The authors reply
First, Dr. Lazaridis (1) astutely recognizes the implications of denying any morally significant difference between physician-assisted suicide or euthanasia (PAS/E) and withholding/withdrawing life-sustaining therapy (WWLST). Opponents of PAS/E will agree that if one denies any distinction between these two practices, then nonvoluntary WWLST naturally leads to nonvoluntary PAS/E. Proponents of PAS/E might stipulate that mandating voluntariness is an important safeguard around the practice of PAS/E to ensure that patients wishes to remain alive are not violated.
Dr. Lazaridis (1) argues that there is no significant difference in intent between PAS/E and WWLST. Opponents of PAS/E will disagree. As we laid out in our article, WWLST does not require any intent to cause death: WWLST achieves palliation regardless of whether the patient subsequently dies. PAS/E by definition requires intent to cause death. Although the overall intention may be similar (relief of suffering), the specific actions of PAS/E necessarily engage intent to cause death in a way that WWLST does not. So, there is a clear difference in intent between the practices.
Whether this distinction is of any ethical significance turns on Dr. Lazaridis’ third point: the wrongness of deliberately causing death. He argues that the Kantian position of respect for persons as ends rather than means requires respect for their autonomy, such that one is “morally obligated” to cause death upon patient request. In fact, Kant (2) himself argued that killing oneself out of respect for one’s autonomy (suicide) violates the principle of respect for persons: to kill oneself (destruction of person) treats oneself as a means to an end (satisfying preference).
The precise metaphysical basis for the wrongness of causing death (inviolability of persons) is a complex and controversial issue over which the medical community is unlikely to reach consensus. However, lack of consensus over the grounds of the inviolability of persons does not render the fact of their inviolability vacuous. Just as we may know that a drug is efficacious for a given disease process even while we do not entirely understand “why” it is efficacious, those who know that causing death intentionally is wrong from basic moral intuition need not give a fundamental account of why that is the case in order to uphold their belief. Of course, when others do not share that basic moral intuition, appeals to some transcendent metaphysics become the only basis to convince others that one’s moral intuition is justified. Certainly, appeals to the principle of respect for personal autonomy are insufficient to function as this transcendent standard because they cannot adjudicate conflicting wishes between autonomous persons; such appeals cannot serve as any kind of authoritative moral foundation (3).