Leading Tasmanian philosophers reflect on the dignity of all humans, the concept of autonomy and the fact that the dignity of the human person is not bound to their ability to be autonomous
Euthanasia and the issue of autonomy
Prof. Jeff Malpas and Prof. Norelle Lickess
Key Reasons why Euthanasia should never be legalised:
RE: Inquiry into Dying with Dignity Bill 2009 – submission from Prof Jeff Malpas and Prof Norelle Lickiss
How we approach end-of-life care and the manner of our dying is one of the most important questions for any society. In providing a submission to this Committee we bring two different perspectives – that of a philosopher working in the field of practical ethics and of a physician with a lifetime’s experience in clinical practice (Professor Lickiss is also making an additional submission more directly focused on her personal experience as a clinician). In the course of preparing this submission we have also consulted with some of the leading international figures in the area, including Professor Margaret Somerville of McGill University and Professor G. W. Hanks, of the University of Bristol (a past President of the European Association for Palliative Care), and we believe that the views we set out here are very much in accord with a developing consensus among many of those most closely involved in work in this area.
We acknowledge that there is an impression of widespread public support for a change in the law to allow certain forms of euthanasia including physician-assisted suicide. We believe, however, that the surveys that give rise to this impression should be treated with some care. The issues surrounding end-of-life care are complex, and not always well-understood, while for many people the topic is one that is fraught with fear and anxiety. Public debate has also bee subject to emotive and sometimes one-sided interventions from lobby groups on both sides in such a way as to lead to oversimplification of the issues at stake as well as a highly polarized set of responses.
Yet although the survey evidence on this matter should be treated with caution, it is notable that one feature of those surveys, which also appears in much anecdotal evidence, is the degree to which support for physician-assisted suicide reduced according to the degree to which individuals are more closely and regularly involved in end-of-life care. This is a particularly important consideration for two reasons: first, because individuals involved in end-of-life care are precisely the individuals one might expect to be most directly familiar with the issues and circumstances surrounding end-of-life decision-making; and, second, because these are also the individuals who might be called upon to administer assistance should physician-assisted suicide be made legal (the alternative, which is to use specialist physicians, raises additional concerns of its own).
Sometimes evidence has been cited in support of the case in favor of physician-assisted suicide based on the reported incidence of physician-assisted suicide. Once again, we believe that survey evidence in relation to this matter should be treated with some caution, but we would also argue that its relevance to the case for or against physician-assisted suicide is not al all clear-cut. Rates of reported physician-assisted suicide may well vary according to social and other circumstances, and yet the incidence of physician-assisted suicide is surely no more relevant to the ethical acceptability of the practice than is the incidence of burglary, or of any serious crime, relevant to its criminality. A high reported rate of physician-assisted suicide should certainly be a concern, but it cannot be taken unequivocally to support the case for or against legalization.
Much of the argument regarding euthanasia and physician-assisted suicide can be construed in terms of the tension between an insistence on the importance of individual choice and autonomy, often fairly narrowly conceived, and concerns about the broader social and interpersonal consequences of such choices. We believe that there are important questions concerning our conception of individual and social good that are at stake in this discussion. It is easy, however, to overstate the tension between individual autonomy as against social good.
There can be no doubt that respect for individual choice is a key element in societies such as ours, and the experience of suffering may well lead individuals to express a desire to die or to be killed. Choices are, however, often inconsistent with one another, and the prioritisation of individual choice is no such a clear-cut principle of decision-making as it may appear. One of the central problems with the legalization of euthanasia or physician-assisted suicide is that such legalization may itself lead to changes in the choices available to individuals at the end of life, for instance, through certain choices becoming more salient than others. Thus one important report on this matter concludes (in a way that echoes many other such reports): “If euthanasia is legalized in any society, then the potential exists for: (i) pressure on vulnerable persons; (ii) the underdevelopment or devaluation of palliative care; (iii) conflict between legal requirements and the personal and professional values of physicians and other healthcare professionals; (iv) widening of the clinical criteria to include other groups in society; (v) an increase in the incidence of nonvoluntary and involuntary medicalized killing; (vi) killing to become accepted within society.” In this respect, while one may take issue with the strong and sometimes simplistic emphasis on the narrow conception of individual autonomy and choice that often underpins the argument for the legalization fo euthanasia and physician-assisted suicide, one can also view such legalization as itself having the potential actually to compromise certain possibilities for choice and to limit aspects of autonomy.
End-of-life decision-making does not involve only the autonomy or right to choose of one person alone, and individual choices do not occur in isolation, but instead ramify outwards encompassing a network of other persons, other decisions, and other choices. Moreover, every death has an effect on those who are agents in or witnesses to it, and the manner of an individual’s dying can itself be enormously affecting to those involved in that death. While there is a clear ethical imperative to try to alleviate the often intolerable suffering of the dying individual, and this is an key motive in the proposal to legalize physician-assisted suicide, we should not ignore the different forms of suffering that may be experienced by those who are witness to that dying, and that may well continue well beyond the even in question. Moreover, the effects at issue are not always emotional alone, but may also extend into the attitudinal and dispositional. The fact that the act of killing or assisting in such killing can itself cause serious harm and distress for those involved is something that is itself directly tied to the value placed on human life and the prohibition against the taking of such life – and as we know from the experience of war, the reduction of the feeling of distress at the involvement in the taking of another’s life can itself lead to a reduction in the value placed on human life and in the force of the prohibition against taking it, and vice versa.
There can be no doubt that the redress of suffering constitutes a key ethical imperative, and yet the redress of suffering is itself a complex demand, and also one that can never be completely fulfilled – certainly not by physician-assisted suicide or euthanasia, nor, it must be acknowledged, by the best of palliative care. Recognition or our inability to bring suffering completely under our control is perhaps the most difficult and yet also one of the most important steps in our being able more adequately to address issues of end-of-life care and decision-making. The desire for completeness of control is, we would argue, one of the most problematic, and also one of the deepest motivations in the argument for physician-assisted suicide and euthanasia, as well as perhaps the least recognized or well-addressed. It is a desire impossible to fulfil, whose pursuit may well give rise to suffering as much as relieve it.
There is certainly a need for us better to address issues of end-of-life care and decision making. We do not believe, however, that the legalization of euthanasia or of physician-assisted suicide would constitute any advance in this respect, but would actually be a step backwards. There is, however, an opportunity for Tasmania to take a lead in this general area. Instead of making it easier for individuals to kill themselves, we argue that it should be made easier for patients to ensure that they receive end-of-life care that is appropriate to their own commitments and values.
The EAPC report from which we quoted above also contains as one of its conclusions the following: “Within the modern medical system patients may fear that life will be prolonged unnecessarily or end in unbearable distress. As a result euthanasia or physician-assisted suicide may appear as an option. An alternative is to take action through the use of ‘living wills’ and advance directives contributing to improved communication and advanced care planning and thereby enhancing the autonomy of the patient.”We believe that the use of some form of advance directive (understood as a form of pre-emptive refusal of consent) and advanced care planning may provide the best means to address the underlying issues of appropriate end-of-life care (this is also discussed in Professor Lickiss’ separate submission). This could be facilitated through the development of an established and institutionalized framework to make it easier for advanced care planning to be undertaken even before individuals are affected by serious illness or debility, and through ensuring that health care professionals are familiar with the advanced care planning process and are committed to ensuring that patients wishes in terms of end-of-life care are respected.
We thank you for the opportunity to make this submission and would be very happy to provide any additional advice or information that may be required.
Prof Jeff Malpas
Professor of Philosphy and ARC
Professorial Fellow, University of Tasmania
Distinguished Visiting Professor,
La Trobe University
Prof Norelle Lickess
University of Sydney
Senior Staff Specialist,
Royal Prince Alfred Hospital, Camperdown
Consultant Emeritus, Royal Hospital for Women, Randwick
Other studies have also made the same observation – see, for instance, Lars Johan Masterstvedt, David Clark, John Ellershaw, Reidun Førde, Anne-Marie Boeck Gravgaard, H. Christof Müller-Busch, Josep Porta I Sales and Charles-Henri Rapin, “Physician-Assisted Suicide: a View from an EAPC Ethics Task Force”, Palliative Medicine, 17.2 (2003), p99: “Studies of attitudes to euthanasia and physician assisted suicide among professionals, patients and the wider public as well as studies of their experiences of these issues may inform the wider debate. Most of these studies, however suffer from significant methodological weaknesses raising doubts about the evidence base. A more co-ordinated approach to these studies is recommended”.
See for instance C. Seale, “Legalisation of euthanasia or physician-assisted suicide: survey of doctors’ attitudes”, Palliative Medicine, 23.3 (2009), p.208 – a copy accompanies this submission.
One of the most recent surveys of this matter suggests that rates of physician-assisted suicide are more common in the Netherlands, Belgium and Australian than in the UK – see C. Searle, “End-of-life decisions in the UK involving medical practitioners”, Palliative Medicine, 23.3. (2009), p. 198.
http://www.eapcnet.org/projects/ethics.html. Since June 2003, this paper has been taken as setting out the official position of the European Association for Palliative Care (EAPC) a copy accompanies this submission. Lars Johan Materstvedt, David Clark, John Ellershaw, Reidun Førde, Anne-Marie Boeck Gravgaard, H. Christof Müller-Busch, Josep Porta I Sales and Charles-Henri Rapin, “Physician-Assisted Suicide: a View from an EAPC Ethics Task Force”, Palliative Medicine, 17.2 (2003), p7-101 – the paper as well as extensive commentary and discussion is available at
“Physician-Assisted Suicide: a View from an EAPC Ethics Task Force”, p.99.
Significantly, this is similar to the course suggested by Professor Margaret P. Battin (Distinguished Professor, University of Utah) as being the most fruitful way forward in the face of the highly polarised nature of much of the public debate – see Margaret P. Battin, “Euthanasia and Physician-Assisted Suicide”, Hugh LaFollette (ed), The Oxford Handbook of Practical Ethics (New York: Oxford UP, 2003), pp. 697-699.
Jeff Malpas is Professor of Philosophy at the University of Tasmania and Distinguished Visiting Professor at LaTrobe University.
Jeff established the Centre for Applied Philosophy and Ethics at the University of Tasmania in 2000 (now the Inglis Clark Centre) and has long been active in public debate on a wide range of ethical issues.
He is the author or editor of many books, and over a hundred articles and other works. His most recent book, Heidegger and the Thinking of Place appeared with MIT in 2012.
Growing up in NZ, Jeff completed his PhD at the ANU, held positions at the University of New England and Murdoch University before coming to Tasmania, and has also been a Humboldt Research Fellow at the Universities of Heidelberg, Munich and Freiburg.