Doctoral Dissertations

Date of Award

5-2003

Degree Type

Dissertation

Degree Name

Doctor of Philosophy

Major

Philosophy

Major Professor

Glenn C. Graber

Committee Members

J. Davis Allen, James O. Bennett, John R. Hardwig

Abstract

The starting point of my dissertation is a traditional goal of medicine, the relief of suffering. The central question that I dealt with is the appropriate clinical response to a patient’s suffering. An underlying assumption in the answer that I provide is that a physician’s clinical response must be guided primarily by the principles of beneficence and respect for patient autonomy. I argue that both principles require the physician to respond in a proportionate manner with medically appropriate care, which has the backing of relevant scientific and clinical data, and must be provided in a manner deemed acceptable by the patient. Central to the process of providing medically appropriate care aimed at the relief of suffering is an understanding of suffering itself. To develop that understanding, I studied the works of Freud, Bakan, Frankl, and Cassell. I concluded that suffering is primarily an existential problem associated with the whole person, in contrast to physical pain, which is primarily a neurophysiological problem associated with the body. I define suffering itself as a state of emotion, consisting in an unrelenting tension between hope and despair, caused by a serious and unacceptable disruption in important personal matters. As Frankl put it, when one suffers, one perceives a gap between the way important personal matters are at the moment as compared to how such matters ought to be. The matters are important because they involve something that the sufferer holds dear, while the disruption is unacceptable because the possibility of not overcoming that disruption is potentially devastating. The sufferer’s hope derives from desire and belief v that disruption will be resolved favorably, while the feeling of despair reflects the threat of being overwhelmed by the disruption Although the intensity and duration of suffering vary with subjective factors and the particular circumstances, it follows that relief comes about in one of two ways. Either hope is fulfilled, in which case the sufferer no longer perceives a gap, or relief is a matter of genuine acceptance, as opposed to resignation. Genuine acceptance is the kind possible after adjusting to the death of a loved one, or the consequences of a divorce, or some other personal tragedy. Since some patients hope for relief through physician-assisted suicide, I next examined that issue from the physician’s perspective, and argue that physicians should not agree to such requests. I base my conclusion in part on a requirement defended by Pellegrino and Thomasma, which is that physicians must provide medically appropriate care in a proportionate manner. I developed their principle of proportionality with both a classical and a modern interpretation of that concept. Aquinas provides the basis of a classical interpretation of proportionality, while Gury and Knauer provide the basis of a modern interpretation. Based on a classical version of proportionality, I argue that physician-assisted suicide is morally unacceptable for three reasons. One, it is contrary to the physician’s duty to heal, which does not necessarily mean cure. The healer’s commitment is to care for patients even when cure is not possible, or the patient has a poor quality of life, or death is imminent. This commitment reflects a long-standing legal, medical, and moral tradition that bars the practice of physician-assisted suicide. Two, it is contrary to the public good due to its inherent potential for abuse. I cite evidence from the Netherlands vi and from our own criminal justice system in relation to the death penalty in support of this claim. I also dispute Brock’s claim that safeguards are an effective method of reducing the level of abuse in physician-assisted suicide to a level below that in other end-of-life care strategies. Third, I claim that physician-assisted suicide is contrary to the virtuous practice of medicine because it does not qualify as medically appropriate care. Due to this deficiency, physicians are led to substitute their own personal views about the worth of continued living, which exceeds the limits of their professional expertise. This deviation from established medical protocol goes beyond the particular case to the level of medical principle for all other patients similarly situated, without ethical warrant. Based on a modern interpretation of proportionality, I argue that physicianassisted suicide fails Gury’s version of that principle, which requires a predominance of good in the immediate outcome. Such results cannot be calculated in a case of physicianassisted suicide, because the immediate results of death are known only by the patient, if at all, after death. Physician-assisted suicide also fails Knauer’s version, which requires that the net effect must be measured in the long run and on the whole, which are likewise unknown by the physician. Knauer also requires that there be no less harmful way of securing the value sought, in this case, relief of suffering. In the case of suffering, however, a less onerous method is available, namely, acceptance. Although acceptance is not possible for some patients and not appropriate for others, it is an avenue of relief in all cases of suffering. Because suffering involves the whole person, I draw on the works of Frankl and Cassel to conclude that the appropriate clinical response to a patient’s suffering is a holistic approach to patient care. From the individual’s perspective, Frankl claims that vii resolving suffering depends on the meaning and value that we each give to our experience of suffering. From a clinical perspective, Cassell focuses on suffering as a psychological condition and offers a holistic response, consisting in two primary methods of relief. One is to guide patients to assign meaning to their medical condition, which often resolves the suffering associated with that condition. The other is to assist patients in developing a feeling of transcendence, which helps restore a sense of wholeness after injury to personhood. His approach has three goals. One is to define treatment plans in terms of a sick person, rather than in terms of a disease only. The second is to maximize the patient’s function and not necessarily length of life. The third is to minimize the family's suffering as well as the patient's. In this respect, holistic medicine is centered in community, caring, compassion, and comfort, with a special emphasis on spiritual concerns. Its chief aim is inspire patients to view themselves as persons of value to be cared for, even at end of life when suffering can become unbearable.

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