Physician Assisted Suicide is a Sign of an Uncaring Society

by Phillip Brown

In my last article, I laid out a brief biblical argument for why we should not endorse physician assisted suicide, PAS. In this article, my aim is to do the same thing, yet use something more akin to a philosophical approach to make my case. My central claim is that a society which allows for the practice of PAS is not one which truly cares for its members. Drawing on the disciplines of nursing a profession strongly associated with the notion of ‘care’ and care ethics, CE, I intend to flesh out some of the central features of what it means to ‘care’. I will then attempt to demonstrate why PAS is not a caring practice and as such, PAS should be rejected on those moral grounds. 

What Does it Mean to ‘Care’?

As the central pillar of my argument revolves around the concept of care, it seems essential to try and gain at least some understanding of what it means to ‘care’. To that end, it will also be important to provide reasons for why this idea of ‘care’ has anything at all to do with PAS. I should begin by addressing why care and PAS are linked. My position on this is straightforward. Anyone in a position where they would possibly be considering PAS would either be under a circumstance wherein, they would be receiving direct care of some sort, say from a nurse, a homecare worker, or a family member, or they would otherwise just be vulnerable and thus in need of some sort of care. Also, whether or not a society sanctions PAS, I think, has some sort of correlation with that society’s view about sick and vulnerable people. I do not believe that it needs to be argued further, that the concept of ‘care’ and PAS are, in some ways at least, closely connected. 

On the idea of care, it seems most reasonable to draw our understanding from those whose focus would seem to be centered on the concept. I think that it goes without saying that nursing would be a good starting point for this discussion. Kalfoss and Cand carried out important literature reviews in search of increased knowledge of the concept of care from a nursing perspective. They preface their study by pointing out two things, which I believe impinge upon the present article. First of all, they note that there has been difficulty in defining care and as such it is very much an immature concept in their profession (Kalfoss and Cand 996). This means that, as a point of departure for a discussion on the relationship between ‘caring’ and PAS, there is much to be explored and I think presents a new and potentially powerful avenue for demonstrating why PAS is not at all in line with the idea of caring. Kalfoss and Cand also point out, as others have, that without some kind of theoretical commitment to the concept “clarification becomes an arbitrary and vacuous exercise in semantics’ ‘ (996). While I do not necessarily agree that a theoretical commitment is required for a clear understanding of care, I do believe that theories about care can help us to define care and caring, and as such, can fill that vacuous space in discussions about those concepts, even outside of theoretical frameworks. So, it is certainly worth our while to investigate along theoretic lines, even if just to draw on those ideas, which are useful to our cause. 

Kalfoss and Cand investigated whether or not a specific theory of care, known as Swanson’s middle range theory, could be used to organize concepts of care as seen in various academic works. The result of this is, in effect, the clarifications of salient features of ‘caring’. The five features important to care, what Swanson calls  levels of, of Swanson’s theory can be summarized as follows: 1. A person’s capacity for caring; 2. Commitment to beliefs/values which undergird one’s actions in caring; 3. The conditions and circumstances related to the quality of care; 4. Actual, concrete caring actions; 5. The positive and negative consequences and outcomes of care (Kalfoss and Cand 996-7). With these five levels as a baseline, Kalfoss and Cand, they conducted two literature reviews. Beginning with over 400 citations, they used a series of exclusion criteria related to language, the relevant concepts of care/caring, the appropriate scientific discipline, and duplication. This resulted in the use of citations from a final sample of 29 articles. 

From these 29 articles Kalfoss and Cand drew the following ideas about care based on Swanson’s five levels. Regarding having a capacity for care someone must be knowledgeable, compassionate, empathetic and have a positive outlook (Kalfoss and Cand 999). Regarding commitments underlying care, they noted the necessity of connecting with others, focusing on their circumstances and feelings, being present, or aware of the self, in general, doing the right thing which is an issue obviously related to morality    and importantly, “recognizing the dignity and worth of each person” (Kalfoss and Cand 999, emphasis in original text). Under conditions impacting care, they pointed out the importance of conditional limitations, one’s personality traits, the ability to communicate well, the patient’s condition and other administrative and personnel related issues (Kalfoss and Cand 999). It is important to remember here that their study is specific to nursing concerns and thus are, at least partly, institutional in nature. This increases the applicability of their findings to my argument as my goals to push back against the idea of systematic, societal, and institutional acceptance of PAS.  Regarding level four, concrete actions, it seems that those are so situation specific that a discussion at an abstract level is not possible. But their Level 5 related findings are most important to this discussion. They found that, in terms of consequences of care, important features of caring had to do with both physical and emotional and spiritual outcomes as well as maintaining a sense of autonomy and control. This seems to be underpinned, however, by the way in which those things relate to a patient “finding a sense of worth and a reason to live” (Kalfoss and Cand 1001, emphasis mine). Another of their findings which I see as germane to PAS related issues is that outcomes for a healthcare system which have an impact on caring are linked to impacts on the culture of care of the system (Kalfoss and Cand 1004). 

The implications of these findings for the present discussion are, I think, fairly obvious. I would argue that each of the Levels of Swanson’s middle range theory can clearly draw out important features of the concept of ‘care’ and what is required of a person and a system in terms of providing good care. In particular, a commitment to the importance of a person’s worth and the idea that care outcome goals should be aimed at the one being cared for seeing a reason to remain alive seem to be vital components of what it means to ‘care’ for someone. And this, I hope to show later on, does not line up with PAS.

As is often my practice, I tend towards textbooks as a means of attempting to develop a baseline understanding of a concept. Caring in Nursing Classics is just that. In the chapter titled “Concepts of Caring and Caring as a Concept” Morse and colleagues, like Kalfoss and Cand, admit to the difficulty in defining ‘care’. Nonetheless, from their literature review of 35 authors, they were able to define five categories of care. These categories cover, for the most part, the same features discussed by Kalfoss and Cand. They are “caring as a human trait, caring as a moral imperative, caring as an effect, caring as an interpersonal relationship, and caring as a therapeutic intervention” (Morse el al. 20). 

As much of the material Morse and colleagues covers reflects the same general sentiments as already discussed, I will focus on the one element of Morse and colleagues’ work which I think has the most impact on our current subject. The idea that caring is a moral imperative is more than just an empty claim. Anyone familiar with Immanuel Kant’s famous categorical imperative can speak to the idea that a moral imperative refers to something which we must do in order to call our actions ‘good’. Clearly Morse and her colleagues view care as something which is essential to being a moral person. I will address this more in the section on care ethics, but if care is a moral imperative this would suggest that all of the features of care are also necessary if one were to call themself a moral person. Morse and colleagues make a very interesting claim related to the morality of care. They note that, paradoxically, “nurses are caught in a dilemma created by a mandate to care in a society that does not value caring” (Mores et al. 22). The original publication year of the article in question was 1990. Whatever else is meant by the above statement, clearly Morse and her colleagues had recognized problems with the direction that society was going in regarding the moral imperative to care, even back then. I submit that things have only gotten worse. 

I would now like to see what we can glean about the concepts of ‘care’ or ‘caring’ from what is known as care ethics, CE, or an ethics of care. CE is a feminist approach to ethics which is constituted by various forms of theories which, generally, focus on the notions that caring, broadly construed, is essential to moral action and, unlike other moral theories wherein emotions effectively have little or no role, emotions and the bonds formed between the caregiver and the cared for, typically those closest to you, are central to ethical action. The relationship between the caregiver and the cared for is, then, a primary hub in care ethical thinking. Like the nursing theorists I spoke about above, the CE theorists work which we will, briefly, review here does not address PAS in any apparent way. Apart from there being some clearly moral element to caring, I do not at all endorse a care ethical system of morality. But I believe that the perspectives CE theorists discuss on ideas related to care and caring are certainly helpful to me in terms of establishing some sort of, at least minimally solid, understanding of those concepts. 

Raja Halwani is one such theorist. Halwani argues that CE should in fact be placed within that broader theory of Aristotelian virtue ethics, VE. A key presupposition for his discussion on this topic is that many have claimed that CE cannot be considered to be a proper moral theory and care in and of itself cannot be “…the soul foundation of such a theory…” (Halwani 161). Using Nel Noddings’ 1984 foundational work on CE as a point of departure Halwani, like Morse and colleagues, points out that because of the above reasons, and because care is an essential component of morality, an imperative of sorts, it makes sense to place CE within the framework of virtue ethics. VE can make up for the missing pieces of a care ethical theory, specifically, VE on its own has a stronger moral foundation in that it allows for reason to play a regulating part in moral decision-making and VE can preserve important features of CE, such as the legitimacy of partiality  that is a commitment to those closer to you and within your direct care above others which is central to CE, as well as the role of emotion in partiality, partiality’s application to moral actions, and in general, its importance to areas of moral thinking which other theories tend to leave out. 

The emotional and commitment components of partiality are important to Halwani’s argument here. Of particular importance is the notion that commitment requires the caring person to support and endorse the goals of the one being cared for. Halwani discusses a situation wherein a friend had an abusive partner. This friend cared for and was deeply committed to her partner and desired to stay with him. Halwani says that a situation like this brings up the question of whether or not the goals of the one being cared for need to be morally good for the caring person to endorse them? His response, in this case, was a resounding no. Given that his friend’s well-being is paramount in caring for them and that her goals were in fact harmful to her, Halwani argues that her goals should not be supported (165).       

It is with this kind of partiality conflict in mind that Halwani begins to argue a case for making CE just one of many other virtues within VE. As a virtue, Halwani asserts, “care would not simply be a natural impulse … but also ethical” (168). There simply is not enough space here to discuss all of the salient features of VE. But the essence of Halwani’s position is that because, from a VE perspective, people are relational beings and because relationships, and the subsequent emotions at play in relationships, are central to caring, CE can quite comfortably fit within the space of VE. Halwani argues that the wisdom facilitated by moral reasoning in VE provides a mechanism for regulating the intimate relationships which are so central to CE (Halwani 175).

Halwani’s argument is a bit confusing because he is speaking across two dimensions, CE, and VE respectively, so I want to narrow the focus down to those key elements of his argument which impact our attempt to develop an idea of what it means to ‘care’. Like Morse and her colleagues, it seems clear that Halwani views care as an essentially moral activity. This suggests that good care is moral, while providing no care, or not really caring at all should be thought of as behaving immorally. This is especially true if we consider the notion of partiality which Halwani made clear was a problem for CE. To care requires a necessary commitment to the well-being of the one being cared for. On CE alone, this could mean requiring the one caring to act in support of immoral goals simply because those are the goals of the one being cared for. But on Halwani’s view, this problem is fixed by couching CE in the broader VE framework. Using reason, which is accounted for by VE, this allows for not supporting the goals of the one being cared for if it is clear that those goals are not moral or just not what is best for them. So, the two chief issues are dedication to what is best for the one being cared for and viewing ‘caring’ as an essentially moral action. 

Joseph Walsh brings the idea of partialism into focus with regards to its relationship to commitment. Walsh’s central claim is that partialism, or partiality, is “a necessary implication of any care-ethical view” (818). He makes it clear that for a person to actively ‘care’ they must not only be seeking the best for the one being cared for, but also be motivated by an actual concern for the one being cared for (Walsh 819). Further to that, if someone’s actions are primarily a result of obligation or the expectation of some sort of reward for those actions then “they cannot be said to be exercising caring agency” (Walsh 819). Also in Walsh’s view, any agent which either only has concern for the cared for from time to time, or who does not regularly behave in such a way as to meet the needs of the one cared for, in essence, does not really ‘care’. What is more, Walsh argues that unless goals of the cared for are made a priority and actions taken to achieve those goals, the whatever commitment claimed by the caregiver is not genuine. Early on in his discussion, Walsh provides us with a very helpful list of what kinds of results care should bring about; the prevention of or cessation of unnecessary suffering, recovery from a particular illness, and healthy growth and development (818). Given what I have addressed so far, I think that it is very reasonable to suggest that if the cared for’s needs are not met to achieve these specific results on a regular basis, the caregiver cannot be said to genuinely care.

So, what does it mean to ‘care’? Well, it seems that caring is, in some way or another, a moral imperative. It is our duty as people, and I argue as a society, to engage in caring for those who need it. The aims of caring must be the health, spiritual and physical well-being, and the dignity and autonomy of the one being cared for. Caring requires some kind of commitment to the one being cared for in the sense that we must take on their goals and endorse them, so long as they are clearly moral. The caregiver must be dedicated to consistently carrying out actions in an effort to achieve the desired aims. And those actions must be motivated by a genuine concern for the one being cared for and not as a result of expecting a reward, or out of pure obligation. 

A Caring Society Does Not Endorse PAS

I would now like to proceed with making the case against PAS. My argument is as follows:

1. A caring society must be committed to the health, spiritual and physical well-being, and the dignity and autonomy of those within its fold. This is a moral imperative.

2. The practice of PAS does not demonstrate that it meets the standards laid out in premise one.

3.  Therefore, because many in Canadian society, through supporting a government which endorses PAS, have brought about the legalization of PAS, our society cannot be said to ‘care’ about its citizens.

Premise one is supported by the simple expansion of the concepts of care already discussed to a macro scale. I do not think that it is unreasonable to suggest that ‘care’ = care. Whether it has to do with a relationship between two people, a relationship between a government and its people, or the relationship between the broader societal view about how to look after those in need and those actually in need, caring is caring. As such is the case, the same principles apply regardless of the scale. One example would be the similarity in psychology and actions between a nurse and those of a government. Just as it takes commitment to the aims of promoting the health and well-being of a patient on the part of a nurse, it takes commitment to those same aims on the part of legislators when setting health policy for a country. And in both cases, that commitment must be consistent, and it must be out of some kind of genuine concern for those being cared for, not just obligation or because of the anticipation of some sort of return, for example, re-election. The point is simply that, when it comes to what ‘caring’ looks like, the scale is not a relevant factor. So, premise one is vindicated on those grounds. 

Premise two is more difficult to establish, but certainly has merit in my view. Many PAS advocates argue that PAS is a good thing because it is compassionate, it ends suffering, and is about personal autonomy. In fact, dyingwithdignity.casays just that. Under the background section of their website, they say that the passing of Bill C-14, Canada’s PAS legislation, will be remembered as one of enormous change, driven by compassion, an end to suffering and discrimination, and a desire for personal autonomy”.  The preamble to Bill C-7, which is an earlier form of PAS legislation, clearly states that Parliament recognizes the need for balancing “societal values, including the autonomy of persons who are eligible to receive medical assistance in dying, the protection of vulnerable persons from being induced to end their lives and the important public health issue that suicide represents”. There is an interesting contradiction between valuing the protection of the vulnerable and how they seem to view autonomy. justice.gc.ca also cites autonomy as an objective of Bill C-14.

There are few philosophical problems with these reasons. Kalfoss and Cnad established that being compassionate is definitely part of caring, but it does not sit alone, so to speak. Positive consequences of care also require that the caregiver seeks to promote the notion that the cared for also has reasons to live. Assisting a person in dying would seem to run contrary to that. The same goes with dignity. Kalfoss and Cand argue that caring for someone requires that we endorse a person’s dignity, but also that we endorse and recognize the worth of each person. I argue that endorsing PAS sends a message that many people’s lives have little worth.

David Boonin, who is not actually in favour of restricting access to PAS, speaks on the idea of providing PAS, as opposed to simply stopping treatment of an otherwise gravely ill patient. He admitted that by being willing to participate in PAS, what he calls active euthanasia, you “concede that you are deliberately destroying something that, at least under most circumstances, has tremendous value: the life of an innocent human being” (Boonin 163). By endorsing PAS, Boonin argues that a physician would have to agree to killing the patient if 1. The patient consented to it, and 2. That physician agreed that that patient’s life is not worth living, in other words, the patient’s life is of no value. If Boonin is correct, it would seem that, even though things may not look good for the patient, to endorse PAS you would have to violate the elements of caring which speaks to promoting spiritual and physical well-being and giving the one being cared for reasons to live. That physician would not be committed to those aims and so cannot truly be said to care. I would argue, then, that anyone who supports the practice of PAS must also endorse the feelings and actions of those providing PAS and therefore they are not caring either.

Boonin goes further and argues that, in terms of public policy, people should not be using the power of government to endorse one set of values over another. So, by sanctioning PAS, the government, and those who support that government, are effectively saying that our society does not care about some lives. If Boonin is correct, and if my description of ‘care’ is correct, then any society which sanctions PAS cannot be said to be a caring society. And at a minimum, it is not a society, or at least a government, which values the views of substantial numbers of its members who do not endorse PAS. 

Finally, I want to address the issues of autonomy and the ending of suffering. Autonomy should be looked at in terms of its relationship with caring. A caregiver should promote the autonomy of the one being cared for. But for it to actually be cared for, the one caring must also recognize that the life of the one being cared for has worth and that they should be helping them find reasons to live. Also, when it comes to a person suffering from a severe illness, the level of autonomy possible for an individual is unquestionably circumstance specific. It cannot be said to be a universal principle under the circumstances. So, it makes little sense to argue that autonomy, or a lack thereof, has anything to do with wishing to die. Further to that, it has been argued that, simply by giving the option to receive PAS, not only does it imply that their life may not be worth living even if they may feel that it is it may also put pressure on them to choose PAS as they might begin to see themselves as a burden to their family or society in general. At a minimum the pressure may cause the person to begin to rethink their wish to live in light of the views of those around them. Velleman makes just such an argument. It is worth quoting the passage in full.

“… even if a patient antecedently believes that his life is worth living, he may have good reason to assume that many of the people around him do not, and that his efforts to convince them will be frustrated by prevailing opinions about lives like his, or by the biases inherent in their perspective. Indeed, he can reasonably assume that the offer of euthanasia is itself an expression of attitudes that are likely to frustrate his efforts to justify declining it. He can therefore assume that his refusal to take the option of euthanasia will threaten his standing as a rational person in the eyes of friends and family, thereby threatening the very things that make his life worthwhile. This patient may rationally judge that he’s better off taking the option of euthanasia, even though he would have been best off not having the option at all” (Velleman, 14).

I agree with Velleman. And I add to his argument by pointing out that this pressure also reduces a person’s autonomy because they will, effectively, be succumbing to the will of a society which they think expects them to choose PAS giving the state of their health. Simply having the choice, at least in some way, contributes to the reduction of one’s autonomy. To care means to promote autonomy, but it also means to promote life, regardless of the level of autonomy of the one being cared for. 

Where ending suffering is concerned, there is a simple logical problem with this being used as a reason to endorse PAS. For one to suffer, they must remain living. Killing them will not put an end to their suffering, it simply puts an end to their life. And with a view to care ethics in mind, it may be argued that because both the cessation and reduction of suffering are goals of caring, and because promoting life is a necessity in caring, when ending suffering is not possible, acting to reduce suffering should be seen as far more ethical than ending one’s life.  

Conclusion

What I have not done here is attempt to challenge the notion that persons who wish to end their lives should have the right to do so. I do not think that they do, and my previous article makes that case on biblical grounds. In this article I have attempted to establish a baseline understanding for what it means to ‘care’. And by expanding that understanding to include situations beyond the one-on-one caregiver and cared for relationship, I have shown that the practice of PAS cannot be seen to meet the established understanding of care. Finally, I have endeavored to show that, with a view to caring in mind, any society which endorses, or even just sanctions, PAS cannot be said to be one which cares for its most vulnerable. The Canadian government has not only legalized PAS, but it has also continually sought to expand it to include mental health as a legitimate reason to receive PAS. To be fair, the government has not gone about this willy-nilly. There have been attempts to put in place safeguards against the misuse and over-referral of PAS. But in my view, no matter how one goes about supporting PAS as a viable option in any circumstance, there is little room for them to argue that they are motivated by genuinely caring for others. 

Works Cited

Bill C-7: And Act to Amend the Criminal Code (Medical Assistance in Dying). Royal Ascent. 43rd Park. [Ottawa]: Library of Parliament, 2021. Parliament of Canada. Web. 05 Mar. 2023.

“Background.” Dying With Dignity Canada, 2021, https://www.dyingwithdignity.ca/end-of- life-support/get-the-facts-on-maid/.

Canada. Ministry of Justice. Legislative Background: Medical Assistance in Dying (Bill C-14), 2016. [Ottawa]: Ministry of Justice, 2016, Ministry of Justice. Web. 06 Mar. 2023.

Boonin, David. “How to Argue Against Euthanasia.” Journal of Applied Philosophy, vol. 17, no. 2, 2000, pp. 157-168.

Halwani, Raja. “Care Ethics and Virtue Ethics.” Hypatia, vol. 18, no. 3, Autumn 2003, pp. 161-192. Wiley

Kalfoss, Mary and Jenny. Owe Cand. “Building on Knowledge: The Concept of Care.” Open Journal of Nursing, vol. 6, 2016, pp. 995-1011. Scientific Research Publishing. 

Morse, Janice M, et al. “Concepts of Caring and Caring as a Concept.” Caring in Nursing Classics, edited by Smith, Marlaine C et al., Springer Publishing Company, 2012, 19-32.

Velleman, David. J. Beyond Price: Essays on Birth and Death. Open Book Publishers, 2015.

Walsh, Joseph. “Commitment and Partialism in the Ethics of Care.” Hypatia, vol. 32, no. 4, Fall 2017, pp. 817-832.