How Far Can We Fall If There is No Bottom?

A May 26th post in the Bioethics Forum of The Hastings Center asks “Are we reaching a tipping point in the debate over physician aid in dying?” The author cited the case of a Cornell psychologist who opted to commit suicide with physician assistance before Alzheimer’s caused her to lose “all quality of life” and “meaning.”

Cases such as these are compelling, because aging, infirmity, and dying are so. Each instance causes distress, and to remove distress seems to be the ultimate humanitarian act.

We must ask, however, why Hippocrates thought it necessary so long ago to include in the physician’s oath the injunction against assisting suicide. What was it he saw that made it necessary to draw this bright line? Certainly suffering was at least as common then, as physicians did not have nearly as many tools to alleviate it. For Hippocrates to draw this line in the face of suffering, he would have had to see how far physicians could go in willfully causing their patients’ deaths, and the consequences of such actions on the profession, the community, and the relationship between them. We don’t see such problems today, as we are still living off the fruit of that ethical standard.

In ethics we ought to consider the importance and value of clear lines such as those written into the Hippocratic Oath. They do not guarantee that nothing undesirable will happen. They do, however, serve as a floor, guaranteeing that professional conduct will only fall so far. If removed, what then becomes the insurance that we will not step lower and lower?

Many years ago I spoke with the head of a large shelter for the homeless. He had an impressive background, retiring from the Army where he had served in the Rangers. Driven by the imperative of his Christian faith to aid his fellow man in need, he had become a nurse and eventually in charge of this shelter in a Georgia city. I asked him what was it that he saw that worried him the most. He said, “Youth today have no bottom.” After I asked him to explain, he said that many youth so lacked any moral foundation that there was no depths of depravity to which they couldn’t fall. A few months later was Colombine.

We could debate in detail each of the author’s premises, such as claims as to what is “quality of life,” or “meaning,” or the role of physicians. One thing we must recognize, however, is that line drawn so long ago by Hippocrates has served as a “bottom,” preventing physicians from plumbing the depths of increasingly abhorrent acts. In discussions of PAS, proponents of it extract the positive feelings and leave the scene before the unpleasant consequences emerge. Hippocrates must have known those full well, and with that knowledge wrote his oath. I fear that we will soon regain that knowledge…the hard way.

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Mark McQuainBarry Orvell, MD Recent comment authors
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Barry Orvell, MD
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Barry Orvell, MD

But, did Hippocrates really comment about Assisted Suicide? Or did he comment about murder? “Nor shall any man’s entreaty prevail upon me to administer poison to anyone; neither will I counsel any man to do so”. Or using dangerous treatments, ie., primum non nocere. No one wants legalized murder. Those of us who see a limited value in PAS might say that refusing to listen to the pleas for release by a clearly terminal patient, is an abdication of our mission to relieve suffering. And such a refusal is an ethical error, in my opinion, if we look for absolutes… Read more »

Mark McQuain
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Mark McQuain

But why involve physicians at all. If death is indeed the ultimate relief of a patient’s suffering (N.B. there is no known way to actually confirm this hypothesis), and if we as a society are going to permit someone other than the patient to cause his or her death for this purpose, why not employ someone really good at killing people and killing them quickly. Physicians are the last group of people we should think of to perform this act. Physicians spend their training learning how not to kill people and the rest of their practices specifically avoiding killing people.… Read more »