Physician-Assisted Suicide and the Profession's Gyrocompass

In recent years, a substantive ethic for the ends of medicine (one going beyond process values such as honesty) has often been taken for dead--as the scary fossil of Paternalosaurus Rx or the relic of Saint Hippocrates. Vital ethics has been autonomy centered, correcting the abuses of a silent clinician-patient relationship and its arrogant assumptions regarding the values that guide the healing encounter. Autonomy-based ethics, however, has long since moved from empowering persons to refuse or choose any therapy or experiment. It has become a comprehensive ethic in which individually or contractually defined norms for medicine supplant professionally grounded boundaries for medical practice. Miller and Brody's effort to understand how a substantive ethic of medical professionalism applies to physician-assisted suicide is admirable. A professional ethic is a gyrocompass pointing in a precalibrated direction. Ideally, it forces a prolonged testing of ideas that the present moment would otherwise too quickly accept. It is neither a dead letter nor a scriptural truth. It bears a message of moral reflection from the past and may properly be recalibrated in the evolving dialogue between the profession and the society that values it, about the profession's goals, accountability, and duties. It does not legislate. Constructing professional ethics is difficult in a modern society where internationalism, skepticism, and respect for pluralism are fundamental values. Even so, the influential ethic against physician participation in torture and on human subjects research demonstrates the vitality of these constructions. Amendments must be forged over time in response to the changing relationships between patients, clinicians, and society. A professional ethic neither trumps all countervailing claims nor capitulates to any state or powerful individual. Its balancing weight is not simply the force of present arguments or powers, but derives from the way the norms have been constructed in the history of the profession. This kind of ethic is cultivated as the prudential voice of a historical community.[1] It is created out of the values of the society, whose political powers it reflects. It speaks from its own practical experience in moral problem solving.[2] Brody and Miller argue that the exceptional practice of voluntary physician-assisted suicide can be compatible with physicians' professional integrity. To assess their claim, it is necessary to distinguish four different ways of relating a professional ethic to public permission for physician-assisted suicide. * Case 1: A person (who happens to be a physician) in an intimate relationship with a very ill person (perhaps her patient) uses medical knowledge or equipment to assist a suicide. * Case 2: A physician assists a patient with intractable suffering to commit suicide. * Care 3: Public policy is to grant persons the right and means to commit suicide under certain circumstances and permits physicians to assist in this act. * Case 4: Public policy grants physicians the exclusive authority to assist and supervise persons in the practice of licit suicide under certain circumstances. To the extent that Miller and Brody's discussion of professional integrity applies to Cases 1 and 2, few would disagree that the extraordinary accounts of clinicians who have administered or supplied drugs with the intention of ending a person's life should be listened to with a nuanced casuistry and empathic understanding. The present societal debate is about Cases 3 and 4. It shifts from retrospective understanding to prospective permission and from case-casuistry to general laws describing the powers of professions as regulated institutions. Oregon's new law, for example, defines the conditions under which physician-assisted suicide (and not nonphysician-assisted suicide) shall be deemed an unexceptional medical practice rather than one that is forgiven as an exceptional event. …