By David Geddes.
Since Beauchamp and Childress introduced the four pillars of medical ethics in their 1979 book Principles on Biomedical Ethics, there has been a discourse on which of the pillars, if any, accurately upholds the principles and values of contemporary medicine. Each pillar can be considered fundamental in some contexts, yet in others it is reinterpreted, compromised, or even dismissed.
Among these, the pillar of non-maleficence (The obligation to avoid causing harm) highlights a significant tension within medical ethics. On one side, medical practitioners do not subject individuals to unnecessary testing and procedures. For example, a patient will not be given an arterial blood gas unless clinically necessary. On the other hand, medical practitioners continuously subject individuals to varying levels of harm and distress when it is deemed clinically necessary, for example performing an arterial blood gas in the case of a patient with respiratory acidosis.
Who deems this harm to be of an acceptable and necessary level? What level of harm inflicted is for the betterment of the patient’s condition? At what point does the pillar of non-maleficence shift to accommodate the emergency of a new ‘reality’? Often the patient themselves will make the decision as to whether the level of harm experienced is tolerable, but how does this work in the context of end-of-life decisions for those with a terminal illness?
The Hippocratic oath, one of the most famous medical texts, states “I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect ”. This excerpt would suggest that assisted dying for terminal illness is outside the scope of medical practice as proposed at the time. However, as the practice of medicine changes and society advances, so do does our interpretation, and observance of the Hippocratic oath.
There has been a paradigm shift over the previous decades, moving from a sole focus on extending individuals lives, towards one of prioritising the quality of that life and easing the experience of dying. As society becomes more accepting of death and dying, it may be the appropriate time – or indeed a pressing imperative – for the medical profession to follow suit. Death should no longer be considered a failure in the medical profession, rather a privilege of the job when “done right” – “a good death” – an opportunity to minimise harm and ensure a compassionate death.
For those with a terminal illness, assisted dying can significantly reduce harm: for both the individual and those surrounding them. Palliative care can alleviate vast amounts of pain and suffering, but its scope is finite. For some, even the best palliative care measures cannot relieve the harm and distress caused by their illness. By considering ‘true’ non-maleficence, assisted dying offers an alternative: it can prevent undue harm. The physical suffering and pain experienced by many terminal individuals is intolerable; to the individual, their families, and their communities, directly causing harm to their quality of remaining life. Instead of facing intense and prolonged suffering, individuals can choose a controlled death, avoiding the continuing pain inflicted by their illness as well as possible side effects of aggressive interventions. In a world where compassion and non-maleficence are unified, Individuals would no longer have to suffer from their illnesses merely to prolong their life. Assisted dying for terminal illness should not be a debate about life or death, it should be a debate about one experience of death, or another.
Similarly, assisted dying can prevent the psychological harm a terminally ill person may face. The loss of autonomy, independence and control associated with a terminal illness can cause profound emotional harm. For many, control and autonomy are pivotal in shaping their sense of self, who they are and what they do. Losing this control over self, either directly through illness or indirectly through knowledge of the terminal illness, is a significant source of harm for individuals. The dignity provided by assisted dying can therefore minimise the psychological harm experienced, by allowing agency over their identity.
Furthermore, the harm caused by terminal illness extends beyond the individual, significantly impacting family members and friends who have witnessed a loved one suffer at the hands of an illness. Witnessing the prolonged suffering of a family member or friend can be deeply distressing, creating overwhelming feelings of helplessness and exhaustion. Assisted dying can prevent harm in this context by providing those close to an individual with a sense of comfort and relief.
Non-maleficence is evolving. It is time that medical practitioners stop thinking of end-of-life harm for those with a terminal illness in objective terms and begin considering it as subjective. Medicine is no longer about solely prolonging and preserving life at all costs. Modern medicine is about providing a good life AND equally importantly, a good death.
Author: David Geddes
Affiliation: Medical Student, University of Edinburgh
Competing interests: None declared