March 08, 2004

Physician-Assisted Suicide

Mark A.R. Kleiman trashes an argument against physician-assisted suicide by Leon Kass (scroll down to the Update). MARK is right that the argument has a hole, but I think it might be possible to fix it.

The argument, in paraphrase, is: If your physician can help to kill you at your request, your physician might pressure you into authorizing her to do so. If you are on guard against this possibility, you will be constrained about the information you reveal to the physician. This would corrupt the doctor-patient relationship. Therefore, a doctor should never help to kill her patient, even if requested.

MARK points out that nothing in this argument rules out another physician's assisting the patient's suicide. Fair enough. But perhaps we can argue--in order to be able to assist a patient's suicide, a physician must be in contact with the patient, and know her record. Therefore, a doctor should never help to kill a person with whom she does not have a doctor-patient relationship.

This problem might be solved if the patient's physician recommended another doctor to assist in the suicide, but then the recommendation itself would be subject to Kass's original argument.

So we'd have a dilemma here for physician-assisted suicide. It's unacceptable to perform it for someone who is your patient, and it's unacceptable to perform it for someone who isn't your patient. This is similar to a dilemma that I've occasionally found convincing about the death penalty: It's unacceptable to forbid the jury to take into account the particular circumstances of the crime (because death should be reserved for the worst crimes), and it's unacceptable to allow the jury to take into account the particular circumstances of the crime (because it opens the door to prejudice, as can be seen in the statistics cited in McCleskey v. Georgia I think it is.)

Just to place this firmly in the realm of abstract argument:

(1) I don't find Kass's original argument convincing. It seems to me that the same argument might apply to a physician's power to recommend that the patient be committed to a mental institution, or that the patient move to a nursing home, or something. If you don't already think assisted suicide is outside the realm of medicine, I don't see why you should accept Kass's premises. (Though I am inclined to oppose assisted suicide on the grounds that it would be could lead to abuses under cost-cutting pressure from insurance companies. I'm not sure if I've just contradicted myself.)
(2) I see no reason to doubt MARK's assessment of Kass's character. He was there, I wasn't, he reports others as having agreed, and the response he quotes from Kass is sophistical and inadequate.
(3) At the moment I'm not actually opposed to the death penalty in the U.S. It seems to me that the death penalty can be appropriate when the prison system is so porous that you can't guarantee that someone will stay in prison. The recent New Yorker article on the Aryan Nations prison gang makes it sound as though something similar is going on--the gangs have taken over the day-to-day running of the prisons to the extent that life in prison won't work as a punishment. Responsibility for this lies in part with the people supervising the prisons, but as the prosecutor says at the end of the article, there doesn't seem to be any way to combat this without putting the prison gang leaders to death. This still leaves about 95% of executions unjustified by my lights.

Posted by Matt Weiner at March 8, 2004 12:47 PM

Your criticism of Kass's argument does not work--if anything, you seem sympathethic to Kass's view in the following way. Kass's argument is that physician assisted suicide (PAS) is wrong because it is vulnerable to corrupting physicians in that they will no longer be acting in the best interests of their patients. Instead, they will encourage their patients to choose PAS, and this is often for cost-saving reasons. This criticism of PAS seems to be an instance of the more general point that physicians will be manipulating vulnerable persons who are already worse-off or disadvantaged, people who ought to be protected. Your comments regarding why we should not accept Kass's premise are things that Kass would willingly endorse--that physicians can wrongly coerce patients into nursing homes, mental institutions, etc. The case of PAS is just another instance of physician's wrongly asserting their authority. It is just especially problematic in the case of PAS because they will be dead at the end of it, being (arguably) REALLY worse off. So if you feel that PAS might be wrong because of financial incentives from insurance companies, your worry complements Kass's concern with PAS nicely.

Posted by: Linda Fiorentino at March 9, 2004 09:35 AM

Hi Linda!

My criticism of Kass's argument is that it potentially proves far too much. The physician might pressure the patient into choosing PAS for cost-saving reasons; but a physician might conceivably refuse to recommend needed surgery for cost-saving reasons as well (and this wouldn't be mere pressure, it would probably be impossible for the patient to get the surgery without the recommendation)--or coerce the patient into unnecessary and possibly life-threatening surgery for financial reasons. This doesn't mean that physicians shouldn't be in the business of recommending surgery or not, but that they shouldn't be coercing their patients, and that preferably safeguards should be put up against that coercion.

(I favor single-payer insurance on independent grounds; this might reduce the incentive to coerce patients, but it might not.)

Note that it doesn't follow from Kass's argument that PAS is always a case of physicians wrongly asserting their authority; that requires proving that PAS is always an inappropriate procedure, as well as a claim that it always results from the physician's authority. So the fact that physicians might sometimes abuse their authority with respect to PAS doesn't entail that they should never be able to participate in PAS, any more than the fact that they might sometimes abuse their authority with respect to other procedures means that they should never be able to participate in those procedures.

In the original argument as described by Kleiman, Kass draws an analogy with seducing a patient. This seems to me inapt; seducing a patient is something outside the doctor-patient relationship, while PAS's advocates would argue that it is part of the doctor's treating the patient.

I am sympathetic to the idea that death is so singular that the danger of coerced PAS is something that should especially be avoided. But that isn't the argument Kass seems to be making.

Posted by: Matt Weiner at March 13, 2004 11:08 AM