Voluntary Euthanasia, Physician-Assisted Suicide, and the Goals of Medicine

Abstract

It is plausible that what possible courses of action patients may legitimately expect their physicians to take is ultimately determined by what medicine as a profession is supposed to do and, consequently, that we can determine the moral acceptability of voluntary euthanasia and physician-assisted suicide on the basis of identifying the proper goals of medicine. This article examines the main ways of defining the proper goals of medicine found in the recent bioethics literature and argues that they cannot provide a clear answer to the question of whether or not voluntary euthanasia and physician-assisted suicide are morally acceptable. It is suggested that to find a plausible answer to this question and to complete the task of defining the proper goals of medicine, we must determine what is the best philosophical theory about the nature of prudential value.

Keywords:

• goals of medicine
• justification
• objective
• physician-assisted suicide
• subjective
• voluntary euthanasia

I. INTRODUCTION

It is plausible that what possible courses of action patients may legitimately expect their physicians to take is ultimately determined by what medicine as a profession is supposed to do and, consequently, that we can determine the moral acceptability of voluntary euthanasia and physician-assisted suicide on the basis of identifying the proper goals of medicine. ¹ Considering the recent bioethics literature, a distinction can be made between two main approaches to defining the proper ends of medicine. On the one hand, it is taken that the ends of medicine can be given an objective characterization in terms of such things as preservation of life, promotion of health, relief of pain and suffering, etc. On the other hand, philosophers stressing the value of individual autonomy in biomedical ethics would seem to be committed to accepting that the proper goals of medicine are ultimately determined by the autonomous decisions of patients. If the moral acceptability of what physicians may do is always dependent on the autonomous judgements of patients, the goals of medicine are in the end defined by the patients' autonomous decisions. In this article, I will examine the implications of these two ways of defining the ends of medicine to the question of whether or not voluntary euthanasia and physician-assisted suicide are morally acceptable. I will argue that, on the most plausible interpretation of them, neither of these two ways of defining the goals of medicine can present a clear answer to the problem of whether or not voluntary euthanasia and physician-assisted suicide are morally acceptable. I suggest that in order to solve this problem, and to complete the task of defining the goals of medicine, we should aim to identify the most plausible theory about the nature of prudential value. ²

II DEFINING THE TERMS

I will be talking about voluntary euthanasia, physician-assisted suicide, individual autonomy, subjective and objective theories of value, and subjectivism and objectivism about the goals of medicine. By voluntary euthanasia I mean a doctor's intentionally killing a patient at the patient's autonomous request. By physician-assisted suicide I mean a doctor's intentionally helping a patient to commit suicide by providing the patient with the means to end her life at the patient's autonomous request. ³

Although the notion of autonomy has been used in many distinct senses in different connections, it seems that in biomedical ethics there is a common core understanding of the meaning of this notion (see, e.g., Beauchamp & Childress, 1994; Harris, 2003; and Mappes & Zembaty, 1991). ⁴ According to this idea, autonomy means self-government. As an actual condition of an individual agent, autonomy means, roughly, that an agent uses her capacity to make her own decisions concerning her own life, and lives by these decisions. Of course, what exactly this means is controversial. I would however argue that all plausible theories of individual autonomy accept at least the following requirements of autonomy. If a person's decisions, beliefs, desires, etc. are due to such external influences as unreflected socialization, manipulation, coercion, and brainwashing, they are not autonomous but heteronomous. And if a person's beliefs concerning some matter are false, inconsistent with each other, or she is insufficiently informed about that matter without realizing it, ⁵ then she is not autonomous with respect that matter. Similarly, if a person's behavior results from such things as compulsion and weakness of will, then it is not autonomous but heteronomous. This conception of the nature of individual autonomy is rough, but sufficient for the purposes of this article.

According to the commonly accepted understanding of what the distinction between subjective and objective theories of value is about, subjective theories make value dependent on individuals' attitudes of favor and disfavor. Objective theories of value deny this dependency (see, e.g., Arneson, 1999; Bernstein, 1998; Parfit, 1984; Sumner, 1996; and Thomson, 1987). Thus, when our task is to determine whether or not some particular thing, activity, or state of affairs is valuable, the subjective theories of value advise us to consult individual agents, to pay attention to their preferences and attitudes of favor and disfavor. Usually subjective theories require that the preferences that determine value must be informed or rational. ⁶ Objective theories, in their pure forms, maintain that value is not determined by individuals' own attitudes of favor and disfavor. Instead of these kinds of subjective states, objective theories usually make value dependent on such purportedly objective issues as whether a thing or an activity satisfies human needs, realizes the human nature, etc.

Above I distinguished between two different ways of defining the goals of medicine. The view that the ends of medicine can be given an objective characterization in terms of such things as prevention of disease, relief of pain and suffering, avoidance of premature death, etc., I will call objectivism about the goals of medicine. The other stand mentioned above, namely that the ends of medicine are determined by the autonomous decisions of patients, I will call subjectivism about the goals of medicine. With this understanding of the notions of voluntary euthanasia, physician-assisted suicide, individual autonomy, subjective and objective theories of value, and subjectivism and objectivism about the goals of medicine, I turn to considering the two ways of defining the goals of medicine and their implications to the issue of the moral justifiability of voluntary euthanasia and physician-assisted suicide.

III VOLUNTARY EUTHANASIA, PHYSICIAN-ASSISTED SUICIDE, AND SUBJECTIVISM ABOUT THE GOALS OF MEDICINE

The case of subjectivism about the goals of medicine and the moral justifiability of voluntary euthanasia and physician-assisted suicide seems relatively straightforward. Subjectivism about the ends of medicine maintains that what possible courses of action physicians can legitimately take is ultimately determined by the autonomous decisions of their patients. Consequently, subjectivism about the goals of medicine would seem to be committed to holding that the moral acceptability of voluntary euthanasia and physician-assisted suicide is also dependent on the patients' autonomous decisions. But before we draw the conclusion that subjectivism about the ends of medicine permits voluntary euthanasia and physician-assisted suicide under these circumstances, we should need a better understanding of this way of defining the proper goals of medicine and, hence, ask why individual autonomy is such a central value in subjectivism about the ends of medicine. Two main reasons for valuing individual autonomy have been presented in the bioethics literature. Firstly, it has been maintained that autonomy is valuable as an instrument of promoting the patient's well-being. Secondly, it has been claimed that, in addition to whatever instrumental value autonomy has in enhancing the patient's well-being, autonomy is also valuable for the patient independently of its role in promoting her good (see, e.g., Beauchamp & Childress, 1994; Buchanan & Brock, 1989; Crisp, 1990; Gillon, 2003; Harris, 2003; and Veatch, 2000). Let us briefly consider the latter view.

If autonomy's value for a patient is not exhausted by its role in promoting her well-being, then the patient's autonomy should be respected even if the courses of action she is considering taking were harmful for her. But how should this be understood? Since it is commonly accepted that medicine should be looking at things from the point of view of the patients' interests, it is plausible that the view that a patient's autonomy should be respected even if the courses of action she is considering taking were harmful for her should be interpreted to be saying that we must allow a patient acting from self-interested reasons to harm herself. But whose conception of harm is at use here? It rationally cannot be that of the patient herself, since an autonomous person acting from self-interested reasons will not want to take courses of action that she herself considers as harmful for her and, consequently, there is no good reason to require that the patient should be allowed to act in such ways. ⁷ So, it seems that the conception of what is harmful for the patient would have to be that of someone else.

Since other persons' subjective determinations of what is and what is not prudentially valuable might not apply to the patient's case at all, the question here rationally must be about an objective conception of what harms persons. And it would seem that we might have reason to think that a person's autonomy has value for her over and beyond its role in promoting her well-being only if objectivism about what harms and benefits patients is true, for it appears that only then we could have any grounds to require that patients should be allowed to take courses of action that are harmful for them. This is because then a patient's conception of what is harmful for her could differ from the standard of harm adopted by the proponents of the view that a patient's autonomy should be respected even if the courses of action she is considering taking would be harmful for her. Consequently, the patient acting from self-interested reasons could be willing to take courses of action that are harmful for her according to that standard. However, even if what is and what is not prudentially valuable were determined objectively, the patient as an autonomous agent would be aware of what is good and bad for her, or at least could appreciate it when it was presented to her, and, consequently, she would not insist on taking objectively self-harming courses of action from self-interested reasons. ⁸ Again, we have no good reason to require that autonomous patients acting from self-interested reasons should be allowed to harm themselves, since they are not willing to do that. ⁹

Thus, the only reason for insisting that autonomy has value for patients' beyond its instrumental value in promoting their well-being would be that it would guarantee that heteronomous patients are allowed to hurt themselves if that is what they happen to want. But since we are now considering the case of autonomous patients, this reason does not apply here at all and, consequently, we have no good reason to hold on to the view that autonomy's value for patients is not exhausted by its worth in enhancing their well-being. But if this view is rejected, then the patients' autonomy should be valued only when, and to the extent that, it enhances their well-being. In other words, the primary value here is well-being, not autonomy, and whether or not voluntary euthanasia and physician-assisted suicide are morally acceptable depends on whether they harm or benefit the patient. And importantly, what benefits and harms individual patients need not be determined by their autonomous decisions; it is possible that prudential value is objective in the sense defined above. Thus, after considering the reasons why subjectivism about the goals of medicine stresses the value of autonomy, we are led to the conclusion that in this way of defining the ends of medicine the moral acceptability of voluntary euthanasia and physician-assisted suicide is ultimately determined by what is harmful and beneficial for patients. And this is not necessarily defined by the patients' autonomous decisions. ¹⁰

IV VOLUNTARY EUTHANASIA, PHYSICIAN-ASSISTED SUICIDE, AND OBJECTIVISM ABOUT THE GOALS OF MEDICINE

To determine the implications of objectivism about the goals of medicine to the question concerning the moral acceptability of voluntary euthanasia and physician-assisted suicide, we must first identify the objective goals of medicine. I will here concentrate on a group of goals that includes, I think, what have been taken to constitute the appropriate objective ends for medicine in the bioethics literature. The list of goals to be considered here contains the following entries:

1. avoidance of premature death,

2. preservation of life,

3. prevention of disease and injury,

4. promotion and maintenance of health,

5. relief of pain and suffering,

6. avoidance of harm, and

7. promotion of well-being. ¹¹

Since it seems plausible that the nature of the relationship between at least some of these goals and voluntary euthanasia and physician-assisted suicide may be dependent on the particular characteristics of the patient who requests to be euthanized or assisted in committing suicide, I will consider this relationship in connection with the cases of two different persons, A and B. Person A has a fatal disease that causes her great pain and suffering, and it is known that A will die shortly. Knowing this, A autonomously asks her physician to euthanize her, or at least to assist her to commit suicide. Person B is in good health, but has for long felt that her existence is quite futile and useless. Although B is not in agony, she does not see any point in continuing her life and, as a result of this, B autonomously asks her physician to help her to commit suicide. ¹²

A Avoidance of Premature Death

Whether or not voluntary euthanasia and physician-assisted suicide are incompatible with avoidance of premature death depends on how the evaluative notion of “premature” is defined. If subjectivism about value is accepted, then the definition of premature is determined on the basis of the autonomous preferences of individual persons and, consequently, voluntary euthanasia and physician-assisted suicide are morally acceptable when the person in question does not consider death as premature for her and requests for euthanasia or assistance in committing suicide. If objectivism about value is accepted, whether or not voluntary euthanasia and physician-assisted suicide are morally acceptable depends on the nature of the objective values relevant to the issue. For example, if it is an objective evaluative fact that all death that is hastened is always premature, voluntary euthanasia and physician-assisted suicide are incompatible with avoidance of premature death. And, for another example, if it is an objective evaluative fact that death would be premature for a healthy person like B, but not for a fatally diseased person like A, then the goal of avoidance of premature death would deny voluntary euthanasia and physician-assisted suicide in the case of B, but allow them in the case of A.

Thus, to decide whether or not avoidance of premature death is compatible with accepting voluntary euthanasia and physician-assisted suicide, we need to determine whether subjectivism or objectivism about the nature of value is plausible. Although there are different views concerning what exactly qualifies as a legitimate goal for medicine, the general view that medicine ought to aim at promoting the patients' interests is generally accepted. So, it is reasonable to take that the values that determine whether or not voluntary euthanasia and physician-assisted suicide are morally acceptable should be primarily connected to what is in the patients' interest. ¹³ Above I argued that, irrespective of whether harm is defined subjectively or objectively, autonomous patients acting from self-interested reasons are not willing to take courses of action that they consider as harmful for them. If this argument is correct, then there is no good reason to require that allowing patients to harm themselves would be in their interests. Consequently, it can be said that only actions that are good for the patients can be in their interests. If so, then the question of whether or not voluntary euthanasia and physician-assisted suicide are incompatible with avoidance of premature death leads to the question of whether or not they benefit or harm the persons requesting for them. And we can give a reasonable answer to this question only after we have identified the most plausible theory of prudential value.

B Preservation of Life

If medicine should always preserve life, then it is clear that euthanizing a person or assisting her in committing suicide is not compatible with the ends of medicine. However, although preservation of life has often been considered the main goal of medicine, many bioethicists currently accept that maintaining life of any quality is not a morally legitimate end for medicine. Instead, it is frequently argued that when the quality of a patient's life remains permanently below a certain threshold, as is thought to be the case for patients in a permanent vegetative state, physicians need not preserve her life. Let us however now consider the view that physicians should aim to preserve their patients' life irrespective of its quality. ¹⁴ Is this view plausible?

It can at least be said that the value of preserving life is not self-evident, since it is possible for autonomous persons, such as A and B and the bioethicists who maintain that a vegetative life is not worth preserving in the case of human beings, to deny it. So, some grounds are needed for the view that a patient's life should always be preserved. Again, for the reasons presented in discussing avoidance of premature death above, these grounds must concern what would harm and benefit the patient. Thus, since the value of maintaining life is not self-evident, the question of whether or not voluntary euthanasia and physician-assisted suicide are wrong because they are incompatible with preserving the patient's life leads to the question of whether voluntary euthanasia and physician-assisted suicide would benefit or harm the patient.

C Prevention of Disease and Injury

Of what kind is the relationship between voluntary euthanasia, physician-assisted suicide, and prevention of disease and injury? In the case of A, who is fatally and incurably ill, voluntary euthanasia and physician-assisted suicide could be the only ways of preventing further disease and injury. Because of this, adopting prevention of disease and injury as a goal of medicine would not be in conflict with, and could even support, accepting voluntary euthanasia and physician-assisted suicide in the case of A. What about the case of B, the healthy and autonomous suicide-candidate? In B's case, euthanasia and suicide would prevent future disease and injury, but it would, of course, be patently absurd to maintain that physicians should euthanize healthy people or to help them to kill themselves in order to prevent future disease and injury. So, it can be taken that the goal of preventing disease and injury does not apply to B's case at all and, thus, that preventing disease and injury speaks neither for nor against voluntary euthanasia and physician-assisted suicide in the case of B.

D Promotion and Maintenance of Health

How is the goal of promoting and maintaining health related to voluntary euthanasia and physician-assisted suicide? In terms of this goal of medicine, there are two possibilities to be considered with the case of A. Firstly, it can be maintained that since A has permanently lost her health, there is no reasonable question of whether or not her physician should aim at promoting and maintaining her health. Secondly, it could be claimed that although A is suffering from a fatal disease, she is not totally incapacitated and her physician should strive to maintain her health to the degree that it still is possible. ¹⁵ The case of the first option is quite straightforward. It sounds intuitively plausible to say that A has permanently lost her health. If we accept this, then considerations pertaining to promotion and maintenance of health do not apply to A's case at all, because in her case there is no health to be maintained and no reasonable expectation that any measures taken to promote health would be of use. What about the second option? Its implications concerning the justifiability of voluntary euthanasia and physician-assisted suicide are as clear as those of the first option. If the physician should aim to promote and maintain health to whatever degree it is possible, then it would be wrong of her to euthanize A or to assist A to commit suicide.

But is it plausible that physicians ought always to promote and maintain health in situations like that of A? The case we have here is relevantly similar to that of the claim that medicine ought to preserve life discussed above. Since A, an autonomous patient, can consider euthanasia or assisted suicide as real options for her, it cannot be self-evident that health should always be maintained and promoted. ¹⁶ So, some reasons are needed for the view that A's physician should promote and maintain A's health to the minimal degree that is possible. And again, it is plausible that these reasons must connect primarily to what would harm and benefit A. So, adopting the view that A has not lost her health, the question of whether or not promotion and maintenance of health are incompatible with voluntary euthanasia and physician assisted-suicide leads to the question of what benefits and harms A.

Promoting and maintaining health is clearly incompatible with assisting B to kill herself and would thus seem to provide a good reason against accepting voluntary euthanasia and physician-assisted suicide in B's case. However, although the need for justification for the view that health should be maintained and promoted is not as clear in the case of B as it is in the case of A, B's request to be euthanized or assisted in committing suicide is autonomous and, consequently, good reasons should be presented for the view that health ought to be maintained and promoted in cases like that of B. And again, it is reasonable to accept that these reasons should connect to what would be good and bad for B.

E Relief of Pain and Suffering

Probably the most common reason for accepting voluntary euthanasia and physician-assisted suicide is that sometimes they are the only ways of relieving unbearable pain and suffering. In the case of A, the goal of relieving pain and suffering speaks for voluntary euthanasia and physician-assisted suicide, at least when there are no other ways of alleviating A's agony. In B's case, considerations pertaining to relieving pain and suffering do not apply at all, since B is not suffering nor in pain, but merely has continuous feelings of futility and uselessness. ¹⁷ So, accepting relief of pain and suffering as an objective goal of medicine supports voluntary euthanasia and physician-assisted suicide in A's case, but has no implications concerning the moral acceptability of voluntary euthanasia and physician-assisted suicide in the case of B.

F Avoidance of Harm

Of what kind is the relationship between avoidance of harm and voluntary euthanasia and physician-assisted suicide? The goal of medicine now at issue mentions the evaluative notion of harm and, consequently, we can determine whether avoidance of harm supports or is against voluntary euthanasia and physician-assisted suicide only after we know more about the nature of harm. On the one hand, if what is harmful and what is not is always determined on the basis of the subjective preferences of individual persons, then voluntary euthanasia and physician-assisted suicide should be accepted if patients autonomously request for them. On the other hand, if objectivism about the nature of harm is true, then we can determine the moral acceptability of voluntary euthanasia and physician-assisted suicide on the basis of identifying what in objective fact is harmful and beneficial for persons.

As I said above, since it is commonly accepted that the general end of medicine is to promote the patients' interests, I will assess the moral acceptability of voluntary euthanasia and physician-assisted suicide primarily from the point of view of what is in the interest of the patient who requests to be euthanized or assisted in committing suicide. However, since there is an important criticism of euthanasia and physician-assisted suicide that concerns the interests of people other than that patient in question, I will now briefly consider the acceptability of voluntary euthanasia and physician-assisted suicide from a more general point of view.

According to the criticism in question, accepting voluntary euthanasia and physician-assisted suicide could lead to general devaluation of life. Once the ban on killing patients was removed, this line of criticism maintains, physicians who would euthanize persons or assist them to commit suicide at their own request could also consider it permissible to kill patients who are not willing to die. And if this kind of attitude toward the value of life were adopted in medicine, it could spread to other spheres of life with the possible eventual effect that one of our basic values would cease to exist. ¹⁸ Pellegrino, a proponent of this line of criticism of voluntary euthanasia and physician-assisted suicide, writes as follows:

Once a moral precept is breached a psychological and logical process is set in motion which follows what I would call the law of infinite regress of moral exceptions. One exception leads logically and psychologically to another. In small increments a moral norm eventually obliterates itself. (Pellegrino 2001, p. 98)

I am not sure about what Pellegrino means by one exception's leading logically to another in this connection. However, it is plausible to accept that the conclusion of a logically valid argument cannot say anything that is not either explicitly or implicitly included in its premises. Consequently, if we adopt the premise that a physician may kill a patient at that patient's autonomous request or that a physician may assist a patient to commit suicide if the patient autonomously asks for such assistance, we logically need not accept the conclusion that physicians may kill their patients for other reasons. This is because, as such, the view that voluntary euthanasia and physician-assisted suicide are morally acceptable does not say anything about killing patients on other grounds. If the conclusion that physicians may kill patients for reasons other than their own autonomous request is to follow logically, other premises are needed. ¹⁹

What about an exception's leading psychologically to another? I am not sufficiently familiar with the research pertaining to the empirical question of whether or not accepting voluntary euthanasia and physician-assisted suicide leads to increases in non-voluntary euthanasia and to general devaluation of life. ²⁰ I would, however, like to make one point concerning the logic of this argument. If it were a fact that in practice permitting voluntary euthanasia and physician-assisted suicide would lead some persons to think that physicians should be allowed to kill their patients against the patients' will, this as such would not be a sufficient reason for rejecting voluntary euthanasia and physician-assisted suicide. It could, I think, be more reasonable to try to improve the logic of those who would require that since voluntary euthanasia and physician-assisted suicide are permitted, physicians should be allowed to kill their patients against their will. I conclude that these kinds of considerations pertaining to possible general harm do not provide a sufficient reason for rejecting voluntary euthanasia and physician-assisted suicide.

G Promotion of Well-Being

How does promotion of well-being relate to voluntary euthanasia and physician-assisted suicide? Since A is already suffering and her illness is only getting worse, I presume that the view that voluntary euthanasia and physician-assisted suicide are not morally acceptable in A's case because physicians should help A to enjoy whatever well-being is still possible for her to have is not acceptable. If any well-being at all is possible for A, it is so minimal as to be negligible. ²¹ Then adopting promotion of well-being, as opposed to relief of pain and suffering, ²² as a goal of medicine does not apply to A's case at all and, thus, has no implications to the question concerning the moral acceptability of voluntary euthanasia and physician-assisted suicide in A's case. In the case of B, the view that allowing voluntary euthanasia and physician-assisted suicide would promote well-being does not seem to be as clear as in the case of A, since it sounds suspect that death could enhance the well-being of a healthy person. However, since B requests for assistance in committing suicide, she herself must be convinced that death would be good for her. Then, once again, to find a reasonable answer to the question of whether or not voluntary euthanasia and physician-assisted suicide should be accepted, we would need to know exactly how patient harms and benefits should be defined.

To summarize, in the cases of both A and B, the goals of avoidance of premature death, preservation of life, and maintenance and promotion of health lead to the question of what benefits and harms persons. Prevention of disease and injury allow voluntary euthanasia and physician-assisted suicide in the case of A and deny them in the case of B. Relief of pain and suffering is silent about the acceptability of voluntary euthanasia and physician-assisted suicide in the case of B, but allows them in the case of A. The relationship between avoidance of harm and voluntary euthanasia and physician-assisted suicide can be determined only after the best theory about the nature of harm is identified. And promotion of well-being leads to the question of what benefits and harms persons in the case of B and does not apply to A's case at all.

The case of the objective goals of medicine and the moral acceptability of voluntary euthanasia and physician-assisted suicide can then be understood in two different ways. On the one hand, if the objectivist sees only prevention of disease and injury as a suitable goal for medicine, then her conception of what medicine is about provides a clear answer to the question concerning the moral acceptability of voluntary euthanasia and physician-assisted suicide. But why should only prevention of disease qualify as a goal of medicine? ²³ Why not also relief of pain and suffering and promotion and maintenance of health, for example? For reasons presented above, these kinds of questions can be reasonably answered only by considering what would be good and bad for the patients.

On the other hand, if the objectivist adopts other goals in addition to, or instead of, prevention of disease and injury, then her ends of medicine do not provide a clear answer to the question concerning the moral acceptability of voluntary euthanasia and physician-assisted suicide. But how is she then to determine her stand in this issue? It would beg the question if she chose to respect only those goals that would produce the result concerning the moral acceptability of voluntary euthanasia and physician-assisted suicide that she happens to favor, or if she defined the priority relations between the different goals so that that result is achieved. So, the objectivist about the goals of medicine needs good reasons to determine her stand concerning the moral acceptability of voluntary euthanasia and physician-assisted suicide. And again, it is reasonable to accept that these reasons must have primarily to do with what would benefit and harm the patients who autonomously request for euthanasia or assistance in committing suicide. But if what physicians should do ought always to be determined on the basis of what harms and benefits the patients, then the primary concern of medicine is to promote the patients' well-being. And if the primary goal of medicine is to enhance the patients' well-being, then medicine has no use for such general principles like always preserve life, etc., whose compatibility with the end of promoting the patients' welfare is not clear.

V CONCLUSION

In this article, I took as my point of departure the view that the moral acceptability of voluntary euthanasia and physician-assisted suicide can be determined on the basis of identifying the proper goals of medicine. I considered the two main ways of defining the goals of medicine found in the recent bioethics literature, subjectivism about the ends of medicine and objectivism about the ends of medicine, in connection with voluntary euthanasia and physician-assisted suicide, and argued that, as they are, neither of these two approaches provides a clear solution to the question concerning the moral acceptability of voluntary euthanasia and physician-assisted suicide. Instead, both of them ultimately lead to the question of how what benefits and harms patients should be defined.

I conclude that in order to solve the problem concerning the moral acceptability of voluntary euthanasia and physician-assisted suicide, and to complete the task of defining the proper goals of medicine, we should turn away from the ends of medicine as they have been understood in the recent bioethics literature and determine what is the best philosophical theory about the nature of prudential value. Furthermore, since what promotes individual well-being may include such things as appreciation of true beauty and sailing (see, e.g., Parfit, 1984), it is plausible that medicine should not concern itself with promoting whatever enhances the patients' well-being. Hence, in order to specify the proper goals of medicine, we should, in addition to determining the most acceptable theory of prudential value, delineate that part of well-being that can legitimately be taken as a suitable concern for medicine. I must leave these tasks for another occasion. ²⁴

Notes

1. For discussions of the moral acceptability of voluntary euthanasia and physician-assisted suicide in terms of what medicine is supposed to do see, e.g., Dworkin (1998); Kass (1989); Pellegrino (2001); and Seay (2001).

2. I will concentrate on the question of whether or not it is morally permissible for physicians to euthanize their patients or to assist them to kill themselves. However, since it is plausible to accept that considerations pertaining to the moral acceptability of physicians' euthanizing their patients or assisting their patients to kill themselves are to a great extent coextensive with those concerning the moral acceptability of killing, assisting in killing, and committing suicide, this article is relevant to this latter question also. I thus assume that questions pertaining to the moral acceptability of voluntary euthanasia and physician-assisted suicide should be evaluated in terms of general factual and evaluative considerations and hence reject the view that there could be reasons purely internal to medicine, reasons that could override general factual and evaluative considerations that is, that could decide these questions. In my view, the questions of what the proper goals of medicine are and are voluntary euthanasia and physician-assisted suicide morally acceptable rationally cannot be answered without referring to general evaluative and factual considerations, or by reaching a reflective equilibrium between acceptable principles of logic and rationality, the best factual information about ourselves and our environment, and our most deeply held moral and prudential intuitions (see, e.g., Rawls, 1971; Daniels, 1979). For a plausible argument to the effect that such purely internal reasons do not exist see Beauchamp (2001).

3. Some dictionaries and many philosophers define voluntary euthanasia and physician-assisted suicide in terms of suffering, so that these concepts can apply only to cases of patients who are suffering. I am not sure whether or not suffering should be required here. On the one hand, if a patient autonomously wants to die, why should she suffer in order for it to be morally legitimate for physicians to euthanize her or to assist her to commit suicide? On the other hand, it sounds plausible that autonomous persons acting from self-interested reasons would not want to die unless they are suffering. However, the case of Edward Brongersma, an 86-year-old former senator in the Dutch parliament, who committed suicide with the assistance of a doctor simply because he was elderly and tired of life, provides an example of a case that does not seem to involve suffering but which should, I think, be counted as a case of physician-assisted suicide. Since whether or not suffering is included in the definitions of voluntary euthanasia and physician-assisted suicide does not affect the main argument of this article, I will not go deeper into this issue in this connection.

4. This understanding of the core idea of autonomy is accepted also outside biomedical ethics, see, e.g., Dworkin (1988) and Young (1986).

5. According to this conception of individual autonomy, an autonomous person may thus have false beliefs and beliefs that are inconsistent with each other and she may be uninformed about some matter as long as she realizes it; in self-regarding matters an autonomous person may choose not to know certain things, she may want to take risks, or she may consider a decision she is to make too inconsequential for information gathering.

6. Perhaps the most popular theory of this kind is that of Richard Brandt, which maintains that desires are informed or rational when they have undergone cognitive psychotherapy, i.e. when they have survived maximal criticism by facts and logic (See Brandt, 1979).

7. An anonymous reviewer has objected that this ignores the possibility that an agent may autonomously want to select one harm in order to avoid other harms she prefers to avoid. I assume that the choice between living with increasing suffering and dying could be an example of this kind of choice. When we are talking about people in general and other things are being equal, it is plausible that the options of living with increasing suffering and dying are usually both considered as bad options. But the reason for this is that people usually have other options in addition to living with increasing suffering and dying. When living with increasing suffering and dying are the only options that a person has and she then chooses death (or living with increasing suffering), it would be implausible to maintain that that choice is bad for her in the particular circumstances that she faces. When the person is autonomous, as she is now assumed to be, she chooses death (or living with increasing suffering) for the reason that it in her considered view is the best option open to her. She thus does not choose one harm in order to avoid another harm she prefers to avoid. That dying and living with increasing suffering are considered as bad options when persons have a variety of other options and other things are being equal does not make both of these options bad in the circumstances of this person.

8. There could be theories that maintain that actual persons as opposed to ideal observers and such are in principle incapable of knowing the nature of the objective evaluative facts. However, since these kinds of theories would be quite uninformative and utterly trivial for practical purposes, to be useful they would have to present such a loosened conception of the nature of evaluative facts that actual persons could be aware of them. And if the patient were unaware of this kind of facts, or unable to appreciate them when they were presented to her, she would not qualify as an autonomous agent.

9. An anonymous reviewer has objected that the above argument is problematic because it would seem to make an autonomous person incapable of harming herself. It is indeed true that autonomous persons can harm themselves when they sacrifice themselves for others or when they disregard their own well-being for other reasons. But we are now considering what an autonomous patient acting from self-interested reasons would want to do. Sacrificing oneself for others, as opposed to going trough the motions of sacrificing oneself in order to, say, get appreciation from others, is by definition something that is against one's own interest and, consequently, a person rationally cannot want to sacrifice herself for self-interested reasons. And it is plausible that autonomy should require rationality of this kind. Similarly, to the extent that a person is acting from self-interested reasons, she cannot be willing to disregard her well-being by taking courses of action that may harm her, when the harm is not part of a net benefit for her. That we are now looking at things from the point of view the patient's interest follows from the assumption made above that medicine should be looking at things from that point of view. Although in practice there can be hard cases that require one patient to sacrifice herself for others, when other things are being equal, it is not plausible that medicine should require a patient to act against her own interest or in disregard of it. When other things are not being equal and a patient's interest conflict with those of others, she may make an autonomous decision to sacrifice herself to help the others. But in that case, although medical procedures may be in use, the patient who is sacrificing herself has, I think, stepped out of the sphere of health care proper.

10. It is sometimes taken that respect for individual autonomy implies subjectivism about prudential value. For an argument to the effect that this is not the case, see Varelius (2003). And in any case, if my argument above is correct, the primary value here is well-being, not autonomy. Consequently, considerations pertaining to autonomy alone cannot determine the implications that subjectivism about the goals of medicine has to the question concerning the moral acceptability of voluntary euthanasia and physician-assisted suicide.

11. In presenting the list of objective goals of medicine above it was not my purpose to describe any internal morality of medicine. The notion of internal morality of medicine has been used in many different senses in the recent bioethics literature (see, e.g., Arras, 2001, p. 645 ff.), and I do not find it necessary or useful to refer to any of them in this connection. It is possible to accept the objective goals of medicine I mention without accepting internal morality of medicine in any of these senses. And although it is possible to combine these objective goals of medicine with some kind of internal morality of medicine, accepting internal morality of medicine in one or all of these senses need not commit one to accepting these objective goals of medicine. Admittedly, among the different senses in which this notion has been used, there is a sense in which internalmorality of medicine means that the morality of medicine is derived from reflection on the essence of medicine, on its proper nature, goals, or ends. But in my view, criticisms presented by Beauchamp (2001), Arras (2001), and Veatch (2001) refute the different theories of internal morality of medicine recently presented. As I say in endnote 2, I think that what the goals of medicine are should be determined on the basis of general evaluative and factual considerations, by reaching a reflective equilibrium between acceptable principles of logic and rationality, the best factual information about ourselves and our environment, and our most deeply held moral and prudential intuitions (see, e.g., Rawls, 1971; Daniels, 1979), and there would not seem to be any reasonable and useful sense in which these kind of considerations could be said to be internal to medicine.

12. I assume that B is not so depressed as not to qualify as an autonomous agent. The case of Edward Brongersma (see endnote 3 above) provides, I think, a real-life example of this kind of person. If it is shown that it is an objective evaluative fact that dying is always bad for a person, then these requests of A and B will turn out to be heteronomous after all. However, since the existence of this kind of an objective evaluative fact has not been established, we may legitimately assume that A and B may autonomously request for euthanasia and assistance in committing suicide.

13. I will briefly return to questions pertaining to other people's interests below.

14. I will return to questions pertaining to quality of life below in discussing promotion of well-being as an objective goal of medicine. As it has usually been used in bioethics literature, the concept of quality of life means the patient's own subjective experience and evaluation of how well or badly she is faring. The nature of the relationship between well-being and quality of life depends on whether or not we accept that only things that enter an agent's experience can have an effect on her well-being. If we accept this experience requirement, then it is reasonable to accept that quality of life is the same as well-being, for then only things that enter an agent's experience can have an effect on her well-being. And it seems to me plausible that things that have an effect on how well a life is going for the person who is living it, that is, on that person's well-being, will influence the person's quality of life as understood in the present sense. I do think that the experience requirement should be accepted and thus that well-being is actually the same as quality of life, but I am not able to present my arguments to this effect here. So, those who accept the experience requirement may assume that what I say below is directly relevant from the point of view of quality of life, whereas those who reject the experience requirement must assume that I will be talking about well-being as distinguished from quality of life.

15. This comes close to, or is the same as, what has sometimes been meant by healing as a goal of medicine. Pellegrino (2001, p. 96), for example, maintains that important dimensions of the dying person's life are susceptible to healing right up to the moment of death.

16. An anonymous reviewer has objected that, contrarily to what I suggest above, autonomous agents can choose to act against self-evident moral propositions. This objection refers to certain perennial questions pertaining to the nature of moral motivation. I cannot go into these problems here in detail, but would however like to say the following. Above I assume that morality is action-guiding and that (sincere) persons engage in moral argumentation in order to find the morally right way to act. There are persons who choose to ignore all moral considerations and, assuming that they can be autonomous, these autonomous agents can act against self-evident moral propositions. However, if we know that a person will reject all moral considerations, there is, from the moral point of view, no good reason to try to engage her in moral argumentation. So, the above problem concerning whether or not voluntary euthanasia or physician-assisted suicide should be performed is assumed to arise between parties who are motivated to act morally. If the moral proposition that health should always be maintained and promoted is self-evidently true, I think that an autonomous person committed to acting morally cannot act against it if she is aware of it and other things are being equal. However, if other things are not being equal and in addition to acknowledging that moral proposition an autonomous agent would also be aware of some other moral proposition obligating her to act in a way that is incompatible with her acting in accordance with the moral proposition that health should always be maintained and promoted in the particular circumstances that she faces, she could not act in accordance with both of these moral propositions in that situation. Then she would have to choose to act against one of them. However, that a moral obligation is overridden by another moral obligation in some particular case does not result in the overridden moral obligation's losing its obligating power. If, for example, a person's rescuing a child from a burning house makes it impossible for the person to keep her promise to be elsewhere to meet her friend, that person should still explain to her friend her failure to keep her promise and perhaps also try to make up for that failure in other ways. In other words, even if moral dilemmas, situations where a person is under two or more moral obligations all of which she cannot obey due to some contingent feature in the circumstances she faces (see, e.g., Gowans, 1994), would make it necessary for an autonomous person who is motivated to act morally to act against a moral obligation, the person should still not act against that moral obligation when the dilemma is over.

17. Again, it would be quite absurd to maintain that medicine should aim to relieve future pain and suffering by euthanizing healthy persons or by assisting them to make suicides.

18. A version of this criticism maintains that permitting voluntary euthanasia and physician-assisted suicide would have the effect that patients could no longer trust physicians. If physicians were allowed to kill, this argument maintains, patients could not trust that their physicians would always do their best to promote their patients' interests. However, it is clear that this argument begs the question, since it presupposes that voluntary euthanasia and physician-assisted suicide can never be in the patient's interests.

19. Of course, this view is not incompatible with allowing that the patient herself may want to be euthanized because she does not want to be a burden to others or for other similar reasons. The crucial issue here is that the patient autonomously requests euthanasia or assistance in committing suicide.

20. On this issue see Bok (1998, pp. 112–117), Frey (1998), and Singer (2003, pp. 538–541).

21. If this is not accepted, then we are once again led to the question of what benefits and harms the patient, i.e., would it be best for her to die as she herself wants to or to continue living and have whatever minimal amount of well-being is still possible for her to have.

22. I will not now go into the question of exactly how avoidance of harm and alleviation of pain on the one hand and promotion of well-being on the other can be distinguished from each other, but will just assume that such a distinction can be made and thus that the goals of avoidance of harm and alleviation of pain can be seen as distinct from the goal of promotion of well-being.

23. For a view stressing the centrality of relieving suffering in medicine see Cassell (1991), contrast Gunderman (2002).

24. I thank professor Veikko Launis and an anonymous reviewer for their helpful comments on an earlier version of this article.