A terminally ill man requests that his life be brought to a peaceful end by the doctor overseeing his care. The doctor, an atheist, regretfully declines. The patient, unsatisfied by the answer and increasingly desperate for relief, presses the doctor for an explanation. During the ensuing dialogue the philosophical, ethical and emotional arguments brought to bear by both the doctor and the patient are dissected.
- physician-assisted suicide
- end of life
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The ongoing debate about euthanasia stimulates humankind to look intensely and deeply into itself, but it is a debate that is rarely conducted between the parties most closely involved; those who want to die and those who might provide the means. By the time patients are in extremis they may no longer have the ability to make a case, although it is quite possible that in their muted thoughts they wish only to die. Instead, the argument is conducted at a philosophical level, and at a safe remove from the kind of distress that stimulates the argument in the first place. It is possible that at such a distance the correct approach to this matter, and the most appropriate legislature, cannot be made. By way of a dialogue, in which philosophical arguments are tainted by personal bias and the power of the immediate, I have tried to close this distance. In this way issues unique to the suffering of the patient and the anxiety of the doctor can be contrasted with oft quoted, but perhaps over generalised ethical principles. It is for the reader to judge which party proves most compelling.
Scene: Patient and doctor in a side-room.
P. You have the ability to end my life peacefully, please do.
D. I'm sorry, I cannot do that.
D. It's against the law.
P. We both know that what is legal and what is right are not the same thing. Right is universal, but laws change across every border in the world. They are just the best approximation to what is right, as perceived by the societies that produced them. Let's not waste our time with the law. Imagine that you could do what you please, what you think is right, and tell me, why will you not end my painful, joyless life?
D. Right is universal, as you say, but there is no definition of right. I can only adhere to what I think is right, and I think it is fundamentally wrong to end life.
P. Fundamentally! You know nothing of the fundaments, of our world and our universe. To say you do would be unbelievably arrogant. You cannot comment on the fundaments.
D. Then I feel it would be wrong.
(Sanctity of life)
P. That is better. You feel it. That is a reason. Now explain to me, why?
D. It's the enormity of it. Human life, and its meaning, its purpose, is so great a mystery that I cannot be sure what it is I would be destroying. Without life there is no thought, and without thought there are no attempts to comprehend and order the universe. If we have a meaning it seems to be just this, to try to comprehend. Our existence may well have come about accidentally, but we are here, and in the absence of God, whose presence I deny, it seems that if we have a duty it is to live out our lives and contribute to the overall effort of understanding. In this context, to take a life is too massive an undertaking.
P. We are flying too high, way too high, but I will entertain you. You seem to assume that the universe exists for humanity only. But there must be other thinkers, on different planets. It is a certainty. If we were not here they would continue to seek a meaning in existence. Your argument falls apart if there our other cognisant beings on faraway planets. As a species we are not vital.
D. We must assume that we are vital. All of our instincts tell us as much; we fear death and injury, our hormones and responses help us to avoid it. We feel a great urge to procreate, or to perform the acts that lead to procreation; the continuation of life is in the fabric of our being. To take life opposes this. We have developed to believe in our importance.
P. Then why am I so anxious to die? Why, if I had the energy, would I throw myself from this window.
D. Because your short term need for comfort is overriding all that your nature has fought for up to now, your continued existence.
P. But my nature is me, and I can see that there is nothing to be gained in living. I can contribute nothing. You have denied the existence of an external force, or God, who can judge the worth of our lives absolutely, so why am I not allowed to make the judgment that my life is no longer worth anything, to society or to the universe? Your assertion that life is precious just because it is life is fatuous. It is an argument drawn from thin air. If you were a believer in God it would have more solid foundations, for you could then say that in His eyes, in my creator's eyes, my destruction would be counter to His benign and unchallengeable plans, but neither of us believe that. You have argued that my life is sacred, but you have based that assertion on ignorance, on the mystery of life. That is not a strong argument. Life is not sacred. It is accidental.
D. It is precious. It is given to us …
P. Given! You're an atheist!
D… . and its very existence allows us to attempt to comprehend who we are and why we are here. You are derived from two single cells. Your neighbours in the ovary did not have the benefit of your luck. If any one of those millions had, I would not be having this conversation, and another brain, with different genetic characteristics, would be roaming the earth. You would not have had the chance to ponder such infinities. You have been lucky to be introduced to the universe as a consciousness. Such a privilege was denied millions of potential humans in the lottery of your parents' reproductive organs. The fact that you exist is a most unlikely phenomenon, a million to one chance. Can you not see how that makes your life sacred, and to be respected until it comes to its natural conclusion?
P. Life, my life, and therefore, by your solipsistic argument, all life and all meaning, as far as I am concerned, is coming to an end, and painfully at that. I am often in such pain that I cannot even think. I may as well not be here. I don't want to be here.
D. Well you are. Your life is ending, and I can prescribe drugs to ease the pain, but I do not have the right to bring forward the end of your life, and dissolve the memories and the meanings that it contains. Why should I have the right? We only know each other by chance; I happen to work in this hospital, you happen to live in this area.
(Rights and autonomy)
P. I am giving you the right. I have autonomy over my lifespan. I give it to you.
D. Perhaps you do not have the right to give it to me.
P. What are you saying? Are you denying me free-will? Do you think I am unfit to make the decision to give you that right? Am I mentally unsound? I haven't had morphine for over four hours, my mind is as clear as day. If I am not mad, why should I not have the right?
D. No. You do have the right to end your life, suicide is often defensible, but you cannot give me the right to commit your suicide.
P. The result is the same. My death. The means are irrelevant.
D. Can you not see the transgression? My actions leading to your death?
P. The fact of one man killing another can easily be justified. When I shot and bayoneted German soldiers in the second world war, no more than three as it happens, my actions were thoroughly justified … in the minds of my countrymen and rulers, in the eyes of the world in fact. I transgressed your boundary, your clean, philosophical boundary that to kill a man is fundamentally wrong, but the fact is that your boundaries have never been tested. World war, the threat of invasion by what is roundly accepted as an evil force, can prove an excellent test. The fact is my friend, killing can be done justly.
D. But that justification is on a national, very terrestrial level.
P. You are flying away again, into the dark universe. You cannot draw your arguments from the firmament, there is no relevance.
D. As philosophers we must cast our net for truth beyond the mere planet on which we happen to live.
P. But what are you looking for? We have no other civilisations with which to compare ourselves and our actions, or our transgressions. You have already told me that you do not believe in a God, so what can it be that you are hoping to find in that beloved universe of yours. Come back down. Concern yourself with human matters, such as pain. You look pained yourself. What is it?
D. You are arguing yourself into a corner. You say there can be no useful search for truth and right beyond our earth, but we have already established that earth's version of right, in its many societies, is best approximated by the law. Our law has decided that euthanasia is wrong. You therefore have to accept this version of what is right, especially as you have relied on those same laws throughout your life. Socrates confronted the same dilemma. He did not change his view just because it suited him to ignore it on the day that he heard of his imminent execution, so that he might make his escape, and you cannot change your view just because it does not allow your own escape, from pain.
P. I cannot believe that you are an apologist for the living compromise that is the law.
D. I don't want to be. The law is often plainly wrong, by virtue of its consistency. It must be consistent to be considered fair, but unfortunately the actions and the people to which it must be applied are individual. Mistakes, unfairness, will arise.
P. Fine, fine, I admit that I could be accused of hypocrisy if I choose to reject the law at this time, but is this not a special case? You have to focus my friend, and stop broadening your arguments. We are trying to find out why you will not do me the favour of ending my miserable existence. I would suggest that the law begins to look indelicate at this juncture. I am quite prepared to admit to hypocrisy; it is not an evil. If I may change my mind just once in my life, let it be just before it ends. I admit it, the law no longer suits me, I am prepared to break it, or to convince you to break it, but I still need to know, assuming that you are not refusing out of cowardice before the law, why you will not do it. You want to end my suffering, don't you?
(Suffering is complex)
D. I want to stop you suffering.
P. And I can assure you, even if you increase my diamorphine, and somehow heal this massive bedsore, I will still be suffering. I will still see the pain reflected in my children's eyes when they come in to see me.
D. I cannot end your life to ease somebody else's suffering.
P. It augments my own suffering.
D. Because you feel guilty, for emotionally burdening them.
P. Guilt, pain, the stench of my own rotting hip, it's all suffering my friend. You cannot distinguish between them, I assure you. I could give you many other reasons why a person in my position experiences suffering. The result is the same. I wish to end it. But be honest with me now, do you want to, would you, if the law allowed? You see, your answer to this question is the true reflection of what you think is right and what you think is wrong, and what you think, as you have said, can be challenged by no one. Would you?
D. I would find it difficult. It is irrevocable.
P. That's exactly why I need it, silly. Do you really think I want to come back?
D. But what if it is wrong?
P. Nebulous. You are being nebulous. Wrong in who's eyes? God's? You do not believe in him. Are you having doubts about that? If you bring God into this we will be here until accursed nature kills me off, for it is impossible to argue about the existence of God satisfactorily. No one can produce proofs. You either believe, or you do not believe, and that is the end of it. And you my friend, will either do what I ask or you will not. But you must justify. You want to …
D. I did not say that.
P. But you did say that you want to ease my suffering, and I can assure you that there is only one way to do that. I repeat, you want to, but you are frightened. I don't believe you are frightened of the law or of your peers, because I know you are a person of conviction, so what is it that you are afraid of?
(Fear of judgment)
D. Try to imagine. When the drug in the syringe had moved up your arm, and has been distributed to the far reaches of your body and brain by your pumping heart, what will I be left with? I will be left with you, your lifeless body, in this bed. Your face will be relaxed, the pain will have gone. What am I to feel? Your spirit, this mind with which I am grappling, will be gone. I will have destroyed it. The members of my society, whose opinions I have to respect and care about, will ask me, will interrogate me. You will not be there to give your arguments. You will not be there to affirm your right to give me the power to kill you. It is I who will have to justify why I believed I had the right to kill you. And you can see how shaky my own conviction will seem. You, a man with only a month at most to live, are having difficulty persuading me why euthanasia is right. How then will I be able to convince my society that I was right in obeying your wishes?
P. I will leave a written argument, a living will. It's common practice. You do not need to worry about justification, that is my concern.
D. You should have written it when you were well. It would have had more clout now.
P. Well there's a lesson for us all, but I didn't think did I. If I write it now it will be worthless, that's what you are saying. You really don't think I'm of sane mind do you?
D. You are … desperate. And when you have gone you will be beyond reproach. I won't be.
P. Then it is cowardice. This is all about you, not me. You really are afraid of society's judgment on you. I need to find a doctor with more courage.
D. It is not that.
P. Then why, when you have accepted that the only way to stop my suffering is to end my life (and don't tell me about the damn pain-killers—the dose I need would make me so drowsy as to rob me of thought, and in that case I might as well be dead), and having stated that you want to stop my suffering, why will you not do it? Are you squeamish? I know of means whereby you will have to do no more than press a button.
D. How did you feel when you killed your first German?
(Nature is cruel)
P. Terrible. He was young, nature had not intended that he lose his life. I say it was justified, that murder, justified by society and humanity, but I did not say that I had justified it to myself. I recall the faces of each of those soldiers. I had no choice. My own society, my fellow soldiers at my side, permitted no evasion from that terrible responsibility, but that does not mean I have justified it to myself. Theirs was not a natural death, but look, nature, and nothing else, tripped one of the cells in my bowel into uncontrolled division, and one of those entered my bloodstream and settled in my liver, and another in my lung. I am riddled with cancer, and nature is pulling me towards the end of my life, but it is doing it cruelly and without sympathy. Nature is cruel. Just because it is nature does not mean it cannot be modified. I have only one destination, and you can give me a lift. Will you?
D. You are playing with my emotion.
(Loss of objectivity)
P. God, you are hard. You feel yourself agreeing with me, but have to back away from my pain.
D. You are a philosopher, and so am I, and that is why you chose to have this conversation with me. I must remain objective to preserve the overview. I must be able to see the landscape.
P. There you go, off with your need to generalise again …
D. If my decision cannot be generalised to others in your situation there is no point in trying to get to that decision, no point in clarifying the reasons.
P. So we are brought to this. Only by stimulating your compassion can I bring you near to doing this one thing for me, for detached from that compassion, in the cold comfort of objectivity, you cannot countenance euthanasia … and even then, as a philosopher, you cannot justify that decision. Even then, in your refusal, you seem motivated only by some vague fear, societal, quasi-religious, you—an atheist. Only when I display my agony do you come close to accepting that euthanasia is right. It seems that only if I take away your intellect and instead ask you to rely on you feelings, might I be able to persuade you.
D. But you see, don't you, that that is not an argument that I can use in my defence. It is too personal. It is fuelled by images, odours and thoughts that are unique to our interaction in this side-room.
P. God, how many people have they put in here to die?
D. Tens, hundreds …
P. But it can be generalised. If justification can only be found, even in a hard nut like yourself, in extreme suffering and a clear, desperate plea from the patient, then why can we not accept that as an indication, as justification in itself …
D. Because the decision of rightness is being made by a doctor who is submerged in that emotion.
P. And why is that wrong? This doctor is a trusted practitioner during her working day. She makes thousands of “decisions” each week, big and small. They are not questioned. Why, when faced with such suffering, should we lose faith in that doctor's ability to make the right decision once again? Doctors are in stressful situations all the time, and we trust them … this is another stress. They can deal with it. Let them decide whether the appeal for euthanasia is appropriate.
D. In countries where euthanasia is legal that is the case, and to make the decision more secure the opinion of another, perhaps less involved doctor is required before the act is done.
P. Then why has that law not been universalised?
D. Because people have doubts.
P. What doubts?
(A unique view)
D. Vague doubts. You have exposed how vague my own doubts are, quite mercilessly.
P. Marvellous. He's upset because I haven't shown him mercy!
D. I'm sorry.
P. The doubts. Vague, fearful doubts like yours, theological, irrelevant, philosophical doubts. We have established that objectivity has no place here, because objectivity involves removal from the pain. The pain is central. It must be incorporated into the argument. The pain in my eyes must be in the minds of those who decide. It is the pain that is the justification. We humans do not understand the universe, or the meaning of our existence, yet we try to make judgments about a person's right to end his own existence. That person is at the end of life, he has been afforded a unique view of existence. He begins to understand, after a life that may have been full, if he were that way inclined, of attempts to come to grips with his meaning, and from the edge of the chasm that is his mortality he begins to see the truth.
D. What is the truth?
P. You will know when you get here my friend.
D. You talk like that, like an evangelist, and you expect me to accept your wish as justification?
P. I am not rambling. I am dying. You are not in a position to challenge anything I say. I can see everything from my vantage point, but I cannot come down from this great height to spend years enjoying the memory of the view. The footpath has become overgrown with cells, the bridges have been eaten away by my tumour. I wish I could bring you up here my friend, but one makes only a single visit to this precipice.
D. And that, I'm afraid, is where your argument stutters. The very uniqueness of your view, the fact that it cannot be afforded to me, to society, to the arbiters of good medical practice, or to the makers of law, renders its power incommunicable. I can try to empathise with you, because I know you, and I can sense the power, but you cannot expect me to relay that compelling sense to others. I'm sorry. It is too unique.
P. Hah! Unique. Unique you say, and yet one day you will enjoy a view of similar power, as will all your law-makers. The details will be different of course, the memories and the regrets, but if you are made to linger there, in pain, held back by law from the inevitable descent, you will perhaps come to agree with me. You will see that from this position one gains a true perspective. One knows what is right at this time. I am asking to be killed, for my suffering is achieving nothing. I know it is right, and you, and your society, and your laws, must accept that those who find themselves on this lonely precipice are right, by virtue of being here.
The patient rapidly dismisses the relevance of the law and the possibility of the existence of a God. If the latter exists it has never made its presence felt, nor aided us in reaching any decision. In its place we have our own conscience and our own conviction as to what is right and what is wrong. The doctor, an avowed atheist, still harbours an uneasy fear that she will be transgressing in the eyes of some external power, and in the end admits that the fear largely arises from the judgment that society is bound to make after the act. Before this is established however, the doctor attempts to persuade the patient that even in the absence of a God, life is still sacred, by its very unlikeliness, and by the unique product of this off-chance, the human mind, wherein lies the ability to appreciate the marvels and wonders of the universe. That is all very well, but the patient has had quite enough of all that. He is in continual pain. The pain is more than can be alleviated with drugs; it is a pain of thought and regret and some little guilt too. The patient asserts his right to die, and establishes that he is of sound mind. The doctor comments that after the patient's death that right will no longer exist, but that it is the doctor's rights that will be examined. The patient accuses the doctor of cowardice, in not following her convictions; how can the doctor not, in truth, want to end this suffering? Seeing that the real source of the doctor's reluctance can never be established, the patient stimulates the doctor's compassion. In this way the philosophical defences will be surmounted. The patient individualises the argument, and defends that belief that here is a problem that should perhaps not be generalised. In the end he closes the argument by obstinately stating that only those in his position can make a real judgment about life, only those who are staring the end of life in the face. It is difficult to argue against such a stance.
Philip Berry MRCP, is a Medical Senior House Officer at St Thomas' Hospital, London.