The American Journal of Bioethics
Physician-Assisted Dying—What Would
Aristotle Do?
James Duffy, University of Texas
As a palliative care physician who cares for patients with
incurable medical disorders, I remain uncomfortable with
attempts to normalize physician-assisted dying (PAD) as a
routine approach to or care of the terminally ill.
Although the invocation of deontological ethical princi-
ples and the introduction of new laws (such as the Oregon
Death with Dignity Act) may provide the physician with
ethical and legal “safe harbor”, they do little to dissuade
my visceral discomfort to the act of assisting another hu-
man being hasten their death.
It would seem, according to the ethical and legal argu-
ments posited by Lindsay (2009), that PAD is now a well
packaged “moral fait accomplit” that is likely to spread to
other states in the United States. How then can I frame
the ethical justification for my real and very personal re-
sistance to participating in PAD? The answer is apparent
to me each time I consider the option of providing my pa-
tient with a premeditated lethal prescription that is intended
to facilitate their death. Simply stated, it simply does not
feel virtuous to participate in any patient’s deliberate and
pre-meditated self-destruction (whether you describe it as
physician-assisted dying or physician-assisted suicide).
Unfortunately, principle-based ethics provides little in-
sight into the genesis of my “dis-ease” regarding PAD. It
may rationalize the act—however, it does not sanctify it. The
official position of my professional association also fails to
provide moral safe-harbor. It is interesting to note that pal-
liative and hospice physicians (i.e. those physicians who
are most involved in the provision of end-of-life care), have
been noticeably absent from the public debate on PAD.
Clearly their absence from this debate reflects their reti-
cence and not their disinterest—for the relief of suffering
represents the cornerstone of their work as physicians. The
profession’s ambivalence on the topic is reflected in this
comment contained within the official American Academy
of Hospice and Palliative Medicine Position statement on
Physician-Assisted Dying (2007):
AAHPM takes a position of “studied neutrality” on the sub-
ject of whether PAD should be legally regulated or prohibited,
believing its members should instead continue to strive to find
the proper response to those patients whose suffering becomes
intolerable despite the best possible palliative care. Whether
or not legalization occurs, AAHPM supports intense efforts
to alleviate suffering and to reduce any perceived need for
PAD .
This statement is ’clearly ambiguous’. However, it does
clarify what I believe to be the central ethical mandate of a
Address correspondence to James Duffy, University of Texas, 1515 Holcombe Blvd, Houston, TX 77030. E-mail: jamesduffymd@gmail.com
30 ajob
physician when called on to provide care to any patient—
i.e., the physician “should strive to find the proper response
to those patients whose suffering becomes intolerable de-
spite the best palliative care”. I would like to suggest that
the operative word in this statement (i.e., proper) can logi-
cally be replaced by the term phronetic.
The term phronesis was coined by Aristotle to describe
“practical wisdom” which he considered to be the single
most important virtue. As the linkage point between intel-
lectual virtue (the truth) and good character (the good),
phronesis describes our capacity to monitor whether our
individual actions (formulated through intellectual eval-
uation) are consistent with our long-term virtuous goals.
Phronesis describes the practical wisdom necessary to em-
ploy skillful means as we attempt to “achieve the good
outcome”. Phronesis is concerned not just with the out-
come, but also with the particular actions taken towards that
goal. Pellegrino and Thomasama (1993) describe phrone-
sis as “the indispensable connection between the cogni-
tion of the good and the disposition to seek it in particular
acts” (84).
I would suggest that without the wisdom container of
phronesis, principle-based ethics simply becomes the cogni-
tive sanitation of anxiety provoking situations and an expe-
dient means to side-step our moral imperative to examine
the deeper moral ends of our actions. While this “moral side-
step” has apparent utility in a secular society, I suggest that
phronesis must be an indispensable part of any significant
goal. From this ethical perspective, the application of deon-
tological and legal approaches alone to the morality of PAD
is simply inadequate because they fail to address the larger
moral issue—i.e., Under what circumstances (or goals) is it
acceptable for one human being to willfully participate as
an agent in the death another?
As a palliative medicine physician, phronesis allows me
to examine my role in PAD through a wider moral lens than
that provided by deontology alone:
1) Physician-assisted suicide is physician-assisted suicide.
Attempts to replace the term physician-assisted suicide
with the term physician-assisted dying may provide com-
fort to the prescribing physician but distorts the ulti-
mate goal of providing the patient with a lethal dose of
medication to deliberately assist a patient in their self-
destructive act. Reasoning that the patient suffers form
a terminal illness does not negate this fact. Indeed, one
could argue that all human beings must inevitably die
and that suicide is therefore a rational choice for any
March, Volume 9, Number 3, 2009

person—at any time. Phronesis suggests that my role as
a physician is not to simply rush to ’amputate suffer-
ing’ through suicide, but rather to support my patients
in their attempts to redefine their relationship to the in-
evitable nature of human life and death.
2) As a virtue, phronesis requires the “wise” physician to
have achieved equanimity with his own mortality. This
highlights the fact that phronesis cannot simply be taught
but must be earned through the physician’s personal
experience and hard- won insights. This suggests that
our patients are also our teachers who participate in the
shared experience of our mutual mortality.
3) Phronesis suggests that the ‘doctrine of double-effect’,
and not PAS, should shape our response to the suffer-
ing of our patients. Lethal prescriptions provided to a
patient at one point of their illness are no substitute for
‘HealthCaring’. Patient’s diseases and personal circum-
stances will fluctuate and their response and experience
to these changes are seldom constant. Patients have a
right to expect that their physician accompany them on
their journey towards dying and be available when nec-
essary to tailor they care to the particular circumstances
of that moment. One could argue that to relinquish this
role in favor of a single lethal prescription is tantamount
to abandonment. The doctrine of double-effect allows the
physician the flexibility to titrate medications to the end
of relieving suffering, and not simply the hastening of
death. By allowing the physician to participate in absen-
tia, PAS diminishes the vital role that physicians should
play in supporting their patients through all stages of
their illness.
4) Phronesis recognizes that the art of medicine is the skill-
ful application of our “techne”, and not simply the imper-
sonal generalization of our science. Phronesis demands
that every patient be recognized as a unique individual
confronting unique challenges that demand unique re-
sponses of the physician. The institution of impersonal
laws and ethical guidelines devalues the art of medicine
and the unique covenant that exists between each patient.
Whilst the Oregon Death with Dignity Act has not cre-
ated a slippery slope in terms of numbers, I am concerned
that it will have a corrosive effect upon the nature of the
healing relationship between patient and physician.
March, Volume 9, Number 3, 2009
Oregon’s Experience
5) Phronesis suggests that what patient’s are seeking in a
lethal prescription is not so much a quick exit from life
but rather as a statement of understanding and support
from their physician. The data from the Netherlands
suggests that physicians are actually not very skilled
in determining the lethal doses of their prescribed
medications. If PAS is to become the “standard of care”
then should we require that all physicians undergo
formal training in the most efficient (evidence-based)
methods of lethal prescribing? Phronesis suggests that
my response to a patient’s request for assisted suicide
should be focused on better understanding the nature of
their experience of their suffering than seeking a rapid
dissolution of their experience.
6) Phronesis suggests that the goal of my medical care
is not simply the removal of suffering but rather to
support my patient in his attempts to discover a way
through the suffering of life and death. In this regard,
Aristotle’s reminds us that in situations where we are
unable to discover the “Golden Mean” we should seek
the lesser of to evils. I would suggest that suicide is
not the lesser of two evils and that suffering holds out
an opportunity for spiritual growth that can seldom be
achieved without the torment that suffering entails.
So, as I perform my duties as a palliative care physi-
cian I often reflect upon “What would Aristotle do in this
particular circumstance?” Guided by phronesis, I believe
Aristotle would likely advise great prudence before partic-
ipating in PAS. I think he would state that my single most
important ethical responsibility is to always be present as
a reliable and authentic witness to my patients’ suffering
and to respond with compassionate intent. Not through
a lethal prescription but through my role as a journey-
man with my patients on their journey through life, and
death.

REFERENCE
Lindsay, R. A. 2009. Oregon’s experience: Evaluating the record.
American Journal of Bioethics 9(3): 19–27.
Pellegrino, E. D., and Thomasama, D. C. 1993. The Virtues in Medical
Practice. New York, NY. Oxford University Press.
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