Rights vs. Liberties
The “provider” label has also reinforced the notion that the “consumer” or “customer” is entitled to certain “rights” which—in some circumstances—may be at odds with the traditional ethical constraints of the physician. The consumer/customer oriented model seemed to give priority to the patient’s wishes rather than to the accepted norms of medical practice. In my view, this has been particularly evident in the narrative put forward by groups advocating physician-assisted suicide (PAS). Their main contention invokes the language of rights and entitlement, rather than the language of liberties.
This distinction is critical in assessing the claims of those who assert PAS as a “right.” The late Thomas Szasz, MD—famous for his libertarian views—made this distinction: a right is a privilege or activity that requires others to assist or cooperate in some fashion; a liberty is something that we may exercise without imposing obligations on others.17
So, for example, if citizens have a right to vote, the government incurs an obligation to provide a mechanism for voting. In contrast, citizens may be at liberty to smoke, but the government has no obligation to provide cigarettes. Szasz did not believe that suicide was a full-fledged “right,” but rather, a personal liberty.
He argued that people ought to be “left alone” to commit suicide—but he did not believe that physicians ought to “assist” in killing their patients.17
Advocates of PAS (or “assistance in dying”) often adopt the consumer-oriented language of “rights.” Thus, in their book, To Die Well: Your Right to Comfort, Calm, and Choice in the Last Days of Life,18 Dr. Sidney Wanzer and Dr. Joseph Glenmullen write:
“Doctors vary in their willingness to discuss end-of-life options and they vary in their comfort level with patients who want to maintain control…You are a customer who is purchasing a product (health care) and you have every right to choose who provides that care…the patient as a consumer has the right to make the decision.” 18, p. 17, (italics added)
Similarly, the organization called “Last Acts” is described in the Wanzer-Glenmullen book as “…a national coalition of health-care providers and consumers dedicated to improving care near the end of life…” 18, p.188
Indeed, we can expect that this consumer-centered perspective is likely to become more common in the coming years. As British journalist Yvonne Roberts has put it,
“…as our population ages, choosing when to make an exit will be regarded as a consumer’s right by individuals reared in a society in which market forces dominate and the customer is always correct.” 19
As a medical ethicist, I find the trend toward the commodification of health care very troubling. To be sure, there have been many positive aspects of the consumer rights movement, as it has influenced medical care. For example, Wanzer and Glenmullen, to their credit, emphasize the patient’s right to adequate pain relief at the end of life—a critical issue that orthodox medicine, historically, has sorely neglected.
That said, I don’t believe most physicians entered the field of medicine with the understanding that they would be “providers” servicing “consumers” or “customers,” whose wishes were to be respected no matter how they conflict with traditional medical ethics.
The challenge going forward is how physicians and patients—not providers and consumers—can work collaboratively and respectfully, while preserving the traditional role of the physician as healer and teacher. This challenge is nowhere more critical than in the complex and controversial area of end-of-life decisions.
** As of this writing (7/8/16), the proposal re: PAS for mature minors with mental illness has not yet been enacted into Canadian law. However, Canada’s Parliament recently passed Bill C-14, which provides for “one or more independent reviews relating to requests by mature minors for medical assistance in dying”—potentially including “requests where mental illness is the sole underlying medical condition.”
If, after review, the mental illness clause is enacted into law, this could mean that young people with potentially reversible conditions like major depression or schizophrenia would be able to receive a physician’s “assistance” in committing suicide.
Thus, according to a CBC report, “Health Canada will continue to work with the provinces and territories as provisions of the legislation come into force and further study will be done with respect to medical assistance in dying in the context of mature minors, people for whom mental illness is the sole underlying condition and advance requests.”