The medical ethics of physician-assisted suicide.

Absolute prohibitions of physician assistance in suicide have long been canonical in medical ethics, but a powerful reformation of views on euthanasia and physician-assisted suicide is now underway in several countries. The law on physician-assisted suicide in the state of Oregon, social approval of euthanasia in the Netherlands, and the (in principle) legality of active euthanasia in Japan are clear signs of the future. The key moral issue that will drive discussion is the liberty to choose the means to one's death and the justification , if any, for limiting that liberty. Until very recently the consensus view in most countries was that a passive euthanasia of letting die is acceptable, but an active euthanasia of killing is not. An extraordinary transformation in our conception of the role of patient autonomy had occurred to bring about this consensus. We migrated from a fear of any form of intentional hastening of death to a confidence that it is permissible under a variety of conditions intentionally to forgo life-sustaining technologies of all types, knowing that death will ensue. This history is now shifting from refusal of treatment-where the consensus was originally formed-to request for aid that involves physicians (or other second parties). The issues of first-party refusals of life-sustaining technologies are behind us. The issues are now about how patients will be able to request aid. My concern here is not with issues of legalisation or appropriate public policy. I want to suggest why certain acts that have traditionally been considered mercy killings are better framed as forms of requested aid-in-dying. The term "killing" has done more to confuse than to clarify thinking about these matters. None the less, killing remains the centrepiece of the current discussion. The influential distinction between killing and letting die is essential to the traditional view that killing (even at another's request) is prohibited and letting die permitted under specified conditions. However, the multipurpose term "killing" does not entail a wrongful act or a crime, and there are several generally accepted justifications of killing, such as killing in self-defence and killing to rescue a person endangered by the immoral acts of other persons. Correctly to apply the label "killing" or the label "letting die" to a set of events will therefore not determine whether the set of events is morally acceptable or unacceptable. This is as true in medicine as elsewhere. Killing may typically be wrong and …