The Right to Die
The concept of a fundamental right to life is widely accepted and codified in legal systems around the world. From the Geneva Conventions to the Eighth Amendment, the value of life forms a cornerstone of human existence— protected by both law and an innate moral imperative. However, as our understanding of personal autonomy has evolved, particularly in light of advancing technologies, a provocative question has emerged— what about the right to die?
The ethical discourse surrounding physician-assisted suicide (PAS) is inextricably linked to the broader evolution of bioethics and patient rights. The 1970s marked a pivotal shift in medical ethics, with the philosophers Beauchamp and Childress spearheading an emerging field of bioethics that challenged traditional physician paternalism in favor of greater patient autonomy. [1] The principle of patient autonomy asserts that patients, not their physicians, should be the ultimate decision makers regarding their health. It has driven mandates such as informed consent and treatment refusal rights, and now, as activists argue, debates over PAS.
This issue challenges our traditional notions of life, death, and freedom, bringing into focus the tension between personal choice and societal values. The debate over this question reached the Supreme Court in 1997. Vacco v Quill, 521 U.S. 793 (1997) and Washington v. Glucksberg, 521 U.S. 702 (1997) asked the question of whether physician-assisted suicide (PAS) was protected by the Constitution or the Due Process Clause, specifically. If protected, PAS could be deemed a fundamental right— described as a right “deeply rooted in this nation’s history and tradition,” such as being implicit to liberty and essential to a free society.
Like Roe v Wade, 410 U.S. 113 (1973), this challenged the Court to balance individual autonomy, medical ethics, and the state's role in preserving life— all while weighing the broader societal impact of acknowledging such a right. Ultimately, the Court rejected the notion that assisted suicide constitutes a fundamental liberty interest protected under the Due Process Clause. The Court's reasoning hinged on the PAS’s conflict with societal values and traditions. Applying rational basis review, the justices determined that Washington's prohibition on assisted suicide was reasonably linked to several legitimate state objectives. [2] These included maintaining the integrity of medical ethics, safeguarding vulnerable populations like the disabled and terminally ill from potential coercion, and, most critically, upholding the state's interest in preserving human life. This ruling effectively validated the constitutionality of the state's ban on assisted suicide, recognizing it as a rational exercise of governmental authority in pursuit of legitimate aims.
To this day, legalization remains unanswered on a national-scale, instead decided on a state-by-state basis. Thus, the legal landscape of physician-assisted suicide (PAS) in the United States has evolved into a complex patchwork. As of 2024, eleven jurisdictions have enacted "death with dignity" laws, legalizing PAS under specific circumstances. The remaining states continue to debate the issue, which seems to be gaining momentum this year. [3] For instance, advocates are closely monitoring legislation in Maryland, Massachusetts, New York, Minnesota, and Virginia regarding PAS, with New York state Senator Brad Hoylman-Sigal noting unprecedented momentum for the cause, particularly following the New York State Bar Association's first-time support of related legislation this year.
The Hippocratic Oath, a cornerstone of medical ethics, presents a case study of the ambivalence surrounding physician-assisted suicide. [4] The modern translation reads: “With regard to healing the sick… I will take care that they suffer no hurt or damage. Nor shall any man’s entreaty prevail upon me to administer poison to anyone; neither will I counsel any man to do so.” In other words, while the oath enjoins physicians to alleviate suffering and act in their patient's best interests, it simultaneously proscribes the administration of lethal drugs.
This tension encapsulates the ethical quandary at the heart of the PAS debate: how to balance the imperative to preserve life with the duty to respect patient autonomy and relieve unbearable suffering. Proponents of PAS argue that, in some cases, hastening death is the ultimate act of compassion, aligning more with the spirit, if not the verbatim, of the oath. Moreover, as put forth by Professor LW Sumner from the University of Toronto, physicians have a duty in certain circumstances to help patients end their lives. [5] Instead of abiding by an unyielding mandate to preserve all life, Sumner posits that the right to life, like other fundamental rights, derives its meaning from its optionality and the autonomy it confers—including the autonomy to relinquish it under certain circumstances. He contends that the true value of a right is not merely in its possession but in the freedom to exercise or forgo it. To mandate the continuation of life against an individual's reasoned wishes, thus, paradoxically undermines the very concept of rights it purports to uphold. The Ninth Amendment embodies this principle that individual liberty extends beyond the explicitly enumerated rights in the Constitution. It affirms that the absence of a right from the constitutional text does not negate its existence or importance. By asserting that unenumerated rights are retained by the people, it preserves a broader conception of personal liberty and limits governmental power.
It is critical, however, to understand that decisions over PAS cannot be black and white— neither resolved by unregulated access nor outright prohibition. Legalizing PAS poses several dangers, particularly the risk of abuse and coercion among vulnerable populations. Patients with disabilities, the elderly, or those experiencing depression may feel pressured—either directly or indirectly—to choose death due to societal biases or financial burdens, especially in systems where healthcare is costly or inadequate. There is also concern that legalizing PAS could erode trust in the medical profession, shifting the focus from care and healing to ending lives prematurely. Furthermore, insufficient safeguards could lead to situations where individuals make irreversible decisions without full clarity or autonomy, heightening the risk of errors or abuses. The slippery slope argument contends that legalizing physician-assisted suicide, even in narrowly defined cases, could set a dangerous precedent, gradually expanding to more ethically questionable practices, such as involuntary euthanasia or the acceptance of life-ending measures for those with non-terminal conditions, thus undermining the sanctity of life.
Thus, when evaluating PAS, the courts ought to adopt a nuanced, law-by-law stance that weighs individual autonomy against the state’s responsibility to preserve life and prevent potential abuses. The 2009 Montana Supreme Court decision in Baxter v. Montana, 354 Mont. 234, 224 P.3d 1211 (2009) provides a framework for how courts might approach this issue. The court didn’t address the issue from a constitutional standpoint; rather, it ensured that the debate remained in the Montana legislature rather than setting a binding statewide precedent through constitutional interpretation. Similar to Washington v Glucksberg, the Court emphasized the importance of legislative debate on this complex moral issue, stating that it should continue in a democratic society.
It is generally preferable for courts to defer PAS cases to legislatures, as they can more flexibly address the evolving nature of this complex issue. Legislative processes allow for swift adjustments to laws as ethical and medical understandings develop, ensuring a responsive legal framework. However, courts play a crucial role in interpreting these laws and protecting individual rights when legislatures fail to act or infringe upon them.
The ideal approach involves a balance where legislatures lead in crafting PAS regulations, with courts ensuring these laws respect fundamental rights and are applied fairly. This collaborative approach allows for adaptable legislation while maintaining constitutional safeguards. Courts should consider patient autonomy, grounded in constitutional privacy rights, allowing terminally ill individuals to make personal decisions about their medical care and death. Simultaneously, they must balance this with the state's duty to protect vulnerable populations from coercion. Ethically, PAS can be viewed as a compassionate option for relieving unbearable suffering when palliative care is insufficient. However, courts must implement strict safeguards to prevent abuse and ensure decisions are voluntary. Ultimately, courts should adopt a nuanced approach to PAS that respects both individual autonomy and societal interests, allowing it under carefully regulated conditions while preventing misuse or harm to vulnerable populations.
Furthermore, this decision implicitly recognizes the complex ethical considerations surrounding end-of-life care. By not establishing a constitutional right [6], the ruling permits regional variations in PAS policies across different states, acknowledging that views on this issue may differ significantly. Ultimately, the Montana Supreme Court's approach serves as a potential model for other state courts facing similar cases, demonstrating how to navigate these complex issues while respecting judicial restraint and maintaining the court's role as an interpreter of law and protector of individual rights.
What began with Washington v. Glucksberg has evolved into a dynamic, shifting legal landscape with far-reaching implications. This dilemma compels us to confront challenging questions about the nature of medicine, the boundaries of autonomy, and the definition of compassionate care. The resulting lack of uniformity in the law has ignited polarizing debates over the roles of law in medicine and ethics, as well as the relationships between patients and physicians and the fundamental issues of life and death.
Edited by Hanrui Huang
Endnotes:
[1] Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 7th Edition Volume 65 Issue 1, (Oxford Academic 2014), online at https://academic.oup.com/occmed/article/65/1/88/1433004
[2] Washington v. Glucksberg, 521 U.S. 702 (1997)
[3] Maya Goldman, More states are considering bills allowing medically assisted death this year, (Axios 2024), online at https://www.axios.com/2024/02/09/medically-assisted-death-states
[4] Miles, Steven H, The Hippocratic Oath and the Ethics of Medicine (Oxford; New York: Oxford University Press, 2004)
[5] L.W. Sumner, Assisted Death: A Study in Ethics and Law, Volume 123 No 490 (Mind 2014), online at https://www.jstor.org/stable/24489498
[6] Baxter v. Montana, 354 Mont. 234, 224 P.3d 1211 (2009)