Question Description

I’m working on a philosophy question and need guidance to help me learn.

A Reading Responses (RR) is an opportunity for students to individually reflect on what we read in class. Understanding, questioning, and writing about texts is part of the work of a philosopher. RRs are also opportunities for students to prepare to talk about texts in class. A thoughtful RR translates to a prepared and robust classroom discussion.

Each RR should be one full page, as best you can. You should also try to do the following three things: (1) understand the author’s perspective, (2) support your interpretation of this perspective, and (3) engage with it with your own experience and opinions. This follows a straightforward three-paragraph structure.

First paragraph: What is the author’s perspective when considering the text as a whole? You should try to restate the text into your own words, but this is different from merely restating each paragraph from beginning to end. How would you explain this perspective to a reasonably intelligent friend? How about a parent, who thinks taking philosophy classes is a waste of time? When doing this, it’s important to keep in mind something called the principle of charity. This is the idea that we should try to make as much sense of another’s argument as we can before we criticize it. When a charitable listener hears something that doesn’t make sense to them, they work to figure out how the other person might have arrived at that idea.

Second paragraph: What evidence from the text supports your interpretation of the author’s perspective? How did you arrive at this particular interpretation of the text? Here you’re quoting specific sentences and relating them to your interpretation in the first paragraph. Please provide page numbers so others can more easily follow your thinking.

Third paragraph: What do you think about what the author is saying? You can respond in any number of ways. You might argue that the author’s reasons they give don’t support their conclusion. You might provide additional examples or counterexamples, tell a story, refer to another relevant text, ask questions, or reframe the discussion to suggest another way to see the problem.1 attachmentsSlide 1 of 1

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Assisted suicide, many argue, honors self-determination in returning control of their dying to patients themselves. But physician assistance and measures proposed to safeguard patients from coercion in fact return ultimate authority over this “private and deeply personal” decision to medicine and society. W hy have physician-assisted suicide and voluntary active euthanasia taken on such vitality in recent years? Some authors stress the conjunction of powerful medical and cultural trends. The advances of modern medicine in association with its overwhelming bias to treat have engendered widespread and increasing fear. More than death itself, what seems frightening is the very real prospect of losing control over one’s own dying process.’ The reaction to this exorbitant sway of medicine has been nourished since the 1970s: patients’ empowerment or, more generally, the liberal individualism that has vigorously extended into the medical system. In response, advance directives, health care proxies, and other devices founded on the right to forgo medical treatment aim to “protect” patients from physicians, medicine, and hospitals’ institutional imperatives. From the perspective of this recent history, physician-assisted suicide and even voluntary active euthanasia are just one more necessary and justified step in this process. It is as if what modern medicine has expropriated from individuals could be returned to them through physician-assisted suicide: control over their own deaths.^ These considerations condense two widespread current assumptions in the debate over aid in dying. Tania Salem, “Physician-Assisted Suicide: Promoting Autonomy— Or Medicalizing Suicide?” Hastings Center Report 29, no. 3 (1999): 30-36. HASTINGS CENTER REPORT The first is that these practices are, for better or for worse, paradigmatic expressions of patients’ autonomy. Although proponents and opponents evaluate very differendy the adequacy and the limits conferred to self-determination in this context, they both endorse this general assertion. The second assumption is that physician-assisted suicide and voluntary active euthanasia are ultimate brakes on the unrestrained use of medical technology at the end of life. They are instruments to promote the “demedicalization” of death. I propose to challenge these assumptions. I want to argue that physician-assisted suicide does not demedicalize death; rather, it medicalizes suicide. By this I mean it transforms a private act (suicide) into a medical event. Indeed, physician-assisted suicide implies not a resistance to but an extension of medical power over life and death. And second, that instead of asserting an individual’s autonomy physician-assisted suicide is in fact an impediment to it. My analysis accepts the liberal/libertarian presumption that one of the essential attributes of the individual is precisely the liberty to govern oneself free from external constraints. Despite my belief in both the indispensability and inevitability of social constraints,^ as an analytic device here I will assume radical autonomy to be a moral goal. I will also assume that from the perspective of the physicianpatient dyad, more than killing, “assisted suicide” is literally what the phrase states: suicide with assistance, not only because it is the patient who makes the request, but also because it is she who is responsible for the final deed. May-June 1999 bate about death and dying has shifted focus from medical norms to individual rights, choices, and desires,'” a shift from outer codes to inner indiany of those who favor physividuals.” Michel Foucault argues that cian-assisted suicide analyze every moral system necessarily comand support it in reference to free prises these two aspects: socially stipchoice, individual rights, and moral ulated codes of conduct, and a relaautonomy.” This line of argument tion to oneself as a moral entity who rests on a conception of autonomy must evaluate and define a personal primarily as “negative liberty”: the stance regarding the proposed conright to act and govern oneself in acduct.’^ Outer codes and inner indicordance with one’s own private beviduals thus point not to a dichotoliefs, values, and choices without inmy but to the predominance of one terference as long as one’s behavior or the other moral perspective: some does not harm others.’ Proponents moral systems emphasize codes (re- ‘ assert that this right should encomquiring from the individual a strict pass patients’ control over the timing conformity to them) while j(5thers and circumstances of death up to and shift the focus to personal “choices.” including assistance in suicide. So There is no doubt that the emphaconceived as a “personal and intimate With the relationship between pasis on inner individuals prevails in decision,” the right to aid in dying tients and doctors increasingly seen as contemporary arguments for physirefers to a sphere of self-determinaa zero-sum game pitting vulnerable cian-assisted suicide. Influences from tion that should be lefi: free from any patients against the power of doctors the outside, whether subtle or blapaternalistic interference, whether and medicine, demedicalization is retant, are seen as pernicious in subthat interference emanates from the garded as a prerequisite to patients’ verting the main goal: the “pure” or state, from doctors, from family autonomy and empowerment in the “true” choice reached from within members, or from religious or philoface of death. that at bottom takes account of the sophical orthodoxies. Physician-asThus proponents uphold physiinterests of the decisionmaker. This sisted suicide is, in short, advocated cian-assisted suicide as a “natural” self-centered ethics rests on a nonrelaas a “natural” extension of the constiand indispensable development of tional conception of personhood. tutionally protected “right to privathe widely accepted right to refuse The second—and closely relatcy,” and as a mere specification of the and/or withdraw life-sustaining meded—pillar of this discourse is the inmoral right to self-determination.’^ ical treatments. Indeed, Peter Singer sistence that individuals be radically Opponents of this line of arguargues that the right to refuse is infree to exercise their singularities and ment contest the pre-eminence consufficient to grant individuals real idiosyncrasies. In pluralistic societies, ferred on autonomy vis-a-vis other control over their dying process. In it is asserted, “there is far from any social values and interests. The sanctihis own words, “Not killing is not agreement, or near-agreement, about ty of life, the protection of those who enough. . . . The right to refuse medhow one can establish as canonical a are vulnerable to medical or family ical treatment can help only in a limparticular normative view of life.”‘^ abuses, the “common good,” and the ited number of cases in which it leads Because personal styles, experiences, ethical integrity of the medical proto a swift and painless death. Most and beliefs are radically irreducible, it fessional (that is, the preservation of cancer patients, for instance, are not is impossible to suppose a priori that its ancient vow never intentionally to in this situation . . . . [This is why] individual choices will coincide; each kill) are variously seen as competing the desire of control over how we die must find his or her own way of facvalues that in fact outweigh individ.. . will not be satisfied by the concesing dying and death.'”‘ ual autonomy. What is contested is sions to patient autonomy withir Yet there is a paradox underlying not physician-assisted suicide as an framework of [traditional] ethics!”” physician-assisted suicide. It is coninstrument of personal autonomy; ceived of as an intimate, existential critics insist that even if assisted suicide act and indeed a response to modern does serve autonomy, limits should , medicine, but at the same time it is a be imposed on this value for the sake / request for the complicity of physiof other goods. Daniel Callahan’s ar/ Tncontestably, from a certain percians (and society). In contemporary JLspective physician-assisted suicide gument is illustrative: “the acceptance Western societies the decision to take is a dramatic expression of autonomy, of euthanasia would sanction aMew death into one’s own hands has been empowerment, self-determination, of autonomy holding that individuals construed as an act that is not simply and the like. The contemporary demay, in the name of their own pri- [ May-June 1999 vate, idiosyncratic view of the good life, call upon others, including such institutions as medicine, to help them to pursue that life, even at the risk of common good.”‘ Thus though they diverge in respect to how far personal autonomy and self-determination should extend, proponents and opponents converge in assuming that these values are ultimately the major forces driving the movement for physicianassisted suicide.’ A second assumption widespread in the literature—particularly among defenders—is that by enhancing the patient’s control assisted suicide represents just one more necessary step m the demedicalization of death. HASTINGS CENTER REPORT personal, private, and solitary, but contrary to social norms and expectations. From a societal perspective, the individual who commits or attempts suicide is in this sense an outsider. What seems unusual in the debate about aid in dying is the request for public endorsement and legitimization of the act of suicide. Whereas in suicide the individual “drops out” of Medicalizing the act of suicide. In the typical physician-assisted suicide scenario, the patient is responsible both for requesting aid in dying and for performing the final deed, and she or he construes the act basically as suicide. Yet as long as the physician is in charge of assisting the patient— either by his or her physical presence or by supplying the medical means to The decision to die by suicide is treated precisely as if it were a set of clinical problems to be solved medically— tbe “private,” “intimate,” “self-determining” decision to commit suicide is translated into a clinical event. the social order, in the context of physician-assisted suicide the individual “drops into” a system that recognizes and must even authorize this particular (ostensibly private) choice. In other words, displacing suicide from the private arena to bring it under medicines stewardship means surrendering suicide to the (medical) “establishment.” Precisely because assisted suicide requires the connivance of others (direct from doctors, indirect from society), it cannot be seen as an act that solely expresses the ideal of individual autonomy. On the contrary, as long as it entails assistance it implies a mutual decision. Additionally, and even more importantly, more than a mutual decision, assisted suicide presupposes that medicine has passed judgment on the act of suicide. In sum, physician-assisted suicide both introduces tensions in the principle of personal autonomy and entails an increase of medical power- over death and social morality. M edicalizing suicide encompasses three different (though interrelated) facets: the medicalization of an act, of a practice, and above all of the social ethos of death and suicide. HASTINGS CENTER REPORT perform the act—physician-assisted suicide entails the medicalization of the act of suicide. Ideally, for the physician to assist a patient’s suicide the physician must be physically present—as attested in Timothy Quill’s regrets for “abandoning” Diane, leaving her to take the prescribed lethal medication alone.” Thus what is intriguing in physician-assisted suicide is not that ventilators, tubes, CPR, and so on are supplanted by “lethal drugs,” but that even in this context the physician and medicine are overwhelmingly present in the setting of death. Even without the doctor’s physical presence in the last scene, as long as physician-assisted suicide presupposes medical assistance it cannot be conceived as immersed in the realm of self-determination. Unless doctors are reduced strictly to being instruments to fulfill their patients’ desires, physician-assisted suicide enacts what must be seen as a mutual decision. But what kind of questions are at stake in this joint decision? Proponents of assisted suicide suggest that patient and physician discuss the patient’s medical condition and explore alternatives for alleviating pain and suffering. If it comes to it, the physician should provide a prescription for a lethal drug that leads to a “rapid” and “painless” death.”‘That is, the decision to die by suicide is treated precisely as if it were a set of clinical problems to be solved medically—the “private,” “intimate,” “self-determining” decision to commit suicide is translated into a clinical event. Medicalizing suicide as professional practice. Medicalizing suicide also points to the fact that if legalized, physician-assisted suicide as a legitimate practice would become the prerogative of . physicians. Indeed, Jack Kevorkian has seen the ex: elusive right as the foundation for a new medical sub” speciality of “obitiatry.””’ This monopoly leads to the more general question of why aid in dying should be provided only by a medical practitioner. Why, that is, should assistance in suicide be understood as requiring medical authority rather than, for instance, a community of family or friends? The most obvious answer is that physicians—and only physicians—have the necessary technical skills to ensure a “rapid” and “painless” death. But as some critics have noted, “Assisted suicide does not even require medical skill. . . . If freeing up patients truly is the goal, then assisted suicide’s advocates disserve patients when they do not advocate ending the physician’s exclusive power to prescribe medication. Ironically, the advocates of patients’ rights end up empowering doctors more than they do patients.”” Yet even those who maintain that technical knowledge is imperative do not confme their justification of physician-assisted suicide to this rea- son. Placing suicide under the stewardship of medicine is further defended as a way of “enhancing public accountability of the practice” and “protecting against abuse.”” From the patient’s perspective, the request for aid in dying may mean a “desire for companionship in pursuing a difficult course of action, a wish for confirmation of a decision about which the patient is unsure or simply a cry May-June 1999 ability, and even to assure the autonomous character ofthe patient’s choice. Surely these aims are respectable and the setting up of criteria just and reasonable. Yet establishing medical guidelines also introduces tensions into the value of autonomy in several ways. The requisites for physician-assisted suicide (must the patient be terminally ill? which medical specialists are best qualified as consultants?) are still being debated. There is, however, agreement about the moral attributes that the patient and his or her request must evince: the decision to die must be “informed,” “rational,” “stable,” and “fully free” or “voluntary.”^^ And there is broad agreement that to ensure that these conditions are fulfilled the patient must submit to screening by a team of doctors (the treating physician, a consulting physician, and a psychiatrist) who would evaluate the request for aid in dying. This requirement assumes that besides undue external influences, some impulses or dispositions emanating cial and symbolic power already confrom the patient herself or himself— ferred on medicine and medical professionals in our societies. In other words, such as depression or guilt—may threaten “pure choice.” “Voluntariit is not (or not only) the need for ness” in this sense must be safeguardtechnical expertise that impels us to ed from undue influence stemming /)/;_)/«VM«-assisted suicide. Rather, our not only from outside, but also from culture, so impregnated by medicalwithin. Ultimately, this is to assume ization, takes for granted that assisted that the inner world may be obscure suicide should fall under the control to the individual, that she or he may and supervision of medicine. be half blind to her or his own Medicalizing the morality of suichoice, desire, or personal truth. cide. As a legitimate domain of proThe presumption that the inner fessional practice, then, physicianassisted suicide necessarily involves world is or may be opaque to the individual suggests a second underlying medicalizing the moral questions surpresupposition: someone other than rounding suicide. Physician-assisted the person requesting aid in dying suicide presupposes, and ultimately is, a medical judgment about death or has greater expertise in judging the appropriateness of that request. Medsuicide; it is a medical evaluation of ical authority, that is, is assumed to the fairness and legitimacy of a person’s (not simply a patient’s) desire or have the proper ability to unveil the “real truth” behind the request to die. choice to end his or her life. The patient’s treating physician, With some few exceptions, even along with psychiatric and/or palliathe most radical advocates of physitive care consultants, is charged to cian-assisted suicide recognize the distinguish authentic from distorted need to establish protocols and guidechoices; that is, to discern whether lines to prevent abuses, protect the the request is pertinent or pathologivulnerable, guarantee public accountfor help” (pp. 88-89, note 42). Moreover, since suicide is still stigmatized, “seeking a physician’s assistance may be a way of trying to remove that stigma.”^” But inasmuch as cultural preconceptions and loneliness (whatever its source) are far from being exclusively medical issues, we must ask why we expect doctors to respond to them. Two possible answers come to mind: either medicine is moving beyond its proper role, or the scope of medical competence has already been extended beyond appropriate boundaries. It seems reasonable to conclude that ceding monopoly of assistance in suicide to doctors is anchored in an inflation of the physician’s role, as well as in the extreme idealization of physicians’ character and the relationships they establish with patients. The bond physicians establish with patients is supposedly effective, collaborative, and committed.^’ Both this idealization and the willingness to delegate to physicians the exclusive right to assist suicide bespeaks the so- May-June 1999 cal (and if so, whether it is “curable” by medical means). Both these premises obviously collide with the principles of autonomy and self-determination. Both displace the final decision concerning suicide from the patient to the physician’s judgment that the request is appropriate and free from “undue influence.” The insult to autonomy is not exerted through repression, as was the criminalization of suicide. Rather, it is exercised through what Foucault would call the “normalization” of suicide, the subordination to medical scrutiny of this event and the person making the request.” The “patient” is subjected to observation, examination, and inquiry to confirm the “rationality” and “voluntariness” of his or her request. Thus medicalizing (assisted) suicide jeopardizes autonomy not only when the patient’s request is denied for one reason or another. Requiring that the patient submit to medical surveillance is, in itself, an outrage to autonomy as this value is classically defined.^”* To illustrate how complex is the apparatus through which suicide is normalized, consider guidelines suggested by Frank Miller, Howard Brody, and Timothy Quill, for example. To ensure public accountability for physician-assisted suicide, to guarantee that the procedure is used only as a “last resort,” and to assure that the patient’s decision is genuinely voluntary, the authors su…
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