Six questions about physician-assisted death, from a conscientious objector

Ewan C. Goligher*

Canadian policy makers have recently proposed to require all doctors to provide an effective referral for physician-assisted death (PAD) upon the patient's request. Forcing doctors to knowingly send their patient to another doctor willing to cause the patient's death will seriously compromise the moral integrity of conscientiously objecting doctors and risks undermining the quality of patient care. To understand the position of conscientiously objecting doctors, consider the following questions.

1. Should doctors provide physician-assisted death merely because it is legal?

Doctors should provide PAD only if it is both legal and ethical. The Supreme Court has ruled that PAD ought not to be legally prohibited, but it cannot define whether it is ethical for doctors to intentionally cause death. In their decision on the legality of PAD, the Supreme Court Justices stated that "nothing in this decision would compel physicians to provide assistance in dying." The Justices recognize that we need not automatically accept that PAD is ethical in the wake of this sweeping change in law.

2. Must all doctors accept the assumptions underpinning the claim that physician-assisted death is good medical care?

Advocates for PAD contend that death should be used to treat suffering because for some patients, death is better than life. This assumes some notion of what it is like to be dead. Yet the medical profession has no idea what it is like to be dead. All beliefs about the afterlife (including the belief that there is no afterlife) are metaphysical (quasi-religious) beliefs which cannot be confirmed or refuted by scientific medical evidence. Thus PAD is innately experimental and its outcomes are hidden from us. Though there is always a measure of uncertainty in medicine, medical care must be based on evidence and observation and sound reasoning, and doctors should not be forced to practice medicine based on untestable quasi-religious assumptions.

The case for PAD also assumes that respect for the patient's wishes, rather than respect for the patient as a whole, is the foundational value of medical ethics. Respect for the patient's wishes is unquestionably part of respecting the patient, but valuing these wishes above the patient herself would prevent doctors from ever refusing any patient request, even if it would clearly harm her health. The long-accepted firm foundation for medical ethics (including the duty to respect the patient's wishes) is the incalculable intrinsic objective worth of the patient. Intentionally causing death would require us to render valueless that which is of essential value: the patient.

In sum, given the tenuous assumptions underpinning the case for PAD, doctors need not accept that PAD is good medical care.

3. If physician-assisted death remained illegal, would doctors be legally liable for making an effective referral?

If a father were to request that his daughter undergo circumcision (i.e. genital mutilation), and I deliberately provided an effective referral to a willing physician, I would be complicit in an extremely grievous breach of medical ethics. This scenario is not ethically identical to PAD but it effectively illustrates the moral and ethical responsibility attached to an effective referral. This moral responsibility is recognized in law: doctors are legally liable for referring a patient for a procedure that is forbidden by law, even if requested by the patient (as was the case for PAD until now). Knowingly referring a patient to a physician willing to cause the patient's death makes doctors complicit in that death. Therefore, if upon considered moral reflection we find that PAD is unethical, we ought not to provide referrals for PAD.

4. Does the Charter right of Freedom of Conscience apply to doctors?

Some argue that doctors cannot claim the Charter right of Freedom of Conscience because we willingly accept responsibilities and duties that limit our freedom when we commit to care for the patient. Accordingly, doctors are duty-bound to deliberately cause death upon the patient's voluntary request. This argument is successful only if PAD is ethical: the commitment to care does not extend to providing unethical care. Doctors are duty-bound to ensure that their patient's suffering is relieved by all effective means available. Whether this commitment entails a duty to cause death is a controversial moral question contingent upon certain philosophical assumptions. Those who insist upon a duty to refer for PAD impose their personal ethical beliefs and assumptions upon others. The freedom of individuals to decide this issue and to act in accordance with one's deeply held moral beliefs is precisely what the Charter right of Freedom of Conscience protects.

5. How does respect for conscientious objection affect patient care?

Even given the assumption that PAD is ethical, robust respect for conscientious objection is still ultimately good for patients. Patients entrust themselves to their doctors, and doctors must be worthy of this trust. The doctor's moral integrity—a commitment to acting in accordance with moral norms—is foundational to his/her trustworthiness. Suppressing conscientious objection prizes moral conformity over moral integrity and systematically teaches physicians to suppress their basic moral intuitions in favour of constantly evolving social conventions. It also teaches the profession to be less sympathetic of and tolerant toward patients' diverse moral beliefs. Thus, robust respect for conscientious objection should be viewed as an important public good that upholds the quality of medical care.

6. Will respect for conscientious objection obstruct access to physician-assisted death?

Upholding respect for conscientious objection to PAD need not present a significant obstacle to obtaining PAD. Making referrals mandatory does not immediately guarantee access as PAD will not be routinely provided by any particular medical specialty and many in the medical community do not know physicians willing to accept such referrals. Conscientious objectors have proposed simple solutions allowing patients to refer themselves for PAD, and this may in fact be the most reliable means of facilitating access. Yet policy makers have disregarded such proposals to this point. Carefully considered policy frameworks for providing PAD can show robust respect for conscientious objection while enabling universal patient access.

Dr. Ewan Goligher practises intensive care medicine in Toronto. The views expressed here are his own and do not necessarily reflect the views of any institutions with which he is affiliated. Visit http://www.canadiansforconscience.ca to learn more.