Al Rabadi et al1 compare statistics on physician-assisted suicide (PAS) available from public databases for the states of Washington and Oregon and find similar profiles and trends, which is unsurprising given the similarity of the laws and demographic characteristics of these states. Among the unanswered questions are what such a study can contribute to medical ethics (about PAS or any other ethical controversy) and what the limits are of such work.
First, it should be noted that the medical literature is, in general, favorably disposed toward the empirical and the new. Although this predilection is often advantageous for scientific progress, it introduces a problematic bias when applied to ethical questions. The appeal of the study by Al Rabadi et al1 is that it is empirical, and by comparing data from 2 states for the first time, it can be considered novel. Because there are new reports each year and the practice of PAS is legal in only a few states, descriptive reports about PAS are published frequently. This means, however, that articles defending the ethical status quo (ie, against PAS) tend to be shut out of the medical literature because they are not reporting anything new and, therefore, cannot have any data. The result is an impression of growing acceptance of PAS, but it really represents an artifact of a scientific bias. . . . [Full text]
Daniel P. Sulmasy, Ilora Finlay, Faith Fitzgerald, Kathleen Foley, Richard Payne, Mark Siegler
It has been proposed that medical organizations adopt neutrality with
respect to physician-assisted suicide (PAS), given that the practice is
legal in some jurisdictions and that membership is divided. We review
developments in end-of-life care and the role of medical organizations
with respect to the legalization of PAS since the 1990s. We argue that
moving from opposition to neutrality is not ethically neutral, but a
substantive shift from prohibited to optional. We argue that medical
organizations already oppose many practices that are legal in many
jurisdictions, and that unanimity among membership has not been required
for any other clinical or ethical policy positions. Moreover, on an
issue so central to the meaning of medical professionalism, it seems
important for organized medicine to take a stand. We subsequently review
the arguments in favor of PAS (arguments from autonomy and mercy, and
against the distinction between killing and allowing to die (K/ATD)) and
the arguments against legalization (the limits of autonomy, effects on
the patient-physician relationship, the meaning of healing, the validity
of the K/ATD distinction, the social nature of suicide, the
availability of alternatives, the propensity for incremental extension,
and the meaning of control). We conclude that organized medicine should
continue its opposition to PAS.
Arguments against physicians’ claims of a right to refuse to provide tests or treatments to patients based on conscientious objection often depend on two premises that are rarely made explicit. The first is that the protection of religious liberty (broadly construed) should be limited to freedom of worship, assembly, and belief. The second is that because professions are licensed by the state, any citizen who practices a licensed profession is required to provide all the goods and services determined by the profession to fall within the scope of practice of that professional specialty and permitted by the state, regardless of any personal religious, philosophical, or moral objection. In this article, I argue that these premises ought to be rejected, and therefore the arguments that depend on them ought also to be rejected. The first premise is incompatible with Locke’s conception of tolerance, which recognizes that fundamental, self-identifying beliefs affect public as well as private acts and deserve a broad measure of tolerance. The second premise unduly (and unrealistically) narrows the discretionary space of professional practice to an extent that undermines the contributions professions ought to be permitted to make to the common good. Tolerance for conscientious objection in the public sphere of professional practice should not be unlimited, however, and the article proposes several commonsense, Lockean limits to tolerance for physician claims of conscientious objection.