Most people who defend physician-assisted death (PAD) endorse the Joint View, which holds that two conditions—autonomy and welfare—must be satisfied for PAD to be justified. In this paper, we defend an Autonomy Only view. We argue that the welfare condition is either otiose on the most plausible account of the autonomy condition or else is implausibly restrictive, particularly once we account for the broad range of reasons patients cite for desiring PAD, such as “tired of life” cases. Moreover, many of the common objections to an autonomy only view fail once we understand the extent of the autonomy condition’s requirements—in particular, the importance of one’s values for autonomous choices. If our view is correct, then the scope of permissible PAD is broader than is currently accepted in both the philosophical literature and the law and therefore poses an important challenge to the current consensus on justified PAD.
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Of course, this is just another way of describing the right of informed consent, which is most often grounded in autonomy but can also be grounded in welfare. There is perhaps a worry here about cases in which patients autonomously forgo this knowledge. This is an important question, but it is beyond the scope of this discussion.
That welfare and autonomy are treated as separate values in bioethics is at odds with the way many philosophers discuss well-being, which often includes some type of autonomy condition. For examples, see Mill 1859, Kymlicka 1989, and Wall 1998. Sumner’s own theory of welfare includes autonomy (Sumner 1996). Because of this, someone might object to our approach by claiming that we can’t avoid welfare. By treating autonomy and welfare separately, we are not ruling out this account of welfare, and these accounts are not at odds with our argument, given that they give significant weight to autonomy.
One might worry that this definition begs the question: a medical condition is just whatever relies on medical skills, but these are defined in reference to the conditions they are aiming to treat. But this is not the case. For one thing, as patients seek out doctors for various treatments of whatever sort, doctors might develop new skills—that is, the two concepts might, and probably do, co-evolve. Boorse and Hesslow advocate for revising the way medicine usually identifies itself as a healing profession. Their arguments, and ours, require a change in that perspective.
There are also pragmatic and legal reasons for a terminal-illness condition. Pragmatically, it might have a better chance of being passed into law (Young 2007). Legally, R.A. Sedler argues that the state’s interest in preserving life doesn’t apply to those with a terminal illness: “A ban on the use of physician-prescribed medications by a terminally ill person to hasten inevitable death does not advance any conceivable interest in ‘preserving life’” (Sedler 1993, 24). Because we are focused on the ethical justifications for PAD, we will set aside arguments of this sort.
Are doctors now to be given the right to make judgments about the kinds of life worth living and to give their blessing to suicide for those they judge wanting? What conceivable competence, technical or moral, could doctors claim to play such a role? Are we to medicalize suicide, turning judgments about its worth and value into one more clinical issue? Yes, those are rhetorical questions. (1992, 55)
Pace Callahan, the point of the Autonomy Only model is that it removes the need for physicians to make such judgements. Their gatekeeping role is narrowed to determining capacity.
One might worry that we are here abandoning our point about Autonomy Only being less ableist than the Joint View, insofar as Autonomy Only might still create barriers to access for those with less commonly accepted conditions or values. It may be true that in practice Autonomy Only still allows for certain ableist judgements of this sort. But it should be clear enough that Autonomy Only does better on this front than the Joint View, which counts in no small way in its favour.
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For their helpful feedback and discussion, we would like to thank the audience at York University, Steve Coyne, Wayne Sumner, and two anonymous referees for this journal.
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Davis, J., Mathison, E. The Case for an Autonomy-Centred View of Physician-Assisted Death. Bioethical Inquiry 17, 345–356 (2020). https://doi.org/10.1007/s11673-020-09977-8
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