autonomy is profoundly constrained. It is limited by the judgment of the medical profession as to what treatments are effective and appropriate.
How does the medical profession decide what’s effective and appropriate? Clearly there are important implicit assumptions (life is good, health is good, pain should be ameliorated, benefits should outweigh risks, the dignity of the patient should be respected, etc). But notice what is not a part of the medical profession’s decision about effectiveness and appropriateness—autonomy. Respect for autonomy plays no role in the judgment of the medical profession as to the effectiveness and appropriateness of a medical treatment.
Ultimately, negative autonomy—the right of the patient to refuse treatment—is always to be respected, but positive autonomy is always a merely an assertion of choice among several treatments deemed appropriate by the medical profession. Positive autonomy is always really an exercise of negative autonomy on a limited list of options.
Patients have a right only to negative autonomy—a right to accept or refuse medical treatments appropriate to their illness. The medical profession decides what acts constitute appropriate medical treatment. Thus the assertion that physician-assisted suicide is a matter of patient autonomy is mistaken and even misleading. The issue of physician-assisted suicide has nothing to do with issues of autonomy; all patients have a right to choose among appropriate medical treatments—about this there is no debate.
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The issue of physician-assisted suicide hinges on whether or not killing is medical treatment. If killing is medical treatment, then patients who have a disease for which the medical profession has decided that killing is an effective and appropriate remedy have a right choose it. If killing is not a medical treatment, then patients do not have a right to choose it, at least as a part of their medical treatment.
The assertion that autonomy is an important factor in physician-assisted suicide is a phantom. “Autonomy’ conjures specters of freedom from compulsion, yet patients always retain the right to refuse medical treatment. And they never have the right to acts by physicians that are not medical treatment. In the debate over physician-assisted suicide, it is the status of killing as a medical treatment that is the issue.
Here’s my view: the intentional taking of innocent human life – one’s own or that of another— is never medical treatment, and is never ethical. There is no such thing as physician-assisted suicide. There is merely suicide, at times assisted. The profession of the accomplice is accidental to the act.
Suicide can be carried out quite effectively without medical assistance. We need not add pentobarbital to ropes, bullets, and bridges, none of which are medical instruments, either. Suicide isn’t a medical act, and assisted suicide has nothing to do with autonomy as understood in medical ethics. Autonomy is the right to refuse medical treatment, not the right to a non-medical act performed by a physician.
Advocates of physician-assisted suicide use ‘autonomy’ as a diversion from the real ethical issue—an issue that, if understood clearly by the public and by the medical profession—would end the cause of physician-assisted suicide:
Should we grant a medical imprimatur to killing?