TOPICS > Health

Medical Ethics and the Right to Die

April 8, 1996 at 12:00 AM EDT


MARGARET WARNER: Now, two views on the ethical dimensions of doctor-assisted suicide. Margaret Battin is a professor of philosophy at the University of Utah, where she also teaches in the division of medical ethics. Mark Siegler is a practicing physician and director of the Center for Clinical Medical Ethics at the University of Chicago. Welcome both of you. Peggy Battin, you have endorsed these tworecent court decisions. Why is that?

MARGARET BATTIN, University of Utah: (Salt Lake City) I think they’re to be celebrated as real recognitions of basic civil personal rights. I think we should all sleep a little easier knowing that if we were ever in these circumstances, uh, we could call for this if we ever really needed it.

MARGARET WARNER: Dr. Siegler, how do you see it?

DR. MARK SIEGLER, University of Chicago: (Chicago) I fear that these decisions are very dangerous for both patients and for our society, Ms. Warner.

MARGARET WARNER: And what do you mean, dangerous?

DR. SIEGLER: Well, I mean that they set dangerous precedents of permitting or at least weakening the prohibitions against private killing, something that most civilized countries have not tolerated since the Middle Ages. And even though it’s done in a medical context, private killing is, is wrong, and very difficult to control, and is subject to many abuses. And I fear that these court decisions have opened the door to permitting assisted suicide and I think also euthanasia.

MARGARET WARNER: Peggy Battin, how do you respond to those concerns?

MS. BATTIN: Well, in the first place, we’re not talking about private killing in the sense that anybody who has a vengeance or some bone to pick with somebody else can simply up and off them. We’re talking about a situation in which patients who have reached what they regard as the end of the line can arrange with their physicians under a set of really careful controls to meet death in what they regard as the easiest, least worst way.

MARGARET WARNER: Dr. Siegler, what about Petty Battin’s main point, that this is a question of sort of personal freedom and, and that, that patients deserve to have this freedom to make this decision themselves?

DR. SIEGLER: It’s a powerful point, and, and I’m extremely sympathetic to the rights of people to make their own health care choices. Uh, I merely say that there ought to be limits on, on those rights. There are always limits on most of the things we do in life, and when we’re talking about breaking down barriers that have existed in every civilized country, umm, I’m desperately worried. I’m worried for my patients. I’ve practiced medicine for almost 30 years now, and I’d like to think of myself as being someone who respects my patients’ wishes and attends to their needs. And occasionally in my practice, I’ve cared for dying patients who have at one time or another asked for assistance with suicide. That’s often a cry for help. It often indicates that pain management is not adequate, that counseling is not adequate, or sometimes even that the patient is profoundly depressed and needs help in that regard. It, in my practice at least over the 30 years, I’ve never had a sustained request for a patient who wanted to be assisted with suicide or to be killed. Now, I read about some patients, and I often fear that it’s failures of adequate care that they have received along the way, rather than assertions of, of libertarian rights claims.

MARGARET WARNER: Peggy Battin, do you think Dr. Siegler could be right, that, that really in most cases even patients who think they want to end their lives could have their pain addressed in other ways as we saw in the taped piece and as Dr. Siegler is saying?

MS. BATTIN: Well, I certainly think that we could do a better job of pain control. There is a substantial amount of evidence that we don’t do it as well as we could. And I, even a report from Susan Tolle’s group suggests that we’re improving in our techniques of pain care. Hospice deserves a lot of credit here, however, pain can’t always be controlled, and even if it could be controlled, there are some people who are patients who simply don’t wish to endure that last downhill course or all of the tail end of it, so that they would prefer to avoid that rather than waiting until they found themselves in which, in a position in which they had very little remaining control over what happened to them.

MARGARET WARNER: Dr. Siegler, do you–what about that point, that there are patients who just don’t want to go through that final several months?

DR. SIEGLER: And I’m deeply sympathetic to them. I want you to note, however, that such people might not always be terminally ill patients for whom the laws seem to apply at this point. I mean, you may have people who fear that they’re suffering all the time, or that they’ve lost their sense of dignity, or they’re always unhappy, uh, who may claim the same right that the courts have now accorded to terminally ill people, and that is the right to be assisted with dying. I’m very worried that the class of people will rapidly expand, but even while acknowledging that such people do exist, I don’t think that we should take the chance of legalizing assisted suicide and euthanasia that’s likely to follow to meet the needs of that small group. They can often find appropriate care from physicians who are sympathetic to their needs. Those physicians, if they assist such patients, have never been subjected in this country to prosecution. Prosecutors have used considerable discretion in acknowledging the rights of patients and doctors to reach certain agreements between themselves. But legalizing this is going to trivialize it. It’s going to expand it widely for large numbers of people who may not want this so much, particularly, I’m deeply afraid of the vulnerable populations, the poor, the uninsured, the disabled, the mentally and physically incapacitated, racial and cultural minorities. They’re the people who will have most to fear from this policy, not the civil libertarians who have one more right. I’m sorry, but the exit polls on the West Coast demonstrate consistently that the people who are most against assisted suicide tend to be the elderly African Americans, Asians, and women, interestingly enough. Those in favor tend to be young men, people in control of their life, who are successful. I’m worried about the vulnerable populations who will be affected by, by the legalization of assisted suicide.

MARGARET WARNER: Peggy Battin, speak to that point if you would, this idea that you could move to a slippery slope where you really end up having involuntary euthanasia of people who are the most vulnerable.

MS. BATTIN: Notice what, first what Dr. Siegler is recommending, that there will still be room for private arrangements between physicians and their patients. He said something about, un, physicians who are sympathetic to the needs of their patients, umm. He’s worried about legalization, but he seems to make no case about stopping the practice. Now we’ve just seen data that the practice is occurring. Every study with which I’m familiar shows that there is a substantial practice. Umm, as far as the slippery slope goes, you have to remember that physician-assisted suicide is just one option for meeting the end of one’s life. Uh, the other options are, of course, continuing aggressive treatment but also stopping treatment, discontinuing treatment already in progress, or not starting treatment that’s in–that could be put in progress, discontinuing nutrition and hydration, either artificial or ordinary, turning to permanent sedation, a policy recommended by some parties to this discussion.

MARGARET WARNER: And let me just interrupt. Your point is that much of this is legal already?

MS. BATTIN: Much of–all of what I’m discussing now–

MARGARET WARNER: Is already legal.

MS. BATTIN: –is currently legal and practiced.

MARGARET WARNER: Dr. Siegler, speak–

MS. BATTIN: Let me add one more.



MARGARET WARNER: Let me just finish this one point, and then I’ll come back to you. Dr. Siegler, speak to that particular point, because this is what the court in New York said, that there are already all these other measures doctors may legally do, such as withdrawing life support, artificial feeding, and hydration, and that there’s really no difference between that and then letting–giving the patient drugs to actively end their life.

DR. SIEGLER: And for many years, uh, that distinction between killing and letting die has been a gray line, and the New York court in one step obliterated that gray line and in doing that, I really fear that, that chaos will ensue. It may seem like a subtle distinction, but let me give you one very important implication of obliterating that distinction. The people who are potentially susceptible to having life support withdrawn at any particular moment are only those who require life support to be on board to begin with. They’re a relatively small number of people in the population. By contrast, all of us, everybody is potentially at risk if you have a public policy that permits active assistance or active intervention to hasten death, i.e., anybody coming to an emergency room or being at a hospital.

MARGARET WARNER: So you’re saying that there is an important distinction between letting “nature take its course,” i.e., taking someone off artificial life support, versus actively intervening to hasten a death?

DR. SIEGLER: I think there’s not only philosophical and ethical and clinical distinctions, there’s a very important policy distinction in terms of which people are vulnerable or susceptible to the intervention. And the number, the number multiplies rapidly.

MARGARET WARNER: Peggy Battin, speak to that point, that he’s saying there is a difference between the two.

MS. BATTIN: He seems to forget that we’re talking about a policy which would, umm, by statute only respect documented voluntarily choices. So the specter of somebody coming into an emergency room and being somehow pushed into, umm, assisted suicide is just simply not reasonable. We’re talking about time delays, we’re talking about a set of protections, including repeated documentation, uh, that just makes the scenario he’s describing, uh, not at all plausible.

DR. SIEGLER: Professor–

MS. BATTIN: As far as the slippery slope goes, the real point is that the argument that Dr. Siegler is making suggests that we are now at the top of the slope and should worry about stepping out onto it. The real truth is that we are already on that slope and the question is can we get ourselves back up to the top? The practices I was starting to enumerate include also the over-use of opiates, umm, opiate sedation, in a way that is legally permitted and also incidentally permitted under the teachings of the Catholic Church, provided it is done in a way that is intended to treat pain, though it is foreseen, though not intended that it will cause death. Well, if you think it is a safe practice to excuse your physician from causing your death because that physician gave you pain medication which would kill you by depressing respiration, although he or she claims that he didn’t intend to cause your death, that’s not a safe situation. That’s a situation in which all the groups which Dr. Siegler enumerates are at far greater risk than if the practice of assisted suicide is made legal, is brought out into the open, is practiced only under careful–careful restrictions. So I think–

MARGARET WARNER: All right, let me–

MS. BATTIN: –the case for preventing abuse is much stronger with legalization than without it.

MARGARET WARNER: Dr. Siegler, address that point, i.e. that you, yourself, acknowledge this already goes on and what Peggy Battin is saying is in a way that’s not only hypocritical or potentially more dangerous than having it out in the open and having guidelines and so on.

DR. SIEGLER: I think the practice may go on at an extraordinarily low level. I think legalizing it is going to generalize it to large numbers of people in the population. It’s going to expand it in ways that we’ll not be able to control. It will be subjected to far more abuses than currently exist. I’m not happy with the way it’s going on right now. I mean, if it were left to me, I would say that while doctors and patients might agree between themselves that the doctor will supply the patient with enough medication perhaps for the patient to kill himself or herself, it ought to be regulated first by being looked at in advance by a committee of professionals and lay people and even perhaps getting some prior judicial review, and secondly, it ought to be looked at retrospectively in a public arena so that these actions are not done in private.

MARGARET WARNER: Dr. Siegler, thank you so much, and Peggy Battin. I’m afraid we’ll have to leave it there.

DR. SIEGLER: Thank you.