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Is “aid in dying” suicide?

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Abstract

The practice whereby terminally ill patients choose to end their own lives painlessly by ingesting a drug prescribed by a physician has commonly been referred to as physician-assisted suicide. There is, however, a strong trend forming that seeks to deny that this act should properly be termed suicide. The purpose of this paper is to examine and reject the view that the term suicide should be abandoned in reference to what has been called physician-assisted suicide. I argue that there are no good conceptual or philosophical reasons to avoid the suicide label. I contend that intending one’s death is essential to the nature of suicide, and this intention is normally required on the part of the terminally ill patient when she knowingly takes a life-ending drug. Additionally, the analysis shows that any plausible strategy that avoids the term suicide is counteracted by the way in which advocates of the practice want to make it legal.

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Notes

  1. For some version of the claim that this should not be referred to as suicide, see, e.g., [1,2,3,4,5,6,7].

  2. To the best of my knowledge, the only writer who admits that his abandonment of the suicide term is merely for political reasons is Gerald Dworkin [8].

  3. See, e.g., Compassion and Choices (http://itsnotassistedsuicide.org) and the Campaign for Dignity in Dying (http://www.dignityindying.org.uk/assisted-dying).

  4. In the suicide literature, only Joseph Kupfer adopts a position that explicitly repudiates use of the term “suicide” in reference to what has been called physician-assisted suicide [9, p. 68]. However, a number of analyses seem to entail that (at least in many cases) the suicide label can be appropriately rejected for this practice [10,11,12,13,14].

  5. Some bioethicists think that there are good moral grounds for extending the right to die only to individuals who are terminally ill [15, 16].

  6. One could argue that (a)–(c) are necessary for suicide but not sufficient. In this case, one would need to supply one or more conditions that would be sufficient. Some possibilities are that the act must be morally wrong, that it must be non-coerced, that the agent’s death must not be imminent, or that the agent must seek death for its own sake. These conditions are considered and rejected below.

  7. This is true, at least, if genuine human action, including intention as a component, makes sense only under the presupposition of freedom [32, 33]. If, however, intention and necessity are compatible, then there would be no reason to deny that intention to die is absent when the agent could not do otherwise. See also the third and fourth sections below.

  8. See, e.g., the higher support over time for a physician’s help in carrying out TISK when the word “suicide” is omitted [34]. See also [35, 36].

  9. Similarly, some proponents of TISK who deny that TISK is suicide confuse common characteristics of suicide (e.g., that it is performed by people who are depressed, that it occurs in isolation from family and friends) with necessary or essential ones.

  10. United States laws permitting TISK require that the cause of death be recorded as the underlying illness rather than the fatal dose of drugs; in doing this, these laws attest to something that is, in fact, false.

  11. As Joseph Kupfer remarks, “In order for an act to be a suicide, … the agent must have the option of a rather indeterminate period of life” [9, p. 68].

  12. See, e.g., [18, p. 354; 21; 42].

  13. Cf. Michael Cholbi: “there does not appear to be grounds for restricting coercion only to interference by other people, since factual circumstances can be similarly coercive” [45]. Cholbi’s view here runs counter to most philosophical work on coercion (e.g., [43, 44]).

  14. My own view is that the principle of double effect can apply appropriately to these practices, which means in part that they should not be regarded as assisted suicide. Agents need not intend a patient’s death when they carry out such practices.

  15. Battin does not discuss in her article the difference between intending the means and intending the end.

  16. For a full defense of this view, see [49].

  17. These are the ostensible goals of the legislation anyway. In fact, however, the laws in the United States allow TISK even if a patient requesting it suffers from depression, provided the depression is not impairing judgment. At the time that the patient ingests the drug, which may be months after receiving the prescription, there are no parameters requiring or testing for patient competency.

  18. For these moves, see, e.g., [3, 10, 12, 13, 23].

  19. See, e.g., [51, pp. 45–47]; even Wayne Davis’s view is too strong, for instance, when he insists that intending that p “implies being glad or optimistic that p” [51, p. 45].

  20. This kind of counterfactual reasoning to determine agent’s intentions is a remarkably common mistake in the double effect literature; see, e.g., [52, p. 571; 53, p. 128; 54, p. 394].

  21. Edwin Shneidman, for example, argues that there is a spectrum of intentionality/lethality involved in distinguishing suicide from non-suicide [24].

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Acknowledgements

I presented an earlier version of this paper at The Romanell Center for Clinical Ethics and the Philosophy of Medicine Conference, University at Buffalo, July 2016; the Catholic University of America, February 2017; and the American Society for Bioethics and Humanities Annual Conference, Anaheim, CA, October 2018. I’m grateful to the audiences on those occasions for helpful feedback, especially to David Hershenov, Stephen Kershnar, Neil Feit, Jim Delaney, Travis Timmerman, and Eric Mathison. I also thank several anonymous referees for their instructive comments on previous drafts.

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Reed, P. Is “aid in dying” suicide?. Theor Med Bioeth 40, 123–139 (2019). https://doi.org/10.1007/s11017-019-09485-w

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